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I
W YORK MEDICAL JOURNAL
INCORPORATING THE
PHILADELPHIA MEDICAL JOURNAL
AND THE
MEDICAL NEWS
A WEEKLY REVIEW OF MEDICINE
EDITORS
CHARLES E. DE M. SAJOUS, M. D., LL. D., Sc. I).
SMITH ELY JELLIFFE, A. M., M. D., Ph. D.
ASSISTANT EDITORS
Charles F. Boi.uuan, ^^. D. Louis T. de M. Sa.ious, B. S., M. D.
Cary Ecigleston, M. D. William F. C. Stkinbugler, M. D.
John E. Lind, M. D. „ „ , ,
Charles Greene Cumston, M. D.
James F. Rogers, M. D.
„ * Tir Til AT W. H. Donnelly, M. D.
Caswell A. Mayo, Ph. M.
Benjamin T. Tilton, M. D. J^m^^s J. Walsh. M. D.. Ph. D.
^[atthias Lanckton Foster, M D. Karl M. Vogel, M. D.
VOLUME CVOL
JULY TO DECEMBER, 1918, INCLUSIVE.
NEW YORK
A. R. ELLIOTT PUBLISHING CO.
1918
COPYRIGHT, 1918, BY A. R. ELLIOTT PUBLISHING CO.
LIST OF CONTRIBUTORS TO VOLUME CVIII.
Those whose names are marked witli an asterisk have contributed editorial articles.
Adams, Charles B., M. D.
Ali.en, Robert McDowell, M. D.
Allen, Walter C, M. D., Chicago.
Allport. Frank, M. D., Chicago.
Andresen, Albert F. R., M. D., Brook-
lyn.
Angevine, Robert W., M. D., Rochester,
N. Y., First Lieutenant, Medical
Corps, United States Army.
Apfel, Harry, M. D.
Aranow, Harry, M. D., F. A. C. S.
Aronson, Edward A., M. D.
♦Arrowsmith, Hubert, M. D., Brook-
lyn.
Bardou, Vincent. M. D., Medical
Corps, French Army.
Barker, Lewellys F., M. D., Baltimore.
Bastedo, Walter A., M. D.
B.^TES, W. H., M. D.
Behrend, Moses, M. D., Philadelphia.
Bellows, Charles M., M. D., Brooklyn.
Bennett. William H., M. D., Atlantic
City, N. J.
Berg, Henry W., M. D.
Blackwood, Norman J.. Medical Direc-
tor, United States Navy.
Blumgarten, a. S., M. D.
*BoLDUAN. Charles F., M. D., Wash-
ington, D. C.
BooRSTEiN, Samuel W., M. D.
Borden, W. C, M. D., F. A. C. S.,
Washington, D. C.
Bovver, John O., M. D., Philadelphia.
Bowers, Edwin F., M. D.
Bram, Israel, M. D., Philadelphia.
Braun, Alfred, M. D.
Beav, Aaron, M. D., Philadelphia.
Brewer, Isaac W., Lieutenant Colonel,
Medical Corps, United States Army.
♦Brink, Louise, A. B.
Brodhead, Gf.orge L., M. D.
Buerger, Leo, M. D.
BuLLOWA, Jesse G. M., M. D.
Byrne, Joseph, M. D., M. R. C. S.
Carrfra, Jose Luis, M. D., Ann Arbor.
Climenko, Hyman, M. D.
*Clouting, Charles A., M. D.
Cobb, J. O., M. D., United States Public
Health Service.
Coghlan, John, M. D.
Cohen, Solomon Solis, M. D., Phila-
delphia.
Copeland, Royal S., M. D.
CoRciA, John, M. D.
Cornwall, Edward E., M. D., F. A.
C. P., Brooklyn.
Coston, H. R., M. D., Birmingham, Ala.
*Cumston, Charles Greene, M. D.,
Geneva, Switzerland.
Cunningham, William P., M. D.
Danzigfr, Ernst, M. D.
Davin, John P., M. D.
Delfino, D., M. D., Columbus, Ohio.
Diamond, Joseph S., M. D.
♦Donnelly, W. H., M. D., Brookyn.
Downing, T. J., M. D., New London,
Mo.
Duncan, Charles H., M. D.
Eckles, C. H., D. -S. C, Columbia, Mo.
*Eggleston, Gary, M. D.
♦Elliott, George, M. D., Toronto, Can-
ada.
Ellis, A. G., M. D., Philadelphia.
Farnell, Frederick J., M. D., Provi-
dence, R. I.
Finkelstein, Reuben, M. D., Brooklyn.
Fischer, Louis, M. D.
Fisher, H. M., M. D., Philadelphia.
♦Foster. Matthias Lanckton, M. D.,
New Rochelle, N. Y.
Fowler, W. Frank, M. D., Rochester,
N. Y.
Frankel, Bernard, M. D.
Franklin, George W., Albany, N. Y.
Freudenthal, Wolff, M. D.
Friedel, Herman, Stapleton, S. I.
♦Friedman, Henry M.. M. D.. LL. M.
Fuller, William, M. D., Chit!ago.
Garrison, Fielding H., M. D., Wash-
ington, D. C.
Glass, Jacob, M. D.
Gluck, Charles, M. D.
Gluckman, I. Edward, M. D.
Goldfader, Philip, M. D., Brooklyn.
Goldwater, S. S., M. D.
Gradwohl, R. B. H., M. D., St. Louis.
Graham, John Randolph, M. D.
Greeff, J. G. William, M. D.
Griffith, J. P. Crozer, M. D., Philadel-
phia.
Hance, Irwin H., M. D., Lakewood,
N. J.
Hansell, Howard F., M. D., Philadel-
phia.
Harris, Louis I., M. D., Dr. P. H.
Herb, Ferdinand, M. D., Oiicago.
Hertzberg, G. R. R., M. D., Stamford,
Conn.
Hodgson, Millard B., Rochester, N. Y.
Hoguet, J. P., M. D.
Howard, Tasker, M. D., Brooklyn.
Iglauf.r, Samuel B. S., M. D., Cincin-
nati.
♦Ivimey, R. Muriel, A. B., Baltimore.
Jahss, Samuel A., M. D.
James, Walter B., M. D.
♦Jelliffe, Smith Ely, A. M., M. D.,
Ph. D.
Jones, Frank A., M. D., Memphis.
Josephson, Isidore, M. D.
Kahn, Moses. M. D., Brooklyn.
Kane, P. A., M. D., Chicago.
Kantor, John L., M. D.
Kaplan, D. M., M. D.
Katzoff, Simon L., Ph. G., LL. B.,
Bridgeport, Conn.
Kearney, J. A., M. D.
Kennedy, J. W., M. D., Philadelphia.
♦Keyes, Edward L., Jr., M. D.
Klotz, Hermann G., M. D., White
Plains, N. Y.
Knopf, S. Adolphus, M. D.
Kobler, E. Willis, M. D.
Kuhn, I. RussEL, A. B., M. D.. Falls-
burgh, N. Y.
Lambright, George L., M. D., Cleveland.
Landsman, Arthur A., M. D.
Lane, Harold C, M. D., Denver.
La Roque, G. Paul, M. D., F. A. C. S.,
Richmond, Va.
Leikauf, John E., Ph. D.
Levbarg, John J., M. D.
♦Lind, John E., M. D., Washington.
Linder, Charles O., M. D., Spokane,
Wash.
Lowenburg, Harry, A. M., M. D., Phila-
delphia.
Lubman, Max, M. D.
LuTTiNGER, Paul, M. D.
McGrath, John J., M. D., F. A. C. S.
Mackenzie, George W., M. D., Phila-
delphia.
McKenzie, R. Tait, M. D., Philadelphia.
McMurtrie, Douglas C.
MacNair, Robert H., M. D., Springfield,
Mass.
Manges, Morris, M. D.
Marcus, Joseph H., M. D., Atlantic
City, N. J.
Marlow, F. W., M. D., M. R. C. S. Eng.,
F. A. C. S., Syracuse, N. Y.
Martin, Franklin, M. D., Washing-
ton, D. C.
Matson, Ralph C, M. D., Major, Medi-
cal Corps, United States Army, Port-
land, Ore.
Mayer, Emil, M. D.
♦Mayo, Caswell A., Ph. M.
Meltzer, S. J., M. D.
Mendel, Lafayette B., M. D., New
Haven, Conn.
♦Merritt, Arthur H., D. D. S.
Michel, Leo L., M. D.
Miller, Julius Asher, M. D., Sunder-
land, England.
Minor, J. C, M. D., Hot Springs, Ark.
Mix, Charles L., M. D., Major, Medi-
cal Corps, United States Army.
Morton, Rosalie Slaughter, M. D.
NiES, Edward H.
Nisselson, Max, M. D.
Norman, N. Philip, M. D., Captain,
Medical Corps, United States Army.
Novack, H. J., M. D., Philadelphia.
Oberndorf, C. P., M. D.
Osborne, Oliver T., M. A., M. D., New
Haven, Conn.
Palmer, Leroy S., Ph. D., Columbia,
Mo.
Park, William H., M. D.
Parker, George M., M. D.
Peterson, Frederick, M. D.
♦Phelps, Edith B.
PiSKO, Edward, M. D.
PoHLY, Albert E., M. D.
Pridham, Frederick, Baltimore.
Ramirez, M. A., M. D.
Ray, E. L., M. D., Louisville, Ky.
Redfield, Casper L., M. D., Chicago.
Reede, Edward Hiram, M. D., Wash-
ington, D. C.
Retan, George M., M. D., Syracuse.
Richardson, Anna M., M. D.
Roberts, Percy Willard, M. D.
Rodman, Harry, M. D.
♦Rogers, James F., M. D., New Haven.
Rosenberger, Randle C, M. D., Phila-
delphia.
Rosenheck, Charles, M. D.
RouTH, Amand, M. D., F. R. C. P.,
London, England.
♦Rovinsky, Alexander, M. D.
Roy, Dunbar, A. B., M. D., F. A. C. S..
Atlanta, Ga.
RuBENSTONE, A. I., M. D., Philadelphia.
Rucker, James B., Jr., M. D., Philadel-
phia.
Sabshin, Z. I., M. D., Stapleton, S. I.,
United States Public Health Service.
Sadler, Mark, M. D., Montreux, Swit-
zerland.
♦Sajous, Charles E. de M., M. D.,
LL. D., Sc. D., Philadelphia.
Sajoi-s, Loris T. dk M., H. S., M. D.,
Philadelphia.
Sautter, C. M., M. !>.
ScAL, Joseph C, M. D.
*Scarli;tt, Rufus B., M. D., Tixnlon,
N. J.
SCHWATT, H., M. D.
Shaweker, Max, M. D., Licuten;uit,
Medical Corps, United States Xavy.
Sheffield, Herman B., M. D.
SiDis, Boris, M. D., Portsmouth, N. H.
SiMONTON, L. J., M. D., Cumberland
Valley, Pa.
Smith, John J., M. D., Captain, Medi-
cal Corps, United States Army.
Snyder, R. Garfield, M D.
*Spaulding, Harry Van Ness, M. D.
Spivak, C. D., M. D., Denver, Colo.
Staller, Max, M. D., Philadelphia.
*Steinbugler, William F. C, M. D.,
Brooklyn.
Steindler, a., M. D., F. a. C. S., Iowa
City, Iowa.
Steixfield, Edward, M. D.. Philadel-
phia.
*Steinmetz, Innis, B. A., Richmond,
Va.
Stern, Adolph, M. D.
Stevens, George T., M. D., Ph. D.,
F. A. C. S.
Stewart, Douglas H., M. D., F. A. C. S.
Stewart, George David, M. D.
Stivelman, B., M. D., Bedford Hills,
N. Y.
Svmmers, Douglas, M. D.
Taylor, J. Madison, A. B., M. D.,
LL. D., Philadelphia.
Tilney, Frederick, M. D.
*Tilton, Benjamin T., M. D.
*TousEY, Sinclair, M. D.
Trasoff, Abraham, M. D., Medical
Corps, United States Army.
Tribondeau, L., M. D., Corfu.
TuRCK, Fenton B., M. D.
Upham, Roy, M. D., F. A. C. S., Brook-
lyn.
Van Alstyne, Eleanor Van Xess,
Ph. D., M. D.
+V0GFI,, Karl, M. D.
Von Tiling, Johannes H. M. A., M. D.,
Poughkeepsie, N. Y.
VooRHEEs, Irving Wilson, M. S., M. D.
Wali -FIELD, J. M., M. D., Brookl^'n.
*Walsh, James J., A. M.. M. D., Ph. D.
Waltz, Claude D., M. D., Cleveland.
*Warburton, Gladys Bagot.
*Waterson, Davina, London.
XN'echsler, I. S., M. D.
Weidler, Walter Baer, M. D.
Weinstein. Julius W., M. D.
Welton, Carroll B., M. D., Peoria, 111.
Wenner, John J., Ph. D., Philadelphia.
Wilder, Amos P., New Haven, Conn.
Wile, Ira S., M. D.
Woldkrt, Albert, M. D., Tyler, Tex.
Wright, Jonathan, M. D.. Pleasant-
ville, N. Y.
Ybarra, a. M. Fernandez, A. B., M. D.,
Madrid, Spain.
Zufblin, Ernest, M. D., F. A. C. P..
Cincinnati, Ohio.
LIST OF ILLUSTRATIONS TO VOLUME CVIII
]'>anquet to special British mission. One Illus-
tration 116
Blackwood, Norman J., Medical Director,
U. S. Navy. Portrait 335
Bruce, Colonel Herbert Alexander. Portrait.. ' 113
Calculus, salivary. One Illustration 109
Campbell, William Francis, Major, Medical
Corps, U. S. Army. Portrait 690
Columbia war hospital. One Illustration 554
Debarkation hospital No. 3. Four Illustra-
tions J 035- 1040
Defecation, mechanics of. Two Illustrations. . 945
Diachylon plaster dressing in the treatment of
war wounds. Two Illustrations 818
Dislocation of hip, congenital, in three genera-
tions. Two Illustrations 550
Dyspituitarism. One Illustration 5
Fmbarkation hospital No. i, Hoboken, N. j.
One Illustration 553
Emergency hospital in France. Four Illustra-
tions 688-689
Food, spoon and strainer for artificial com-
minution of. One Illustration 8
Fracture depression of laminse of cervical
vertebrae. Two Illustrations 364
Fractures of long bones, plaster splints in treat-
ment of. Four Illustrations 1028-1029
Functional reeducation of the wounded. Eight
Illustrations 683-686
( "lOnorrheal infection of kidney and ureter. Six
Illustrations 1023-1027
Helmets, war. One Illustration 1041
Hospital ship Mercy. Five Illustrations 333-335
Hospitals, embarkation and debarkation. Eight
Illustrations 553-559
Hyperpyrexia in pneumonia. Two charts. . . . 3-4
Influenza at U. S. Marine Hospital. Twelve
charts 888-893
Influenza, Spanish. Four charts 843-846
Ireland, Major General Merritte W., Surgeon
General, U. S. Army. I'ortrait 597
Kennedy, Colonel J. M., Al. C, U. S. Army.
Portrait 551
Lane, Colonel Sir William Arbuthnot. Portrait. 115
Locomotion as an aid to diagnosis. Eight
Illustrations 495
Mackenzie, Sir James. Portrait 115
Monaghan, Major W. J., JNIedical Corps,
U. S. Army. Portrait 1035
( )rthopedic cases in Fordham Hospital. Seven
Illustrations 813-817
I'aget's disease of the bones. Four Illustra-
tions 678-679
Plan for special examination of recruits for
tuberculosis. Two Illustrations 200-201
Plan for base hospital near Hot Springs,
Arkansas. One Illustration 507
[Master of Paris bandage roller. One Illustra-
tion 7
Protein treatment of psoriasis. Four Illus-
trations 328-329
Rainbow Division. Two Illustrations 601
Iveeducation centre at Bombay for disabled
soldiers. Two Illustrations 33^^-337
Siiipyards, health and sanitation work in.
Three Illustrations 598-600
Site for base hospital near Hot Springs,
Arkansas. One Illustration 507
.Stenosis of the esophagus. Two Illustrations. 108- 109
Surgeons of allied armies visit Washington.
One Illustration 821
Syi)hilis of the stomach. Three Illustrations. . 545
.Syphilitic joints. Three illustrations 107
Trudeau statue at Saranac Lake. One Illus-
tration 33 1
Wounds of lower jaw. Three Illustrations. . .595-596
X ray localization of bullets. Four Illustra-
tions 2
X rays in abdominal disease. Nine Illustra-
tions 672-676
Yale's medical activities in Changsha, China.
Four Illustrations 1029-1030
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal ^li Medical News
A Weekly Re-view of Medicine, Established 1 843
Vol. CVIII, No 1.
NEW YORK, SATURDAY, JULY 6,' 1918.
Whole No. 2066.
Original Communications
DEVICE FOR X RAY LOCATION OF
BULLETS AND OTHER FOREIGN
BODIES IN WOUNDS.
Bv Sinclair Tousey, A. M., M. D.,
New York.
Our entry into the European war and my desire
to be of the greatest possible service to my country
caused me to undertake special studies in this sub-
ject, and I have placed my device freely at the
service of both government and the medical profes-
sion. Consider the published experience of Guille-
minot, a distinguished expert, who searched for a
foreign liody in a patient's hand or wrist under
direct fluoroscopic observation for forty-five minutes,
inflictino; burns upon the patient and himself which
required many months to heal. This and other cases
demonstrate the danger of removal under the fluoro-
scope as a routine measure. Localization by means
of radiography presents no difficulty in the case
of a finger. Here there are distinct bony landmarks
recognizable from the surface, and it is easy to take
two pictures in planes at a right angle to each
other. And if we employ a ray vertical to the plate
at its centre, no correction is required for the sHght
lateral di.splacement of the shadow if the foreign
body is not exactly at the spot where the ray is
normal.
In many other situations two pictures at a right
angle are either impracticable or are totally inad-
equate, owing to the thickness of the part, the ab-
sence of very accurate bony landmarks recognizable
from the surface, and often the great distance of
the foreign body from the surface. In these cases,
radiographic localization resembles a problem in
surveying, like the exact localization of a point upon
an island by observation from the mainland. The
exact depth at which the foreign body is located is
the difficult problem.
Previous to my recent device, fifty-seven methods
of radiographic localization had been published, in-
cluding one of my own. Many of these were called
forth by experience in the European war, and all
these methods have the patient in an appropriate
position in contact with the photographic plate,
while a metallic marker often fastened to the surface
of the body shows in the picture, and so does the
foreign body. Without changing the position of the
body relative to the plate, or to a second plate sub-
stituted for it, but with a measured displacement
of the X ray tube, a second oicture is made. The
two positions of the image of the foreign body
afford a means of determining the direction and dis-
tance of the foreign body from the spot where the
metallic marker is, fastened to the surface. The
■ methods previously in use fall into two groups : the
AlacKenzie Davidson and another to which no dis-
tinctive name is attached, though I have published
a description of it ( i ).
The MacKenzie Davidson localizer lays the fin-
ished picture vipon a table, and above it are fas-
tened two points in the positions occupied by the
anticathode of the x ray tube during the two ex-
posures. From these two points threads are
stretched to the two images of the foreign body,
and the place of intersection of these two threads
is the place at which it was located when the pic-
tures were made.
The other type of radiographic localization has
the X ray tube at a measured distance from the pho-
tographic plate and, for the second exposure, dis-
places the tube a measured distance laterally. The
displacem.ent of the image of the foreign body is
measured. And from these factors a mathematical
calculation enables one to determine the distance
from the plate to it at the time the pictures were
made.
My new device is a modification of the latter
type.
Apparatus required. — A piece of galvanized iron
netting measuring eight by ten inches, and having
meshes or openings one eighth inch square, and the
wire l>eing of such a thickness itself that there are
seven meshes to the linear inch. A single dis-
tinctive lead marker like the letter T. A set of lead
numbers. Facilities for moving the x ray tube lat-
erally a measured distance after the first exposure.
A stereoscopic or tunneled plate holder for the very
common cases in which two exposures are better
made upon separate plates.
^Manipulation : The distinctive lead marker is
fastened to the skin where it will be in contact with,
or near the middle of the wire netting while the
pictures are made. The position of this marker is
recorded upon the skin with an indelible pencil. The
plate holder is laid upon the table, and the wire
netting covers it, patient lying upon that. The lead
serial number is invariably placed over the lower
external corner of the plate. And the same num-
ber had better be marked upon the skin with an
indelible pencil. Lead markers R and L (right and
left) will be of occasional service. For the thigh
Copyright, igis, by A. R. Elliott Publishing Company.
TOUSEY: X RAY LOCATION OF BULLETS.
[New York
Medical Journal.
or any part of the head or trunk the anticathode
is at a distance of twenty one inches from the plate,
and is displaced laterally three inches after the first
exposure. For the forearm or leg the distance
from the anticathode is fourteen inches and the
displacement two inches. The number of subdi-
visions, one seventh inch each, that the image of
the foreign body is displaced represents a definite
distance from the foreign body to the netting when
the exposures were made. The
ABC table herewith should be re-
ferred to for exact locaHza-
tion.
Roentgen Localization of
Foreign Bodies.
Over the plate is galvanized
iron netting, one eighth inch
mesh. This, including the
thickness of the wires, runs-
seven meshes to the linear
inch.
In the case illustrated, the
base of the foreign body is
two meshes internal to the
wire passing through the
lower part of the letter T, and
in the other picture it is five
meshes external to the same
wire. The image has been
displaced seven meshes by a
tube displacement of three
inches at a distance of twenty-
one inches. Reference to the
table shows that the foreign
body was at a distance of 5.3
inches from the wire netting
at the time of the two ex-
posures. I advise reference
to the printed table rather
than extemporaneous calcula-
tion, but this particular case
will serve to show the manner
in which I have calculated the
table.
If this distance is consider-
able, we must bear in mind
the fact that the foreign body
is located in a direction from
one image to the correspond-
ing position of the anti-
cathode, not always in a ver-
tical direction from its image
on the plate. Each of the two
exposures should lie of the
same intensity and duration as
for a single picture, wdiether
the exposures are made upon
the same or separate plates.
Five and one half inch spark
gap gives the most suitable
picture. Development should
be continued until the wnre
netting shows clearly in the
lightest part of the plate. An
intensifying .screen had better
be u.sed for cases where a
Anticathode distance ?/ inches,
tube displacement J inches
Image displaced Actual distance
//7 mch meshes foreign body to
plate, inches
Fig. I. — A, first posi-
tion of anticathode; G,
first radiographic image
of foreign body, D; C,
second position of the
anticathode; E, second
radiographic image of for-
eign body.
I
0.9
I
2
1.8
2
3
2.6
3
4
3-2
4
5
3-7
S
6
4.6
6
7
5-3
7
8
5-7
8
9
6.3
9
1 0
6.8
10
I I
7-3
1 2
7-7
12
13
8.3
13
14
8.7
14
15
8.9
16
9-1
17
9-3
18
9.6
19
lO.O
20
10.3
21
10. s
Calculation of Distance i-rom
Known factors
BD-|-DF = 2i inches
AC = 3 inches
AB— inches
EG=i inch (7 meshes of 1/7
inch each)
YG—Y, inch (in this particular
case)
ABD is a triangle whose angles
are equal to those of the tri-
angle DFG.
Anticathode distance 14 inches,
tube displacement 2 inches
Image displaced Indicates foreign
1/7 inch meshes body distance
from plate, inches
0.9
1.8
2.5
3-'
3- 7
4- 2
4.7
51
5- 5
5.8
6.1
6.5
6.7
7.0
Foreign Body to Wire Netting.
Therefore :
AB : FG : : BD : DF
I : 'A : : BD : DF
Hence :
DF is as long as BD
DF is 'A of BD-fDF
DF is 14 of 21 = 5.25 inches.
As the table is not carried be-
yond the first decimal place this
is given as 5.3 inches.
Fig. 2. — Position of the image of the foreign body in the first
radiograph.
Fig. 3.— Changed iiosition of the image of the foreign body in the
second radiograph. The wire net and the lead marker, T, are fixed
landmarks.
July 6, 1918.]
GRIFFITH: HYPERPYREXIA.
3
twenty-one inch tube distance is desirable. The
cases where a single plate is unsuitable are the
numerous ones in which the shadow of the for-
eign body might chance to lie in the shadow of
a bone, and might, therefore, not be clearly visible.
When two plates are used some device like a
stereoscopic or tunneled plate holder is required if
the patient lies upon the plate. I use simply a
board one half inch thick, with a space underneath
for the plate in its cassette, usually with an inten-
sifying screen. The plate must be removed without
moving the patient, or the lead marker, or the wire
netting. The second plate need not be in identi-
cally the same position as the first, since the wire
netting is the final guide, not the plate. The com-
parison of the two plates is by noting the diiler-
ence in longitude of the two images as compared
with that of the lead marker ; not at all by super-
position of the two plates so as to form a trans-
parency of double thickness.
When two plates are used with the x ray tube
below and the plate laid on the patient, the process
is greatly simplified. One has merely to be sure
that the patient does not move, that the lead marker
remains in place, and that the wire net is flat against
the plate, not curved to fit the body surface, and
has its lines parallel with those in the first picture.
REFERENCE.
I. SINCLAIR TOUSEV: Medical Electricity and the X Ray, 1910.
850 Seventh Avenue.
UNUSUAL HYPERPYREXIA IN PNEU-
MONIA : RECOVERY.*
By J. P. Crozer Griffith, M. D.,
Philadelphia.
Professor of Pediatrics in the University of Pennsylvania.
In reporting these two cases which occurred in
children of two and a half and five and a quarter
years, I would first point out that terminal hyper-
pyrexia is unfortunately not at all an infrequent
ending of various affections. It may take place in
any of the infectious diseases, and is, of course, a
well known incident in thermic fever. I have
known it to reach iio° F. in children during ex-
cessively hot weather, the symptoms being digestive,
but only slightly marked, and the fatal termination
being attributable to the direct influence of the heat
It is true that sometimes children bear hyperpyrexia,
if not excessive, surprisingly well. I recall one Mi-
stance of typhoid fever, with a several days temper-
ature continuously not lower than 105° and 106°,
and on several occasions 107° F., yet with no un-
favorable symptoms whatever, the little girl of ten
years lying comfortable and smiling in her bed.
Temperature above this degree, with subsequent re-
covery is, however, in my experience very uncom-
mon, and my two cases with their temperature
charts may not be without interest.
The first one, seen in consultation with Doctor
Myer SoHs-Cohen, was observed in a girl baby of
two and a half years. The course in most respects
was that of a typical bronchopneumonia, with in-
creasing and finally rather extensive consolidation
•Read by title before the American Pediatric Society, May, 1918.
involving parts of both lungs in scattered areas. The
total duration was about two weeks. Throughout
the attack there was considerable cyanosis, at times
restlessness, and occasionally profuse sweating. Al-
though the patient was evidently severely ill, the
heart sounds throughout remained fairly good, the
l^aticnt never appeared to be in any immediate dan-
ger, and a guardedly favorable prognosis was given
at all times. The most Interesting feature was the
continued tendency to high fever, with a daily max-
imum of 104" to 107°, and on one occasion io8° F.,
with rapid drops to loo^ or ioi°, as shown in the
first chart.
The second case, seen in consultation with Doctor
E. ]. Lupin, was even more interesting. It well
illustrates the danger of giving a favorable progno-
DAY OF MONTH
DAY OF DISEASE
-T
7
/ 1
'3
/s-
lb
TIME
OF
DAY
P.M
II
rfHP
-180
-f
J6-
- —
-84.-
-H)8-
-&z-
-170
-80-
-4-
-78-
-160
Ib-
p74-
-toe-
-150-
-72-
-70-
1
68-
-140
-
F
b(r
-64-
-KM-
•130
•6^
-60-
V
58-
-120
56-
1
54-
-K>2-
-52^
-no
1
-
50-
— <
48-
-HH-
-100
16^
1
14-
I
■I
-too
-90-
42-
40-
-99-
-38-
-80-
36-
URMU
UNE
-34-
-96-
r
-32-
-70-
30-
Chart I. — Hyperpyrexia in child of two and a half years.
sis for any individual case, basing this upon the gen-
eral experience with the disease ; and, on the other
hand, of prognosticating unfavorably even in the
presence of most alarming symptoms The case was
at first an ordinary typical one of croupous pneu-
monia in a boy of 5^4 years. Realizing that the dis-
ease at this age nearly always terminates in recov-
ery, the parents were told that it was progressing
in an entirely normal manner, and that there was
no cause for anxiety. The temperature had been
not unduly elevated, the mind entirely clear, the car-
diac strength excellent. This favorable condition
continued until the seventh day of the attack, when
an unusual degree of drowsiness developed, and the
temperature became higher. On the tenth day, in-
stead of the convalescence which we had fully ex-
pected even earlier, the temperature began to rise,
the pulse grew very weak, and the child appeared to
4
LEVIN AND COHEN: RADIUM AND CATARACT.
[New York
MiDicAL Journal.
be rapidly sinking. Doctor Lupin and myself were
summoned hurriedly about 8 p. m., and found two
other physicians, called in the emergency, already
present. The fever had risen to 109° F., as record-
ed by two different tlicrmometers. A warm mus-
tard bath had been given, and the temperature had
fallen to 106°, yet with the pulse still rapid and no
improvement in the general condition of the child,
who was unconscious and evidently extremely ill.
We looked at each other with solemnly shaking
heads, and the whispered words "terminal hyperpy-
rexia, hopeless," and the like. In twelve hours,
however, the teni])erature had dropped nearly 12°
F., as shown by the chart, and the general condi-
tion, although still very bad, was better. There
DAY OF MONTH
3.1'
Z 2
Z3
1.*
f Xl
30
OAV OF DISEASE
S'
T
?
10 1
( ( 2-
TIME
OF
DAY
A M
P.M
m
tsn.
rnip.
H»
-f —
i-
-180
-i
S6-
i-
J-
I-.
-84-
-H)8-
h -
-8^-
-170
-80-
-tor
-78-
-160
76-
-74-
-K>6-
-72-1
-150
-70-
&8-
-H)5-
-
-140
-64-
-KM-
M
I
•130
-62-
-60-
-58-
-W3-
—
-120
— -i
f
-56-
54-
-110-
-52-
-50-
48-
-KH-
-100
-£
t6-
w-
■i
42-
-90-
40-
-99-
-38-
-60-
36-
WRMU
UNE
-34-
-96-
~W-
32-
30-
Chart II. — Hyperpyrexia in child of five and a quarter years.
followed a sHght extension of the pneumonic pro-
cess, with return of fever of moderate degree ; great
restlessness, delirium, and sleeplessness which
yielded to neither bromides nor morphine. By the
thirteenth day of the disease the child was weak and
listless, but with mind entirely clear, and convales-
cence appeared established. There was no further
return of fever.
Cases of this nature are certainly most unusual,
and fortunately so. I recall an instance reported
by Couch (British Medical Journal, 1896, II, 1212)
of recovery in a case of croupous pneumonia in a
child of three years, after a temperature of 109° F.
had been attained ; but no other has come to my no-
tice, although doubtless a search through medical
literature would revfeal other instances.
1810 Spiutcf. Street.
THE ACTION OF RADIUM ON CATARACT.
A Preliminary Communication.
By Isaac Levin, M. D., and Martin Cohen, M. D.,
New York.
Until recently there was no agent known which
could in the slightest degree change or influence the
natural course of the development of a cataract
from its period of incipiency to maturity. Surgery
had reached a high degree of perfection and was
followed in the majority of cases by a clinical suc-
cess which meant restoration of vision. Surgery,
however, does not influence or change the develop-
ment of the lenticular opacification, but simply re-
moves the entire lens. A great many attempts were
made to influence the development of cataract by
chemical means, yet without success.
But in the last decade a great deal of progress
has been reported in radium therapy of various
pathological conditions, and the field of usefulness
of the biologic action of actinic rays in the domain
of therapeutics is constantly widening. Further-
more, a great many cases of eye disease, such as
trachoma, vernal catarrh and various tumors of
the eyeball and the adnexa have been treated with
radium without in any way injuring the normal
structure of the eyeball or having impaired the
vision.
One of us, Martin Cohen — who has contrib-
uted to the chemical study of the subject, sug-
gested that all the above mentioned facts made ex-
perimentation as to the possible value of radium
as a therapeutic agent in the treatment of cataracts
both justifiable and desirable, and offered his clini-
cal material for investigation. Three cases were
selected which present various types of the disease
and were subjected to radium treatment. The fol-
lowing is a brief report of their clinical conditions
and results obtained :
Case I. — Mr. O. M., aged thirty-three. Retinitis pig-
mentosa complicated with posterial bilateral cortical cata-
ract of thirteen years' standinR. Vision of right eye
equaled twenty-two one hundredths. Vision of left eye
counts fingers at three feet. The appearance of the lens
of the left eye was as follows : with transmitted light with
electric ophthalmoscope one perceives a faint fundus re-
flex associated with distinct blackish fine fibrils having a
sector light arrangement. In between the sectors one
perceives fine blackish lines interspersed with a few small
dot-like highly reflecting spots. The left eye of this pa-
tient was subjected to radium treatment. One week after
the beginning of treatment the eye was reexamined and the
condition found as follows : the vision was counting fingers
at seven feet. The fundus reflex was clearer than at
the previous examination. The sector striations were less
apparent and the appearance of the small dot-like globules
became more apparent. No change was noted on the optic
nerve or in the proliferated retinal pigment. Nine days
later the examination showed the following condition :
vision = twenty-two one hundredths (read first letter on
Snellen's test chart). Fundus examination showed a
larger area free from lenticular opacification. The strise
were less in number, the small globules were more evident.
Twenty-six days after beginning of treatment the vision
= twenty-one one hundredths minus one (read second
line of Snellen's te.st chart, excluding one letter). Oph-
thalmoscopic examination revealed again more of the ,
fundus reflex, striations were finer, slightly tortuous, hav-
ing a distinct sector outline showing lesser globules than
at the previous examination.
Case 11. — Miss D., forty-five years old. Acute iri-
docyclitis complicated with secondary cataract of five
July 6, 1918.]
CUMENKO : DVSPITUITARISM.
5
years' standing. Iridectomy was performed on account of
secondary glaucoma. Examination before treatment re-
vealed vision = counting fingers at six inches. Numerous
deposits were present on Descemet's membrane and the
lens showed distinct conglomerate opacification in the cen-
tre of the pupillary space. The fundus reflex was visible
only in the periphery. Four days after beginning of treat-
ment the vision = counting fingers at eight inches. The
fundus reflex could be recognized over a larger area.
Three radial striations were now evident and two small
globules were visible in the centre of the pupillary space.
Seven days after beginning of the treatment vision =
counts fingers at three feet. Deposits on Decemet's
membrane were fewer in number and their size was re-
duced. Fundus reflex is now more evident than at pre-
vious examinations. Striations and globules were about
the same.
Case III. — Mr. J. V., forty-one years old. Subcapsular
or senile cataract of the right eye. Left eye normal. Ex-
amination before treatment gave the following results :
vision -— motion fingers at three feet. Oblique illumination
showed a diffuse grayish mass in pupillary area. No fun-
dus reflex could be obtained. Five days after beginning
of treatment vision-motion fingers at ten feet. Direct
examination revealed a grayish white conglomerate mass
in the pupillary space, while in the periphery a large reddish
fundus reflex is clearly visible. Seven days after beginning
of treatment vision = motion fingers at eighteen feet, counts
fingers at four feet. Oblique illumination showed a gray-
ish area covering the pupillary space with a few white
linear striations scattered in the centre, also smaller gray-
ish white dots nearer the periphery. Direct ophthalmo-
scope examination showed a much larger diffuse reddish
fundus reflex with distinct sector-like striations radiating
from the periphery of the lens.
The improvement of vision noted in these cases
was accompanied by an increased visibility of the
fundus reflex which could only be due to a decrease
in the lenticular opacity. A similar phenomenon
was never reported to have occurred spontaneously
or to have been caused by any other agent.
The writers have undertaken a broad study of
the subject on animals and on clinical material and
expect to present an extensive report at a future
date. It is premature to say whether the action of
radium on cataract will have a permanent or any
therapeutic value, -but the efTect it produced on the
cases reported is of sufficient interest to warrant the
present communication.
As for the technic of radium therapy employed
in these cases a detailed report will appear in the
next paper, but the basic principle may be given
briefly. The writers found no mention in the litera-
ture of radium treatment of cataracts, but Flemming
reported in 191 1 a case of a malignant tumor of the
orbit which was treated with comparatively small
doses of radium. It was diminished to such an
extent that the cornea became visible and then a
senile cataract was found which was not influenced
by the radium nor was the perception of light im -
paired. On the basis of this case it was decided
that for the treatment of cataract as large quantities
of radium should be employed as in the modern
treatment of cancer with strong filtration so as not
to injure the normal structures of the eye.
A New Bacillus. — Dr. H. Tissier has isolated a
new bacillus from the must of beer and has found
the same in war wounds and the intestinal flora. It
is a mobile, spore giving bacillus, ovoid in shape,
swelling slightly in the centre.
A CASE OF DVSPITUITARISM.*
By H. Climenko, M. D.,
New York,
Attending Neurologist, Central Neurological Hospita!; Adjunct
Attending Neurologist, Montefiore Hospital; Chief of
Neurological Clinic, Mt. Sinai Hospital.
This case is presented because ,of its multiplicity
of symptoms; the noncorrelation of these to any
single anatomical focus ; and to emphasise again
tliat, when the metabolism of the endocrine confed-
eracy is disturbed, no single gland can be held re-
sponsible as sole cause of the clinical picture ; that
at least some psychotic symptoms may be the result
of the metabolic disturbance; and, in some of the
well advanced cases of endocrine disturbance,
opotherapy is of no avail.
Cask. — The patient, R. W., aged twenty-two, a clerk, was
born in Russia of Jewish parents. Family history was not
obtainable. She came to the United States when seven and
attended school until fourteen, showing average intelli-
gence. She gave a history of having suffered from diph-
theria, scarlet fever, whooping cough, and typhus. Menses
began at the age of eleven, and during the first year she
menstruated three times, after which, until eighteen, she
menstruated regularly every thirty days with a duration
of three days and a heavy flow. With the onset of men-
struation the patient
began to gain weight
rapidly and at four-
teen she weighed 225
pounds. At this age
she had a tapeworm ;
her appetite was in-
creased, and she had
other associated
symptoms. She was
working as an errand
girl in an office. Be-
tween the ages of
fourteen and nineteen
she lost fifty pounds.
.A.t the age of nine-
teen she claims she
lost the tapeworm; At
this time she began
to suffer from head-
ache located in the
right temporal region.
It became general, at
times interfered with Fio.-^Patient showing marked dys-
.l„„„ T. .-ii pituitarism.
Sleep. It still per-
sists with some severity and in the same location. At
the onset of the headaches the menses ceased for seven
months and then returned in periods, regular, but scanty
in quantity in contrast to the previous record. At pres-
ent menstruation continues with some regularity. With
the second establishment of the menses she began to lose
weight, and today weighs, stripped, 145 pounds. At the
age of twenty-one she was taken to Mt. Sinai Hospital,
where she developed marked psychotic restlessness with
suicidal impulses. She complained of general weakness
and vague pains all over the body and pain in precordium.
Her head is dolichocephalic in type. McEwen sign is nega-
tive, but even slight percussion causes pain all over her
scalp. There is bilateral nystagmus and nasal edges of
both optic nerves are hazy. There is a yellowish deposit
in both maculae. Field vision is not contracted in either
eye. All the other cranial nerves are intact. The nose is
depressed and the tongue bulky. Papillae prominent.
Pulse is 108 and regular. Systolic blood pressure is 100,
diastolic 60. Both malar bones zygomae are protruded.
There is pharyngeal innervation and intact reflex ; chin
reflex is present. There is hirsuties on the lateral side of
the face. Panniculus adiposus is increased, but there are
*Read before a joint meeting of the New York Neurological
Society and the Neurological Section of the Academy of Medicine,
January 8. 1918.
6
BENNETT: A PLASTER BANDAGE ROLLER.
[New York
Medical Journal.
no local accumulations of fat. The buttocks are of the
male type. The growth of hair in the axillae is increased;
the pubic hair is of the female type, with a tendency to re-
semble the male, and there is a profuse growth of hair on
the legs. Strije are seen over the abdomen, probably due
to loss of former adipose tissue. The palms are broad,
fingers short with a tendency to taper. All the teeth in
upper jaw are missing. The mammse are large and pendu-
lous, reaching to about an inch from the umbilical line.
Height is lifty-five inches and the circumference of the
head through the occipital protuberance twenty and one
half inches. Other measurements are as follows: From
acromion to tip of olecranon, twelve inches; from there
to styloid process of ulna, nine ; from sternal notch to
symphysis, thirteen ; from anterior superior spine to in-
ternal malleolus, twenty-nine on both sides ; from heel to
great toe, eight ; from one anterior superior spine to the
other across abdomen, twelve and a half ; bitrochanteric
across buttocks, eighteen. Perspiration of feet profuse
and offensive. Pupils react to light and accommodation
and consensually. A marked tendency to hippus is noticed.
The abdominal reflexes are lively, knee and ankle jerks
normal. No Babinski. The general sensibility is in-
creased so that light pressure gives pain, reminding one
of Dercum's disease. The general sensibility is intact.
The deep muscular sense, joint sense, postural and snace
senses are intact. Hypotonus is noticed at knees and el-
bows. There is no past pointing of any extremity. Barany
test is negative. All laboratory tests for blood, serum,
cerebrospinal fluid, and urine are negative with the ex-
ception of a marked polyuria, the patient passing at a time
three to four thousand cubic centimetres in twenty-four
hours. The specific gravity of this urine averages 1015.
There is also a marked sugar tolerance, so that 300 grams
of glucose on a fasting stomach give no evidence of sugar
in the urine. The x ray report showed an increased intra-
cranial pressure without any changes at the sella turcica.
Organotherapy in all forms and combinations and doses
was tried in the treatment of this patient, but without any
notable effect.
Analyzing this case, we see that we are dealing
primarily with a marked pituitary disturbance which
would best be called dyspituitarism, for the patient
shows signs of both hyperactivity and hypoactivity
of this gland. It is especially worth while noticing
the fact that with the establishment of the menses,
contrary to the usual rule, the patient began to gain
rapidly and tremendously in weight so that in a
short while she weighed, as seen above 225 pounds.
This may be explained by a lack of activity of the
. thyroid gland. It is, however, well known that the
thyroid increases in its activity at the begiiming of
menstruation. It may also be argued that the rapid
increase of adipose may be due to an inactivity of
the pituitary, but here, too, the menses would or-
dinarily be scanty instead of profuse as they were
so that this case does not fit in well with all known
theories of endocrinology in the correlation of
glandular activity.
It is also worth noticing that with all that increase
in weight the patient was rather bright mentally ;
she was able to keep up in her class at school and,
later, held a rather responsible position. At nine-
teen another change took place ; menstruation ceased
completely and she developed symptoms that un-
doubtedly pointed to pituitary involvement ; again,
with the reestablishment of menstruation, which was
this time scanty, she lost weight rapidly and mas-
sively, an indication probably of thyroidal hyper-
activity ; but this time her psyche also changed and
instead of being a useful member of society she
became morose, hypochondriacal and even suicidal,
and is still this way after four years, with perhaps
slight improvement as far as her suicidal impulses
are concerned.
Of course, one may argue that the nystagmus, the
headaches and the increased intracranial pressure,
together with such changes in the eyegrounds, might
be due to a frontal neoplasm, but this theory must
be dispensed with, since for the last four years the
optic nerves not only have not increased in their
pathological changes, but on the contrary seem to
have cleared up and her headaches today are not as
severe as they were three years ago. Her psyche,
too, is somewhat improved. Besides the pituitary,
thyroid and ovarian glands, the adrenals seem to be
involved ; her rapid pulse, as well as the marked
disproportion between the systolic and diastolic
blood pressure, can be explained only by unbalanced
adrenal efficiency.
252 East Broadv/ay.
A PLASTER OF PARIS BANDAGE ROLLER.
By "V^'illiam H. Bennett, M. D.,
Atlantic City, N. J.,
President, Children's Seashore House, Atlantic City, N. J.
Every one who has practised the making of plaster
of Paris bandages by rubbing the plaster in by hand,
and rolling a few inches and then rubbing more and
rolling again, will appreciate the value of a simple
machine that will fill and roll them almost as rapidly
as a pain bandage can be rolled. At the Children's
Seashore House, Atlantic City, about a thousand
plaster of Paris bandages are made and used an-
nually. During the past six months all used have
been satisfactorily made with one of the machines
described.
The machine may be of any convenient size, made
to roll one or more bandages at a time, or a long
roll to be afterward cut into smaller bandages. It
can be used either by hand or by power. The
following is a desirable model to roll one or two
bandages at a time by hand and is typical for all
others. It consists of a tray of wood eighteen
inches long, twelve inches wide, and two inches
deep. At a distance of ten and one-half inches
from the front end is fastened on each side a per-
pendicular block three and one-half inches wide by
five inches high. In the centre of each block is a
vertical slot two and one-half inches deep, and in
these lie an axle with a crank at one end. The
axle is square except where it rests in the slots
where it is rounded. At the farther end of the tray
there is on each side an upright eight inches high
and one inch wide, and extending across from these
two uprights there is a bar. The upright and the
block with the slot can be made stronger if on each
side of the tray the two are made out of one piece.
A short distance in front of the table there is a block
extending from side to side of the tray. This block
is one inch wide on the top, one inch deep in the
front, and one and one-half inches deep at the back.
The bottom is therefore bevelled at an angle of
about 35°. This block is made partially revolvable
by means of eccentric trunions extending into the
sides of the tray. The trunions of this block are
so placed that the bottom of it is always raised
July 6. ,9,, S.I LOWHNBURC: AUMENrARV DISTURBANCES IN INFANCY AND CHILDHOOD.
7
aboA'e the floor of the tray at least one-eighth of
an inch, and by revolving forward, the distance can
be increased for convenience in inserting bandages.
The back of it is so blocked by a strip of wood that
it cannot be revolved backward, but can be forward.
Extending from the front edge of the tray and se-
cured there by being wrapped around a tightly fit-
ting strip of wood is a piece of muslin the width
of the tray, which extends from the front under-
neath the bevelled block and imderneath the band-
age, up over the crosspiece on the uprights at the
back, and falls to the level of the bottom of the tray.
The distal end of this muslin holds in a hem a piece
of pipe or other weight so that it is always keot
taut, and always hugs the bandage, increasing m
size as it is rolled. The front edge of the tray is
pierced with holes into which can be placed pegs
or screw eyes which act as guides for the crinoline
as it is fed to the axle. To operate the machine
the crinoline should be torn in strips the proper
width and length and rolled. These rolls can be
placed for convenience in a box with compartments
and held on the lap of the operator. The free ends
A plaster of Paris bandage roller.
are fed between the screw eye guides, underneath
the bevelled block, and around the axle. The tray
is heaped with plaster of Paris on top of the crino-
line. As the crank is turned and the axle engages
the end of the crinoline, some of the pile of plaster
in the tray is drawn on the top of the crinoline under
the bevelled edge of the strip, and by it pressed into
the meshes of the crinoline, while portions of it
carried up by the forming bandage fall over the top
into the muslin which at all times closely hugs the
forming roll of bandage. This excess plaster fur-
ther fills the meshes of the crinoline from the under
side, while the muslin, always in contact with the
under side of the bandage, prevents any leakage
from the crinoline of the plaster which has been
pressed into it by the bevelled strip.
With a one or two bandage roller one nurse can
make a small bucketful of bandages evenly rolled
in an hour, each holding as much plaster as if
made by an expert in the old fashioned, laborious
way. A crippled girl of sixteen who formerly
made many bandages for the institution at the rate
of one in fifteen minutes, now makes them on a
one bandage machine in less than two minutes. By
means of the slot the axle with the bandages on it
can be lifted out, and tlie Ijandages easily removed
in the usual way. A readily removable pin passed
through the axle support above the axle prevents the
axle from rising out of place while it is turning.
The machine should be run evenly and without any
jarring which might shake the jilaster out of the
crinoline while the bandage is forming. The plas-
ter should be well heaped up in the tray in front
of the bevelled strip, and there should always be
a surplus betv/eeji the top of the forming bandage
and the muslin. To avoid tearing of the crinoline
the plaster should be freed from lumps and splin-
ters by sifting.
The machine is dedicated to the Red Cross So-
ciety, and the inventor freely offers all rights in it
to that society.
MECHANICAL COMMINUTION OF FOOD
IN THERAPEUSIS OF ACUTE ALI-
MENTARY DISTURBANCES OF
INFANCY AND CHILDHOOD.
Preliminary Report.
By H.\rry Lowenburg, A. M., M. D.,
Philadelphia,
Pediatrist to the Mount Sinai Hospital and to the Jewish Hospital,
Philadeliihia, etc., etc.
It is scarcely ever possible to hazard an opinion
with any certainty that a particular result was di-
rectly dependent upon a definite therapeutic maneu-
ver. The difficulty increases when recorded observa-
tions are purely clinical and lack laboratory
confirmation. The trend of modern medical thought
]s toward chemical and biochemical investigation
arid the value of clinical data is naturally discounted
unless the latter can bear the searching scrutiny of
the cold eye of the laboratory. And this is as it
should be. It does not follow however that cHnical
conclusions should be discredited or discarded while
they await laboratory proof. It is also true that,
when with almost unfailing regularity, certain def-
inite results follow certain definite procedures, one
may be forced to conclude that dependence of the
former upon the latter is real and not chimerical.
Such has been my experience with the treatment of
r.cute alimentary disturbances in infants and in older
children with reference to which I have evolved a
method of procedure which has at least apparently
been responsible for consistently splendid results.
Diarrhea, or an acute alimentary disturbance, may
be defined as a condition wherein there is present,
as the result of stimulation of the muscular fibres of
the gut, either direct or indirect and of the mucifer-
ous glands of the lining membrane, an increase in
the peristalsis and of the fluid contents of the intes-
tinal tube. The local effects consist mainly in an
increase in the number of bowel movements and of
a change in their character. These various local
elYects, depending of course as to their intensity
upon the nature of the irritant and the duration of
its action, occur directly as the result of the irrita-
tion, whatever its nature. They are identical to the
efYects which ensue when the Schneiderian mem-
brane is irritated by snuflf or by irritating vapor.
Congestion is followed by an increase in the nasal
8 LOWENBURG: ALIMENTARY DISTURBANCES IN INFANCY AND CHILDHOOD. „ [New York
Medical Journal.
secretions. The "nose runs." So too one may say,
"the bowel runs." The secondary, systemic or re-
mote effects depend upon the degree to which the
"bowel runs," in other words, upon the number and
nature of the discharges and the duration of the
condition. The greater the number of discharges
the more rapid and severe are the systemic features
which maj- be described as slow or rapid systemic
dehydration and demincralization entailing more
or less rapid loss in weight, more or less diminished
kidney and skin function, more or less debility, ir-
ritability and, in severe cases, tetany, convulsions,
depression, coma, shock, etc. Systemic toxemia,
glycosuria, albuminuria, rajjid. feeble pulse and high
temperature vary as to their presence and intensity
at the nature of the changed intestinal contents and
as the degree and rapidity of its absorption into the
circulation.
The irritant wliich causes the diarrhea may in-
clude various agencies, some of which act locally
and others both locally and systemically. Most
commonly these are found to be the various food
elements themselves or foreign agents attached
therc'tn. notably l)actcria, wliich act most often, not
A, fine double meshed strainer tlircnigh which food is jiushed sev-
eral times to insure its fine comminution by spoon.
directly upon the intestinal mucosa itself, but upon
the food substances. These are thereby so changed
in character that they assume the role of foreign
irritating substances. Thus, a particular infant may
be perfectly capable of digesting and assimilating a
certain combination of fat, protein, sugar, and salts
until the physical nature of any one or all of these
various ingredients becomes changed through some
external agency or the tolerance af the individual
becomes depressed through some extracorporeal in-
fluence, summer heat, for instance. It appears use-
less, therefore, in the main to discuss etiologic rela-
tionship of fat, protein, or sugar to acute alimentary
disturbances in so far as any one of them may be
regarded as the primal cause. Depending upon the
action of the individual lo them, any one of them or
all of them may be, as a consequence of a change,
in their physical makeup, or as just stated, in the
individual's tolerance.
If therefore we agree that diarrhea results from
the disturl)ed function of the intestine, it follows that
treatment should have for its object the speedy
lestoration of that function to normal, yet that treat-
ment which recognizes the individual merely as a
gastrointestinal tube and is directed only toward the
treatment of the local condition must fail. If the
])hysical character of the food can be so changed
I hat it will be acceptable to the intestinal glands
with very little eft'ort, and, on account of this
change, to the absorptive apparatus, and if, mean-
while, the cause of the diarrhea be removed, not
only will the latter disappear but the nutritional
balance will be conserved.
A common error, which leads to disastrous re-
sults or at least to frequent relapses is that a return
to milk or to milk preparations is made too soon.
All authorities seem to agree that the cause for the
acute alimentary disturbance resides somewhere in
cow's milk. In spite of this, based perhaps upon the
trite expression, with reference to the perfection of
milk as a food, no time is lost to attempt as early a
return as possible to some form of milk. It is at this
juncture that the fatal error is often made, largely
on account of our inability to successfully change
the physical character of this food and also on ac-
count of the inexperience of the individual physi-
cian. With reference to the former it may be stated
that the protein of the milk is its only ingredient
whose physical nature is readily susceptible to
change. Therapeutic use of this fact has been made
m the employment of buttermilk and of Finkel-
stein's Eiweismilch. Reference will again be made
to this fact. The fats and sugars, while reducible
:n quantity cannot be successfully, at least from the
standpoint of clinical therapeutics, changed or en-
tirely eliminated. Another fact of practical impor-
tance is that chemically the various individual food
elements are identical wherever they are found.
Physically, however, they are decidedly different.
The curd of cow's milk is identical chemically, as
far as we know, with that of mother's milk and that
of the milk of goats and of asses. The same is true
of the fats. Physical! v they are different. It is the
writer's opinion that a failure to grasp this funda-
mental fact has led to such wide divergence of opin-
ion between the American and the German School
of Pediatrics with reference to the etiologic influence
of cow curd upon the alimentary disturbances of
infancy and consequently to much confusion in
reference to therapeutics. One may feed incalcul-
able quantities of cow's curd as found in buttermilk
or in eiweismilch without causing irritation, in fact
allaying it and yet one may inaugurate considerable
disturbance by feeding a comparatively insignificant
quantity of mechanically or chemically unchanged
card. Therefore when one speaks of the etiologic
influence of curd upon the diarrheas of infancy it
becomes necessary to designate the physical state in
which it is fed.
Likewise cellulose, a hydrocarbon, as it exists in
wood is not identical physically with the same sub-
stance found in the delicate fibre of the orange or
in apples, peaches, plums, potatoes, etc., and its
caloric yield and food value are just as great. It is
its physical nature whicli makes it unacceptable, as
wood, to the digestive apparatus of man. One
could readily conceive however of this substance
being so changed physically, by mechanical and
July 6. .gis.j LOWENBURG: ALIMENTARY DISTURBANCES IN INFANCY AND CHILDHOOD.
9
chemical processes as to make it easily digestible
and highly nutritious. So examples could be multi-
plied innumerably. These however sufficiently
illustrate the fact that the digestibility and absorbil-
iiy of any substance depends finally upon its physical
makeup. Chapin, although his references are largely
directed toward the influence of the curds of the
miiks of various species upon the future develop-
ment of their respective digestive apparatuses, has
for years contended that the physical nature of the
food is of great importance. Thus he sees a reason
v/liy the milk of one species clots in thick tough
masses, another in gelatinous form and still another
in fine feathery flocculi. If this be true in a devel-
oped mental sense, there is no reason why its in-
fluence should not logically determine digestive,
absorptive and consequently nutritional problems.
This can be proven clinically. It further follows
lhat if the system requires fat, protein, sugar, and
salts it matters not from whence their source. This
has not been sufficiently appreciated in reference to
the feeding of infants in health and particularly in
reference to the treatment of the acute and subacute
alimentary disturbances.
I would not lightly dismiss the importance of
iood chemistry. Without chemical interchange it is
recognized that life itself could not continue. It is
intended, however, to emphasize the fact that with
reference to digestion the real purpose of chemical
interchange is to so alter the physical nature of food
that it ultimately will become suitable for absorption
and assimilation. We have a simple but forceful
example of this in the first processes of the digestion
of protein. Coagulated protein (by heat or by fer-
ment) is insoluble, nonabsorbable, nonassimilable,
etc. The chemical changes which ensue as the re-
sult of the chemical activity of pepsin and of trypsin
transform it into soluble, absorbable peptone. By
further chemical processes it is found in the blood
c-s a part of the soluble proteins of the complex sub-
stance. Such examples may be innumerably multi-
plied and in reference to the fats and carbohydrates
cis well, all illustrating that the ultimate purpose of
food chemistry is to alter the physical state of the
aliment.
It also appears that much may be gained in the
conservation of infant energy and nutrition, in fact
in infant life itself, if extra corporeal changes may
be accomplished in the physical nature of the vari-
ous food elements which will render these more
acceptable to the organism, less irritating and at the
same time not diminish their nutritional value, in
fact, increase it. This finds practical demonstration
in the mechanical comminution of food. The idea
is not new. Its miethod of accomplishment for prac-
tical purposes will he found to be more than simple.
It permits us to feed to sucklings even substances
which in their unchanged state are correctly re-
garded as noxious. This in itself provides us with
a sense of security in handling the acute alimentary
disturbances of these patients in whom, up to now,
we have believed that a maintenance of nutritional
balance is absolutely dependent upon some form of
milk feeding. If it can be proven that this is not so,
we are at once made independent of milk and its
derivatives. This is another of the important logical
deductions to which reference was made and it pro-
vides almost limitless possibilities in managing the
various gastrointestinal and nutritional abnormali-
ties of the young.
Treatment. — 1 divide the treatment of diarrhea
into that for older children, v. e., those who have
teeth, or are a year or more old, and, second, that
for sucklings, (a) artificially fed babies, (b) breast
fed.
The quickest and best results by the method to
be described are obtained in the first class, although
the fact that the infant is an artifically fed suck-
ling by no means precludes its use. My experi-
ence, however, with this type of patient, though en-
couraging, has not been as extensive, since there
are other means at hand which are of service as
well, and to which reference will be made.
Children with teeth; a year or more old. — A hun-
ger period, or starvation of twenty-four to thirty-
six hours, is indicated. This removes the cause of
the diarrhea, viz., the milk. Depending upon the
infant being very toxic, castor oil is or is not ad-
ministered. It is usually not needed, as, during
the hunger period, the bowel will empty itself on
account of its irritating contents. If high fever,
drowsiness, and other evidence of toxicity indicate
the employment of castor oil, a large dose is neces-
sary. Never less than one half of one ounce should
be given if the temperature persists, and a second
dose may become necessary. If the child struggles
much, or vomits, the oil may be injected by means
of a large ear syringe through a small catheter
passed into the stomach through the nose. During
the hunger period the child receives nothing by
mouth save saccharated tea (one grain of saccha-
rine to the quart of tea). This is freely admin-
istered at room temperature, irrespective of the
presence or absence of vomiting. It is usually ac-
ceptable, well retained, and thus supplies fluid, and
is very slightly astringent. At the end of twenty-
four hours, usually the characteristic "tea stool" —
a small, dark brown, greenish mucous deposit — is
obtained. From this point the character of the
stools is practically ignored. This is an important
clinical fact, for my experience teaches me that the
physician frequently becomes vacillating and un-
certain when the desire to see normal stools becomes
uppermost in his mind. His zeal impairs his good
judgment, and is responsible for too frequent, and
usually erroneous, changes in the food. Should
vomiting be troublesome, a single lavage with warm
bicarbonate soda solution (dram one to the pint)
may suffice, or one twentieth of a grain of calomel
well triturated with a few grains of milk sugar
should be placed dry on the tongue every fifteen
minutes for about ten doses. During this time
absolutely nothing, not even water, is given by
mouth. The last dose is followed by a half ounce
of castor oil, as above stated. Those cases which
vomit considerably are the very toxic ones. After
the oil has acted, tea feeding is inaugurated. Coun-
ter irritation with mustard over the epigastrium is
often very serviceable. I believe tea to be of greater
service and less irritating than dilute cereal or albu-
men water, during this period of treatment. Other-
wise medicinal treatment is not prosecuted except
in those cases wherein the intestinal discharges are
highly acid. The following is antacid and astrin-
lo LOW EN BURG: ALIMENTARY DISTURBANCE
gent, and is of much assistance, besides being scien-
tifically correct.
Ex. tincture kino ni x-i5;
Mist cretje, dram i.
Freshly made, without sugar. Four times daily, before
food.
The most important part of treatment, viz., the
dietetic, is now inaugurated at the end of the hun-
ger period. Four meals are given daily, as follows,
the hours indicated being subject to change accord-
ing to the routine of the household. The prepara-
tion of the various ingredients will be discussed
following the elaboration of the diet.
6 a. m. : Fat free broth (about six to eight
ounces).
lo a. m. : (a) Fat free broth (six to eight
ounces) plus sieved rice or farina, or cream of
wheat (about two tablespoonfuls) , or (b) fat free
broth plus a two minute egg rubbed into a paste
with pulverized bread crumbs made from stale bread
dried out in an oven.
2 p. m. : Fat free broth (five to six ounces)
plus one half of a large, or one whole small, mashed,
sieved, baked potato, plus two teaspoon fuls of one
or two different kinds of mashed, sieved greens
(lima beans, celery root, squash, spinach, boiled let-
tuce, carrots, beets, etc.) plus one teaspoonful of
finely cut and sieved rare roast beef, lamb chop,
chicken or fish, plus dried out bread.
6 p. m. : Fat free broth (six to eight ounces),
plain or with two tablespoonfuls of mashed, sieved
cereal.
Between 6 p. m. and 6 a. m. nothing is fed unless
it is urgently demanded, or needed to conserve
strength. Then fat free broth or weak tea may
be employed. Weak tea may always be given be-
tween feeds as a drink.
This diet may or may not show an immediate ef-
fect upon the stools. As a rule it does, the bowels
becoming constipated. Not all children, especially
those who are still on the bottle, take to it kindly,
for the reason that the feeding of new substances
to children in a new way is largely a matter of
establishing a new habit, and a matter, therefore,
of educating the individual. Force should never
be employed ; tact gives better results. For those
who Avill not or can not take food except through
a nipple, the difficulty is not increased. The greens
may be rubbed into a smooth mass with the po-
tato, and then the whole is mixed or agitated with
six to eight ounces more of broth. The entire con-
coction is fed through a nipple. It fiows readily,
and, should difficulty be experienced, the hole of
the nipple may be readily enlarged.
When the stools are normal, or nearly so, and
considerably reduced in (juantity, a cautious return
is made to milk feeding, as follows : One of three
kinds of milk, variously modified as will be indi-
cated, are employed, viz. : Skimmed milk, albumen
milk, or butter milk. At first the milk prepara-
tion is substituted for the 6 a.m. feed, and a few
days are allowed to pass, and the effect noted. If
no disturbance occurs, another milk feeding is sub-
stituted in addition for the lo a. m. feed, and again
the eftect is noted. Finally, the 6 p. m. feed is re-
placed by a milk preparation. Subsequently, the
strength of the milk feed is increased, as will be
iii'hcated shortly, until 'he proper strength for the
IN INFANCY AND CHILDHOOD. CN«w York
Medic.xl Journal.
normal individual is reached. Milk is never given
with the 2 p. m. feed. If demanded, one milk feed
may be given during the night.
Of the great value of skimmed milk in infant
feeding, 1 have written elsewhere.^ In the present
instance the milk is first given diluted one half or
two thirds with water, with the addition of one tea-
spoonful of tiour or powdered arrowroot added.
The whole is boiled for ten minutes, and suffi-
cient boiled water added so that the final bulk equals
one pint. A pinch of salt is added, and the mix-
ture sweetened with one half of a grain of sac-
charin, and, later, sugar is gradually added up to
five per cent. Cane sugar is to be preferred. Grad-
ually the water is reduced until plain, undiluted
skimmed milk is 'employed. The saccharin and su-
gar, and the flour or arrowroot are gradually re-
duced and finally omitted, the milk being boiled for
five minutes, with constant whipping. A gradual
return is now made to boiled, undiluted, whole milk.
Skimmed milk may be employed with "Larosan"
and sweetened with saccharin. One small package
(two thirds of an ounce) of this is added to a pint
of properly diluted skimmed milk, boiled ten min-
utes and strained. It is sweetened with saccharin.
Unfortunately, on account of the war, this valuable
preparation cannot now be secured. Albumin milk
cannot now, either, be purchased, on account of the
war, nor is it easy to make. A very valuable sub-
stitute is found in buttermilk. Two teaspoon fuls
of flour are rubbed up with one pint of water, and
boiled ten minutes. The water of evaporation is
replaced ; salt is added. The solution is allowed to
cool. One pint of buttermilk is added, and the mix-
ture is brought to the boil with constant stirring
from the moment heat is applied. This mixture is
employed to supplant one broth feeding at a time,
as the skimmed milk feeding was employed. Grad-
ually cane sugar is added, one dram at a time until
eight drams are employed to the mixture above.
Of course the saccharin is eliminated.
Later, the buttermilk feeds are replaced by boiled
skimmed milk undiluted, and later by boiled undi-
luted whole milk.
Results with this treatment have almost uniformly
been prompt. In neglected cases a little time and
patience has been necessary — and also courage,
especially in those cases in which the stools contain
blood. Here the diet is not changed from that
given above. A daily intestinal irrigation of one
half of one per cent, to a one per cent, solution of
tannic acid (temp. ioo°) has seeined to do good.
Large doses of bismuth are useless. In combi-
nation with the kino and chalk mixture, five to ten
minims of paregoric have seemed to be of service.
But the necessity for the use of this agent seemed
to arise in very rare instances indeed, and only in
long standing cases.
Preparation of foods. — The feeding of solid sub-
stances to young children, and even to sucklings,
suffering from acute alimentary disturbances, as
indicated in the diet above, may only be success-
fully accomplished if these substances are intro-
duced into the intestinal canal in an acceptable form,
so that they may be readily attacked by the intes-
Clinical Consideration of the Etiological Importance of Fat.
etc., H. Lowenburg, Therapeutic Gazette. July 15, 191 7.
July 6, .9.8.] LOU'ENBURG: ALIMENTARY DISTURBANCES IN INFANCY AND CHILDHOOD.
tinal juices. This can only be brought about by
the thorough physical comminution amounting prac-
tically to pulverization of all animal and vegetable
substances suppHed. It has been found clinically
that foods thus fed become not only nonirritating
to the intestinal mucosa, but, by an increase of
the adhesive attraction between the comminuted
inirticles, tends to form smooth and homogeneous
masses from which moisture is readily absorbed
by the intestinal glands, thus promoting the ten-
dency toward constipation. In order to promote
this adhesive tendency to its utmost, it is necessary
that the diet contain not only sufficient starch, but
a shght excess (?. c, an excess over the amount
thought to be digested by the individual). This is
provided for by the potato or rice, etc. This me-
chanical effect of food prepared in this way is by
no means its least important action in accomplish-
ing the cure of diarrhea. Thus food may be utilized
not only for its nutritive effect, but for its cura-
tive mfluence as well, and it can be readily demon-
strated by microscopic slides that much of the com-
minuted food passes out unchanged, c, nondiges-
tion. but not indigestion (fermentation, putrefac-
tion, etc.), has taken place. If this same bulk of
food be fed uncomminuted serious irritation and
fermentation, with an increase in the diarrhea,
would ensue.
Having adopted food comminution as an impor-
tant therapeutic maneuver, its method of accom-
plishment is the next important step. I have found
sufiicient for my purpose a very fine meshed
wire tea strainer. That is why I used the word
"sieved." The attendant is instructed to cook the
food as indicated below, then to mash it well and
push it two or three times through the tea strainer
by means of a pusher or a spoon. The substances
are fed singly or are all incorporated into a mass
and fed dry or moistened with the broth. The
whole process is not unlike that adopted by an
apothecary in the manufacture of an ointment. The
starch is cooked — either the potato or the rice —
and well mashed. This is then pushed several times
through the strainer, and may be likened to the
base of the ointment. The greens are mashed and
sieved once or twice, and by mixing are incor-
porated with the starch. They may be likened to
the various medical ingredients of the ointment.
Having by thorough mixing obtained a homoge-
neous mass, the entire substance is again pushed
through the tea strainer. The meat or fish is treated
in the same way, and may or may not be incor-
porated with the mass. It is now warmed, and may
be partially moistened with the broth, and warmed,
and thus fed, or may be fed dry, and the broth fed
separately, or a sort of puree may be prepared by
incorporating the entire amount with the broth and
then feeding it with a s;poon, dropper, or through
a bottle and nipple.
Fat free broth. — One pound of meat, preferably
mutton ; chicken, lamb or beef will do. One quart
of water. Boil until meat is tender. Strain. Ice.
Remove fat. Add sufficient boiled water and equal
one quart. Salt to taste.
Egg. — Bring to the boiling point, in a saucepan,
sufficient water to cover an egg. Remove from the
source of heat. Allow egg to remain immersed in
this water two minutes. Open at once.
Cereal. — All are cooked three hours in plain wa-
ter. Strain. Salt and taste. Push several times
through a tine wire meshed tea strainer.
Baked potato. — Wash clean. Punch full of holes
with a fork. Dampen the exterior. Roll in salt.
Bake quickly in a very hot oven. Open at once.
Mash well. Push several times through a fine over-
meshed tea strainer and employ as previously indi-
cated, alone or incorporated with mashed, sieved
greens, dry or moistened with broth, or mixed with
the entire amount of broth allowed for the meal.
Greens.- — Cooked until tender in salt w^ater.
Strain, wash and remove skins. Push through the
strainer, and feed as above indicated.
Meats. — Broiled or roasted, rare. Chop tine.
Push through the fine wire or tea strainer.
Treatment of diarrhea in mckUngs. A. Artifi-
cially fed. — My experience with infants under one
} ear arc as yet to immature to offer any positive
proof that the treatment outlined above for older
children is applicable to them. However, in those
few instances in which it has been employed, my
results have been good. Where several teeth have
been erupted I would not hesitate to recommend it.
In other infants the foUow'ing procedure will yield
good results. The preliminary treatment is identi-
cal to that previously described with reference to
starvation and purgatives and other medicines.
Following the hunger period and tea feeding,
suitable amounts of one third of a pint of skimmed
milk (skimmed at home) and two thirds of a pint
of water, boiled with two thirds of an ounce of
Larosan and sweetened with one half of a grain
saccharin, are fed four to six times in the twenty-
four hours and give the best results. An immediate
change for the better is usually noted in the stools.
The strength of the milk is gradually increased and
the Larosan omitted until the normal food is
reached. No unboiled milk, however, is ever fed.
Larosan is expensive and now unavailable, there-
fore, use is made of the butter and milk mixture
with flour, sweetened with saccharin as previously
described. Thus may be fed far into convalescence,
replacing the saccharin by gradually increasing
amounts (one dram up to eight drams to one quart
mixture) of cane sugar or dextrimaltose.
Finkelstein's albumen milk is just as serviceable,
but is difficult to make. When returning to diluted
whole or skimmed milk preparations the change is
made abruptly, 7. e., a feeding is omitted and from
thence the suitable milk formula is substituted for
the buttermilk mixture, the albumen milk, or the
Larosan preparation, whichever had been employed.
All of these preparations simply act upon the as-
sumption that, regardless of the initial cause that
produces the change in the intestinal contents, the
direct cause of the irritation and hence the diarrhea
is an excessive acidity of these contents produced by
changes in fermentation in the fat and sugar of the
milk. Plence, by withdrawing milk, the cause is re-
moved. The period of starvation with or without
purgatives permits the bowel to empty itself of the
offending substances. These food preparations con-
tain excessive amoimts of finely comminuted cal-
cium paracasein (curd) which not only acts me-
12
PARKER: THE PSYCHIC FACTOR IN SHOCK.
[New York
Medical Journal.
chanically in allaying irritation but favors the pro-
duction of putrefactive bacteria, hence alkalinity, as
the acid producing organisms require carbohydrate
and hydrocarbon. I'hese substances are only grad-
ually added as tolerance seems to be reestablished
during the period of convalescence. The chalk and
kino mixture favors the development of alkalinity
as v^^ell by neutralizing the acids of the gut and by
the astringent effect upon the muciparious glands.
Breast fed babies. Starvation. Tea feeding.
Purgative rarely. Chalk and kino mixture. Return
to breast feeding at four hour intervals. Hydro-
therapy.
262 South Skventeenth Street.
ANALYTIC VIEW OF THE PSYCHIC
FACTOR IN SHOCK.
By George M. Parker, M. D.,
New York.
By a process of reasoning, for which, in its human
quality, Hume cherisbed little respect but much af-
fection, we have looked upon the psychic results of
a physical damage or trauma inflicted upon the per-
son as singularly damaging. This has appeared to
be the instance irrespective of the degree of the
trauma. Yet, with a naive inconsistency, society
has always selected a series of traumata, designated
as punishment, graduated in relation to its hierarchy
of morals, and has inflicted these upon the persons
of those about it. In the visitation of these selected
traumata we have assumed the function to be re-
medial, constructive, and not destructive. This
happy ef¥ect we believe to be accomplished by way
of a consciously communicated conviction to the
recipient that such traumata are designed for his
ultimate and higher good. It must be said that such
a belief is not constantly accepted nor participated
in by the recipient. At least, this he declares by
word of mouth and deed. Yet something of truth
must reside here, else punishment, in all its forms,
would long ago have been completely abrogated. We
are far, of course, from beliveing that specific pun-
ishments have checked specific tendencies. Nor, in-
deed, do we possess the slightest faith in the con-
scious salvation of the sinner, thus achieved. On
the other hand, we do know that something, included
within the general notion of punishment, effects cer-
tain results and changes within the personality. So
far as our limited vision permits, we use two fac-
tors ; the possibility of an outside situation effecting
a modification, and the presence within the indi-
vidual of something which is modifiable. We now
realize the most powerful external agent is neither
the hand of God nor the fist of man, but reality.
What is transformable within seems never to be a
specific and single item of conduct. It is neither
drink nor lust nor theft nor deceit which is singly
erased. The change, indeed, is so much larger, so
much more profound, that we fear to recognize its
possibilities as existing within the range of human
performance, and, for safety's sake, imputed it to
God or some agency outside ourselves. We are thus
relieved from imminent danger or ourselves per-
forming this, for are we not miserable creatures
who mav never aspire to divinity?
In thus giving a thoroughly moral introduction to
a discussion of the psychic effects of physical trauma,
we might seem to have created a split as wide and
deep as that separating the reasoning applied by
science from that engendered by theology. Yet in
our application to man, we are becoming aware that
he is a creature growing well beyond the bounds of
causality, and living, achieving, and progressing in
a way that reminds one but little of scientific method.
In the field of morals, where his attempts at pro-
gression have been laid, there is to be discovered a
large deposit of what we have referred to as the
antithesis of causality. One would hesitate long be-
fore stating that the most violent infliction of reality
had caused an aspiration. There is nothing about
poverty which could, in a strict responsiveness, lead
to more than an immediate abatement of it. There
is nothing in a gutter which, in strict relationship
to its evil and malodor, would lead to more than a
temporary or immediate arising from it. Yet we
know the transcending limits to which former dwell-
ers in both these areas have arisen. But no one can
decently call this a causality series. It has to do with
something which cannot be there included. Perhaps
no man has failed to be edified, openly or subtly, by
the tales of those who in a second have faced death,
yet returned. To be told that the whole of life,
under these circumstances, flashes suddently on the
screen before one, in some way stimulates. From
our universal interest we may be sure that a truth
resides here, but one so large that perhaps both the
narrator and his hearers miss it. Something in
reality at the moment of danger, with its physical
infliction, shocks us. Reality, at this moment,
strikes as at no other. Can we draw now an analogy
between its effect, under circumstances of shock, and
that which culturally we have, long and vaguely,
been aware of in the application of selected traumata
to man? If the scales fell from the eyes of Saul of
Tarsus under circumstances described in Holy Writ,
with the results therein detailed, may we be justified
in suspecting that a smiliar resultant might be ob-
tained in a railroad day coach where suddenly one
of those accidents took place of which every traveler
takes his chance? Psychologically, one effects here
apparently an immediate comparison. Saul's con-
version is described as eventuating with no sudden
infliction of an outer reality change. Yet it is only
because those who described this occurrence imme-
diately imputed it to God, that we fail to have the
causative relationship detailed, which led to the
major transformation of personality. But it would
be remote from our end to suggest to pathographize
the great disciple. If, however, we may discover a
similar, though much disguised, resultant in a lesser
personality, we may thus at the same moment both
better satisfy scientific canons from the careful ex-
amination of present material, and placate those of
a religious temperament who see the interest of the
Almighty vested in a sparrow no less than in man.
A young woman was traveling one evening to
her home. She had been away for a vear in another
city, which had witnessed her initiation into the
world as a wage earner. Up to that time she had
lived with her mother, where not all the circum-
stances of her life had been entirely happy. When
she was twelve vcars old her father and mother
July 6, 1918.]
PARKER: THE PSYCHIC FACTOR IN SHOCK.
were separated. He had gone far from home, and,
much later, had remarried. She had been always
devoted to him, nor had he failed to remain as her
ideal. She had not seen him for a number of years,
nor had she met his wife, whom she thought of
always as her stepmother. There had, however,
been an active correspondence carried forward, at
first largely by the girl herself. Her own mother,
whom she physically resembled, had seemed to her
daughter always to have been less fond of the girl's
father than seemed proper or expected. Indeed a
major part of the blame for what later had trans-
pired seemed to have been laid at her door. Yet
this had destroyed no outer evidences of afifection or
feeling, although there was evident to the girl a
lack of sympathy and afifection.
In her year away frorii home she had succeeded
admirably in her business, which was of a kind
demanding concentration, exactness, and much
alertness. She had become ambitious ; had striven
to perfect herself, and, as a further development
had taken up music after hours and was workmg
with much pleasure upon it. Socially she sought
those older than herself and valued men not only
older in years but especially those accomplished,
experienced and cultured. The personality thus
issuing seemed one much better than that usual in
her class of life. A late cultivation of graceful
manners of demeanor, probably represented that
which she described as to be so much desired under
the term of "poise." A certain personality de-
veloped, with a clear coincidence with what Jung
describes as the essence of personality as enclosed
in the term "persona," meaning a cloak worn by
the actor to designate a given part selected for por-
trayal by himself.
On her trip there was a colHsion in which noth-
ing more happened than that many were thrown
from their seats ; the car was not derailed. The
girl herself was thrown forward, striking the cush-
ioned back of the seat in front of her with her jaw.
It did not cut her lip nor her tongue nor damage
jaw nor teeth. She was not stunned, simply shaken
and saw about her many others similarly afifected.
The crash and jar, however, were very considerable.
She was four or five hours late in arriving home.
A reasonable fatigue was produced by this, but ex-
amination by a physician upon her arrival revealed
nothing. Her first night was not disturbed, but on
.the second she began to have that which she des-
cribes as nightmares. These have caused her the
largest concern of anything eventuating from the
shock. She significantly relates them to the other
changes which soon began to appear. There super-
vened a dififuseness of attention, which is especially
disturbing as it concerns her work. She cannot
concentrate ; there are many dreamy states from
which, with inceasing difificulty, she pulls herself
out, yet which, in their constant recurrence, make
many of her reactions to those about her inapposite
and, at times, stupid. She takes no interest in her
work. People appear extraordinarily trivial, their
remarks and their lives futile. A kind of depression
generally envelopes her, with a distinct desire to
be alone. A constant fatigue is in evidence, but
there is a good deal of motor restlessness ; she has
become irritable, especially with children, of whom
she was very fond, and she feels peculiarly the loss
of her highest prized possession, poise.
It would be difficult to define here any definite
damage, yet there has been some kind of a dis-
ability inflicted, evidenced in work and, behavior.
Because it lacks the objective qualities of a fracture
or a contusion constitutes no reason why we may
not see it quite as objectively displayed here, in her
difficulties of adjustment. Something has hap-
pened, dating from the accident, quite as real as
that which occurred to Saul of Tarsus in his con-
version. Yet if the actual physical damage, as a
causa, seems to be eliminated by way of the absence
of any physical series of symptoms, is the accident
as an efficient cause to be erased? Is it not pos-
sible that that to which we have given the term of
"shock," may have contained those suddenly appear-
ing reality elements which are seen to possess so
profound an efifect in producing psychological modi-
fications ? Obviously we can study this only with
profit from that viewpoint which may embrace a
closer inspection of the psychic alterations. Nor
are these to be understood from an inspection of
symptoms, where the most astute scrutiny issues
only in suppositions. We have, however, in her
dreams something of an importance which she her-
self has dimly recognized. Whatever unconscious
phenomena reveal the real psychological basis of
her present condition, our access to this lies in the
dreams. Her earlier nightmares were of a kind
in which, not the actual collision was recreated, but
rather bizarre arrangements presented, as of sub-
way trains running free upon the street surface,
as motor cars, repeatedly escaping a crash. Ob-
viously, if the particular accident stood as the sole
expressor of a threat, a danger, this might and
would have been reproduced in the unconscious.
Yet it seems as though the unconscious were con-
cerned with something more imminent. The threats
of disaster are daily occurring in the place of her
work, not in the locale of the accident. They are
localized in cars in which she travels daily, yet upon
the street surfaces where they never travel, but upon
which she walks. Something, then, in the subway
and on the street conveys a threat ; displays an ac-
cident from which she escapes. Something which
usually is below threatens above. Here is the dan-
ger for her which the dream indicates. It is a short
step to arrive at a suspicion that what is feared is
something in herself ; it is she, in the subway and
in the street, who fears a crash in herself. Yet this
is quite unconscious, for there have been no leaks,
displayed in timidities or apprehensions in traffic
since the accident. So far as she is aware there is
no increased reaction to outer disturbing noise or
other stimuli. Now, in the apprehensions of the
damage in herself, one might readily go further in
a definition of kind, for the figures in the dream are
sufficient for this if one chooses to take them as
a sign or token of primitive processes. Our use,
however, coincides more with Jung in imputing to
the figures in the dream, a positive value, one which
conveys to the dreamer a definite meaning possible
of application. Yet the crystallization of the dan-
ger is not arrived at here, save in disguised forms,
where a considerable analytic aid would be neces-
sary in amplification through association in order
14
PARKER: THE PSYCHIC FACTOR IN SHOCK.
[New York
Medical Journal.
thai the patient .should arrive at any degree of a
conscious appreciation of it as a whole. Whatever
obtains is something obviously of the unconscious;
but it is disturbing, and the affect from the dream
persists vaguely into waking life. It seems to be
of some significance.
It is presumable that, if this dream be built upon
a thought process such as we have predicted, this
will further expand itself or in some way so develop
that the patient may arrive at conscious modes which
may closer approach a solution. In a dream, se-
lected by her as one standing out, there is a little
party with several men, who she latter left upon
their invitation to a card game, urging that she had
no luck at cards. Returning with a vague appre-
hension, she discovered that a man had wagered
away her rings given to her by her father. The
dream closed as she sought in shop after shop to
recover these, yet never finding them. These three
men were all older than she, an age which she
favors. They were, when fused into a single per-
sonality, the man of the world, the successful man
and dilettante. Yet actually no single one of these
has pleased her. Hence, probably, the fusion rep-
resents that tendency which one sees so frequently
in the woman who seeks a husband made to order.
Yet there must be some pattern for this production
which she seeks to love, for, unlucky in cards and
lucky in love, her response to the playing of cards,
signifies that some such motive is here present. Yet
she leaves them and goes beyond. There is some goal
other than the composite. Her apprehension about
her rings, her father's gift, displays now the goal
a trifle more plainly. It is this which she seeks. But
they have been lost by one of the men. And she
cannot find them. It is this which is the terror.
She cannot regain the father's tokens. Yet she has
lost these really in her seeking of him ; in the dis-
satisfaction of single individuals ; in her wanting
many men for their additive qualities, in her leaving
them and going on still further. Whatever one may
read beyond this in the fixation to a parent, here is
a confrontation of its loss. While this, as Freud
says, is the obverse of the desire, yet it has the posi-
tive meaning of a loss and, with this, a realization
of its being conditioned by her own acts.
We find this motive further developed by a later
dream, again chosen by her for relation. This
freedom of selection from a mass of dreams, in her
case extending over a month, is of much use when
we must, within a brief hour, arrive at a project of
the situation, as the present case demanded. At a
tea party the filling for the sandwiches was not quite
enough. Her father's second wife, whom the pa-
tient calls her stepmother, said she would get some
roses, and at the same moment her own mother came
in with peanut butter. The patient said, "Oh, do not
mix the two." In this dream as in others, the step-
mother always appears as tall, beautiful, with
"golden" hair, graceful, and the traditional lady.
She in reality is rather of the outdoor type, strong
and rugged, and rather dark, as is the patient, who.
as we have said, resembles closely her mother. Clearly
we have here an alternative, roses or peanut butter ;
hut there is to be no compromise, they are not to be
mixed. Whichever is to be used applies to some-
thing which is not filled completely, which needs
more. One, of course, sees tiiis here as a food at
a function which is associated with her home life
and with her mother. This life we know to have
been felt as inadequate. She has not felt sympa-
thetic with her mother ; there has been a distinct
aggression, or at least critique, directed at her. This
is expressed in her picture of someone almost like
a fairy godmother, or mother framed in the beauti-
ful stepmother, one to whom she would feel drawn,
one who would be intimate and ideal. It is she who
brings the roses for the filling, while her own mother
delivers the practical butter. The conscious reaction
against the mother is one in which we now recognize
a profound menace. It cuts off from the individual
a tremendous root. It is of less importance that it
is motivated from a desire for an identification with
the mother, an impossible gain thus to be achieved
in itself as an access to the meanings of self, as
well as in the closer relationship to the father. The
damage to the psyche is what is significant and what
is related to the patient in this dream, for though
neither is directly chosen, yet the accent is laid on
not mixing the two, while the application of her own
mother's contribution to the situation is evident.
Here, then, the dream mother, for strictly she is
thus, only in dream being the true lady, is no longer
paramount. Her own mother is to be chosen. A
confrontation is again developed before the patient.
The tmconscious is driving its lesson further for-
ward.
Finally a comparatively recent dream is recited as
exemplifying what she calls the facing of purposes
which are superhuman, impossible. Here she is at-
tempting to curl the hair of a little girl, but the hair
is so very short that it is impossible to do so ; the
feeling of a task calling for superhuman powers
carries a deep affect with it, which goes into waking
life. This little girl, whom she used to love before
the accident, now strangely irritates her. The child's
hair is straight and long and on certain evenings in
the week she has curled it, an easy task. Her own
hair was naturally curly when a child. Here, then,
is a task which is impossible ; the very short hair
makes it thus. The dream offends reality, for the
hair is long and easy to do. Why is a task of a
superhuman character defined in this apparently
trivial setting, and one of such apparent insignifi-
cance? Or what really superhuman thing is here
expressed? Is it that quite as it is ismpossible for
this hair to be curled so it is impossible for her, the
patient, ever again to have the curls of childhood?
Is it this which we see in her conscious and new
irritation at the child, an envy of her as the child?
Is there here a confrontation of the fact that she is
at the end of her desires as the child ?
Thus seen, a certain implacability is presented, is-
suing from an unconscious. Yet can one verify this
hypothesis in her behavior? We know she has lost
her earlier garments of poise. Surely, if the dream
were only a reinforcement of desire this should not
be ; one should rather expect to see it more strikingly
set upon her as a personality. If, before the acci-
dent, she had power to concentrate, to work, if she
seemed satisfied and interested, something has come
to produce the grayness and remoteness of disillu-
sionment. Could anything more effectually accom-
plish this than a realization of the frail foundation
July 6, 19 18.]
PARKER: THE PSYCHIC FACTOR IN SHOCK.
15
of the past desires and a confrontation with tlieir
abandonment? Which is the better, before or after
the accident? As we have seen her, the question
answers itself. She was making adjustment before,
now she is not. But, were those adjustments sound
and effective and straight psychologically ? They
worked, at least. Only that can we. say, who know
nothing exact as to them beyond her limited ac-
count. But if sound, why should they have been
so instantly disturbed by a passing shock? Here is
the acid test apparently. We might appreciate it
better if we knew more of what this is, or better, if
we were to recognize it, for all know it. And here
we return to what apparently happens in shocks,
with Saul of Tarsus, or through the physical crash
of a railroad wreck, or, perhaps, in the trenches.
In an article, "The Predisposing Factors of War
Psychoneuroses" (Journal of the American Medi-
cal Association, February 2, 1918), we find a similar
question poised by Dr. Wolfsohn. In carrying out
a study of 100 cases, in which the varied marks of
psychoneuroses occurring under war conditions at
the front presented, he sought to check these up
by a series of 100 other cases in which definite
somatic injuries had occurred. His purpose in this
was to explain what amounts to our problem as
to why shock with no traceable physical damage
produces an effect far more disorganizing in certain
instances than does shock coupled with definite
physical damage effect in another instance. He
has, of course, Hmited himself to predisposing fac-
tors, isolated from the family and personal histories
in both sets of cases. He has, moreover, shown
conclusively that within one, the effects of the shock
by itself have educed symptoms known to be char-
acteristic of the psychoneurotic to a far higher
percentage than obtains in the other group, in which
there has been shock and also physical damage.
Again, something is located within the shock as more
effective in one instance than in another, but with
enough of an effect common to both to suggest that,
under extreme conditions, no one may be considered
immune to these possibihties. This latter point is
nicely emphasized in a few cases of that which he
calls the acquired neurasthenic state. Here the
conditions of strain have been so prolonged that the
results are similar to those obtaining after a single
exposure to shock.
Beyond defining, thus, certain fixed predisposing
conditions of shell shock, there is no approach to
the psychology imminent in the shock. Yet the
family history of these cases disclosed parental
types of a kind we now recognize as especialy liable
to afford a vicious psychological environment for
the child. By this we mean no more than that the
adjustments to life have been rendered singularly
difficult, and the liability of unwholesome relations
to family and parents as considerable. The per-
sonal history also suggests actual occurrence of
many marks verifying such maladjustments. What
has happened at the time of the shock, then, has in
many instances occurred episodically, or in a minor
continuous way, pi^evious to their army experience.
One might assume, then, that the psychological
effect of shock represented something much Hke
that which is presented in less striking and isolated
manner previously. It is obvious, also, that what-
ever these previous effects had been, a certain de-
gree of personal recompounding has subsequently
taken place, so that it did not become manifest until
the moment of the shock.
It is possible, however, to get another angle on
the psychological factor in shock from the intro-
duction by Bailey to Wolfsohti's article. The for-
mer concisely evaluates the varied treatments ap-
plied to this group since the beginning of the war.
His summarization of the present situation is as
follows : Quite recently the attitude in respect to
the management of this condition has undergone a
marked change. Eighty-five per cent, of all shock
patients are not now returned to England at all.
it has been found much better to treat them nearer
the front, and any release from military discipline
is regarded as unfavorable for recovery. More-
over, the general methods of treatment, such as
iliversional occupation, extra diet, and entertain-
ments, have been replaced by more rapid and much
more satisfactory procedures.
Electricity given for psychic effect, which at first
was disapproved, has been found to be a valuable
agent. This is accompanied by strong persuasion.
Cases are reported cured in this way in a few hours
which had formerly endured for months, and had
resisted all other methods. The personality of the
medical officer is a most important factor.
It would appear, therefore, that the experience
in England has substantiated what has been ob-
served in similar cases in France, namely, that such
patients should be kept under strict military regi-
men. They should not be sent to the interior. Sug-
gestive measures properly applied and accompanied
by electricity for its psychic eft"ect are successful.
Delay in the treatment allows the fixation of the
neurosis, and once a soldier has reached the interior
because of shell shock, it is very difficult to utilize
his services again. There is a large significance
here contained in two factors possible of isolation.
In the first place, we are made to realize that re-
covery is conditioned by maintaining the treatment
nearer to the front than formerly, and that time is
an essential factor. That is, the soldier no longer
is removed to an environment encouraging a non-
confrontation with that from which he had just
emerged. Again, we see here the same significant
imputation of a certain curative element involved
in the confrontation of reality. There is next de-
fined the necessity for instant treatment ; the quicker
the better. This would seem to indicate that some-
thing has occurred which must instantly be seized
in order that a benefit may accrue to the patient.
We then have defined for us, in a necessarily un-
expanded form, what has worked out to be appar-
ently the best method. This is "persuasion" accom-
panying "electricity given for psychic effect." This
is especially effective as enclosed in the personality
of the medical officer. Here, then, is a train of
purely psychic effects necessary to be applied in-
stantly, under conditions where the patient is not
utterly removed from the environment producing
the shock. With the best results thus obtained,
there seems little doubt that the effect of shock is
psychic, which, in our study of a single shock, we
i6
PARKER: THE PSYCHIC FACTOR IN SHOCK.
[New York
Medical Journal.
have dortned tentatively. In the shell shock cases
one may arrive at a suggestive verification of this
only indirectly or inferentially. We have, in the
first place, a large value imputed to a continued
confrontation of a somewhat similar environment
to that which was associated with the conditioning
factors. Something apparently good, then, for the
individual obtains here. Yet, equally plainly, it
cannot be read simply in the value of reality in
forcing a confrontation of it. There seems to be
another kind of confrontation necessary, described
in the use of persuasion through the personality
of another, and heightened by an artifice enclosed
within the application of electricity. While we are
left in the dark as to what is urged upon the pa-
tient, as to what he is persuaded to do, or what
attitudes to take, we are somewhat informed of this
possible direction by the insistence upon the im-
portance of the physician's personality. Now it is
an obvious fact that personahty appeals to person-
ality ; that whatever is efifected by one personality
is located within the other personality. The argu-
ment, in other words, is always ad hominem. In
the word "persuasion" also is involved the notion
of bringing about a course of action which has been
resisted by the individual. If, then, there is any-
thing eftected, it would appear as though this rested
upon bringing about a personal attitude by one per-
son in another wdiere a resistance to such an attitude
had previously existed. It is this, of course, which
is the factor concealed under the requirement that
the patient be treated in the environment condition-
ing the shock. This can mean that only under such
an environment can there be w^rought the psychic
change which demands persistence in a position
where something within the individual may be con-
fronted, and to which confrontation he may be per-
suaded by the personal appeal of a personality to
which he is singularly liable. What is brought
about, then, appears to be much more a confronta-
tion of self than a confrontation of reality. That
which persuades him to this is a personal relation.
In this personal relation, then, is included the thera-
peutic agent, for through this he has been enabled
to be persuaded to an attitude which represents a
healing.
While this is all largely inferential, it appears to
meet, or at least suggest, the possibility of a coin-
cidence with our own hypothesis as to the psychic
factors in shock. But there is added to this a ther-
apeutic tryout, which, while seeming to verify this
hypothesis, also introduces another factor in the
personality of the persuader. As yet, however, w^e
have described no relationship between any of these
factors, apparently common to all traumatic psycho-
neuroses, and the more general psychoneurotic
marks. It is reasonable to suppose, however, that
within the substantial data accruing about this latter
general mass, there should be discovered much that
would illuminate the particular problems which have
been singularly well crystallized in the traumatic
neuroses. It is obvious that the point illuminated
by the latter seems to reside in its initiation and
the factors therein included. In a general way we
have for long given considerable attention to what
is called the point of break in the neurosis. It is
pretty nnicii related to reality ; something here which
the patient may not or cannot meet. It seems, at
least, to be in front of this site that the patient
crumbles. Hence the worship we have come to
pay reality for itself. Our confrontation seems to
have become a modern ordeal by fire, with all the
conditions of an inquisition fulfilled, society as the
grand inquisitor, and reality its thumb screw. Yet
in these demands of adjustment, there is some kind
of an aim, just as we recognized a goal in the more
defined demands included within punishment. In-
deed, there seems little doubt that in society's pun-
ishment of others there is involved a left handed
accusation of self. Analytically, however, the con-
sideration of the breal< in the psychoneurotic rarely
yields so clear a precipitate as that shown in the
unconscious of the case briefly presented, this be-
cause only under unusual circumstances does life
contain so sharp an accent, so impending a quality,
as included in the shock. There is also always
related in the general course of analysis a series
of minor breaks and subsequent readjustments.
Whatever has happened has been fairly well patched
up. Even after the major break a disturbance is
rarely so immediate ; the case presents long after
the point in which we are now interested, in that
phase where another set of adjustments have super-
vened in the symptoms, from wdiich the patieht de-
mands relief and comfort only. The particular na-
ture of this has so especially blinded us to what
has happened, that not until Adler and Jung was
any attention paid to the much earlier incident of
the break. Now, while in a proper analysis all or
many of the unconscious motivations appear, it is
just this course between the break and the appear-
ance of the symptoms which is so frequently sub-
jected to resistance in its emergence, that, as a
datum, it is slow in appearing. Indeed, it seems
pertinent here to recall the importance of quick ac-
tion defined in the shell shock case. That is, we
seem to have a right to see a difference here in a
time sense. The shock case w^e have described and
the shell shock all have had an earlier interference
than the usual psychoneurotic. Hence the finding
here might w^ell illuminate an unapprehended part
of the usual neurotic structure. Yet, if our sup-
position as to the nature of the break actually shown
in our single case and possible of inference in the
army cases be true, this same mechanism ought to
be displayed some time in the course of the analysis
work with the usual ps3^choneurotic. Moreover, the
symptoms of the latter, in their common quality
with those of the shell shock, should be further
illuminated and probably themselves illumiinate.
Finally, the remedial agency, so miraculously effec-
tive in the shell shock, should have explained its
extraordinary efficacy, to the end that we may pos-
sibly define similar modes for the treatment of the
usual psychoneurotic.
In the case of the railroad shock we possess the
knowledge of a sequence of symptoms, correlated
with an approximation to a particular series of
personal considerations appearing in the dreams,
which we have thought to be of considerable sig-
nificance. In this there is nothing unusual except
that, chronologically, it proceeds from a point close
July 6, 1918.]
IVILE: DISPENSARY ABUSE.
17
to the time of shock. All of Freud's effective work
has been in the nature of interrelating symptoms
to unconscious phenomena. His particular system
is of less significance than this general principle of
determinism. Yet, so far as we have gone, there
has been considered only the unconscious in its
prospective directive tendency. This has been ap-
parent. We have related it to shock, which has
been suggested as possessing the unique potentiality
of such a confrontation. But there has been no
attempt to relate the symptom to what we have
stated to present here, i. e., a conscious noncon-
frontation with the unconscious direction which the
shock brings apparently near the surface. The
symptom relation, largely, in psychoanalysis has
been cast, as we have seen, in relation to the uncon-
scious. Yet here we suggest that it possesses a
distinct relationship to a conscious nonconfronta-
tion. Is there, then, something which may illu-
minate the appearance of the symptom at a given
time ?
There must be imputed to the symptom not only
a meaning in a deterministic relation to an uncon-
scious motivation, but also a kind of adaptative
quality. In a rather crude way this has been seen
in defining the symptom as an attempt at cure. In
Adler's "finaiistic" sense, the symptom is an ar-
rangement toward the goal of power ; nor is it dififi-
cult to recognize that Freud has much ground under
his feet in establishing the symptom as a mode of
releasing the repressed sex. An adaptation can
be read in both these instances, however one may
take the relation of the power principle to the sex.
Jung, however, has defined the symptom by what
he calls its prospective meaning, as exhibiting an
adaptation of a very different type. This is best
expressed in his consideration of the symbol as "not
merely a sign of something repressed or concealed,
but at the same time an attempt to comprehend and
to point out the way of the further psychological
development of the individual." {Analytical Psy-
chology: Introduction.) The symptom is, of course,
never else than a symbol. If confrontation, as we
see it, is a freeing of a definite directive expression,
so well exemplified in the dream in a manner to
illustrate the "attempt to comprehend and to point
out the way," then under conditions of noncon-
frontation, the presentation of a symptom would
appear as though its presence here possessed a well
defined adaptive sense, as a kind of partial or dis-
guised confrontation, if we stick to our notion of
the symptom being adaptive. Here, then, we relate
it, in an adaptive sense, to a conscious noncon-
frontation ; instead of to a retroactive series, it
stands with one prospective. But more than this,
it is conditioned, not only by an unconscious pros-
pective movement, but also by a conscious noncon-
frontation of this. If the shock has so far made
a nonconfrontation imminent that this consciously
comes to be declined, then the appearance of the
symptom, as a disguised confrontation, is related
to the shock and, in a way, seems adaptive.
It would appear, then, that the usual series in
the neurotic would be the shock or the reality situa-
tion containing the psychic factor of a sudden ap-
proximation to consciousness of a definite, directive,
critical movement, then a nonconfrontation of this.
and the appearance of what we call the symptom.
The older and still prevailing mode of presentation
was the reduction of the symptom by analysis to
the sex, or power components, issuing usually in a
relief of the symptom and a considerable access
of energy by a cessation of a coincident sex re-
pression. Yet also it was becoming more obvious
tliat an approximation to any directive movement
by the individual might be as far removed as ever
and incapable of handling save through a loose
mode of conscious direction in what was termed
"sublimations." A chief hazard in analysis emerged
here ; at times it did harm, however correct in
method the reductive process might be. It has
been a curious development that we should count
those among our psychotherai)euts whose efforts
are described by them as finishing up the person
who has been analysed by another. The commen-
tary as to the inadequacy of the straight reductive
mode is striking. Jung attempts to make the an-
alysis take the point of view of the individual and
is thus to be understood as embracing more than
the reductive method of the symptom analysis of
Freud and Adler. He has moved in the direction
of placing within the conscious control of the in-
dividual the general directive tendency of the un-
conscious. Yet even this has seemed possible only
after going through the usual reductive modes ; his
analyses, he states, are much like those of Freud
in a considerable part of this work.
{To be concluded.)
DISPENSARY ABUSE.*
By Ira S. Wile, M. D.,
New York.
The dispensary population of New York City is
well over a miUion ; the average number of visits
paid is probably about four. The number of pa-
tients attending dispensaries has increased more
rapidly than the growth of the population. Un-
employment, a large number of chronic ailments,
the failure to secure satisfactory relief, together
with the increased interest in and attention paid
to public health, are probably responsible for the
rapid growth in the dispensary population, partic-
ularly under the urge of an increased cost of living,
together with special campaigns for the control of
tuberculosis, infant mortality, cancer, and mental
diseases. An increasing demand for clinical mate-
rial on the part of medical institutions has also
caused an extension of dispensary facilities, so that
today we find a vast number of public and private,
free and pay dispensaries operating as specialized
clinics or as out patient departments connected with
hospitals covering almost the entire field of med-
icine.
The general dispensary, and I use the term to
cover both those connected with and those detached
from hospitals, provides opportunities for the pub-
lic to secure services in general medicine or sur-
gery, diseases of the eye, ear, nose, and throat, dis-
eases of childhood, dermatology, neurology, venereal
*Read before the New York City Conference of Charities and
Corrections, May 7, 1918.
t8
WILE: DISPENSARY ABUSE.
[New York
.Medical Journal,
d-seases, gynecolog}', obstetrics, orthopedic surgery,
and dentistry, together with x ray, chemical, and
pathological laboratories.
Public health movements have played an impor-
tant part in the rapid development of the modern
dispensary system. There were only twenty public
health dispensaries in 1904 in the entire country,
vv'hile today there are very nearly one thousand.
The rapid growth of new types of dispensaries dur-
ing the past few years indicates former weaknesses,
when the dispensary was regarded as a secondary
institution.
Special activities have become the evidence of
dispensary progress. Diseases of occupation now
find themselves cared for in a clinic. There is a
special cHnic for whooping cough, for heart dis-
ease, etc. Specialism has fastened itself upon the
dispensary system so that, today, the best type of
dispensary is a cooperative association of special-
ists in all fields.
The older idea, that the function of a dispensary
was to provide drugs for the sick poor, or to serve
as a medium of feeding interesting cases into a
hospital for purposes of study or teaching, is being
relegated to the background.
The present time finds the dispensary situation
in a state of transition. Dispensaries are now being
thoroughly involved with numerous educational
problems, as well as those economic and social,
conseciuent upon the expansion of the probation sys-
tem and the broadening of our views with refer-
ence to family rehabihtation.
When it is realized that New York City constantly
has more than 135,000 persons suffering from sick-
ness, and that less than ten per cent, have an oppor-
tunity for treatment in hospitals, one can perceive
the tremendous responsibility thrown upon dispen-
saries as collaborators with the general practition-
ers upon whom the community depends for the
maintenance of public health, in conjunction with
the highly developed and generally efficient health
department, whose service to the community has
been of inestimable value.
As to the problem of dispensary abuse, I am not
talking in terms of any particular dispensary. I
am considering the dispensary stiuation as a whole.
Purthermore, I am aiming to take another view of
dispensary abuse, in that I shall stress abuses by,
lather than abuses of, the dispensary.
We all realize that a very small percentage of
dispensary attendants, averaging about three per
cent., can afford to pay fees, but it is questionable
whether these have sufficient family funds to be
able to afford the fees of specialists at current rates.
In Boston, it was found that forty per cent, of the
families of dispensary patients earned less than fif-
teen dollars a week, and only fifteen per cent, over
twenty dollars a week. The possibilities of abuse
by the attendance of patients from such families
is exceedingly small, so that the number who are
falsely receiving charitable aid need not excite us.
One hears of the effect of dispensaries on private
practice, but it is doubtful if the financial rewards
from patients of the dispensary type would greatly
enrich the profession.
Doctor C. N. B. Camac has grouped the ordinary
forms of dispensary abuse, and has pointed out
the poor and hurried work of dispensary physicians,
the attempts at diverting patients to their offices,
and the habit of what he calls "manikinizing the
patients," for purposes of instruction. He refers
to the possibilities of pauperizing the public, the
dangers of under equipped departments, their utili-
zation merely as channels for hospital patients or
subjects for medical teaching. He stresses the ten-
dency to destroy clinical accuracy as a result of
poor dispensary organization, or inadequate equip-
ment, and, finally, dismisses the question involved
in the statement that dispensaries deprive practi-
tioners of legitimate sources of income.
I might call attention to the fact that many of
GUI free dispensaries are expensive to patients be-
cause of the time lost from work. Some one has
called dispensary medicine bargain medicine ; and
all bargains may prove to be, at times, expensive
luxuries. Again, many patients are, in a sense, suf-
fering from attempts at inadequately outfitted dis-
pensaries to give service that is impossible for them.
In this connection, I may quote from E. O. Otis,
who says : "I do not believe that it is the province
of the dispensary to treat its tuberculosis patients,
ror can it satisfactorily do so." He points out the
necessity of home visitation by physicians and
nurses, and dwells upon the possible advantages
arising from the class method of handling this type
of patient. But take a larger view of dispensary
abuse, in terms of the modern ideas concerning
dispensary values. I point out three types : first,
those visited upon individuals ; second, those affect-
ing local communities ; third, those affecting society
as a whole.
While there have been marked improvements, one
is able to see the results to patients and the disad-
vantages of hurried treatment and overcrowding in
dispensaries, unnecessary medication, and a lack of
follow-up work and home visitation. Small dispen-
saries are allowed to build up clienteles larger than
they can manage. More than one half of the patients
seek relief for conditions requiring the attention of
speciaHsts rather than of general practitioners. The
lack of specialized departments and inadequate
equipment, together with insufficiently trained spe-
cialists, result in an unintentional abuse of the pa-
tient who is placing his trust in the dispensary
doctor.
The overcrowding of dispensaries interferes with
proper medical work, when the physician must nec-
essarily give a part of his time to clerical work that
is essential, but can be done by one without medical
training. In some New Vork dispensaries physi-
cians are handling over 3,000 new cases annually ;
a state of aff airs which is opposed to efficient service.
On a three day a week service one physician cannot
properly attend to more than a thousand new cases
a year. Five new patients a day and ten to twenty
old patients represents an amount of work that is a
reasonable maximum, viewed from the standpoint
of the work accomplished. As A. Flexner says :
"The well conducted dispensaries are well equipped
and well organized dispensaries. The moment that
equipment and organization fail, omission begins;
no general rule prescribes where it will stop." The
July 6, igiS.]
WILE: DISPENSARY ABUSE.
19
mere establishment of laboratories, however, is in-
sufficient : they must be used ; dispensary rush and
laboratory use are not generally compatible.
It is unfortunate, but true, that an abuse of pa-
tients ensues because dispensaries do not hold a
large proportion of their clientele until cure can be
written after their names. Tlie institutional char-
acter of the dispensary has tended to destroy the
personal relation which should exist between doctor
and patient in order to achieve the most successful
results. The institution of free dispensaries, which
for the most part are not free, making a charge for
registration, for drugs, and the appHances supplied,
tends to force some people into accepting charity
when they are perfectly willing to make some pay-
ment for service. The California Social Insurance
Commission, for example, found that of 2,587 pa-
tients, only fifty-three were dependent upon charity
for support, indicating that the great mass of dis-
pensary patients were not really in the dependent
class.
The hours are not properly fitted to the needs of
the clientele, requiring many to absent themselves
from gainful occupation and others from educational
institutions, occasioning losses which may actually
outweigh the benefits gained by the visitation.
When the New York County Medical Society in
1913 had a committee investigating dispensary abuse,
it was recommended that charges for drugs and ap-
pliances be stopped. Would it not be advantageous
to make the charge for services given, rather than to
point out that the drugs and appliances v^ere, after
all, the main things for which people should pay at
a dispensary?
The support of dispensaries of various types falls
upon what may be regarded as a loosely defined com-
munity. In some instances expenses are borne by
unions, department stores, community centres, sup-
porters of organized hospitals or private detached
dispensaries. That the funds expended shall accom-
plish the maximum results is desirable.
It is obvious that certain shortcomings arise from
the fact that patients do not get under dispensary
treatment early enough, and many are assigned to
a single department of the clinic wherein diagnosis
cannot be made without reference to other depart-
ments. There is a constantly growing need for
team work in diagnosis, wherefore dispensaries
should serve their communities by developing diag-
nostic centres. This achieved would be a distinct
advantage to the doctors, in that it would be possible
for them to go with their patients to such diagnostic
centres for the purpose of securing consultations at
fees which are not prohibitive. It would also raise
the standard of medical practice by more closely
linking the private practitioner with the diagnostic
specialist. Diagnostic centres are by no means new,
and their establishment on a pay basis in conjunc-
tion with existing institutions is one of the problems
of the immediate future. The establishment of d's-
pensaries should be more related to the needs of spe-
cific portions of the population. Zoning systems have
been attempted in connection with the treatment of
tuberculosis, and are now being considered in rela-
tion to maternity and prenatal care. There is no
reason why the various neighborhoods now repre-
sented by distinctive associations should not serve
as a starting point for a consideration of dispensary
needs, with a view to safeguarding the welfare of
the neighborhoods.
For greatest community efficiency, the outpatient
department of a general hospital represents an ideal
situation, although some of our most successful dis-
pensaries are dissociated from intimate hospital re-
lations. The advantages to be derived from the in-
terrelations of hospital and dispensary stafifs, the
rapid transfer from hospital to dispensary or dis-
pensary to hospital, as may be required, together
with follow up work and social service attention,
would redound to the advantage of the community.
Unfortunately, communities have been accustomed
to assess the value of dispensaries upon the number
of patients treated, a faulty basis of judgment, for
tlie number of patients is not an index of the char-
acter of the work performed. The number of visits
made by each patient would be a safer index, while
a tabulation of those who have accepted and fol-
lowed the advice received until they were recorded
as cured would be of far greater value. Here is an
instance : the inquiry into the Department of Health,
Charities, and Bellevue and AUied Hospitals report-
ed a study of a thousand patients at the Gouverneur
Hospital Dispensary. The average number of vis-
its in the general medical clinic was 2.3, and 3.7 in
the gynecological clinic. Of the thousand patients,
52.6 per cent, paid only one visit, and one half of
these said they had received no benefit ; 47.4 per
cent, made two or more visits ; 26.5 per cent, stated
that no benefit had been derived, and only 6.4 per
cent, were reported as cured. Under such circum-
stances, it would be difficult to say that the value of
the dispensary for this thousand patients had been
very great ; but, hear further : in one clinic 16^ pa-
tients ivcre treated by tzvo physicians in an hour and
a half.
The previous Health Commissioner, Doctor
Amster, has raised this question : "Is it better for
a patient to have competent medical services within
his means of payment, or to have indifferent medical
care which is considered free?" This question in-
troduces a number of problems. As demonstrated
in the report of Chapin, 1909, "Expenditure for
the cure of sickness increases as income increases."
"An income of less than $800 does not permit ex-
penditures sufficient to care properly for the health
of the family." Under circumstances existing to-
day these figures would probably be raised in the
city of New York to .1ii,200 The place, therefore,
of dispensaries is particularly in connection with
families in the low income group. On the other
hand, families having incomes between $1,200 and
$1,800, under the pressure of prolonged illness, or
of sufferings which require most careful diagnosis
and continuous study, would soon be reduced be-
low the line of self support if there were no in-
stitutions enabhng them to cut down on their med-
ical expenditures without sacrificing their efficiency.
Under such circumstances the establishment of pay
clinics appears to be of the utmost importance. The
charges that could be made by willing patients would
then be for medical service rather than for drugs
and appliances, as too generally the present cus-
tom. Pay clinics are not new. A genitourinary
clinic in Brooklyn, a neurological clinic in Manhat-
20
IVILE: DISPENSARY ABUSE.
[New York
Medical Journal.
tan, a clinic in charge of labor organizations, have
already introduced this measure, modeling them in
part upon the most excellent pay clinic plan devised
and established by the Boston Dispensary. The pay
dispensary takes on new value because of the possi-
bility of the growth of social insurance. Health
insurance laws will not suffice to control disease,
but they have a tendency to decrease it as a means
of decreasing compensations. On the other hand,
health insurance, by giving adequate financial re-
lief to individuals, will make families less dependent
upon charity. For this reason society tends to be
relieved of the burden of a free dispensary by the
substitution of a dispensary system which will help
families maintain their independence and self re-
spect.
One of the greatest social abuses lies in the fact
that modern medicme is stressing preventive work,
while dispensaries for the most part are devoting
little thought to this service. As some one has
suggested, modern medicine deals with disease on
a wholesale, rather than on the retail plan. The
institution of babies' welfare stations in connec-
tion with clinics and cardiac classes, tuberculosis
classes, and similar bits of educational machinery,
represent an attempt of dispensaries to participate
in large preventive movements. The inadequacy,
however, of work in this direction, evidences a form
of social abuse which easily may be rectified. The
dispensary should expand to become a health edu-
cational centre in order to live up to its most modern
obligations.
The dependence of dispensaries upon vokmtary
service is unsatisfactory. There is no reason why
dispensaries should be wholly dependent upon med-
ical charity. Voluntary medical service is not to
be regarded lightly in so far as efforts and interests
are concerned, but there is a grave question as to
v/hether society as a whole can safely depend for
sufficient and efficient medical service upon unpaid
medical care.
Then, as to following up patients. If dispensa-
ries are to treat ambulant cases only, obviously,
assuming that illness prevents attendance at the dis-
pensary, there is a break in the medical care, unless
provision is made for home visitation by doctor,
rairse, or social worker. H. F. Day, in the Boston
Medical and Surgical Journal, March 2, 1916,
points out the gains of a follow up system. In a
male genitourinary service, during 1911-1912, be-
fore the follow up system was installed, only 37.6
per cent, of the patients made more than one or
two visits, while during 1914-15, after follow up
care, 76.5 per cent, made more than one or two.
Similarly, on the medical service the figures were
fifty-one per cent, before and ninety-four per cent,
after follow up work was begun. As to the advan-
tages of dispensary service, in the eye clinic in 191 1-
1912 before follow up, fifty per cent, of those advised
10 secure glasses purchased them, while in 1914-15,
after the follow up system, ninety-seven per cent, pur-
chased glasses. In the gynecological clinic, 1913, seven
per cent, took advantage of the opportunity to secure
the operation advised, while in 1914, ninety-five per
cent, accepted the operation as a result of the fol-
low up plan. Seeing all this, it might properly be
asked whether society is not being abused when
there is failure to institute a follow up scheme which
results in such a marked advantage to patients.
The Webbs, in The State and the Doctor quote
E)r. I.auriston Shaw of Guy's Hospital as stating,
"These great institutions (outpatient departments
of voluntary hospitals) while preventing the proper
development of other agencies, are quite unable
clnciently to fill their places. They cannot carry
their services to within reasonable distance of every
patient's door, nor can they follow the patient to his
home when too ill to attend at the outpatient depart-
ment, and ill enough, or suitably ill, for admission
to the wards." This criticism loses force when dis-
pensaries are properly organized with investigators,
visiting nurses, social service workers, and f)Ossibly
visiting physicians.
Many dispensaries are not located with relation
to the cHentele to be served. A new plan is required
for the development of industrial clinics, ambulance
zones and first aid stations in order to promote so-
cial efficiency. From the standpoint of effective
social use the partial employment of a dispensary
plant is unsatisfactory. By rotation of physicians,
dispensaries may give better service and provide for
tpecial hours for children and workers without in-
terfering with work or education This also would
be more economical in that the per capita cost would
be decreased through the spread of the overhead
cliarges.
The time has come when the dispensary must take
on the character of a health centre. A department
for the prevention of disease was projected at
Mount Sinai Hospital, and every dispensary should
have a department for the examination of those
who believe themselves to be in good health. The
numerous studies which have already been made
through the agency of the City Health Department,
through life insurance examinations, through school
medical inspection, and the examination of potential
recruits have revealed the importance of greater
stress being placed upon the study of supposedly
normal individuals. Dispensary work oecomes
most effective through the early detection of dis-
eases or the recognition of defects, which, if neg-
lected, may lead to incapacity. It is to the credit
of the city that ^he health centre idea has already
been recognized and at least one such centre is in
actual existence.
It appears essential that some large coordinating
movement be instituted that will serve as a clearing
house for dispensary activities. A step in this di-
rection has been taken in the Babies' Welfare Asso-
ciation which coordinates a large number of institu-
tions interested in the welfare of children. The
principle involved however, is applicable to the dis-
pensaries when petty jealousies are cast aside and
dispensaries are recognized as possessing an excuse
for existing only in proportion to their service to
society.
There has been marked failure to utilize construc-
tively the statistical material available from dispen-
sary records, faulty as they may be. They hold a
vast amount of valuable material which might lead
to reforms in medical and social treatment.
We are in an age when dispensaries can no longer
July 6, 1918.]
MARCUS: BIBLICAL EVOLUTION OF MEDICINE.
21
feel the individual case to be more important than
the disease for which he is treated. Treating a man
for rheumatism is entirely different from treating
rheumatism in men. Too frequently a rare disease
presenting itself in a clinic is deemed of far greater
importance than the vital resources of the patient
suffering from it. Social benefit is derived from
the study of the patient and his exhibition as clinical
material, but equal interest should be manifest in
his rapid restoration.
Dispensaries abuse society in applying the term
"minor" to conditions which are not fully appreci-
ated as factors in social economics. Chronic rheu-
matism, bronchitis, cardiac diseases, renal degenera-
tion, arteriosclerosis, "colds," are conditions which
may appear to be too routine and individually incon-
sequential in the hurried dispensary. From the
social standpoint they are conditions of major im-
portance. The amputation of an index finger is
economically and socially of equal importance to the
diagnosis and operation upon a patient with appen-
dicitis. Social values of diseases are emphasized
with the development of highly specialized clinics
for the early detection of disease or the prompt giv-
ing of adequate first aid treatment. In cancer,
mental diseases, pediatrics, and venereal diseases,
this has given rise to new types of dispensaries in
which public education is deemed of the utmost im-
portance.
Of primary importance is the lack of adequate
dispensary standards, a condition which is being
gradually remedied as a result of recent recognition
of its value.
In the thirty-fifth annual report of the Charity
Organization Society, discussing a study of 103 fam-
ilies, the comment is made that fifty-five per cent, of
the sickness was "of the chronic and degenerate type
where the individual needs reeducation and adapta-
tion to lead the efficient life, and where the social
and economic situation must be understood in order
to improve conditions." The change required in-
volves shifting the viewpoint from the Individual pa-
tient to the social, economic, educational, public
health point of view which should mark the purpose
of every dispensary. The private patient is a term
which has long been employed, but without due
thought to the significant fact that every patient has
his relations to the public health. When dispensary
systems regard themselves as social institutions for
the protection and promotion of public health, and
adjust their organization, methods, and means of
support, in accordance with this view, the various
abuses now attributed to dispensaries will cease 10
exist.
230 West Ninety-seventh Street.
Noma Following Paratyphoid B Infection. —
E. Romanelli (La Riforma Medica, April 6, IQ18)
reports a case with a fatal termination in a child of
two years. The noma followed an infection with
paratyphoid B and the mouth condition was shown
to i)e due to the same bacillus. .A.ntidiphtheric serum,
so highly recommended by some, was found ineffica-
cious, while arsenobenzol successfully used in sev-
eral cases by NicoU was given without effect in this
case in daily doses of .30 gram. The unfavorable
result was probably due to the severe infection.
A BRIEF BIBLICAL EVOLUTION OF
MEDICINE.
By Joseph H. Marcus, M. D.,
Atlantic City, New Jersey,
Attending Physician to the Jewish Seaside Home, Atlantic City.
According to ancient tradition, a woman after
giving birth to a male child remained unclean for
seven days ; in the case of a female child, four-
teen days. Then followed a period of purification —
for a male, thirty days ; for a female, sixty-six.
Referring to another source, miscarriages fell under
the same law, provided, however, the fetus was
completely formed and its features were well differ-
entiated. Monstrosities and all fetuses not viable
were exempt from the above named rule. This
interpretation of the Biblical law served as an in-
centive to the scholars of that period for the dili-
gent study of embryology. The esteem in which
those were held who occupied themselves with this
study is shown in the legend of King David, who
devoted a great deal of his time to the diligent pur-
suance of these investigations. Samuel, it is said,
was able to tell the exact age of a fetus. The fetUa,
it was held, is completely formed at the end of
the sixth week. A grave digger, by occupation,
but also an enibryologist, describes an embryo ai
the end of the sixth week as follows: "Size, that
of the locust; eyes are like two specks at some dis-
tance from each other ; so are the nostrils ; feet like
two silken cords; mouth like a hair; the soles are
not well defined." He adds that the embryo should
not be examined in water, but in oil, and only by
sunlight. Samuel contended that it was impossible
to differentiate the sex prior to the end of the fourth
month. As mentioned in Gen. R. xiv., the soft parts
are formed first, then the bones. Monstrosities,
cyclopia, monopsia, double back with double spinal
column, and atresia esophagi, etc., are also men-
tioned.
The Bible identifies the blood with the soul. The
ancient scholars regard blood as the essential prin-
ciple of life. The relation between strength and
the development of muscles is mentioned in the
Bible. These students noted the fact that the muscles
changed their form when in motion. Respiration
is compared to burning, and expired air cannot
sustain life. The life of the organs of the body
depends upon the heart. Each gland secretes a
fiuid peculiar to itself, although all the glands de-
rive their material from the same source. The
difference in the structure of the teeth in herbivor-
ous and carnivorous animals is noted. Saliva, be-
sides moistenmg the tongue, adds to the palatibility
of food. The stomach performs a purely mechan-
ical function, that of churning the food ; it is com-
])ared to a mill. Digestion proper is carried on in
the intestines. The time occupied in the process of
digestion is not the same in all individuals. The
end of the digestive period is made manifest by
the return of hunger. Eating when the bowels are
full is likened to the making of a fire in a stove
from which the ashes have not been removed. Nor-
mal defecation hastens digestion. Birds digest their
food rapidly ; dogs slowly. The reasoning faculties
are lodged in the brain. The movements of the
body depend upon the integrity of the spinal cord.
22
MARCUS: BIBLICAL EVOLUTION OF MEDICINE.
[New York
Medical Journal.
There are numerous references to the influence of
climate, customs, trade, etc., upon the development
of the organism as a whole, and upon certain groups
of muscles. By one savant, the menstrual is con-
sidered as an extra nutritive material which is dis-
charged periodically when of no use, but which is
converted into milk during the period of lactation.
Absence of menstruation indicates sterility ; fear
and cold may be instrumental in the arrest of the
flow.
That medicine was an integral part of the religion
of Israel is made more evident from the patholog-
ical studies of the rabbis than from any other branch
of medical science. It is, indeed, remarkable that
ihtse philomaths seem to have been the first to
recognize practically, wliat is at present the prevail-
ing theory, namely, that the symptoms of all dis-
eases are merely outward manifestations of in-
ternal changes m the tissues — a theory never ad-
vanced by their contemporaries, e. g., Hippocrates
and his disciples, and only vaguely hinted at by
Galen. Their pathological studies were a direct out-
growth of the law concerning the "flesh that is torn
of beasts in the field," which becomes unfit for food.
Certain rules concerning this infection are enjoined
upon those who come in contact with the flesh of
an animal that "dieth of itself or is torn by beasts."
These students went a step further, and declared
that the word "unfit" included the flesh of animals
aftiicted with any disease that sooner or later would
have caused the death of the animal.
In order, therefore, to determine the condition
of the internal organs, each slaughtered animal was
subjected to an autopsy, that is the practice even
today. The pathological changes of the lungs have
been most diligently studied as to color, consistency,
cavities, and vegetable growths. Redness of the
lungs indicates hyperemia, a condition which is not
fatal; blue and light green discoloration is not con-
sidered dangerous ; black designates that the object
has begun to disintegrate ; and the part of the lungs
thus affected cannot return to its normal state.
Bright yellow is regarded as the color indicative
of the most fatal condition. If, on inflating the
lungs, it is found that air does not enter into a
certain part of them, it is then important to find
out whether the obstruction is caused by pus or
mucus in the bronchi, which might have been ex-
pelled by coughing, or is due to thickening of the
tissues. In the latter case the animal is unfit for
food. Caseous degeneration "in which there is no
blood, and it crumbles under the nail," makes the
flesh of the animal unfit for food. Softening of
the lung is most fatal. In the case of an animal
with collapsed lungs the following rule is given :
If after they have been immersed in water they can
be inflated with air, the flesh of the animal is fit
for food; if they cannot be so inflated, it is unfit.
A pitcher shaped cavity in the lung, filled with fluid,
renders the animal unfit for eating. An empty cav-
ity is not dangerous to life. The rabbis speak of
vegetable growths on the lungs in connection with
adhesions of the lung to the thorax; and they de-
scribe several forms, all of which are not considered
dangerous.
Perforation of the outer coat of the brain is not
fatal ; but the slightest perfusion of the inner coat
is mortal. One scholar contended that an injury
of the spinal cord is deadly, while another held
that it is only fatal when the injury extends to
more than one half of its transverse diameter. A
sheep that dragged its hind legs was diagnosed as
suft'ering from ischiagra, but an opposing factor
maintained that it was a paralysis due to the solu-
tion of continuity of the spinal cord. The sheep
was killed, and the diagnosis of the latter was con-
firmed. This is the only case on record in ancient
literature where a diagnosis was made during life
and verified at a post mortem examination. Rabbi
Levi saw one who suffered from tremor of the head,
and he remarked that the man was in sufferance
as a result of softening of the spinal cord; he held
that such cases were not fatal, but that the pa-
tients lost their reproductive functions.
Penetration of the heart is considered fatal, but
no other pathological changes of the heart are men-
tioned. A transverse division of the trachea is not
regarded as fatal, provided it is less than one half
of its circumference. Longitudinal wounds of the
trachea heal rapidly. Perforation of the esophagus
is quickly mortal in its consequences, since the food
may escape into the mediastinum. Valvus is held
to be fatal, and perforation gf the stomach or of
the intestines is fatal. Extirpation of the spleen
in animals and m man is not considered fatal, but
rupture or wounding of this organ is. Ablation of
the uterus is mentioned, and is not considered mor-
tal, but atrophy and abscess of the kidney are.
Accumulation of transparent fluid in the kidney is
not fatal.
The pathological changes in the liver mentioned
in one of the ancient books -of learning are: that in
which the organ becomes dry and bloodless and
"crumbles under the nails" ; abscess, and stonelike
hardening. Extirpation of the liver is not consid-
ered fatal if there is left intact the part which sur-
roimds the biliary duct and "that place from which
the liver receives its vitality." Absence of one tes-
ticle is spoken of, and the unfortunate is looked
upon as sterile. Hypertrophy and atrophy of the
testicles, scrotal hernia, and elephantiasis scroti are
also mentioned. Various forms of hypospadias and
epispadias are described. One hundred and forty
pathological conditions are enumerated which in
the eyes of the law make a man a "cripple," and,
therefore, unfit to perform any religious service in
the Temple. Fifteen of these describe various oste-
ologic deformities of the head, spine, and extrem-
ities.
The rare cases of individuals having a tendency
to hemorrhage are related, and the fact that this
affection is hereditary is noted.
Wounds in the different parts of the body caused
by various weapons, sword, arrow, hammer, etc.,
are mentioned in the Bible, and often elsewhere.
Inflammation and abscesses, gangrene, and putrid
discharges are also referred to. Wounds were
treated by the application of wine or oil, bandages
or sutures. The surgical operations mentioned in
the Bible are those of circumcision, and castration,
the latter being prohibited. During the Scholastic
Period, surgery attained a high degree of develop-
ment. Many physicians devoted themselves to it.
Surgeons, when operating, used to wear a tunic
Juh 6, 191S.]
MARCUS: BIBLICAL EVOLUTION OF MEDICINE.
23
over their dress. They used various surgical in-
struments. In major operations the patients were
given an anesthetic or sleeping potion. Venesec-
tion was extensively used upon the healthy and the
sick alike, one authority going so far as to recom-
mend its use once in thirty days, but after the age
of fifty venesection should be employed less fre-
quently. It is not to be performed during inclement
weather; and a careful dietetic regime should be
followed for some time after the operation. Bleed-'
ing by means of leeches and by means of cupping
is frequently mentioned.
Dislocation of various joints, fractures, amputa-
tions, and trephining, are discussed in the Talmud
(the Book of Learning). Artificial teeth, made oi
hard wood, gold, or silver were employed. Extir-
pation of the spleen was successfully employed upon
man. The following forms of castration are men-
tioned : amputatio membri ; extirpatio testiculorum ;
subcutaneous stretching or cutting of the cord; and
obliteration of the testicle by means of gradual
pressure. Intubation of the larynx was practiced
upon animals, and a plate was used in case of loss
of substance of the cranium. A uterine speculum
is also mentioned.
The practice was adopted of freshening up the
borders of old wounds in order that union might
be effected. The operation for imperforate anus
in the newborn is described. In an accident in
which the abdominal viscera were protruding
through a wound, the reposition of the organs was
effected automatically by frightening the patient,
which caused the abdommal muscles to relax; after
this the external wound was closed by means of
sutures. Nasal polypus is said to cause "fetor ex
ore." Crutches and various other orthopedic appli-
ances are mentioned, while intestinal parasites and
hydatids are frequently spoken of. Extraction of
the fetus through an incision made in the abdomen
was an operative procedure known to these Tal-
mudic students.
Human anatomy, the basis of all medicine, had
not been studied scientifically by the physicians of
the Talmud ( they seem only to have boiled human
bodies, as the physicians of other countries had
done, and, counting the bones, to have come to erro-
neous conclusions), by Hippocrates, by Galen, who
used monkeys for his subjects ; by the Arab physi-
cian, Avicenna, or by their respective followers.
The Jewish and the Mohammedan religions, and
the Christian church were all opposed to a desecra-
tion of the human body such as proper anatomical
investigation would have required. The German
Emperor Frederick 11 permitted dissection ; but
Pope Boniface VIII prohibited it. Hippocrates
and Galen ruled supreme in the medical world up
to the thirteenth century. The Arab physician,
Avicenna, wrote his celebrated Canon, which work
took rank next to the writings of Hippocrates and
Galen. But their works were translated into Ara-
bic, a language which, in Europe, was known only
to the Jews, who translated them into Hebrew and
Latin, and thus held the key to medical science.
Learning from these great scholars, the Jewish
teachers and physicians wrote works of their own.
They excelled in surgery and in medicine (includ-
ing ophthalmology), in therapeutics, pharmacology,
and toxicology. Their connection with the drug
trade of the East helped them to contribute also to
a practical knowledge of pharmacology at a time
when every apothecary posed as a doctor ; but with
these branches of the true science of medicine, there
was during the first miilenium of the common era
combined also a knowledge of pseudoscience, astrol-
ogy, and cabala. Superstition was still all pervad-
ing, and it was against these pseudosciences Mai-
nionides wrote. Astrology was to him not based
on science, but on superstition ; and in his works
he warns against its usage. Luigi Mondino de'
Luzzi, professor at Bologna, who died about 1326,
dissected three female bodies. From that time anat-
omy received, with little or no interruption, the
attention it deserved, and medicine, from being a
more or less pseudoscience, commenced to be a real
one, although half a millennium had still to pass
before it was entirely liberated from mysticism and
superstition.
52T Pacific Avenue.
Treatment of Wounds of the Pleura and Lungs.
— Gregoire {Fresse mcdicale, March 14, 1918), dis-
cussing the indications for radical surgical treatnient
in these cases, states that while persisting hemor-
rhage is a definite indication for operation, it seldom
presents itself, the injured subject seldom reaching
the operating table while still alive. The remaining
dangers to which these cases are exposed are practi-
cally limited to infection. Primary infection, while
rare, is so severe and sudden as to resemble an actual
pleuropulmonary gangrene, and the subject gener-
ally succumbs under any form of treatment. Usu-
ally, infection is secondary. Pleural infection is
commoner and more grave than lung infection. The
pleura may have become infected either directly or
from the injury to the parietes or a wound of the
lung itself. The second of these varieties is very
frequent; its prophylaxis consists in treatment of
the existing compound fracture, the removal of free
bone fragments, and proper cleansing measures.
Fluid accumulations in the thorax should not be
neglected, forming a good culture medium. Even
in the absence of infection, some effusions must be
eliminated by thoracotomy because they are recur-
rent ; thoracentesis is insufficient in these cases,
probably because it fails to remove clots and false
membranes. Foreign bodies still constitute a per-
plexing problem. Projectiles, while highly septic
and causing a large mortality by lung infection, are
nevertheless often tolerated perfectly for months.
Some fragments, it would seem, can be allowed to
remain ; others must be removed. But to decide
which ones are those likely to cause serious com-
pHcations is a difficult matter. Doubtless any in-
trathoracic projectile which is causing no alarming
physical signs, hemothorax, nor copious hemoptysis,
may, unless of large size, be allowed to remain with-
out immediate risk. Where, in addition to a re-
tained projectile, an effusion exists, mere evacua-
tion of the thorax is followed by recovery in the
very great majority of cases, provided the foreign
body is smaller than a hazelnut. In such cases the
thorax need be drained only if pus is found. Larger
projectiles should be surgically removed, but these
are seldom retained in the thorax.
Medicine and Surgery in the Army and Navy
THE liPlDKAlIOLOGY OF TRENCH
WARFARE.
Bv Vincent Bardou, M. D.,
France,
Auxiliary Physician, 124th Regiment.
It is generally recognized that the physical con-
dition of the soldier on campaign of¥ers an excellent
culture medium for all known types of bacteria.
The present trench warfare is somewhat sedentary,
obligmg the men to remain for hours at a time in
mud in winter and in water when the thaw comes.
1 will give my personal experience of one year
passed with my regiment in the trenches, as far as
the epidemiology of the situation is concerned.
Cases of typhoid fever were quite numerous in
one of our battalions after a sojourn of twelve days
in muddy trenches on the Somme, a place where
infiltration of water was practically nil, the soil be-
ing composed of clay. The mud, dampness, and
fatigue were important factors in the etiology of the
various diseases observed in our regiment, but their
importance was only relative. The extent these
different edipemics assumed is hardly to be com-
pared with that formerly noted.
From the beginning of October to the month of
January every man who came to the medical visit
with symptoms of febrile gastric disturbance was
kept under observation at the regimental infirmary,
and if, at the end of two days, no improvement took
place and if fever continued, he was evacuated to
an ambulance at the rear with a diagnosis of "febrile
indisposition."
Each month the ambulance returned a report to
us showing the number of cases of typhoid (labora-
tory diagnosis), the number of deaths and the com-
plications arising. Up to November there were
eight cases of typhoid with quite serious complica-
tions.
From the month of December we began vaccinat-
ing all the men at the front with Vincent's vaccine,
the ambulance doctors notifying us of their arrival
on a certain day and time. All the men without
exception, led by their sergeants, were brought to
be vaccinated and after each injection they were
given either one gramme of antipyrine or analgesine.
The vaccination was carried out in three series,
one week apart and each individual received five c.c.
of serum in all. Theoretically, after each injection,
the soldiers should rest up for at least twenty-four
hours. I shall show hov%' this rest was observed.
It is hardly necessary to say that a very strict con-
trol was exercised in order to see that every one
got his vaccine. Officers, under officers, and soldiers
were obliged to present themselves at the infirmary
on vaccination days. Those who had exceeded the
quarantine, as well as sick men, were of course
exempted. Let me take one battalion of our regi-
ment as an example and follow it during its vac-
cination, so as to give an idea of the way in which
prescriptions were carried out, given the circum-
stances. The battalion in question had been twelve
consecutive days in the trenches, with rain, snow,
and infected mud. The poor fellows were rationed
only during the night and therefore only got cold
food. They were iinally relieved and on the next
ray received orders to go to a village some distance
away. Without having any rest of any consequence
they started on the march and when they arrived at
the cantonment they were informed that the first
injection of antityphoid would be given them in two
hours. Our commander, always very solicitous for
the health of his men, tried by every means to put
off the vaccination until the men were in better con-
dition, but he failed in the attempt.
Consequently, all these fagged out men, in a rather
bad physical condition, were obliged to be vac-
cinated. After their injection they were given anti-
pyrine, and with it some hope that they would get
some rest. But at 1 1 o'clock that same" night there
was an alert sounded in the cantonment and after
divers orders the departure was fixed for lo 130
in the morning. Consequently, the men passed a
sleepless night, only to leave the next morning for
a point eight miles ofif on the march. By good luck,
cart.s had been requisitioned so that their outfits
could be carried for them and it was only after a
day passed in a railway train that the greatly desired
rest was at last given them !
After such adventures it might be supposed that
many men would be ill. Far from it. The number
of sick who came to the medical visit, was just about
the same.
The second series of injections were given imder
better conditions, although the next day's rest was
interfered with by a review that a general was to
pass a mile and a half from wdiere the battalion was
stationed. Upon this occasion the men reacted
more. The second injection was more painful and
the temperature was higher, although in no case
did it go above 102.7° F. As to the third series
of injections, it offered nothing in particular.
One might suppose that numerous and rather
serious accidents in anaphylaxia would arise, but
such was not the case. However, I w^ould record
the following three cases :
Case I. — Soldier N., ten minutes after his second injec-
tion, complained of feeling generally ill and of an intense
pruritus. A scarlatiniform eruption covered his body,
particularly over the trunk. No rise in temperature. The
eruption diminished in intensity and a half an hour later
there was no trace of it. On the following day there was
nothing abnormal and the patient had passed a good night.
Case II. — Soldier G. presented, several days after being
vaccinated, a kind of tension of the tissues over the point
of injection and pain in the entire upper left limb upon
the slightest movement. He developed an abscess. I men-
tion this case because this complication after vaccination
with Vincent's serum, although not common, is occasion-
ally met with and is due to the serum itself and not to im-
proper asepsis.
Case III represents atiother form of accident following
typhoid vaccination which cannot be attributed to the
injection is the following case. A soldier, at the time of
the injection, was seized with a mild syncope of a very
transitory type, but which left him in a condition of gen-
eral weakness which persisted until the next day. This
individual was alcoholic and very emotional.
The above are the only instances of untoward
effects of typhoid vaccination which I observed.
Did the antipyrine have anything to do with them?
July 6, 191S.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
25
I do not think so. The results were very appre-
ciable and cases of typhoid decreased rapidly.
There is an epidemic disease particularly to be
feared in all agglomerations of men ; I refer to
measles. It is true that we had many cases, espe-
cially in January and in June. The first case de-
veloped during the first week in January, and after
this several cases occurred in dififerent companies.
There were few complications in the form of rather
obstinate bronchitides but generally mild in typo.
I think that the majority of cases of measles were,
in reality, rubeola, not merely because the subjects
attacked had already had the measles in childhood,
but also on account of the mildness of the process.
But for all that, we certainly observed true measles
with an intense eruption, high temperature and com-
plications. The contagiousness was, taken all in all,
very slight, and our regiment only gave a total of
sixty-two cases of rubeola and among these there
were not more than ten cases of true measles.
During the entire year a single authentic case of
scarlet fever occurred, and, as soon as discovered,
all necessary precautions were taken, viz., isolation
of all the men who had been in contact with the
patient, disinfection of the rooms occupied and
whitewashing the walls. Every morning the order-
lies made the men gargle with potassium perman-
ganate solution, and at the visit their throats v/ere
carefully examined in order to detect any suspicious
angina.
I well remember the ravages caused by scarlet
fever and measles in 1912 among the different gar-
risons, and yet these men were far less fatigued
than our regiment was during trench warfare.
The most serious epidemic we had was mumps,
and it can be truly said that not a month passed
without some cases occurring. However, in the
summer there were decidedly fewer cases. The
height of the epidemic was during January-Febru-
ary, and in these two months we had over 100 cases.
Then the epidemic began to subside gradually, so
that by July there was not a single case, but as the
season advanced they began to recur. As to prophy-
laxis, as soon as a case was diagnosed, the patient
was isolated in the first place, and then evacuated
at once to the rear in a special automobile for con-
tagious cases.
Although we were in a country rather inclined to
cerebrospinal meningitis, only two cases occurred
in the entire regiment. Here, briefly, are the case
reports :
Case I. — D. was brought to us on a stretcher on Jan-
uary 20th. He was unable to move ; he could not speak,
but gave us to understand that his head pained him. Ker-
nig's sign distinct. Easy and frequent vomiting. The di-
arrnosis of cerebrospinal meningitis was only too evident.
Temperature 103° F., abdomen distended. He was imme-
diately evacuated to the rear and the entire company iso-
lated. Each, morning all the men had their throats swabbed
with iodine glycerine, and a careful disinfection of the
nose and eyes was carried out. No other case occurred in
the company. The patient was heard from later when he
was on the road to recovery.
Case H. — Corporal R. came to the office with a tor
ticolis and headache, in April. The patient stated that he
had vomited in the evening before the visit. Examina-
tion showed that the movements of the neck were painful,
tongue coated, temperature 101° P., and a slight Kernig.
The patient was placed under observation in the con-
tagious ward, and, on the following day, the stiffness of
the neck was more marked, Kernig's sign distinct. He was
evacuated with the diagnosis of cerebrospinal meningitis,
which was confirmed at the base hospital. Eventually, he
recovered.
On both occasions, the buccal mucus was exam-
ined in all the subjects who have been in contact
with both patients. Germ carriers were detected
and evacuated to the rear, where they remained
until all danger from them had disappeared.
It is to be remarked that although Ca.se I had
only been at the front for a fortnight, the second
had been there since the beginning of the campaign,
and in the cantonment where we were no case of
meningitis had been observed. Therefore, here
are two sporadic cases of cerebrospinal meningitis,
but an epidemic of the disease in the true sense of
the word, there was none. And these two cases
did not occur after particularly arduous days. The
first occurred while the regiment had been at rest
for twenty days; the second case developed while
we were in a quiet sector.
No case of tuberculosis was observed during the
year. There were some tuberculous subjects who
entered the ranks voluntarily and whose lesions
progressed from the fact of the campaign, but, of
primarily healthy men, becoming tuberculous from
fatigue and general war conditions, there were none.
Undoubtedly, life in the open, constant exercise,
healthy food, life in pine woods and, above all, reg-
ular and methodical use of time, such as can be car-
ried out in trench life, greatly influenced the sani-
tary condition of the soldier, because in barracks a
year does not pass without some cases of tubercu-
losis developing.
Finally, from the viewpoint of epidemiology for
one year, our regiment showed :
Mumps, about 150
Rubeola 62
Typhoid and paratyphoid 49
Cerebrospinal meningitis 2
Scarlet fever i
It appears to me that this little list is rather reas-
suring than otherwise, and proves that the sanitary
condition of the French troops during this war is
excellent, as it may be taken as a fair average of the
existing conditions throughout the western front.
MEDICAL NOTES FROM THE FRONT.
Resection of War Wounds.
Geneva, June 7, 1918.
In order to understand the indications in cases of
crus for resection, one must reflect upon those
cases in which it will be useful in a healthy subject.
For example, a joint is traversed by a bullet; there
results a comminutive fracture of the bones com-
posing it. Now, what end is to be attained by re-
section and what does the operation offer ?
If the patient is seen within a few hours after the
receipt of the injury the object of resection is to re-
move the contused and crushed portions which, if
left to themselves, will result in the production of a
suppurating arthritis. As soon as the crushed and
lacerated portions of hone are removed, those that
are deprived of all vitality, the essential condition of
26
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New Yo«k
Medical Journal.
conservative surgery lias been fulfilled and it is only
from the viewpoint of perfecting the orthopedic re-
sult derived from a resection that more extensive
sacrifice of osseous tissue is permissible.
If resections had only for ultimate end the thorough
removal of decomposing matter and to prevent the
retention of sepsis liquids which may develop in any
wound of warfare, the operation would be prac-
tically useless when the same objects in view can be
attained by other means. Render a wound aseptic
and afterward to maintain the asepsis is the essen-
tial indication to fulfil.
But this ideal antisepsis has not as yet been found,
and numerous are the cases where resection is indi-
cated without question, regardless of all the progress
made during the past three years.
When the patient is first seen it is often one or
more days after traumatism, at a time when a sup-
purating arthritis is already in progress or perhaps
a septicemia requiring radical measures of treatment,
yet a conservative treatment may still be essayed.
In these circumstances, resection has no other end
than to assure a free drainage, but it should be
economical, because it is of necessity done in healthy
tissue. Resection is to be done in cases of severe
crushing, serious wounds of the joints in which the
epiphyses are practically destroyed or at all events
are reduced to numerous fragments of all shapes
and sizes or when irrigation washes away a number
of splinters and bits of bone and where the rest of
the bone tissue is merely retained by a few strips of
periosteum or capsule. In most cases of war in-
juries a resection will be an essentially atypical one
on account of the infinite variety of¥ered by these
traumata. The treatment of a joint injury presents
for each articulation certain peculiarities derived
from its anatomical makeup and the function be-
longing to the limb. It is better to do a bloodless
operation by means of an Esmarch band, since a dry
wound will allow the surgeon to estimate better the
amount of damage done to the bone. The incision
is begun over the traumatic focus and should be car-
ried down to the bones. It must be long enough to
give proper exposure of the parts involved as well
as sufficient room to operate with ease. The mobile
bone splinters are removed, as well as missiles and
other foreign bodies, after which the number and
extent of the bone fissures are to be noted. The re-
section of bone will naturally vary in extent from
one case to another, but it is useless for drainage
purposes and bad for the future of the limb if too
extensively done. The amount of bone resected
should be in proportion to the extent of the lesions.
In subjects of twenty years of age or less, whose
growth is yet incomplete, it is better practice to re-
move nothing beyond the cartilages of conjunction.
In older subjects the extent of the exsection may be
greater, as the danger of future shortening from re-
moval of a fertile bone productive area is of much
less import. In the majority of cases it is necessary
to resect the other bone of the limb to the same ex-
tent as its fellow if the forearm or leg is the seat of
injury, as this is the only means for obtaining satis-
factory drainage and good union without pseudar-
throsis. The bone ends should be sawed of? evenly.
It is a question whether or not the bone should be
sutured with wire or other material. Some advise
suture, but since resection is done with the end of
obtaining good drainage between the two fragments
no suture should be used. It is hardly necessary for
me to say that the resection must be strictly sub-
periosteal, following the classic technic of Oilier and
the Lyons school. Immobilization is of the utmost
importance and may be realized by plaster casts or
some good splint, particularly the Thomas pattern.
American surgeons will do well not to overlook the
plaster casts with handles as used by the French, as
tl'.ey are unquestionably of great value for the treat-
ment of the wound and the ease they ofifer for fre-
quent change of dressings. Carrel's method with
Dakin's solution should be employed whenever pos-
sible. The dressings are to be changed as seldom as
possible, the temperature chart being relied on as an
indication for renewing them. The patient's facies,
pulse and pain, if any, must also be taken into con-
sideration. V/hether the case is one of immediate or
secondary resection the conduct to follow is the
same, but in the latter circumstance long incisions
and counter openings are essential. To obtain
asepsis of the traumatic focus, quite independently
of minute disinfection of all undermined foci in the
wound, every portion whose vitality is compromised
by suppuration should be cut away, in other words
the resection must be free and all necessary counter
openings made to assure absolute drainage. If any
benefit is to be derived from secondary resection it
must be done early. An important factor from the
viewpoint of operative results resides in the choice of
the time selected for the interference and it is more
than possible that this may explain the numerous un-
successful results obtained by resection recorded by
surgeons. In the majority of their reported cases
the lesion was advanced pyarthrosis where arthrot-
omy, attempted in the first place, failed and amputa-
tion became obligatory. It was thought that such
a sacrifice might be avoided by resection ; the results
were evidently mediocre, but the deplorable condi-
tions and the late date at which the operation was
undertaken explain the unfortunate results.
Finally, although resection performed during the
period of inflammatory reaction has quite a diflferent
prognosis from that where infection has developed,
it is nevertheless surprising to obtain excellent re-
sults occasionally, because the inflamed periosteum
becomes irritated functionally and consequently
ofifers a more powerful osteogenesis.
It is hardly necessary to say that many objections
have been raised against resection and there are
three that should certainly be considered. Firstly,
ankylosis has been said to result, but from the func-
tional viewpoint this cannot be considered as such
a bad outcome after all. It is often preferable to
have an ankylosed limb in good position than a joint
which ofTers a few movements, not extensive enough
to be of any practical use. As to flail joints, they
may be considered fortunate when the gravity of the
injury at the tim.e of operation is considered and a
useful limb may often result by modern perfected
orthopedic apparatus and limbs preserved by re-
section are of infinitely greater use than an ampu-
tated member. But no matter how encouraging and
excellent the results, conservative treatment cannot
July 6, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
27
be applied in all cases, and the continued progress
of a lesion that resection cannot eliminate must
ultimately lead to amputation, and this sacrifice
must sometimes be quickly made in order to be suc-
cessful, if after resection the case does not go
well, if suppuration continues or it osteomyelitis de-
■velop no hesitation is permissible. /Vmputation alone
can save the patient from death from septicemia. It
must also be done in extensive wounds of the limbs
with crushing of the bones and joints, severe lacera-
tion of the soft strictures or injury to the important
arteries and nerves. Here conservative surgery is
worse than useless.
Charles Greene Cumston.
ARMY MEDICAL SERVICE IN AUSTRALIA.
Differences in Organization from American Forces. —
Nurses Have Relative Rank. — Pharmaceutical Corps
with Commissioned Rank. — Scientific Service Corre-
sponds to Our Sanitary Corps.
Australians are more like Americans than any
other section of the Anglo-Saxon peoples, except the
Canadians. It is interesting therefore to note the
points of difference in the forms of organization
which have been adopted by the two peoples in their
army medical service.
In their general outlines the two services follow
the British model, rather than the Continental. Both
have a corps of medical officers and of dental offi-
cers of graded rank, the Australians have a corps
corresponding to our Sanitary Corps, in which, as
in our own army men of special attainments in
any direction may be commissioned, even though
not graduates in medicine. Theirs is called the
Scientific Service, a happier title than ours.
Their nurses have relative rank, and their pharma-
cists actual rank, in both of which they differ from
the United States.
Surgeon General H. D. Fetherston, Director
General of the Army Medical Service of Australia,
accoinpanied by his staff, passed through New York
some weeks ago on his way to the battle front in
France. During his stay in the United States,
General Fetherston visited the Surgeon General's
Office in Washington and was also afforded an op-
portunity to observe the operation of the medical
department at Camp Greenleaf and at the medical
supply depots in Washington and New York.
Major D. A. Cossar, staff officer for pharmaceuti-
cal, sei^ices in the Australian army, recently spent
a week or so in the United States, visiting the Sur-
geon General's Office and the medical supply depot
in Washington and the medical supply depot here.
He was on his way home through Canada after a
nine months' tour through Egypt, Palestine, Greece,
Italy, F"rance, Great Britain, and Canada, during
which he made a study of every phase of the med-
ical supply service of the Australian army. When
war was declared. Major Cossar was conducting a
pharmacy in Hawthorn, a suburb of Melbourne. He
was president of the Australasian Pharmaceutical
Society, and was called on in an advisory capacity,
with the honorary rank of captain, to help in the
reorganization of the medical supply service. As a
result the service was placed in the hands of ex-
pert pharmacists, with commissioned rank, and now
Australia has about a hundred commissioned phar-
macists with rank ranging fi^om second lieutenant to
major. There is a captain in charge of the medical
supply depot in each district, a political division cor-
responding to our state, and a captain or lieutenant
in 'charge of the medical supply service at each hos-
pital.
All the dispensing for the troops is done by "qual-
ified men," that is, men legally qualified to handle
poisons and corresponding to our registered pharma-
cists. This change came about eighteen months
after the war began. At first the Imperial forces
did not recognize the Australian commissions, but
now they do, and there are twenty-one commissioned
pharmacists serving with the Australian troops
"overseas" in France and England.
The length of the voyage between Australia and
Europe necessitates special care regarding sanitation
of the troop ships, and the medical department of
the Australian army has a special transport unit
which voyages to and fro constantly, to look after
the health of the troops going to and of the invalids
returning from Europe.
The whole of Australia has about 3,000 physicians
in active practice, though more than that are regis-
tered. Of these, 1,200 are in the Army Medical
Service. Some of them have been loaned to the
Imperial army, some are on duty with the Australian
troops in Egypt, Palestine, France, and in England,
and some are on duty in Australia. Many of the
medical reserve officers on duty in Australia are not
on full duty, but are called upon to give a day or
half a day as their services may be required, and
are paid only for such time as they put in on active
duty. This effects a great saving both from a finan-
cial and from a professional standpoint. A surgeon
residing near a base hospital can keep vip his own
practice, look after his own affairs, and still put in
two or three days or half days each week at the base
hospital. This method has been very helpful in
bridging over the lack of doctors for civil practice.
Australia has over 100 dentists in the "overseas"
army, and 300 in Australia, all of whom have com-
missioned rank, ranging from second lieutenant to
lieutenant colonel. Each dental unit is composed
of one dentist, two sergeants who are mechanics, and
a private as orderly. The scientific reserve includes
specialists in any line which will be likely to be use-
ful to the medical department, but who are not grad-
uates in medicine. The Australian Nursing Re-
serve includes 2,100 nurses in "overseas" duty, and
400 on duty in Australia. Every one of these nurses
has completed a full three years' training course.
Besides looking after the Australian forces, 400 have
been loaned to the Imperial army for service in
India, 400 for service in Greece, 200 for service in
Egypt, and a number for service with other than
Australian forces in France and England. Aus-
tralian nurses are paid at the rate of $2 a day and
upward, with allowance of sixty cents a day for
rations. There are two matrons in chief with the
relative rank of major, one in England and one in
Australia. Matrons, or chief nurses^ have the rela-
tive rank of captain ; head nurses, lieutenant, and
staff nurses, second lieutenant.
28
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
MEDICAL NEWS FROM WASHINGTON.
Readjustment of the Army Medical Corps. — Selection of
Surgeons. — Reorganization of the Army Nurse Corps. —
A^cw Appointments. — More Commissioned Officers
Needed in the Public Health Service. — Estimates for
New Marine Hospitals.
Washington, D. C, June 2g,
Important legislation affecting the medical service
of the military establishment has been embodied in
the army appropriation bill by the Senate, it being
based on the subject matter of separate bills that
long have been pending before Congress.
By the Senate amendments, the Medical Depart-
ment of the regular army is increased by one as-
sistant surgeon general with the rank of major gen-
eral, and three assistant surgeons general with the
rank of brigadier general, all of whom shall be ap-
pointed from the Medical Corps of the regular army.
The President also is authorized to appoint in the
medical department of the national army, from the
Medical Reserve Corps or the regular army, not to
exceed four major generals ancf eight brigadier gen-
erals for each 1,000,000 officers and enlisted men
of the entire national army. The amendment also
provides that the commissioned officers of the Medi-
cal Corps of the regular army, none of whom shall
have rank above that of colonel, shall be propor-
tionately in the several grades as now provided by
law ; and that the commissioned officers of the Medi-
cal Reserve Corps, none of whom shall have rank
above that of colonel, shall be proportionately dis-
tributed in the several grades as now provided by
law for the Medical Corps of the navy. The Presi-
dent is authorized to designate as "consultants" offi-
cers of either the Medical Corps or Medical Reserve
Corps and may relieve them as the interests of the
service may require. It is anticipated that promo-
tion in the Medical Corps of the regular army will
be at a normal rate during the war, and that the
commissioned personnel will not become too large
for the eventual military force to be maintained in
this country after the war.
The increased rank for reserve officers is intended
as a slight measure of recognition of the efforts of
distinguished surgeons and physicians in aiding the
government during the present emergency.
Those members of the commissioned personnel
of the army medical department who are selected
for surgical work are taken after the exercise of
the utmost care in ascertaining qualifications for
this particular kind of work. Selection comes under
the general surgery division of the Surgeon General's
Office, which is cliarged with the classification of
the surgical qualifications of all surgeons in the
United States, with selecting and grading those best
qualified to be military surgeons, and with placing
those that are commissioned where they can render
the best service to the army. Having selected those
that the army will require in a given time, the di-
vision assembles them in training camps and more
frequently in special schools for instruction in the
latest methods of surgery. Three of these schools
are in New York City, and one each in Philadelphia,
New Orleans, Rochester (Minn.), Chicago, St.
Louis and Cleveland. Attention also is given by the
general surgery division to surgical equipment, with
a view to keeping pace with the latest developments
in devices, apparatus, methods, etc. ; it selects the
personnel for overseas duty ; and it holds the record^
of all surgical cases in camps and cantonments.
The division also publishes a monthly magazine,
giving special surgical methods in use abroad, and
it has prepared a complete indexed digest, constantly
revised to date, of all the leading reports of cases
taken from American and foreign journals and
from the leading surgeons of the allied armies.
Colonel William H. Moncrief, Medical Corps, is
chief of the surgical division, and he is assisted by
Lieutenant Colonels M. G. Selig, R. P. SuUivan, and
A. B. Knaevel, and Captains H. Wilson and H.
Davidson.
Another amendment made by the Senate to the
army appropriation bill is the embodiment in that
measure of a separate bill relating to reorganiza-
tion of the Army Nurse Corps. The amendment
provides that the Nurse Corps shall consist of one
superintendent and as many chief nurses, nurses,
and reserve nurses as the Secretary of War may
prescribe. For each army or separate military force
beyond the continental limits of the United States
there is provided one director and not exceeding two
assistant directors of nursing service. The rates of
pay for the members of the corps are prescribed as
follows: Superintendent, $2,400; assistant superin-
tendents and directors, $2,000 ; assistant directors,
$].8oo; chief nurses, $360 in addition to the pay of
a nurse ; nurses, $780 for the first period of three
years' service, $840 for the second period of three
years' .service, S900 for the third period of three
years, $960 for the fourth period, and $1,020 after
twelve years' service (including in all cases time of
service as a contract nurse) ; reserve nurses, when
on active duty, shall receive the same pay as nurses
that have served in the corps for periods corre-
sponding to the full period of their active service ;
and all members of the corps, in addition to the
foregoing, the sum of $10 a month when serving
beyond the continental limits of the United States
(excepting Porto Rico and Hawaii). Provision
also is made for retirement after twenty years'
service ; for cumulative and sick leave ; quarters,
heat, light, transportation, and necessary expenses.
sjC ^ Sj^ ^ ifc
Lieutenant Colonel Charles F. Morse, Medical
Corps, has been appointed director of the Army
Veterinary Service, in place of Colonel Reuben. B.
Miller, Medical Corps, National Army, assigned to
other duties. Lieutenant Colonel C. J. Marshall,
Veterinary Corps. National Army, has been ap-
pointed assistant director. An advisory conned of
the Army School of Nursing has been appointed,
consisting of Colonel W. H. Smith, chairman. Colo-
nels C. L. Furbush and W. F. Longcope ; Misses
Adelaide Nutting, Lillian D. Wald, and Anna C.
Maxwell; the superintendent of the Army Nurse
Corps ; superintendent of the army Nurse Corps ;
'superintendent of the navy Nurse Corps ;
director of Department of Nursing, American Red
Cross ; president of the American Nurses' Associa-
tion ; president of the National League of Nurse
Education ; president of the National Organization
of Public PTealth Nurses ; and the dean of the Army
July 6, 191S.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
29
School of Nurses. A standing committee, com-
posed of Colonels F. F. Russell and B. C. Vaughn
and Lieutenant Colonels W. H. Welch and H. D.
Arnold, has been appointed to consider and report
to the Surgeon General of the Army upon all ques-
tions of poHcy concerning undergraduate medical
education used by the medical department, the
medical colleges, or other instrumentalities con-
nected with such undergraduate education, or with
hospit^al internships, etc. Lieutenant Colonel
Arnold has been designated as the representative of
the Surgeon General to the committee on education
and special training of the War Department. Col-
onel W. R. Parker, Medical Corps, National Army,
is to be officer in charge of the division of head
surgery in the Surgeon General's Office, vice
Colonel T. C. Lyster, Medical Corps, National
Armv. Colonel R. B. Miller, Medical Corps, Na-
tional Army, has been placed in charge of the per-
sonnel division, vice Brigadier General Robert E.
Noble, Medical Corps, National Army.
Assistant Surgeon General J. C. Perry, of the
Public Health Service, recently appeared before the
House appropriations committee and explained why
thirty additional commissioned officers were needed
by that service. There is need for these additional
officers because of extension of activities that are
not of a temporary nature, but permanent. Marine
hospitals need fifteen of these additionals. With
equipment of the hospitals to maximum bed ca-
pacity, including additions for which money already
has been appropriated, there will be a total increase
of 744 in the number of beds, and estimating that
a physician can only give adequate professional
attention to fifty patients, it is evident that the
fifteen additional medical officers will be required.
In wards where acutely ill - medical and surgical
patients are treated, thirty should be the maximum
for each physician. Quarantine stations will require
seven additional officers, and field investigations
eight.
The Secretary of the Treasury has asked for the
following additional appropriations for completion
of authorized marine hospital construction, equip-
ment, and furni3hing, etc.: at Savannah, $124,644;
Reedy Island, $127,000, and Cape Charles, $377,325.
The sundry civil appropriation bill as it passed
Congress provides $151,500 for a quarantine station
at Cape Charles; $61,500 for two barracks build-
ings, quarters, etc., at Reedy Island ; $26,000 for
four barracks buildings, etc., at Savannah; $15,000
for repairs to the old marine hospital and grounds
at Cincinnati, and for a refrigerating plant at
Mobile, Ala.
Army Medical Rank. — A doctor who had been
for some years on the stafif of a special hospital,
joined up at the beginning of the war, and was soon
appointed "Medical Specialist" to the leading mili-
tary hospital at one of the largest camps in his
country. When asked what he was specialist in,
he replied ''Specialist in everything." Whenever a
serious case occurred, of whatever nature, he was
the soecialist called in for consultation !
A Search for Nonphysical Standards for Avia-
tors.— Dr. R. P. Parsons {United States Medical
Bulletin, April, 1918) says our navy has rejected
hundreds of applicants for the flying corpsbecauseof
trivial minor defects, most of whom could have be-
come successful aviators, and many of whom have
since made good in the Canadian Royal FlyingCorps.
One of Great Britain's greatest flyers has but 4/20
vision uncorrected in one eye and not a great deal
more in the other. Such a man would have been
rejected from our own corps. Aviators are re-
quired to have T 5/ r 5 hearing in either ear, although
when flying the aeronaut plugs his ears tightly with
cotton to diminish his annoyance from the sound
of the motor. Doctor Parsons says : "Let us remem-
ber that, after all, we want for the personnel of our
flying corps, men who can fly or at least who can
learn to fly." A great number of flight instruc-
tors were asked to state the most essential quali-
ties for a successful aviator. All agreed that the
candidate must have the following characteristics :
Coolness under strain. Dependableness to always
do the correct thing at a critical moment. Mental
and physical alertness. Lack of any inherent fear
of being in the air. Persistence and perseverance
in his ambition to become a successful aviator.
The points generally agreed upon were that he
must be : Intelligent, athletic and endowed with
good muscular coordination, possessed of a keen
sense of equilibrium, a good judge of velocity and
distances.
There was disagreement as to whether the tem-
peramental type of extreme stolidity or that of
great nervous energy was preferable, many cases
being cited of men of each type who had proved
their expertness as aviators. Two instructors re-
garded physical strength as a valuable asset, but
on being questioned most of the instructors deemed
it not indispensable, citing cases that clearly dis-
proved the contention of those two instructors.
There was a notable paucity of opinions con-
cerning qualifications which were purely physical;
indeed, the question of exceptional vision was men-
tioned by only one instructor.
The author gives the results of the applica-
tion of a series of tests to flyers of different grades
of excellence. He concludes that the Barany test
for equilibration is not so useful a test as one de-
A'ised by himself which gives a direct test of a man's
ability to judge of equilibrium by tipping a seat in
any direction, the results being recorded electrically.
He concludes that "almost any young man with a
reasonable amount of common sense, the usual
amount of 'nerve' possessed by most young Ameri-
cans, and a keen desire to be an aviator, can realize
his ambitions and learn to be a perfectly good flyer
in a very few hours. It is questionable indeed
whether more actual skill is required in learning to
fly than in learning to drive an automobile. We
are coming to believe that, after all, the most im-
portant quality that determines one's success as a
flyer, is that of 'nerve.' Every one realizes that fly-
ing is a dangerous occupation. The flight pupils
realize this as much as any one, and those who can
just forget it and feel perfectly at ease in the aero-
plane, are the ones w^ho are most successful."
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc. D.
Philadelphia
SMITH ELY JELLIFFE, A.M., M.D. Ph.D.
New York
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers
66 West Broadway, New York
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Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
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Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, JULY 6, 1918
EXTENSION AND LIMITATION OF THE
"PRACTICE OF MEDICINE."
One of the ways through which progress has
repeatedly to be won is by means of the breaking
up of the crystallization that continually tends to
form around language. The demands of the wide-
spread methods by which the modern world
reaches out for healing aid throw science and
legislation back to the originally broader use of
the term medicine. Both the Greek and Latin
forms of this current term comprehended much
more than is commonly included in it, even if we
do not confine ourselves strictly to the use of
drugs or "medicines." To these ancient peoples
the root and forms of the word referred to that
which "cured, remedied, helped, was good for,"
even "protected, ruled over." In all there was
the wider meaning of necessary service in the
face of weakness and need which should at least
form the background of all modern medical prac-
tice.
Two important steps have been taken in a for-
ward direction toward both a broader policy and
one of greater responsibility in the restatement
recently of the definition of the practice of medi-
cine.
First the Supreme Court of Illinois, in a de-
cision of a few months ago, defined medicine to
include "the healing art," that is, the science of
preserving health and treating diseases, whether
with medicinal substances or otherwise. Any one
so occupied with the treatment of disease is a
physician, but this only emphasizes the require-
ment of the necessary educational qualifications
for all such persons. The specifications of the
decision which permits any physician to sign a
death certificate further emphasizes this funda-
mental requisite. Then the Supreme Court of
New York has also recently reiterated the defini-
tion of the "practice of medicine" in the case of
the reversal of a judgment affecting an unquali-
fied practitioner, who undertook the removal of
superfluous hair from the skin of a certain patient
with an electrical needle.
The statutory definition of the practice of med-
icine is as follows: "A person practices medicine
within the meaning of this article, except as here-
inafter stated, who holds himself out as being
able to diagnose, treat, operate, or prescribe for
any human disease, pain, injury, deformity, or
physical condition and who shall either offer or
imdertake by any means or method, to diagnose,
treat, operate, or prescribe for any human dis-
ease, pain, injury, deformity, or physical condi-
tion."
The treatment of a growth of hair may consti-
tute but a minor bit of medical practice, but sci-
entific logic as well as often lamentable results of
untrained manipulation would lead one unhesi-
tatingly to admit that it falls into the category of
the treatment of human ills thus defined and
necessarily safeguarded by the requirements for
training and skill demanded of the licensed physi-
cian. At any rate, such a standard is set by the
legal authorities and is therefore encumbent on
the would be practitioner.
This by no means extends a dangerous license
to the physician, but, by laying stress upon the
educational requirements of any practitioner, it
puts all forms of healing upon a basis secure
and responsible in regard to public need. At the
same time it places the many forms of practice
which have arisen and become approved through
their ability to meet this public demand properly
in the hands of those capable of testing and using
them to the best advantage. It safeguards the
l)rofessional ranks, but still more it safeguards
the public, at the same time granting them fuller
July 6, 1918.]
EDITORIAL ARTICLES
31
opportunities for seeking and finding the peculiar
sort of help they need. None the less it puts a
far greater responsibility upon the physician to
prepare himself conscientiously in the require-
ments which make for good judgment and skill
and in that broader mindedness which not only
welcomes but seeks out what is new to extend
and enlarge the old.
THE NERVOUS ELEMENT IN GOUT.
Many conditions, heretofore etiologically ob-
scure, are now associated either definitely with
disturbances in the glands of internal secretion,
or with deranged innervation in some part of the
nervous system, particularly of the vegetative
nervous one. It seems, in fact, that the latter
has exclusive control over the glands of internal
secretion, and disturbance in the latter must be
directly credited to this part of the nervous sys-
tem. The so called constitutional diseases and
the various diatheses are chiefly concerned in
these neuroendocrinic disturbances. In all of
them, however, there is a basic constitutional in-
firmity, which accounts for their common familial
distribution. Among the conditions around which
this nervous element seems to be particularly
active are the neuroarthritic, asthma, hemophilia,
epilepsy, urticarial conditions, hay fever, and par-
ticularly gout and gouty conditions. Familial
eosinophilia is probably included among them.
The eosinophilia is particularly interesting be-
cause of its previous close association with
parasitic infections. Most probably all the so called
diatheses are of vegetative origin. The joint
conditions in gout are explained as catarrhal
joint conditions brought about by disturbed in-
nervation. While the previous theories concern-
ing the relationship between gout and uric acid
are not so religiously held, it is still likely that
while the relationship exists the uric acid lies in
relation to efifect rather than cause. In all likeli-
hood it is the renal condition in gout that causes
the uric acid retention. It is only the severer
manifestations of this form of neuroarthritis
which are manifested by clinical gout. Minor
involvement is manifested by skin manifestations
or the various metabolic conditions still very
poorly classified under "acid" conditions. As long
as the elimination of uric acid is not too restricted,
attacks of gout do not occur.
Of the internal secretion of glands which are
largely concerned in the causation of gout, the
thyroid holds first place. The fact that men suf-
fer more from gout than women is explained on
the ground that thyroid activity is less in the male
than in th6 female. On the other hand, after the
menopause, when the thyroid activity is much
lessened, the tendency to gout in the female is not
so markedly less than in the male. The thyroid
seems to have a trophic control over the organ-
ism with respect to the development of neuro-
arthritic conditions. It is not certain that the
endocrinous system controls the vegetative nerv-
ous system or whether it is vice versa, but, in all
likelihood, both can react upon each other to form
a vicious circle. The sympathetic controls me-
tabolic activity in this respect through the thy-
roid, and stimulation of the sympathetic inhibits
the overfunctionation of the autonomic system.
Overfunctionation of the latter, especially when
not held in check by proper functioning of the
sympathetic, causes sluggish metabolic condi-
tions which ultimately are at the bottom of the
neuroarthritic conditions. The tendency to these
diatheses is reduced by~ stimulation of the sympa-
thetic, as occurs in acute febrile conditions when
many of these neurotic diatheses such as asthma,
enuresis, etc.. seem to disappear. The sympa-
thetic and the autonomonic systems exercise an
antagonistic control over each other. When one
outstrips the other, whether because of gland dis-
turbance or otherwise, the balance is broken and
organic disturbances usually follow.
GREAT BRITAIN DRAFTS DOCTORS.
The draft age has been widened in Great Britain
to include all men between the ages of eighteen and
fifty. For the first time doctors, as such have been
included in the draft and are paid the compliment
of having the limitation of age for them extended
to fifty-six. This step shows how urgent is the need
in the British army both for fighters and for physi-
cians. In view of the fact that we are but entering
upon the road which Great Britain has traveled
these four years past, it is well that we should study
the eft'ects of this act as it may furnish a guide as
to what we may have to do later ourselves.
The wording of the regulations issued show t'aat
it is not expected that every physician under the age
of fifty-six shall enter the army medical service,
although they may have to do so if in the opinion
of the government, their services are more impor-
tant to the army than to civilians. It does mean,
however, that the British government proposes tak-
ing full charge of the practice of medicine both in
civil and military life. Application for exemption
from drafts may be made on any of the following
grounds :
(a) That it is expedient in the national interests that the
practitioner should, instead of being employed in military
32
EDITORIAL ARTICLES.
[New York
Medical Journal.
service, be engaged in other work in which he is habitually
engaged ; or in which he wishes to be engaged ; or, if he is
being educated or trained for any work, that he should
continue to be so educated or trained.
(fc) That serious hardship would ensue if the practitioner
were called up for army service, owing to his exceptional
financial or business obligations or domestic position.
(c) 111 health or infirmity.
{d) Conscientious objection to combatant service.
Such applications may be referred to a medical
tribunal having authority to grant a certificate of
exemption. This certificate may be for absolute,
conditional or temporary exemption, and we learn
from the regulations that: "A certificate granted
or renewed on occupational grounds shall, and a
certificate granted or renewed on personal grounds
may, be subject to the condition that the practitioner
shall undertake such professional service and under
such conditions as the Director General of National
Service may, after consultation with the medical
tribunal and in concert with any government de-
partment concerned, from time to time deem best
in the national interests."
The wording makes it clear that the Government
purposes to make such use of the services of the
practitioner as circumstances may be deemed best
for the public welfare. Some physicians will be
assigned to civil practice in certain districts with a
view to relieving others who vnW be ordered into
the army service. The British Government has as-
sumed a very grave responsibility, though it seems
to have been incumbent upon them to take such step
because of the unfortunate conditions existing in
some sections where the civil population has been
deprived of adequate medical ministration. Fortu-
nately the Government will consult the local organi-
zations of physicians with a view to avoiding the in-
fliction of unnecessary hardship either on doctors or
patients.
We hope that we are as yet a long way from
the necessity of following the example of Great
Britain of drafting medical men, but if our army
is increased in the next twelve months as it has been
in the past, it will not be long before we face the
same need, and this would mean a necessity for the
governmental regulation of civil practice as in Eng-
land. It is estimated that we have 76,000 doctors
under the age of fifty-five. Already we have ap-
proximately one in eight of these in the service.
We are told that we are to have an army of 4,000,-
000 by the end of 191 8. This would mean 40,000
doctors out of the 76,000, or more than half of those
who are of military age. Notwithstanding the
thoroughness with which the profession has been
organized, and the enthusiasm with which its mem-
bers have taken up military duty, it is doubtful
whether we can double our present medical stafT
within the year without resorting to the draft, and
it is therefore well to study the experience of our
British Allies who are now going through this novel
experience.
CONTROLLING VENEREAL INFECTION.
Military authorities are keenly alive to the dangers
from venereal diseases and have instituted vigorous
measures both for the prevention of infection and
for the prompt and efficient treatment of the soldiers
who have contracted either gonorrhoea or syphilis.
But no regulations, however severe or well enforced
which are purely military, can deal adequately with
the problem. If success is to be hoped for, the only
path to it lies in a campaign conducted among the
civil population. The difificulties are immense, but
not too great to be overcome by energetic, intelli-
gently directed efforts. The menace of venereal
diseases proceeds from the civil population, and
drastic steps must be taken to deal effectually with
them. This is thoroughly recognized by army and
public authorities everywhere, and in no country
more so than in the United States.
Surgeon General Blue, of the Public Health Serv-
ice, has shown himself fully alive to the peril and
has stated that, in his opinion, the need for control
of venereal infections, in connection with the prose-
cution of the war, constitutes the most important
sanitary problem at the present time confronting
the public health authorities of this country, and
the army medical authorities are at one with him
in this belief.
According to a distinquished British medical spe-
cialist. Lieutenant Colonel L. W. Harrison, writing
in The State Journal of Medicine for April, 1918,
the burden of dealing with venereal disease will fall
on the civil community. Soldiers infected during
the war, while in the army are efficiently treated,
because they are under disciplinary control. More-
over, preventive measures to some extent have been
brought into effect for their protection, but, with
regard to the civil population, the situation is very
different. Boys and girls, and of course girls espe-
cially, have been divorced from home restraint, atid,
in some countries the necessity for bringing into
force laws calculated to prevent the dissemination
of venereal infection has been appreciated. The
most comprehensive and most carefully thought out
of these is an act known as the venereal diseases
prevention act, which has been passed by the gov-
ernment of Ontario and which became a law on July
I. This act is somewhat drastic, one provision pro-
hibiting marriage by any person suffering from ve-
nereal disease, while another provision is to the effect
that any action or conduct likely to result in the
spread of the disease is regarded as a serious offense.
July 0, 191S.]
EDITORIAL ARTICLES. '
33
The penalty for contravention of either of these
clauses is a heavy fine or imprisonment for a year.
Lieutenant Colonel N. W. S. McCullough, the able
chief of the Board of Health of the Province of
Ontario, was mainly responsible for the framing
of the Ontario act and his foresight is to be highly
commended.
The Province of Saskatchewan has also passed
laws with view to controlling venereal disease and
both that province and Ontario require venereal dis-
ease to be reported and those suffering from it to
be placed under proper treatment.
The pioneer country in this direction was Western
Australia, where a bill for the control of venereal
disease was passed in 191 5. Another province of
Australia, Victoria, has followed suit. The records
for 1916 in Western Australia justify the legislation,
for during the last seven months of the year 191 7
cases were notiiied. While legislation of the kind
referred to above is without doubt a long step in
the right direction, and while educational propaganda
and other measures now in vogue will go far toward
scotching the evil, there are those well qualified by
experience to speak with authority who contend that
still more radical methods should be enforced.
The example set by Ontario, Saskatchewan, West-
ern Australia and Victoria should serve as an in-
centive for the initiation of a universal campaign
against perhaps the most destructive disease known,
one said to be as easily prevented as some diseases
which by hygiene and other measures have been
exterminated. The military importance of such a
movement cannot be overestimated, for venereal dis-
ease in a command materially reduces its military
effectiveness.
EXCHANGE IS ROBBERY?
This was the decision arrived at by the War
Office in London concerning the proposed ex-
change of English for German prisoners. To
exchange thousands of well cared for Germans
for invalids or cripples would certainly be un-
profitable, so, for a fraction of time, John Bull
j5rided himself on being a very practical and far-
seeing man. Some said he had not been practical
because he had not made reprisals and ill treated
the Hun prisoners. Well, that was contrary to
his humanity, and the German nation needed a
lesson most surely in that. Some said that to
release so many thousands would retard the con-
clusion of the war, but examination showed that
those affected would not perhaps be more than a
quarter of a million, perhaps not more than a
hundred thousand. Meanwhile, stories of cow-
ardly abuse of English prisoners were multiplied
by those who had escaped or who had actually
seen things done. France had already entered
into a treaty, while English soldiers were still
dragging out a wretched existence, fed on little
that was real food and much that was also unreal
in the way of lies concerning disaster and defeat.
Was this a fair reward for fighting? Some of
tliem liad been prisoners since 1914. It surely was
not, and the edict has gone forth that an exchange
is to be made. Imitating France, the chief clause
in the treaty will release all who have been in
captivity more than eig'hteen months. With such
a possible "home coming week" awaiting Ameri-
can boys in the unknown future, a keen observ-
ance of results in all such movements among the
Allies will be kept by authorities as well as the
rank and file.
TO ELIMINATE ROTATING HOSPITAL
SERVICE.
In the need for medical men for the army, a
need which will increase as the war goes on, it is
necessary to cut to a minimum the number of men
who are engaged in hospital service. Dr. S. S.
Goldwater, whose special knowledge of hospital
administration entitles his opinion to great weight,
has written a letter to the editor of the New York
Medical Journal, which appear? in another col-
umn, advocating the elimination of the rotating
service in hospitals. This service, as at present
organized in most hospitals, assigns a physician to
a particular service for a limited period, after
which some one else takes over the same service.
In this way, many men will appear as being as-
signed to the same service, though as a matter of
fact they give but a few months out of the year
to it. This practice is entirely proper in peace time
but, as Doctor Goldwater points out, it should be
abrogated for the present in view of the over-
whelming need for medical men in the army.
THE SIZE OF TFIE FRENCH ARMY
In view of the vague guesses which have been
made from time to time regarding the size of the
French army, it is interesting to have an authori-
tative statement from an official representative of
the French Medical Department, Colonel Charles
U. Dercle, who is liason officer in the office of the
Surgeon General of the United States Army, that
about one million of the French army have been
permanently disabled, 'and a little more than a mil-
lion killed in battle. On January i, 191 7, there
were, not including natives of the French colonies,
and workmen in war factories, 4,725,000 men and
officers in the French army, of whom about 3,000,-
000 are at the front. The western front measures
755 kilometres in length ; of this the Belgians hold
25 kilometres, the English 165, and the French 565,
or three quarters of the line. This is a wonderful
showing for a people who were reported in some
newspapers to have been, a year ago, "bled white."
34
NEWS ITEMS.
[New York
Medical Journal.
News Items,
First Woman Lieutenant on Duty as Surgeon. —
Lieutenant Ollie Josephine Baird, of Detroit, began her
duties as contract surgeon at Camp McClellan July ist,
and has the rank, pay, and quarters of a first lieutenant.
She has not yet been allowed to wear the insignia of her
rank, but the regulation salute has been accorded her.
Lieutenant Baird was one of the first five graduates from
the Mayo clinic and formerly practised medicine at Detroit.
Iowa State Medical Society. — At the annual meeting
of this association, held in May, the following officers were
elected : President, Dr. Max E. Witte, of Clarinda ; presi-
dent-elect. Dr. William L. Allen, of Davenport ; first vice-
president, Dr. William A. Rohlf, of Waverly; second vice-
president, Dr. Evan S. Evans, of Grinnell ; secretary, Dr.
Tom B. Throckmorton, of Des Moines ; treasurer. Dr.
Thomas F. Duhigg, of Des Moines ; editor. Dr. D. S. Fair-
child, of Clinton.
Annual Meeting of Railway Surgeons. — The twenty
eighth annual meeting of the New York and New England
Association of Railway Surgeons will be held in New York
on October 21st, with headquarters at the Hotel McAlpin.
A special feature of the program will be a symposium on
the Modern Treatment of Infected Wounds. Dr. J. S.
Hill, of Bellows Falls, Vt., is president of the association,
and Dr. George Chaffee, of Little Meadows, Pa., is cor-
responding secretary.
New Officers of the National Tuberculosis Associa-
tion.— At the annual meeting at Boston, June 6th-8th,
the following officers were elected for the ensuing year:
President, Dr. David R. Lyman, of Wallingford, Conn.;
honorary vice-presidents, Hon. Theodore Roosevelt, Sir
William Osier, Colonel George E. Bushnell, M. C, U. S.
Army; secretary. Dr. Henry Barton Jacobs, of Bal-
timore, Md. ; treasurer, William H. Baldwin, Washing-
ton, D. C
Formation of Emergency Relief Units in New York.
—The formation of emergency relief units for service
during calamity in any part of the city was discussed at a
meeting of two hundred physicians and nurses from the
city hospitals on July ist in the West 125th Street police
station. Special Deputy Police Commissioner Rodman
Wanamaker has given to the officers of the units informa-
tion about police relief measures in London and Paris.
Classes of fifteen women each will be instructed in the
police station Monday, Tuesday, Wednesday, and Thurs-
day evenings. One of the physicians said that the Grand
Central Palace, at Lexington Avenue an Forty-seventh
Street, will be turned into an emergency hospital. The
hospital will accommodate 2,500 patients.
American Red Cross Sets Record in Preparing Evac-
uation Hospitals. — Three hospitals were established in
record time along the line northeast of Paris a few days
after the last German offensive was launched. In the
case of one hospital, the officer in charge left Paris with
ten nurses and ten tons of equipment, without knowing
exactly where the hospital was to be located. He found
a desirable building, and had the place fully equipped, in-
cluding an operating and x ray room, within three days.
The second hospital had a few beds and a little equipment
when the officers arrived. Its capacity was increased to
six hundred beds by means of eqtiipment rushed from
Paris on motor trucks. The trucks reached the hospital
simultaneously with the wounded from the battlefield.
Another Hospital Ship Torpedoed. — The Canadian
hospital ship Llandovery Castle was torpedoed by a Ger-
man submarine about seventy miles southwest of the Irish
Coast. There were on board about 258 persons, includ-
ing the crew, nurses, and members of the Canadian medi-
cal service. Of this number all except twenty-four were
drowned. Among those saved was Major T. Lyon, Cana-
dian Army Medical Corps. The German U boat com-
mander said that the ship was sunk because he had intima-
tion that eight American flight officers were on board.
There were no combatants on board and the ship had been
engaged exclusively in hospital service for several months.
When sunk she was on her way to England. Her identity
as a hospital ship was clearly indicated and was known to
the U boat commander. In consequence of this attack the
sailing of the U. .S. hospital ship Comfort has been delayed.
Higher Rank for Medical Officers. — To remedy the
fact, that because of inferior rank the medical officers
of the regular service and the National Army were unable
to compel obedience to their orders, the Senate has adopted
an amendment allowing four assistant surgeons general for
the Medical Corps of the Regular Army, one to have the
rank of major general and the other three to have the rank
of brigadier general. In the National Army, for each
million men four major generals and eight brigadier gen-
erals are provided from the Medical Reserve Corps of the
Regular Army.
American Laryngological, Rhinological, and Oto-
logical Society, Inc. — At the recent annual meeting of
this society, the following officers were elected to serve for
the ensuing year: Colonel H. S. Birkett, Canadian Army
Medical Corps, of Montreal, president ; Dr. Robert Lewis, of
New York, chairman of the Eastern Section; Dr. Clifton M.
Miller, of Richmond, Va., chairman of the Southern Sec-
tion ; Dr. Otto J. Stein, of Chicago, chairman of the Middle
Section ; Dr. Claude E. Cooper, of Denver, chairman of
the Mid-Western Section; Dr. John J. Kyle, of Los An-
geles, chairman of the Western Section ; Dr. Ewing W.
Day, of Pittsburgh, treasurer ; Lieutenant Colonel William
H. Haskin, Medical Corps, U. S. Army, of West Point,
N. Y., secretary; Dr. George L. Richards, of Fall River,
Mass.
Military Course at Columbia Compulsory. — Full
plans for introducing compulsory military training and for
enrolling all students of the college in the Reserve Officers'
Training Corps will be put into operation at Columbia next
fall. It is calculated that there will be 850 men in uni-
form. The coordination of academic, military, and athletic
training has been worked out by Dean Hawkes, Colonel
John P. Finley, U. S. A., retired, who will be professor of
military science and tactics, and Professor George L. Mey-
lan, medical director of the gymnasium, who will introduce
the new ideas in mass and play athletics found by France
to be invaluable for war. The plan proposes to take men
who are not physically fit and make them physically fit.
It is estimated that the percentage of students fit for high
military service can be doubled by the training.
Personal. — Dr. Walter B. James, president of the
New York Academy of Medicine, has been appointed head
of the State commission for the study of the feebleminded.
How to provide institutional care for the feebleminded,
of whom there are about 30,000 in New York State, has
been a problem that has vexed the legislature many years.
Dr. David L. Edsall, Jackson professor of clinical medi-
cine in the Harvard Medical School since igi2, has been
appointed dean of the school, succeeding Dr. Edward H.
Bradford, whose resignation has been accepted. Doctor
Edsall will assume his new office on September 1st.
Colonel Jef¥erson R. Kean, M. C, U. S. Army, has been
promoted to the rank of brigadier general. General Kean
was medical director of the American Red Cross and
organized the first fifty base hospital units for overseas
service before the United States entered the war.
Major Harvey Gushing, Medical Reserve Corps, United
States Army, has had conferred upon him the honorary
fellowship of the Royal College of Surgeons in Ireland.
Major Gushing is on leave of absence from Harvard
University.
Dr. Joel E. Goldthwaite, of Tufts University, Boston,
director of military orthopedics with the American Expe-
ditionary Force in France, has been promoted to the rank
of lieutenant colonel.
Dr. A. R. Cushny, professor of materia medica and
pharmacolog>' in the University of Dublin since 1905, and
who was formerly connected with Johns Hopkins Uni-
versity and the LTniversity of Michigan, has been made
professor of materia medica in the Edinburgh University.
Dr. Bernard S. Rosenzweig, 993 Park Avenue, New
'S'ork, announces that pursuant to an order of the Hon.
lustice Edward B, La Fetra, in a Special Term of the City
Court, that on and after July i, 1918, he has been author-
ized to change his name and assume that of S. Bernard
Ross.
Colonel William .S. Thayer, of Baltimore, professor of
clinical medicine at Johns Hopkins Hospital, has been
elected a foreign member of the French Academy of Med-
icine.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
RECENT OBSERVATIONS IN DIGITALIS
THERAPY.
IJy Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Continued from page 1153.)
in spite of its well known property of slowing
the heart rate by stimulating the vagal cardioinhibi-
tory apparatus, digitalis is not efifectual in all forms
of heart involvement associated with an increased
rate. In at least some of the conditions in which
it fails to benefit, diminished sensitiveness of the
vagus — or possibly, reduced power of the vagus to
act owing to abnormal tone of the opposed accelera-
tor, sympathetic mechanism — appears to be respon-
sible.
In the so called "irritable heart" of the soldier, in
which, in addition to a constant slight increase of
rate during bodily rest, a markedly excessive rise in
rate takes place upon exertion, Lewis finds that,
while vagal tone is not abolished, it is questionable
whether vagus activity is unaffected, for the pulse
fails to return to normal after exercise. Experi-
ments with adrenalin and apocodeine having shown,
on the other hand, that the sympathetic (accelera-
tor) system is more easily stimulated or depressed
than normal in these subjects, Lewis thinks one may
best account for the high pulse rate as being due to
an excessive irritabiHty, among other structures, of
the acceleration reflex arc and the rhythm produc-
ing centre itself. Mental strain appears at least as
important a factor in bringing on the condition as
])hysical exertion. Absence of physical signs, ex-
cept the tachycardia itself, is characteristic of most
cases. The uselessness of digitalis in nearly all
these patients now seems well recognized. Rest in
bed is itself contraindicated in most instances;
Meakins and Gunson, 1917, found it to exert a
most unfavorable influence on the return of the
pulse rate to normal after exercise. Evidently the
heart, in spite of its poor response to the functional
exercise test, is in no need of the rest which con-
finement to bed or digitalis, if it succeeds in slowing
the rate, affords. For indeed, gradually increasing
exercise has, as a rule, proven the best corrective
measure in this condition. Garrod, 1917, and
others, have maintained that "soldier's heart" is not
a single clinical entity, but comprises a number of
dillerent morbid states. Garrod states that even
among men exhibiting the "effort syndrome," some
respond well to exercises while others do not. In a
variety of war heart observed among soldiers of the
British Mediterranean Forces, in which the myo-
cardium seemed temporarily damaged by malaria,
dysentery, or trench fever, complete rest proved to
be the most imiportant factor in the treatment. The
morbid condition in this type of case is believed to
be a dilatation of the auricles, especially the right
auricle. Garrod is not convinced of the efficacy of
either digitalis or mix vomica in these patients, but
mentions Graham as believing that the former drug
lessens the chance of redilatation, to which the
heart in such cases is very liable.
Whereas the various observations already pre-
sented tend to .show that in tachycardia of nervous
origin, digitahs is usually of relatively slight or no
utility — the heart not being subjected under these
conditions to overwork such that its nutrition is im-
j)aircd — nervous heart disturbances do at times be-
come so pronounced that actual cardiac insuf-
rtciency is induced, thus affording digitalis the
opportunity to act beneficially. As Hoover, 1915,
points out, there are instances met with of myo-
cardial incompetence following prolonged, intense
mental, and emotional distress. Such cases are prob-
ably related at times to overactivity of the thyroid
gland, which, in turn, is associated with overactivity
of the sympathetic cardioaccelerator mechanism.
The excessive katabolic chemical changes charac-
teristic of hyperthyroidism doubtless themselves
liasten the ultimate weakening and dilatation of the
heart in this condition by preventing adequate nutri-
tion of the myocardium. While in mild nervous or
hyperthyroid disturbance of the heart digitalis
seems relatively ineffectual in reducing the heart
rate, where actual weakening and dilatation result,
with further increased heart rate, digitalis may be
expected to reduce this additional increase in rate,
overcome dilatation, and on occasion promote
diuresis. According to A. W. Meyer, 1912, the fre-
quent pulse of tuberculosis yields but little or not
at all to therapeutic doses of digitalis, not only in the
presence of fever but likewise when hyperthermia
is absent.
Paroxysmal tachycardia, it is well known, ex-
hibits a relatively regular rhythm with greatly in-
creased rate. A considerable variety of pathologic
states of the .heart may underlie it, but the chief
predisposing or exciting cause appears to be an un-
due irritability — or irritation — of the heart which
leads it to break away from the control of the
normal pacemaker and respond to excessively fre-
fiuent impulses arising usually in the auricle but
occasionally in the ventricle. According to Lewis,
1912, the new rhythm in this condition shows only
limited subordination to vagal and sympathetic con-
trol. Remembering that digitalis is credited with
the property of increasing the irritability of the
heart muscle, and noting further the relative in-
susceptibility of the heart to vagal influences in this
condition as pointed out by Lewis, we may readily
understand why the drug fails in the majority of
instances to arrest seizures of paroxysmal tachy-
cardia. Prolonged paroxysms tend to induce dila-
tation of the heart, which owing to the extremely
high rate does not have a sufficient opportunity to
empty itself ; yet digitalis seems unable to afford
much benefit. W. T. Vaughan, 1918, suspects that
digitalis in large doses may itself be an exciting
cause in the production of the ventricular form of
paroxysmal tachycardia where conditions predispos-
ing to it already exist. The fact that vagal stimula-
36
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
tion induced otherwise than by digitalis, c. g., by
pressure on the vagxis nerve or on the eyeballs, the
swallowing of cold water, the induction of vomiting,
etc., not infrequently succeeds in arresting a parox-
ysm, while digitalis so often fails, is perhaps ac-
counted for by the added action of the latter in
enhancing cardiac irritability, the other measures
acting upon the vagus alone. Lewis states that in
the intervals between paroxysms a full course of
digitalis may ultimately improve the condition. As
a rule he gives one half to one drachm of the
tincture or one half to one ounce of fresh infusion
daily for the first week. The dose is then increased
until nausea or headache appear, and finally re-
duced to the maximal quantity borne without undue
discomfort. This treatment he finds sometimes suc-
cessful where other remedies have failed.
{Tn be continued.)
Phototherapy and the Air Cure in Surgical Tu-
berculosis.— R. Brunon {Presse medicale, Febru-
ary 24, 191 8) pleads for more widespread recogni-
tion of the benefits of light and air, and less routine
hospital treatment. He reports the case of a boy of
fourteen years with multiple tuberculous bone
lesions who, after remaining in a hospital bed for
a long period and being subjected to repeated curret-
tage of the disease foci, one day disappeared. A
few months later he returned almost unrecognizable,
having grown, filled out, walking without difficulty
and with sinuses nearly all closed. It was learned
that, despairing of recovery in the hospital and
longiiig to live unrestrained in the country, he had
had himself helped over the hospital wall, and had
wandered from farm to farm, generally sleeping in
the open air, rain or shine, and begging food from
peasants. In a few days his dressings had all been
pulled oft' by thorns and he was merely wiping his
wounds with grass or leaves and leaving them un-
covered. Winter had brought him back to the hos-
pital for shelter; all the benefit from his escapade
was soon lost and after a few months he succumbed
to tuberculous meningitis. Such a case from the
start should have at least been out of bed in the
hospital garden for a few hours a day. Another
case, in a young man of twenty, was one of long
standing hip disease with numerous sinuses. Ex-
cision of the head of the femur yielded improve-
ment, but, in the subsequent months, the condition
became very grave. The family took the patient
back, that he might die among his kin, and the fol-
lov/ing measures were instituted : Starch enemas,
raw meat, general alcohol rubs, and an air and light
cure at the open window. Twice daily the affected
tissues were exposed for a few minutes to diffuse
light. A nurse taught the mother to apply antiseptic
dressings. Within two weeks diarrhea ceased, and
the general condition improved in the succeeding
months. Three summer months in the country did
no good, loneliness and absence of the family being
keenly felt. Upon return to town in the fall and
resumption of the open window treatment progres-
sive improvement began at once. Soon he was able
to walk with a special shoe, the general condition
was good, and but little suppuration remained. In
this case, air and diflfuse light saved the patient.
Fractures of the Femur.— John McH. Dean
(Journal of the Missouri State Medical Association,
May, 1918; sums up the treatment under three heads :
first, the general good care of the patient, preferably
in t. c- upright or semiupright position ; second, re-
duction with care not to break up impactions ; third,
good retention apparatus. In intracapsular frac-
tures removal of the head of the femur is recom
mended by some surgeons, but lately autogenous
bone pegs have been extensively and successfully
used ; wire or steel nails are to be discarded. In the
young, the adult and the middle aged Whitman's
plaster of Paris cast with Buck's extension seems to
be the choice of retention splints, while after sixty
we should resort to the Hodgen splint. Extra-
capsular fracture shows seventy-seven per cent, par-
tial or total disability, while intracapsular fractures
seldom result in bony union owing to the fact that
the nutrient vessels enter the neck of the femur
about its middle and the vessels in the capsule are
destroyed by the damage to the capsule, and finally
the vessels entering the head of the femur with the
ligamentum teres are inadequate. Another unfav-
orable anatomical condition is the absence of real
])eriosteum on the femoral neck.
Treatment of Psoriasis. — H. W. Barber (Brit-
isli Medical Journal, March 30, 1918) recommends
the following plans of treatment in order to return
men to active military duty in the minimum period
of time. Where there is a generalized eruption on
the body and extremities the patient should receive
a bath every morning, the first two baths containing
cresol and sodium or potassium carbonate, there-
after only the alkali. Following the bath and again
in the evening all of the affected parts, except the
genitals, are to be covered with the following oint-
ment :
Chrysarobin, 0.6 (gr. x) ;
Salicylic acid, i.o (gr. xv) ;
Phenol, 0.6 (gr. x) ;
Zinc oxide, 6.0 (dr. iss) ;
Petrolaturn ^^'^^ equal parts, to make 30.0 (oz. i).
During this treatment the same suit of pajamas is
worn night and day and allowed to become impreg-
nated with the ointment. The genitals are protected
by thorough application of Lassar's paste. If any
area becomes acutely inflamed Lassar's paste con-
taining a little ichthyol should supplant the oint-
ment. At the end of a week the eruption is usually
well cleared up, when Lassar's paste containing two
per cent, of salicylic acid is applied to the treated
parts, the pajamas are changed, and the bath re-
duced to alternate days. Very resistant patches of
eruption may require the application of an ointment
like the one given, but containing 1.3 gram of
chrysarobin and 1.6 gram of salicylic acid. Lesions
on the scalp and forehead should be treated by the
application of the following ointment after cutting
the hair very short and shampooing:
Pyrogallic acid, 0.6 (gr. x) ;
Salicylic acid 1.0 (gr. xv) ;
Phenol, 0.6 (gr. x) ;
Ointment of yellow oxide of mercury, . .30.0 (oz. i).
Florid j>ersons with an inflamed eruption should
have a milk diet with free purgation and a mixture
of wine of antimony and potassium citrate.
July 6, 1 918.1
MODERN TREATMENT AND PREVENTIVE MEDICINE.
37
The Results of Treatment in Pernicious Ane-
mia.— Arthur Bloomfield {Bulletin of the Johns
Hopkins Hospital, May 1918) in analyzing the re-
sults of the newer methods of treatment in per-
nicious anemia, as transfusion, splenectomy, and at-
tempts to eliminate "foci of infection" does not hold
quite so optimistic a view of the efficacy of these
measures as others who have reported their imme-
diate results. He considers fifty-seven cases in de-
tail, turning particular attention to the comparative
value of the various proceedings now being tried
to prolong the life of the sufferer from pernicious
anemia. In this series there was no definite evi-
dence that these therapeutic measures had any effect.
When it has been decided to resort to transfusion
Bloomfield recommends repeated injections if the
patient responds well, as single transfusions in cases
which were not affected by other treatment were
of no benefit. In patients who are not refractory
to any of the forms of treatment, remission has oc-
curred after transfusion, although transfusion did
not appear to increase the duration of the remission.
While the count was high the patient usually ex-
perienced a sense of well being after the transfu-
sion, quite possibly due in some cases to the psychic
effect. The central nervous system symptoms were
not benefited by any of these procedures. The
cases in this series did not bear out the view that
transfusions were "held" better after splenectomy,
nor did splenectomy make the remissions longer or
more marked, or have any eff'ect in prolonging life.
Rubber Grafts. — Delbet (Presse medicale, April
.4, 191 8) reports concerning four cases — two under
the care of Veaudeau and one each, of Huguier and
Basset. Two of the grafts were used for muscular
hernias of the thigh ; in the other two cases the ob-
ject was to liberate muscles or tendons caught in
scar tissue. In one of the hernia cases a sheet of
rubber was fastened by interrupted catgut sutures
to the margins of the opening in the fascia, which
was of about the size of a silver dollar. The muscle
hernia did not recur, though when the fascia lata
was under tension, resistance to the pressure was
less at the site of the graft than in the surrounding
area. In the other hernia case, a better method of
fixation was employed, the margins of the sheet of
rubber being cut into short strips which, after the
rubber had been slipped between the muscle and the
aponeurosis, were worked into the latter. A per-
fect result was obtained. The third case had broad
scars on the forearm, adhering to the flexor muscles
and preventing motion at the wrist. There were
also signs of injury of the ulnar nerve. At the
operation the whole of the adherent scar was re-
moved, the nerve sutured, the muscles drawn apart,
and the destroyed fascia replaced by a sheet of rub-
ber four centimetres broad and ten centimetres long.
Two months later one half the normal motility at
the wrist had been recovered, but the ulnar paralysis
persisted. In the fourth case the flexor tendons of
the index and middle fingers, adherent to callus on
the second metacarpal bone, were liberated and a
sheath of thin rubber made for each tendon. The
result was excellent. Rubber is thus shown to be
useful both as a means of sustaining tissues and to
permit of the sliding of tissues one upon the other.
Comparative Activity of Local Anesthetics on
the Cornea. — Torald Sollmann (Journal of Phar-
tiidcolu(jy and Experimental l^herapeulics, h'cbru-
ary, 1918) found the application of various agents
to the rabbit's cornea a satisfactory method for
comparing their efficiency as surface anesthetics.
The order of efficiency proved markedly different
from that of the same agents in immersion or con-
liuction anesthesia, and the results furnished re-
markable confirmation of the clinical experiences of
ophthalmologists. On the cornea, cocaine and holo-
caine were the most efficient ; then followed beta-
cucaine, alvpin, quinine and urea hydrochloride,
tropacocaine, and lastly, novocaine. Antipyrin and
potassium (chloride) were practically ineffective.
The rapidity and duration of the action varied with
the concentration. I'or just effective concentra-
tions, the duration was shortest with cocaine and
tropacocaine and longest with quinine and urea.
Addition of sodium bicarbonate, one quarter per
cent., increased the efficiency of the anesthetics con-
siderably— two to four times — with the exception of
quinine and urea, which was rendered less efficient.
Addition of epinephrine, one in 20,000, failed to in-
crease the efficiency, and is therefore inadvisable
in practice. Mixtures of the anesthetics with each
other or with potassium did not lead to potentiation.
The results showed why cocaine is still considered
tlie superior anesthetic for mucous membranes and
why novocaine has failed to establish itself in this
field.
Prophylactic Triple Inoculation Against the
Typhoid Group. — Georges Dreyer, A. Duncan
(iardner, Alex. G. Gibson, and E. W. Ainley
Walker (Lancet, April 6, 1918) record the results
of a series of carefully conducted observations
made to determine the most favorable conditions
for the production of immunity by the injection of
a combined vaccine for typhoid and the para-
typhoids. As a result of these observations th?!y
conclude that the combined vaccine should contain
1,000 million of each of the three organisms per mil
and that the initial dose should be half a mil and
the second one mil. The agglutinin curve for each
of these three organisms varies in different persons,
both in the maximum reached and the precise day
of its attainment, but in general the height is
reached from the first dose between the sixteenth
and twenty-fourth day after injection. Following
this the titres fall rapidly at first and slowly later.
The administration of the second dose on the sixth
or seventh days after the first checks the rise of the
agglutinin titres and delays it somewhat; if given
between the thirteenth and sixteenth days, or before
the time of maximum, the effect is but a slight nick
in the rise of the titres, or a brief plateau; if the
second dose be given later than the twenty-fourth
day the fall in the titre is temporarily arrested after
a few days and then slowed down materially. The
chief eff'ect of the second dose, given within a few
days of the maximum of the titre produced by the
first, is to delay the fall in agglutinin titre and pro-
long the period of effective immunity. It seems
probable that it would be best to postpone the ad-
ministration of the second dose to the eighteenth
to twentieth day after the first.
38
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[Xew York
Medical Journal.
Prophylaxis of Malta Fever. — H. Vincent
{Frcsse )>icdicale, March 7, 1918) advocates, for
this purpose, active immunization of goats in the
same way as lierds of cattle and sheep are vacci-
nated against anthrax. He has prepared from ten
strains of the Micrococcus melitensis and one strain
of Micrococcus paramelitensis, a polyvalent vaccine
each mil of which contains about two thousand mil-
lions of the organisms. The animals are given two
injections, each of two mils, at an interval of four to
eic^ht days. Such injections awaken an immunity
of sufficient strength to protect against a large dose
of the virus, administered either under the skin,
intravenously, intraperitoneally, or by mouth.
Acne Vulgaris. — C. E. O'Donnell (American
Medicine, March, 1918) treats acne by eradicating
the seborrhea : Internal medication is of little value.
Calcium sulphide and other preparations have been
knov.-n to cure but, as a rule, their effect is disap-
pointing. Sulphur is excreted through the sweat
glands as sulphur dioxide, a local antiseptic and
astringent. Vaccines may be of benefit. Antisep-
tic ointments should not be used. Chemical caus-
tics should be used in treating persisting sebaceous
folliculitis. They may be applied by means of a
toothpick. Tonics in the form of iron, small doses
of thyroid, and Fowler's solution are of value.
The Workingman's Hand: Its Treatment in
Sepsis. — Edward H. Risley {Interstate Medical
Journal, April, 1918) emphasizes the importance of
bed treatment in septic hand infection, and of
splints in finger and hand infection from the very
outset. Edema of the dorsum of the hand more
often denotes a palmar than a dorsal focus ; lym-
phangitis in some degree is almost always present.
The white blood cell count is not a reliable guide as
to the severity of the infection. Lateral incisions
arc of the greatest value and are less liable to open
uninfected tendon sheaths. When the infectious
process is locahzed dry dressings with boric wick or
rubber tissue drains are the best, whereas wet
dressings help to localize infection. Early passive
motion and massage are of the utmost importance
in shortening the period of disability, and early
plastic operations or amputations are desirable after
a preparatory course of the Zander treatment.
Rheumatoid Arthritis. — Ernest A. Dent {Brit-
ish Medical Journal, March 30, 1918) says that
much can be done in this disease to arrest it in the
early stages and to relieve the suffering of the ad-
vanced stages. Since it is prone to attack specially
those with lowered vitality nothing must be done
which further impairs resistance. In acute and sub-
acute cases the patient should be in bed and the
joints should be kept at rest during acute pain, but
when this subsides they should be moved gently to
prevent stiffness. To lessen the pain the joints may
be painted with guaiacol and tincture of iodine, one
to six. mesotan in olive oil, or a twenty-five to fifty
per cent, mesotan ointment in lanoline may be ap-
plied. Methyl salicylate with three parts of olive
oil or six of tincture of iodine can be painted thickly
over the aiTected parts and covered with lint and
oiled silk. Blisters are specially useful in chronic
cases. Adhesive pla.ster splinting reduces pain and
swelling in many cases. Extension with light
weights to prevent the joint surfaces from rubbing
together is also often helpful for the relief of pain.
Flexion of joints can be prevented in large part by
suitable splinting worn for part of each day only.
The joints should be used as much as possible with-
out causing pain. Breaking of adhesions under an-
esthesia is not satisfactory. The diet should be
light in the acute cases, but in chronic cases it should
be ample, with an abundance of fats. Woolen
clothing should be worn at all seasons and a warm,
dry climate is beneficial. In febrile cases guaiacol,
the salicylates, creosote, quinine, and salol are all of
value, and aspirin and phenacetin often relieve the
pain. Hyoscyamus and cimicifuga should be tried
for the relief of cramps. Opium and morphine
should never be given on account of the danger of
habituation. Constipation and digestive disorders
should be cared for, oral sepsis and other foci of
infection should be treated, and lavage should be
practiced when there is dilated stomach. Colchicum
and alkalies should be prescribed where gout is
present. Passive congestion, heat, massage and
electricity are all of value in relieving pain, promot-
ing suppleness, preventing contractures and main-
taining nutrition of the parts. Stock vaccines
should not be used, but where there is an active
focus of infection a vaccine made from the con-
tained organisms may prove helpful. Pituitary and
other gland extracts have been recommended.
Rectal Anesthesia. — R. H. H. Goheen {Indian
Medical Gazette, January, 1918) says that rectal
ether has proved with him in eighty-two cases a safe
and satisfactory method of general anesthesia when
intestinal lesion cases are excluded. It is not suit-
able for laparotomies. It is particularly convenient
for surgery of the mouth, head, neck, and other
regions above the diaphragm. It is not economical
for operations that can be performed in less than
thirty minutes, but almost ideal for nervous thyroid
cases, or others who dread inhalation anesthesia.
There is less hyperemia about the head and neck,
and consequently less hemorrhage in operations in
this region. It is less irritating to the lungs than
ether given by the open method, probably because it
reaches the lungs in a naturally warmed and dilute
condition. The postoperative nausea and vomiting
is also less than with inhalation anesthesia. His
method of administration is as follows: Weigh the
patient ; clear the bowels by cathartics and a saline
enema ; give hypodermically morphine grain one
sixth and atropine grain 1/150 one half to one hour
before operation, or, instead of this, induce primary
anesthesia by chloroform inhalation and proceed at
once with a mixture of three parts of ether to one
part of olive oil. This mixture is shaken thoroughly
for one minute and then one ounce of the mixture
to every twenty pounds of the weight of the
patient is introduced into the rectum through a
catheter at the rate of one ounce per minute.
The patient's hips should be slightly raised while
this is being done. To prolong or deepen the
anesthesia a httle more may be given, for an over-
dose some may be drawn oflf through a rectal tube,
and to cause the anesthesia to cease, draw off all
the mixture and wash out the lower bowel with one
pint of soapy water.
July 0, 1918.I
MODERN TREATMENT AND PREVENTIVE MEDICINE.
39
Ligation Treatment of Causalgia. — Lortat-
Jacob and Hallez {Pressc mcdicale, March 28,
1 91 8) report the case of a wounded man with as-
sociated paralysis of the right median and ulnar
nerves and marked and persistent sensory disturb-
ances of causalgic type in the median distribution.
A vascular injury had necessitated ligation of the
brachial artery. Galvanism, the ethyl chloride
spray, and salicylic ionization having all proven
useless in relieving the pain, surgical treatment was
decided upon. The median was freed for a dis-
tance of five centimetres and a moderately tight
ligature of No. 1 catgut placed about the nerve in
its infraxillary portion. On the first day the pain
W3S markedly diminished and on the second disap-
peared completely. Evidently such a ligature is
capable of inhibiting or eliminating for a time the
perineural sympathetic irritability and the conges-
tion of the trunk of the nerve without injuring the
nerve fibres themselves which are underging cen-
trifugal repair. The procedure is simpler and
more easily carried out than denudation and ex-
cision of the periarterial nervous plexuses, and
deserves recognition as a radical means of relief .
for severe causalgia in certain cases of median
paralysis. It can' be accomplished under brief
general anesthesia with ethyl chloride.
Severe Cicatricial Stenosis of the Esophagus. —
Sencert {Bulletin dc 1' Academic dc medicine,
March 12, 1918) asserts that the chief obstacles
to the passage of sounds in tight esophageal
strictures are met with at the upper opening of the
stricture and in its interior. In the former situation
the obstacles are, the narrowness of the orifice, its
eccentricity, and the presence of a prestrictural
dilatation presenting diverticular false openings
which may be confused with the true opening. Ob-
stacles within the stricture itself consist in the
multiplicity of the strictured points and the irregu-
larity of the lumen, which may be sinuous, oblique,
or deflected bayonet fashion. The only way to cir-
cumvent these obstacles is to attack the stricture
from below upward and to abandon the idea of
carrying out repeated catheterization through it,
the progressive dilatation being efifected only along
a permanent conducting strand passed through the
stenosis. Gastrostomy is the first step in the pro-
cedure. Then, apart from exceptional cases in
which a leaden shot and silk thread can be gotten
through from above, the thread is passed by re-
trograde catheterization of the esophagus under
visual control either through direct gastroscopy or
retrograde esophagoscopy. The third step consists
in continuous dilatation, carried out by the passage
of rubber tubes of progressively increasing diame-
ter, these, in turn, being fixed to the gastric end of
the esophageal thread and drawn through the
stenosis with the aid of traction on the oral end of
the thread. The first rubber tube pulls after it a
second silk thread which on the next day will draw
through a second rubber tube of larger calibre, and
so on until the necessary dilatation of the stenotic
channel has been secured. In six weeks to two
months the most severe strictures can be mastered
by this method. Sencert had carried it out with
success in fourteen cases.
Analgesics in the First Stage of Labor, — R. W.
Stearns {Nort Invest Medicine, March, 1918) urges
the early use of small and repeated doses of mor-
phine to produce analgesia in the first stage of
labor. The initial dose should never exceed fifteen
milligrams (one fourth grain) and the selection of
cases is of importance if the remedy is to prove
truly valuable. There are six general indications
for its use. The first is for the relief of the wear-
ing, early, pinching or back pains so common in
young and nervous primaparas. The second,
tetanic contraction of the lower uterine segment
and cervix; the third, threatened shock from long
and severe pain ; the fourth, inertia of the uterus
from reflex causes in nervous, highly sensitive pa-
tients. The last two are : For patients with fulmi-
nating pains of great severity which must be
checked to prevent too rapid delivery and damage
to the maternal soft parts, and for the relief of
pains of any sort in patients not used to bearing
pain and who do not stand it well, even in modera-
tion. These indications will include about thirty-
five per cent, of all cases seen in general obstetrical
practice. The only contraindications are idiosyn-
crasy, previous habituation, the patient's own
scruples against taking any drug, and cases with
irregular and feeble pains.
Simplified Method of Blood Transfusion. —
Rieux (Paris medical, March 23, 1918) uses two
trocar needles — the one plain, for insertion in the
recipient's vein ; the other with an additional inlet
forming an acute angle with the narrow shaft of the
needle, for the donor. A graduated receptacle
holding about 500 mils and containing an isotonic
citrate mixture at 38° C. is connected by tubing with
the oblique inlet of the donor's needle. Another
receptacle with an opening at the top and two lateral
openings, the one above for entrance of the citrate
mixture, and the other below, for exit of the
mixture, is connected at the upper lateral opening
v/ith the longitudinal inlet of the donor's needle,
and by the lower lateral opening with the needle
leading to the recipient's vein. The citrate solution
mixes with the donor's blood as the latter leaves the
vein, and consists of sodium citrate, either six or
eight grams ; sodium chloride, 7.5 or seven grams,
in 1,000 mils of distilled water. In an injection of
one litre of blood and citrate mixture in equal parts
the patient receives, according to the citrate solution
used, but three or four grams of sodium citrate. The
elevation of the citrate receptacle is so regulated be-
forehand that the citrate solution and blood mix in
approximately equal amounts. The needle for the re-
cipient's vein may be inserted either before or after
the blood has been obtained from the donor. The
amount of blood injected is known by noting the
difl^erence between the entire quantity of mixture in-
troduced and the amount of citrate solution that has
left the upper receptacle. Obtaining the donor's blood
by mere puncture into the vein facilities the procedure
as a whole and permits of obtaining 250 to 300
grams of blood — an amount removable with im-
punity— from each of two or more donors, if neces-
sary. The blood meets the citrate and becomes in-
coagulable immediately upon leaving the donor's
vein.
Miscellany from Home and Foreign Journals
The Cardiac Disabilities of Soldiers in France.
— W. E. Jlunie {Laiiccl, April 13, iyi8j has made
a careful inquiry into the cardiac disabilities en-
countered in 5,000 soldiers sent up with the diag-
nosis of valvular disease or disordered action of the
heart (V. D. H. or D. A. H.). At the preliminary
examination a little more than eight per cent, of the
patients were found to be suffering from easily
recognizable diseases not of circulatory origin. The
remaining ninety-two per cent, complained of
breathlessness, pain in the chest, palpitation, giddi-
ness, and other vague symptoms. Of these 5.5 per
cent, were found to have gross organic cardiac dis-
ease, while the remainder fell into the class of D.
A. H cases. A very careful investigation was made
of these latter and it was concluded that the symp-
toms of which they complained might occur under
varying conditions of the body and mind and that
no detinite pathological basis for them could be de-
termined in the vast majority of cases. No single
underlying cause could be discovered. Some of the
men belonged to that class of persons who through-
out life are unable to undergo any prolonged strenu-
ous physical exertion without cardiac symptoms. In
such it might be supposed that the heart muscle, like
the skeletal, was incapable of much increase in size
and power through training. In another and a small
group of men "the D. A. H. was definitely due to
some permanent or temporary damage to the heart
muscle as the result of rheumatic fever, influenza,
the enteric group of infections, trench fever, or
other infectious diseases. A third group seemed to
depend upon a disturbance of the innervation of the
heart. Except in the first group and in a proportion
of the cases in the second, the majority of the men
could be returned to active duty following a course
of graduated exercises.
Paroxysmal Tachycardia. — Frederick W. Price
(Laiicci, April 13, 1918) uses this term to include
the conditions in which there occurs a marked in-
crease in the heart rate, which begins abruptly
without apparent cause and ceases as abruptly after
a variable period, and which is due to the assump-
tion of an abnormal rhythm. The abnormal rhythm
varies, and, while its point of origin is usually in
the auricle, it may arise in the ventricle. Tempo-
rary auricular fibrillation and auricular flutter are
the commonest causes. The duration of each at-
tack and the frequency of the repetitions vary
within very wide limits. The etiology of the con-
dition is obscure, but it is commonest in males and
during m?ddle life. A rheumatic historv and the
presence of some valvular or myocardial involve-
ment are very common, but the condition also often
occurs in the absence of all such factors. The
symptoms may vary all the way from none recog-
nizable by the patient to those typical of decided
cardiac failure. The pulse rate is generally above
140 and may rise to 300, though it usually lies be-
tween 150 and 190. The pulse is of smaller volume
than normal and mav be regular or absolutely irreg-
ular. Pulsus alternans is very common during the
paroxysms. The blood pressure is usually diniin-
islied in the attack. J he area of cardiac dullness
may enlarge materially, but with the cessation of the
attack, the heart rapidly regains its normal size.
Polygraphic and electrocardiographic tracings show
different features, depending upon the origin of the
abnormal impulses. The diagnosis rests mainly
upon the cardiac rate and the abrupt onset and dis-
appearance of the attacks. It may be confused with
the tachycardias of less severe grade associated with
the normal rhythm, but is readily differentiated by
the suddenness of onset and termination and by the
discovery in graphic records of the abnormal
rh} thm. The prognosis for a particular paroxysm
is generally good, but when the attack is very pro-
longed it should be more guarded and should be
based upon the rate of the heart, the duration of the
attack, and the degree of cardiac failure present.
Prognosis as to the recurrence of paroxysms is im-
possible. The degree of integrity of the myocardium
sh^mld be estimated between the attacks and if there
is no material limitation of the field of cardiac re-
sponse and the attacks are infrequent and of short
duration the prognosis may be regarded as good.
Nature and Symptoms of Cardiac Infection in
Childhood. — F. J. Poynton (British Medical Jour-
nal, April 13, 1918) here presents some of the
features of rheumatic disease of the heart and
points out that the first attack of rheumatism in
childhood may be of any grade of severity from the
most transient and vague to the rare, rapidly fatal
type. In the early cases with cardiac involvement
there are two important groups : The one with sore
throat, arthritis, and morbus cordis ; the other with
chorea and morbus cordis. In the very mild cases
of the acute type, as in all other rheumatic cardiac
cases, some degree of cardiac dilatation is to be
found. In these very mild cases this is often the
only evidence of cardiac involvement and must be
looked for in every case of rheumatism in children,
even in the absence of cardiac symptoms. It is best
made out by carefitl percussion of the cardiac dull-
ness with records kept by taking tracings from the
points marked. The chief symptoms of this condi-
tion, aside from the slight enlargement of the heart,
are shortness of breath, pallor, palpitation, and
fainting attacks. The pulse is rapid and compressi-
ble. The first sound is often shortened and a soft
mitral systolic bruit may be heard. In the severer
grades all of these svmptoms are exaggerated. The
opposite picture to this mildest one is that of the
most severe type of rheumatic heart infection. In
<his type the general evidences of severe, acute in-
■ction are pronounced, the rheumatic symptoms
marked, and the cardiac dilatation and weakness are
great. Death ensues in a very brief time, with or
without the developinent of pericarditis and evident
valvular lesions. A second form of this fatal carditis
is the insidious type, occurring in feeble children.
Here the symptoms are not very definite, but pro-
gressive weakness and evidences of cardiac dilata-
tion are striking. The author says that the consid-
eration of pericarditis, endocarditis and myocarditis
apart from carditis is essentially artificial but is
July 6, 1918.]
MISCELLANY FROM HOME AND FOREIC^' JOURNALS.
\
41
necessary on account of their individual importance.
Rheumatic pericarditis in children is of three types ;
acute pericarditis, acute internal and external }>eri-
carditis with mediastinitis and pleurisy; and malig-
nant pericarditis. The striking feature of peri-
carditis in children is the rarity of large effusions.
It must be constantly borne in mind that the symp-
toms of all types depend largely on the presence of
a concomitant carditis. A brief sketch of the fea-
tures of each of tlic three forms of pericarditis is
giveti.
Paroxysmal Tachycardia of Ventricular Origin.
— W. T. Vaughan {Archives of Lntcrml Medicine,
^March, 1918) has encountered since 1913 eighteen
patients with the characteristic features of parox-
ysmal tachycardia, viz., sudden onset and offset;
constant, regular, rapid rate and typical electrocar-
diographic tracings. In sixteen cases the pacema-
ker lay in the auricle, as was demonstrated graph-
ically. In two, however, the condition was of an-
other type, the impulse originating in the ventricle
during the paroxysms. The author presents a de-
tailed description of these cases, with electrocardio-
graphic tracings, and summarizes the similar cases
previously recorded in the literature. Digitalis
might be an exciting cause of the condition, but
there must in addition be some other predisposing
factor, such as excessive irritability of the ventricles
from impaired blood supply or some other cause.
Digitalis in therapeutic doses in the majority of
cases does not markedly increase the tendency to
successive ventricular extrasystoles.
Adhesive Phrenopericarditis. — F. Tremolieres
and L. Caussade [Pressc medicale, April 4, 1918)
have encountered twenty cases of adhesion of the
apex of the heart to the diaphragm, and establish it
as a distinct nosological entity having special char-
acteristic symptoms. Precordial oppression is com-
plained of generally coming on during rapid walk-
ing or running, though at times apparently induced
by the process of digestion or even occurring during
rest. There is more or less severe pain of the
anginal type, occurring in paroxysms. Yet careful
examination reveals no aortitis, arteriosclerosis,
chronic nephritis, tabes, diabetes, nor high blood
pressure. Auscultation reveals only a rise in the
heart rate, reduplication of the first sound or muf-
fling of both sounds, but inspection and palpation
will show absence of the apex beat. This, with the
anginal pain, is the chief cHnical symptom ; the diag-
nosis is clinched, however, by x ray examination,
which shows that the left cardiodiaphragmatic
sinus, normally clear and especially marked in deep
inspiration, has disappeared, being replaced by a
triangular area of opacity, plainly circumscribed
externally, with its base resting on the diaphragm
and its summit merged with the cardiac apex, or
oftener, with the lower part of the left ventricular
margin. The angmal attacks may recur only once
a month or become more frequent up to one every
hour. In some cases the apex beat is perceptible
almost as well as normally, but its site remains fixed
and is not displaced during lateral inclination of the
thorax. Exclusive limitation of adhesions to the
apical region is suggested by absence of the other
physical signs generally attributed to cardiac bands.
.Such patients constituted two per cent, in a series'
of 1,000 heart cases. In seven of the cases the
original cause was tuberculosis or protracted bron-
cliitis ; m six, rheumatic fever, and in five, the
eruptive fevers, especially scarlet fever, and in the
other two, possibly dy.sentery and malaria. Gener-
ally the initial stage of the adhesive disease remains
latent. Only rarely does it follow an acute diffuse
pericarditis or a combined inflammation of the
serous membranes. Symptoms appear at the long-
est in five years after the original pathological
change.
Amyl Nitrite in Diagnosis of Mitral Stenosis.
— R. A. Morison (British Medical Journal, April
20, 1 91 8) emphasizes the fact that the diagnosis
of early mitral stenosis is often a matter of great
difficulty, though one of great military importance.
In many doubtful cases a diagnosis can be made
by auscultation successively in the standing, in the
recumbent, and in the recumbent position after ex-
ercise. Lying, alone, will sometimes bring out a
previously inaudible presystolic murmur, and this
is more likely to appear on lying after exercise.
In other cases, however, these procedures fail to
bring out a murmur, while the inhalation of a pearl
of amyl nitrite to the point of a reaction will often
cause the appearance of the typical presystolic or of
a full diastolic murmur. In other words the amyl
nitrite advances the scale of physical signs to the
point where a diagnosis is possible. In some other
cases where a diastolic or presystolic murmur was
present the inhalation of amyl nitrite abolished the
murmur. Such cases also had definite aortic insuffi-
ciency and the presystolic or diastolic murmur was
evidently of the Flint type.
Time Element in Isolation of Dysentery Bacilli
From the Stools.— C. J. Martin and F. E. Wil-
liams {Briiish Medical Journal, April 20, 1918)
recall the fact that prior to the war the bacteriologi-
cai diagnosis of dysentery was held to be as satisfac-
tory as that of diphtheria, and the further fact that
a number of workers among the troops of both sides
have recently reported very large proportions of
negative results from bacteriological stool examina-
tions in cases of clinical dysentery. Using a per-
fected technic, which they describe, the authors were
able to isolate dysentery bacilli from fecal material
when they were present in anything above the ratio
of one colony of dysentery to 500 of other organ-
isms in the primary plate. With the employment
of this method 1,050 eft'orts to recover the organisms
were made in a large number of cases of clinical
bacillary dysentery at various stages of the disease
and they obtained positive results in sixty-eight per
cent, up to the fifth day of the disease ; in 17.4 per
cent, between the sixth and tenth days ; in 6.3 per
cent, between the eleventh and fifteenth days, and
in about three per cent, between the sixteenth and
fiftieth days ; after which no positives were obtained.
In other words the chance of recovering the bacilli
diminished very rapidly after the first few days
of the disease, and this was true without reference
to whether the stools remained dysenteric or not.
This fact puts a very serious limitation on the bac-
teriological diagnosis of bacillary dysentery.
42
MISCELLANY PROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Typhoid Infections of the Mouth and Pharynx,
— A. Campani and F. Berf^olli (La Rifonna Me-
dico, April 6, 1 91 8) describe several dilferent types
of oral and pharyngeal alterations in typhoid.
There may be a simple reddening with edema of
the pharynx, either with or without tonsillitis,
which is frequently seen at the onset of the disease.
This is called the erythematous type and is found
in thirteen per cent, of cases. Another form occur-
ring in 5.5 per cent, and especially in the grave
cases is the crustomucus, with encrustation of the
lips and tongue, congestion of the soft palate and
pharynx with abundant mucus secretion. A third
variety is the miliary vesicular seen in the third
week of the disease in 16. i per cent.; a fourth is
the true angioma of Duguet and was noted in thir-
teen of 108 cases. The last category comprises
cases where punctiform or lenticular vesicles are
present on the hard palate.
The Factors Concerned in the Appearance of
Nucleated Red Blood Corpuscles in the Periph-
eral Blood. — Cecil K. Drinker, Katherine R.
Drmker, and lienry A. Kreutzmann {Journal of
Experimental Medicine, March, 1918) in the pres-
ent paper studied the influence of hemorrhage and
infusion as procedures designed to increase the rate
of blood flow through the blood forming organs. In
thirteen out of nineteen dogs a slight increase in
the number of nucleated red cells followed hemor-
rhage and infusion, in five cases there was a slight
decrease, and in one, no change. This slight in-
crease the authors term a pseudocrisis. The true
crisis is more extensive and occurs just before a
rapid increase in the red cell count, and usually
about the last of the first week following hemor-
rhage. As bleedings are continued, regeneration
takes place irrespective of the appearance of nucle-
ated red cells in the peripheral blood. The obser-
vations of Hough and Waddell that a sudden and
unaccountable leucocytosis may foretell rapid re-
generation are upheld.
Mumps Meningitis. — Julius Kaunitz {Journal
A. M. A., May 18, 1918) calls attention to the
fact that this complication of mumps is very
seldom recognized, there having been reports of
only 150 cases in the literature. The rarity of its
recognition may be due to the fact that it is often
mild, and, usually, of very brief duration, with
prompt recovery. In a few autopsies a serofibrin-
ous meningitis has been demonstrated. Three cases
of this complication are reported. In one of them
symptoms were very severe and threatened death
from medullary compression, but were promptly re-
lieved by lumbar puncture. In the other two the
symptoms were very mild and transitory. The con-
dition closely resembled tuberculous meningitis in its
course, but it could be differentiated from that dis-
ease by its association with an attack of mumps
within two weeks of the onset of that disease, by
the fact that the spinal fluid did not contain tubercle
bacilli, and by the presence of many mononuclears in
a clear or opalescent fluid within the first twenty-
four hours of the beginning of symptoms. The prog-
nosis was usually very good, but the complication
might prove fatal occasionally, or leave a hemiplegia
or damaged optic or auditory nerves.
Bacteriological Studies in Bacillary Dysentery.
— Bezangon, Kanque, Senez, Coville, and Paraf, in
studies of 300 stools during an epidemic whicli
broke out similtaneously in several small foci m a
certain military district in the late summer of 1917,
were able to estabhsh clearly the role of Shiga's
bacillus in the more severe and clinically typical
cases, while in the mild the Shiga organism was
generally wanting and was replaced by aberrant
bacilli of the dysentery group. The Shiga bacillu;>
was isolated in large numbers from forty-three
cases, and in dishes of lactose litmus agar at times
almost completely replaced the normal intestinal
flora, no colonies of colon bacillus being found. In
twenty-six milder cases were found a number of
difl^erent forms of organisms which did not corre-
spond to any of the classical types of dysentery
baccillus and never occurred in the severe or fatal
cases. These atypical organisms are divided by
the authors into five separate classes, according to
their respective behaviors with indol and various
sugars and their susceptibilities to agglutination by
anti-Shiga and anti-Flexner serums. In each focu?
of dysentery the organisms responsible for the mild
cases were of a single type. In one focus, however,
the examinations revealed, in addition to the Shiga
bacillus in five cases, the A paratyphoid organism
alone in four cases and the typhoid organism alone
in one case, in spite of the fact that the symptoms
were those of dysentery. In no case in the entire
series was the Flexner or the Hiss bacillus encoun-
tered.
Studies in Calcium and Magnesium Metabolism.
— Experiments on Man. — Maurice H. Givens
[Journal of Biological Chemistry, April, 1918) in
order to determine whether there is any "normal"
range for the urinary excretion of calcium and
magnesium in adult man, and what the quantitative
relation of these elements to each other is, observed
nine healthy laboratory workers in this study. The
character of the diet was not particularly limited,
with the exception of the amount of milk taken. At
first the articles in Sherman's diet containing more
magnesium than calcium were taken, and the urine
collected for three days. Then the relationship of
calcium to magnesium ingested was reversed by add-
ing to the diet either fresh or dried milk, calcium
lactate, or magnesium citrate, and the urine was col-
lected for a second period of three days. In the first
instance the daily output of calcium ranged from
0.05 to 0.24 gramme, and that of magnesium from
0.03 to 0.15 gramme. On the diet having more
calcium than magnesium the limits were 0.12 to
0.47 gramme of calcium and 0.05 to 0.23 gramme of
magnesium. In these subjects there was generally
a greater excretion of calcium than magnesium in
the urine, or if this was not the case, it could be
readily produced by the ingestion of either dried
skimmed milk or raw milk, which increased the
urinary output of both calcium and magnesium. By
taking calcium lactate it was always possible to in-
crease the urinary calcium excretion, but the excre-
tion of magnesium in the urine was apparently not
affected by magnesium citrate. Milk was more effi-
cacious than calcium salts, e. g., calcium lactate, in
increasing the urinary excretion of lime.
CANADIAN MEDICAL CONGRESS
Held in Hamilton, Ontario, May 27 to 29, 1918
By far thr largest medical meeting zvhich has ever been held in the Dominion was opened
by the (jovcrnor General of Canada, on May 3J, ipi8, in the picturesque city of Hamil-
ton, Ontario. The congress was a combined meeting of the Canadian Medical Association,
the Ontario Medical Association, the Canadian Public Health Association, the Ontario
Health Officers' Associatio)i, and the Canadian Association for the Prevention of Tubercu-
losis. During the entire week the meetings were largely attended. Some thirty zvcll knoum
physicians and surgeons from the United States read papers and took part in the discus-
sions.
€f)c proceedings
CANADIAN PUBLIC IIPZALTH ASSOCIA-
TION AND ONTARIO HEALTH OFFICERS'
ASSOCIATION.
Annual Meeting, Held May 2'/th and June ist.
Dr. W. H. Hattie, of Halifax, Captain, Canadian Army
Medical Corps, in the Chair.
Two features marked the proceedings of the first
two days. One was the special attention paid to
the problem of .venereal diseases, and the other
that child welfare occupied the most prominent
place in the programme.
The Control of Venereal Diseases. — Lieutenant
Colonel John W. S. McCullough, M. D., D. P.
H., of Toronto, opened the proceedings with a paper
which dealt almost wliolly with the act for the
control of venereal diseases in Ontario which
Colonel McCullough has been largely instrumental
in putting through the legislature. By its provisions
any person under arrest, may, if, considered neces-
sary by the medical health officer be examined to
discover if he is siitfering from venereal disease.
If this be so, he is liable to detention and treatment.
Physicians in charge of places of detention are re-
quired to report cases within twenty-four hours.
Examination and treatment may be enforced by
a medical officer of health. To protect physicians
reporting such cases after examination, the act pro-
vides that action of this character can only be
brought with the consent of the provincial board of
health. It is further provided that the medical
health officer or his deputy has the right of entry
in the dav time, to premises for the purpose of in-
quiry or examination of persons known to be in-
fected. Hospitals designated by the board are
required to provide facilities for treatment, only
qualified physicians are allowed to attend or treat
sufferers from venereal disease under pain of heavy
penalties. Those advertising remedies or cures for
venereal disease, are subject to severe punishment,
as well as those found guilty of infecting others.
Provision is made for maintaining secrecy in the
matter. Reporting the names of sufferers which
has not worked well whorever it has been tried, is
not i;anctioned by the act, those reporting using
serial numbers.
Doctor BriXl, of Ottawa, gave as his opinion
that the success of carrying out the act would de-
pend on the facilities provided by the eighty-eight
hospitals called upon to treat these cases. The
question of free treatment of venereal diseases had
been discussed, but no definite conclusion with re-
gard to this point reached. One advantage pertain-
ing to free treatment was, that as the suppression
or control of venereal diseases is not so much for
the good of the individual, as for the race and state,
and because treatment as outlined in the act could
be relied upon, such treatment would tend to do
away with secret treatment. Treatment in the
hospitals named in the act would be free, that is
the hospitals are required to treat all cases of
venereal disease sent to them, but at the same time,
as Colonel McCullough l;ad pointed out, it would
not be fair that all should be treated free. With
respect to the term cure in connection with venereal
diseases Colonel McCullough had stated that the
term was only used in a relative sense. If the dis-
ease were made noninfective t!ie object of the act
would be fulfilled. He further stated that no pro-
vision for the inspection of prostitutes, had been
made, other than the clajse permitting those au-
thorized to go in daylight and make examination,
and this power would be exercised by the large
majority of the medical officers of the province.
A Plea and a Plan. — Captain W. H. Hattie,
M. D., of Halifax. N. S., theii. delivered the presi-
dential address of the Canadian Public Health As-
sociation, entitled "'A Pica and a Plan."
Value of Public Health Work. — The address
following was that of Captain H. W. Hill, M. D.,
of London. Ont., as president of the Ontario Health
Officers' Association. Captain Hill pointed out that
at one time public health officers were regarded by
the body of the profession as nuisances, almost as
outcasts, but that of recent years somewhat grudg-
ing admission had been made that their theories
were often correct, and, put into practice, had re-
sulted in a great saving of life and in increasing
general good health. The war had brought health
officers completely into their own and had demon-
strated the incalculable value of sanitation and
hygiene. He considered that there were three es-
sential fields of these twin preventive measures,
venereal diseases, tuberculosis, and child welfare.
So far as the prevention of infective diseases was
concerned, the only ones of any great moment were,
venereal diseases and tuberculosis. The others
were relatively small matters. Typhoid fever had
been virtually driven out, while diphtheria and
scarlet fever still take their toll but are being rapidly
eliminated. As for the control of venereal dis-
eases, the speaker thought the problem was difficult
rather on account of its psychological bearings. A
commencement looking to the suppression of vene-
real diseases, must be made with prostitutes. These
must be examined and when found to be infected,
isolated. The places of incarceration must be sup-
plied by the Government.
44
COXGRESS OF CANADIAN MEDICAL ASSOCIATIONS.
[New York
Medical Journal.
Means of Infection in Venereal Diseases. —
C aptain Gordon J^ates, of 'J'oronto, read a paper
(loaliiig with the venereal problem. The gist of the
information contained therein was gained through
a considerable experience in treating venereal dis-
eases in private practice and in the medical service.
In his opinion, illicit sexual intercourse was the crux
of the problem. The general public was beginning
to understand from statistics available from military
districts that a large proportion of the cases of
venereal disease existing in the Canadian army were
contracted previous to enlistment. \\'hile organized
prostitution was and is present on a comparatively
large scale in Canada, it was, perhaps, by means of
illicit intercourse that infection was most widely
spread. Young girls who work in the daytime sold
themselves for a small sum or gave themselves for
sexual intercourse. Feebleminded females were re-
sponsible for a good deal of venereal infection and
were particularly difficult of restraint. Captain
Bates drew attention to the fact that the control
of venereal diseases was very largely a civilian ques-
tion. In the army, effective steps could be taken
to prevent the spread of infection, but in civilian
life the matter was surrounded with difficulties.
Among preventive measures advocated by the speak-
er was educational propaganda, the providing of
wholesome recreation and the provision of home
like, clean houses in which girl workers could live
at a moderate cost in place of cheap and nasty
boarding houses.
Detection of Syphilis in Its Primary Stage. —
Captain Hill, referring to the detection of syphilis
in its primary stage, stated that the Wassermann test
was absolutely unreliable at this stage as a means
of diagnosis. In the primary stage of syphiHs the
Wassermann test was generally negative and conse-
quently misleading.
House Disinfection after Scarlet Fever and
Diphtheria. — Another point which gave rise to
much discussion was as to the value or otherwise
of disinfection of the house, clothes, furniture and
so on after contagious fevers, scarlet fever initiating
the discussion. Several present recommended dis-
infection by formaldehyde and potassium perman-
ganate. Captain Hill, however, said that so far
as experience with scarlet fever had taught him,
if there were any discharge from ear, or even if a
herpes he would not permit a patient to leave the
hospital. Any form of discharge following scarlet
fever, rendered the patient liable to transmit the
infection. Moreover, he declared that scarlet fever
infection from a discharging ear could be carried
almost indefinitely. He quoted a case in which in-
fection had been transmitted five months after con-
valescence had set in. Further, he had not carried
out house disinfection after scarlet fever for some
years. Many in the audience were firm behevers
in the efficacy of house disinfection and strenuously
upheld their views. A resolution was therefore
moved by Colonel McCuUough and carried, that a
comm.ittee should be formed to investigate with re-
spect to house disinfection after communicable dis-
eases, with special reference to scarlet fever and
diphtheria. Such a committee was named and will
proceed on their investigations immediately.
The Problem of Infant Feeding in Rural Dis-
tricts.— The first paper read on the subject of
child welfare was by Dr. Al.\n Brown, of Toronto,*
on the subject of the rural infant feeding. He
pointed out the many difficulties that mothers living
in the country have to face, in nursing, feeding, and
weaning babies, often far removed from the advan-
tages of regular observation and advice.
Infant Feeding in War Time. — Dr. Grace L.
Meigs, Washington, D. C, read a paper on infant
welfare in war time. She said, in part that the lack
of trained women to stimulate interest in nursing
was one of the greatest obstacles to the conservation
of hifant life. She suggested that rural hospitals
might be one way of overcoming the handicaps that
women have to contend with when giving birth to
children.
The Medical Student in Child Welfare Work.
— Dr. Richard Bott, of Cleveland, Ohio, discussed
the question whether the medical student of today
was equipped to meet the problems of child welfare:
private medical practice in its relation to public
health service for children, and whether the present
medical education scheme could be adapted to the
needs of training in infant and child welfare work.
He advocated a broad premedical education in this
direction for students.
Dr. Charles J. Hastings, medical officer of
health for Toronto, said child welfare work, the
country's home line of defense was, at last, coming
into its own. He strongly advocated breast feeding,
as well as the pasteurization of milk as a precaution
against various epidemics and against the contrac-
tion of tuberculosis by infants.
Mental Defectives in Canada. — At the com-
bined session of the Public Health Associations held
on the afternoon of the second day, the first paper
v/as read by Dr. Clarence Hincks, of Toronto,
who gave statistics showing the prevalence of men-
tal incapacity, and suggesting remedies. He stated
that there were 30,000 mental defectives in Canada.
Venereal disease played a prominent part and a
campaign of education was sorely needed.
Other Papers Read. — These papers included:
"An Experiment with Diphtheria Carriers," by
Dr. A.. B. Rutherford, of Owen Sound; "The
Value of Establishing Sewerage Systems in Small
Ontario Towns," Mr. A. F. Dallyn, Toronto; "In-
terpretation of Water Analysis," By Dr. H. M.
Lancaster, Toronto, and "The Study of Some
Outbreaks of Typhoid Fever," by Dr. W. C.
Allison, of Toronto.
Officers for the Coming Year.— The officers
elected for the coming year of the Canadian Public
Flealth Association were : President, Dr. J. A.
Hutchinson, Westmount, Que.; vice-presidents. Dr.
H. W. Hill, London, Ont. ; Mr. L. A. Hamilton,
Toronto ; Dr. R. W. Bell, Toronto ; secretary, Dr.
R. D. Defries, acting in the absence at the front of
Major Fitzgerald, M. D. Officers were elected for
the Ontario Health Officers' Association as follows :
President, Dr. G. R. Cruickshanks, Windsor, Ont. ;
first vice-president. Dr. W. A. McCauley, Cooper
Cliff, Ont.; second vice-president, Dr. Dickenson;
secretary, Dr. J. W. McCullough, Toronto.
July 6, 1918.]
CONGRESS OF CANADIAN MEDICAL ASSOCIATIONS.
45
ONTARIO MEDICAL ASSOCIATION, CANA-
DIAN PUBLIC HEALTH ASSOCIATION,
AND THE CANADIAN MEDICAL
ASSOCIATION.
General Session.
The Problem of the Returned Soldier. — The
first paper read dealt with psychogenetic conditions
in soldiers, their etiology and treatment and was
contributed by Lieutenant Colonel Colin Russell,
C. A. M. C. The psychogenetic conditions and the
subdivisions of this type were described. Such con-
ditions comprised physical and mental disabilities,
but the futility of refinement of classification was
obvious. Psychogenetic conditions represented a
conflict between the natural inherent instincts and
the more lately acquired control of these instincts by
the higher centres. The eltect on the result of the
conflict of deficient control was either congenital as
in mental deficiency or due to lack of proper train-
ing as well as to natural exhaustion of the acquired
higher control under prolonged strain. The defeat
of the higher centres and the abolition of the critical
activities of the censor rendered the patient open to
suggestions that met the wishes of the conquering
instinct. They varied in type from complete blind-
ness to complete mutism and, curious to relate, all
these types appeared in epidemics. During the early
stages of the war, trench fever was remarkably
prevalent. This type had almost wholly disap-
peared. The conditions following shell shock pre-
sented no physical or pathological symptoms. They
simulated, however, a variety of pathological states.
For example, convulsive seizures resembling epi-
lepsy occurred sometimes subsequent to shell shock.
These seizures differed from true epilepsy, in that
the movements were purposeful, whereas, in true
epilepsy, the reverse obtained. These conditions
were classed formerly under the term hysteria. War
had not been responsible for their initiation, but had
aggravated inherent instincts. The treatment of
such conditions consisted in putting down the usurp-
ing instincts and stimulating the higher centres to
resume the duties allotted to them. The conditions
of shell shock being often due to an idea, the treat-
ment of these cases should be in special hospitals
in charge of experienced men. An authority on the
subject had stated that ninety per cent, of psycho-
genetic cases were capable of cure.
Attention was drawn to the fact that soldiers suf-
fering from shellshock frequently had no induce-
ment to dismiss the idea from their mind. On the
contrary, from their point of view, if they did so
they would be returned to the army, while, on the
other hand, if they continued to harbor and foster
the idea that they were shell shocked, designated by
Russell as loss of control of mental intelligence, they
would draw a nice pension. Several instances were
given in which men presenting various symptoms,
as paralysis and so on and who were by means of
rational measures disabused of the idea that they
were thus afflicted.
It had been stated that shell shock cases disap-
peared from the French Army when a rule was
made that a soldier claiming to suffer from it would
not receive a pension.
The Mental Attitude of the Returned Soldier.
— Colonel I. H. Cameron, C. A. M. C, read a paper
on General Surgical Observations, with Special
Reference to Orthopedics.
Althougli the title of the paper was as above, it
dealt more with the economic and social treatment
of the returned soldier than with the surgical aspect.
A resume of the history of orthopedics was given
and the address abounded with apt quotations and
allusions. Colonel Cameron stated that the returned
men came liome with the idea that the state owed
them everything and they in return owed the state
nothing. The state never owed them anything, and
now it only owed them the equality of the law.
Well meaning people who formed organizations to
look after the soldiers were responsible for the pres-
ent conditions. It was suggested as a solution that
foolish sentiment be excluded, that returned men,
among other things, be given better literature and
be provided with educational films in place of the
comedy ones now being exhibited.
Lieut. -Col. Hadlev W'illiams, C. A. M. C, dis-
cussed the surgical treatment of nerve injuries and
Lieut. -Col. RoiiERT Wilson read a paper on The
Place of Physiotherapy in the Treatment of the In-
valid Soldier.
Tribute of Canadian Universities to the War. —
At the meeting Dr. J. H. Elliott, of Toronto, paid
a touching tribute to the graduates and undergrad-
uates of the Canadian universities and their part in
the war. He read the names of all those who had
fallen, while the audience stood with bowed heads.
Of these, forty-one belonged to the University of
Toronto, seventeen to McGill University, Montreal ;
six to Queens University, Ontario ; five to Dalhou-
sie LTniversity ; two to the University of Manitoba,
and one to VVestern University, making a total of
seventy-two. Doctor Elliott then recited that im-
mortal poem by John McCrae, "In Flanders Fields."
The Prevention of War Neurosis, Shell Shock.
— In the Section of Medicine, Dr. Thaddeus Hoyt
Ames, of New York, read a paper on the Preven-
tion of War Neuroses, Shell Shock.
Doctor Ames said that although he had not
been at the front, he had' gained a considerable
amount of experience concerning the effects of shell
shock, having witnessed a large number of cases of
neurosis arising from it in returned soldiers in the
hospitals of Montreal and Toronto. Such neur-
oses only occurred in some regiments and not at all
when organic disease was present. Discipline
played a great part in the prevention of war neur-
oses, but discipline alone was not sufficient to pre-
vent their occurrence. Men should be ehminated
in medical examination for the army, whose ner-
vous temperaments were unstable, while mental de-
ficiency, and insanity should absolutely preclude ad-
mittance. Men who have had neuroses but who
had completely recovered might be favorably con-
sidered. It was pointed out that traumatic hysteria
was a thing of the past, largely owing to the publi-
cation of Pearce Bailey's book. A large proportion
of cases of neurosis might have been avoided had the
patient been assured by one who understood and in
whom he had confidence that fear was nothing to
be ashamed of.
The medical officers had something to clo with the
46
COXGRESS OF CANADIAN MEDICAL ASSOCIATIONS.
[New York
Medical Journal.
state of aftairs. There were some men who exerted
control over soldiers. When neuroses were fre-
quent, the medical ofilicers were to a large extent to
blame, and authorities went so far as to say that
shell shock should be always warded oft if the men
were properly looked after. The line officers were
equally responsible for the outbreak of neuroses in
a rej;iment. They should assume responsibility for
the welfare of their men and take a personal inter-
est in them. The lieutenants and noncommissioned
officers, being most intimately in touch with the men,
it was in these reliance must be placed to prevent
neuroses. They should make themselves acquaint-
ed, as far as possible, with their men, and should
behave to them as if they were human beings like
themselves, and not as merely cogs of the machine.
The slightest change in a man's demeanor or habits
should be reported immediately. The line officer
rather than the medical officer had the first oppor-
tunity to notice any such change. The man should
be given something to interest him, to divert his
mind from introspection, put between two veterans,
in fact every means taken to distract his attention
from himself. Sharp reprimands, so as to bring
about a reaction, sometimes served this purpose.
Chatting with some, joking with others, and speak-
ing sharply to yet others. They must be dealt with
according to their several temperaments, and wheth-
'cr they had neuroses or not, nearly entirely depend-
ed upon their officers. Rarely had officers of this
stamp to say: "If you do not carry on I have a bul-
let for you here." They induced the men to relieve
themselves of the burden that oppressed them. The
medical officers did not have such constant oppor-
tunities of watching the men, but when sick they
had somewhat exceptional ones for becoming ac-
quainted with their idiosyncrasies. The human
mind was always peculiarly open to suggestion. The
soldier was so, in particular, and the sick soldier
preeminently so. Moreover, they believed in their
medical officers.
Subjection to strict discipline, the fear of severe
punishment or death from allowing their emotions
to run riot, had a strong restraining influence.
Training of the body and mind tended to keep up
morale. The life of the soldier w-as apt to lead to
the unleashing of the primitive emotions and espe-
cially of that of fear. Soldiers could be prepared
to be harassed by Huns. They could be prepared
to combat fear successfully or to hold in check sex
emotions. They could be taught that discipline was
both for the good of the state and themselves. They
should be taught the cause and origin of neuroses
by the medical officer and told that fear is a normal
healthy reaction, in the presence of danger, and
came to all except to the insane and the liar. A
discussion of fear did soldiers much good. When
they ::new that e"\-erv one was doing his bit, the
knowledge gave them confidence, and confidence
was essential. Officers, then, were responsible for
the existence of neuroses in regiments, and the con-
dition could be prevented by the establishment of
confidence between them and their men.
Significance of Heart Murmurs in Candidates
for Military Service. — Dr. Lewellys F. Barker,
Baltimore, delivered the address in medicine at the
afternoon session of May 30, the subject being on
the Significance of Heart ^Murmurs Found in the
Examination of Candidates for Military Service,
Doctor Barker said in part that under improved
methods and standardization a large proportion of
men suffering from heart murmurs and now not fit
for active service would be rendered wholly or
partly fit. The methods for determining which of
the men with an apparent heart murmur was fit for
military duty, also the methods for determining the
condition of those incapacitated for full duty but
eligible for part, was dealt with by the speaker, who
added that some of the murmurs heard in the region
of the heart were outside of the heart and were
made by other organs near. These, however, had
no effect upon the man's capacity for military serv-
ice. The various forms of intracardiac murmurs
were referred to, differentiating the man totally ex-
empt on physical grounds from the man who was
just as fit to carry on as if the murmur was not
apparent.
Pneumonia in Army Camps. — Dr. W. G. Mac-
Callum. Baltimore, read a paper in the Section in
Medicine on The Pneumonia of Army Camps. He
said that while he did not wish it to be regarded as
a dogmatic statement, it might be said that an epi-
demic type of pneumonia different from the ordi-
nary types had occurred in army camps and among
the civilian population recently. In San Antonio,
Texas, this disease had been studied and during the
past few months at Camp Upton and at Camp
Dodge, Iowa. The disease was not lobar pneumo-
nia, but of bronchial form caused by a hemolytic
streptococcus, gave rise to empyema, was very
deadly and epidemic. The pneumomoccus of lobar
pneumonia was now being very closely studied.
There were other types of pneumococcus in differ-
ent parts of the world, notably, the Rand pneumo-
coccus of South Africa. It was easy to produce
serum to treat pneumococci, but, with the exception
of one' form, such treatment was useless. Little
was known as to the clinical side of streptococcal
pneumonia. It was a condition that came on spon-
taneourly, after a cold, for instance; frequently
after measles, sometimes after scarlet fever. Ex-
posure to cold was a predisposing cause. The dis-
ease had a rapid course, accompanied by sore throat,
swelling of tiie larynx, voice affected, owing to deep
ulceration of the vocal cords, dyspnea, vigorous
efforts to get breath, rales everywhere, tubular
breathing but not distinctly so. This condition con-
tinued in most cases when fluid collected in the
jileural cavity. The lungs became compressed with
accumulation of fluid and flatness appeared. The
fluid, at first, was slightly turbid, of a strawlike
color, became brown, and later purulent and thick.
.Measures for relief were by aspiration, or by re-
section of ribs and washing out with Dakin's solu-
tion. All cases ended in a high mortality. No
really reliable statistics with regard to this point
v.-ere available. This statement was in reference to
streptococcal pneumonia. The mortality, accord-
ing to INIacCallum, was higher in streptococcal pneu-
monia than the figures indicated.
At autopsies it was revealed that the lungs were
distended with air, the lymph glands in the bron-
chial region enlarged, and there were many distinc-
tive physical features which clearly diff'erentiated it
July 6, 1918.]
LETTERS TO THE EDITORS.
47
from lobar pneumonia. On section of the lung
large nodules were found which could be felt; they
were no longer hemolytic, they were peribronchial
nodules which looked like miliary tubercles. So
much like were they to miliary tubercles that they
were sometimes mistaken for these. Occasionally
they grew as large as a pea, and quite firm and hard.
The cut surfaces, when death had occurred from
lobar pneumonia, looked like a pancake ; in strep-
tococcal pneumonia like marble. The fluid accu-
mulated rapidly, adhesions often imprisoned the
fluid, and this encapsulation made aspiration diffi-
cult. Finally, induration took place, thickening of
the framework of the lungs. Microscopically, the
alveoH above the bronchus were filled with blood.
Polynuclears were in the alveoli. The alveolar and
bronchial walls became indurated and thickened.
The rapid infiltration of the tissues suggested the
name of interstitial bronchopneumonia. The great
distinctive feature was the filling of the bronchial
tubes with polynuclear cells. The condition was
one which dififered from bronchopneumonia. It had
been known for some time, but the idea of connect-
ing it with streptococci was somewhat new.
As for its etiology, careful investigations, bac-
terial studies at autopsy, and so on, discovered in all
cases one organism, a streptococcus, which was rec-
ognized as hemolytic. The streptococcus was per-
verse to work with and yielded the most meagre
results. It grew in long chains and matted together,
agglutinating spontaneously. Some of the strepto-
cocci permeated sugar and some did not. They were
divided into hemolytic and nonhemolytic organisms.
There were diH:'erent types of nonhemolytic strepto-
cocci.
Occasionally pericarditis and abscesses were
found in patients sufi^ering from the interstitial type
of pneumonia, but no septicemia. Doctor MacCal-
lum was confident that no septicemia set in until
shortly before death. No streptococci were found
in blood. This statement had been contradicted,
other observers had claimed to have found strepto-
cocci in the blood. The infection was severe and
transmitted readily. It was conveyed by personal
contact, by spray from the mouth and nose, and the
infection spread rapidly. Sterilizing methods did
not appear to stay its spread, while mechanical sani-
tation was almost impossible, and other forms of
prophylaxis must be referred to with caution. Vac-
cine had been made but not employed, for the reason
that the epidemic was on the wane and therefore
the efifects of its use could not be tested thoroughly.
Interstitial bronchopneumonia was a very serious
disease, and it was not unlikely to demonstrate its
virulence soon and in all parts of the country among
the civil population. Some cases had occurred in
Canada.
Doctor ]MacCallijm, of London, Ont., in dis-
cussing Professor MacCallum's paper, said that he
had seen cases of pneumonia in Camp No. i in Can-
ada the postmortem examinations of which agreed
with the Professor's description of autopsy findings
of the cases he had seen.
Dr. TiJOMAs JMcCrae, of Baltimore, predicted a
new type of pneumonia. Its association with
measles was imperfect. One man associated it with
measles while another stated the contrary. He sug-
gested that milk and butter might be sources of in-
fection by means of hemolytic streptococci. These
were found in milk. The disease should be recog-
nized as a new clinical type.
Professor W. G. MacCallum stated that it had
been suggested by Rosenau that cheese might
convey the infection. He had caused cheese and
butter to be examined, but no streptococci were
found in either. He reiterated the expression of
his conviction that the infection was transmitted
bv personal contact by spray from nose, throat,
and mouth. He did not believe in Rosenau's
theory of the transmutation of germs. In answer
to Professor McPhedran's question as to the possi-
bility of establishing immunity by vaccine treatment,
he would say that efforts in this direction had been
made in South Africa, and that complete success
had not been achieved because the proper strains
had not been employed. Experiments made at
Camp Upton appeared to offer a favorable outlook
so far as bringing about immunity by vaccination
was concerned. In immunization by vaccination ap-
peared to lie the chief hope of successfully fighting
the disease. It was conceivable that an antitoxin
might be produced. However, such a conception
was visionary, and reliance must be placed rather
upon a vaccine. Probably a satisfactory immunity
would be produced by this method. Tests with
vaccines should not be made until the autumn, when '
recruits came into winter quarters. Infection in-
creased when men were huddled together in bar-
racks. The disease began at Camp Dodge among
negroes, and the largest number of cases among
white troops occurred in the barracks adjacent to
those occupied by the negroes.
{To he continued.)
<^
Letters to the Editors.
DO AWAY WITH ROTATING SERVICE IN
HOSPITALS.
New York, June 27, igi8.
To the Editors:
The United States is now in the war. The nation is
getting into its stride. The changes and readjustments
required for the effective conduct of the war are difficult,
and are becoming more difficult every day, but they are
never impossible. Of necessity, the business of the country
has been reorganized ; the same imperious necessity calls
for the reorganization of the civil hospitals.
Up to the present time, the enrolment of medical men
has kept pace with the army's growth. But a million
Americans have now taken their place in the fighting line;
ships are available for the rapid transportation of a second
million ; a third million is streaming into the training
camps, and more doctors are needed. The hospitals of the
country must help to furnish them; they can if they will.
By undertaking to retain in its service only the actual
number of men required to care for its patients, the hos-
pitals can at once release a large number of physicians for
army service. Every hospital that has not already done
so should at once place its staff on a war footing by
abolishing the rotating service.
What is the rotating service? It is a plan of organ-
ization which requires or permits two, three, four, or even
six men. each serving six. four, three, or perhaps only two
months annually, to hold down one man's job. There rnay
be reasons of educational policy which justify a rotating
service in ordinary times ; today any such plan is contrary
48
BOOK REVIEWS.— BIRTHS, MARRIAGES, AND DEATHS. • [New Vckk
Medical Journal.
to tlie national interest and is self condennied. In this
crisis no plan of organization is admissible which does not
release ever> competent physician who can be spared for
military duty. No man should be permitted to excuse
himself from entering the Medical Reserve Corps on the
plea that a hospital needs him, unless his presence in that
hospital is indispensable — not two, three, or four months in
the year, but all the year.
For the period of the war the rotating service must go.
The continuous service plan is the only patriotic one for
hospital organization at this time. One job, one man! It
is the duty of hospital authorities to adopt this plan now,
and to make it plain to the men who are thus released from
hospital service for the period of the war that the purpose
of their release is to make it easier for them to decide
where the path of duty lies.
(Signed) S. S. Goldwater, M. D.,
Chairman, War Service Committee, American
Hospital Association.
€>
Book Reviews.
yWe publish full lists of hooks received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Talks on Obstetrics. By Rae Thornton La Vake, M. D.,
Instructor in Obstetrics and Gynecology, University of
Minnesota; Obstetrician in Charge of the Out Patient
Obstetric Department of the University of Minnesota,
etc. St. Louis : C. V. Mosby Company, 1917. Pp. 157.
The plan and scope of this book is rather unusual, but 11
may be said without qualification that the material is ex-
cellent. Doctor La Vake discusses eleven topics in obstet-
rics which represent to him the most important problems
in the field. He does not pretend to treat these exhaust-
ively, but gives the result of his personal study, experience,
and judgment in each case, following no consistent plan
of presentation, and the later chapters in the book assum-
ing the form of notes rather than a formal discussion.
This is no adverse criticism, however, as his judicial state-
ments and his advice are always definite, practical, and
sound, making a liook particularly valuable to the young
practitioner. He discusses sepsis, toxemias of pregnancy,
and hemorrhage in obstetrics in greater detail than the
other topics. These occupy more than half the volume ;
the balance of the book is occupied by short, pithy "talks,"
as he likes to call them, on Heart Lesions and Tubercu-
losis, Forceps, Podalic Version, Prolapse of the Cord,
Breech Delivery, Delivery of Twins, Caesarean Section, and
Occiput Posterior Positions. The work furnishes a prac-
tical and informal supplement to standard' texts.
Health for the Soldier and Sailor. By Irving Fisher,
Professor of Political Economy, Yale University;
Chairman, Hygiene Reference Board of the Life Ex-
tension Institute, and Eugene Lyman Fisk, M. D., Med-
ical Director of the Life Extension Institute. Adapted in
part from their recent woik, "How to Live." New York
and London : Funk & Wagnalls Company, 1918. Pp.
xxii-148. (Price, 60 cents.)
Since the royalties from the sale of this book go toward
the philanthropic work of the Life Extension Institute —
whatever that is — it may be assumed that the authors
mean well. The reviewer can say with a clear conscience
that he has rarely seen a more futile and inept book. Out
of the six chapters, 148 pages, the first chapter only, thirty-
two pages, applies even remotely to the soldier's or sailor's
needs or interests. The rest is quite irrelevant. The
soldier is informed that "tight shoes with extremely high
heels deform the feet"; "when possible, sandals, now for-
tunately coming into fashion, are preferable to shoes,
especially in early childhood" ; "wealth gained at the ex-
pense of health always proves in the end a bitter joke."
He is advised to follow faithfully the admonitions and in-
structions of the surgeon and company commander. This
little — thank God ! — book abounds in flat and childish ob-
servations. For the re t, tiie men would have no oppor-
tunity to practice the advice and instructions in chapter i.
What the medicomilitary authorities cannot accomplish for
the health and well being of the men does not have to be
taught by such a volume, however i-vatty and convenient in
its khaki binding. It never would be missed. Whatever
is pertinent and valuable has been already mastered by
medical officers in training, and is applied for the benefit
of the whole personnel.
The Diagnosis and Treatment of Heart Disease. Practical
I'oints for Students and Rractitioncrs. By E. M. Brock-
ii.\NK, M. D., F. K. C. p., Hon. Physician, Royal In-
firmary, Alanchester ; Clinical Lecturer on Diseases
of the Heart; Dean of Clinical Instruction, Uni-
versity of Manchester. Third edition, with illustrations.
New York: Paul B. Hoeber, 1917. Pp. viii-147. (Price
$1.50.)
With the addition of a chapter on General Physical Signs
and Symptoms of Heart Disease came the change of title
of a small manual on Heart Sounds and Murmurs, Their
Causation and Differentiation, first edition, to Diagnosis
and Treatment of Heart Disease of a third edition. We
cannot help but feel that the present title promises more
than the book has to ofTer, much as it gives. It covers con-
cisely and clearly, just what the original title presented.
The new chapter reviews almost in outline form in eigh-
teen pages the general signs and symptoms of heart dis-
ease and nothing else, while the chapter on Practical Points
in Treatment of Cardiac Disease contains an elementary
discussion of the subject in twelve pages. This little book
is intended to present only the elements of cardiac ausculta-
tion and a summary of the treatment, in no detail, for
students. It seems to cover the subject with these limita-
tions; is well founded, and scientifically presented. Its
frequent cross references and reference to larger works
add to its value.
<^
Births, Marriages, and Deaths.
Married.
Rac: on-Buttfkfielij. — In New York, on Saturday, June
29th, Dr. Gorham Bacon and Miss Margaret Butterfield.
Dlrcin- White. — In Newtonville, Mass., on Monday,
June loth, Lieutenant Edward Chase Durgin, Medical Re-
serve Corps, U. S. Army, and Miss M. Violet White.
Joslin-Kane. — In Fredericksburg, Va., on Saturday,
June 22d, Dr. Royal Knight Joslin and Miss Beryl Higbee
Kane.
Lyle-De Sabla. — In New York, on Friday, June 28th,
Dr. William Gordon Lyle and Miss I^eontine de Sabla.
Piggott-Bell. — In Fort Oglethorpe, Ga., on Tuesday,
June i8th. Major John Burr Piggott, Medical Reserve
Corps, U. S. Army, and Miss Alice Frances Bell.
Spruance-Whipple. — In Santa Ana, Cal., on Wednes-
day, June I2th, Assistant Surgeon H. E. Spruance, U. S.
Navy, and Miss Elise Johnson Whipple.
.Died.
Bennett. — In Pawtucket, R. I., on Tuesday, June 4th,
Dr. John Hillman Bennett, aged forty-eight years.
Deaton. — In Toledo, Ohio, on Friday, May 31st, Dr.
U. S. Grant Deaton. aged fifty years.
DE RoALDEs. — In New Orleans, La., on Thursday, June
13th, Dr. Arthur Washington de Roaldes, aged sixty-nine
years.
Dii.LON.— In Brooklyn, N. Y., on Wednesday, June 26th,
Dr. William Dillon, aged sixty-one years.
Hendricr. — In Duncllen, N. J., on Wednesday, June
26th, Dr. Charles C. Hendrick, aged fifty-five years.
Hopkins. — In Richmond, Ind., on Thursday, May 30th,
Dr. Robert R. Hopkins, aged seventy-three years.
MacDonald.— In Binghamton, N. Y., on Thursday, June
20th, Dr. Jeremiah MacDonald. aged fifty-nine years.
Mattingly. — In Johnstown, Ohio, on Tuesday, June 4th,
Dr. Joseph Henry Mattingly, aged fifty-eight years.
MiLLEK.— In Albion, Ind., on Friday, May 31st, Dr.
Benjamin E. Miller, ageci seventy-two years.
Nichols.— In Saranac I^ke. N. Y., on Monday, June
17th, Dr. Joseph Longworth Nichols.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII, No. 2.
NEW YORK, SATURDAY, JULY 13, 1918.
Whole No. 2067.
Original Communications
SOME RELATIONS OF DIET TO DISEASE.*
By Lafayette B. Mendel, M. D.,
New Haven, Conn.,
Professor of Physiological Chemistry, Yale University.
The expression "malnutrition," once a favorite
term to cloak our ignorance of the underlying cause
of ill health, by describing an obvious manifestation
of it, has lost its popularity. It is gradually being
replaced by more specific designations which give a
nearer insight into the pathogenesis of whatever is
being observed. Diabetes leads to malnutrition ; so
do hyperthyroidism and hypothyroidism, osteoma-
lacia, various neuroses, and a host of other equally
unrelated diseases. By "malnutrition" it is usually
intended to imply the outcome of an undesirable
performance on the part of the organism — possibly
in ultimate analysis a defect of metabolism.
More recently the term "deficiency disease" has
come into vogue. By this still somewhat loosely
employed designation emphasis is placed upon path-
ological states of the body due to deficiencies pri-
marily in the diet rather than in the organism. My
justification for discussing the subject here lies in
its comparative novelty. The most recent volume
on nutrition and clinical dietetics that I have been
able to consult devotes almost as much space to the
diet of speakers, singers, brain workers and athletes
as to the important clinical subject of deficiency
diseases.
Jn the conventional conception of an adequate
diet as it was formulated only a few years ago em-
phasis was placed essentially upon a sufficient con-
tent of energy and upon the presence of sufficient
protein. This is well illustrated by a quotation from
a popular textbook published as recently as 1905, in
which the author wrote :
"In a healthy adult the main objects of a diet are
to furnish suilicient nitrogenous and nonnitrogenous
foodstuffs, salts, and water to maintain the body in
equilibrium of material and of energy — that is, the
diet must furnish the material for the regeneration
of tissue, and the material for the heat produced
and the muscular work done. Nutritional experi-
ments prove that this object may be accomplished
by proteid food alone together with salts and water.
It is doubtful, however, whether, in the case of man,
such a diet could be continued for long periods
without causing some nutritional disturbance, di-
*Read before the Connecticut State Medical Society, at Hartford
May 16, 1918.
rectly or indirectly. It will be remembered that a
pure meat diet is not entirely proteid, since all flesh
contains some fats and carbohydrates (glycogen).
The functions of a diet are accomplished more
easily and more economically when it is composed
of proteids and fats, or proteids and carbohydrates,
or, as is almost universally the case, of proteids,
fats, and carbohydrates. The experience of man-
kind shows that such a mixed diet is most beneficial
to the body and most satisfying to that valuable
regulating mechanism of nutrition, the appetite.
The proportions in which the proteids, fats, and
carbohydrates are mixed in a diet vary greatly
among different nations and individuals. So far as
the fats and carbohydrates are concerned, their use
is mainly that of fuel to supply energy, and from
this standpoint we ought to be able to exchange
them in the diet in the ratio of their heat values."
At that period the difference of opinion involved
for the most part the quantities of protein and
energy requisite. Now, it is not impossible to test
the efficacy of diets prepared from this standpoint.
Smaller animals, such as rats and mice, serving as
experimental subjects, have been placed upon ra-
tions made up of purified foodstuffs: proteins, fats,
carbohydrates and inorganic salts. The outcome of
feeding trials with such "synthetic diets" has almost
invariably been complete nutritive failure. Studies
in this field have led tc the demonstration that
something more than energy, something more than
these long recognized foodstuffs, is necessary, and
this is found in many of the naturally occurring
foods, but is often lost when the proximate princi-
ples are removed from them. These hitherto un-
recognized and unidentified indispensable com-
ponents have been termed "vitamines."
At least two types of these are at present believed
to be essential, along with the more familiar factors
for perfect nutrition. One is found in tissues con-
taining active cells. It occurs in the embryonic
parts of plants, in cells like the yeast, in milk, in the
egg and in many active animal cells such as glandu-
lar epithelium. Thus, in the cereals, this water
soluble vitamine is found in the embryo rather than
the endosperm or storage parts. The other type of
vitamine, the need of which is particularly con-
spicuous during growth, is found in certain natu-
rally occurring fats: mdk fat (cream and butter),
egg yolk fat, codliver oil, the oil of other animal
glandular tissues; and it is said to occur in some of
the edible green parts of plants.
Copyright, 1918, by A. R. Elliott Publishing Company.
MENDEL: DIET AND DISEASE.
[New Yokk
Medical Journal.
The symptoms of animals kept on rations that are
restricted in respect to their vitamine content sug-
gest analogies in the domain of clinical medicine.
For example, if a rat or mouse receives a diet con-
sisting of a purified protein such as the casein from
milk or the globulin from a seed, along with starch,
sugar, fat and a mixture of inorganic salts made up
to resemble those of milk, the animal may eat the
mixture for a time and be maintained or even grow
somewhat ; but before lor>g there will be a cessation
of growth, a dechne in appetite and body weight,
and ultimately death will follow unless a change is
made. If such an experimental animal is given a
few milligrams of brewer's yeast or wheat embryo
or com germ — quantities too small to have any
significance as sources of energy — the entire se-
quence is changed. This cannot be a matter of
flavor of the diet; for the adjuvant may be adminis-
tered by itself, like a medicine, and bring this
prompt restoration of appetite and nutritive well
being. Any one who has never seen this remarkable
response to what corresponds to a therapeutic
dose of active cell material can scarcely realize the
unique efficacy of this addition. A scrawny,
lethargic animal, rapidly dwindling in size, with un-
sleek coat and evident malnutrition, will completely
change its appearance and responses in a few days
at most on a diet unchanged except for a tiny bit
of yeast. What can thus be brought about with
yeast can also be accomplished with other substances.
Their vitamine yielding portions are usually in-
corporated with nutrients so that the result is not
so striking, in a quantitative way, as the simple ex-
periment just cited. When extracted meat forms
the protein basis of a ration such as has been de-
scribed, nutritive failure likewise occurs ; it can be
averted by addition of a small amount of glandular
tissue, like liver or kidney, to the otherwise un-
changed diet. Highly milled, that is, embryo free,
cereals are inadequate when there is no added
source of water soluble vitamine present; the un-
milled grain, on the other hand, may permit good
nutrition. Many of the vegetables — I may mention
potatoes and cabbage from my own experience — •
serve as sources of this vitamine and thus make an
otherwise inadequate diet adequate.
What has just been described is merely one type
of vitamine deficiency. Peripheral neuritis may be
one of its manifestations. If, in the ration of pro-
tein, starch, sugar, salts, fat, and yeast, or cereal
germ, the fat is lard or some vegetable oil like olive
or cottonseed oil, or fat is missing, a nutritive de-
cline will presently ensue even when these other
factors seem adequate. The body weight may fall
rapidly, the eyes may show a peculiar diseased con-
dition, and autopsy may show extensive calculi in
th.e urinary tract. All of this can be prevented or
remedied by the inclusion of butter fat, egg yolk
fat, or codliver oil — and perha])s certain leafy vege-
tables— in place of part of the fat used. These
adjuvants are the carriers of a fat soluble vitamine
that is evidently indispensable to the organism.
Like magic a few meals of the same diet containing
butter fat in place of lard or cottonseed oil will cure
a xerophthalmia which no amount of antiseptic
treatment would otherwise catise to disappear.
Tiie manifestations of pellagra have been de-
scribed tersely as consisting of diarrhea, dermatitis,
delirium and death. Practically all of these can be
induced in dogs, as experience in our laboratory has
shown, by an exclusive diet of peas, cracker meal
and cottonseed oil. This is not the outcome of re-
stricted feeding as such ; for dogs can be maintained
for months on an unvaried diet of meat and other
foods. In the list quoted we are presumably deal-
ing v/ith a definite deficiency which Underbill and I
are at present investigating.
A guineapig put upon a diet which is seemingly
adequate for rats may soon show signs of experi-
mental scurvy. They can be averted by the inclusion
of a few grams of cabbage in the diet. Such are
some of the phenomena of the laboratory. They
cannot be explained in terms of energy or the
familiar nutrients.
Cattle kept on a so called "balanced" ration de-
rived entirely from wheat will die, whereas they
thrive when corn and oats are included. There are
subtle dietary combinations to be taken into account
here, and modern methods of investigation have
opened the way to unravel them.
Milk contains both t3'pes of vitamines. The new-
est experience of Osborne and myself indicates that
it is not as rich in the water soluble vitamine as
many assume ; hence liberal quantities must be used.
This is a matter of importance in infant nutrition,
particularly in relation to the dilution of cow's milk
for feeding. Further, there is some evidence that
vitamines are transmitted from the mother to the
milk, without being formed to any extent in the
body. Hence the necessity of including sufficient
vitamines in the diet of the mother is brought into
prominence.
I cannot here unfold further the manifold possi-
bilities which the recognition of these dietary de-
ficiencies and their pathological manifestations has
suggested. Obviously we are dealing with a new
order of phenomena. With a liberal widely varied
diet the danger of deficiencies in the unrecognized
dietary essentials is minimized ; but where wide
latitude in choice is impossible, for geographic,
economic, or personal reasons, /'. c, wherever re-
strictions are enforced, the danger exists. Hence
we need not be surprised to read that in the siege
of Kut-al-Amara so late as 1916, beriberi broke out
among the British troops while they were on their
normal ration of white wheaten flour, and it cleared
up when they were obliged to share in the more
coarsely milled (and doubtless germ containing)
grain of their Indian fellow soldiers ; or that
xerophthalmia has lately occurred with some fre-
quency among Scandinavian children fed upon
cereals and fat free (skimmed) milk, the disease
being cured by the use of cream or codliver oil rich
in vitamine; or that v/ar edema is a manifestation
of a very onesided diet in sorely stricken Rou-
mania ; or that scurvy (if it is indeed a deficiency
dise£i.se) has become appallingly frequent in the
stricken districts of Russia ; or that pellagra can be
averted in our South^n States by following Gold-
berger's admonitions regarding greater diversity in
diet.
The student of nutrition and dietetics finds num-
July 13, 1918.]
ZUEBLIN: PITUITRIN AND ADRF.NAUN IN HAY FEVER
51
erous questions raised by these considerations. He
inquires about the distribution and stabihty of the
vitamines ; the relation of infection to deficiency
diseases ; the sequences of the symptoms and their
true mterrelationship ; more familiar deficiencies in
proteins and salts, which have not been touched
upon here because they are somewhat better known.
My main purpose will have been accomplished if I
have succeeded in leading readers to evaluate more
seriously the possible role of newly ascertained
factors in a variety of clinical manifestations.
Yale University.
PITUITRIN AND ADRENALIN INJECTIONS
IN HAY FEVER.
By Ernest Zueblin, M. D., F. A. C. P.,
Cincinnati, Ohio,
Associate Professor of Medicine, University of Cincinnati.
In a former paper dealing with this subject (i)
1 published favorable results obtained in hay fever
patients subjected to a course of subcutaneous in-
jections of pituitrin and adrenalin. While certain
clinical symptoms arising from a weakened circula-
tion were observed, it was of interest to watch for
similar manifestations in similar instances of that
disease. The following case histories seem signifi-
cant from the diagnostic standpoint as well as from
the point of view of treatment. Although all un-
necessary detail is avoided, some observations made
during the course of injections must be included.
C\s,v. I — Miss I. M. E., age twenty-seven years, had a
sister suffering from violent asthmatic attacks, while
occasionally present. No constipation or irregularities in
menstruation were recorded. The patient weighed at ex-
amination 128 i)ounds ; height, five feet five inches. She
was seen early in SeiJtember, 1915, while complaining for
the past three weeks of violent attacks of hay fever, which
occurred chiefly at night.
Physical findings were as follows : Congestion of the
mucous membranes of the nose and throat. Hemoglobin,
70 i)er cent. Limgs : Supraclavicular fossae and supra-
scapular regions on both sides well marked by retraction,
impaired percussion sound, harsh granular breathing, nu-
merous crepitant rales over the right apex and bronchoph-
ony. Threshold percussion and auscultatory findings
of the heart, and blood pressure findings are summarized
in table below.
The patient showed marked flushing of the skin and ex-
cessive dertriography ; besides a moderate slowing of the
pulse rate during bulbous pressure, the pulse becoming very
indistinct, hardly perceptible. The urine examination
showed high specific gravity, 1030, trace of albumin, high
acidity, and excess of indican and urobilin reaction. Ex-
amination of the feces, beyond mucus and impaired meat
digestion, did not show anything abnormal. Very soon
after the first injection of pituitrin and adrenalin the
patient's heart became smaller and the heart sounds re-
turned to normal. Subjectively, the patient observed less
discharge from her nose, less burning sensation in her
eyes, and less sneezing. This improvement became more
noticeable, the shortness of breath on exertion disap-
peared, and patient felt very well. At first four injec-
tions were given, then for two weeks the heart was fur-
ther observed, but no attacks of hay fever or asthma were
noticed by the patient. There was still noticeable an ac-
celeration of the pulse during and after exercise and in
order to keep that symptom down, digalen, minims, seven,
three titues a day, was tried. Patient had taken an acute
cold recently but this did not seriously affect her im-
proved general health condition. The cough and sneez-
ing had entirely disappeared. Shortly before her last call,
she underwent another examination of the heart. As
recorded on the table from which we note the size of the
heart was more nearly normal, the action of the organ
much better, the pulse rate slower. It was a hard trial
Date
Injection,
Adrenalin 0.5 03 0.5 0.4 .... .... .... 0.6 0.5 .... 0.5
Pituitrin 0.-8 i.o 0.7 0.8 0.5 0.5 .... i.o
Heart before injection was given:
Apex V in. sp. V
To L. M. S. L 3/2 in. 3^^ 3H
To R. M. S. L ^ in.
Transverse diameter in. 3)4 3j4
Height 2V2 in. 2'A 2j4
Oblique diameter in. 4 ^ 4J4
Triangular surface 5.56 sq. in. 4,218 4.68
Pulse 92 99 105 76 94 102 go 75 81 78 78
Systolic pressure 118 108 126 118 114 112 118 116 120 106 108
Diastolic pressure 86 76 80 76 80 68 68 78 76 72 78
Pulse pressure 36 32 46 42 34 44 5° 38 44 34 3°
Mm. Hg. in one minute 18,768 18,216 21,630 13,964 18,236 18,360 16,740 14,550 15,876 13,884 14,508
Heart sounds:
Mitralis: ist, split; 2d, indistinct normal n.
Tricuspid: ist, accented normal n.
Aortic: normal normal n.
Pulmonalis; 2d. split and accentuated normal 2 acc'd
another sister, one brother, and the parents enjoyed per-
fect health. Malaria and typhoid fever excepted, the pa-
tient had most of the children's diseases. Asthmatic at-
tacks, called "hay fever" began in the summer of 1914
and continued throughout the entire year, but are most
marked during July and August. Goldenrod and asters
were mentioned as the exciting causes. A nose operation
— resection of the septum — performed a year ago, as well
as all kinds of medical treatment, local and general,
failed absolutely in relieving the patient. The symptoms
were chiefly : itching of the nose and eyelids ; fullness in
the head; stuffed up nose; sneezing spells; free watery
discharge from the nose; slight cough; impaired voice;
and heaviness after meals. Belching and vomiting were
for the patient to abstain from sports and exercise, which
were always attended by a higher pulse rate. About one
year later the patient's mother reported that her daughter
had been doing considerably better and that the attacks
of dyspnea had not returned, but occasionally normal
sneezing was noticed.
Case II. — Miss B. S., age twenty-seven years, had a
negative family history. Previous diseases : mumps,
whooping cough, and measles. Asthmatic attacks were
recorded for the past three years, lasting from the end
of August to September. Sojourn in the mountains or on
the sea coast had no curative or prophylactic influence
upon the nature or duration of these attacks, which were
attended by much sneezing, watery discharge from the
52
/AJlinUN: PITUITRIN AND ADRENALIN IN HAY FEVER.
[New York
Medical Journal,
nose, eyes, sore throat, and general tired feeling. Local
and general treatment, sprays, etc., brought no apparent
relief. Patient did not know of any intUience of flowers
as the cause of the hay fever symptoms. There were no
suggestive signs of indigestion and no indication of idio-
syncrasy to certain articles of food were noticed. Mod-
erate constipation was admitted. The patient who was
accustomed to a fair amount of physical exercise, felt
particularly tired during the period of these attacks which
lasted from four to six weeks and longer. She perspired
easily and profusely. History as regards mental activity,
menstruation, etc., negative.
The pertinent physical findings were as follows : The pa-
tient was very slender and delicate, weight ninety-one
pounds. Tonsils were enlarged, nose slightly depressed,
chest expansion moderate ; there were moderate retraction
of right apex anteriorly and posteriorly, impaired percus-
sion note, granular inspiration, prolonged expiration, and a
few crepitant rales. Examination of the heart revealed the
following facts : Relative dullness overlapped right ster-
nal border and reached lower border of third rib ; trans-
verse diameter, 4.^ inches; height, 3% inches, oblique
diameter 5 inches, cardiac triangle 7,515 square inches;
double indistinct first mitralis sound ; second aortic and
pulmonic sounds were accentuated. Pulse 76, fairly reg-
ular, of medium volume; systolic pressure, 104 milli-
metres, diastolic pressure, 74; pulse pressure, thirty milli-
metres, or 13,528 millimetres Hg pressure in one minute.
Urine was cloudy; specific gravity, 1,017; faint trace of
albumin ; marked indicanuria and moderate urobilin re-
action. Feces, fetid; greenish in aspect; digestion of
meat and starch fair; much neutral fat; absence of blood
and parasites. Stomach content after Leube-Riegel meal,
three hours after intake; free HCl, forty-two per cent.,
total acid, 98 per cent. The changes in blood pressure,
pulse rate, etc., are given in the following table as well
as the dose of pituitrin and adrenalin injection:
Date S- ?! ~^ 5,-0
Injection, c. c: p o & c e & o s
Adrenalin i.o 0.5 ... 0.2
Pituitrin 0.2 o.y ... 0.8 i.o
Before injection
was gi'^TU :
Pulsr 76 72 T2 75 84 78 75 75
Systolic pressure 104 98 100 110 110 104 106 112
DiaMolic pressure T\ 76 70 66 64 76 64 70
Pulse 30 22 10 44 46 28* 42 42
Mm. Hg. in one
minute 13,528 12,528 12,240 13,210 14,716 14,040 12,750 13,650
*After dancing.
After May 22d, the patient, being unable to return reg-
ularly for the injections, was given the following pre-
scription : Extract ergot ; tincture of belladonna ; tincture
of gentian mixed in equal quantities in the dose of three
minims thrice daily. The small pulse pressure on May
26th after dancing suggested one more injection of one
c. c. pituitrin ; the drops were increased to seven minims
thrice daily and without any further pituitrin medication
the figures on May 30th and June 3d were obtained. The
heart findings on June 3d were interesting : namely, reduc-
tion in the size of the cardiac dullness ; transverse diameter
three inches; height 2'^ inches; oblique diameter 3'<2
inches ; corresponding to cardiac triangle of 3.75 square
inches compared to 7.515 square inches noticed on May ist.
The first mitral sound had becoine strong, accentuated, the
split sound had disappeared. The urinary examination
presented a very weak reaction for indican and also for
urobilin.
From June 3d patient lived in Atlantic City, re-
porting perfect health until September 8th, when she
came to the office with the following report : She had a
slight cold in June but without any consequences. About
August 17th she noticed a slight tickling of throat and
a dry cough, with no dyspnea, but no distinct attack of
hay fever as in former years. The eyes were waterv for
one day; slight sneezing was noticed at her visit. Pulse
full and regular; systolic pressure, 104; diastolic pressure,
78; pulse pressure, 26, or 14,288 millimetres Hg pressure
in one minute. The weather being very damp and warm,
the patient was advised to report at the office if the symp-
toms should become more manifest. On September 9th
there appeared a sensation of stuffed up nose, difficulty
in breathing, some sneezing, dry sensation of throat, and
moderate mucoid expectoration ; pulse was found at 99,
easily depressible. Injection of pituitrin 0.8 and of adren-
alin 0.4 c. c. was given. Patient went to a dance the same
evening, could not sleep very well, and the following day
had a spell of sneezing with difficult breathing through
the nose. Seen on the following day she felt better, simi-
lar symptoms as recorded were present in the morning,
though to a lesser extent ; the pulse rate was found at 87,
systolic pressure, 104; diastolic pressure, 78 millimetres,
leaving a pulse pressure of 26 millimetres, or 15,834 milli-
metres Hg in one minute. No further medication or in-
jection was given. The patient interviewed a few weeks
later reported perfect health and stated that in her opinion
the hay fever symptoms this year had become unusually
attenuated.
In this patient, whose nutrition and circulation
was below par, the physical findings showed im-
provement and a better pulse pressure. With five
injections of pituitrin and partially of adrenalin,
extending over four months, a cure, apparently
could not be obtained, but a striking attenuation
of the morbid symptoms was noted. Probably un-
dernourished, delicate patients with habitual low
pulse pressure must be told to abstain from pro-
longed straining exercise, which evidently interferes
with the normal circulatory function, particularly
in cases where asthmatic or hay fever attacks are
noted in the history.
Case III. — C. F. B., age thirty-eight years, married, no
children, musician. His mother died at age of sixty-five
years from heart failure. He had measles and whooping
cough when a child ; gastroenteritis when nine or ten years
old ; scarlet fever at age of eleven years, which was very
severe infection, lasting six weeks; and a Neisser infection
when twenty-one years old, which seems to be cured. His
present illness dated back to 1890, twenty-five years ago,
when, about August 14th, the attacks of hay fever started,
lasting till frost. Sometimes this was preceded by an early
June "rose cold." The primary irritants, to the knowledge
of the patient, are pollen from the .golden rod, ragweed,
and certain midsummer grasses. As secondary irritants
were mentioned, rust, heavy atmosphere, rainy days, strong
sunlight, certain exposures to wind, humidity, perhaps
susceptibility to nervous or other influences upon the nasal
and bronchial tracts. The asthmatic attacks for several
years became milder, usually happening during sleeping
hours when body in prone position, only one small cushion
being used. Certain kinds of food, too much meat in
the diet, fruit acids — tomatoes — according to patient's re-
port, were thought of importance.
Course of the attacks: On awakening, even though
quiet, quickening of the pulse and sneezing in spasms of
about twenty minutes duration or more occurred. Dur-
ing the morning and late afternoon the patient again had
sneezing attacks and irritation of the eyes, and another
sneezing spell at the time of retiring to bed. Itching of
the eves, much irritation, sight being slightly impaired,
puffiness and blurred sensation were reported. On anoint-
ing the nasal tubes with camphor vaseline or another oily
base, the sneezing stopped and sleep followed. Occasion-
ally with such a treatment bronchial irritation arose during
the night, and was relieved by sipping sherry, drop by
drop. Previous treatments resulted only in temporary
alleviation. For instance, during nasal treatment, accord-
ing to the patient, the bronchial reaction was worse ;
asthma, bronchial secretion, wheezing, and sensation of
oppression were much more severe than without anv thera-
peutic interference at all. He seemed to have tried all pos-
sible treatments — nasal, pharyngeal, and throat treatment
for years, and climatic changes — Europe, Adirondacks,
White Mountains, Blue Mountains, and Blue Ridge Moun-
tain.s — without result. Seashore rendered his condition
much worse. One summer he left Baltimore at the begin-
ning of the hay fever season for Lake Champlain ; all
sneezing stopped, but, instead, a bronchitis started, and a
severe eruption of the skin about the ears, with watery
discharge from little ulcers were noticed.
Other manifestations in the respiratory tract outside
the period of attacks : Patient had occasionally some
July 13, 1918.]
ZUEBLIN: PITUITRIN AND ADRENALIN IN HAY FEVER.
53
mucous discharge from the posterior pharynx. No partic-
ular circulatory disorders except rapid pulse, sometimes
preceding the hay fever attacks. Digestive functions : At
the present time occasionally some gas and belching oc-
curred after eating certain foods, as starch, potatoes,
onions, etc.; meat digestion is good. Bowels regular;
movements not very copious. Genitourinary functions :
Patient passed about three pints of urine daily, got up
once during night, particularly after drinking greater
amounts of water on the preceding evening. Absolutely
negative to other symptoms. Sexual functions seemed to
be normal and satisfactory; no relation was observed be-
tween this function and the character, intensity, or dura-
tion of the hay fever symptoms. He worked about eleven
hours a day during eight months of the year, and for four
months about four hours while up in the mountains. He
slept well. For the past four days the patient had been
sneezing a good deal in the morning without having a cold.
He was exposed to wind and dust a good deal lately.
Physical examination showed a well nourished individ-
ual, rather stout. Teeth were in good condition ; throat
moderately congested and dry ; tonsils of medium size,
surface irregular. The chest was very well developed ;
rather emphysematous ; full percussion note obtained
throughout. Over both apices and in front, granular
breathing, harsh expiration, numerous sibilant rales, a
few rales posteriorly over the apices and lower parts of
the lungs, nowhere bronchophony obtained. Heart : Apex
beat in sixth interspace, 4K' inches outside of midsternal
line, indistinct in character. Absolute cardiac dullness up-
per part of third interspace to the left sternal border;
extended to the right sternal border in the fifth inter-
space. Relative dullness : outside of mammillary line, 4!4
inches to the left; i]^ inches to the right from the mid-
sternal line, overlapping the right sternal margin for
^ inch ; upper border of relative dullness found in second
interspace. Diameters of the heart: transverse diameter,
4-}:4 inches to aYa inches in height ; 6^4 inches in oblique
diameter. Content of cardiac triangle, 12,218 square inches.
Heart sounds were not very distinct, embryocardia over
mitralsis, first and tricuspid first sound hardly audible,
accentuation of second aortic and pulmonic sounds, no
murmurs heard. Pulse rate, 78 ; not well sustained, slight
irregularity. Systolic blood pressure, 122; diastolic, 92;
pulse pressure, 30 Hg ; pressure for one minute, 16,692
millimetres Hg. The liver was enlarged, overlapped right
costal margin, and extended two and one half inches to
the left from the midline. Findings of the abdomen were
otherwise negative. Urine: specific gravity, 1,022; dark
amber color; faint trace of albumin found; no casts;
sugar, negative ; excessive amount of indican present ; uro-
bilin reaction present. Stomach content after Leube-Riegel
test meal, removed after four hours: moderate amount of
gastric juice obtained; free HQ, seventeen per cent.; total
acidity, twenty-eight per cent. As seen from the following
table, the patient was also given the combined tre;itment
of pituitrin, adrenalin, and atropine.
Date
Injection , c. c.
Pituitrin
Adrenalin
Heart before injeetion:
Apex, in. sp
To L. M. S. L
To R. M. S. I
Transverse diameter . . .
Height
Oblique diameter
Triangular surface
Pulse
Systolic pressure
Diastolic pressure
Pulse pressure
Mm. Hg. in one minute.
Heart sounds:
Mitralis
Tricuspid
PulmonaHs
Aortic
•0
CV
>^
0.8
1 .0
1 .0
I .0
0.8
0-5
o-S
0.5
VI
V
V
V
4'A"
iV/'
5V4"
4!4"
4'/4"
3 54
4l-i"
3"
354"
6 'A"
5"
S'A"
4H
1.0
0.5
1 .0
0-5
7»
7.S
69
72
75
1 22
118
122
124
122
72
72
70
86
82
30
46
52
38
40
iVi" 4V2"
2V4" 3"
4'A" 4V4"
8.75 6.906 5.156 4.469 6.7s
78
114
78
36
16.692 14.250 13.662 15.120 15.750 14.386
embryo-
cardia
ist better
faint sustained
2d accen-
tuated
2d accen-
tuated
medication
see below
"Went to the mountains.
Date
III jectionj c. c. :
•~> ,^ Co ^-^ 0^
Pituitrin i-o i.o l.o ... i.o
Adrenalin 0.2 0.2 0.3
Heart before e.raniina-
Apex" in. sp V V V .. V V V
To L. M. S. L 3A" 3H" 254" i'A" 3"
To R. M S. I ^" I Mi" A" 54" 54"
Transverse diameter.. 3]A" 4%" 4/^" 3A" 4" 3/4"
Height 3" 3" 3'/4" 3" 3%" 2'A"
Oblique diameter ... 4A" 4V2" sVi" 354" 4/4" 55^"
Triangular surface... 5.25 6.18757.327 2.437 6.25 4-37S
Fnhc 78 75 72 78 70 66 72
Systolic pressure ....122 122 118 122 124 116 122
Diastolic pressure . . . S5 74 92 78 70 76 72
Pulse pressure 37 48 26 44 54 40 50
Mm. Hg. in one min-
ute 16.146 14.700 15.120 15.600 13.580 12.672 13.968
Heart iciinds:
Mitralis first accen- well normal
tuated sustained
Tricuspid indistinct
normal
Aortic 2d accen- normal normal
tuated
Pulmonalis 1st split normal normal
The first injection consisted of 0.8 c. c. of pituitrin and
0.8 c. c. of adrenalin solution I : 1,000. The patient did
not feel the slightest discomfort and on the following day
the indistinct first mitralis sound had become better sus-
tained, the heart had diminished about 44.7 per cent, of
its former size, while the liver had lost inch in the
transverse diameter of its left lobe. The second, third,
fourth, fifth, si.xth, and seventh injection the dose of pitui-
trin was one c. c, the dose of adrenalin was 0.5 c. c, given
snlicutaneously. From May 4th the patient received in ad-
dition the following prescription :
R Atropin sulph gr. 1/40;
Aq. menth. piperit 3ii.
One drop thrice daily.
At the same time a trial was made with digalen terr
drops thrice daily. The heart sounds became very reg-
ular and vigorous. The patient had left the city and
went to the Blue Ridge Mountains, and after June 5th
reported only at irregular intervals at the office. The
moisture over the lungs had cleared up considerably:
only occasionally, in the morning while it was cold, the
patient noticed very slight, hardly pronounced sneezing.
On June 27th and July 14th the heart examination showed
a better condition, and the patient felt very well, having
experienced no serious attack as in previous years. As
a precaution, the patient was given calcium chloride ten
grains, thrice daily after June 20th, while the digalen
medication was gradually diminished and ceased. On Sep-
tember i6th the following report was tnade : One mod-
erate sneezing spell on August 7th lasting for three quar-
ters of an hour, shortly after breakfast. On the i8th,
during the blooming season of ragweed, goldenrod, and
horsevveed, following a rapid change in temperature, he
contracted a cold, attended by cough, but no dyspnea in
any form was noticed, nor were there any other cotn-
plaints or manifestations. Digalen and calciuin chloride
medications continued during that time did not seein to
help the patient. On October loth he noticed a tendency
to sneezing spells followed by relief after local applica-
tion of rarbolated vaseline ointment. The physical find-
ings on August i6th and the days following were of in-
terest as seen in the table above ; especially interesting
was the enlarged heart, the high diastolic blood pressure,
the low pulse pressure, and the weakened heart sounds
over the mitral and pulmonic areas. The urinary find-
ings revealed marked indicanuria and urobilinuria, which
was considerably improved by the administration of Bacil-
lus bulgaricus in five grain tablets, one twice daily. When-
reexamined, pronounced dermography and considerable
slowing and change in pulse were found during bulbous
pressure. The sneezing spells after the pituitrin and
adrenalin injections became shorter and less intense; dry
sensation in nose and throat was absent, and less moisture-
was found over the lungs. With the improvement of the:
«
54
ZUEBLIN: PITUITRIN AND ADRENALIN IN HAY FEVER.
[New York
Medical Journal.
circulation, the vasomotor phenomena subsided entirely
and the patient reported normal health conditions.
This case is of special interest as it seems to sug-
gest that with a weakened circulation the hay fever
symptoms are more likely to occur. The admin-
istration of pituitrin and adrenalin can secure relief
in the intense attacks in aiding the circulation, but
it is not desirable to allow too long intervals between
the injections. The patient should be kept under
close supervision while treatment is given, the phy-
sician should be within easy reach to give the in-
jections and the treatment. A reason why in this
instance no absolute cure, but only relief of symp-
toms, could be secured cannot be given. It appears
plausible, however, that the patient would have ob-
tained better results with more regular treatment.
Case IV. — Mr. H. L. M., reporter, age forty years, had
one aunt suffering from asthma; father died at forty-two
j'ears of age of nephritis. The patient had measles at
age of six years; pleurisy in 1899; several attacks of
grippe since 1904, with distinct tubercular manifestation
of apices; and several attacks of rheumatism during 1910
to 19T4. Present illness: Attacks of hay fever since 191 1
recurred regularly in the latter part of August, lasting
with very marked intensity from four to eight weeks. The
symptoms were typical of hay fever, involving the mucous
membranes of the eyes, nose, throat, bronchi, and they
assumed such a character that for several weeks in suc-
cession the formerly very active patient was simply unable
to attend to his literary work. All kinds of treatments
so far advised by numerous doctors in the past four years
vverc absolutely resultless with the exception of the locally
used adrenalin spray to the nose, which secured a few
hours of relief. The patient, five feet inches in
height; weight, 197 pounds; was an inveterate user
of tobacco in any form, and complained lately of pre-
cordial pain. E.xcept for the symptoms referring to hay
fever, which, according to patient's own observation, were
favored by inhalation of pollen from ragweed and asters
and dust, no other complaints were made. Patient was
fond of heavy eating, and favored free consumption of
beer, etc. ; he observed no signs of idiosyncrasy to any
kind of food; bowels were constipated. An examination
of the physical status made on September 23d was of
interest: Patient heavy built; male; weighed now 180
pounds; flushed appearance of face; eyelids reddened;
bloodvessels of conjunctiva pink; swelling of mucous
membrane of nose; deviation of nasal septum and conges-
tion of its vessels ; same condition held for tongue, palate,
and pharynx. Chest emphysematous ; slight diffuse wheez-
ing sounds on breathing over bases ; harsh breathing over
right apex anteriorly and posteriorly ; no local activity
present. The size of the neart, as examined preceding
and following the treatment, could be estimated from the
following table :
Besides the cardiovascular changes recorded, this case
presented a marked and long lasting derraography, the
pulse rate before bulbous pressure was 78, fairly regular
and full in cpiality, and during the bulbous pressure it
dropped to 66, so weak that the pulse waves became
hardly perceptible. The inspiratory pulse rate before
bulbous pressure was two; during expiration, three; under
bullsous pressure the inspiratory and expiratory rates were
equal, three.
The urinary findings on August i8th revealed a slight
trace of albumin. Phenolsulphonephthalein test elimina-
tion in first hour, fifty per cent.; in second hour, twenty
per cent. ; total, seventy per cent. On September 24th,
there was present a considerable urobilin and indican re-
action besides albumin and a reduction of Fehling's solu-
tion, the specific gravity being 1017. On September 30th
the total urinary output was in twenty-four hours 1,700
c. c. ; specific gravity, 1013 ; 2.2 decinormal NaOH solution
pro ten c. c, again trace of albumin with the reduction
produced by Fehling's ; no casts found in the sediment,
■but few epithelial cells and leucocytes. With the
improvement of the patient's condition the albumin dimin-
ished, and the indican and urobilin tests were hardly no-
ticeable; the specific gravity was found at 1015; the acid-
ity amounted to 2.7 c. c. decinormal NaOH pro ten c. c.
of fluid. Gastric analysis made on August 18th gave
free HCl, twelve per cent. ; combined HCl, twenty-six
per cent.; total acid, thirty-eight per cent.; absence of
lactic acid. On August 28th, gave free HCl, eight per
cent. ; total acid, twenty-six per cent. ; no mucus. Feces
examined on September 26th, very fetid odor ; coarse
looking masses; fair amount of mucus; meat digestion
incomplete ; many blue starch granules and fattv acids ;
few globules of neutral fats; absence of parasites and
blood ; hydrobilirubin reaction moderate. Hemoglobin,
114 per cent.; white blood cells, 18,680; negative Was-
sermann.
The patient, when examined on September 24th, pre-
sented an enlarged liver. In the right mammillary line it
was found in height 55-4 inches; in median line, three
inches ; left lobe extended three inches to left of median
line. After pituitrin, on September 25th, it measured
inches in height ; one inch in median line ; left lobe ex-
tended inches to left of median line. On October 8th
the measurements read 4-34 inches, iy» inches, and i^A
inches.
The day after pituitrin medication was started, the
moisture over the lungs noticed at first cleared up within
a few days, and with it the sneezing spells and the head-
ache, which before was very marked, were checked. The
sensation of dryness and stuffiness of the nose vanished,
and so did the marked vasomotor signs. With the im-
proved function of the heart, the diminished size of the or-
gan, a higher pulse pressure will be noticed. The anginoid
oppression in the cardiac region disappeared entirely. The
patient succeeded in reducing his weight between seven and
eight pounds in four weeks by restrictions in his diet. As
seen from the table in the first period of observation, Sep-
Date
Dose c. c.
CX
'ember
'ember
-0
•ft.
to
Adrenalin 0.5
Pituitrin 0.8
Examination before treatment :
Apex V
To L. M. .S. L 4^"
To R. M. S. L i"
Transverse diameter ...
Height 4'A"
Oblique diameter 6^"
Triangular surface 12.48
Pulse 78
Systolic pressure iiR
Diastolic pressure 86
Pulse pressure 32
Mm. Hg. in one minute 15-912
Heart sounds:
Mitral ist very
weak,
blurred
Pulmonalis 2d weak
0 i
V
3%"
sVs"
4"
sVa"
10.25
74
1 20
80
40
14.800
V
'A"
4"
3" ,,.
AVi"
6.0
80
I 10
84
26
15.620
better
sustained
better
V
3^;;
3W'
iVi"
4Vi"
6.54
75
124
80
44
15-300
accen-
tuated
accen-
tuated
V V
4 1/16"
Va"
4 i3''i6"4/4"
2^"
SVs"
6.91
75
1,30
S6
44
16.200
3%'
6V4"
6.88
66
122
84
38
13-596
3'A"
I'A"
3^"
sVs"
8.15
75
1 22
80
42
1 5.150
5"
iVi"
6V4"
4"
6V4"
'2-5
Si
118
86
22
■5-714
3'A"
sVs"
8.09
75
132
82
50
16.050
V
4-M"
sA"
3'A"
5V4"
8-93
78
1 26
88
38
16-692
82
136
82
54
17.302
78
122
78
44
I 5.600
42
17.300
o 4
o 3
normal
75
1 20
82
38
15-150
normal normal
normal doubled single,
accen-
tuated
doubled single,
accen-
tuated
sounds
well
sustained
I
July 13, 1918.]
ZUEBLIN: PITUITRIN AND ADRENALIN IN HAY FEVER
55
tember to October, 1916, only two injections of pituitrin
and adrenalin were given, besides atropine medication
whicli consisted in
Atrophine sulph grs. 1/60.
Ac], menth piperit., ad. dr. i.
Min. II, t. i. d., p. c.
Once the heart sounds and the size of the heart had be-
come normal, it was of interest to watch the duration of
the therapeutic results so far secured. We noticed a ten-
dency to gradual enlargement, but still the pulse piessure
remained above the low figures recorded before. On the
same date a few moist rales were noticed over the bases.
The patient, thinking he was well, indulged in a heavy eve-
ning meal and, after some cardiac distress and oppression,
vomited his food several hours after his meal. Consid-
ering the marked indicanuria, an attempt was made to
determine whether by the administration of Bacilli bul-
garici lactic acid tablets, one tablet twice a day, this symp-
tom of abnormal intestinal absorption could not be brought
to disappear. The urine analysis made at a later date
showed the correctness of our therapeutic calculations.
Although no more injections were given, the patient,
notwithstanding the late, murky, and hot season, had no
attacks of hay fever or any suggestive symptoms. There
was still present the tendency to an enlarged heart. The
patient had lost nine and one half pounds in twenty-five
days, and was given greater liberty in the selection of
his food.
This case is particularly instructive as one year
later it could be watched. Based upon former find-
ings of a nasal obstruction by a much deviated sep-
tum, the submucous resection of this defect was
made in May, 1916. The patient did very well,
making an uneventful recovery and was kept under
the impression that he should be immune against
any recurrence of hay fever attacks. On June 26,
1916, patient returned to me with the following
history :
Three weeks ago he contracted a "rose cold," marked
cardiac oppression, dyspnea, stuffy feeling in nose and
throat, tickling of eyes, constipation and alternating diar-
rhea. He had begun smoking and chewing again. He
weighed four pounds more than in 1915, being- about
twenty pounds overweight. He was unable to work, com-
plaining of general lassitude, and giving, in short, a history
of hay fever manifestation. According to the patient's im-
pression, these symptoms were much milder in character
than those of the past year prior to the pituitrin adrenalin
injections. The table contains the result of the cardio-
vascular examination, when we noticed the striking re-
sults : Considerable enlargement of the heart, with a car-
diac triangle of similar size when patient was first seen ;
duplicated heart sounds ; exceedingly low pulse pressure ;
high diastolic blood pressure ; a higher pulse rate ; dicrotic
pulse ; marked indicanuria ; faint trace of albumin. The
result of one pituitrin adrenalin injection is recorded in
the table. Furthermore, subjectively the patient noticed
immediate disappearance of the tedious spells of sneezing;
also the cardiac oppression and hypersensitiveness had
entirely subsided. Considering the renewed presence of
marked vasomotor signs, dermography, and Ashner's bul-
bous ohenomenon, it was of interest to know whether
the subcutaneous administration of pituitrin and adrenalin
could not be substituted by the intake of appropriate vaso-
constrictor remedies. This seemed the more justified since
the patient, editor of a magazine, had to leave the city
for several days in succession, and office treatment could
•not be kept up regularly. The medication consisted in :
Tr. strophant.. )
Tr. belladon., ?• aa dr. ss ;
Extract fluid ergot, ;
Elix, gentian comp., dr. iii.
Min. V. t. i. d.
Three days later, the patient being in the meantime ex-
ceedingly active, and weather conditions very unfavorable,
heat and high humidity, circulation was not so good. Dis-
regarding medical counsel, he had indulged in heavy din-
ners and paid with precordial nightly oppressions, which
he described as a feeling of swelling and tightening of
the heart After coitus the disagreeable sensation in the
heart seemed to subside temporarily, but returned later.
Having omitted the drops, he had a sneezing attack. After
that report an increase of the drops to seven minims
three times a day was tried. No particular symptoms
were recorded until seen two days later, when the Quality
of the pulse was not so good, so another uituitrin injec-
tion was given. On July 10, 1916, a very disagreeable,
moist and warm day, with no relief during night, the pa-
tient noticed one slight sneezing spell and, except for the
tight precordial sensation, no other symptoms were re-
ported. Seen on July nth, a lower pulse pressure was
recorded and, although the heart sounds seemed normal,
the same dose of 0.8 c. c. pituitrin and 0.4 c. c. adrenalin
was administered subcutaneously. This was the last dose
given by myself. Later information from the patient, re-
ceived on September 26, 1916, is of interest, as he experi-
enced in August a very marked hay fever attack. After
vaccination had demonstrated a sensitiveness to ragweed
and aster pollen — not golden rod — a regular course of
seven injections of ragweed and aster pollen was started,
extending over a period of twenty-eight days. The first
four injections were attended by very marked symptoms;
severe general malaise, asthma, much coughing, and lack
of sleep; but, three weeks later, the symptoms suddenly
abated. Occasional sneezing spells were still noticed, but
otherwise the patient felt well. The intelligent patient
noticed that before the pituitrin treatment the heart symp-
toms were always much in the foreground, but after being
injected with pituitrin these symptoms from the circula-
tory apparatus disappeared.
This case is of particular interest since it illus-
trates the value of the vaccination treatment, which,
when pituitrin could not be given, proved of consid-
erable value to the patient. As shown in some of
my cases, pituitrin injections should be given over a
longer period, and the patient should be watched
carefully for the indications of cardiovascular mani-
festations which require treatment. It is probable
that Case III would derive better results from a
treatment with vaccine and cardiovascular stimula-
tion combined, this being indicated particularly in
cases of severe character and long standing. The
present and former study of the symptomatology
and treatment of hay fever seems to me interesting
and deserving of short recapitulation and discussion
of the facts.
As regards the physical findings, in all instances
we meet signs of a cardiac dilatation, controlled by
successive and later examinations. The enlarged
lieart, revealed by threshold percussion, was present
in cases I, II (i) and I, II, III, IV, chiefly demon-
strating an enlargement of the right heart. In a
few instances the enlargement may also include the
left heart — II and IV. As regards the auscultatory
findings the first mitral sound may be weak — II (l),
IV; indistinct — I (i), II; distant; split — I, II; or
roughened — I (i), while the second mitral sound,
though weak, was less frequently involved. Over
the tricuspid area the first sound was weak — II (i),
HI — while faint and distant first aortic sounds were
noticed in one case only — I (i). More frequently
however accentuation of the second aortic sound
was noticed — II (i), IT, III. As regards the pul-
monic area weak sounds existed — I ( i ) , IV ; re-
duplicated second sounds were noticed — II, IV; and
accentuation of the same in three instances — I (i),
III, and IV.
In comparing the pulse rates, referring to the
male patients — I (i), II, IV — no particular accel-
eration of the pulse is found. Female patients pre-
sent a rapid pulse — II (i), I — of over ninety. In
judging the work of the heart we pay more attention
56
ZUEBLIK: PITUITRIN AND ADRENALIK IN HAY FEVER.
[Xew York
Medical Journal.
to the blood pressure readings, and it is advisable to
consider the age and sex of the patient according
to standards recommended by Faught. According
to this author, for a male aged twenty years the
systolic pressure of 120 millimetres is considered
nonnai, while for every additional two years of
life one millimetre is added; for female patients of
tlie same age ten millimetres less are admitted.
Applying this rule to our male cases, we find that
the systolic blood pressure is several millimetres
below the normal : the difference in Case I ( i ) is
lwent}-two millimetres ; in Case twelve milli-
metres ; in Case III. seven millimetres below normal.
As regards Case I (i) it must be remembered that
n reading could be obtained only by the palpatory
method, the sounds being too weak to be heard by
auscultation. Among the female patients we en-
counter in Case I a slight increase of 4.5
millimetres, while in the other two cases the
systolic pressure was found below normal — in Case
II (i), 17.5, and in Case II, 9.5 millimetres below
normal. As regards the diastolic blood pressure,
among three male patients we notice in Case III one
high reading of ninet\--two ; in another instance —
IV — eight\--six ; in the next instance — I (i) — sev-
enty-six millimetres. Examining the pulse pressure,
supposed to be one half of the diastolic blood
pressure, we likewise notice a diminution from
liorma] values, especially in Case III with sixteen,
Case IV with eleven, Case I (i) with eight points
below the expected figure. Among the female
patients the diastolic blood pressure is found not so
far above the expected normal figures ; in Case I
eighty-six millimetres ; in Case II ( i ) eighty-two,
in Case II sevent}--four millimetres were recorded.
The pulse pressure was below the normal mark;
in Case II (i) fifteen, case I eleven, and Case II,
seven TX)inls belcw the expected figure.
In the study of heart cases, the relation between
the pulse rate and the sum of the systolic and dia-
stolic pressure combined, seemed to me of practical
value, as an expression of the work of the heart
furnished in one minute. It appeared difficult to
ascertain the normal cardiac action of a dilated
heart : a way to overcome this obstacle was the
comparison of the size of the heart, when under
treatment, it had reached its minimum size, ascer-
tained by threshold percussion. The results of such
a comparison are given as f oIIoavs : In Case I (i)
the initial figure of 14.720 millimetres was found to
be 5.360 millimetres below the optimimi, while in the
other male patients an OA^erexertion of the cardiac
activity was suggested, namely, in Case III the
initial figure was 942 to 3,112 miUimetres and in
(.ase only a slight excess of 292 millimetres were
recorded. Among the female patients excess cardiac
activity was noticed, namely Case II (i) ranged
3,822 millimetres. Case II with 1.288 millimetres,
the least, Case I, with 552 millimetres being ob-
tained.
When I began studying hay fever httle attention
was paid to the vasomotor disturbances, while in the
progress of the observations these phenomena were
included in the clinical report. In all instances a
marked dermography. with long lasting vasodilata-
tion and flushing of the skin could be elicited. The
A.'hner bulbous phenom.enon was equally encount-
ered, not so pronounced in Case II, but markedly
present in cases I. Ill, and IV, where a distinct
slewing of the pulse prevailed, which even became
hardly perceptible. The clinical symptoms and find-
ings enumerated a cove may be observed in other
hay fever cases subjected to close observation ; a
decision as to their importance to and correlation
w;th the hay fever attacks may appear hastv at
present, but whether primary or secondary to the
liay fever attacks, they should be considered in the
treatment of such cases.
In all my cases the immediate response of the
heart to the pituitrin adrenalin injection could be
noticed, as evidenced by the decrease in size, the im-
provement in heart sounds, and the increase of a
formerly low pulse pressure. When is it advisable
to give the next injection and how many doses are
sufficient for a therapeutic result ? To decide these
points we had better keep watching the pulse rate,
the blood pressure figures, the heart sounds, and
the extent of the percussion outHnes of the heart.
As shown in the above tables an injection was
repeated when there was evidence of a lowered sys-
tolic and a low pulse pressure and the result justified
such a procedure. The dose of pituitrin was in the
average of cases from 0.8 to one c. c. In a few
instances the dose was reduced to 0.25 c. c. ; the re-
sult observed in Case II (I), however, was not as
favorable. The dose of adrenalin varied from 0.5 to
0.2 c. c, the higher dose being given first, then
gradually reduced.
Another important point should be mentioned.
The patient should be cautioned against excessive
exercise while under the action of the drug, advice
whose importance was observed over and over again,
especially in Case II. A larger dose of adrenalin
than that mentioned is not desirable. Frequently
the patients complain of persistent pain at the site
of injection. In substituting the pituitrin by other
cardiac stimulants, such as digalen, the effect ob-
served is not uniform; in some instances the pulse
rate may be kept down and the tendency toward
cardiac dilatation may be checked, but not in all
instances averted. This seems to me important and
to a certain extent a reason why in some instances
with home treatment in the absence of the physician,
the attacks, though mildei in their clinical manifes-
tations, could not be entirely warded oft. Atropine
medication used in some of my cases seemed to
check the pulse rate, but such an action could not
be obtained in all cases. Among the remedies pro-
moting vasoconstriction the use of extract of ergot
may be considered ; cases II and IV, among others,
suggest that a rise of the diastolic and systoHc blood
pressure may occur as well without material change
in the pulse pressure, an undesirable result. The
influence of physical exercise upon female patients
could be likewise studied, the comparison of pulse
pressure and heart findings showing that these pa-
tients react very quickly upon unphysiological ex-
ercise by changes in vascular cardiac functions.
From the therapeutic standpoint it may be sug-
gested that hay fever patients should be treated in-
dividually according to the variety and intensity of
their symptoms. As can be learned from my pre-
vious communication (i) and the present study of
cases, the cardiovascular stimulation may in some
July 13, i9'8l
ZUEBLIN: PITUITRIN AND ADRENALIN IN HAY FEVER.
57
cases be sufficient to discard the severe symptoms
for several consecutive seasons. In all cases so far
studied, an attenuation of the attacks can be secured,
provided that the proposed injections with pituitrin
and adrenalin are given in the proper doses and at
not too long intervals. As Case IV teaches us a
certain reserve as to the final results, it must be
admitted that vaccine treatment gives the best re-
sults in severe cases. Perhaps further investigation
will teach us to separate genuine cases of hay fever
from milder forms with similar clinical manifesta-
tions which are not based on a primary irritation
from the pollen of a definite character, but are the
result of endogenous or exogenous toxins or a com-
bination of both.
Not so much emphasis has been laid in the present
study upon pulmonary manifestations. Suspicion
of tuberculosis was justified in several instances.
The objective and subjective respiratory symptoms
were found in close relation with the heart function ;
when heart function was improved, the moisture
would disappear promptly. Present studies of asth-
matic tuberculous individuals in my clinical service
suggest at least the possibility that the disintegrating
proteins from the lung tissue may frequently cause
the marked vasomotor disturbances evidenced on
the surface of the body and the cardiovascular
functions as well. Why in the process of breaking
down lung tissue should not histidm or similar
chemical bases be formed which lead to an anaphy-
lactic reaction with pulmonary symptoms? The
answer to this question is approached experimentally
in our laboratory.^
In discussing details in the administration of
pituitrin and adrenahn injections, the cardiovascular
changes seem to me of chief interest. As one point
of importance I would allude briefly to the means
of deaHng with other abnormal findings in my series
of cases. It will be seen that in the female patients
a tendency to a marked increase in the output of
free HQ was noted, while the male patients sug-
gested a low output of free HQ. As the indi-
canuria which was present may depend upon a de-
fective gastric or intestinal digestion, such a relation
should be considered, since clinical and experimental
observation tends to prove an intimate relation be-
tween gastrointestinal absorption, a marked indi-
canuria, and defective cardiovascular function.
Therefore in the presence of digestive disorders and
anomalies in the gastric secretion the use of diluted
hydrochloric acid in hypoacidity, and the use of
alkalies after or before meals in cases of hyper-
secretion have proved advantageous. Since a full
stomach is inclined to empty itself slowly, light
evening repasts should be recommended.
In all of my cases, so far examined, a striking
indicanuria, alone or with urobilinuria, was notice-
able, particularly in cases where the liver shared in
the symptoms of weak cardiac fvmction. During the
course of treatment these vasomotor symptoms be-
came less noticeable and finally disappeared. The
favorable effect of Bulgarian bacilli lactic acid
tablets upon the marked indicanuria could fre-
quently be observed coincident with a more regular
*Percy Shields Memorial Laboratory and Cincinnati Municipal
Sanitarium.
function of the sluggish intestinal tract. From the
asthma literature of last year we find the frequency
of indicanuria in such cases confirmed, so a study of
Allan Eustis {2), who in a series of 178 patients
found this symptom absent only in 1.7 per cent,
cases. The role of decomposition products from
putrefaction of proteins, amino bodies similar to
cadaverin and putrescin, as irritating upon the
bronchial tract, and the experiments of Banger and
Dale, with the ergot base, betaimidazolylethylamine,
also the split products derived from histidin and its
amidoacids as evidenced by Kehrer's experiments,
throw an interesting light upon the possibility of
faulty digestion as a possible cause of asthma.
Wc all admit an individual, functional power for
the elimination of waste products which, as life goes
cn, is likely to lessen, a stage being reached at which
the cells, especially those of the liver, if not of other
organs, have diminished or lost their function to
disintoxicate certain products of disturbed and low-
ered metabolism, which retained in the body pre-
dispose or cause the clinical symptoms of asthma
and hay fever. For the difterential diagnosis of hay
fever and asthma as well as for successful treatment
it will be necessary to distinguish between the dif-
ferent proteins originating from animal, plant, or
bacterial proteins, the inhalation or ingestion of
which may be the cause of the symptoms ascribed
to hay fever or asthma respectively (3). I shall not
attempt to review the interesting literature on the
subject of sensitization, but shall refer the reader
to some of the many valuable contributions. Al-
though the primary results obtained by pollen vac-
cination treatment were very encouraging, with
more clinical evidence at hand (4) we cannot expect
everything from such an immunization treatment ;
further therapeutic means must be considered.
With the aim of securing an immunization the rec-
ommendation of Blair (5) may be tested to accus-
tom oneself to the pollens by frequent exposure and
contact with the plants before their blooming sea-
son has started. Just as the injection of blood
serum has given good results in asthma treatment
(6) the method may be applied in hay fever cases
with a possibility, by introduction of fresh serum
protein, of stimulating the organism to overcome
the impaired cell functions.
Considering the favorable results obtained by
treatment with vaccines derived from streptococci
and other bacteria (y) and those obtained by pollen
\accination combined with treatment (8), with a
vaccine prepared from a culture from the naso-
pharv^nx at the time of attacks, is there any discrep-
ancy between the etiological factors such as pollen
from plants and the consequences of former bac-
terial infections? Further experiments bearing
upon the subject will help decide that question.
Personally I believe that with increase of knowl-
edge of the split products from bacteria and toxins
resulting from protein decomposition, their indi-
vidual action upon the human system may be better
understood. Perhaps the hay fever and asthma
attacks simply express the inability of certain indi-
viduals to eliminate or disintoxicate certain endo-
genous or exogenous waste products. The
frequency of vasomotor disturbance in most in-
58
PARKER: THE PSYCHIC FACTOR IN SHOCK.
[New York
Medical Journal.
stances of incomplete elimination, also in hay fever,
1 am pleased to find endorsed by various medical
men (9) as worthy of therapeutic consideration.
Oily substances, applied to the mucous membranes
(10) intended for the protection of the mucous
membranes of the nose, are not contrary to the con-
ception of a predisposing condition of these mem-
branes to react upon pollen irritation.
Some years ago Dr. Charles Ritter, a prominent
physician in Carlsbad, directed my attention to the
frequent passive congestion of the mucosas of the
i;Ose and throat early in myocardial weakness. His
theory of elimination and cardiovascular stimulation
v;as considered worth personal investigation, and in
still unpublished observations I had to admit the
truth of the theory applied to my patients who were
treated unsuccessfully by nose and throat specialists
for years. As soon as better circulation was
achieved they were freed from their symptoms, and
some of the specialists themselves were struck by
the local changes which had occurred without their
treatment. The diagnosis of vasomotor disturb-
ances, weak heart, low pulse pressure, and indi-
canuria should be borne in mind, and in their pres-
ence therapeutic means, as outlined above, should
be used in order to remove congestion of the mucous
membranes, which are exposed to irritation from
pollens. I am inclined to beheve that a better blood
cn-culation will help in the attenuation of distressing
symptoms, which necessarily cause much distress to
the patient and concern to the attending physician.
REFERENCES.
I. E. ZUEBLIN: Medical Record, 1917, xcii. No. i, p. 10. 2.
ALLEN EUSTIS: Southern Medical Journal, 1916. 3. GOODALE;
Boston Medical and Surgical Journal, August 10, 1916, clxxv, 181;
ibid., July, 1915; ibid., 1914, clxxi, 695; TALBOT: ibid., August
10, 1916, clxxv, 194. 4. GOTTLIEB: New York Medical Journal;
SCHEPPEGRELL: ibid., December 4, 1909; Journal A. M. A..
March 4, 1916, p. 707. 5. S. BLAIR: Medical Council. 6. KAHN
and EMSHEIMER: Archives of Internal Medicine, October, 1916,
xviii, 445- 7- SOERRE OFTEDAL: Journal A. M. A., Mav, 1916;
SIR LEONARD ROGERS: Practitioner, June, 1916; see Billings,
Practical Medicine Series, 1917, i, 172-76. 8. F. M. FARRING-(
TON: Laryngoscope, 1913, xxiii, No. 12, p. 1133; CHARLES B.
MORREY: Journal A. M. A.. November 15, 1913, p. i8'o6; S.
STROUSE and IRA FRANK: Journal A. M. A., 191 1, Ixvi. No. 10,
p. 712; LEON S. MEDALLIA: Boston Medical and Surgical Jour
nal, August 10, 1916, clxxv. 9. XVIII Annual Meeting of Amer-
ican Therapeutic Society, Tune 1-2, 1917, F. M. Pottenger, and
others. 10. EBSTEIN VERNOON: Deutsche medicinische Wochen-
jchrift, 1910, No. 43.
Purther Study on the Cultural Conditions of
Leptospira (Spirochaeta) Icterohaemorrhagiae. —
Hideyo Noguchi, M. D. (Journal of Experimental
Medicine, May, 1918), says that suitable animal or
human serum is necessary for the cultivation of the
Leptospira icterohccniorrhagice . He considers rab-
bit, horse, and goat serum better than other animal
sera, and while human serum is suitable, ascitic fluid
is not. Growth occurs luxuriantly in a medium of
Ringer's solution to which more than ten per cent,
of normal rabbit serum has been added. An un-
diluted serum is not better than a diluted one, if
this contains at least ten per cent, of serum. The
reaction of the medium, which is important, should
be slightly alkaline, not exceeding that of the serum.
Oxvgen is necessary for the growth of the organism,
and the best temperature for its development is be-
tween 30° and 37° C Noguchi describes three dif-
ferent media for the cultivation of freshly isolated
strains.
ANALYTIC VIEW OF THE PSYCHIC
FACTOR IN SHOCK.
By George M. Parker, M. D.,
New York.
{Concluded from page ij.)
We have noted in the shell shock reports the
rapid cure of many psychoneurotic marks, defining,
clinically, this group of cases. Cure seems a proper
statement when one considers that the case is re-
turned to the fiercest environmental tryout ever
made for man, and one in which the initial break
occurred. From the mode described as "persua-
sion" an inference seems justified that what is really
achieved is something to which the individual oflers
opposition, and that in this might be recovered some-
thing suggesting a confrontation with what, in the
railroad shock case, we saw as amounting to the
close approximation to consciousness of the direc-
tive, critical movement located, rather artificially,
in the unconscious. Here, then, is a direct handhng
of the confrontation, apparently through the symp-
tom, or at least in part thus. We signalize this
symptom relation because of the use of "electricity
for its psychic effects." One, of course, could find
no use for a current in driving an individual to con-
front a critical unconscious reflection, conceived, as
most difficult of facing and one in which the per-
suasion could rest on no such measures of help.
Yet obviously the symptoms need to be removed ;
but is this only on account of their own damage,
or is it more because they afford a subtle resistance
to the confrontation? It is probable that under the
exigent conditions prevailing on the front that any
such extraction of a problem has to wait upon the
results themselves. This seems definite. However,
psychologically, it has been achieved, is of less im-
portance. Can we, however, go further in this
cjuestion through the added data of the railroad
shock case? There is here plainly a critical direc-
tion afforded the patient from the unconscious, so
far as one reads it in the dreams. Within a few
days the symptoms appear. Also, no therapeutic
eft'ort of any kind had been made, and it seems clear
that no confrontation had occurred. The establish-
ment of the symptoms, as an adaptive partial con-
frontation, followed.
Apparently, now, under quite similar circum-
stances of shock, a course of persuasion, with "elec-
tricity for psychic effect," is carried through by a
medical officer ivJiose personality is of large im-
portance. Can one in this terminal phrase gain here
a further illumination of a psychic therapeutic agent,
which may also better expand our notions, both of
the psychic efl'ects of electricity and of the effect
of this agent with the human agency upon the
symptom formation? In this, for the moment, we
lay aside the question of whether the removal of
symptoms really effects the possibility of a per-
suasion to confrontation, or whether the latter, by
itself, results in the removal of the symptoms. The
purpose now rests in an expansion of the symptom
in its adaptive character. That is, any explanation
of what the personality of the persuader may mean
psychologically will, perhaps, throw further light
on the symptom, which apparently, in some way is
eft'ectively removed by this persuader, conjoined
♦
July 13, 191S.] PARKER: THE PSYCH
with a "psychic effect of electricity." The symptom
here, then, is related to a human agent, who effects
in it a change. Is this change one which is solely
to be further placed in a series of unconscious de-
terminism ; are we here to view it only as it has
usually been seen in relation to hidden motivations,
or can one also trace the work of the human agency
in a more or less conscious transformation? As
to the first alternative, this amounts to nothing more
than has been firmly established as to the adapta-
tion of the symptom to unconscious formations.
The symptom is a production of the unconscious
in part, as all our analyses define. Yet there remain
the conditions for its appearance. Is the explana-
tion of the symptom solely to be found in the im-
puted presence of very deep or firm fixations, or
are we to believe that the essential conditioning fac-
tor rests in something like that which we have ex-
pressed in a nonconfrontation ? Weight is given to
the latter, both because it is suggested as a constant
at the point of the break and because thus one bet-
ter understands the effect of a powerful personality
in persuading toward a confrontation, and the ease
with which a current of electricity appears to dis-
solve a mutism, or phobia, or paralysis which, adap-
tively, would no longer be of service as a substitute
confrontation after the patient had seized the critical
expression of his unconscious, brought near the sur-
face by the psychic factors of the shock. On the
other hand, we are aware, in an operating agency
of personality as effecting the erasure of a symp-
tom, that there is suggested something much like
a transference ; only this appears to be made extra-
ordinarily rapidly ; none of the usual resistances
function for the usual space of time. Granting the
mechanism of transference as presenting, with the
symptom erasure initiated by this, as in any psycho-
neurotic, how can one explain the rapidity and the
completeness of the transference so far as it is to
be read in the instant removal of symptoms ? Sug-
gestion cannot enter, for it is only again a relative
of transference, and by itself is of little use; it has,
indeed, been tried and discarded with its congener,
hypnosis. The persuasion here seems also as a
word to be chosen as bearing a different connotation
as suggestion. All analysts reckon upon the resist-
ances of transference ; many enormously emphasize
in this its importance especially among the Freu-
dians. And it is peculiarly important for them in
their lacking anything beyond a reductive basis ;
any ameliorism, such as is contained in the prospec-
tive mode of Jung, must be supplied by the analyst
in his conscious direction of the patient with the
artifices of sublimation.
The new factor emerging in the series we are
having to do with is that of confrontation. Is the
arrival at a transference peculiarly easy because
of the initial effort toward such a confrontation,
both in the harsh, impinging environment with its
psychic factor, and in the instant handling of the
case with the persuasion? We relate transference
now to this conscious interference which is ex-
pected in the shell shocks. In transference we
realize that it depends upon the analyst arriving
at a point, hitherto jealously guarded by the pa-
tient, wherein a relation m.ay be shifted over to
him which had hitherto maintained for itself a prim-
: FACTOR IN SHOCK. 59
i;ive object. It often seems as though this re-
quired an intrusion, and one backward by the an-
alyst ; as though, indeed, he were stepping back
or down to primitive levels in order that through
him the patient might pass outward. If this has
been achieved by the persuader it has been a re-
markably brief short cut; yet it is possible that
something becomes efi'ective in bringing forward
tiie fixation, achieving a quicker transference and
thus erasing more rapidly the symptoms. Is it the
confrontation which does this, under the peculiar
drive of the reality and treatment? We are car-
ried further along this line when we consider the
estiblished fact that the shell shock cases rarely
recovered after they had been for long far back in
The quiet retreat where they were at first treated.
On this native heath of the psychoneurotic they
have presented all the difficulties inherent to this
group. If this issue or termination be accurately
reported, there can be no reason for distinguish-
ing these shell cases from the other members of
this class, solely on the basis of a definitely deter-
mined conditioning factor. Indeed, whatever is
fruitful would seem to lie along a line defined in the
question as to whether in all psychoneurotics the
eame type of break does not occur, with a rapid
appearance of symptoms, which display an imme-
diate adaptation to something more than to a hidden
motivation, to something conscious, not unconscious.
At the moment, we have one point only distin-
guished definitely in the shock cases, that of out-
come. This has been strikingly favorable and rapid
under a set of circumstances which we have sub-
jected to a kind of analysis ; unfavorable in an
antithetical setting. The psychic factor of a shock,
however, we have described more accurately in a
single case of shock, with a suggested relationship
here of symptoms to other factors rather different
to that usually presented by psychoanalysis. The
therapeutic agency we have related both to trans-
ference, out of the items afforded by the shell
shock case, as well as to the confrontation phe-
nomena presenting in the railroad accident. So
far as the prevailing Freudian modes of analytic
treatment are concerned, the dependence upon
transference, with a reduction of symptoms, is the
chiefest. The matter of re-^istance is, of course,
only related to this. Jung's prospective method,
however, offers many points of contact with what
we have considered in relation to confrontation.
It has seemed to us that both the transference and
the confrontation had been probably effective in the
shell shocks. But our chiefest interest has been
to explain, if possible, the instant results in a type
of case where months usually ensue in analysis be-
-ore cure. We are, of course, accepting the proof
of cure here in the test of a return to the trenches;
equally definitely we have rejected the notion of
these results being gained by so shallow an effect
as suggestion, which we have seen as a pallid
shadow of transference.
It now seems obvious that if the transference
has been so slow in effecting results in the ordi-
nary reduction of the ps3'choneurotic symptoms,
certain conditions must have supervened to render
its w^orking here more rapid and efficient. We be-
6o
PARKER: THE PSYCHIC FACTOR IN SHOCK.
[New YoRit
Medical Journal.
lieve a certain justification presents for the assump-
tion that soniethinjj much like a confrontation has
been achieved because of a pecuHar acceleration af-
forded by reality phenomena of a violent kind.
That is, here certainly, reasons present for a clearer
piecipitation of this apparently significant therapeu-
tic need. At least, it looks to be the added factor,
that which here is easy to discern in its origin and
in its effect. Yet can we assume, only because
of the slow working of the usual analyses, that it
does not also present there ; or may we suggest that
it has been overlooked in the larger movement of
the reduction of the symptom, to which a con-
siderable accent has been given from a preponder-
ant emphasis upon the unconscious relationships of
the symptoms, for the resolution of which only that
operating through the unconscious seemed to be
effective. Similarly, in the matter of transference
the consideration has been of much the same kind.
One must, so to speak, enter the unconscious to
approximate the site of fixation ; the prevailing re-
lationship to the analyst is to be one necessarily
upon this primitive level.
Yet if there has been a transference here, sug-
gested in the importance of 'the personality of the
medical officer, obviously it has not been gained
by the slow plodding approximation to the fixation
site from which the transference emerges in the
usual analytic procedure. Is it possible that the con-
frontation has effected the transference at a level
which we can best describe by making it one de-
fined by the adaptation, imputed to be served in the
sudden appearance of the symptom, as a partial
confrontation? That is, instead of pursuing,
through reduction, the symptom back to its primi-
tive site to achieve there a transference and later
release it, it has been used in its immediate adap-
tive presentation, following the break as a point
d'appui, for a transference at a site where it might
more rapidly yield to the persuasion for a con-
frontation with none of the disability of the usual
infantile stage of transference issuing at the point
of fixation. If the symptom, then, is an adapta-
tion both to the site of fixation and to the pros-
pective movement of the unconscious, what issues
in the persuasion, directed in the shell shock, seems
to be the utilization of the second form, in which
there is brought about so effective a confrontation
with the directive movement that the arrest at the
primitive site seems instantly to be overcome. Again,
the issue seems directly related to the confronta-
tion.
If, however, the psychological value of confronta-
tion be what it appears here, how may one explain
its apparent absence as a mode in the general work
of psychoanalysis? It is not exact to speak o( it as
absent, for it has been touched upon in one way
or another by many workers. Jung, as we have
seen, has defined in his constructive method the
prospective element which emerges, and with which
iie supplemented the reductive work of Freud and
Adier. Deeper than this, he has seen the need of
an individual philosophy built up by the patient.
Adler and his disciples long ago expressed vividly
the need of a surrender of fictitious goals in order
;o arrive at a fair balance. Freud, undoubtedly, in
his sublimination, aimed at much the same end.
Yet, in all this, and indeed in all analytic procedure,
such an attempt had a place only after a long re-
ductive procedure. As an integral part of the ini-
tiation of analytic treatment it has been absent.
When we consider, however, the exigencies of the
problem before the therapeutist the matter is easier
to understand. After all, the work of analysis has
grown from an intensely practical application to a
distinct presentation of symptoms. The symptom
had been both the initial point of attack and the
problem, which Freud had stated for him. The an-
sv/er to it he found, apparently, in the unconscious
motivations. It is here that his work had led analy-
sis in the purely reductive mode. Nowhere, how-
ever, has he been able to distinguish, psychologically,
what peculiarly operates to make the psychoneurotic
as distinguished from the so called normal indi-
vidual. All his mechanisms are universals. The
determinism is, of course, traced and retraced in
each case analysis, and discovered by him in the
collective unconscious of the myth or tradition or
savage ritual. He has, to be sure, in "Das Kleine
Hans," subjected a child to analysis, and in its ori-
gins reveals his peculiar causae. Yet the peculiar
conditioning factors leading to the psychoneurosis
are not substantially distinguished. It appears as
though, again, the course traversed from what we
speak of as the point of break to where the symp-
tom appears, has been slurred over. But, more than
this, if our hypothesis be true as to the symptom
representing a substitute confrontation, then, the
longer these symptoms be interfered with, the more
effectively is the patient aided in avoiding that
confrontation which the symptom draws upon itself.
It is much like giving aid and comfort to an alien
or enemy. Hence, not only has the exigency of
the symptom necessarily determined this as the point
of entrance, but in the accent thus directed at the
symptom, emphasis has been instantly diverted from
the confrontation. Moreover, aside from the men-
ace, well defined by Jung, in the mechanistic hand-
ling of man with a total indifference to any move-
ment in him toward a constructive goal, we must
realize the imputation seized by the patient in
the connotation of a single unconscious origin of
liis disabilities as revealing a total irresponsibility
for them. They are of his unconscious, represent-
ing deep desires of which he has no knowledge.
Even any resistance created by him is almost un-
conscious, and of a kind solely to be dissolved by
tlie analyst. Thus, in the usual initiation of treat-
ment, it seems as though the direction were almost
antithetical to that which has appeared to be most
effective in the cases of shell shock, which we have
used as possible paradigma of what the attachment
in the conditioning factor of confrontation might
represent.
Aside, however, from these observations, the mat-
ter of the practical application of this mode to the
usual psychoneurotic comes up. At first sight it
might seem that in the shell shock series one was
having to do with a clean initial break, one which
had not stood and suffered integration for years in
its symptom formation. Yet Wolfsohn, in his tab-
ulation, recites a long antecedent history of psycho-
neurotic symptoms in a considerable proportion of
his cases. This can mean only that there have been
July 13, 191S.]
KAPLAN AND GREEFF: ADRENOPATHIC HYPERCHLORHYDRIAS.
previous breaks, in well defined episodes, making
them no different to our usual material. Yet it
may well be argued that in the shell cases there is
a definition and localization which is unusual. It
is probable, however, that an almost equal dis-
tinctness might be gained by a proper attention to
ihe point of break, such as Adler and Jung have
suggested. Undoubtedly, however, the extraordi-
nary value of the environment has been of a kind
to bring forward that critical and constructive move-
ment in a way which other situations perhaps less
well effect. Yet it is here that we believe an omis-
sion is defined in the over consideration of what
external the patient has refused to meet, the omis-
sion being intensified by a failure to insist upon a
confrontation and coincidence with the critical and
constructive line v/hich is brought sufificiently far
forward to be realized. Reality is played too much
for itself and much too little for that which it
demands of a deeper adjustment to self. It is not
simply maintaining the patient well to the front and
near the conditions prtcipita.ing the break, but a
persuasion is effected here which, to us, has seemed
to define nothing less than something like this con-
frontation.
It is certain, however, that in the usual psycho-
neurotic one is placed in no such advantageous re-
lation to an emerging constructive movement as
seems to be the case with shock. Indeed, a slow
presentation of symptoms is so much more in the
usual line of evolution of the malady that one
reads from this a lack of the exigency which fea-
tures the former. It is, indeed, this gradual inter-
position of symptoms which subtly effects so com-
plete a dual adaptation that the recovery for con-
Irontation of the sequestrated trend is much less
easy. Yet the symptom formation here may be
attacked, not so preponderantly on its adaptive func-
tion to the early fixation, but rather with the accent
placed upon its adaptation, as a partial confronta-
tion, to that directive movement which only thus
far and thus disguised is met. The analysis of the
symptoms thus may be no less searching, but instead
of a sheer reduction to an expression of fixation,
it remains at a level where the progression has
carried it. One here interfering with it makes it
ntilizable as a further emergence of what is con-
structive. The adaptation is pursued and made
larger by the access created with an increasing con-
frontation. The extraordinary resistance to this is
vested almost entirely in the symptom ; and until
this latter may be used as a finger post to the proper
direction, it may not disappear. Its existence is
coterminous with its function. Of course, the re-
ductive method does do away with the symptom in
the psychoneurotic, although it has succeeded less
amply in any complete restoration of the psychotic,
where especially the sequestration of the directive
trend has been most profound. Yet it appears to
have missed in its pure reduction any view of the
initial conditioning factors through a complete sub-
mergence of interest in the unconscious mechanism
appearing to produce the symptoms. It has admi-
rably described this mechanism as a universal, with-
out the vision necessary to explain its single dis-
organizing effect in producing the maladjustment of
a particular, the neurotic, where, as an agency, it
is postulated as operative as a universal. Nor can
this be answered save by the examination of that
early part of the neurotic route with which we
have occupied ourselves in the consideration of the
problem of confrontation, in the paradigma of the
railroad shock case and the inferred data from the
shell cases beginning now to be reported. That it
illuminates the problem of the psychoneurotic seems
clear. How far it may be incorporated as procedure
is less definite. That it contains certain wholesome
elements, demanding a conscious coincidence and
occtipation, may appear as a further exemplification
of that taking stock of self, which to a greater or
less degree is certain to issue within the oncoming
future. That it coincides with the curious experi-
ence of man, embalmed in notions of punishment,
perhaps no less svistains it than by itself it would
seem to clarify tradition and authority to the end
that what punishment really sought, yet never dared
relate, was a confrontation of self, and not merely
of outer reality. The extent to which society ven-
tured was to punish others, and not itself ; to im-
pose external morals rather than develop or condi-
tion the development of that type which may issue
only from confrontation. Yet, in this left handed
method there is to be read at least a substitution
for confrontation, as is the symptom. Taken thus,
one may possibly conceive a justification for an ap-
proach to a psychological problem from the point
of view of morals, where a universality permits
the consideration of a Saul of Tarsus, or a soldier
from the trenches, as defining in their reactions the
psychic factor of shock.
34 E.AST Eighty-first Street. •
ADRENOPATHIC HYPERCHLORHYDRIAS.
An Endocrine Therapeutic Study.
By D. M. Kaplan, M. D.,
New York,
Late Director of Laboratories, Neurological Institute,
and
J. G. William Greeff, M. D.,
New York,
Adjunct Attending German Hospital.
This is only a preliminary communication, as
we do not want to give lengthy notes of the theories
involved in the study of the internal secretions as
applied to constitutional medicine, but just the re-
sults in a few isolated cases treated, and to all in-
tents cured. In another article the principles will
be expounded as we see them, together with a new
method of analysis and a procedure for designating
and successfully treating properly selected cases
with the various endocrine products.
Case I.— Mr. D. S. V. W., age sixty-three years, mar-
ried, had two children ; one died of diphtheria. Patient is
second child of four. Had measles at six, and later
whooping cough. Attended school and was of average in-
telligence, and preferred mathematics to other school sub-
jects. At sixteen he obtained a position as a machine shop
assistant, where he worked up to his twenty-first year,
then until twent5'-six travelling extensively over the world
as a sailor and never complaining of anything. From then
until thirty he served as an engineer, and about that time
married. One year later a girl was born, three years later
a boy, who died of diphtheria when eighteen months old.
Up to his thirty-eighth year he was variously occupied in
62
KAPLAN AND GREEFF: ADRENOPATHIC HYPERCHLORHYDRIAS.
[New York
Medical Journal.
South America, where he contracted yellow fever ; he
claimed the attack lasted only twenty-four hours, being
cured by castor oil and as much whiskey as he could swal-
low. He said that on the following day he was strong
enough to resume work. He continued to work in South
America as an engineer, where, when forty-three, he con-
tracted a violent diarrhea. He suffered two collapses in
one day, had from eighteen to twenty bowel movements
in twenty-four hours, and came near dying. At no time
did he have pain with his intestinal trouble. This ailment
lasted for about seven months, during which time he lost
a great part of his strength and came down from 136 to
94 pounds in weight. During this period of illness he
could do absolutely nothing,* and decided to return to
North America. While still an invalid he undertook the
trip to New York, where he spent the last four months of
his illness.
He believed the sea voyage did him great good, so that
he substantially recuperated, enabling him to resume work.
About that time he noticed the gradual appearance of a
rupture in his right inguinal region, which, however, gave
him no concern. In 191 1, when fifty-eight, he had a fall,
and from that time on until now the hernia began to bother
him, and also increased in size so that it is now about as
big as a goose egg. Otherwise the patient was able to per-
form his duties as an engineer, complaining of nothing.
In the spring of 1915 he noted a gradual disappearance of
appetite, together with a sour and disagreeable taste in his
mouth. The latter two phenomena occurred particularly
after eating. No matter what he would eat, the discomfort
would always assert itself and last from two to three
hours after meals. Lobster and other shell food would
provoke a particularly distressing sour taste. The bad taste
was invariably accompanied by a griping feeling in the
pit of the stomach, and during one year he vomited six
times, bringing up very sour tasting material, containing
the food eaten, together with much foamy mucoid sub-
stance. After a vomiting spell he would feel better. Unable
to digest his food, he steadily lost in weight and strength
so that he had to quit work three times during that year.
He lost his sexual power at that time also. For ten months
previous to consulting me (May, 1916) he was treated by
several physicians, but obtained relief from none, or at
most for a few days only. For the last six years the pa-
tient had suffered from a dry, hacking cough, particularly
distressing at night, often keeping him awake for hours,
and culminating in an expectoration of glary and stringy
tough mucus. He often could not lie down to sleep, as
this would provoke a cough, so that not infrequently he
would pass the night in a Morris chair. This state of af-
fairs prevailed for a period of three weeks before the
patient presented himself for treatment.
Upon examination May, 1916, he shows shallow
chest, a grayish, cadaveric complexion, and large
veins on wrists and arms. He is five feet ten inches in
height, weighs no pounds, with hardly any pan-
niculus adiposus. He has gray hair in normal quan-
tity for his age, none on chest, very little on shins,
and a normal amount on his face. He shows a
capillary girdle across chest two inches below
xiphoid, right inguinal hernia goose egg si^e, on
both scapulae pin head size pigment deposits, two
telangiectatic spots on back. He has only six teeth
left, four upper incisors and two lower. The eyes
are blue, with marked arcus senilis. Pulse 96, car-
diac action normal, with poor muscular sounds and
no accentuation of ostial sounds. Vasomotor reac-
tion shows a sluggish pink hue with white borders ;
the pink lasts only one and one half minutes. Blood
pressure, 180 systolic.
May 12, 1916. — Was given one half grain of suprarenal
extract once a day for one week.
May 13, 1916. — Slept much better, could lie down, and
did not cough so much. Appetite markedly changed, had
a hearty breakfast and a good lunch.
May 14, 1916. — Slept still better, coughed much less.
May 16, 1916. — Slept very well, woke up only once dur-
ing the night to cough, but brought up phlegm with ease.
Had gained four pounds.
May 23, 1916. — Strength increased every day. Appetite
wonderfully improved. Still had slight sourness in mouth
after eating, otherwise no other discomfort after meals.
Slept very well, did not awake more than once a night,
coughed very little, and mucus was brought up with ease.
Mind clearer, not so much forgetfulness as before. Gained
one more pound since last week, and physical condition
(subjective) better than for the past two years.
June 6, 1916. — Sourness from stomach entirely gone, ap-
petite and sleep very good. Coughed only once during last
week, and brought up some phlegm. Although he rarely
dreamed before, he had a dream as if he were fighting
somebody. Patient said his hernia was much harder than
before and it felt tougher.
Sexual power returned. Digestion perfect. Can do
more work now than ten years ago. Sleeps, with no cough
and no awakening. Discharged, but told to report every
month.
Continued well until December, 1916, when he
had some canned food, and was taken ill with
symptoms of ptomaine poisoning. Was treated
during the emergency by another physician, and
given castor oil and other drugs, and when seen by
me a few days later, showed a very pronounced
facies of prostration, had ten to fifteen bowel
movements in twenty-four hours, could not sleep,
and his cough returned. All drugs were stopped,
diet regulated, and four days after the beginning
of his present trouble he was given one dose of one-
third grain suprarenal. Next day he was a little
stronger, and slept better. Did not cough so much.
In one week of guarded suprarenal therapy of one-
third grain once a day, he was able to go home,
and resumed work the Monday following, having
been ill in all ten days, and lost nine pounds in
v,feight.
February 7, 1917. — Is capable of performing the
duties of engineer in the boiler room alone (his assistant
having left him), and does not feel in the least bit dis-
turbed by the additional work. Eats everything, sleeps
without interruption, and has gained another one and one
half pounds during the last week.
LABORATORY FINDINGS.
Initial. Final.
Blood—
Hbg 68% 88%
R. B. C 4,664,000 4,860,000
W. B. C 8,200 9,400
Differential ... Normal Normal
Mild form hemoglobinemic degeneration.
Urine —
1028, acid, normal Normal
Feces—
Mild carbohydrate fermentation Still present
Gastric contents —
Ewald meal :
Total acidity 108 84
40 40
Free HQ 74 42
40 40
Microscopic normal.
Case II. — Mr. T., age twenty-nine years, pharmacist,
single. The fourth child of six. Diphtheria at four. Was
bright at school. Is capable of doing hard work for long
hours. Complained of pain in right inguinal region and
poor digestion for six years. Had terrible heartburn after
meals, which came on about one half hour after eating
and caused great discomfort for about two hours.
Used to take bicarbonate of soda and magnesia usta regu-
larly, but had only temporary relief. At times pain was
so great that he could not attend to business. Later he
July 13. 1918.] KAPLAN AND GREEFF: ADRENOPATHIC HYPERCHLORHYDRIAS. 63
suffered from occipital headaches of a throbbing nature.
He had been constipated for the last four years. At times
he had a pain in his anus from a small hemorrhoid which
bled occasionally. When the hemorrhoid bled he felt bet-
ter. He lost twenty-two pounds in one year.
Physical examination showed a man five feet six
inches in height, with a sallow complexion, a dark,
bright eye, eyebrows that met over the bridge of
the nose, raven black hair, abundant over the head,
with an implant of hair low over the forehead. He
found it necessary to shave each day. Teeth-
showed yellow spots on grinding surfaces, molars
intact, canines sharp and long. No pathological
spacing. Tongue large and bright colored, the mu-
cuous membranes normal. There was a large
amount of long, black hair over his entire chest.
On his back were three small and one pea-sized
brown birth marks. Vasomotor reaction was first
white, then a diffuse red with a white centre. It
was slow in appearing (fifty seconds) then disap-
peared in five minutes. Reflexes were normal al-
though lively. Heart sounds showed normal ostia
and a vigorous musculature with accentuation of
the second aortic sound ; there was no enlargement.
The abdominal contents showed no abnormality
except a slight tenderness at the xiphoid. The
abdomen was covered with an abundance of dark
hair. In the inguinal region on the right side could
be felt when he coughed a distinct impulse against
the examining finger. The left testicle was two
inches lower than the right. The legs and arms
showed an abundant hairy growth and a few dis-
crete pigment deposits, and were normal in so far
as structure and function were concerned.
LABORATORY FINDINGS.
Urine —
1022 s. gr., and in all other respects normal.
Blood — :
Three per cent, eosinophiles. Rest normal.
Gastric contents —
104 total.
82 free HCl.
Feces —
Hard scyballae, and a moderate amount of fermenta-
tion. 2V2 c. c. gas in twenty-four hours' inculcation.
The futility of the so called standard drugs used
for such a well defined condition brought about a
mental status bordering on despondency. Being a
pharmacist and having a large acquaintance among
physicians, he gradually lost confidence, so that
when he presented himself to me it was a difficult
task to make him enter into an agreement to help
along his cause. He was told to take one small dose
of suprarenal (one fourth grain) and present him-
self a week later, keeping close observation on any-
thing that might happen in the meantime. He re-
turned with an evident expression of satisfaction
and related the following :
After taking the tablet of suprarenal he felt a
sensation of warmth in his epigastrium, and a slight
feeling of tightness in his head. The food eaten
that day gave him no distress, a condition not ex-
perienced for years. The following three days
M^ere also free from distress after eating, but on
the fourth the trouble returned, although in a much
less violent form. His physical condition, particu-
larly the vasomotor response, was unchanged ; he
was given one quarter grain of suprarenal every sec-
ond day and told to report in two weeks. The follow-
ing visit showed an entire absence of gastrointes-
tinal trouble ; no pain, regular bowel movements,
and no throbbing headaches. The second aortic
sound was accentuated. The vasomotor reaction
was first pink (appearing in ten seconds) then
spread, assuming a white diffuse border, then faded
away in fifteen minutes. He was advised to take
only one tablet a week and keep note as to his con-
dition. A month later he was entirely free from
all complaints, and at the time of writing (eight
months after the first visit), he had not taken any
drug, including suprarenal, nor any of this five
months.
The chief laboratory improvement, as in the pre-
vious case, was the diminished acid excess, par-
ticularly in so far as the free HCl is concerned.
Casl hi. — Mr. E. F., age thirty-nine, married. Had one
child, which was operated on at six weeks of age for
pyloric obstruction. Patient had always been well until
eight years ago, and did not recall any children's diseases,
but had been told that during childhood he was scrofulous.
Ihere had been a tendency to constipation all his life, but
no suffering from the effects. No history of lues or gonor-
rhea. Patient does not drink, but is a heavy smoker. For
eight years had been troubled with his stomach; an acid
taste, belching, pain after eating, feeling of pressure, and
his constipation had been worse for those eight years. He
never noticed blood in Iiis stools and never had vomiting.
The patient's father died of apoplexy, but otherwise his
family history was negative. Seven months ago, while
drinking water, he suddenly had a spasm in his throat so
that the water would not go down. Since then he had
been afraid to drink; it seemed to him that fluids would
not go down. By holding his nose, with a mouthful of
fluids, he was able after a while to swallow. Fluids other
than water, such as milk or soup, seemed easier to swallow,
and solids passed down quite readily. Since the onset of
this difficulty in swallowing he had complained more of a
burning sensation and a heaviness in his epigastric region,
and also of a pain coming on from one to two hours after
eating. This pain was worse after starchy food. He also
complained of loss of weight, belching, and great nervous-
ness.
On examination the patient presents hiinself as a
slight man, weighing 129^ pounds, rather poorly
nourished, and having a decided stoop. He has a
high forehead, very little hair on his head, but
rather heavy eyebrows thinned at the outer third.
His chest is well covered with hair, he has a curva-
ture of the spine. The abdomen is flat and drawn in
at the epigastric region. There is no pain on
pressure. Splashing could be heard within a hand's
breadth of the symphysis. Heart: sounds are clear,
accentuated second pulmonic, no murmurs. Lungs :
negative.
A sound passed through the esophagus passed
without any obstruction and a test meal obtained
after an Ewald Boas test breakfast in forty-five min-
utes showed free HCl chirty-six, total of seventy.
(Normal amount of food.) Microscopical examin-
ation was normal : there were no sarcinae nor yeast
fungi.
Impressions: Spasm of esophagus and relative
hyperchlorhydria suggested possibility of a duodenal
ulcer. He was put on an anticonstipation diet and
atropine and bismuth subnitrate with magnesia usta.
September 3, 191 3. Stomach symptoms better,
could swallow easier, had less pain and gas. He
was told to continue with the above regime and
64
ARANOW: TWILIGHT SLEEP.
[New York
Medical Journal.
come in from time to time. While he improved
sHghtly from week to week, he would go back and
at times all his symptoms would come on in the
same degree as at first. Various medications, such
as bromide of strontium and mild catharsis would
relieve him of his most distressing symptoms tem-
porarily. He would have periods when his swallow-
ing became almost normal, yet under nervous ex-
citement would become worse again. With all this
his weight slowly increased by two pounds in the
course of four weeks.
During November of the same year, about six
weeks after he first presented himself, I put him on
daily lavage of the stomach, which eased up his stom-
ach symptoms somewhat until he contracted a bron-
chitis during the second week of December. Under
proper medication this cleared up, and when he
again came to the ofifice on the 7th of January, 1914,
he had entirely recovered from his bronchitis; his
stomach symptoms, such as pain, belching, etc., were
gone, but he again found swallowing very difficult.
This trouble decided him in May to go to Europe
for a complete rest. After an absence of two years
he returned to consult me, and told me that his
stomach had behaved quite well, the esophageal
symptoms had left him soon after he got on
the steamer, and by the time he arrived in Europe
he felt quite well. He gained in weight, his bowels
were regular, and he felt less nervous.
April 10, 1916. He came to see me and said that
for four months he had again been troubled with
pains after eating, belching, and constipation. He
had been under the care of a "stomach specialist"
was treated and given antacid medicine, but was
losing weight steadily ; was afraid to eat on account
of pains, and felt very nervous. His weight had
gone down to 129. Examination of the patient re-
vealed the same findings, though no analysis of the
stomach contents was made. He received one half
grain of suprarenal gland in the office and was told
to report in five days. He was told to eat every-
thing, simply avoiding extremes. On the 15th of
April he reported that he could eat without any dis-
tress. His pain was gone the next day, and had not
returned. The bowels were less constipated. He
was still nervous. No medicine given.
April 22, 3916. Had complained of slight pain
for two days. His bowels were more regular and
he had gained four pounds. Suprarenal gland one
half grain daily ordered until pain should go.
May I, 1916. Patient felt well after two doses of
suprarenal. Could eat everything without distress
and had gained another 1^-2 pound. He was seen
by me at various times for colds, etc., from then
until October 20, 1916, his last call. During this
time he only complained of stomach pains once or
twice, which were immediately relieved by one half
grain dose of suprarenal. He has gained in weight
so that he now weighs 138 pounds, and can eat
almost everything; his bowels are quite regular.
The above cases are only a selected few of the
many that show markings of an endocrine impor-
tance, and these will be used in a later communica-
tion to elucidate the method of analyzing endocrine
situations when we shall point out the relationship
between the subjective and objective symptoma-
tologv and the underlying endocrine causes. Suf-
fice it for the present to state that many cases of
suspected ulcer and even frank ulcer of stomach
and intestines could be treated with great benefit
and lasting results to the patient by a proper en-
docrine understanding of the case. It seems to us
that in treating these adrenopathic hyperchlorhy-
drias we shall eliminate or correct the cause that
produces them, and in view of the close relationship
between excessive acid and tendency to the forma-
tion of vilcer in the gastrointestinal tract, we know
we have minimized opportunities for the develop-
ment of this serious disease.
A POST MORTEM .ON TWILIGHT SLEEP.*
By Harry Aranow, M. D., F. A. C. S.,
New York,
Assistant Attending in Obstetrics and Gynecology, Lebanon Hospital.
Every new method of treatment is subject to
all the dangers to which a first and only child is
exposed. It is spoiled by too much praise and
killed with kindness. The fond parent of a new
method, naturally proud of his creation, believes
that the child of his imagination is most wonderful
and most accomplished. His child can do things no
other child can do. Then come a host of aunts and
cousins, the young enthusiasts in medicine, and
spread the story of the new wonder broadcast. New
qualities are attributed to it that were not detected
even by the watchful parent and discoverer. It is
said to do things that make the conservative physi-
cian and scientist gasp with astonishment and in-
credulity. Nobody is as enthusiastic about a new
discovery as the young specialist. In every branch
of medicine there are young and ambitious special-
ists who are anxious to bring themselves into promi-
nence before the medical profession. As most of
the "old" subjects are pretty thoroughly exhausted,
and the average physician is tired of listening to
"rehashes," these young men are always on the
lookout for something new, something radical,
something striking. As soon as a new treatment ap-
pears they pounce upon it. They try it out in per-
haps a half a dozen cases, nearly always with "the
most excellent results." and immediately they write
an essay or a book on the subject. Of course, the
majority of these men are dreadfully afraid le,st
their name accidentally get into the lay press. You
cannot blame them. Competition is keen, and it is
only on a new treatment that the young specialist
can openly claim that his opinion is as good as
that of the old and experienced man. He is also
afraid to wait until he has given the treatment a
real test in a sufficient number of cases lest the
other fellow get there first. This is all human, but
is it a wonder that so many real discoveries have
died in their infancy, to be rediscovered later?
I do not wish to take time to go into the history
of twilight sleep. I only wish to give my present
opinion on the use of scopolamine and morphine
in obstetrics, based on personal observation and ex-
perience. I have had the privilege of watching
Doctor Shlesink give twihght sleep in the first series
of cases in this country on the service of Doctor
Rongy at the Lebanon Hospital. I have also watched
♦Read before the Bronx County Medical Society, February 20, 191S.
July 13, 1918.]
ARANOW: TWILIGHT SLEEP.
♦
65
a larger and more successful series on the same
service under the care of Doctor Rongy and myself.
I have read nearly everything published on the sub-
ject, not excluding the New York Journal, the New
York Times, the Ladies Home Journal, etc., etc.
What is wrong with twilight sleep? What has
happened to the enthusiasts, who hailed it as the
greatest discovery since Mother Eve tasted the for-
bidden fruit? Why have the men who have pro-
claimed the wonders of twilight sleep from every
housetop suddenly grown mute? Why has it gone
into practical oblivion after such a short life? My
opinion is that twihght sleep died a sudden death,
not through lack of real merit, but because it has
failed to live up to a false reputation. Physicians
expected too much from the use of scopolamine and
morphine and, as a result, were disappointed and
discouraged. Patients were promised too much
and, as a result, felt themselves cheated. No man
who has watched the administration \v a series
of obstetrical cases could help being impressed by
its real usefulness and many advantages. Let me
point out some of the universally recognized ad-
vantages and drawbacks of twilight sleep.
Advantages. — i. Jt unquestionably shortens the
first stage of labor. The reason for this seems to me
as follows : As you will recall, there are three ele-
ments in the mechanism of the dilatation of the
cervix : ( i ) , the mechanical stretching by the bag of
membranes, or, if the membranes are ruptured, by
the presenting part of the fetus ; (2), the contraction
of the longitudinal fibres of the uterus which end
spirally in the cervix like a rubber tobacco pouch,
or perhaps more like the leaves of the diaphragm
of a camera ; by their contraction, the cervix uteri
is opened and shortened; (3), the physiological re-
laxation of the circular fibres of the cervix, which
usually takes place in conjunction with the contrac-
tion of the uterus. This action is similar to the ac-
tion of the sphincter of the bladder and rectum
during micturition and defecation. This relaxation
is frequently interfered with or entirely obstructed
by a spasmodic contraction of these fibres. An
antispasmodic such as scopolamine or morphine
overcomes the spasm and the cervix dilates rapidly.
2. The actual perception of pain in labor is either
entirely obliterated or markedly diminished. 3. The
duration of the labor pain is shortened without any
apparent shortening of the length of the uterine
contraction. A patient in labor can usually feel the
coming of the next pain for a variable period before
the actual contraction takes place. Again, for a
variable period of time after the contraction, the
patient generally sufit'ers from the aftereffect of the
last pain. Under the influence of the drugs, how-
ever, one can usually see the contraction of the
uterus before the patient begins to show signs that
she is conscious of the pain. Again, as soon as the
contraction is over, the patient immediately re-
laxes. If she has had her arms and legs bent while
bearing down, the arms relax, the legs drop, and
she either Hes perfectly still or goes into a light
sleep. 4. The patient gets periods of complete rest
between the pains. 5. There is an entire absence of
the agonized cries, which always exhaust the patient
and physician and often lead the physician to inter-
fere when no interference is necessary. 6. There is
comparative absence of postpartum exhaustion and
shock. Immediately after dehvery, the patient
usually goes into a deep sleep and, when she
awakens, she usually feels well enough to get up.
Drawbacks. — i. Repeated doses of scopolamine
are dangerous. Those who have had any experience
with hyoscine medication know what a dangerous and
unreliable drug it is. 2. An experienced physician
and nurse must be constantly at the bedside. This
excludes the general practitioner who does most of
the obstetrical work of the community, it interferes
with the obstetrician's other work, and, it makes
the expense of a confinement prohibitive to all ex-
cept the well to do. 3. It prolongs the second stage
of labor. 4. The efifect of the drug and the prolonged
second stage of labor on the baby is evidenced by
the increased number of oligopneic and partly as-
phyxiated children bom under twilight sleep. 5. One
more drawback is its absolute failure in a certain
number of cases. In order to overcome the dis-
advantages and make use of the advantages, I have
administered scopolamine and morphine during labor
according to the following method. I do not believe
I can claim anything new or original. It is only
for fear that in our disappointment over the so
called twilight sleep we might discard a very valu-
able drug, that I take the liberty of presenting this
subject. When a patient comes to engage me for
her confinement, I make no promises of twilight
sleep and the absolute freedom from pain which a
woman usually expects from such a promise. Dur-
ing the prenatal period I have the patient come to
my office regularly and I make all the necessary
external and internal examinations, take all the
measurements of the pelvic inlet and outlet, approxi-
mate measurements of fetus, etc., so that by the
time the woman is ready to go into labor I have a
very definite idea as to the presentation, position,
size, and shape of the pelvis, size of the baby, and
the probable character of the expected labor. When
a patient goes into labor I visit the patient and make
another abdominal and rectal examination. I make
no vaginal examinations during labor unless there
is an mdication for it, such as an unsatisfactory
rectal examination or the suspicion of a prolapsed
cord or placenta prsevia. The patient is shaved and
prepared as for a major operation.
Every woman expects to have a certain amount
of pain during childbirth. During the greater part
of the first stage, when the pains are comparatively
of short duration and the intervals of rest are long,
the great majority bear the pains cheerfully and
rarely complain. However, toward the end of the
first stage, when the pains increase in frequency
and length, the patient's attitude changes. The
woman who has been sociably and cheerfully chat-
ting in the intervals of rest gradually becomes mo-
rose. Her entire attention becomes centered on
her pains, and soon after she begins to inform her
nurse, physician, friend, or any one who happens
to be present, that she cannot stand the pain any
longer. It is my opinion that at this stage it is the
duty of every physician to give the woman some
relief, if possible. If you cannot give scopolamine
and morphine you can usually give morphine. I
have no patience with the doctor who sits calmly
by and lets a woman suffer the agonies of hell.
66
KOBI.ER: EAR CONDITIONS IN SCHOOL CHILDREN.
[New York
Medical Journal.
"Not interfering with nature" is often a camouflage
for our ignorance or our indilTerence to suffering.
The doctor who proudly boasts that he never gives
morphine in the first stage nor chloroform or ether
in the second is worse than a midwife.
To return to my subject : I instruct the nurse that
as soon as the patient begins to complain bitterly of
pain, she is to be put to bed in a quiet room. The
bed is draped with a sterile sheet and the patient is
covered with another sterile sheet. She is then to
receive, hypodermically, 0.25 of a grain of morphine
and 1/150 of scopolamine stable, or 1/6 of mor-
phine and 0.005 of scopolamine stable, depending
upon her physique and constitution. The nurse
then reports to me. By the time I arrive again, the
patient is rapidly going under the effect of the nar-
cotics and the os uteri is usually fully dilated, and
I remain until after the delivery. However, if I
think the labor is going to take some time, I leave
the patient, after instructions that in case the eft'ects
of the first injection wear off, the medication is to
be repeated once only, and half of the original dose.
In this way I do not spend any more time at the
bedside than is usually necessary. The absence of
crying and moaning, on the other hand, add greatly
to my own comfort and that of the nurse and the
patient's family, thus removing one of the most ob-
jectionable features in obstetrical practice.
To one who has never given scopolamine and
morphine in obstetrics, it must be a striking picture
to enter a delivery room and find absolute quiet, the
patient apparently asleep and the doctor and nurse
sitting quietly by the bedside. During a pain, the
patient automatically draws up her legs and strains
and is encouraged by the doctor and nurse to bear
down harder. Every now and then the patient will
arouse sufficiently to inquire whether the baby is
born, or to inform you, as if it were a matter of
surprise, that she still has some pains. As soon as
the pain is over the patient's arms and legs drop
and she either lies perfectly still or goes oil into a
"soft snoring" sleep. When the occiput presents at
the vulvse, I always let my patients have a whiff of
chloroform or ether with every pain. Under scopo-
lamine and morphine I occasionally find it neces-
sary at this stage to pin the patient's wrists to the
mattress so as to prevent her from subconsciously
reaching down the perineum and apparently trying
to remove something which annoys her.
To show the complete mental relaxation and de-
tachment of the patient I relate one experience : At
about 2 a. m. December 24th last, I was quietly sit-
ting at a bedside watching a patient under scopola-
mine and morphine in the second stage of labor,
when I was suddenly startled by a piercing shriek
of "Fire!" by a woman in the hallway of the same
apartment. There was considerable excitement for
a while. I watched my patient's face very carefully
for signs of alarm or fear, but her expression re-
mained absolutely calm. The next morning I asked
her whether she know that there was a fire in the
house and she replied : "Yes, I heard them yell
fire, but 1 did not care." This brings out a point I
wish to emphasize. I do not try to get complete
amnesia. This patient remembered the fire. The
main object of my treatment is not to obtain com-
plete amnesia, but to give the patient relief I rarely
find it necessary to give a second dose. Every now
and then I come across a case where it seems to
have no effect whatever, but, as I have not promised
the patient a painless labor I have not lost her con-
fidence and, as the drugs nearly always shorten the
first stage of labor I have gained that much.
CONCLUSIONS.
T. Scopolamine and morphine have a distinct and
merited place in the practice of obstetrics.
2. By its administration, the first stage of labor is
shortened ; the perception of labor pains is either
shortened or entirely obliterated ; the patient gets
periods of complete rest between the pains ; there is
an absence of crying and moaning with comparative
absence of postpartum exhaustion a:nd shock.
3. By following this technic the drug can and
should, be used in nearly every case because the
dose is never large enough to be dangerous ; it does
not require the constant presence of a specially
trained attendant ; it can be used by every physician ;
the second stage of labor is not prolonged suf-
ficiently to be dangerous to either mother or child,
and, as the physician and patient do not expect
painless labor, they will not be disappointed if the
drugs do not have any effect.
355 East 149TH Street.
A SURVEY OF EAR CONDITIONS IN
SCHOOL CHILDREN.
By E. Willis Kobler, M. D.,
New York,
Instructor in Laryngology and Otology, Columbia University;
Assistant Aural Surgeon, Manhattan Eye, Ear,
and Throat Hospital.
A survey of the cars of 500 school children in the
public schools of New York City was completed by
me in the early part of 1917, a work performed in
connection with my duties as medical school in-
spector in the health department.
This special study of ear conditions in school chil-
dren relative to defective hearing included history of
previous ear discharge ; abnormal conditions of the
external ear, malformations, etc. ; relative degree of
impairment of hearing; relative amount of cerumen
present ; existence of present discharge from the
ears ; presence of marked associated defects bear-
ing upon the hearing. The study was based upon
inspection and examination of the ears of 500 school
children; 250 girls and 250 boys, including 150 boys
in Truant School P. S. No. 120. The ages of the
girls ranged from nine to fifteen years; the boys six
to fifteen. All the children were white.
Children in the upper classes were selected, be-
cause more reliable histories and tests were thus
obtainable. They were taken in small groups into
the inspector's office under quiet surroundings. No
attempt was made to select individual cases ; the
pupils were taken in routine examination order.
Class, age, sex, history, and color were recorded
and general tests for hearing were made separately
in each ear with voice and watch, eyes closed.
Lesions of external auditory canal and adjacent
structures — skii; conditions, malformations, etc. —
July 13, 1918.]
KOBLER: EAR CONDITIONS IN SCHOOL CHILDREN.
were noted. Examination of each ear was made
separately for relative amount of cerumen present
by means of head mirror, aural specula, and re-
flected light. There was no attempt at instrumenta-
tion otherwise. The existence of any present dis-
charge was noted, and its present history. Throat
and nose were examined for marked associated de-
fects bearing upon condition of hearing, also the
general condition, malnutrition, etc.
SUMMARY.
Of 500 children examined, 1,000 ears, sixty- four
gave history of some previous ear discharge ; nine
had skin lesions, malformations, etc., of the external
auditory canal and adjacent structures; 152 showed
relative degrees of impaired hearing; 285 had ceru-
men in relative degree of excess over normal; eight
hod a present ear discharge, and nfty-nine exhibited
marked associated defects bearing relatively upon
the condition of hearing.
CONCLUSIONS.
Discharge from the ears of young school children
is more prevalent than is generally supposed and is
usually considered to be of relatively slight impor-
tance. It is, however, of vast importance as bearing
upon acuteness of hearing in later school life ; note
tables showing relative degree of impaired hearing,
in cases where a previous discharge existed. The
number of cases of impaired hearing is relatively
small in later school life, evidently and apparently
because of the treatment or removal of tonsil and
adenoid defects in the younger children, as accom-
plished through the regular, repeated, routine medi-
cal inspection and treatment carried on by the medi-
cal examination from the kindergarten classes up.
Manv cases of defective hearing, however, exist
among the older children which may be accounted
for by : neglect and refusal by parents to remedy
tonsil and adenoid defects ; deformity of the nasal
se])tum, which cannot be corrected in early age ;
abnormal collection and deposit of cerumen coupled
with uncleanliness ; catarrhal conditions of the naso-
pharynx coupled with incomplete and insufficient
instruction in oral and nasal hygiene ; lack of, or
inadequate instruction in aural hygiene. So called
"common earaches" are always treated with harm-
ful home remedies and adjuncts.
Abnormal collection of cerumen in the ears of
school children is far more prevalent than should
be, which is due largely to lack of complete instruc-
tion in aural cleanliness. Inspissated or impacted
cerumen is etiologically of vast importance to the
hearing and definite pathological aural conditions
both present and future. Cases of present ear dis-
charge are comparatively few in number. All such
cases show improvement because of persistent
supervision by the school medical inspector and
nurse. Cases of associated defects, as inarked
hypertrophy of tonsils, defective nasal breathing,
including adenoids, etc., are relatively small in num-
ber. All are under treatment where advisable and
possible. Objection of parents to operation and
treatment is the principal factor responsible for
these persistent existing defects.
A special extended survey and examination of the
ears of school children should be made with refer-
ence to the above conditions.
-Boys-
2 ^1 ^
9 208 4;
14 4
13 3
1 58
36
IS
9
4
4
9
IS
RESULTS
Previous Discharoe
Gave history of previous discharge 20 13
Malformatio.vs, Skin Conditions
OF External Ear
Impairment of Hearing
Slight impairment 12 23
Marked impairment ig 7
Marked impairment in one ear
and slight impairment in other
Total With Impaired
Hearing
Normal bearing in both ears...
Cerumen
Slight excess, over normal and
ear not clean 2S 21
Moderate and ear noticeably un-
clean 6 8
Impacted or inspissated 14 12
Moderate in one ear and im-
pacted in other
Cerumen in one or both
Normal
Present Discharge 5 i
Associated Defects
Children showing marked de-
fects probably relating t9 im-
pairment of hearing
Individual defects
Hypertrophied tonsils
Defective nasal breathing. Ab-
normal septum — and one
congenital nasal deformity
Perforated tympanic membrane
General malnutrition
Old mastoid operation
Chronic otitis media purulenta
(one double in one boy)..
Complete Totals
Previous discharge
Malformation, skin, etc
Impaired hearing
Cerumen
Present discharge
Associated defects
RESULTS IN TRUANT SCHOOL
150 boys examined (soo ears), ages 8 to 16
years, all xvhite
Previous Discharge
Gave history of previous ear discharge 16
Malformations, Skin Conditions op Exter-
nal Ear
Impairment of Hearing
Slight impairment 10
Marked impairment 15
Marked in one ear and slight in other
Total with impaired hearing
Total with normal hearing in both ears. .
Cerumen
Slight excess over normal and ear not clean 19
Moderate and ear noticeably unclean 6
Impacted or inspissated 2
Moderate in one ear and impacted in otlier
Total with cerumen in one or both
Total normal
Present Discharge 4
Associated Defects
Boys showing marked defects, probably re-
lating to impairment in hearing
Individual defects
Hypertrophied tonsils
Defective nasal breathing (abnormal sep-
tum)
Perforation of tympanic membrane
General malnutrition
Old mastoid operation
Chronic otitis media purulenta (i double)
Totals
Previous discharge
Malformations, skin conditions, external ear
Impaired hearing
Cerumen
Present discharge
Associated defects
171 West Eighty-first Street.
68
FRIEDEL: SCARLET FEVER AND EPILEPSY.
[New Vork
Medical Journal.
SCARLET FEVER AND EPILEPSY.
By Herman Friedel, M. D.,
Stapleton, S. I.
Ovaritis is one of the recognized possible com-
plications in mumps. Ihe following case seems to
indicate that any of the infectious diseases may af-
fect the ovaries. So, while the acute degenerative
change in the kidneys is the best known complica-
tion of scarlet fever, there is no reason why almost
any tissue of the body should escape being the scat
of inflammation.
Case. — S. O., a girl, thirteen years of age. Family his-
tory was negative except that father weighed 280 pounds,
was extremely nervous, and had taken treatment at Carls-
bad for his nervousness. Personal history showed that the
patient was born normally, was breast fed till two years
of age, began walking at sixteen months, and had con-
vulsions with every tooth. In infancy she had measles,
chicken pox, whooping cough, cervical gland abscess run-
ning for two years. She was, at the time of examination,
five feet three inches in height, and weighed 165 pounds ;
scanty hair, small breasts. At fourteen years of age she
was in grade 5 B. At the age of eleven years she had a
severe attack of scarlet fever, but made an uneventful re-
covery. Shortly afterward her mother noticed that she wet
her bed at intervals. Then followed what they called
"slight spells." The girl would appear tired, yawn all day,
complain of dizziness, and have a slight convulsion. Grad-
ually these attacks became more frequent and usually
lasted longer. It happened at school and at her hom.e. A
six months' vacation from school did not improve matters.
Bromide medication at clinics did very little good. This
condition lasted for two years, when the girl came again
under my care. Now she would be unconscious for a
whole day, with nine to twelve convulsions. The attack
was really a series of short attacks. I gave her corpora
lutea, five grains, and anterior pituitary gland ; menstruation
began and she was free from any attacks for three months.
On the advice of neighbors, she stopped the medication,
and the attacks returned. On resuming the treatment,
she once more became free of attacks. I have now lost
track of her for some time.
My reason for giving anterior lobe pituitary was
that the experiments of Gushing have shown that
the removal of the anterior lobe leads to retarda-
tion of growth, failure of development of secondary
sex characters, sluggishness, and tendency to exces-
sive obesity. As can be seen, this patient had the
excessive obesity, sluggishness, and marked failure
of development of secondary sex characters. The
absence of menstruation and the periodic attacks in-
duced me to give her corpora lutea, with the good
results noted above. Those who believe that epi-
lepsy is more frequently due to heredity than any
other single factor will note the facts given con-
cerning the father. It is also important to remem-
ber that she went through a very difificult dentition.
This shows a neuropathic predisposition. Spratling
states that convulsions in infancy are very apt to
recur at one of the physiological epochs — puberty,
maternity, menopause, or senescence. I have noted
that the patient began to wet her bed soon after
having scarlet fever. Nocturnal enuresis represents
an abortive or unnoticed attack of epilepsy. The
question remains, was this case just such a one as
Spratling mentions and the scarlet fever merely a
coincidence, or did the scarlet fever cause ovaritis,
and this in turn absence of menstruation and epi-
lepsy ?
Lebedinsky and others, from observation of
changes in ovaries after death from scarlatina,
state that the Graafian follicles suflier from a paren-
chymatous inflammation, and that the degeneration
of such a number of follicles must result in more
or less impainnent of the function. It seems prob-
able that the pelvic organs are more or less af-
fected in almost all cases of infectious disease, and,
should the disturbance be of a serious nature, it
will mean the beginning of a subacute or chronic
ovaritis. What does ovaritis mean? Fraenkel has
shown that the chief function of the corpus luteum
is to elaborate a secretion which regulates the blood
supply of the uterus, and thus controls the pro-
cess of menstruation. Beyond doubt, menstruation
is a function of a normal ovary. If, however, the
ovary is the seat of a chronic or subacute inflamma-
tion it cannot fimction properly. Now, we know
that at the time of the menopause the ovaries begin
to atrophy, and the Graafian follicles begin to dis-
appear. The result is that they begin to function
irregularly, and we have irregular menstruation and
a disturbance of the vasomotor and central nervous
systems. The patient becomes more or less neuras-
thenic. So we see that the nervous system is dis-
turbed when the ovaries are not normal. We have
seen that scarlet fever may cause degeneration of
the Graafian follicles, and the menopause causes
the Graafian follicles to disappear. Where is the
difference as far as function is concerned? Thus
we are justified in assuming that an individual with
a neuropathic predisposition who suffers from a
chronic or subacute ovaritis, instead of being
merely nervous, may be subject to epileptic con-
vulsions. Therefore, in this case the epilepsy was
caused by the ovaritis, which was due to scarlet
fever, and the inheritance was a secondary cause.
The menstrual function should, of course, occur
painlessly and with perfect periodicity. Yet some
observers report that seventy-five per cent, of girls
give a history of painful menstruation. How much
of this is due to the infectious diseases? A wom-
an's usefulness and wellbeing are very largely de-
pendent upon a normal condition of her menstrual
function. If we want to materially decrease the
number of those who have to go through life han-
dicapped by nervous troubles and sterility we must
make the infectious diseases of childhood as scarce
as smallpox is today. The only remedy is prompt
and complete isolation. This means that a suscepti-
ble child should not get into immediate contact with
or be in the neighborhood of the sick child. To be
effective this must be done early and continued for
these diseases are generally infectious before they
can be diagnosed and remain so after the patient
has apparently recovered. The early symptoms are
those commonly termed "a cold" ; but a cold may
mean the beginning of an infectious disease. There-
fore, instead of waiting for a diagnosis we must ex-
clude from school every child vi^ith a cold, and in
this way the likelihood of schools being the means
of conveying any of these diseases is immediately
minimized. The statistical evidence in support of
school attendance being responsible for the spread
of infection is overwhelming.
932 Van Duzer Street.
Medicine and Surgery in the Army and Navy
EYE, EAR, NOSE, AND THROAT WORK AT
THE RECRUITING DEPOT.*
By Captain John J. Smith, M. R. C,
Fort McDowell, California.
{Published by Permission of the Surgeon General.)
The eye, ear, nose, and throat service of the
Army covers a large field.
The following questions are often asked of me:
"Of what does your examination consist ?" and
'"What are the requirements demanded of an appli-
cant in order that he may be accepted?" I was
asked to prepare a paper for the society in which
this ground would be covered, because only a few
of the specialists not in the army are familiar with
duties required of the specialist in the service.
It has been the practice to give the physician and
surgeon who applies for an army commission a rigid
•examination, and, if he were accepted, to send him
to the Army Medical School located at Washington,
D. C. He remained at the school for three months,
during which time he was given lectures covering
the various branches of medicine and surgery, as
well as army tactics and army paper work. At the
end of the three months of intensive training he was
again examined, and if not found wanting, was
given a commission as a first lieutenant in the Medi-
cal Corps of the United States Army with a
monthly salary of S166.66 together with certain
quarters or allowances which approximated $50
more. A man so commissioned was supposed to be
prepared to care for any kind of a medical or surgi-
cal case which might present itself, and in addition,
he was required to do an endless amount of paper
work. It will not be necessary to go into details or
show that such a system would fall down under the
stress of mobilization of troops for war purposes.
Great wisdom was shown by the Surgeon General
and his advisory board in that they called in large
numbers of reserve doctors and assigned them to
the work in which they had been especially fitted, in
so far as possible, obviously providing better care
for the troops than possible under the former sys-
tem. To be sure, at some of the general hospitals
there ' have been stationed men who managed by
persistent methods to become proficient in special
lines of practice, but there were only a few general
hospitals existent and of the 500 Regular Army
Medical Officers, who were on duty at the time
mobilization was begun, the number which could be
classified as specialists was very small. It was a
notable fact that when members of families of army
officers required medical or surgical attention, the
majority of them employed the services of civilian
doctors. It naturally follows that we will expect
that the Medical Department of the United States
Army, will in the future consist of trained and able
specialists. However, the younger men who are
being commissioned in the Medical Reserve Corps
are to be sent first to one of the officers' training
camps, such as Fort Oglethorpe, where they are
given an intensive course of training in miHtary
work. This will result in tbe turning out of a med-
*Read before the County Medical Society, San Francisco, Cal.,
February 26, 1918.
ical officer who can command the respect and dis-
ciphne of the corps and thus help to perfect a high
standard of organized efficiency.
The eye, ear, nose and throat specialist who is
located at one of the recruiting stations has duties
which differ somewhat from those of his brother
who is assigned to a base hospital. He helps to
determine whether or not the applicant be physically
fit to perform the duties of a soldier. He is given
a set of instructions. General Orders No. 66, 1910,
from which I have taken a few extracts. These
regulations do not apply to the drafted men.
In regard to the eye, the visual requirements for
the line of the army and for the signal corps are
20/40 for the right eye and 20/ 100 for the left,
provided that no organic disease exists in either
eye. A recruit may be accepted for the fine of the
army when unable to read correctly all of the let-
ters on the 20/40 line provided that he is able to
read some of the letters on the 20/ 30 fine.
For the Ordnance Department and for the Hos-
pital Corps 20/70 in each eye, correctable to 20/40
with glasses, provided that no organic disease exists
in either eye. Candidates for appointment in the
Medical Corps must have a visual acuity of 20/ 100
in either eye or better, and with the proper correc-
tion the visual acuity must not fall below 20/20 in
either eye. Presbyopia is a cause for rejection, as
is strabismus of any type, or color blindness for
red, green, or violet. In addition to the require-
ments of visual acuity a number of conditions are
listed which are a cause for rejection ; briefly stated,
they are diseases or results of disease. Many appli-
cants have some form of strabismus or pterygia.
Such defects may be corrected at the recruiting
depot.
Concerning the ears : The hearing must be 20/ 20
in both ears, but here again we may obtain waivers
for defects, providing no organic disease is present.
Among the causes for rejection, we find the highest
percentage of ear troubles attributable to chronic
suppuration of the middle ear. It is needless to
say that this condition is extremely serious, and
it is impossible to lay too much stress upon its im-
portance as cause for rejection.
Concerning the nose : Its condition is an impor-
tant factor in the determination of a man's fitness
for military service. Chronic sinusitis with polypi,
hypertrophic rhinitis, chronic suppurative condition
of sinuses, antra and ethm_oici cells, also atropic rhini-
tis with ozena are causes lor rejection. Nasal ob-
struction due to septal deviation is not a cause for
rejection if correctable by operation. The British
army officers have tried to impress the examiners
with the folly of sending into the field a man who
has nasal obstruction, because they state that the
man cannot perform ordinary duties without quicklj'
becoming winded, also that other disorders of the
respiratory tract develop early in such men who
are on duty in the field. Correction of such defects
is one of the duties which should be performed at
the recruiting depot if the civilian doctor has over-
looked it.
Regarding the mouth, pharynx, and larynx : The
70
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
most frequent causes for rejection are chronic phar-
yngitis, syphilis, and tuberculosis of the larynx.
Many of the applicants have diseased or hypertro-
phied tonsils, and this is one of the most important
findings that should be remedied at the recruiting
depot. Furthermore, the condition of the teeth
should receive careful attention.
Undoubtedly these instructions will be modified
in the near future, as we are advised that changes
are already in the course of preparation. Just as
in the Medical Corps we have enlisted specialists,
so also in the rank and file of the army we have
enlisted a corps of artisans, and it has been justly
and wisely decided that an engineer whose work
would be the building of railroad lines or felling
trees would not necessarily be handicapped if his
vision was not up to that required of an aviator
or an infantry man. The requirements for drafted
men are as follows :
Ears: The hearing must be above 10/20 in both
ears. Less than 10/20 in one ear or both, but more
than 5/20 shall be accepted for special and limited
military service providing no otitis media exists.
The test consists of a low conversational voice, not
a whisper. Perforation of the tympanum is not
a cause for rejection unless a discharge is present.
Eyes: The sight must be 20/100 in one
eye and 20/40 in the other eye, or 20/100 in
each eye without glasses if correctable to 20/40
in either eye. For special or limited military ser-
vice. 20/200 in one eye and 20/40 in the other,
either right or left, without glasses, or 20/200 in
each eye without glasses if correctible with glasses
to 20/40 in either eye.
Among the defects which do not constitute a
cause for rejection are slight nystagmus and slight
conjunctivitis and trachoma.
Mouth, nose, fauces, pharynx, larynx, trachea,
and esophagus: Causes for rejection are tubercu-
losis of the parts mentioned, malignant disease,
stricture of the esophagus, syphilitic laryngitis if
the ulceration is of such degree that the registrant
has permanently lost power of talking so that he
is understood, fullv developed exophthalmic goitre
when there is present thyroid enlargement, pulse
rate above 120 and exophthalmos. Registrants with
definite signs of myxedema, Hodgkin's disease, or
lymphosarcoma.
In making our examinations a record is retained
of each case. Naturally, many are very anxious
to serve their country in this great war. Some who
know that they have defects which would call for
rejection try to conceal them. A story is told of
one man having a glass eye, who went before the
local exemption board for his examination. When
his vision was tested he was told to place his hand
over his left eye, which was the glass one. The
vision of his right eye then being taken, he was
told to place his other hand over his other eye, and
to read the letters again. He was passed with nor-
mal vision in either eye, but when he reached the
army camp and was again examined it was fovmd
that twice he had covered his glass eye, using his
right and left hands as directed. The first exam-
iner had not noticed the deception. Again, we find
another class who are malingerers, and various
methods have been devised to detect them. Many
are admitted with defects of vision and hearing be-
cause their work does not call for a man perfectly
developed. There is one branch of the service,
however, which is composed of men who represent
the flower of our manhood. They must have nor-
mal vision in each eye ; if there is a nasal obstruc-
tion it must be corrected ; if there are hypertrophied
or diseased tonsils, they must be removed. The
hearing must be normal in both ears. They must
be mentally and physically fit to the last degree.
These are the members of the Aviation Corps.
It is almost impossible to compile a set of figures
which show the average per 1,000 of causes for
rejection, for this reason : the recruiting detachment
reject some who apply, and pass the others along
to the recruiting depot, where the drafted men who
were examined by the local boards are also sent,
and here more rejections are made, hence a fair
average is hard to obtain. During the nine months
which I have been stationed at Fort McDowell we
have rejected 11.8 per cent, of the men for various
reasons. Many more would have been rejected had
we not received special permission from the Adju-
tant General to enlist them. These various irregu-
larities make it impossible to enumerate causes for
rejection.
As the head of the eye, ear, nose and throat
division, I have examined approximately 21,000
men, and have been able to procure this set of fig-
ures : Twenty-five per cent, had septal deviations,
of which twelve per cent, were to the right and
thirteen per cent, to the left. Some of these were
mild deviations, others should have been operated.
Twent^eight per cent, had liA'pertrophied or dis-
eased tonsils, or both ; twenty-three per cent, needed
throat operations ; fifteen per cent, needed nasal
operations ; twenty-five per cent, needed both nasal
and throat operations. A thing which surprised
me greatly was the fact that twenty-five per cent,
of them had contracted membrani tympani of both
ears, and yet only a very few had defective hearing.
The largest number of rejections in my division
have been because of defective vision.
I have found a few anomalies. One man had
apparently a normal ear, and his hearing was 20/ 20
in both ears, but he had no canal on the right side,
simply bone structure normally covered, a congenital
defect. Another man had vision in the left eye
of 20/70, which was not improved with glasses.
Examination revealed the fact that from the optic
disc there protruded an artery directly toward the
centre of the lens, but not touching it ; near the
posterior capsule it doubled back on itself and re-
turned as a blue vein which was twisted several
times around the artery ; there were no branches.
In addition to these tw'o interesting cases a num-
ber of bifurcated uvulae have been seen.
It became evident early during the war that the
larger number of hospital cases had disorders of
the respiratory tract. It is my belief that men hav-
ing nasal disorders, adenoids or diseased tonsils,
etc., are liable to contract these diseases. At Fort
McDowell it has been possible to make personal in-
vestigations along these hues, and findings confirmed
my belief. These facts were presented to the sur-
geon, Colonel P. C. Fauntleroy, and to Surgeon
General Gorgas, and, it was gratifying to say, have
July 13, i9>8.] MEDICINE AND SURGERY IN THE ARMY AND NAVY. 71
met with their approval. I have tried to correct
as many abnormaHties of the eye, ear, nose, and
throat of the recruits as possible with limited equip-
ment. We have now a new hospital building, and,
as result, an operating room and a number of beds
have been set aside for this work. Heretofore I
have been using my own instruments, novocaine,
adrenalin, etc., but supplies of this nature are now
being sent, and in a short time we will have this
branch second to none.
It is clearly evident that the slight expense in-
curred at the recruiting depot in giving a man such
surgical attention as required to put his eyes, nose,
throat and teeth in good shape is not to be consid-
ered when we thereby save the expense of caring
for a man in the field who has become incapaci-
tated because of tonsilitis, measles, pneumonia,
rheumatism, diphtheria, scarlet fever, sinusitis, mas-
toiditis, or other diseases which are contracted in
almost every case through the presence of diseased
tonsils or obstructed nasal passages, or both, and
facial neuralgias, toothaches, etc., which result
from the presence of defective teeth. How much
better to avoid this expense in the field, as far as
possible, by adopting preventive measures at re-
cruiting depots.
THE AMERICAN WOMEN'S HOSPITALS
By Rosalie S. Morton, M. D.,
New York,
The American Women's Hospitals was organized
and put in operation in June, 19:7, by the War
Service Committee of the Medical Women's Na-
tional Association. Dr. R. S. Morton was
appointed chairman of the executive com-
mittee, and associated with her were Doc-
tor Emily Dunning Barringer, vice chair-
man; Doctor Mary Merritt Crawford, correspond-
ing secretary ; Doctor P>ances Cohen, recording
secretary ; Doctor Belle Thomas, associate corre-
sponding secretary ; Doctor Sue Radcliff, treas-
urer. This committee has been gradually increased
as the need of the work demanded, and the follow-
ing names have been added : Doctor Mathilda K.
Wailin, second vice-chairman ; Doctor Caroline M.
Purnell, third vice-chairman ; Doctor Marie L.
Chard, assistant treasurer; Doctor Gertrude A.
Walker, chairman of finance committee; Mrs. Con-
ger, executive secretary, and Miss Bertha Rem-
baugh, counselor.
The plan of work, submitted to and approved by
Surgeon General Gorgas and Doctor Richard
Pearce, Director General of the department of mili-
tary relief of the Red Cross, provided for some
dozen committees and subcommittees, and four
more were eventually formed. These committees
mean that every interest of the allied armies are
watched over.
The headquarters occupy three rooms at 6.^7
Madison Avenue, donated for its use by Leo Schles-
inger, Esq.
There has been great success in organizing the
various states, in each of which there is a com-
mittee of the American Wom.en's Hospitals, who are
in constant correspondence with headquarters, and
in the last campaign contributed most generously to
the fund. From the states alone came more than
840,000 to swell the fund of $260,789 which the
campaign netted. To this fund several of the states
have promised further contributions. Through
Doctor Purnell, chairman of the committee for for-
eign service, civil and military, fifty-two doctors
and seventeen technicians, members of the Ameri-
can Women's Hospitals, were recruited during the
past year for the Red Cross. These doctors are
scattered throughout the devastated region of
France, on the border of Serbia, and in Palestine.
Doctor Lucas, head of the medical division of the
Red Cross in Paris, who has just returned from
abroad, is loud in his praises of the work the mem-
bers of the American Women's Hospitals have done
in his department. Doctor Purnell has also as-
sembled the personnel, consisting of five doctors and
ten nurses, and other aids for the hospital this or-
ganization is sending to cooperate with the Ameri-
can Committee for Devastated France in the depart-
ment of the Aisne.
The treasurer. Doctor Sue Radclifif, reports re-
ceipts of $24,002.08, disbursements of $17,196.77,
with a balance in the treasury of $6,805.31.
Doctor Kinney, chairman of the committee on
dentists, reports seventy women dentists who have
registered for war service, twenty-three for foreign
service, twenty-two for service in the United States,
thirty-six for work in their home towns. Seventy
have offered to serve one hour a day for soldiers.
Doctor Van Slyke, of the reciprocity committee,
reports $5,573 contributed through her and many
donations of clothing, food and books.
The campaign of which Doctor Gertrude Walker
was chairman, and Doctor Mathilda Wailin, treas-
urer, yielded between $250,000 and $300,000, which
will be used to establish hospitals in Europe.
The Committee on Laboratory and Sanitation,
Doctor WoUstein, chairman, has been especially
active and has accomplished excellent results. A
medical laboratory course for war service was of-
fered to college women with the necessary prelimi-
nary training in science and scientific methods, in
cooperation with Doctor Park and Doctor Williams,
of the Health Department, and Doctor Elsie L'Es-
perance, of Cornell Medical College. Twenty stu-
dents entered the first class on November ist. At
the end of the course, five of the class were ap-
pointed as laboratory technicians in the Army Med-
ical School in Washington. This is the first time
that women have been admitted there. Others
received appointments as bacteriological technicians
in base hospitals in this country. One went tO' Pal-
estine with a Red Cross unit. The demand for a
repetition of the course became so urgent that on
April I the second class was organized with thirty
members. These will probably have no difficulty in
obtaining army appointments when they finish the
course in July. Medical women were registered as
sanitarians and as laboratory workers in pathology
and bacteriology. Twenty-six have been recom-
mended to the Bureau of Sanitary Service for work
in the cantonments. Doctor Welton has registered
and classified every woman physician in the United
States who has had training in x ray work, so
72
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
that their qualifications are at the government's dis-
posal for appointment at any time.
Doctor Vedin has classified a large number of
anesthetists, and sent their qualifications to Wash-
ington.
Doctor Mary Almira Smith, chairman of the Com-
mittee on Women's Amiy Hospitals in the Home
Zone, rejwrts that the Lincoln Convalescent Hospital
of Massachusetts is now being used for men in the
navy and for the marine and radio courses, also that
the Women's Relief Corps of the G. A. R. have
equipped and named two wards for war service in
the New England General Hospital. The following
women's hospitals in Philadelphia will be available
when required by the government : Woman's Hos-
pital of Philadelphia, 185 beds; Hospital of
Woman's Medical College, 96 beds; West Phila-
delphia Hospital for VVomen, 70 beds; Woman's'
Southern Homeopathic, 39 beds. Doctor Eliz-
abeth W^inter, of Conshohocken, Pa., and Doctor
Octavia Krum, of Wernersville, Pa., would release
their sanitoria.
Doctor Smart, chairman of the committee on
substitution in hospital and clinical service, re-
ports that twenty-eight young medical women have
been recommended as interns, while four hospitals
have applied for resident women physicians, sub-
stitute for men.
The American Women's Hospitals has effected an
affiliation with the Red Cross ; the former will finance
their own administrative expenses in the United
States, and will, when requested, organize personnel
for hospital and dispensary units to serve in any
country under the direction of the American Red
Cross, who will equip, establish, and maintain all
such medical units as it may call for, to be sent
overseas at any time. The medical personnel will
be recruited by the American Women's Hospitals,
and will be submitted to and approved by the Med-
ical^Adyisory Committee of the American Red
Cross. The nurses, nurses' aids, and dietitians are
to be recruited by the Department of Nursing of
the American Red Cross. Nominations of nurses,
nurses' aids, and dietitians may be made to the de-
partment of nursing of the American Red Cross,
and such applicants will receive consideration.
Three types of regular meetings are held by the
American Women's Hospitals throughout the year
three times a week. The following are some who
have spoken at these during the past season :
Captain Stoughton (Anzac) ; M. Gaston Lie-
bert, French consul general in New York ; Professor
Pupin, professor of physics at Columbia ; Father de
Viile, of Belgium ; Doctor Jane Kelly Sabin, Doctor
Kim, of China; Mrs. St. Clair Stobart, of England,
who commanded a division in the retreat of the
Serbian army ; Lady Davidson, wife of the former
governor of Newfoundland; General Azgapepian ;
Mr. Vesnitch, Serbian high commissioner and for-
mer Serbian minister to France ; Major Gibson, of
the U. S. Army; Doctor William Palmer Lucas, of
the medical department of the Red Cross in Paris.
Many of these were fresh from the other side,
and gave illuminating talks regarding the needs of
fighting men and the civilian population.
MEDICAL NOTES FROM THE FRONT.
Combating Disease.
Geneva, June 14, 1918.
Vincent's angina appears to have assumed a con-
siderable frequency since the beginning of the war.
For example, in the contagious service at the Greno-
ble Military Hospital, out of a total of 255 patients
admitted during one year with a diagnosis of "sus-
picious throat," twenty-one proved to be Vincent's
angina, both clinically and bacteriologically. The
subjects were usually young and had neglected the
toilet of the mouth. This process was frequent in
the spring, less so in summer, and rapidly disap-
peared in autumn. The onset is not marked by any
marked symptom other than a sensation of fatigue
and slight dysphagia, but that which often attracts
the patient's attention is a painful and enlarged
cervical lymph node. There is nothing new to relate
as far as the lesions of the throat are concerned,
but what is particularly striking is the tired look of
the majority of these patients and a very pale face,
corresponding to a certain degree of anemia made
evident by blood counts. The prognosis is good in
most cases, the affection undergoing its complete
evolution in from two to three weeks. Occasionally,
however, the fusospirillse are associated with the
bacillus of diphtheria, but it does not seem to in-
fiuence the prognosis.
The diagnosis must be confirmed by a bacteriolo-
gist and, as to treatment, frequent swabbing of the
lesions with a ten per cent, solution oi methylene
blue, often cleansing of the parts gives good results,
likewise a solution of nitrate of silver. Salvarsan
in powder or in a glycerin suspension has been used
as local application, but it would appear that intra-
venous injections of this drug have a remarkably
rapid action on the throat lesions in quite a number
of cases. A single injection of thirty centigrams in
two to three c. c. distilled water will produce an
almost complete cicatrization in four to six days,
even when the ulcers are quite deep. A second sim-
ilar injection, repeated four days later, will result
in a clinical and bacteriological recovery in a week
or ten days.
This salvarsan treatment is interesting in its re-
sults on account of its control of certain obstinate
cases which would otherwise drag along for several
weeks, in spite of an intense local treatment.
Let me refer briefly to the results obtained by
antityphoid vaccination in the French army. After
vaccination of the troops in 1914 and the early part
of 1915, there was an early autumn epidemic, but
relatively mild in character, but especially due to the
paratyphoid organisms. During February, 191 5, the
antityphoid laboratory of the Val de Grace sent over
5,500,000 doses of vaccine to the front and since
then the French army has been in a remarkably good
sanitary condition. For the past two years and a
half the mortality from typhoid in 100,000 men has
been so low that it has to be figured at a fraction
of a unit.
During the winter 1914-1915 the monthly mor-
tality from typhoid was high. There were for each
100,000 men 678.6 cases with 98.6 deaths. With
these figures as a basis, and supposing that four to
July 13, 191S.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
73
five million men have passed the front, it may be ad-
mitted that without antityphoid vaccination the
nmnber of cases would have by the present time
reached one million !
At present and taking as a term of comparison the
sanitary condition of the French army before the
war (1911) it is evident that typhoid diseases ob-
served in the troops at the front are about seven
times less frequent and the mortality eight and a
half times less than in peace time. Certainly, a re-
markable result and should do away with all squab-
bling over the question of antityphoid vaccination.
Blood transfusion, as done by the older methods
of artery to vein, has the great drawback in that the
artery of the donor and the vein of the recipient are
sacrificed. Likewise it is a blind method, because the
quantity of blood given cannot be estimated, neither
can we know if even any is given. The procedure
recently advised by Jeanbrau, namely, the injection
of citrated blood with Kimpton's tube, ofifers the
same disadvantages, in that the vessels of the donor
and recipient are destroyed functionally.
Generally speaking, all procedures which mutilate
the vessels reduce the number of donors and limit
the number of possible transfusions in the same sub-
ject. The ideal transfusion would be to collect
blood by venous puncture in the donor and then to
inject it intravenously in the recipient, but the diffi-
culty lies in the fact that enough blood cannot be
drawn by puncture, and secondly, to maintain it in
a state of incoagulability.
A sufficient amount of blood can be withdrawn if
venous puncture is made with a needle of a type
similar to that devised by Queyrat and not with the
needles usually offered on the market. In a normal
subject a Queyrat needle will withdraw from 300
to 500 c. c. of blood. Now, since blood can be made
incoagulable by citration, it can be reinjected with-
out danger and the following method, based on these
principles, has been devised by Doctor Ameuille, of
the Surgical Auto No. 2 :
First, the vein of the donor is punctured with
a Queyrat needle (it is painless), and when it is
withdrawn the subject does not experience any
after effects. Secondly, as the blood flows, it
is collected in a sterile glass on sociium citrate,
about ten centigrams of the salt for each 100
c. c. of blood collected. An excess of the salt
will do no harm. There is no objection to hav-
ing the salt in a hypertonic solution. It is first
sterilized in a dry state and the condensation
vapor of the sterilizer will produce a sufficient com-
mencement of dissolution. During the withdrawal
of the blood from the donor, the receiving glass
should be continually shaken. Thirdly, the blood is
injected with an ordinary serum apparatus the pres-
sure being controlled by means of a hand rubber
bulb, just the same as used in intravenous injections
of normal salt solution. The great advantasje of this
technic is that the blood may be kept some little time
before it is injected, even as much as four days if
the container is kept in an autoclave at an even
37° C. By this means quite a little stock of citrated
blood was kept at the ambulance when a large num-
ber of wounded were expected to arrive. By this
procedure a more extended use of blood transfusion
seems possible, not only in posthemorrhagic anemia,
but also in medical anemias, as well as in infectious
processes. Charles Greene Cumston.
MEDICAL NEWS FROM WASHINGTON.
More Medical Officers Allowed the Navy. — New Surgeons
in Naval Medical School. — Naval Health Conditions. —
Treatment of Returned Soldiers. — Contract Surgeons in
the Army. — Mobile X Ray Outfits and School for Ront-
genologists.— Artny Medical Campaign Against Flies and
Mosquitoes.
Washington, D. C, July 8, 1918.
Many additional medical officers are allowed the
Medical Corps of the Navy as a result of the in-
crease of the authorized permanent enhsted strength
of the navy to 131,485 by the new naval appropria-
tion act, the corps being increased from 843 to i,i20
officers. Included in the additional allowance are
two medical directors with the rank of rear admiral,
twenty medical directors with the rank of captain,
and forty medical inspectors with the rank of com-
mander.
The vacancies in the grades of medical director
and medical inspector will be filled by selection,
upon recommendations of a board of high ranking
medical officers, yet to be appointed, who will ex-
amine the records of all officers eligible for advance-
ment, and promotions in the lower grades will be
with "'running mates" in tlie line in accordance with
past practice.
The promotions now in prospect will be tempo-
rary until the vacancies in the lower grades are filled
by permanent officers, niany vacancies now being
taken care of by those temporarily in the service.
;fc ^ 4: jjc *
A new class of sixty-seven newly appointed as-
sistant surgeons commenced a course of eight weeks
of intensive training at the Naval Medical School at
Washington on July 3. Surgeon General William
C. Braisted made a short address to the class, ex-
plaining in brief the duties of medical officers in the
navy, what their aspirations should be, and the high
standard of professional proficiency and personal
conduct they should strive to attain, and he was fol-
lowed by a short talk bv Medical Director Fdward
R. Stitt, president of the school. After r.ompleting
the course at the school, the members of the class
will be short course of further instruction at
naval hospitals before being assigned to duty.
•k ^ ^ :^
Sanitary conditions in the navy continue most
satisfactory, according to the latest reports received
by the Surgeon General from medical officers afloat
and ashore. The death rate from disease is below
1.8 per thousand. There has been a steady decline
in the disease death rate in the naval service since
April, when the figures were somewhat above nor-
mal, due to a considerable amount of fatal illness at
some of the training stations. When it is consid-
ered that the reports are based upon the entire naval
personnel, including the retired list, it will be seen
that the health of the fighting force in the fleet is in
excellent condition.
The weekly percentages are based on reports
from places all over the world where naval and
74
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
marine corps personnel is stationed as tliey are re-
ceived at Washington; and, of course, they do not
give an absolutely exact record of the health of the
service for a given week, as necessarily there is a
fluctuation due to the nonreceipt or delays in receiv-
ing reports from distant .stations.
*****
Some interesting calculations have been made in
the Office of the Surgeon General of the Army of
the number of sick and wounded soldiers to be
brough.t back from France for whom accommoda-
tions will be needed in this country.
From figures based on the experience of the
Allies, it is thought to be a conservative estimate
that fewer than fifteen per cent, of those dis-
abled by wounds will be returned to this country
for treatment. The other eighty-five per cent, will
be treated over there, and after recuperation will
return to duty.
The sick and wounded will be held in hospitals
until they are fit to be discharged, preceding recon-
struction treatment up to the point of vocational
training. It is expected that many will so far re-
cover as to be able to take up their former occupa-
tions, and those that are badly disabled will be sent
to the vocational schools. The tuberculous patients
will be sent to sanatoria, and, of course, every efifort
will be made to restore them to health.
*****
Contract surgeons are being appointed to the
army in considerable numbers, particularly for duty
at remote points where small detachments are sta-
tioned and for special work under conditions where
not all of the time of the appointees is required for
army service, and for duty as specialists. The serv-
ices of many specialists in eye, ear, throat, stomach,
heart, and head have been thus obtained, as well as
some for service as anesthetists, etc. Several wom-
en physicians have been appointed contract sur-
geons, mainly for service as anesthetists.
Contract surgeons dififer in status from the com-
missioned personnel of the Medical Department, in
that they are not given commissions, but render
service under contract. There are two forms of
contract— a standard, which is based on pay of
$i,8oo a year, and a substandard, which provides
for $75 a month — with subsistence, mileage, etc.
The new uniform regulations provide for uni-
forms for contract surgeons, which will be the same
as worn by officers, except that there will be no
shoulder or other rank marks. The insignia worn
on the collar will be the letters "CS" superimposed
on the caduceus, the distinguishing mark of the
Medical Department. Contract surgeons wore a
similar uniform until 1916, when the national de-
fence act, passed in that year, failed to provide a
special attire for them.
New X ray outfits, of the mobile type, are under
examination by officials of the Surgeon General's
Office. The new outfit is packed on one motor-
truck, and it can be opened and set up quickly. It
consists of one large operating dark tent, in which
the operating table is placed, a box containing the
mechanism of the apparatus, and all the usual para-
phernalia. Outside of the tent is a tank for develop-
ment of the plates. The power is obtained from a
dynamo under the truck.
A number of these outfits have been ordered for
use abroad, although it is not thought that many of
them will be required, the main use for x ray ap-
paratus being at the base hospitals, where they are
set up permanently. The British and French allot
two mobile x ray outfits to each army corps.
A school of military rontgenology has been estab-
lished at the medical officer's training camp at Fort
Oglethorpe, Ga., and it supplements the schools that
have been conducted at universities, hospitals, and
elsewhere in different parts of the country for train-
ing selected members of the medical personnel in x
ray work. The course at the school at Fort Oglethorpe
will cover a period of twelve weeks, and about fifty
officers and 100 enlisted men will be under instruc-
tion at a time. It will cover x ray physics, opera-
tion of all types of x ray apparatvis used in the
army, thorough instruction in localizing foreign
bodies, and other special instruction in the practical
application of this valuable aid to the surgeon.
French experience has shown that about 600 ront-
genologists are needed for every million troops in
the field, and each of these officers requires two x
ray manipulators as assistants.
Major Willis F. Manges, Medical Reserve Corps,
is director of the school.
*****
To guard troops stationed in camps and canton-
ments from diseases carried by mosquitoes and
flies, the Medical Department of the army has in-
stalled a system of prevention that is safeguarding
not only the soldiers, but also civilians living in the
neighborhoods of training camps.
There is attached to each camp a division sur-
geon, who is responsible for the health of the camp.
Assisting him is a sanitary inspector, who has the
assistance of a sanitary engineer and from 100 to
200 enlisted men, who are employed continually in
work designed to protect the health of the soldiers.
Special attention is being given at all camps to
cleaning up spots where mosquitoes and flies breed.
Thorough drainage is installed, and spraying is done
at all places in the camp where there is the slightest
possibility of the breeding of flies and mosquitoes.
Arrangements have been made with the Public
Health Service to carry out a similar program in
the territory adjacent to the camps. This servfce
has agreed to fill bogs, open streams, drain swamps,
and continue the oil spraying for a distance of one
mile around all camps.
With the approach of the fly season, orders were
sent to all division surgeons and other health offi-
cers to take all necessary steps to prevent the breed-
ing of flies. Instructions were given on the disposal
of materials that were likely to become breeding
spots, and arrangements were made to protect all
food from flies. With this end in view, all buildings
in which food is stored, prepared, and served were
screened, and the entrances to the buildings have
been vestibuled. An added guard is the placing of
fly traps in all buildings. An average of 6.000 such
traps have been placed in each camp, and more
than 22,700,000 square feet of screening has been
used.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. db M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.iU., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by luiregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, JULY 13, 1918
THE EPIDEMIC IN SPAIN.
The fragmentary reports which are to be found
in recent British and French medical journals
give evidence of a serious epidemic of an acute
catarrhal affection of the respiratory tract which
has been raging throughout a large part of Spain
since early in May. The disease is clearly both
epidemic and readily transmitted if, as reported,
in Madrid alone there have been more than one
hundred thousand cases. The clinical character
of the disease closely resembles that of influenza,
but the symptoms seem so far to have been con-
fined almost exclusively to the respiratory tract.
The attack develops quite suddenly without pre-
monitory symptoms and is characterized by se-
vere headache for a few hours, high fever, irrita-
tion of the throat, dry cough, and slight bronchi-
tis. There are total loss of appetite, slight gas-
tric disturbance, general weakness, and muscular
and joint pains. By the second day there is pro-
fuse sweating and the fever decreases, to disap-
pear by the third or fourth day. The cough is
somewhat looser and productive after the second
day. Relapses are very common and many are
attacked twice within a few days. The disease
seems to aflfect men especially, women less, and
scarcely affects children at all. The death rate
from it is quite low. No statements are avail-
able as to the after effects and the duration of
convalescence, but the implication is that recov-
ery is both prompt and complete.
Such bacteriological investigations as have
been made have failed to disclose the occurrence
of the influenza bacillus, but have shown the fre-
quent presence of an organism resembling the
meningococcus. The clinical picture of the dis-
ease, its very great epideniicity, and the absence
of involvement of the nervous system make it
very improbable that the disease is of meningo-
coccal origin. It has been suggested that the
organism is the parameningococcus, but even this
does not seem plausible. A year or more ago we
had an epidemic over a large part of this country
which resembled grippe quite closely, but which
was marked by more severe symptoms than this
Spanish outbreak. Very careful bacteriological
investigations of the American epidemic showed
the absence of the influenza bacillus, but seems
to indicate that the condition was due to a mixed
infection of the respiratory tract in which the
streptococcus played a very important role.
Whatever may prove to be the true cause of the
Spanish disease, it is evident that more thorough
and painstaking bacteriological investigation
must be made.
While awaiting fuller and more accurate re-
ports concerning the epidemic, its military sig-
nificance deserves mention. It is reported to have
made its appearance in the German army and
even to have impaired its efficiency. The evi-
dent rapidity with which the disease spreads,
its capacity for attacking very large numbers in a
very brief period of time, and its predilection for
the male adult would render its appearance among
the Allied forces a matter of the gravest concern.
Every effort should be made to learn its mode or
modes of transmission in order to establish ef-
fective measures for checking its spread and keep-
ing it confined to the region to which it is yet
limited. What little evidence is at hand sug-
gests that it is communicated from man to man,
and possibly also through carriers. A thorough
study of the conditions in Spain should be under-
taken without the least delay as a purely military
measure as well as for the relief of the victim-
ized country.
76
EDITORIAL ARTICLES.
[New York
Medical Journal.
BOOKS TO WIN THE WAR.
A high place among- the variety of things that
"will win the war" must surely be given to books.
They are food, and, in a sense, ammunition ; they
are constructive agents providing also construc-
tive material ; they are medicine both remedial
and prophylactic. The American Library Asso-
ciation,* having realized these facts and put their
convictions into execution, are emphasizing and
establishing the truth of these contentions.
Modern enlargement of vision perceives the
whole man interdependent ; his welfare and effi-
ciency in endurance and fighting depending on
the mental attitude, mental digestive powers, and
the sort of interest that is nourishing him through
these. In its greater occupation with the details
of all this interdependence it understands still
more clearly the vast number of interests to be
reached through the mental pabulum oflered and
the value of keeping these interests versatile,
alert, and occupied. That is the reason why this
association provides for magazine reading upon
the troop train, libraries to circulate on the trans-
ports, in the navy, from the dreadnought to the
scout patrol and the small tug, at the canton-
ments, in the Y. M. C. A. and K. of C. huts, at all
recreation places, and at bases for training and
for supply. In short, at every point of contact
with the men who are separated from their ordi-
nary surroundings to win the war, there books
are sent. The rousing of interest that results
through the use of books is a measure of health-
ful energy occupation to relieve the high tension
of war service ; it creates or restimulates an out-
flow of energy. It keeps alive many healthful
channels of individual growth and progress which
have been interrupted as our men have been
withdrawn from business life, educational, or
other intellectual pursuits. The wide range of
the books which are collected and sent provides
also material for definite study, some of it partic-
ularly along lines of military progress and effi-
ciency in one form or another, offering, therefore,
actual material, ammunition, for Government and
Allied service.
Last, but not least, is the direct application of
these library resources in the hospital service
through books and the workers to place them ju-
diciously. It is obvious enough how the tedious
hours of convalescence, even those of acute suf-
fering, may be lightened and hastened by the
freshly presented interests of the book of what-
ever sort that makes its appeal. It is furthermore
the stimulating power, perhaps even of the feel
of a book in the pocket, to redirect interest away
^War Library Bulletin, April, 1918, published by the Library War
Service, American Library Association, Washington, D. C.
from the self and from the overwhelming mental
absorption which isolates too often the victim of
"shell shock" from healthful contacts and prevents
his return to duties.
It is far more than a matter of entertainment
and provision for idle hours that the supplying
of books, in well chosen variety, means to the
army and navy and to the winning of the war. It
is one of definite provision for definite interests
and for the actual means of carrying them out in
particular lines of service. It means the keeping
alive and utilizing of a large amount of intellec-
tual interest which would otherwise stagnate or
be diverted from its natural course. But still
more widely and generally it means the directing
of energy in the pathways of external interest
though perhaps only through amusement and
"recreation," perhaps actually creating and re-
creating wholesome and untrammeled energy-
outflow.
A COMMUNITY HEALTH CONGRESS.
The fundamental purpose in the organization
of a community for war service is to bring about
methodical cooperation between the agencies
with a view of eliminating all overlapping of ef-
fort, and to offer inducements to every individual
in the community to become actively engaged in
war work, to bring about, in the words of Presi-
dent Wilson, "A fusion of energies now too much
scattered and at times somewhat confused, into
one harmonious and eflFective power." This com-
munity work cannot be standardized, and the ini-
tial interest around which community war serv-
ice will revolve will vary from place to place.
The idea of a Health Congress was presented by
Dr. E. H. Lewinski-Corwin at a sj>ecial meeting,
convened at Osborne Hall, Bellevue Hospital, on
May 29th, at which representatives of fifty-nine
civic organizations were present. The plan was en-
dorsed by the Community Clearing House and by
the Public Health Committee of the New York
Academy of Medicine for experimental purposes,
and is now about to be tried out in the Gramercy-
Bellevue district, which comprises an area of forty
to fifty blocks.
Increased physical and nervous strain incident
to the war, coupled with the staggering rise in
the cost of living, the drafting of very large num-
bers of women into industrial and other exacting
occupations, the departure of many bread win-
ners from their families for war duty, create con-
ditions predisposing to a lowered physical vital-
ity. Coincident with this condition, which is
bound to be aggravated as the war goes on, is a
diminution by thousands of the available force of
July 13, 1918.]
physicians and nurses. Sympathetic interest and
understanding- on the part of the average citizen
of the underlying principles and the aims of our
administrative policy alone spell success.
In the Bellevue-Gramercy district, for instance,
despite the efforts of the health authorities and
the various social welfare and civic agencies, over
one third of the children in the district sufifer
from marked malnutrition, and the five sanitary
areas comprised within the district show an in-
fant death rate of 112 per 1,000 born. The death
rate for the city as a whole was eighty-nine per
thousand births, while for the Gramercy-Bellevue
area it was 112. In the Gas House district it was
154.9, and in the other sections it varied from
75.06 to 132.
When the people, and particularly the working
people, realize the relation which health bears to
our efficiency as a nation at war, they will see
that what they contribute toward improving their
individual and community health condition is a
direct contribution toward the nation's war
strength.
With this in view it is proposed to organize a
specially constituted body which will meet at regular
stated intervals and which is to be known as "The
War Health Congress" of a district, the membership
to be about equally divided between elected rep-
resentatives of residents of the community and
appointed representatives of the several city de-
partments which deal with the individual citizens,
also the State agencies such as the State Indus-
trial Commission, the State Commission for the
Blind, the State Military Training Commission,
and others, and the Federal agencies such as the
Food Administration, the Council of National
Defense, the Department of Labor, and the Chil-
dren's Bureau. This Health Congress will also
include representatives of the social agencies
working in the district, either exclusively or par-
tially. The election of citizen representatives
would be on a street or house basis.
The Congress will provide an opportunity for
the citizens to meet all representatives of reform
and stimulate collective endeavor in accomplish-
ing the tasks set. There will be committees on
the prevention of disease, the care of the sick, in-
dustrial hygiene, school children, cooperation be-
tween the existing health agencies, and so forth. A
community bureau of information, with accurate
information with regard to the various agencies in
the city, will direct individual citizens to the proper
agencies, maintain a file of all the families residing
in the district, and keep in contact with the residents
through a bureau representative in each house in
the district, who would supply information. It is
77
the hope of the originators of the plan that the
Health Congress might eventually become a body in
which all questions of importance to the neighbor-
hood would be taken up. It might, however, prove
of advantage to organize in each district a separate
congress dealing with other matters — economic, so-
cial, public service, etc. In any event, a representa-
tion from either one congress or of the two con-
gresses could be established, which would go un-
der the name of a Community Council, might be
organized in each district and which would be in
direct contact with the Borough Council, as con-
templated in the larger plan.
From its very inception, the Congress might
find out how every agency and every citizen may
help to win tlie war and upbuild the community
through such effort. A health survey of the dis-
trict should be made and an inquiry as to what
way all existing agencies might contribute to pub-
lic health education, preventive medicine, the
early diagnosis and treatment of disease, and the
social service which is incidental to health serv-
ice. There should be health forums in connec-
tion with various community centres, such as
clubs, churches, etc., to arouse concern in im-
provement of modes of living, and in bettering
home and workshop environment. The problems
of malnutrition among children through "school
lunches" and a better appreciation of food values
should be solved, and in connection with Food
Administration demonstration kitchens, teaching
of the use and economic preparation of foods.
Effective cooperation with the agents of the
Health Department will be established to achieve a
one hundred per cent, efficiency in medical school
inspection work while securing better play-
ground facilities for the children. There will be
cooperation with the food, police, fire, tenement
house, and sanitary inspectors in the protection
of food from contamination, in securing more
sanitary conditions in the dwelling houses, back-
yards, and alleys, in preventing fires caused by
accumulation of rubbish, in keeping streets clean,
etc., to observe rules, particularly with regard to
spitting, and by general oversight of conditions.
Information with regard to hospital and dispen-
sary facilities will be distributed, clinic tacih-
ties for the care and treatment of the teeth of
children secured, and the services of volunteers
enlisted in some branches of community health
work to relieve professional workers.
This cooperation for health will be equally a
cooperation for education, recreation, protection,
moral training, and conservation of family, and it
will develop a war morale capable of sustaining any
hardships which may come.
EDITORIAL ARTICLES.
EDITORIAL ARTICLES.
[New York
Medical Journal.
SOME ETIOLOGICAL FACTORS OF TRI-
GEMINAL NEURALGIA.
]\Iodern medicine tends more and more to limit
the role of symptomatic treatment and to increase
that of the etiological, and, since both means are
resorted to for the cure of trigeminal neuralgia,
it is evident that there are both known and un-
known causes of this dire afifection.
Among the general causes, by far the most im-
portant, because the most frequent, is luetic in-
fection, which should always be looked for in
every case of neuralgia of the seventh cranial
nerve.
In cases where doubt exists, there is a quite
constant characteristic offered by syphilis, name-
ly, an increase in the intensity of the pain during
the early hours of the night, while if the neural-
gia is bilateral it is probably due to a specific
lesion at the base of the brain. Malaria is a
potent source of facial neuralgia, but unfortu-
nately far more obstinate to treatment than when
syphilis is in play. It might seem as if the symp-
toms, when having a malarial basis, should offer
an intermittent character in the majority of
cases, but such is not the case. The pain is quite
as much continued as paroxystmal, although we
have a series of phenomena which will, per-
chance, facilitate the etiological diagnosis. We
refer to the vasomotor disturbances, conjunctivi-
tis, and epiphora.
Of chlorosis, the various neuroses, and diabe-
tes, as etiological factors of facial neuralgia, little
mention need be made, as the subject is generally
fairly well known, and the same applies to gout,
rheumatism, and various intoxications, particu-
larly from nicotine and carbon oxide. Alcohol
does not appear to be a direct factor in the causa-
tion of trigeminal neuralgia, but is undoubtedly
often an adjuvant cause.
The local causes are numerous, but to diminish
their influence all that is necessary is to place the
patient in suitable hygienic surroundings, after
which the local etiological factors are to be con-
sidered. After removal of teeth, the condensing
periostitis arising in the empty alveolae may in-
clude the nerve endings, and this neuralgia of
edentates is rapidly done away with by resection
of the alveolar borders. A badly fitting plate of
teeth or a tooth with an exposed pulp, a badly
fitting artificial eye in contact with the inflamed
and painful ocular stump, and the various otitides
are all causal factors which should never be ig-
nored.
In other cases the causes will be more direct.
Among them may be mentioned periostitis, or
osteitis of the osseous canals existing along the
track of the nerve, resulting in compression of
the trunk. Neoplasms and sinusitis occupy an
important place in this respect, while less fre-
quently the causal factor may be an irritation of
Gasser's ganglion by an aneurysm of the internal
carotid or a neoplasm at the cranial base.
THE PHYSICAL EXAMINATION OF
RECRUITS.
Under special regulation number 65. issued on
June 5th, the same physical standards are estab-
lished for the recruits for the regular as for the
national army, and general order number 66, which
laid down the physical requirements for entering
the regular army, is abrogated. This regulation does
away with the calling of the men to the colors who
are subject to slight defects curable by operative
treatment. Such men as are below the physical
standards, but who may be improved by treatment,
will, under the new regulation, be placed in a de-
ferred class where they will be subject to call later
on. In the meantime, they may have their disabili-
ties removed by private treatment. The principle
of physical classification is retained in the new regu-
lations and these provide information which will en-
able the examining surgeon to determine whether
the recruit is fitted for field service or for special
limited service, this matter being left to the discre-
tion of the examining boards and to that of the
surgeons at the posts or cantonments.
LOCAL MEDICAL MUSEUMS.
The splendid conception of a new Army Medical
Mui-Gum ?t Washington, D. C, will surely soon be
realized, and one way of adding to its interest will
be to encourage the collecting of medical pictures,
manuscripts, instruments, etc., into local museums so
that they may be located and perhaps purchased later
on. There are many doctors with a passion for col-
lecting who gather in their homes medical curios, or
who possess fine engraved portraits of doctors or
first editions of their works, yet, when they die,
their wives or sons, caring not at all for such things,
preserve them for awhile out of respect for the
dead, then relegate them to the attic or send them
to the auctioneer along with other effects. We have
in mind at this moment certain first editions of Am-
erican medical books and models of surgical inven-
tions which will surely vanish when their owners die.
There are medical autograph letters in the posses-
sion of leading living doctors which would make a
collector envious, but will the widow or son, wading
throiigh piles and piles of letters left unfiled by "poor
papa," recognize their literary value ? We sigh again,
thinking of treasures to be destroyed. What a pity
it is that no writ of search can be taken out by the
local medical society to buy or make note of the
contents of the dead doctor's study, then might its
riches he gathered temporarily into the local
m.useum or sent to the tender, appreciative care of
Colonel McCulloch and Dr. Fielding H. Garrison,
instead perhaps of enriching an English museum, as
instanced in the recent presentation by Osier to the
Royal Society of Medicine of Morton's original
])aper3 concerning anesthesia.
*
July 13, 1918.] NEWS
News Items.
Changes of Address. — Dr. Edward Waitzfelder, to 118
West Seventy-seventh Street.
Personal. — Dr. Maximilian A. Ramirez, of New York,
begs to announce that on account of his departure for serv-
ice in France, Dr. J. J. Henna, 24 West Seventy-second
Street, will take charge of his clientele temporarily.
Columbia County Tuberculosis Hospital. — Plans for
the new tuberculosis hospital to be erected near Philmont,
Columbia County, N. Y., have been approved by the State
Department of Health, and the work of construction will
be begim in the near future.
Need of More Complete Casualty Lists. — It has been
suggested, that in addition to classifying the Navy and
Marine Corps casualties, the Committee on Public Infor-
mation should, in future, classify the army casualties as
those of the Regular Army, the National Guard, and the
National Army.
One Control for Public Health Activities. — All san-
itary or health activities especially created for, or con-
cerned in the prosecution of the war, are to be exercised
under the supervision of the Secretary of the Treasury.
This does not apply to those of military character nor to
the investigations of the Bureau of Labor Statistics.
Women Contract Surgeons. — Dr. Loy McAfee, of
New York, has been appointed a contract surgeon by the
Surgeon General and assigned to duty as secretary to the
Board of Publication of the Surgeon General's Office.
Doctor McAfee, who is a graduate of the Indiana Medical
College, is the second woman to be named as a contract
surgeon since the war began.
Twenty-five Thousand Student Nurses Wanted. —
The Council of National Defense finds that it has become
necessary to call immediately for 25,000 student nurses
for training in American hospitals. The enrolment will
begin July 20, and those who register will thereby be
subject to call for training in the Army nursing school
or in the civilian hospitals until April I, 1919.
Twenty-five Thousand Nurses Needed by January
1st. — The American Red Cross has been asked by the
Army Medical Department to secure 25,000 nurses for the
Army Nurse Corps by January i, 1919. It is the duty oj
every trained nurse to come forward at this time. Appeal
is made to married nurses to return to practice or at least
to give a few hours or days each week to hospital or visit-
ing nursing. The general public is urged to start a "save
the nurse campaign" which will discourage the employment
of individual nurses for single patients except in very
serious cases. A course of instruction in home nursing has
been arranged by the Red Cross at Rome, N. Y., to facili-
tate the freeing of the trained nurse for army service.
Increase in the Medical Department of the Army. —
An amendment to the Army appropriation bill has been
passed by the United States Senate which adds one major
general and three brigadier generals to the commissioned
personnel of the medical department of the regular army
and permits the remaining officers from colonels down to
be increased according to the provisions of the present law
as the necessities of the case may require. The amendment
also gives the President authority to commission four
major generals and eight brigadier generals in the medical
department for every million officers and enlisted men in
the national army, the junior officers from lieutenants to
colonels to be of the same ratio as at present provided for
in the Navy.
Industrial Training for Disabled Soldiers. — Recently
at the Red Cross Institute, 311 Fourth Avenue, New York,
directors of industrial training for disabled soldiers were
graduated, following a training course of study, reading,
and research at the Red Cross Institute and a traveling
school in Canada, four weeks in duration, under the direc-
tion of James C. Miller, a Canadian educator of wide
practical experience in dealing with the crippled soldier.
The Vocational Rehabilitation Bill has now become law.
and the Federal Board for Vocational Training is charged
with its administration. Mr. James P. Monroe hopes that
these influences will reestablish initiative and a sense of
individual responsibility in the returned soldier, so that
through training the men will be returned to an indepen-
dent status in the community.
ITEMS.
Women Laboratory Aids. — Eighty women are now
acting as laboratory assistants under the Army Medical
Dei)artment, and more are still needed. Those attached
to base hospitals will go overseas with the hospital to
which they are attached. ,
Women Health Officers for Duty in Munition.
Plants. — Women health officers began an eight weeks'
course of study, June 26, at Mount Holyoke College,
Mass., under the direction of Dr. Kristine Mann, health
supervisor of the women's branch of the Army Ordnance
Department.
British Doctors to Have Women Chauffeurs. — Sir
Watson Cheyne was asked in the British Parliament
whether the chauffeurs of doctors might not be exempted
from military duty, because doctors were very dependent on
experienced drivers. The Parliamentary Secretary for the
Ministry of National Services said that in exceptional
cases time might be given to find a substitute, but men
were were too urgently needed to make the concession
general and women would have to be used as drivers.
The Decorating of Alexis Carrel. — When Dr. Alexis
Carrel recently received the cross of the Legion d'Hon-
neur, M. Mourir, the Under Secretary of State, said the
work done merited the Nobel prize. The ceremony was
private, but the invited included MM. Millerand, former
Minister of War, Professors Pozzi and Tuffier, and Doctor
Hyde and Dr. J. M. T. Finney, of the Johns Hopkins Hos-
pital. The Germans recognized the good work of Carrel
by destroying his hospital with bombs.
Work of the Army Dental Corps. — The Surgeon Gen-
eral's Office announces that the Dental Corps now num-
bers 5,810 officers, which is a sufficient number to care for
an army of more than 5,000,000 men. When the United
States declared war, there were only fifty-eight officers in
the corps Commissions have been offered to 5,460 den-
tists, all but 271 of which were accepted. A school for
dental instruction is in operation at Fort Oglethorpe, Ga.,
where eighty-five officers take a two months' course at a
time, receiving instruction in general military matters as
well as in professional topics. Dental infirmaries have
been established in all the camps and cantonments and
from 225,000 to 250,000 teeth have been filled every month,
in addition to examinations, treatments, extractions, and
bridge and crown work. A specialist in plastic dental sur-
gery is attached to each of the base, the general, and the
evacuation hospitals. No further additions will be made
to the corps for at least six months.
Civil Service Examinations. — Among the positions
for which the New York State Civil Service Commission
will hold examinations on August 3, 1918, are the fol-
lowing :
Laboratory diagnostician, State Department of Health ;
$2,400 ; open to men and women ; minimum age, twenty-
five years; preferred ages, thirty to forty years; and to
nonresidents and citizens of other countries, except those
at war with the United States. A degree in medicine or
an education in a college maintaining a standard satisfac-
tory to the commission, or training and experience in
chemistry, is desirable but not essential. Applicants must
have a thorough knowledge of bacteriology, immunity, and
vaccine and serum therapy. They must have had at least
two years' practical experience in laboratory diagnosis.
Medical officer and inspector. Department of Health
Officer, Port of New York (City Island) ; $1,200. This posi-
tion requires a graduate in medicine and a licentiate for
the State of New York. The appointee must reside at
City Island and give part of his time to the inspection of
vessels from foreign ports and the examination of passen-
gers and crews for the detection of the quarantinable dis-
eases, such as cholera, plague, typhus fever, yellow fever,
smallpox, and leprosy.
Senior assistant physician, Rome State Custodial Asy-
lum; salary, $1,800 with maintenance. Examination open
to men who are licensed medical practitioners in this State.
Resident physician. State Training School for Girls,
Hudson; $1,800 and maintenance; women only. Appli-
cants must be physicians licensed to practice in New York
State.
Application forms will not be sent out by mail after
July 22, 1918. Applications received at the office of the
commission after July 24, 1918, will not be accepted. For
application form, address a postal card to State Civil
Service Commission, Albany, N. Y.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
RECENT OBSERVATIONS IN DIGITALIS
THERAPY.
By Louis T. de AI. Sajous, B. S., M. D.,
Philadelphia.
(Continued from page
I have discussed in preceding issues the influence
of digitalis in heart disorders associated with an
increased rate, but without abnormahty of rhythm.
The fact that a marked increase of rate tends to
impair the output of the heart and endanger its
reserve power, and the apparent suitability of digi-
talis, through vagal slowing, for overcoming tachy-
cardia and any resulting impairment of output, were
referred to. Detailed inquiry into chnical observa-
tions showed, however, that while in certain varie-
ties of tachycardia digitalis is beneficial, at least
partly through its action on the rate per se, in others
it is relatively or wholly useless. The latter are
often cases in which the heart seems organically
unimpaired ; not only is direct strengthening of the
cardiac contractions not the main indication to be
met, but apparently the very nervous or toxic in-
fluence which, through the sympathetic accelerator
mechanism, may be giving rise to the tachycardia,
tends to prevent the customary action of digitalis
on the vagi. Even an increased irritability asso-
ciated with organic weakening of the heart muscle
seems a possible cause of failure of digitalis to exert
its usual slowing action on the heart, the action
of the drug in increasing the already abnormal
irritability tending to antagonize the vagal efifect.
Again, as recently suspected in the case of the sol-
dier's irritable heart, disturbed function of the vagal
system itself may interfere with its responsa to
digitalis.
Arrhythmia comprises another group of heart
disturbances, the effects of digitalis upon which have
been strikingly elucidated by recent studies. Of
the difierent types of irregularity paroxysmal tachy-
cardia has already been referred to. In auricular
fibrillation digitalis has proven so effectual as to
be considered almost a specific. "When the ven-
tricle beats irregularly at a rate surpassing 120 per
minute." says Lewis, 1916, "the irregularity is al-
most always of this nature." "Ventricular rates
which are maintained above 120, unless responsive
to proper therapy," says Gordinier, 1918, "go on to
gradual or speedy cardiac exhaustion." Hence the
importance of the beneficial effect of digitalis in
auricular fibrillation.
This disturbance occurs in rheumatic and non-
rheumatic heart cases in about equal numbers
(Lewis), and among each of these groups is met
with most frequently in the presence of mitral sten-
osis— less often in pure myocardial degeneration,
aortic, general arterial, or renal disease, etc. Nor-
mal impulse formation is replaced by stimulus pro-
duction at multiple auricular foci ; the impulses
reaching the ventricle are rapid and haphazard, and
result in gross irregularity of ventricular contrac-
tion, generally with a marked increase in rate.
Mechanical conditions favorable to a sustained ven-
tricular output are widely departed from under these
circumstances. Many pulsations fail to reach the
radial artery, and the pulse is completely disordered
both as regards strength of successive beats and
length of the intervening pauses. Where fibrillation
is but imperfectly marked, electrocardiograms or
polygrams are rather necessary for its detection,
but in the average definite case, in which digitalis
is so effectual, the practitioner can make an almost
positive diagnosis of the condition without record-
ing instruments upon observing a pulse deficit or
discrepancy between the cardiac rate and that of
the radial pulse, together with a tumultuous irregu-
larity of the ventricular beats on precordial ausculta-
tion. Signs and symptoms of serious heart failure
with a markedly increased rate are also suggestive
of auricular fibrillation, and where the rate is not
much accelerated Lewis lays stress on the results
of moderate exertion, e. g., several quick changes
from recumbency to the sitting posture ; in fibrilla-
tion the pulse shows increased irregularity as its
rate becomes accelerated from the exertion, v/hile
in other arrhythmias, such as premature beats and
partial heart block, the pulse is, on the contrary,
steadied.
Benefit from digitalis in auricular fibrillation is
usually striking, and the improvement seems direct-
ly parallel with the extent to which the drug is able
to lower the rate of ventricular contraction by re-
ducing conduction of the chaotic auricular impulses
to the ventricles. In a few instances, according to
Lewis, the drug fails to influence the rate ; these are
mainly nonrheumatic cases or cases in which the
rate is not markedly excessive. As the heart rapid-
ly weakens under continuous auricular fibrillation,
the drug is doubtless valuable, in the average case
with greatly increased rate, not only in lowering
the rate but also in directly assisting restoration
of the dilated heart muscle to its previous condition
of normal tone.
Until recently the lowering of auriculoventricular
impulse conduction by digitalis in auricular fibrilla-
tion had been thought always due to stimulation
of the vagi ; increased vagal activity is well known
to lower intracardiac conduction. Cushny and his
coworkers, however, have observed that clinically
the effect of digitaHs on the heart rate in auricular
fibrillation is not prevented by complete paralysis
of the vagi with atropine. They are led, therefore,
to ascribe the effect instead to a direct action oi
the drug on the heart muscle, and by analogy with
the results of experiments on excised mammalian
hearts exhausted by prolonged perfusion with Ring-
er's solution, which likewise showed slowing under
digitalis independently of any vagal influence, con-
clude that the occurrence of direct muscular slowing
in clinical auricular fibrillation is due to the co-
existing malnutrition of the heart muscle. Thus,
apparently, the mode of production of one of the
July 13, 1918.] MODERN TREATMENT AND PREVENTIVE MEDICINE.
best known of the actions of digitalis, viz., reduced
conduction, may differ according to the condition
of the heart at the time ; the same, we may add,
appHes to the rate of impulse production at the nor-
mal pacemaker of the heart, Cushny having ob-
served that in the perfused heart fewer impulses
are emitted there under digitalis, independently of
any action of the drug on the vagi.
The dosage of digitalis suitable for auricular
fibrillation in adults is, according to Lewis, ten to
fifteen minims of the tincture or one to one and a
half drams of the infusion three or four times a
day. When the desired reduction in heart rate has
taken place, or toxic symptoms, and especially pulsus
bigeminus, have appeared, the drug must be reduced
or omitted. Halsey, 1918, advises such patients to
continue the drug throughout Hfe, just enough being
taken to maintain the rate below seventy per minute
when counted after a rest in the late afternoon.
{To he continued.)
Surgical Shock and Some Related Problems. —
J. E. Sweet {American Journal of the Medical
Sciences, May, 1918) defines shock as a gradual
progressive fall of blood pressure due to a paresis
or paralysis of the musculature of the arterioles.
He agrees that the central vasomotor nervous system
shows no evidence of failure, and that the heart
shows no weakness, but believes in a primary failure
of the musculature of the arterioles for the follow-
ing reasons: They are the only parts of the vascu-
lar apparatus capable, so far as we know, of being
paralyzed. The idea that the veins are dilated other
than passively, implies a mechanism which has never
been demonstrated. A dilatation of the arterioles
would necessarily be expressed in the veins, because
the pressure of the heart would, by this dilatation,
be allowed to pass directly into these. There would
be no congestion or stagnation in the arterioles be-
cause there must always, as long as there is any
circulation at all, be a greater pressure in the arterial
than in the venous side. In this connection the fact
may be recalled that the arterial system is empty
in the cadaver. The fact that physiologists find
the vasomotor centres intact proves only that the
centres are intact. The point where the controlling
force of the vasomotor centre accomplishes work
is in the arteriole. The centre is the dynamo, the
nerves form the transmissiion system, the arteriole
is the motor which transforms the energy produced
by the dynamo into work. Shock is a toxic condi-
tion. He suspects that the toxins injure the adre-
nals, and these he believes to be concerned in the
preservation of the tone of the muscle cells of the
arterioles. The only way in which he has been able
experimentally to produce anything like shock is
by the removal of the adrenals. The relation be-
tween psychic shock and traumatic shock is com-
patible with these ideas. The relation between fear
and anger and the adrenals is capable of experi-
mental proof, and that between psychic shock and
thyrotoxicosis is universally admitted. These ideas
of shock are compatible with the best and latest
in treatment. Porter advises a special position of
the wounded so that the abdominal vessels shall be
higher than the heart and brain ; heat ; intravenous
injections of saline solution ; intravenous injections
of epinephrin ; transfusion of blood in certain cases,
and the observation of the diastolic pressure every
half hour as an index of the condition of the patient.
Sweet believes that adrenalin produces a good effect
not only because it raises the blood pressure, but
because it supplies a something which is essential to
life and in these cases is apparently lacking. Tlie
treatment of surgical shock must therefore consist,
he thinks, in the continued administration of adre-
nalin plus efforts to remove the causative factor.
Consideration of Local Processes of Disease
and Repair in Treatment of Pulmonary Tubercu-
losis.— H. Morriston Davies {British Medical Jour-
nal, April 6, 1918) points out the more or less gen-
erally accepted inadequacy of sanatorium treatment
of pulmonary tuberculosis and emphasizes the
necessity for considering the pathology of the dis-
ease and the factors which enter into the healing of
its lesions if treatment is to be made satisfactory.
The essential feature of the tuberculous lesion is the
formation of ordinary granulation tissue about the
tubercle bacilli for the purpose of walling them off
and destroying them. The bacilli are of low general
virulence and the reaction to them is in most per-
sons chiefly local. The conditions essential to se-
cure the conquest of tuberculous infection are: i.
Good general resistance. 2. A reasonably small
dose of the organism. 3. Favorable local conditions
at the site of the lodgement of the bacilli. If these
requirements are not met, the granuloma fails as a
protective mechanism and becomes a source of
danger. The general resistance can be raised best
by proper hygienic conditions and diet, both of
which are provided by sanatorium care. The vast
majority of persons have a high degree of general
resistance as shown by the general occurrence of
old healed lesions, and extraneous factors seem to
have some tendency to reduce this resistance, but
usually only to a relatively minor degree. Surgical
tuberculosis teaches that the most important factor
in successful treatment is the maintenance of abso-
lute rest of the affected part to permit the full de-
velopment of the granulation tissue. The same
applies' to the lung, and rest not only promotes the
proper development of granulomas, but also pre-
vents the secondary ill effects of movement such as
bronchiectasis and cavitation. Rest of the lung can
be secured in one of three ways : by nitrogen dis-
placement, by rib mobilization, or by division of the
phrenic nerve in the neck. Of these the first is the
most applicable and it should be practiced at the
earliest possible moment in all cases. The second
is more eft'ective, but since its effects are permanent
it is not to be practiced except where the first fails
or promises failure. The third method is available
to diminish movement of the lower lobe when that
is specially involved, to prevent aspiration of infec-
tive material from the upper lobe, and as a prophy-
lactic again.st bronchiectasis. When the lung is ef-
fectively collapsed the patient can return to his
work and is to a great extent made independent of
those fluctuations in general health which normally
occur and which otherwise impair his chances of re-
covery.
82
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal,
Chronic Peripheral Facial Paralysis. — William
Sharpe {Journal A. M. A., May ii, 1918) limits his
discussion to those cases of facial paralysis of peri-
pheral type in which diligent treatment by medical
measures has not influenced the paralysis after one
year. In such cases very satisfactory results can
be obtained by nerve anastomosis, but the usual
methods of performing this have left much to be
desired. A simple and satisfactory method is to
expose the main trunk of the facial nerve through
an incision behind the angle of the lower jaw, isolate
the nerve for at least half an inch as it crosses the
styloid process, and divide it as close to the foramen
as possible. Then the hypoglossal nerve is sought
and exposed for an inch and a half. This is then
incised longitudinally for at least one inch and at
the lower end of the incision the posterior half is
severed. This is then turned back and upward and
anastomosed with the peripheral end of the cut
facial. The remaining part of the hypoglossal
nerve is slightly split above the transverse hemisec-
tion and a few fibers are freed to be sewed by a
single stitch to the external margin of the distal cut
surface. Throughout the operation there must be
perfect hemostasis and no protecting membrane or
tissue should be placed about the nerves. The
wound is closed loosely to permit the escape of
serum.
Benzol in Leukemia and Other Disorders. —
Vaquez and Yacoel {Bulletins et memoir es dc la
Societe medicale des hdpitanx de Paris, February 7,
1918) report three cases of leukemia in which ben-
zol treatment yielded pronounced benefit. From
these and the other cases previously recorded by
various authors they conclude that in all leukemics
benzol improves the general condition, reduces the
splenic enlargement and excess of leucocytes, and
augments the erythrocytes. In cases of tuberculous
lymphadenitis benzol had no effect other than, in
some instances, to cause the lymph nodes to soften,
ulcerate, and suppurate. In aleukemic lymphatic
enlargements — nontuberculous — benzol often
brought about reduction of the affected nodes. In
erythemia or Vaquez's disease benzol in large doses
was found capable of reducing the number of red
cells, but at the same time caused a prohibitive leu-
copenia, the leucocytes dropping to 1,200. The
leucolytic action of benzol is exerted in two ways,
first, directly, the leucocytes, and especially patho-
logical leucocytes, being destroyed in the blood
stream and the overactive centres of leucocyte pro-
duction inhibited ; second, indirectly through an
autoleucolysin or the leucolytic ferment formed as
a result of repeated destruction of leucocytes. This
second type of leucolysis persists in the intervals
between courses of benzol treatment. Myelocytes
are the most sensitive to benzol, though they do not
disappear permanently. The leucocytes in normal
subjects strongly resist benzol; in such a subject
given benzol they were reduced only from 7,800 to
3,000, whereas as in a leukemic case the same doses
led to a drop from 800,000 to 16,000. The authors
begin with forty drops of benzol a day, increased
progressively to 100 drops by the fifth day. The
treatment is thus continued for the first twelve days
in each month. The blood is examined weekly, and
if the drop in leucoytes is too abrupt, the drug is
discontinued for two weeks. The treatment is kept
up until the maximum of effect in the individual
case has been attained. Albuminuria, hematuria,
excessive gastric disturbance, and diarrhea are all
indications for temporary suspension of the treat-
ment. Chemically pure benzol in capsules, milk,
or wine can be continued for months without diffi-
culty. X ray treatments can be given at much
longer intervals when alternated with benzol. The
latter is effectual even where x ray therapy fails.
Skin Grafting. — J. C. Masson {Journal A. M. A.,.
June I, 1918) discusses the subject of skin grafting
with reference to the extension of its use and points
out that isografting gives as good results as auto-
grafting. The important point in the use of iso-
grafts is the determination of the compatibility of
the bloods of donor and recipient of the grafts, for
skin from a donor whose blood corpuscles are ag-
glutinated by the serum of the patient never "takes."
In all cases the surface to be grafted must be in a
healthy condition. In cases of chronic ulceration
the surface should be prepared by hot fomentations
of boric acid to improve the circulation, and pos-
sibly also by the use of scarlet red ointment to pro-
mote healthy granulations and start a pellicle of
epithelial growth from the margins. Where the
surface is infected it should be treated with hot
saline solution, Dakin's solution or dichloraniin-T
until sterile, as shown by smears on three succes-
sive days. The grafts may then be applied direct
or after rubbing off the granulations if exuberant
and stopping all hemorrhage. The choice of the
type of graft is of importance. The Wolfe graft
gives the most normal looking skin with the best
function, but it often fails to take. It should be
used, however, for at least part of the surface in
annular ulcers of the extremities, about joints, and
for extensive areas. For removing the grafts either
local or general anesthesia can be used. The meth-
od of cleansing the skin to be taken makes little
difference in the results and cleaning with I-Tooo
iodine in benzin, drying and painting with two
coats of 3.5 per cent, iodine in alcohol is
entirely satisfactory. If the skin whence the
graft is to be taken is thick, a Thiersch graft
can first be removed, followed by the removal of
a second similar layer, or the removal of small
island grafts. The wound from which the grafts
have been taken, if at all large, should be reduced
by cutting out an elliptical piece of the central sub-
cutaneous tissues and suturing the edges together
with silkworm gut. The tissue thus removed may
be cut into small pieces and also used for grafting.
When large pieces are placed as grafts they should
be punctured to permit of the escape of serum.
The dressing for Thiersch grafts should be the open
air wire mesh protection with occasional removal
of crusts and the application of dichloramin-T by
atomizer. For areas only partly covered by grafts
paraffin impregnated open mesh net should be ap-
plied first and for three days a wet dressing should
be used over this, being changed every four hours
without disturbing the mesh. The mesh net can
be held in place by sutures or the application of
soft paraffin about the edges. Open air treatment
should then be substituted, combined with the use
of hot dressings at night.
July 13, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
83
Report on Arsenphenamin. — Victor N. Meddis
and William C. Stirling, Jr. {Journal A. M. A.,
May iS, iyi8), from an experience of 1,104 intra-
venous injections of four different preparations of
American made arsenphenamin, especially the brand
known as arsenobenzol, conclude that the arseno-
benzol brand is nontoxic and quite as efYicient as the
original Ehrlich product ; that it may be used in con-
centrated solution (thirty mils containing 0.6
gram) ; that the reactions may be controlled by the
preliminary injection subcutaneously of 0.6 mil
(ten min.) of 1:1000 epinephrine; and that the
only reactions produced are shght headaches or, in
some cases, diarrhea and slight malaise.
Wounds of the Joints. — L. Eloesser (Boston
Medical and Surgical Journal, April 25, 1918) says
that the four sources of infection and their treat-
ment are: i. Direct infection from without by a
foreign body ; remove the offending material as soon
as possible. 2. Indirect infection from communi-
cating bursae or joint fractures ; treat the primary
focus, resect if necessary, resect prophylactically
if manifestly infected. 3. Secondary indirect in-
fection from neighboring abscesses — rare ; leave the
joint alone unless sure it is involved. 4. Metastatic
infection ; evacuate the pus. Infections ma}'^ be
empyematous, when proper treatment will save the
joint, or phlegmonous, when the joint will stiffen.
Leaving a joint wide open is harmful, we should
strive to preserve the synovia. Foreign bodies,
especially lead, induce deforming arthritis, and
should be removed.
Plan of Rectal Feeding. — Edward E. Cornwall
(Journal A. M. A., May 18, 1918) emphasizes the
fact that the colon does not possess adequate diges-
tive functions and that, therefore, the food admin-
istered through it must be predigested or such as is
absorbed readily. Rectal feeding should also aim
to provide an adequate protein ration in the form
of the aminoacids in proper proportions, salts, the
vitamines, and carbohydrate for fuel. Milk provides
the protein constituents, a large proportion of the
mineral salts, and some of the requisite vitamines.
It should be peptonized and pancreatized completely
before being used. Owing to its capacity of under-
going lactic acid fermentation it tends to prevent
protein putrefaction and is of advantage on this
account. Fruit juices provide the vitamines and
other mineral salts, and glucose is the ideal car-
bohydrate. A satisfactory prescription for rectal
feeding, based on these facts, is : Glucose, thirty
grams (one ounce) ; strained juice of half an orange ;
sodium bicarbonate, two grams (thirty grains) ; a
like amount of sodium chloride, and water to
make 300 mils (ten ounces). This is to be given
at 6 a. m., and at 8 a. m., 150 mils (five ounces)
of peptonized and pancreatized skimmed milk are
given. Then the same mixture as for 6 a. m. is
repeated at 4 and 10 p. m., while the milk is re-
peated at noon, 6 p. m.. and midnight. This diet
provides twenty grams of protein and a fuel vrdue
of 700 calories. It may be altered as required by
increase or decrease of the glucose, addition of
glucose to the milk, addition of 0.3 gram (five
grains) of calcium chloride to the glucose enemas,
or by adding a culture of acidophilic bacteria to any
of the enemas. A second plan providing the same
amount of fuel, but no protein, consists in the ad-
ministration every four hours of the glucose mix-
ture of the preceding. The enemas should be given
at 100° F., injected slowly, and the patient's but-
tocks should be elevated while he lies on his right
side during the injection. He should maintain this
position for half an hour after the administration
of each feeding. Every second day he should be
given a colonic irrigation with physiologic salt solu-
tion.
Treatment of Septic Wounds. — R. Tanner
Hewlett (American Medicine, May, 1918) points
out that acridine dyes possess powerful bactericidal
properties, especially in the presence of serum.
Flavine, acting on bacillus coli for twenty-four hours
killed in peptone water in a dilution of 1-1,000; in
serum, in concentration of 1-100,000. Acting on
staphylococcus for twenty- four hours it killed in
peptone water in a concentration of 1-20,000; in
serum, in 1-200,000. Flavine is relatively nontoxic
and does not inhibit phagocytosis and is recommend-
ed in the strength of 1-1,000 to 1-10,000. Some
workers find it has a powerful leucocidal action as
leucocytes treated with flavine for five hours lose
their phagocytic power. In the practical treatment
of wounds a strength of 1-1,000 in saline was first
used, but, later, equally good results were obtained
if after the first dressing a solution of 1-5,000 was
used. When the Carrel method of irrigation is used
a solution of 1-10,000 is of sufficient strength. As
a primary treatment of recent war wounds it has
the following advantages: absence of all toxicity;
prevention of suppuration and spreading sepsis; the
primary dressing need not be changed for two or
three days ; the wounds are not inflamed or painful.
It should not be used in later stages of wounds.
Amputation of Epiglottis for Tuberculosis. —
Lorenzo B. Lockard (Colorado Medical, April,
1918) draws upon the results of his own cases and
the work of others respecting the amputation of
the epiglottis in tuberculosis and concludes that the
operation is quite as safe as tonsillectomy, even in
severely exhausted patients. In nine out of every
ten cases the operation is performed solely as a
palliative measure, mainly for the rehef of pain.
But even when a cure of the tuberculosis is possi-
ble it is not essential that all of the diseased tissue
be removed, since following amputation the re-
maining lesions usually undergo rapid healing.
Healing of the operation stump is usually very
rapid and the operation causes very little discom-
fort. The rehef of pain is usually immediate and
very striking, and there is often a very marked
subsequent improvement in the patient's general
condition due both to this absence of pain and the
resulting capacity to take more nourishment and to
get more rest. The effect upon the pulmonary
disease, though only secondary, is often marvelous.
There is one, and only one, contraindication to the
operation, namely when the tuberculous process is
beginning to involve the base of the tongue of the
pharyngoepiglottic fold. Here the process pro-
gresses so rapidly that the operation offers no
prospect of arrest or relief of symptoms. The one
great indication for the operation is pain.
84
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Replacement of Scalp on a Denuded Dry Skull.
— T. C. Davison {Journal A. M. A., May ii, 1918)
reports a case in which there was a large area of
the skull left dry and denuded as a result of a burn.
There was no blood supply to the whole area and
the outer table of the bone began to necrose. No-
ticing that small granulations sprang up from the
parietal foramina and a suture line, the author
drilled about hfty small holes through the dry cal-
varium at the corners of each square centimetre.
These holes soon lilled with healthy granulations
and pinchgrafts were successfully applied to cover
the entire area.
Collosol Manganese in Furunculosis. — Malcolm
Morris {British Medical Journal, April 20, 1918)
reports highly favorable results from the intra-
muscular or subcutaneous injection of 0.5 to 1.0
mil of collosol manganese in four cases of chronic
furunculosis which had resisted all other forms of
treatment. Usually not over four doses were re-
quired, marked improvement having begun within
four or five days of the first injection. Coincident
with the improvement in the furunculosis there
was a very marked improvement in the patient's
general health.
Fatal Icterus Gravis Following Novarsenobil-
lon. — P. C. Fenwick, G. B. Sweet, and E. C. Lowe
{Britisli Medkal Journal, April 20, 1918) report
two cases of slowly fatal icterus gravis occurring
one and two weeks, respectively, after a series of
five doses of novarsenobillon. The symptoms
were ushered in with mild jaundice which soon be-
came severe ; great reduction in the size of the
liver, persistent vomiting, and progressive weak-
ness. Death resulted twenty-one and forty days
after the onset of symptoms and at necropsy the
liver in each case was found in a peculiar condition
of cirrhosis with atrophy and acute degeneration.
Though no arsenic was found in the urines of
these two patients the condition could not be at-
tributed to any other cause than the action of the
novarsenobillon. No similar cases have been dis-
covered in several large series of hospital cases
receiving the various salvarsan preparations.
Trench Sanitation. — C. E. Burt {Boston Medical
and Surgical Journal, April 25) says that trench
feet can be prevented to a large extent by the fol-
lowing precautions: i. Boots and shoes should be
at least a size too large, so that two pairs of socks
may be worn. 2. Rubber hip boots should be fur-
nished if there is standing water in the trenches.
3. Keep the body warm and dry. Wear water-
proof clothing, especially in rains. 4. Every twen-
ty-four hours the boots should be rem.oved, the feet
rubbed and dried, and dry socks put on. 5. Whale
oil or anti frostbite grease should be thoroughly
rubbed into the feet and legs.. 6. If rubber boots
are not worn, the boots should be well oiled or
greased. 7. Drainage of trench, or dry standing
provided. Avoid standing still as much as possible.
8. Keep the legs elevated while resting, and avoid
the sitting posture while sleeping. 9. Avoid fatigue
by keeping up the physical condition of the soldiers
by proper nourishment and warmth. Frequent use
of hot soups and rum fills the bill. 10. Puttees
should be loosely applied.
Indications for Mastoid Operation. — William
H. Huntington {Medical Record, May 18, 1918)
summarizes conditions calling, for the simple
mastoid operation as follows : i . Cases of acute
mastoiditis with persistent pain on pressure over
the tip of antrum ; persistence of fever after a suc-
cessful paracentesis or where there is sagging of
the posterior superior meatal wall. 2. Cases of
acute suppuration of the middle ear with dizziness,
nausea, vomiting beginning facial paralysis or with
signs of either intracranial or labyrinthine involve-
ment. 3. Cases of long standing middle ear sup-
puration which resist local measures, but which
because of good hearing or other reasons do not
require the radical operation. 4. Cases of per-
sistent mastoid pain either with or without other
symptoms which cannot be accounted for in other
ways. 5. Cases of subperiosteal abscess.
Spontaneous Deterioration of Atoxyl. — Fran-
gois {Bulletin de I' Academic de medecine, March
19, 1918) points out after examination of samples
of pure atoxyl kept three or four years in a tropical
locality, that this agent is liable, at tropical tem-
peratures, to spontaneous decomposition into highly
toxic substances. The decomposition was complete
in the samples examined ; every 0.5 gram of atoxyl
—a dose commonly given to trypanosomiasis — was
changed into 0.03 gram of arsenous anhydride and
0.56 gram of sodium arsenate. This decomposition
is analogous to that undergone by modem gun-
powder, which, while relatively stable at the
ordinary temperature of 15° C, shows rapid
spontaneous decomposition at temperatures of
35° to 40° C, such as prevail in the tropics and
in uncooled holds of seagoing vessels. Atoxyl
should be examined in the locality where it is to
be employed and analyzed before clinical use.
The Baby That Cannot Take Milk.— T. Wood
Clarke {New York State Journal of Medicine,
April, 1918) forcibly brings out the fact that cases
falling under the above description are frequently
encountered and points out the causes and their treat-
ment. The first class comprises those cases in
which the modification of the child's milk is un-
suited to the individual. The chief factor lies in
the use of too high a proportion of fat with the de-
velopment of fat intolerance. The treatment is
simple and consists in the use of a fat free or very
low fat skim milk formula. The second class of
cases includes those which have been either overfed
or, more often, underfed. They show failure of
gain in weight, vomiting, and constipation or diar-
rhea. Proper adjustment of the amount of feeding
quickly cures the condition. The third class is un-
common and comprises those receiving unclean
milk, especially after having had clean milk for
some time. The treatment is obvious. The fourth
class is that of protein hypersusceptibility and can
usually be dealt with by first removing all cow's
milk protein from the diet and then extremely
slowly adding small amounts of cow's milk until a
good tolerance is established. Pyloric stenosis ac-
counts for the fifth class and its treatment is now
well established as including a brief trial of re-
peated small feeds of citrated human milk or
skimmed cow's milk.
Miscellany from Home and Foreign Journals
Rontgen Study of the Chest. — E. L. Davis
{Journal A. M. A., Miy 25, 1918) reports his results
of a rontgen study of 1,000 chests in cases referred
with the diagnosis of probable pulmonary lesions in
men of our new army. He summarizes his findings
under three headings. Pulmonar}' tuberculosis
could be demonstrated rontgenographically in its
earliest stages and activity or inactivity could usually
be determined. Soft, fuzzy, flaky shadows occurred
in the areas usually occupied by the linear markings
of the nomial lungs in the early active cases. Also
a soft mottling of the apices with peribronchial
thickening was very characteristic of early active
cases. Dense, nodular, well defined shadows with
clean cut peribronchial thickening marked the
healed or inactive cases. Intermediate appearances
were found in other cases and proved difficult of
interpretation with reference to activity. Lobar
pneumonia was easily diagnosed even very early by
rontgen signs. Linear shadows due to vascular-
lymphatic congestion, enlarged heart, locaHzed con-
solidation, and high diaphragm were the character-
istic findings. These often occurred even before
clinical evidences of consolidation, the first two be-
ing most characteristic. The enlargement of the
heart was found even in the absence of the usual
physical signs of pneumonia and was attributed to
the toxic manifestations of the infection. It was
also found to persist for one or two weeks after
convalescence had set in. Bronchopneumonia was
found to be unilateral more frequently than bi-
lateral, the heart was not usually enlarged, and the
localized consolidations showed as mottlings rather
than as homogeneous shadows.
The Emotional Constitution. — Dupre (Bulletin
de I' Academie dc mcdecinc, April 2, 1918) de-
scribes, under the appellation "constitution emo-
tive," a special type of loss of nervous equilibrium
characterized by diffuse erythism of general sensi-
bility, sensory and psychic, and by insufficiency of
motor inhibition, reflex as well as voluntary. A
high degree of emotivity is normal in the nursling
and frequent in childhood, but disappears in the
adult owing to development of the inhibitory func-
tions. Abnormal emotivity in adults, while gener-
ally inherited, may be acquired through the opera-
tion of infectious, toxic, and especially traumatic,
influences. Repeated emotion may either thus sensi-
tize the nervous system to subsequent emotions or
create a species of emotional immunity. The phys-
ical signs of the emotional constitution comprise a
dift"use exaggeration of the reflexes ; sensory hyper-
esthesia, with sharp and prolonged motor reactions ;
a lack of motor equilibrium, manifested in visceral
spasmodicity, e. g., pharyngoesophagism. gastroen-
terospasm, cytospasm with pollakiuria, and palpita-
tions ; emotional tremor, shivering, stammering, tics,
etc. ; functional inhibitions, with temporary weak-
ness of the lower limbs, mutism, and relaxation of
the sphincters ; disturbances of circulatory equilib-
rium, such as paroxysmal or permanent tachycardia,
instability of the pulse, alternate peripheral vasocon-
striction and vasodilatation, and dermographism ; lo-
cal variations in temperature, with subjective sen-
sations of cold and heat, principally in the extremi-
ties ; spontaneous or emotional variations in the rate
of secretion of glands; disturbances in intervis-
ccral reflex actions along the vagosympathetic or
cerebrospinal nervous pathways. The psychic signs
are abnormal impressionability, anxiety, and impul-
sive actions, more or less continuous or paroxysmal.
Upon these as a foundation arise timidity, scruples,
doubts, obsessions, phobias, simple or dehrious states
of anxiety, and psychosexual aberrations. In the
most severe cases there appear attacks of anxious
melancholia and chronic obsessional states passing
into incurable deliria of autoaccusation, hypo-
chondria, or negation. The condition as a whole
frequently occurs in association with neurasthenia
and hysteria, but must be clearly distinguished from
them. An essential feature of the emotional con-
stitution is that it represents, not organic lesions, but
deficiencies of fimctional equilibrium. When clearly-
recognized by the physician in a given case it enables
him to understand the patient's entire personality.
Further Studies on the Properties of Pure Vac-
cine Virus Cultivated in Vivo. — Hideyo Noguchi
{Journal of Experimental Medicine, March, 1918)
says that the virulence of vaccine virus for the tes-
ticular tissues increases until its maximum is finally
reached. A prolonged passage through the testes
does not diminish the activity in the skin. The
testicular strain of vaccine virus is no more likely
to localize in various organs than the ordinary skin
strain, while both may localize in adjacent lymph
nodes when introduced intravenously, subcutane-
ously, or intratesticularly, but other organs are not
involved. Experiments to determine the viability
and resistance of the testicular vaccine virus show
that it is best preserved in Ringer's solution or 0.9
per cent, saline solution ; in distilled water it is
weaker. Low temperatures are necessary. At
18° or 37° C. thf. virus deteriorates. Phenol is
less injurious than glycerol for the ripening pro-
cess. Phenol in a concentration of 0.5 to i
per cent, has almost no injurious efifect, while
glycerol is a powerful vaccinicide. Tests to ascer-
tain whether a gradual deterioration of the vaccine
virus could be delayed or prevented in different
atmospheres indicate that in sealed ampules con-
taining hydrogen, nitrogen, or ordinary air, it re-
tained its virulence better than in an open recep-
tacle, and that pure oxygen or carbon dioxide de-
stroyed the virus completely at the same tempera-
ture. The effects of acids, alkalis, and germicides
were also tried. The vaccine virus was completely
destroyed by sodiimi hydroxide in a concentration
greater than I :200. and almost completely destroyed
bv hydrochloric acid in a like concentration. Iodine
was a powerful disinfectant for the vaccine virus,
but iodide salts did not reduce its virulence, even
when mixed in vitro with a thirty per cent, solu-
tion and kept one hour at 37° C. Dessication has
a destructive eftect and does not exert any protec-
tive influence on the gradual deterioration due to
age which takes place at all temperatures.
86
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Value of the Wassermann Reaction. — John H.
Larkin, I. J. Levy, and John A. Fordyce {Journal
A. M. A., June i, 1918), in a reply to an article
on the same subject by Syminers, Darlington, and
Bittman. point out the fallacies of their deductions
as to the unreliability of this reaction in the diag-
nosis of syphilis, and bring forth a large volume of
evidence from their own researches to show that if
the reaction is properly carried out it has a very
high diagnostic value. They conclude that a pos-
itive reaction is the most constant symptom of
syphilis ; that the reaction is positive in practically
100 per cent, of cases of florid syphilis; that it
is positive in about ninety-four per cent, of cases
of active tertiary syphilis of the skin and bone,
and in a hke proportion of cases of syphilitic
aortitis, proved post mortem, and that it is pos-
itive in the blood in about eighty per cent, of
cases of syphilis of the central nervous system.
If the reaction is properly carried out a negative
response is accurate in at least ninety per cent, of
instances. The technic of the reaction employed
should be stated in reporting the results of any in-
vestigation of its value, for there are many modifi-
cations, not all of which give reasonably concordant
results. In the present investigation the results are
based upon the use of three methods : Plain alco-
holic antigen with icebox fixation ; the same with
warm fixation, and cholesterin antigen with warm
fixation.
Intestinal Parasites Among Troops. — De Ve-
zeaux de Lavengne {Bulletins et viemoires de la So-
ciete medicale des hopitanx de Paris, February 7,
1918), in view of the now recognized frequency of
amebic intestinal infection among troops engaged in
trench warfare, sought to ascertain the role played by
other intestinal parasites under the same conditions.
Living in contact with the soil and exposed to geo-
phagia, the soldiers might a priori be expected to
show an increase in parasitic infestation. Among
200 stool specimens examined mostly from healthy
subjects, none showed ankylostoma ova. Of 100
men living in the trenches, however, seventy-three
showed trichocephalus infestation ; eight, ascaris,
and seven, both trichocephalus and ascaris. Thus,
eighty-eight per cent, of the men had parasites — a
percentage comparing rather closely with analogous
figures reported as regards miners. Among men
quartered in cantonments and in other localities
apart from the trenches, sixty-three per cent,
showed trichocephalus and none, ascaris. The
number of adult trichocephalus parasites harbored
in each individual was estimated to range from five
to fifty. Eosinophilia was never found in tricho-
cephalus infestation but was always present, varying
from four to nine per cent., in the ascaris carriers.
The pathogenic role of the parasites seemed rela-
tively slight. In ten cases of afebrile diarrhea
without dysentery bacilli or amebse, parasitic ova
were very numerous, and improvement followed the
use of thymol, calomel, and santonin. Two addi-
tional cases appeared to belong to the group recog-
nized by Chaufifard under the term "lumbricosis of
the typhoid type." In a few cases with backache
and remittent fever numerous trichocephalus eggs
were found and thymol seemed beneficial.
Alkali Reserve of the Blood Serum in Wound
Cases. — E. Zunz {Paris medical, March 23, 1918)
asserts that the alkali reserve, estimated by Mar-
riott's method, remains normal in wound cases pro-
vided there is no fever nor pronounced infection.
As soon, however, as there occurs an extensive in-
fection, marked respiratory difficulty owing to in-
sufficient oxygenation, or a severe intoxication of
intestinal origin, the alkali reserve diminishes. The
streptococcus and the B. perfringens are almost al-
ways present where infection engenders acidosis. A
moderate degree of acidosis is often met with in
hemothorax, and a marked one where there is intes-
tinal perforation or obstruction as well as in many
cases of circulatory collapse. The extent of alkali
reserve in the serum affords useful prognostic indi-
cations in wound cases.
Influenzal Sinus Disease. — H. E. Robertson
{Journal A. M. A., May 25, 1918) calls attention to
the fact that the relation of influenzal infection of
the cranial sinuses to influenza is not generally rec-
ognized, or, when it is found is regarded as a rare
complication. A study of a number of fatal cases
of influenza, as well as of several cases dying of
other conditions, showed that the sinuses were in-
fected in almost every case harboring the influenzal
organisms. Such infections were also demonstrated
in living patients by the application of cocaine and
epinephrine to the interior of the nose, which led
to the drainage of pus from one or more of the
sinuses. The sinus infections were thought to ac-
count for the frequent severe headaches and also
for the occurrence of many of the fatalities from
inflnenza. The infection also made the patients
carriers of the disease.
Toxicity of Certain Widely Used Antiseptics.
— Herbert D. Taylor, M. D., and J. Harold Austin,
M. D. {Journal of Experimental Medicine, May,
1918), in order to test the toxicity of various anti-
septics, injected increasing doses into mice intra-
peritoneally, and into guineapigs subcutaneously and
intraperitoneally, the amount injected being deter-
mined by the weight of the animal. Of the sub-
stances tested, eucalyptol and brilliant green were
the most toxic, the lethal dose of each being o.i
milligram per 100 grams of body weight. Then
came mercurophen, mercuric chloride, and chlora-
mine-T with a lethal dose of one milligram per 100
grams of body weight, followed by dichloramine-T,
proflavine, hj'chlorite, Dakin's hypochlorite, Javelle
water, and magnesium hypochlorite, with a lethal
dose of ten to fifteen milligrams per 100 grams of
body weight. The least toxic chemicals were iodine
and phenol, with lethal doses of about fifty miUi-
grams per 100 grams of body weight. The toxic-
ity of these chemicals for the guineapigs and
mice follows about the same order. As careful sur-
geons do not approve of injecting solutions of iodine
and phenol into closed body cavities, the authors
think it would be advisable not to use any of the
antiseptics discussed for that purpose, as they all
have a greater toxicity than the two above. It is
also recommended that the use of eucalyptol as a
vehicle for dichloramine-T be discarded, since
Dakin's bland solvent, chlorcosane, is available, and
is much less toxic.
July 13, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
87
Virulence of Tubercle Bacilli in Sputum. — H.
J. Corpcr {Journal A. M. A., May 4, 1918) tested
eighty-two cultures of tubercle bacilli, isolated
directly from the sputum of open cases of tubercu-
losis, to determine the virulence of the organisms.
Guineapigs were used for the tests, and the viru-
lence was measured by the nature of the lesions
and by the tissues involved, rather than by the
capacity to cause death. Varying doses of bacilli
were employed with each culture. The results led
to the conclusion that in the great majority of open
cases of pulmonary tuberculosis the tubercle bacilli
contained in the sputum were highly virulent and
that such sputum in the fresh state was capable of
infecting man, especially through droplets.
A Study of Blood Pressure by the Method of
Gaertner. — Alfred E. Cohn and Christen Lunds-
gaard {Journal of Experimental Medicine, April,
1918) point out certain defects in the fractional
method of estimating the systolic pressure in fibril-
lation of the auricles, and suggest as a substitute
the tonometer method of Gaertner, which gives
satisfactory readings. These are always about
twenty millimetres lower than the pressure in the
brachial artery. In some instances a crossing of
the two curves of average brachial pressure and
digital pressure was observed, hitherto unreported
by others, and not seen in cases the mechanism of
whose hearts was normal. Taking the pressure of
both brachial and digital arteries has demonstrated
the existence of certain different types, as that in
which both central and peripheral pressures are
stable ; secondly, when the more central pressure
is stable and the peripheral pressure fluctuates, and
finally, when both pressures fluctuate.
Studies on Immunity, with Special Reference
to Complement Fixation. — • Alfred Blumberg
(Journal of Laboratory and Clinical Medicine, April,
1918) says that a specific antigen (one which con-
tains the etiological factor of the disease to be diag-
nosed) will only work in conditions where there is
a polymorphonuclear leucocytosis. He divides an-
tigens into three groups : A, that which contains
the specific organisms of a certain disease, emulsi-
fied or autolyzed ; B, those essentially the liquid cul-
ture of a specific organism, the only one in use at
present being the heated liquid egg medium tuber-
culosis culture of Besredka ; and C, those which are
the watery or alcoholic extracts of tissues, notably
the antigen for syphilis. The antigen recommended
by Besredka is considered to be specific for tubercu-
losis, a disease in which lymphocytosis is usually
present. Experiments conducted with tissue ex-
tracts of thirteen mammals, ten birds, eight reptiles,
and seven fishes show that an antigen may be ob-
tained for the diagnosis of syphilis from sources
other than the beef or guineapig heart, or the
human liver or heart. There is a fourth group of
complement fixation, that which takes place without
the presence of an antigen. Following the state-
ment of De Luca that hemolytic serum to which the
urine of a pregnant woman is added will show
hemolysis, but that the same system, to which nor-
mal urine is added, will not, Blumberg tested 259
samples of urine by the technic described in his
paper, with very interesting results. Hemolysis
usually means pregnancy, although it occurred in
such conditions as nephritis, scarlatina, and measles.
With such reactions the clinical history of the pa-
tient may usually be relied on to separate the con-
dition. If hemolysis occurs in the third tube, which
is the control and should not heniolyze, it is due
to some cause other than pregnancy.
Recovery From Toxic Jaundice and Atrophy
of the Liver. — Barbara G. R. Crawford (British
Medical Journal, April 20, 1918) reports three un-
usual cases of very severe toxic jaundice developing
from T. N. T. poisoning in which recovery took
place, associated with apparent complete regenera-
tion of the liver. In each of the three cases the
symptoms were typical of the fatal type of T. N. T.
poisoning with atrophy of the liver to such an ex-
tent that its dullness in the mammary line shrunk to
onlv from one to one and a half inch in extent.
The treatment was symptomatic, except for the ad-
ministration of large amounts of sodium bicarbonate
which seemed to have a decidedly beneficial influ-
ence on the symptoms and the recovery. Following
beginning recovery from the jaundice and associated
symptoms the livers of all the patients returned to
normal size with considerable rapidity. In all of
the cases the recovery was permanent and complete,
the patients having been seen six months after dis-
charge from treatment, when they were in good
health and working hard.
The Atropin Test in Typhoid Infections. — Al-
fred Friedlander and Carey P. McCord (Journal
A. M. A., May 18, 1918) applied this test in 228
cases of various diseases other than typhoid or the
paratyphoids in order to be familiar with its technic
and results in the event of an outbreak of one of the
typhoid infections. In typhoid and the paratyphoids
the administration of two milligrammes (grain
"1/30) of atropin subcutaneously is supposed to give
an increase in the heart rate of fourteen or less
beats per minute, while in other conditions and in
normal man this dose of atropine increases the heart
rate by more than fifteen beats per minute. In a
group of 170 nontyphoidal cases, given the test ex-
actly as described by its originator, sixty-four per
cent, reacted negatively with an increase of heart
rate above fifteen per minute, while thirty-six per
cent, reacted positively. Neither the positive nor the
negative reactions were associated with any particu-
lar disease and the positive and negative reactions
were distributed throughout the various diseases in
about the same ratio as for the whole series. Twen-
ty-seven patients were given the atropine test on
two successive days and of these fifteen reacted
negatively on both occasions ; four positively on both
tests, and c'ght were on the borderline, reacting
within the limits of negative on one and positive
on the other day. The results of the application of
this test show that it is in no way specific for the
typhoid fevers, since insensitiveness to atropine is
shown to occur in many cases other than typhoid
infections and even in normal individuals, and since
others have also shown that negative reactions may
be quite frequent in the presence of proved typhoid
or paratyphoid fevers. The outcome of the test
seems to rest upon the condition of the vegetative
nervous system.
Proceedings of National and Local Societies
Canadian i^ictiical Congrc^efjef
{Continued from page 4/.)
CANADIAN MEDICAL ASSOCIATION AND
THE ONTARIO MEDICAL ASSOCIATION.
Joint Meeting^ Held in Hamilton, Ontario, May
'^pth, 30th, and 31st.
On the evening of May 29, 1918, Dr. H. Beau-
mont Small, Ottawa, the president elect of the
Canadian Medical Association, delivered his address.
He spoke in detail of the ideals, aims and purposes
of the association, and gave a brief historical ac-
count of its origin and development. On Thursday
morning, May 30th, the combined sessions of the
Canadian Medical Association and the Ontario
Medical Association commenced.
SECTION IN SURGERY.
Address in Surgery — The Cancer Problem. —
Dr. Charles H. Mayo, of Rochester, Minn., de-
livered this address. He said that unicellular
life of both the animal and plant type divided
the cell, and with it the cell intelligence for
type and habits. The polar bodies, centrosomes,
and chromosomes do not occur in the unicellular
organisms as found in the cells of multicellular
organisms, and while unicellular growth is par-
asitic, increasing as long as food can be obtained
and environment permits, in multicellular life each
cell must be controlled for community existence and
harmony of work, and the controlling agents are
the chromosomes and centrosomes. Probably the
centrosome represents the dynamic power as sug-
gested by Wilson.^ Cancer is created in some man-
ner by the division of one cell failing to carry with
it the centrosome, the next division leaves it with-
out control as a unicellular type of life capable of
lawless growth more or less true to type but with-
out a controlling brain. In reversion of type the
cell becomes parasitic in existence, creating nests
of cells, funguating growth, ulceration and degen-
eration or connective tissue, according to the loca-
tion, tissue and blood supply and reaction to irrita-
tion, and primarily changing the local field into a
slightly acid one as an environment suitable for its
growth. Ultimately this fluid permeates the body,
a curious cancer cachexia occurs, and with it there
may be metastases, later becoming manifest by
growth at any point where cells may be carried. Be-
fore this it occurs in adjacent local lymph glands
permeated by the fluid, and cancer grows freely in
them. It is this need for proper chemical fluid en-
vironment that explains why cancer cannot be trans-
mitted into higher types of life, but can be trans-
mitted in the lower. This explains the metastases
occurring in cachexia, the whole body being in an
acceptable fluid state.
Methods of Training Surgeons. — Dr. Jasper
Hali'ENNV, of Winnipeg, read this paper, which
was a consideration of the training of under-
'Wilson, E. B. : The Cell in Development and Inheritance. New
York, Macmillan, igii, 483 p.
graduates leading up to surgery and outlined the
best way of connecting the training, internship, as--
sistantship, postgraduate work and the visiting of
other clinics. Dr. Halpenny somewhat severely
criticised existing methods of training surgeons and
quoted Rutherford Morison, of Newcastle, England,
as saying that these were not on high lines.
Radical Operation for Cancer of the Breast. —
Dr. D. Guthrie, of Sayre, Pa., read a paper on
radical operation for cancer of the breast. The
paper was largely a resume of the history of the
various classical operative procedures dealing with
cancer of the breast. The comparative merits of
the operations initiated by Von Volkmann-Heiden-
hain, Willy Meyer, Halsted, Warren, Jackson and
Rodman were discussed and beautifully illustrated
on the screen. Guthrie acknowledged his prefer-
ence for the Meyer operation upon which the technic
of the subsequent ones was mainly based.
Doctor CoBORN, of Guclph, Ont., after stating
that a radical operation was needed for cancer of
the breast, said that it would be a good thing if
operations for cancer of the breast could be stand-
ardized. Each great surgeon had his own particu-
lar mode of performing the operation, which w'as
confusing to students. If the best features of each
operation were standardized it would make the
operation simpler. Especial attention must be paid
to the lymphatics in operations for cancer. He had
employed the method of fulguration, Keating Hart,
after operation, with gratifying results. The excel-
lent results after cancer operations obtained by ful-
guration by Dr. W. Seaman Bambridge. of New
York, were mentioned.
Doctor Beal, London, Ont., did not think that
the standardization of operations for cancer of the
breast was quite feasible. True, there was one
essential line of operative treatment which must be
followed, but the small modifications mattered little
one way or the other.
Fractures of the Hip. — Dr. M. S. Henderson,
Rochester, Minn., read an interesting paper on this
subject. The discussion was limited chiefly to the
surgical treatment of cases of ununited fracture of
the hip. Numerous statistics were adduced showing
that ununited fractures were fairly frequent and
arguing that if in the first instance these had been
treated intelligently, those suftering from them
would not have been condemned to go through life
handicapped by lameness. It was pointed out that
different methods had been used for the purpose
of uniting fractures, as for example, metal nails and
screws, bone transplants, autogenous and hetero-
geneous. The type of fixation to be provided Vv^as
governed by consideration of the pathological con-
ditions present.
Teaching of Plastic Surgery on the Head and
Neck. — Dr. Joseph C. Beck, of Chicago, who
read this paper, pointed out the necessity for
teaching plastic surgery and after describing the
types of injuries in the present war, he dealt
with the possibilities of plastic reconstruction,
illustrating his statements by representations on
July 13, 1918.]
PROCEEDINGS OF SOCIETIES.
89
the screen of the work he had done. Amon^
the injuries to which he drew attention were those
of the external nose, the external ear, and the loss
of the greater portion of the nose. He described
minutely, and by the aid of the screen, most clearly,
the plastic reconstruction of the larynx, cartilage,
and bone transplant ; nerve plastic work with spe-
cial reference to the facial hypoglossal and facial
spinal accessory anastomosis, and cosmetic plastic
operations. In concluding this paper on the work
of the surgeon engaged in plastic operations with
reference to war injuries. Doctor Beck emphasized
its importance in civil life.
Surgery of the Biliary Tract. — Dr. G. R.
Secokd, of Brantford, Ont., gave some observations
on the surgery of the biliary tract. Attention was
directed to points in diagnosis and the supposition
was brought forward that cholelithiasis was prob-
ably an end result of cholecystitis. It was shown
that there were two groups of cases, those active,
with colic, etc., and passive with stomach disturb-
ance, scapular pain, indefinite tenderness and so on.
The unreliabilitv of rontgenographic findings were
noted. The following points in pathology were
pointed out : Hydrops with stone in cystic duct,
empyema, multiple calculi, small contracted gall
bladder, "strawberry" gall bladder and adhesions.
The operative treatment was cholecystotoniy and
drainage. Conditions associated with cholecystot-
oniy were angiocholitis and pancreatitis.
Surgery of the Colon. — Dr. G, I. McGuire, of
Buffalo, New York, in a paper discussing surgery
of the colon commenced by reviewing the opinions
of surgeons on Lane's theories as to the causation
of intestinal stasis, and the results thereof and the
surgical measures of the great British surgeon for
the relief of this condition. The question was asked,
what is the general verdict of surgeons after years
of sober reflection on Lane's work. Should his
teaching and practice be entirely discarded, or was
there some real element of truth in it? According
to McGuire, although there was certainly an ele-
ment of truth in Lane's theories and practice, his
operative procedures were altogether too radical. In
the opinion of McGuire, surgery of the large intes-
tine must be limited, with few exceptions, to cases
showing definite evidence of obstruction. Ileosig-
moidostomy should be cast aside as an operation of
election, resection being the ideal procedure. In
fact, it is said that Lane has discarded ileosigmoi-
dostomy in favor of resection. Side by side anasto-
moses were unsatisfactory, as demonstrated by the
frequency with which diverticula developed in the
blind end. End to end anastomosis gave the most
satisfactory results. A feature of Doctor McGuire's
paper was that special points of technic were beau-
tifully and clearly demonstrated by moving pictures
of the operation for right colectomy.
Dr. Jasper Halpennv, of Winnipeg, Man., said
that some of the main contentions of Lane's were
correct. For example, with reference to the cause
of enlargement of the thyroid. Lane had stated that
it was frequently due to infection in the colon. Hal-
penny agreed with the view. He did not sew
mucosa in gastroenterostomy on account of hemor-
rhage.
SECTION IN OBSTETRICS.
Address in Obstetrics. — Dr. Joseph De Lee,
of Chicago, gave this address which dealt with
methods and operations for reducing fetal mortality
with special reference to the newer methods of
Ciesarean section. The older and classical opera-
tions were described minutely. De Lee advocated
the cervical operation of Caesarean section in pref-
erence to the classical operation, because in his
opinion, convalescence was much smoother than
when older procedure had been followed.
Late Repair of Injuries in Labor. — Dr. W. H.
W eir, of Cleveland, Ohio, read a paper concerning
the late repairs of injuries due to labor in which
stress was was laid upon the frequency of injury to
pelvic organs in childbrith and the difficulty of esti-
mating and repairing at the time. Attention was also
drawn to the disproportion between reflex disturb-
ances and the extent of the injury. Onset of symp-
toms might be long delayed, hence the advisability
of repair before condition became aggravated. Ad-
vice was given concerning when to operate and
when to emplov palliative measures, and the pro-
cedures available were given.
Repair of the Perineum. — Dr. B. P. Watson, of
Toronto, discussed the technic of operations for the
lepair of the perineum. Immediate repair after de-
livery was recommended, and the importance of
closure of tear in vaginal mucosa and coaptation
of musculofascial layers was emphasized. Buried
catgut sutures should be used. As for a secondary
operation, there should be a thorough exposure and
union of separated levator ani and of the torn tri-
angular ligament. This paper was illustrated by
lantern slides.
Cancer of the Uterus.— Dr. F. A. Cleland, of
Toronto, read a paper regarding the results of vari-
ous measures in the treatment of cancer of the
uterus in which the vaginal abdominal, radical ab-
dominal, and Percy cautery operations were dis-
cussed. It was stated that preliminary thorough
cauterization was the best means of eliminating pri-
mary dangers of hemorrhage, shock and infection,
as well as of the secondary danger of implantation.
As a palliative treatment of inoperative cases, the
use of the Paquelin cautery, the Percy cautery, and
the ligating of the blood were recommended.
Normal Labor. — Dr. Irving W. Potter, of
Buffalo, N. Y., in a paper on this subject placed
emphasis on the point that all labor cases must be
considered as surgical procedures, and in accord-
ance with this view patients must be properly pre-
pared. Moreover, the element of time was of
the greatest importance. The position of the
patient during as well as after delivery was de-
scribed, and the importance of the care of the
breasts both before and after delivery to prevent
infection was dwelt upon.
Toxemia of Pregnancy.- — Dr. K. C. Mclr-
WRAiTH, of Toronto, discussed in an interesting
paper the toxemia of pregnancy. It was shown that
the toxemia which was peculiar to that con-
dition, was usually of slow development, and, to
some extent, controllable. The controllable factors
were diet, eliminations, chill, neurotic factors. The
essence and mainspring of treatment was the meas-
ure of toxicity v/hich would show wlien delay was
90
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
possible and when action was imperative. The form
of treatment when delivery might be delayeu was
described and the means of delivery when such ac-
tion was imperative was told in detail.
SECTION IN MEDICINE.
Modern Methods in Diagnosis of Nephritis. —
Dr. W. Gordon Lvle, of New York, in discussing
modern methods in the diagnosis of nephritis, pre-
sented case charts of patients studied for renal
function and the value and significance of blood
analysis and functional tests in the diagnosis of
early nephritis were discussed. Findings in sev-
eral hundreds of cases with especial reference to the
nitrogen partition of the nonprotein nitrogen resi-
due of blood were presented.
Treatment of Bronchial Asthma. — Dr. I.
Chandler Walker, of Boston, read a paper on
this subject. The importance of a careful history,
and the sensitization and treatment of sensi-
tive cases and the treatment of nonsensitive cases
were discussed. Bronchial asthma was classified
clinically and such a classification was discussed.
Stress was laid upon the significance of protein in
substances in the causation of bronchial asthma.
Emphasis was also placed upon the fact that it was
of considerable moment that asthma occurred fre-
quently in young children.
Autoserum Treatment of Chorea. — Dr. Alan
Brown, of Toronto, read a joint paper with Dr.
George Smith, also of Toronto, on Autoserum
Treatment of Chorea. The causation of chorea
was discussed. The autoserum treatment was first
introduced by Goodman, of New York. Brown and
Smith have developed three modifications of this
form of treatment. The report of technic and re-
sults obtained were dealt with, and a description was
given of the withdrawal of blood from the patient,
separating the serum from the blood and its injec-
tion into the patient's spinal canal.
Moral Conflict in Functional Neurosis. — Dr.
Beatrice M. Hinkle, of New York, in an able
paper gave a psychological analysis of the moral
conflict in functional neuroses. The views of Jung
that such a conflict is found to be the basis of every
neurosis were cited. It was pointed out that
Freud's psychoanalysis was the first attempt of
medical science to find in the psychic the cause of
neurotic conditions. In his remarkable contribu-
tions to the subject were included his theories of
repression and resistance, transference, infantile
sexuality, dream interpretation, and the technic of
psychoanalysis. Adler's theory of organ inferiority
was explained, as well as Jung's theory of conflict
arising from nonfulfillment of the Hfe's task.
Physiology of Intracranial Pressure. — Dr. I. I.
R. Macleod, of Cleveland, Ohio, who formerly
worked in London, Eng., with Dr. Leonard Hill,
who Doctor Macleod .stated was the greatest liv-
ing authority on the subject, discussed the physi-
ology of intracranial pressure. The physical
principles underlying the circulation of the blood in
the intracranial cavity were considered. The physi-
ological variations in the blood supply as revealed
by comparisons of the pressure in the arteries sup-
plying and veins leaving the brain and the brain
volimie. The different modes by which intracranial
pressure might occur were elucidated. It was ex-
plained that there was a cerebrospinal fluid which
was displaceable in the cranial cavity and to which
had been ascribed the means for bringing about
intracranial pressure. However, under normal
physiological conditions, the amount of cerebro-
spinal fluid in the cranial cavity was extremely
small. In fact, the fluid acted as a lubricant only,
in much the same way as synovial fluid. Expansion
in the brain might occur by expansion of arteries
and constriction of veins. Various experiments
had been made on animals with the object of solv-
ing the problem of intracranial pressure. Inci-
dentally, Doctor INIacleod mentioned that the only
instrument to correctly measure intracranial pres-
sure had been devised by Leonard Hill. Venous
pressure was of greater importance than arterial,
but at the same time these were interdependent.
When the heart failed, the cerebral pressure rose and
the arterial fell. All increase in intracranial pres-
sure was made by venous pressure. It was gener-
ally believed that a tumor of the brain, if so situ-
ated, would cause pressure. Doctor Macleod asked
the question, why did a tumor of the brain cause
intracranial pressure, and answered that it did not
directly cause pressure. Indirectly it did, because
it increased intracranial pressure by producing
cerebral anaemia. Doctor Macleod pointed to the
apparent absence of active vasomotor nerve fibres
in the brain and the consequent dependence of the
blood suppl}' upon changes occurring in other parts
of the vascular system.
SECTION IN PEDIATRICS.
Address in Pediatrics. — Dr. Isaac A. Abt, of
Chicago, 111., gave the address in pediatrics,
the subject being Asthma in Infancy and
Childhood. Attention was drawn to the fact, that
infantile asthma, which was of frequent occurrence,
differed in type from that which occurred in adults.
It was more prevalent among the rich, and the sea-
sons had a considerable amount of influence upon
its incidence. Locality had a curious effect upon
its incidence ; some got rid of it in dry climates,
others in moist climates. It was a capricious dis-
ease, even in a house. In one room in a house it
would occur, while in another room it would be ab-
sent. Therefore, locality exerted no particular in-
fluence. The various hypotheses as to its origin
were discussed at length, bacterial, toxic, and so on.
Asthma might be the expression of an anaphylaxis,
but the view did not especially commend itself to
Doctor Abt. It might, however, be said that in
infants and children anaphylaxis was sometimes
brought about by proteins. Injection of a small
portion of egg albumin would produce asthma in a
certain child. Pollens and horse hair would pro-
duce asthma. It has been claimed to be due to an
exudative diathesis, because asthma was often
found in connection with eczema, urticaria, ade-
noids, etc. Doctor Abt thought that to attribute
asthma to exudative diathesis was purely specula-
tive. Diet played a very important part in the treat-
ment. Bronchial tetany had more relationshin with
asthma than bronchopneumonia. Nasal lesions
might bring on an attack. It had a relationship to
various diseases, to rickets of the nose for example.
July 13, 191S.]
PROCEEDINGS OF SOCIETIES.
91
Asthma occurred at almost any age in children, and
began with marked bronchitis. Calcium chloride
had had a beneficial effect on asthma in young
children. Respiratory exercises were to be recom-
mended for older children.
Infant Feeding. — Dr. Douglas Arnold, of Buf-
falo, N. Y., read a paper dealing witl practical in-
fant feeding for the general practitioner. Reference
was made to the importance of infant conservation
as a war measure. It was shown that the common
sense methods of infaiit feeding were to avoid
formula: and patent foods and to encourage mothers
to employ simple but well balanced milk mixtures
according to tolerance. The vital importance of
tolerance, its estimation, and how to feed within its
limits in order to obtain the best nutritional results
was pointed out. It was demonstrated how nutri-
tional results were gauged and it was shown how
to keep clear of the common pitfalls of infant
feeding.
SECTION IN OPHTHALMOLOGY.
Dr. E. Blaauw, of Buffalo, opened the section in
ophthalmology by reading a paper on a rare eye
case with presentation of patient and m_iscroscopic
slides. How the growth on the cornea began at the
limbus was shown. Its excision, and recurrence,
its second incision and recurrence, and" seventeen
treatments, with radium, with appareni: inhibition of
growth, were described. It might be mentioned thai
vision was good throughout.
Paralysis of Divergence. — Dr. John Wheeler,
of New York, considered the paralysis of diverg-
ence and said, in part, that neurology did not recog-
nize such a condition as divergence paralysis, as no
centre for divergence had been localized. Yet there
could be no doubt of the existence of this condition
and the clinical picture it presented to the ophthal-
mologist was clean cut. It was easily difl'erentiattd
from paralysis of the external rectus although there
was a superficial resemblance. The onset was sud-
den and manifested itself in diplopia for distance.
When a test object was brought toward the eyes,
this diplopia gradually decreased and binocular
single vision resulted. There was no increase in
diplopia when the test object was carried to the
right or left. The ocular relations were not limited
in any direction. A lesion of the hypothetical di-
vergence centre must be assumed.
Treatment of Simple Glaucoma. — Dr. Walter
R. Parker, of Detroit, in discussing the manage-
ment of cases of simple glaucoma gave as his
opinion that all such cases should be divided clini-
cally into anterior or posterior glaucoma, based on
the point as to whether or not the anterior or pos-
terior lymph system was most involved. All cases
should be treated medically before surgical treat-
ment was considered. Visual fields including color
fields, tension, and visual acuity should be consid-
ered in the order mentioned. All cases, in which
medical treatment failed, should be subjected to
iridectomy if anterior glaucoma and the field of
vision was not excessively contracted.
The medical congress in Hamilton, after a five
days' session devoted to the reading and discussion
of papers bearing upon every phase of medical and
surgical activities, came to an end on Tune i, the
sixth day, with a combined medical and surgical
clinic held in the Mount Hamilton Hospital. The
clinic was conducted from the surgical point of view
by Dr. Charles H. Mayo, of Rochester, Minn. Dr.
Frank Billings, of Chicago, who was unable to be
present, should have dealt with the medical aspects
of the cases presented. In his absence the vacancy
was filled by members of the local medical profes-
sion. The following types of cases were represent-
ed: (a) Goitre, simple, toxic and exophthalmic; (b)
Anemias; (c) Focal Infections.
The scientific exhibits were of great interest, es-
pecially the Museum and Laboratory Section. A
large series of beautifully mounted pathological and
microscopical specimens, together with the steps in
various laboratory procedures, were exhibited.
Throughout the week, demonstrations were made
with regard to the scientific methods employed. The
institutions represented in this exhibition were the
Canadian Medical Army Corps, the University of
Toronto, the Western University of Toronto and
the Connaught Antitoxin Laboratories of Toronto.
So far as the museum series were concerned, the
pathological specimens from the C. M. M. C. mu-
seum, shown by permission of Surgeon General
Fotheringham, and mounted in the medical museum
of McGill University, aroused the greatest interest.
These were the first war specimens to reach Canada.
Post mortem specimens were shown, as well as spe-
cimens from men who had recovered, the latter illus-
trating in a striking manner the large number of
lives surgeons in the war hospitals had been able to
save. The LTniversity of Toronto had one of the
finest exhibits and there were shown also many
unique specimens from the Western University of
London. From McGill University came a valuable
series representing congenital cardiac disease, ani-
mal parasites, and bronchopneumonia in infants.
In the laboratory department. Dr. A. H. Caulfield,
of the Connaught Laboratory, of Toronto, gave
daily demonstrations. Doctor Caulfield has been
recalled recently from France for the purpose of in-
vestigating the possibilities of surgical treatment
and prevention of gas gangrene in wounds.
Doctor Davis, of the Toronto Municipal Labora-
tories, on Tuesday and Wednesday of the week dem-
onstrated the methods of conducting a modern mu-
nicipal laboratory, and particularly with respect to
milk supplies and the modes in use for studying and
determining the chlorite and bacterial content of
water. The menace of the house fly was vividly de-
picted by growths of bacteria caused by allowing a
fly to walk across a dish which was then placed in
an incubation oven to permit the bacteria left by the
fly to make their characteristic colonies. The In-
stitute of Public Health, of London, Ont., which is
afifiliated with the Western University, held contin-
uous demonstrations conducted by Doctor Luney,
Doctor Campbell, and Doctor Crawford. A con-
tinuous demonstration of the estimation of the car-
bon dioxide tension of the alveolar was conducted
during Thursday and Friday, by Dr. Paul Roth, of
Battle Creek, Mich., and Dr. Maude Abbott, of
Montreal.
The officers elected to the Canadian Medical As-
sociation were : president, Dr. H. Beaumont Small,
Ottawa ; vice-presidents, the presidents of afifiliated
92
BOOK REVIEWS.— BIRTHS, MARRIAGES. AND DEATHS.
[New York
Medical Journal.
societies and the presidents of provincial societies,
ex-officio ; secretary-treasurer, Dr. W. W. Francis,
on active service ; acting secretary, Dr. J. W. Scane,
Montreal. Officers of the Canadian Medical Pro-
tective Association were elected as follows : presi-
dent. Dr. R. W. Powell, Ottawa ; vice-president.
Dr. J. O. Camirand, Sherhrooke, Quebec ; secretary-
treasurer, Dr. J. Fenton Argue, Ottawa.
The Ontario Medical Association, one of the
associations which took part in the Canadian Med-
ical Week, held its annual meeting in the Royal
Connaught Hotel on the afternoon of May 31st, Dr.
J. P. Morton, of Hamilton, the retiring president,
in the chair. The following officers were elected :
President, Dr. J. S. Cameron, Toronto ; first vice-
president. Dr. J. H. Mullen, Hamilton ; second vice-
president. Dr. J. F. Argue, Ottawa ; honorary
treasurer. Dr. Gordon Bates, Toronto ; honorary
secretary. Dr. T. C. Routley, Hamilton ; assistant
secretary, Dr. F. C. Harrison, Toronto. The place
of meeting chosen for the Ontario Medical Associa-
tion meeting of 1919 was Toronto.
One of the principal resolutions passed at the
meeting of the Ontario Medical Association was to
the effect that in view of the enormous responsibil-
ity thrown upon the medical profession in Canada
as a result of the war, the remuneration of medical
officers should be made commensurate with their
services.
The meeting was distinguished by a great display
of fervent patriotism which was stirred to boiling
point by an impassioned address given by Major
Lauchlin Macxean Watt, of the Black Watch,*
who has been sent by the British Government to the
United States to aid in the formation of the Amer-
ican army and to arouse enthusiasm for the cause
of the Allies. Major Watt is famous as a poet and
novelist, and has also acted in the capacity of an
army chaplain.
The meeting was a great success, a result greatly
due to the efforts of the secretary of the com-
mittee on arrangements. Dr. J. Heurner MuUin,
whose energy was unlimited and whose courtesy and
urbanity were unfailing.
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
The Ungeared Mind. By Robert Rowland Chase, M. D.,
A. M., Physician in Chief, Friends Hospital for Mental
Diseases ; formerly Resident Physician, State Hospital,
Norristown, Pa. ; Member of the American Medico-
Psychological Association. Illustrated. Philadelphia :
F. A. Davis Company, 1918. Pp. ix-351. (Price $2.75.)
A favorite phrase, "I have half a mind to ," will soon be
disused if people come to be convinced that they can bring
a whole and a sane mihd to bear on small worries and big
difficulties, and Doctor Chase is a genteel and cheery con-
vincer for the man secretly obsessed by a fear of "inher-
ited disease" or seemingly invincible tendencies. He admits
the dangers, but bids us mount with him the heights of
experience, which long years among the insane have given
him. and see from thence how exaggerated our hopeless-
ness of victory over the mass of mental diseases swarming
below.
Beginning with the child, he points out that disease is
not a direct inheritance but a tendency, a tendency to be
halted by wise training and wholesome surroundings. Too
often the parents regard the matter as hopeless instead of
making the child strong to resist the evil when adolescence
Ijrings free choice. The peculiarities which characterize
insanity ms-y be traced back to borderland conditions as
promptings and tendencies which had beginnings even in
the sane mind, but, because repressed in the latter, are
designated eccentricities or faults. It is pleasant to learn
that he puts the punster (not the wit) on the borderland,
but not so comforting to many to learn that rhymsters, and
those who love to illustrate by metaphor, or those whose
fancy can see forms and shapes in clouds and trees, in
design of carpet or paper, must be put there too. But these
need not advance into cloudiness of intellect so long as
they can correct their impressions, which a lunatic cannot
do.
Some show madness to be a disease of civilization, and
the author partly confirms this by the fact that insanity
am.ong the colored races, once rare, now equals that among
the whites. At the same time, he remarks that the larger
percentage of cases which have come under his care have
been country folk, small farmers, field workers, etc. This
he attributes to hard work and exposure, loneliness, mo-
notony, and poor food. Another large percentage is drawn
from immigrants who have to face hard work in uncon-
genial surroundings, disappointed hopes, and the loneliness
enforced by knowing only their own language.
He gives as the chances of recovery some figures drawn
from the literature which state that of ten attacked with
insanity five 'recover. Of these five, two will remain well,
the other three have subsequent attacks during which two
will die. The popular idea that the insane return to sanity
just before dying is a mistake; over ninety per cent, die
unconscious, though, just as the rational man will do evil
in "a moment of temporary insanity," so the madman will
sometimes astonish his friends by having "lucid intervals,"
their lucidity so strong that courts of law have admitted
the righteousness of a will made during such a period.
The chapters on autistic thinking and abulia, or the weak-
ened power to will, if comprehended by the laity might do
much to avert the breakdown of those whose actions and
words are excused as "rather queer" or "eccentric" or
wrathfully denounced as "beastly ill tempered" or "insuf-
ferably conceited." But chiefly is the book to be com-
mended for its adaptability to the minds of the scared,
anxious people who resolutely but sometimes unwisely
lock up the secret fear of approaching insanity.
Births, Marriages, and Deaths.
Died.
Bai.ch. — In Galvcay, N. Y., on Wednesday, June .sth, Dr.
William Vestus Balch, aged sixty-eight years.
Davis. — In Kineo, Me., on Sunday, June i6th, Dr. Gwi-
lym George Davis, of Philadelphia, aged sixty years.
Hall. — In New York, on Monday, July Sth, Dr. William
H. Hall, aged eighty-four years.
Hill. — In Washington, D. C, on Tuesday, July 2d, Dr.
Richard Franklin Hill, Assistant Surgeon, U. S. Navy,
of Philadelphia, aged thirty-one years.
Lincoln. — In Brookfield, Mass., on Monday, June 24th,
Dr. Eugene A. Lincoln, aged fifty-two years.
Richardson.- In Duxbury, Mass., on Thursday, June
2oth, Dr. Frank Chase Richardson, of Boston, aged fifty-
eight years.
Severancl. — In Greenfield, Mass., on Monday, July ist.
Dr. William Sidney Severance, aged eighty-nine years.
SoMERs, — Jn Cambridge, Mass., on Monday, July ist. Dr.
John E. Somers, aged sixty-seven years.
Stfdman. — In Baltimore, on Friday, June 14th, Dr.
Joseph Cyrus Stedman, of Boston, aged fifty-one years.
Wf.st. — In Philadelphia, on Friday, June 26th, Dr. S.
Leslie West, aged seventy-three years.
Wevgandt. — In Brooklyn, N. Y.. on Wednesday, June
12 '^ Dr. Frederick \^'cygandt. aged seventy years.
Wtlgus. — In South Bend, Ind., on Friday, June "th. Dr.
James Livingston Wilgus.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal the Medical News
A Weekly Review of Medicine, Established 1 843
Vol. CVIII, No. 3.
NEW YORK, SATURDAY, JULY 20, 1918.
Whole No. 2067.
Original Communications
THE BLOOD AND THE SOUL IN ANCIENT
BELIEF.
Their Relation to the Evnlnticn in Medicine of
Humoral a)id Pneumatic Theories.
I.
THE SOUL AND THE BREATH.
By Jonathan Wright, M. D.,
Pleasantville. N. Y.
As we look over the field of primitive medicine,
open to us in the reports of those who have visited
uncivilized tribes and studied the social phenomena
exhibited by them, and as we seek for the links
which bind the medicine of prehistoric man with the
medicine of the oldest civilizations of which we
have considerable records preserved through the
vicissitudes of many thousands of years and re-
vealed to us by the labors of Egyptologists and
Assyriologists, we take note of two phenomena
which arrest the attention of medical men, notable,
because they rest upon fundamental physiological
processes without the continuation of which life is
impossible. These processes are so familiar in their
manifestations to the observation of all men, even
to those savages lowest in the scale of intelligence,
that their significance cannot be mistaken in the
bearing it has on the existence of living things in
the animal world. I refer of course to the respira-
tion and the vital importance of the blood. It is
plain that, when the breathing stops for any con-
siderable length of time, life leaves the body, which
then is incapable of movement, soon becoming cor-
rupt and mouldering away. Scarcely less insistent in
activities in the reasoning faculties of the mind of
primitive man is the fact that the loss of blood in-
evitably leads to this loss of breath and the depar-
ture of what we mean by animal life. These
phenomena, giving rise as they do to the many
activities in the reasoning faculties of the mind of
primitive man acquire some significance in the at-
tention of all medical men as apart from lay ob-
servers, but for those professional men acquainted
with the history of medicine and with theories upon
which its practice has been based, it possesses an
importance which it is impossible for the unin-
structed to realize. We find medical historians who
have busied themseh-es with the records of the
Egyptian and Me.so])Otamian civilizations, struck
with the revelation that humoral pathology and the
Copyright, 1918, by A. R.
theory of the pneuma penetrated the medicine which
blossomed on the Nile and the Euphrates thousands
of years before the times of Cialen and Hippocrates.
To the evidences of this I shall shortly have occa-
sion to refer. It is as true today as in the begin-
ning, that, after all, blood is the life and the breath
is its food. Nothing is ir_ore plausible than, that
upon derangements of these, sickness and death
ensue. These are fundamental ideas still reasonable
and held in the estimation of men.
Our only resource for an endeavor to pick up the
threads in early cultures on which these ideas in re-
gard to the blood and the breath are strung, is to
search through the beliefs which modern primitive
men entertain. The Mesopotamian and the Egyp-
tian civilizations had progressed too far and had
already become too complex when they first of all
come to our notice for a sufficient analysis of their
thoughts on the nature of things so fundamental.
Ideas in regard to the blood and the soul had be-
come developed beyond the point where they in-
clude, by their mere vagueness, the germs of medical
science in a concept which also includes the mystery
of life and death as held in religious thought and
expressed in magical practice. We must know
more intimately than archaeology can teach the mi-
nute manifestations of these common undififerentiated
primitive ideas. Faulty and full of uncertainties as
is the method, we must question modern primitive
men to get an inkling into how prehistoric men came
to ascribe to the pneuma and to the blood properties
which regulate the physiology of man, or rather
v/hat affiliation these ideas had with other phenom-
ena and mysteries which surrounded the savage.
As a matter of fact it is quite obvious how it came
about that man attached life and death values to
them It needs no very active imagination firmly to
fix in our minds the belief that human intelligence,
as soon as it was capable of reasoning from observa-
tion to sequence, took note that excessive bleeding
was followed by cessation of breathing, of move-
ment and by the stillness of death, even though
there existed no criterion of death but the decom-
position of the body. This was a materialistic man-
ifestation.
The association of the breath with mystical con-
cepts is somewhat less self evident. The gases set
in motion by respiratory movements are such firmly
impressed real facts to us, we do not realize that
they are invisible and naturally fall for primitive
man into mystical categories. Something passes out
Elliott Publishing Company.
94
IV RIGHT: THE BLOOD AND THE SOUL.
[New York
Medical Journal.
of the dying man witli liis last gasp and docs not
return. This he knew, and to the savage mind this
was intimately associated with and might become
the ultimate cause of death, as it is for us the prox-
imate link in a process which now includes for us
certain intracellular chemical changes. It is only
a part, a very small ])art to us of the change which
supervenes, Init for ])rimitive man it included all
those things which we as materialists have grou])e(i
into differentiations of mechanical and chemical,
organic and inorganic formulas and which as spir-
itualists we. with less precision, still associate with
concepts of the soul. P^or primitive man, things
psychical and things physical, much less things physi-
ological, had not emerged into dift'erentiations. Yet
the primitive man's concept lingers in our phrase-
ology and "when we draw our last breath," "we
give up the ghost," just as the Australian was about
to do when he was saved by the doctor in the tale
taken from the lips of the native by Mr. Howitt (i).
"His Murup (spirit or ghost) had gone from him
and nothing remained in him but a little wind.
. . The dead man was just breathing a little
wind when Dorobauk (the doctor) laid himself on
him and put the Murup back in him." This was
exactly the procedure of Elisha in 11 Kings iv : 34-35
after praying to the Lord. "He went up, and lay
upon the child and ])ut his mouth upon his mouth,
and his eyes upon his eyes, and his hands upon his
b.ands : and he stretched himself upon the child ; and
the flesh of the child waxed warm. Then he re-
turned, and walked in the house to and fro ; and
went tip, and stretched himself upon him : and the
child sneezed seven times, and the child opened his
eyes." Hopkins (2) in discussing the religion of
the Rig Veda says that in the earliest periods of
Hindu theology the word atma, so philologically
allied to the German athincn and the anima of the
Graeco-Latin etymology has a very definite mean-
ing, though hard to translate into modern tongues,
since the men who speak them have lost the con-
ception. It is "breath, spirit, self, soul," as Hopkins
gives it, and the connection between these is quite
obvious without going into the examples of its use
in the Rik. In the Ilpanishads. breath and im-
mortal spirit are made one.
Breasted (3) quotes from a hymn to Osiris in
which the god is saluted as the father and mother of
men. It declares "they live from thy breath."
We know it was the breath of life which the Lord
lehovah breathed into men's nostrils (Genesis 2:7).
There can be no (piestion that this "life" for the
Jew and the Egyptian and the Australian was a
thing which we have, in a materialistic way. recog-
nized to be chiefly oxygen and nitrogen and which
wir have in a spiritual way apprehended as the soul
of man. or perha])s as its vehicle. The early ani-
mistic theory of vitality and, to a large extent, mod-
ern belief, thus confounds the breath and the soul
and intimately associates it with physiological
processes. We find it something of a step now,
but primitive man found it a natural inference that
the disturbances of the body were due to disturb-
ances of the soul ; interference with the breath was
its manifestation for him.
The distinction between physiology and pathology
is still indeterminate. To primitive men vague and
indistinct that idea must have been, for some appar-
ently conceived of the body as carrying on its func-
tions for a time at least — though imperfectly per-
haps— in the absence of the soul even without the
patient being aware of it. Its prompt restoration
was urgently required. Confusing the absence of
the soul, as they believed, during a faint with its
absence at death, stories of resurrection were com-
mon. Primitive man seems to have transmitted to
his descendants the belief that the soul leaves the
body at death, and in the Scottish Highlands (4) even
before death those gifted with second sight or per-
haps common people might see the wraith leaving
the victim's body, even if he was to die by violence.
By the Thompson Indians of British Columbia it
was believed that "the soul may leave the body a
long time before death, although it does not do so
as a rule. If the soul leaves the body, the latter
must soon die unless the soul returns. Whenever
the soul reaches the spirit land, the body immediate-
ly dies. The body needs the soul but the soul does
not need the body." (5) . . . "The soul is sup-
posed to leave the body through the frontal fon-
tanelle. Shamans can see it before and after it
leaves the body, but lose sight of it when it gets
farther away toward the world of souls." "When
the ghosts take away a soul (among the Chinooks),
(6) its owner faints at once. Then the seers are
paid and their guardian spirits pursue the ghosts.
The soul which has been taken away sees the
ghosts."
By the time of the Greeks we find Plato putting
into the mouths of Socrates and his interlocutors
in the Phacdo references to the prevalence of belief
among the ordinary people of their day that the
soul issues forth like smoke or air from the body
and vanishes away into nothingness. They are
haunted by a fear the wind may really blow it away
and scatter it. This the philosophers repudiate, but
it points unmistakably to the primitive union of the
soul and the breath or pneuma in furnishing life and
health to the body. The missionary. Weeks, (7)
noticed among the Congo cannibals that the mouths
and nostrils of the recently dead were always
plugged and tied, and, to his questions on the sub-
ject, he always received the same reply. "The soul
of a dying man escapes by his mouth and nose, so
we always tie them in that fashion to keep the
spirit as long as possible in the body." Once re-
leased no one knew what trouble they might cause.
Archsologists have shown that in the Egyptian
tombs a way was arranged through the wrappings
of the mummy for the ba-soul to go in and out.
Curiously enough the human mind, in a considera-
tion of the soul as an immaterial concept neverthe-
less almost invariably thinks of it as requiring some
material object or some geographic locality or cos-
mic space, or supra or infra mundane sphere which
it may inhabit. These old Egyptians in the cham-
ber of death provided stone heads in which it might
find refuge as the body mouldered in decay and
perished. (Maspero.)
With such beliefs, and especially with the ideas
of the soul leaving the body at fainting and the con-
sequent belief in resurrections, there arose also many
July 20, 1918.]
WRIGHT: THE BLOOD AND THE SOUL.
95
tales of the soul's experiences when detached from
the body. In Sumatra and Nias and among the
North American Indians it was believed that the
soul could escape or be decoyed from the body,
linger outside of the body or go for a season to the
land of spirits. The visit to hell by various heroes,
Ulysses, Orpheus, Aeneas, Virgil and Dante, to
nome only a few, grew out of this conception evi-
dently (8). Busy as the poets have been with the
notion, the priest doctor of primitive man was busier
and found it more profitable, on the whok, than
the poets, because it was his job to get the vagrant
souls back, and since the patient could not afford
to have his soul wandering around at the risk of
imminent death to him, he exemplified the adage,
"All that a man hath will he give for his life" — and
here veritably life was the soul.
It would be interesting to follow more of the rami-
fications of this independent soul of man, freed from
the body yet free to return to it. It was not only
man who was supplied with a soul but all nature.
"The dwellers in or habitual travelers in the desert
assert that the mirages seen are the shadows of long
vanished cities, live trees, and assert the same pic-
tures in the air are seen constantly over the same
localities and the leader of the caravan, who had
traveled the route all his life, further declared that
we also, should we perish in the desert, after a cer-
tain period of years, would flit and dance around
in the air over the location of our destruction" (9).
Thus the health of man fell into a perfectly con-
sistent category, made up of an all embracing pan-
theistic scheme of things.
The idea was that the ghost cannot pass running
water. Where Tam O'Shanter eluded the pursuing
spirit, Nanny, was at the "Auld Brig" across the
brawling Ayr. The Algonquins believe that, when
one is sick, his .soul, escaping from the body, some-
times gets as far as the brink of the river of death,
but, not being allowed to cross, returns and reenters
him which rouses him from the stupor in which he
fell on its departure. "Acting upon a similar notion
the ailing Fiji will sometimes lie down and raise a
hue and cry for his soul to be brought back. 'Thus,'
continues Mr. Tylor, "in various countries the
bringing back of lost souls becomes a regular part
of the sorcerer or priest's profession.' "
The physician of primitive man must have been
very reluctant indeed to separate himself from a
companionship which shared in the lucrative re-
wards which must have accrued to ministrations
of this kind. Removing an evil appendix could not
compete with the restoration of a lost soul, and we
need not be surprised that in sickness "among the
Buddhist tribes the Lamas carry out the ceremony
of soul restoration in most elaborate form" (10).
Of course, belief in the success of the crude pro-
cess of lying on one's back and lustily yelling for
the soul t© return must have been discouraged by
progressive members of the profession in Fiji, and
wc have no reason to wonder that in various coun-
tries the bringing back of lost souls becomes a
regular business. "When a person believes that
his soul has been taken away, he must send a Sha-
man in pursuit within two days, else the latter may
not be able to overtake it" (11). When the soul
belonging to the patient cannot be caught, in Af-
rica, according to Miss Kingsley, (12) they
do not give up the fight, but "the witch doctor him-
self gets ready as rapidly as possible another dream
soul, which, if he is a careful medical man, he
has brought with him in a basket." To prevent the
entrance of an unsuitable soul, when the doctor has
discovered the patient's own spirit has flown away,
a cloth is clapped over his mouth and the patient
is almost suffocated. "Then the patient is laid
on his back, and the cloth is removed from the
mouth and nose, and the witch doctor holds over
them his hand, containing the fresh soul, blowing
hard at it so as to get it well into the patient. If
this is successfully accomplished, the patient re-
covers. Occasionally, however, this fresh soul slips
thiough the medical man's fingers, and before you
can say 'knife' is on top of some 100 feet high or
more silk cotton tree, where it chirrups gaily and
distinctly. This is a great nuisance. The patient
has to be promptly covered up again. If the doc-
tor has an assistant with him, that unfortunate in-
dividual has to go up the tree and catch the dream
soul. If he has no assistant, he has to send his
power up the tree after the truant ; doctors who are
in full practice have generally passed the time of
life when climbing trees personally is agreeable."
xA.musing as this is in Miss Kingsley's entertain-
ing narrative, we must halt a moment at the ac-
count of how the doctor had to blow hard to get
the recalcitrant soul back into the body, conceiv-
ing of it, or artfully meeting the conceits his
fellow men had of it as a sort of smoke. An im-
portant part of the surgical therapeutics of practi-
tioners of medicine among many primitive tribes is
the sucking cure. It is not probable that this arose
from the idea of .sucking out a foreign or dis-
ordered soul from the affected body. In all likeli-
hood it came from endeavors to get out more mate-
rial objects. Yet in Australia a mouthful of wind
was sufficient evidence, at times, that the operator
had succeeded in removing the evil influence. Again
in Australia we find the medicine man strengthen-
ing his patient by sitting on the windward side of
him, in order to let the emanation of his stronger
soul pass into the ailing person. In another conti-
nent, among the South Americans, Father Dobriz-
hoffer declares that "if the whole body languished,
if it burns with malignant heat," the practitioners,
whom he impolitelv calls harpies, fly to suck and
blow it. In California (13) as in Australia, we
note the operator claiming he had got out the dis-
ease in the form of air, blowing it out of his mouth
(14). Tylor declares, "such processes were in full
vogue in the West Indies in the time of Columbus,
when Friar Roman Pane put on record his quaint
account of the native sorcerer pulling the disease
off the patient's legs (as one pulls off a pair of
trousers), going out of doors to blow it away, and
bidding it begone to the mountain or the sea; the
])erformance concluding with the regular sucking
(-ure and the pretended extraction of some stone or
bit of flesh, or such thing, which the patient is
assured that his patron spirit or deity (cemi) put into
him to cause the disease, in punishment for neg-
lect to build him a temple or honor him with
96
WRIGHT: THE BLOOD AND THE SOUL.
[New York
Medical Journal.
l^rayer or offerings of goods." Blowing on the af-
fected part Avebury (15) quotes from de Sahagun
as a medical practice among the ancient Mexicans,
and from Hcarne's Travels Bancroft (16) gets his
authority for the assertion that among the Northern
Indians "for inward complaints the doctors blow
zealously into the rectum or adjacent parts."
Vambery (17) declares that in Central Asia they
requested their dervishes or holy men who had
been to Mecca to use the holy breath, that is, they
breathed three times on the painful spot ; usually
immediate relief v.'as experienced. We may con-
jecture that the idea here, and perhaps the origin
were diverse — the healing influence of the afflatus
from an individual who had been impregnated with
the influence of a god or spirit, and the blowing
away of an extracted ethereal or aerial essence of
an evil indwelling spirit.
This may "be a spirit or soul which belongs nor-
mally elsewhere, but in foreign quarters has a path-
ological influence, so that disease may occur not
only from the escape or misbehavior of one's own
soul, but from the invasion of another person's soul,
though what effect it has is not always very clear,
and sometimes the results do not seem very calam-
itous. In order to show the early interlacing of
pneumatic and humoral theories we may here note
that in Africa the life means a spirit (18), and there
also "the blood is the life," hence l3lood liberated
or shed "is the liberated spirit, and liberated spirits
are always whipping into people who do not want
them." Some blood from a female was thought to
have contaminated a young Fan, and "the opinion
was held that the weak spirit of the woman had
got into him." Among the Shoshone, according
to Lowie (19). a dzoap, which he speaks of as a
ghost, may enter the patient's body and fly awav
with his mind. Under these circumstances mad-
ness usually ensues. In Australia (20), "if a young
man or young woman of the Wakelbura tribe eats
forbidden game, such as emu, black headed snake,
porcupine, they will become sick and probably pine
away and die, uttering the sound peculiar to the
creature in question. It is believed that the spirit
of the creature enters into them and kills them."
On the other hand, in a distant quarter of the
globe, in Greenland, the entrance of the soul places
the sick person on the high road to recovery. "When
after an exhausting fever the patients come up in
unprecedented health and vigor, it is because they
have lost their former soul and have had it re-
placed bv that of a young child or a reindeer (21)."
This idea parallels the ministration of the Aus-
tralian doctor whom we have seen generously al-
lowing his more vigorous spirit to be blown by
the wind into the patient.
We might easily pursue the thread of these ideas
into the primitive cult of metempsychosis which
was once so widespread in the ancient civilizations,
and which still lingers in the beliefs of millions of
men, but it will be more profitable to refer to a
subject less well known outside of ethnology — the
belief in a plurality of souls. Lest the Egyptologists
should sav at once this was a theory which arose
in the high civilization which flourished thousands
of years ago on the banks of the Nile, and was
subsequently carried to the primitive African tribes,
I turn first to an account of it from another con-
tinent by Schoolcraft (22) : "It has been found
that the Indians of the United States believe in
the duality of the soul." Among the Chippewa
burial customs it was noted that "over the top of
the grave a roof shaped covering of cedar bark is
built, to shed the rain. A small aperture is cut
through the bark at the head of the grave. On
asking a Chippewa why this was done, he replied :
'To allow the soul to pass out and in.' (Remember
the device noted in the Egyptian tombs for the
same purpose.) T thought,' I replied, 'that you be-
lieved that the soul went up from the body at the
time of death, to a land of happiness ; how, then,
can it remain in the body ?' 'There are two souls,'
replied the Indian philosopher. 'How can this be?'
Said he : 'You know that in dreams we pass over
wide countries, and see hills, and lakes, and moun-
tains, and many scenes, which pass before our eyes
and aflfect us, yet at the same time our bodies do
not stir, and there is a soul left with the body, else
it would be dead. So, you perceive, it must be
another soul that accompanies us.' " The Dacotas
say "one person has four souls ; one goes to the land
of spirits, one goes in the air, one remains about
the corpse, and one stays in the village."
Boas (23) says that among the Chinook Indians
"each person has two souls, a large one and a small
one. When a person falls sick the lesser soul
leaves his body. When the conjurers catch it again
and return it to him he will recover." It is in
Africa, however, where the belief in the plurahty
of souls is most frequently reported, and, while
there is corroboration (24), I have here, as so
often, to draw largely on the works of Miss Kings-
ley, who seems to have devoted a good deal of
attention to this point. It seems quite possible that
this may have been either the origin of the Egyp-
tian ideas or it may have been derived from the lat-
ter. According to the Rev. Mr. Nassau it may be
conjectured that this plurality of souls arises from
the multiplicity of observations which the natives
interpret in more or less allied ways, from the
shadow, the dream spirit, etc. According to Miss
Kingslev (25), "the number of souls possessed by
each individual we call a human being is usually
held to be four :
"The soul that .survives.
"The soul that lives in an animal way in the bush.
"The shadow cast by the body.
"The soul that acts in dreams.
'T believe the most profound black thinkers hold
that these named souls are only functions of the
true soul,^ but from the witch doctor's point of
view there are four, and he acts on this opinion
when doctoring the diseases that afflict these souls
of a man. The dream soul is the cause of woes
V
'The Socratic idea of the plurality of functions of the soul is an
almost exact parallel and this mav also be noted in Malay magic
(WALTER SKEAT: Malay Magic, Macmillan & Co., London and New
York, 1900): "Every man is supposed (it would appear from Malay
charms) to possess seven souls in all, or. perhaps, I should more
accurately say, a sevenfold soul. This 'septenity in unity' may per-
haps be held to explain the remarkable importance and persistency
of the number seven in Malay magic, as. for instance, the seven
twigs of the birch, and the seven repetitions of the charm (in
soul abduction), the seven blows administered to the soul (in other
magical and medical ceremonies), and the seven ears cut for the
Rice soul in reaping."
July 20, 1918.]
WRIGHT: THE BLOOD AND THE SOUL.
97
unnumbered to our African friend, and the thing
that most frequently converts him into that desir-
able state — from a witch doctor's point of view —
of a patient. It is this way : The dream soul is,
to put it very mildly, a silly, flighty thing. Off' it
goes when its owner is taking a nap, and gets so
taken up with skylarking, fighting, or gossiping
with other dream souls that sometimes it does not
come home to its owner when he is waking up.
So if any one has to wake a man up great care
must always be taken that it is done softly — softly,
namely, gradually and quietly — so as to give the
dream soul time to come home. For if either of
the four souls of a man have their intercommu-
nication broken, the human being possessing them
gets very ill. ... In all cases of disease in which
no blood is showing, the patient is suffering from
something wrong in the soul.'' It is the bush soul
apparently that has to do with the bodily health of
its host, who, unless he possesses the very excep-
tional power of second sight, cannot see his bush
soul. "Ofterings of various kinds are made to ap-
pease the bush soul. If it works well, the patient
recovers, but if it does not he dies. Diseases aris-
ing from derangements in the temper of the bush
soul, however, even when treated by the most emi-
nent practitioners, are very apt to be intractable,
because it never realizes that by injuring you it
endangers its own existence. ... A man may be
a quiet, respectable citizen, devoted to peace and a
whole skin, and yet he may have a sadly flighty,
disreputable bush soul which will get itself killed
or damaged, and cause his death or continual ill
health" (26). A Jekyl and Hyde affair apparently.
The body soul of a deceased person may enter
into another person, as we have seen on other au-
thority, but I must refer the reader to the sprightly
Miss Kingsley. "Another soul, an uneasy stranger,
intrudes sometimes and takes the place of the dream
soul. When the patient collapses in a faint, it is
supposed that this treacherous intruder has sud-
denly deserted and left the other souls of the man
in such confusion that they cannot keep the man's
inside in the proper order — other spirits attempt to
get in — convulsions, delirium, high fever, etc., en-
sue, and with all these evil souls the witch doctor
has his hands full. When the doctor succeeds in
getting the original intruder, the 'sisa,' out of the
body, a high fee from the relatives is necessary to
teach it the way to Hell, where it belongs. Other-
wise, if it gets loose, it may act Hke the diphtheria
germ or the typhoid and cause trouble to the neigh-
bors, who have been cautioned to go around with
cloths over their noses and mouths — like the gowns
the modern orthodox doctor dons when he goes into
a case of scarlet fever or diphtheria. The black
man, it seem.s, reasons quite as acutely as his white
civilized confrere; the only difference is the fact
from which they start, the germ or the soul. It is
expensive to get the captured soul to Hell, and
an irregular practitioner, for a smaller fee, under-
takes to dispose of it in some less effectual way —
disinfection not properly carried out — then the first
thing one knows a baby has an attack of tetanus
in the family and dies, and another one has fits,
and those moving in the higher circles take care
that they hire a practitioner that conscientiously goes
to Hell with the bad spirit — whatever the cost.
The babies that have died are chopped up fine, so
as to kill or drive the 'sisa' permanently out of the
family. There are many more diseases which re-
sult from trouble with the dream soul, and more
still from disturbances of the other souls. . . .
Rut of all of the spirits, the 'sisa' is perhaps the
most aggravating. Sometimes it wanders about
and, taking advantage of an open mouth and the
absence of a kra, or dream soul, it enters a person
and causes rheumatism, colic, or other painfttl ail-
ment. The medical man has to be summoned at
once to get it out. All the people in the village,
particularly babies and old people — people whose
souls are delicate — must be kept awake during the
operation and have a piece of cloth over the nose
and mouth."
This is to keep the dangerous soul, when it is
driven out, from getting into any one else, especially
the sttsceptihle. Curiously enough, if the reader
will turn to an illustration of Catlin's (27), drawn
from nature, he will find among the North Ameri-
can Indians, the Blackfeet, bystanders guarding
against exactly the same danger by holding their
hands before their mouths. There in America, as
in Africa, every one howls "so as to scare the 'sisa'
off them."
It is a pleasure to quote even second or third
hand from Miss Kingsley (28), as she infuses her
own humor into a story absurd enough in itself,
but which loses nothing in her telling of it. In
her amusing manner she says, "according to Mr.
Frazer, in that benighted Nass River district, those
native American doctors hold it possible that a doc-
tor mav swallow a patient's soul by mistake. This
is their theory to account for the strange phenom-
enon of a patient getting worse instead of better
when a doctor has been called in, and so the un-
fortunate doctor who has had this accident occur
is made to stand over his patient while another
medical man thrusts his fingers in his throat, an-
other kneads him in the abdomen, and a third
medical brother slaps him on the back. All the
doctors present have to go through the same ordeal,
and if the missing soul does not turn up the party
of doctors go to the head doctor's house to see if
by chance he has got it in his box. All the things
are taken out of the box, and if the soul is not
there, the head doctor, the President of the College
of Physicians, the Sir Somebody Something of the
district, is held by his heels with his learned head
in a hole in the floor, while the other doctors wash
his hair. The water used is then taken and poured
over the patient's head."
Even mere absurd is the account given by Decle
(29) of the performances of a woman doctor of
the Goa tribe in Africa who is treating a patient
who seems to have got mixed up with a germ or
a soul from a relative who had died. "The sick man
sits on the ground, and a female doctor passes
her hands over his leg and pretends to throw that
which she takes from it into a basket at her side.
This is the 'musimo,' or spirit of the dead man,
wdiich has been withdrawn from the heir's body.
The whole family assembles and goes through the
98
W ELTON: TONSIL OPERATION.
[New York
Medical Journal.
same pantomime. They then take a piece of stufif
and wrap it tightly over the basket to prevent the
si)irit from getting out. The next clay the doctor
comes back and says to the basket, which has been
left in the hnt of the invalid, 'You are quite well,
are you not. and have slei)t well ?' The spirit re-
plies; with a whistle, which the medicine lady trans-
lates thus : 'Yes, I have died once, and I am very
well.' 'Are you comfortable in this basket?' the
doctor then asks. 'Will you stay there?' Another
whistle. 'Yes, yes,' answers the spirit, 'I am com-
fortable, and I wish to stay here.' After that fol-
lows a process called 'marombo,' which is pursued
in all cases of illness alike. The doctor dances, and,
during the dance, places a piece of stuf¥ over the
head of the patient and a gourd on the top of
that. In this uncomfortable posture the patient is
expected to wag his head from side to side while
the dance continues. Presently he also gets up and
dances himself, a sign that the evil spirit within him"
— or was it within the basket — "wishes to leave."
"Upon this the doctor pretends to faint, breaking
ofif short in the middle of the dance and clutching
at his, or more generally her, heart — for most doc-
tors are women. . . . The next day the man is
well, or ought to be." Ellis and others tell sim-
ilar stories of the African natives, which add much
to the complexity of the subject, but despite this
and the, ta-us, ridiculous side of many of the sto-
ries, it is plain that this ramifying belief of prim-
itive man in the pathogenic and in the therapeutic
effect of the soul on the body is directly associ-
ated with the respiration and is a primitive' form of
the pneumatic theories which later appeared in med-
ical history.
REFERENCES.
I. A. W. HOWITT: The Native Tribes of Southeast Australia
Macmillan & Co., London, 1904. 2. EDWARD WASHBURN HOP-
KINS: The Reliciions of India. Ginn & Co., Boston, 1895. 3. TAMES
HENRY BREASTED: Development of Religion and Thought in
Ancient Egypt, Charles Scribner's Sons. New York, 1912. 4. J. G.
CAMPBELL: Witchcraft and Second Sight in the Highlands and
Scotland, J. MacLehose and Sons, Glasgow, 1902. 5. JAMES
TEIT: The Thompson Indians of British Columbia, American
Museum of Natural History Mem., ii, Anthrop. I, Jesup North
Pacific E.vped., 4, New York, 1900. 6. FRANZ BOAS: The Doc-
trine of Souls and of Disease Among the Chinook Indians, Journal
of American Folklore, vi, January-March, 1893. 7- J H WEEKS'
'^'"yi'?^-'-'i'\^^r^£Vl"''"'''- ■''e^-'^y. Service & Co., London, 1913.
.^^h^?^^^^^^' ^"^ Medicin der Naturvbiker, Leipzig, 1891.
9. ARMIN VAMBERY: Reise in Mittelasien von Teheran durch
die Turkmantsche U'iistc, 2d ed., F. A. Brockhaus, Leipzig. 1873.
10. E. B. TYLOR: Primitive Culture, 4th ed., 2 vol., J. Murray
London, 1903. 11. JAMES TEIT: The Thom pson Indians of British
Columbia, American Museum of Natural History Mem. ii, Anthrop.
i-^ J^'lK 4^^''r'^'\,f''"f''' I'-^P'^d.. 4, New York, 1900. 12. MARY H.
KINGSLLY: West African 5"<i(rfi«, 2d ed., Macmillan, Ltd., London
New York, 1 90 1. 13. LORD AVEBURY (SIR JOHN LUBBOCK):
J lie Urigtn of Civilisation and the Primitive Condition of Man Long-
mans, Green, London. 1S89. 14. TYLOR: O/-. cit. 15. AVEBURY- Op
rif. 16. H. W. BANCROFT: The Native Races of the Pacific States
V- 5 vol., D. Appleton & Co., New York, 1875-76. 17.
VAMBERY: Op. cit. 18. MARY H. KINGSLEY: Travels in West
Africa, Macmillan & Co., London, 1897. 19. R. P. LOWIE: The
Northern Shoshone, American Museum of Natural History Anthrop.
Papers, ". New York. 1909, p. 165. 20. HOWITT; Of. cit.. 21.
\\. S. hOX: An Infernal Postal Service, Art and Archaeology,
March, 1915, 1. p. 205. 22. H. R. SCHOOLCRAFT: Indian Tribes
of the United States, 6 vol., Lippincott-Grambo, Philadelphia, i85i-i;7.
23. FRANZ BOAS: The Doctrine of Souls and of Disease Among
the Chinook Indians, Journal of American Folklore, vi January-
March, 1893. 24. R. H. NASS.A.U: Fetichism in West Africa
C Scrilmer's Sons, New York, 1904. 25. MARY H. KINGSLEY:
II est African Studies. 2d ed., Macmillan & Co., Ltd., London-New
\ork, 1901. 26. MARY H. KINGSLEY: Travels in West Africa,
Macmillan & Co., London. 27. GEORGE CATLIN: The Manners,
Customs and Conditions of the North American Indians. 2 vol. W.
and A.K.Johnston. Edinburgh, 1S92. 28. MARY H. KINGSLEY:
We.'t African Studies. 2d ed.. Macmillan & Co., Ltd.. London-New
>ork. 1901. 29. LIONEL DECLE: Three Years in Savage Africa,
Methuen & Co., London. i8g8.
(To be continued.)
THE TONSIL OPERATION AND INDICA-
TIONS WHICH REQUIRE IT.*
An Analysis of 430 Cases.
By Carroll B. Welton, M. D.,
Peoria, 111.
In discussing the indications for removal of the
tonsils, I am guided by experience gained in several
hundred operations and from these I quote patho-
logical conditions which require operative interfer-
ence. It is easier to decide when to remove tonsils,
than when to abstain. The percentage would be low
in cases which do not require removal. The major-
ity of patients come to me for some local condition
either of the tonsil itself or closely allied with it
and in a few cases the connection is very remote. I
would advise no operation in an adult person who
has a clean, visible, smooth tonsil surface, has
never had any inflammatory action of the tonsils,
or who at least has not had an attack of tonsillitis
for ten years or longer. Operation should not be
done in patients also of adult age, eighteen or
twenty years, whose tonsils never become tender
or painful and who are in all respects healthy
individuals. Boot ( i ) and others have report-
ed that often tonsillectomy has been done, not
only with no advantage to the patient, but even with
positi\e detriment, this being particularly true in
children. Where a properly performed tonsillec-
tomy has been done and the indications were pres-
ent. I would positively disagree with this statement
I have never seen harm done the patient from this
operation. I further believe that, in children par-
ticularly, the operation is, when properly performed,
justified and of the greatest benefit improving not
only the local condition of the throat, but also re-
lieving and removing a constant source of infection.
Alany remote diseased conditions, such as rheu-
matism, endocarditis, and neuritis are relieved and
the child avoids contracting such acute contagious
processes as diphtheria and cerebrospinal menin-
gitis. Boot further points out that deformities of
velum, absence of uvula, and infected stumps result
from operation and have been made by the inex-
perenced and occasional operator. Of course de-
formities may result from any improperly per-
formed operation, whether surgery of the tonsils,
appendix, extremities, joints, or any other part of
the human anatomy. I would advise the tonsil oper-
ation in persons having some of the following indi-
cations :
I; The operation should be done in all persons
who have attacks of tonsillitis, even if several
years apart, and in those in whom the tonsils be-
come at intervals slightly painful or tender. The
latter applies especially to children. These mild
attacks are perhaps unnoticed in children except
that the parent may state that the child has had a
little fever, has been irritable, or has complained
that the tonsils were tender. On examination of the
throat, no swelling is present ; this condition 's
simply a mild attack of this disease. "Growing
pains," being of rheumatic origin are often traceable
to tonsils.
•Read at a meeting of the Peoria Medical Society, February 19,
1918.
July 20, 1918.]
WELT ON: TONSIL OPERATION.
99
2. In a good many patients, especially adults,
there is a state of chronic inflammation in or around
the tonsils, which is characterized by reddening of
the anterior pillar covering the tonsil and the his-
tory that the tonsils are at times slightly sore or
tender. This condition should indicate the removal
of the tonsils, as ether diseased conditions of the
tonsils are generally found W\ih. it. In adult life
rhe tonsil is so largely fibrous that functionally it is
of no importance and "like the appendix is a ves-
tigial organ which evolution, except in infancy, has
rendered worthless."
3. Chronic inflammation in or around a sub-
merged tonsil requires removal of the tonsil in
every case. In all these cases when the tonsils are
uncovered at the time of operation I find hidden
deposits of foul cheesy material, absorption of toxic
material taking place in the individual. Absorption
•also takes place when these cheesy deposits are
foimd on the surface of the tonsil, without the ton-
sil being submerged ; nearly all of these individuals
have a foul breath. The crypts of the tonsils at all
times contain myriads of disease germs and the
masses in the crypts consist of bacteria, des-
quamated epithelium, and sometimes pus. It has
been shown that acute tonsillitis has been followed
by appendicitis and the same organism that pro-
duced the throat infection has been recovered in the
appendix at the time of operation. The pearly white
spots of Mycosis fungoides closely resemble these
cheesy white deposits and is also an indication for
the complete removal of the tonsils. This latter is
a rather rare condition. The deposit shines like
pearl and is very tough and tenacious in eft'orts at
removal.
4. Another condition which always requires re-
moval of the tonsils is the presence in the tonsil,
either near the surface or deep in the tonsil
structure, of a collection of pus, without any ac-
companying inflammatory action. This condition is
unknown to the patient. The quantity of pus may
be minute or may amount to as much as six or eight
drops, and may be deep in the tonsil and not dis-
covered until a section of the removed gland is
made after removal. A. small abscess of this char-
acter may be broken into at the time of the opera-
tion and is discovered then. An abscess of this
character was found in a woman, who had been
sufifering from perionychia, a disease of the finger
nails. This disease is a secondary infection from
some other focus in the body. In this case the
abscess was broken into while traction on the
tonsil was being made. These patients are all ad-
vised to have the tonsils removed.
5. In all children from four to fifteen years, I
would advise the removal of the tonsils if there is
a single indication for operation, even though they
are free from attacks of tonsillitis. This would only
be a prophylactic measure against not only local
trouble liable to ensue up to puberty, but also as a
preventive of many serious systemic infections. It
is especially necessary that the tonsils of children,
either with or without collection of adenoid tissue,
be removed if there is hypertrophy sufficient to ob-
struct respiratiori or to make swallowing difficult.
Examination of school children has shown enough
of the deformed protruding lower jaws or the nar-
row misshapen arches of the upper maxilla to
warrant removal of the tonsils and adenoids in all
children during this period of life. These deform-
ities, together with the resulting malocclusion of the
teeth, are due to the obstruction of the air passages,
which causes mouth breathing, which in turn results
in faulty development of the bony structures.
Adami (2) says: "In a certain proportion of cases
what appears to be a simple hypertrophy, is found,
in the inoculation of guinea pigs, to be tuberculosis."
It is a mistake, however, for the general surgeon to
remove tuberculous cervical glands, without first
having had the tonsils removed, as the tonsils in
these cases are generally found to be infected and
are probably the pathway by which the tuberculous
infection entered the body.
The proximity of the tonsils to the cervical and
submaxillary glands provides a ready passage for
the entrance of infecting germs to the circulation.
Palpable glands under the jaw or in the cervical
region either in children or adults, are an indication
of infection and the tonsils should be removed.
Tonsils that stand out prominently in the throat,
even if large, are the least harmful. Peritonsillar
abscess rarelv starts in a large open tonsil, but
usually occurs in a submerged or hidden type. The
infectious material seeking an outlet at the point of
least resistance, breaks through the capsule of the
tonsil and infects the peritonsillar space.
These enlarged tonsils, with or without adenoids,
may give rise to ear conditions such as acute or
chronic nonsuppurative and acute or chronic sup-
purative disease, also to deafness, tinnitus, or pain
or sensation of fullness in the ears. In a great many
cases of chronic suppurative disease of the ear, this
condition is not cured until tonsils of this character
are moved. Some of these tonsils will be reduced
in size if the children are put on syrup of iodide of
iron for a few weeks, providing of course that there
be no cheesy plugs or pus in the crypts. This can
be tried before an operation is decided upon and
will also get these patients in a better preoperative
condition.
6. Patients suffering from rheumatism, nephritis,
arthritis, neuritis, endocarditis and some other con-
ditions for which the tonsils can be proved respon-
sible, require an operation. As an illustration of
this last I would cite the following cases :
Case I. — A man of fifty-six years, a storekeeper, had
had attacks of tonsillitis all his life. One year ago, fol-
lowing an attack of tonsillitis which ended in a periton-
sillar abscess, four weeks later, articular rheumatism de-
veloped, and he was then bedridden for three months.
When T first saw him he had to be carried from room to
room. He was placed in a Turkish bath sanatorium, where
he was given treatment for three weeks. By this time he
could get about by himself and was sent home for another
interval of three weeks. The tonsils were then removed,
and patient has had no further trouble and is in very good
health today.
Case II. — An otherwise healthy girl, twenty-five years
of age, had been for some months troubled with an al-
buminuria. She had been carefully examined by the fam-
ily physician, who could find no cause for this, and she
then consulted me. The only trouble I could find were
som.e palpable cervical glands, together with the history
that at times the tonsils became sore and tender. I ad-
vised her to have her tonsils removed, but did not promise
cure of her albuminuria. She then consulted Dr. Frank
lOO
IV ELTON: TONSIL OPERATION.
[New York
Medical Journal.
Billings, of Chicago, who strongly advised her to have
the tonsils removed. This I did on her return to me, and
in three weeks her family physician advised me that the
albuminuria had entirely cleared up.
Case III. — A young machinist, twenty-five years of age,
had a nephritis, which his physician. Dr. Charles Miller,
of Peoria, thought due to his tonsils. He gave a history
of attacks of tonsillitis since a child and had an attack of
acute articular rheumatism when twelve years old. Ten
weeks ago he had an attack of tonsillitis which ended in a
peritonsillar abscess, and at this time his nephritis began
and a general edema set in. Following a slow recovery,
he was sent to me. He had lost twenty pounds in weight
and had a very bad color. At this time he could only keep
at his work half the time. I advised removal of tonsils,
and he was operated the following day. Pus and cheesy
deposits were found in the tonsil. Albumin was present
in the urine the morning of the operation and had entirely
disappeared when tested five days later.
These cases illustrate the connection of the tonsils
with remote general diseased conditions. If the
tonsils are at fault, in the presence of glomerular
nephritis, their removal is indicated. It is of course
assumed that when a suspicious condition is found
in the tonsil in patients with a systemic infectious
disease, other possible points of infection also, such
as the teeth, sinuses, or bowel, have been excluded.
To Billings, the pioneer in the focal infection
theory, we are greatly indebted for clearing up
many questions in regard to the tonsil.
Preparation of patient for operation. — Inquiry is
made to ascertain if the patient is a bleeder. If
such history be given, the coagulation time of the
blood is taken. A physical examination of the chest
is always made. The patient is sent to the hospital
the morning of the operation without food or
liquids, a cathartic having been given the day previ-
ous and a specimen of the urine is examined the
morning of the operation. The patient is put to
bed and given a hypodermic, either scopolamine or
atropine with morphine, an hour and a half before
the operation, but children of six years and under
are not given any hypodermic. A nasal douche of
normal saline solution is given adult patients. Ether
is given in all cases for the anesthetic. I have tried
gas anesthesia, but have not found it as successful
because of the congestion of the head and the sub-
sequent increased hemorrhage ; neither do I con-
sider it as safe as ether. The degree of anesthesia
should be such that, when once under, the opera-
tion can be finished without the need of any more
anesthetic. Unless the patient is thoroughly under
the anesthetic, that is to the surgical degree, gagging
occurs, which will cause bleeding with consequent
interference with the dissection.
Fatalities during or shortly after this operation
are rare. Mortimer (3) calls attention to this
and says : "On account of probabilities and because
an unexpected death in the young is so distressing,
public attention and alarm are aroused to an ex-
aggerated extent when one does occur." A num-
ber of these unfortunate deaths have occurred in
this vinicity and I have never known of a single in-
stance where the cause of death, other than news-
paper accounts, was reported to our society. Mor-
timer considers "the immediate deaths due to: i,
faulty administration of the anesthetic ; 2, respira-
tory obstruction ; 3, shock, or 4, hemorrhage."
Under faulty administration of the anesthetic, some
errors among others he believes to be: "i, failure
to select the right anesthetic; 2, lack of knowledge
of anesthesia, so that a deep anesthetic is mistaken
for a light one ; 3, failure to maintain free respira-
tion." He further says that "serious results are
more likely to occur during the tonsil or adenoid
operation on accoimt of the liability of the anes-
thesia often being impeded and irregular, than in
other operations of greater surgical importance."
This means that a much more skillful anesthetist is
required for this operation, and as the anesthetist
must also act as the surgeon's assistant in holding
the head in position and otherwise rendering assist-
ance, he must, therefore, be thoroughly acquainted
with the special operative technic.
Of course the question of shock is involved only
when operation is prolonged and is uncommon when
the tonsils are enucleated quickly. Mortimer also
does not believe in the familiar "status lymphati-
cus" as a cause of death in tonsil and adenoid ope- ,
rations and thinks the exact cause of death in every
one of these cases should be determined whether
due to shock, hemorrhage, or obstruction to respira-
tion.
Operation. — The patient is placed in the Trendel-
enberg position with the anesthetist holding the
lowered head. The tonsils are removed by blunt
dissection, after first grasping the tonsil, pulling it
forward, and incising the mucous membrane around
the upper margin. After the tonsil is thoroughly
loosened of all attachments down to the base, a
snare is used, the wire being passed around the re-
maining part and the membrane cut through. The
tonsil is removed complete in the capsule. Ade-
noids are then removed, if present, with a curette,
the mouth gag is removed, and the patient is then
turned with the face down and the head lowered
until all bleeding stops. The usual tiine of opera-
tion is from five to seven minutes.
Aftertreatment. — The patient is placed in bed and
no liquids or food given for the first twelve hours.
The morning following the operation they may be
taken home. In adults two or three days after the
operation the area where the tonsil has been re-
moved is touched daily with tincture of iodine.
This facilitates healing.
Results. — In my experience in 430 consecutive
operations during the past four years there have
been no deaths. The ages of these patients ranged
from two to fifty-six years. Nine patients were under
four years ; 184 were between four and ten years ;
there were 126 from ten to twenty years; from
twenty to thirty there were eighty-three, and twent-
ty-eight patients were above thirty years. The re-
moval of tonsils is a much more simple procedure
in children than in adults. It is a good rule, how-
ever, not to operate on children under four years
of age unless there are present well defined indica-
tions. When an adult has had many repeated at-
tacks of tonsillitis with peritonsillar abscess, the re-
sulting scar tissue with adhesions of the capsule to
muscle tissue of the throat renders the operation
much more difficult. Vaccines made from the
tonsils of a number of patients have been tried and
were in some cases of benefit ; these were used in
patients with severe articular rheumatism. I con-
sider this part of the treatment of rheumatism as a
July 20, 1918.]
RICHARDSON: UNDERNUTRITION IN CHILDREN.
lOI
valuable adjunct. In the treatment of hyperthyroid-
ism also, tonsillectomy has a place, and I have had
some good results where the indications were
present.
In five cases the tonsil was removed incompletely
and the patient required a second operation. In one
patient only one tonsil was removed, no attempt
being made to remove the second tonsil as the pa
tient was acting so badly under the anesthetic. The
clamp has been used five times either at the time of
operation or a few hours later to control hemor-
rhage. Two patients had a postoperative hemor-
rhage, one three days following the tonsillectomy
and the other four days after operation. These
patients were put to bed and the bleeding stopped
itself. These postoperative hemorrhages are caused
in most cases from dislodgement of the clot follow-
ing retching or vomiting and for this reason no
liquids are now being given patients for the first
twelve hours. The same danger of hemorrhage
occurs if the patient swallows blood during the
oj)eration which will also produce retching and
vomiting. This is avoided by inclining the body
with the head down, so that the blood does not get
into the stomach.
An accident that happens probably not inire-
quently with other operators, occurred in one case,
a ten year old child. Some blood was drawn into
the larynx immediately after the tonsils and ade-
noids had been removed, and the child suddenly
became black and stopped breathing. The gag was
immediately removed. Artificial respiration with
hypodermics, lowering of the head, and drawing out
the tongtie, saved him. I have found since this
occurrence that if the correct position of the patient,
with the head lowered, is maintained, accidents of
this kind do not occur. Many reports of postoper-
ative pneumonia and lung abscess following tonsil-
lectomy have been made, but this has never hap-
pened in my practice.
Following the operation, when the throat is
healed, deformed pillars follow in a certain percent-
age, even with an operation that at the time one
would consider perfectly satisfactory. Of course
displacements, drawing up, adhesions, and other
deformities also result if injury to the pillars or
velum occurs at the time of operation. Following
tonsillectomy there is frequently complaint of ear-
ache, pain in swallowing, or a nasal twang to the
voice, sometimes also a paresis of the throat muscles
causing regurgitation of liquids through the nose,
but these are all transitory and harmless. Acute
suppurative otitis media occurred in two cases, but
in one of these patients the ear previously had been
the seat of a suppuration. Recovery in both cases
under ordinary treatment followed. An unpleasant
incident which occurred in one boy following ton-
sillectomy was the development of diphtheria. A
neighbor's child was discovered to have diphtheria
the morning after the boy was operated and the two
children had been playing together the day previous
to the operation. The patient acquired severe diph-
theria with membrane covering the whole operated
area and involving the larynx. He made a complete
recovery, however, with large doses of antitoxin.
Tonsillectomy to cure chorea has not been successful
in my experience. The decision as to whether or
not the tonsils should be removed in these cases and
in diseases of similar character should be left to the
internist, providing of course that there is no local
condition in the throat indicating their removal.
The internist may perhaps require the advice and
cooperation of the laryngologist, but he should be
the one to decide if an operation is indicated. This
mode of procedure will save tonsil surgery from
being brought into disrepute.
Regardless of the general condition of the patient
and whatever the systemic disorder, it is ill timed
surgery to attempt removal of the tonsils while they
are the seat of an acute inflammation. In pulmon-
ary tuberculosis the removal of the tonsils is contra-
indicated in the presence of rales or consolidation.
Other contraindications for tonsillectomy, as given
by Crowe (4) and his associates, are in diabetes, the
chronic deforming type of arthritis, acute rheumatic
fever, and endocarditis. So much has been written
for and against the removal of tonsils, that it seems
to me one must be guided solely by his own personal
experience in advising this operation. In solving
the tonsil question for myself, the results of my
work, carried out as outlined in this paper, have
been most gratifying. The type of instrumentation
or method of operation matters little, providing the
tonsils are removed in toto with as little injury as
])Ossible to the soft structures surrounding
REFERENCES.
I. G. W. BOOT: The Tonsil Question in Children, Annals of
Otology, Rhinology, and Laryngology, March, 1917. 2. ADAMI:
Textbook of Pathology, p. 440. 3. MORTIMER: Practitioner,
November. 191 7. 4- S. J. CROWE, S. S. WATKINS, and ALMA S.
ROTHHOLTZ: Relation of Tonsillar and Nasopharyngeal Infections
to General Systemic Disorders, Bulletin Johns Hopkins Hospital,
1917, xxviii, I.
•'ioS Jefierson Building.
UNDERNUTRITION IN CHILDREN,
l U- A nna M. Richardson, M. D.,
New York.
The extent to which school children would benefit
from free lunches is the question brought up re-
cently for action and experimentation. To under-
stand fully the situation it is essential to know just
what the present condition of children is and how
their needs can be most wisely met.
During the last two years 300 children, members
of families applying for advice tO' the Charity
'Organization Society, have been known to me per-
sonally. I have visited them in their homes ; known
their school records, and studied their habits.
Although these children are from families that are
belov/ the self supporting line, I feel they illustrate
the various elements coming into the problem of
undernutrition. An increase in food would not be
expected to improve the condition of children al-
ready diseased, ,so forty-eight sick children will be
excluded from consideration. On the other hand,
ciiildren already in good condition would not war-
rant the expenditure of time and money the new
plan proposed. One hundred children will be
dropped for this reason. This leaves 152, or fifty-
one i^er cent, of the entire group, who present the
condition known as undernutrition and for whom
the school Itmches would be especially planned.
Insufficient food is only one of the causes of un-
dernutrition. Rapid eating, unwise eating, irregular
102
RICHARDSON: UNDERNUTRITION IN CHILDREN.
[New York
Medical Journal.
eating, overeating", and tlie various forms of nerve
strani to which children are subjected produce sim-
ilar symptoms, for then the child's system does not
function normally and food is not assimilated.
With a child, eating habits depend largely on the
home training and environment. Among the 152
under consideration eight had no mothers and were
living under the guidance of well meaning but un-
wise older sisters. Thirty of the children had
alcoholic mothers, which meant unhomelike homes.
The children eat when and where they could. A
good warm meal might be ready for them at noon,
or their mother might be sleeping and no food in
the house. A solid regular meal in a cheerful en-
vironment every noon would surely help this group,
but would not entirely counterbalance home strain.
Fourteen children had feebleminded mothers — ■
women sincerely trying to do the wise things for
the little ones, but unfitted for this responsibility by
lack of judgment and self control.
Forty had parents who might be described as in-
ferior. They are the undernourished children in
the second generation. 1 his, in a few cases, was due
to specific disease in the parents in early life — not
active in the children but giving them inherently
poor powers of growth and development. Usually
these little ones had the added handicap of insuf-
ficient income because the parents were unskilled
workers. An Italian familv consisted of a man, his
wife, and six cliildrcn. All the children were small
for their age. all had defective teeth, and all were
continuallv getting sick. One child spent nine
months of the first year of its life in a hospital and
has since spent more time in institutions than at
home. She will have bronchitis, and after this is
over she will be sent to the country for two or three
months. A week after her return she will develop
tonsillitis, then will follow another rest in the coun-
try— so it goes through the year. School lunches
would help this group, but no amount of food and
care can really make them sturdy, efficient people.
As in all groups in a community so among
these children we find some that are delicate and
ailing. There are families where one or two chil-
dren will be of this type and the rest sturdy and
strong. Here is a family of four little girls. The
older two enjov excellent health. The baby too, is
splendid. Little three year old Florence is pale,
cannot eat this or that, and continually has attacks
of indigestion. There are seven such children in the
group. Frequently with these little ones the dif-
ficulty is to interest them in eating. School lunches
would inspire some and others it would deter.
Closelv allied to this group are six little ones who
had had a serious illness from which they had never
fully recovered. They illustrate the extreme im-
portance of persisting in medical care to complete
recovery. Measles is frequently the cause of this
condition. The general belief that measles is a
slight ailment, leads to neglect of the coughs, run-
ning ears, and other sequelse which should be re-
lieved at the time of the disease.
A small group, six. of the 152 undernourished
children under consideration, but a group that
would be larger among people in better financial
situation, are the little ones who are used to enter-
tain adults. They are kept under .strain and excite
ment almost constantly and while excellent food in
sufficient quantity may be provided, they remain
undernourished and become ineffective adults.
These children keep late hours, recite poetry and
sing songs to am.use callers, stunts satisfying to
parental pride but inconsistent with normal child
growth. Similar in effect is the giving of the child
too great responsibility. When a girl of twelve, is
the oldest of six children, she will, if given re-
sponsibility, so neglect her own health that she will
be old and withered at sixteen. For her the school
lunches would be a boon because she could have a
meal free from responsibility and interruption.
To the children whose parents have incorrect
ideas of health the school lunches would bring a
splendid opportunity to develop normal tastes. The
mother of four children had been told in her youth
that eggs were good for children. Everything has
been sacrificed to provide eggs in amazing quantities
for these children. When the little ones seemed
weak and looked yellow she borrowed money to
procure more eggs. The five year old boy seemed
particularly affected. The mother was persuaded to
allow a diet to be prescribed and provided for him.
This was continued for four months and by fre-
quent mealtime visits some assurance was gained
that the boy actually ate his food. Then the mother
seemed to understand, because the boy had gained
splendidly. Six months later she reports that Paul
is feeling bad again and won't we please send in
some more eggs. Another mistaken idea, fortu-
nately rare in this group, is that a healthy child needs
constant medication. Poor little three year old
Tony is having his constitution and disposition
spoiled by continual and needless medication and
overheating. He spends unhappy days tightly
bundled up. close to the family stove. In many
homes children are totally undisciplined, they eat
when they please and what they please. Their
mothers find it economical to give them a few
pennies "for when Johnnie has had two cents' worth
of candy he does not eat so much for dinner." The
remaining sixteen of these children suffered simply
from lack of food. They had intelligent mothers,
but for various reasons, there was not enough
money. These children are the easiest to relieve
and are the ones in whom the school lunches would
work considerable improvement. Thus school
lunches would be a contribution of constructive
value in providing needed food for sixteen of the
151 children considered. For those with alcoholic,
feebleminded, or inferior j^arents they would help
somewhat. They would be of educational value to
the undisciplined, the overstimulated, and the fussy
child. They would bring relief to the child bur-
dened with home responsibility.
To accomplish these various purposes food is the
prime essential in a small propoition of the cases.
The educational value of simple food, well served at
a regular time, is the essential liabit for children to
form. As few people appreciate anything that re-
quires no efl:ort or sacrifice on their part, it would
be better to charge the cost of materials in most
rases. But in any plan undertaken to get results
commensurate with effort and cost there must be a
combination of intelligent management and an un-
derstanding of community needs.
July 20, 1918.]
DOWNING: A POSSIBLE FACTOR OF DEGENERACY.
103
A POSSIBLE FACTOR OF DEGENERACY.
By T. J. Downing, M. D.,
New London, Mo.
Is it not probable that the very capacity for varia-
tion, so far as animal life is concerned, is hived in
and about the craniocerebral base? The present
holdings of science justify the doctrine that the
hypophysis has a very important developmental re-
sponsibility. There is abundant evidence that it
has also a reciprocal relation in vcstigio with the
general food supply. The sphenoid bone is the arch
of the skull base. The sella turcica, the body of
the sphenoid, is the keystone of the arch. The
hypophysis rests upon and in a groove or fossa on
the upper surface of this keystone. The sphenoid
is preformed in cartilage. There are plural centres
of ossification, and. with all, a strangely independent
but definite time for their several emergences. The
earliest ossification begins toward the end of the
sixth week of fetal life and is not complete until
some years after birth. To be more explicit : plural
centres of ossification emerge in the sella turcica
early in and toward the middle of fetal life. They
appear in two definitely arranged groups, an an-
terior and a posterior group. "The two halves of
the body of the sphenoid do not unite until after
birth, and then but slowly, so that an intersphenoidal
synchondrosis exists for a long time." (Edinger.)
So, for some years after birth there are practically
two sellje turcicse, one anterior, the other posterior,
with joint relations between them.
While considering at some length the probable
causes of the two skull types of man, the dolicho-
cephalic and the brachycephalic, Darwin makes use
of the following findings : "For instance, of two
heads of nearly equal breadth, the one of a wild
rabbit and the other from a larger but domestic
kind, the former was 3.15 and the latter 4.2 inches
in length." Again he says : "I have noticed with
long eared rabbits that even a trifling lopping for-
v.'ard of one ear drags forward every bone of the
skull on that side." (The Descent of Man.) At-
trahens et retrahens aurem are very important for
the rabbit. The bone attachment fields of the two
muscles are both wide and long. For the latter the
attachment field embraces the mastoid, extending
to and including the occiput laterally : for the former
it reaches well forward on the lateral surface of the
frontal bone. The ever open eye, passively sensi-
tive even while asleep, and the ever retracted ear,
passively sensitive also even while asleep, together
with the long hind legs and magnificent leap, have
been for countless ages the only efficient but con-
stant guard and protector of the timid rabbit. The
habitual retraction of the long ears of the wild rab-
bit, the motives of fear and escape being always on
tap, and the indift'erent position of the long ears
of the rabbit domesticated for countless generations,
the motives of fear and escape receding to the van-
ishing point, explain the findings of Darwin, espe-
cially in the light of the intersphenoidal synchon-
drosis. In other words, the habitual contraction of
these two strong and opposing muscles, attrahens
and retrahens aurem, paralleHng the ever present
motives of fear and escape, have had a tendency to
"iam" the base of the rabbit's skull.
It is not my purpose to discuss man's relations
with the lower levels of evolution. I refer to the
rabbit merely to illustrate the probable factor of
fear in skull type formation. It is fruitless to spec-
ulate as to whether the broadheaded man's making
antedated that of the longheaded man, at an age, too,
when his environment was fearsome indeed. How-
ever conditioned, two well defined primitive skull
types are coexistent with the earliest findings of
man on this old earth of ours, the one having a long,
and the other a broad head. That is, one has a
longitudinal diameter of 100 and a transverse diame-
ter of less than eighty, and the other has a longitudi-
nal diameter of 100 and a transverse diameter of
more than eighty. Possibly this same unmixed skull
type, whether of the long or of the broad head varia-
tion, is the most marked example of sirj^ercrystallized
heredity. In the skull type variation, the departure
of the sphenoid exceeds that of any other bone.
That of the sella turcica is even more marked. In
the long head skull type, therefore, the sella turcica
jtresents a longitudinal diameter of exaggerated
length ; but in the broad head skull type, on the con-
trary, it presents a transverse diameter of exag-
gerated length. Thus the real variation is a long
sella turcica type and a broad sella turcica type.
Edinger wrote in 1896: "Kupffer made a discov-
ery a few years ago that is destined to throw a new
light on the significance of this structure [pituitary].
In the embryos of lower vertebrates there exists for
a period a peculiar evagination from the dorsal side
of the primitive pharynx having a forward direction.
He called this the preoral gut. It is known that a
passage leads from the exterior into this preoral gut,
i. e., the fundament of a separate mouth is estab-
lished over the permanent mouth. This whole struc-
ture, the preoral cavity and the preoral gut into
which it leads, becomes the hypophysis. According
to Kupffer, the evagination of the oral cavity of
craniate vertebrates, that is, the hypophysis, is a
vestige of the preoral cavity. In front of this
riobus posterior hypophysis] lies the anterior lobe, a
tuft of epithelial tubules, which, as you know, arises
from the mucous membrane of the pharynx. Re-
cent investigation makes possible the recognition of
two kinds of cells in it, smaller clear cells and larger
and cloudy cells. Since, as is known, exactly simi-
lar cells are found in very active glands, it is thus
probable that the hypophysis performs some physio-
logical function."
Gushing and Goettesch state ( i ) : "Hitherto, the
lethargy of the hibernating stage has been attributed
to two external stimuli [extracorporal] low external
temperature and diminished food supplv." But
they assert also : "On the basis of our observations,
hibernation may be ascribed to a seasonal wave of
physiological pluriglandular inactivity. The es-
sential role may perhaps be ascribed to the pituitary
body, not only for the reason that the most striking
histological changes appear in this structure, but
also because deprivation of the secretion of this
gland, alone of the entire ductless gland series, pro-
duces a group of symptoms comparable to those of
hibernation." It is altogether probable that both
doctrines are near the truth. Lower external tem-
perature and diminished food supply are lusty
colleagues. In the "preoral cavity and preoral gut"
I04
DOWNING: A POSSIBLE FACTOR OF DEGENERACY.
[New York
Medical Journal.
stage of animal life, nature's only efficient accom-
modation to "lower external temperature and
diminished food supply" conditioned "the seasonal
wave of physiological pluriglandular inactivity"
referred to above as hibernation. Hibernation,
therefore, is a transmitted physiological reaction to
certain external stimuli, "external lower tempera-
ture and diminished food supply." In the countless
ages of the past, the reaction was in terms of the
"preoral cavity and the preoral gut into which it
leads." Today the reaction is in terms of the hypo-
physis. Then the reaction was in terms of diges-
tion. Now it is in terms of metabolism. I am not
concerned upon what plane of evolution this change
from a digestive to a metabolic function was ac-
complished. It is fair to assume that the transition
required ages. In the embryonic parallel develop-
ment of the hypophysis, its prepharyngeal and pre-
digestive relations are but transmitted vestiges.
Therefore, as soon as developed, it assumes a meta-
bolic function. At whatever period of fetal life the
transition is accomplished, then and there the hy-
pophysis arrogates unto itself a supervising and
directing attitude and guides the energies and
motives for further development. It appropriates
the very hormones derived from racial and parental
sources.
In the two skull types of man the harmony of
structure and function, hived in and about the
craniocerebral base, bespeak severally the most rigid
and supercrystalHzed racial heredity. All along the
developmental rovite, both as to evolution and fetal
life, reciprocity and interrelation are but empha-
sized. Any departure in structure or any departure
in function of necessity results in a measure of
disharmony. There is a well recognized and much
mentioned relation subsisting between asymmetry
of form, especially of head and face, and degen-
eracy— idiocy, insanity, or criminality. Asymmetry
is usually referred to as the cause, and degeneracy,
as the effect. Are not both due rather to dis-
harmony of structure and function in and about
the craniocerebral base? Is not degeneracy a co-
eflfect with disharmony? What will occur then if
a long head male mates with a broad head female?
Will Mendel's law take efificient care of heredity in
the matter? Will Galton's law insure harmony of
structure and function in this all important region?
The best thing that can be said about Mendel's law
is the following : It was conceived and developed
in terms of the garden pea. Its application and
potency become more and more inadequate as we
ascend the evolutionary ladder, and are practically
nil long before we reach man. Of Galton's law the
most select assertion, as far as I know, is that too
much weight is given to the immediate parentage,
and not enough to the more remote and even racial
ancestry. Two distinct and supercrystalHzed factors
of racial heredity are pitted against each other, with
their all peculiar structure and function. Of these
two contending factors, will one dominate to the
exclusion of the other? A happy medium is incon-
ceivable. Besides, what becomes of that remote
hereditary force known as atavism? On the con-
trary, is it not reasonable to assume that there will
too often be a sort of mixed victory? In some parts
of this all important locality one supercrystalHzed
force will dominate, and in others the other
factor. Too often the result will be disharmony
of both structure and function and entail asym-
metry and degeneracy.
At some uncertain but remote period of the past,
a broad head people occupied a region along and
corresponding to the borderlines between Switzer-
land and Italy, Austria and Germany, and between
Germany and France, reaching even to the Nether-
lands, it would be interesting to determine how
far the mixture of broad heads with long heads is
responsible for the excessive prevalence of certain
kinds of idiocy and dwarfism, an excess which not
only reaches to our day, but which gave color to
folklore handed down from prehistoric times.
Speaking broadly, the long heads occupied all
Asia on this side of a line corresponding to the
western borders of China and India. They overran
India later ; of Europe they possessed the lands west
of central Russia ; of Africa, they occupied at least
the valley of the Nile, and the countries touching the
Red Sea. Practically all other lands were in the
possession of the broad heads.
It is entirely unnecessary to discuss the relative
merits of these peoples, with their well defined skull
type variation, a variation which is supercrystalHzed
in the most rigid terms of racial heredity. How-
ever, latter day students of history have put aside
some of their impatience when confronted with
China's vast claim of antiquity; but from the view-
point of the most narrowly accredited history, China
manifests a continuous and steady stability of civ-
ilization and government, in comparison with which
that of the long heads of Asia Minor, as well as
Middle and Western Europe, appears temporary
and evanescent.
In an excellent article (2) while discussing at
some length certain assertions of Dr. Eugene Apert,
of the Paris hospitals, on the efifects of the present
war upon the human race. Dr. Joseph H. Marcus
quotes the following: "It is true it may be urged
that as the number of women is comparatively
larger than before, selection will be more perfect.
The women may raise the level of racial qualities in
the same proportion as the penury of males would
tend to debase that level." . . . "The reasoning
is correct and justifies the belief that this war will
not be followed by unduly grave consequences from
the viewpoint of race preservation." In another
part of same article he says : "To sum up, the facts
are on the whole reassuring. Gravely as the young
population has been depleted in this war, we may
anticipate that the quaHty of the race will not be
injuriously nor permanently affected." He could
have added : The larger percentage, I will say all of
them, of the rejected young men left at home unfir
for the soldier's life and duties have identically the
same heredity and parentage with the accepted
young men who make up our armies. Acquired
qualities are not transmissible, therefore these
young men left at home have racial and parental
potentialities practically equal with those of our
soldier boys, whether good, bad, or indifferent. No
one can guess the mortality of this long war, but it
seems to mc that to put it beyond fifteen per cent,
would be an hysterical exaggeration."
Thus we have, at the very least, three conserving
July 20, 1918.]
ROBERTS: SYPHILITIC JOINTS.
105
factors looking toward efficient preservation and
perpetuation of the race : superselection for tlie race
when the women outnumber the men ; eighty-five
per cent, of our soldier boys will return after the
v/ar, racially and parentally nondebilitated, if not
virgin ; and the young men who remain at home
have the same racial vigor and parental potentiali-
ties, as compared with the returning soldiers. In
no sense is war itself degenerative. It is destructive
of life and wealth, it is true, but the fountain head
of the race is not tainted. A few generations will
siiflice for complete restoration. So far as our own
beloved land is concerned, there is a fourth con-
servative factor looking to the preservation and
perpetuation of our race. I refer to woman suf-
frage. Chief among the good results will be a more
coniplete segregation and a strong tendency against
race mixing.
Again I assert that wars between peoples of the
same skull type cannot be degenerative. A few
generations suffice for complete restoration. On the
contrary, wars between peoples of different skull
type may be degenerative. In the former case, there
can be no skull type mixing. In the latter, there
may be. The degeneration will depend solely upon
the degree of skull type mixing. Friendly migra-
tion, if as large, would be equally disastrous. It
was not war, though destructive of life and wealth,
which destroyed the splendid manhood and mag-
nificent civilization of ancient Egypt. It was rather
the subsequent skvill type mixing of the Egyptian
long heads with their neighboring African broad
heads. It was centuries in accomplishing. The re-
bound, such as it is, required other centuries. It is
hardly necessary for me to say that Egypt has not
reattained the splendid level of her displaced civili-
zation. It was not the devastating wars, however
many and severe they may have been, that brought
low the gra.nd manhood and brilliant civilization of
Asia Minor. Again it was the skull type mixing of
the long heads of Asia Minor with the broad heads
of Eastern Asia and Eastern Europe, and the
present degenerates of Egypt. Again it required
centuries for its accomplishing, and the rebound is
yet in the future. It was not merely the wars that
wrecked the proud manhood and the glorious civili-
zation of ancient Greece and Rome. The degenera-
tion of Spain and Portugal is not due to war in
itself, but to the race mixing with their neighbors of
Africa.
In every instance the retrogradation has required
centuries for accomplishment. Where there is a
rebound — alas ! sometimes there is rone — it requires
other centuries for its accomplishing. A happy
medium of skull type may be approached in the
centuries to come, and a fair level of manhood and
civilization may be thus insured.
Practically there remain the Celt, the Gael, the
Teuton, and the Jew. These are the long heads
who remain comparatively unmixed, while the com-
paratively unmixed broad heads are still in their
ancient homes, Elastern Asia, Eastern Europe, parts
of Africa, and some isles of the sea. Many peoples
of our old earth are of the mixed skull type. The
broad head peoples and the mixed types largely
outnumber the long head peoples. Where lies the
destiny of the human race? Today a world and
time beating war is on with these people of the pure
long head skull type as the chief contestants. The
destruction of men, of wealth, of art, of the very
land itself, in short, of all that man holds dear, is
unprecedented. There is nothing like it in all
history. Yet there is no cause for despair. Racial
degeneracy and racial retrogradation will not come
if there is no skull type mixing after peace is se-
cured. But there is danger. Religion and com-
merce, and the idealism of universal democracy,
world wide socialism, together with the practical
annihilation of distance, are towing the Greek horse
through the gap in the broken wall.
During the retrogradation following, the race
mixing after the wars of ancient Egypt, Asia Minor,
and Middle Europe, for a period of more than
3,000 years, the children of Abraham, the Arabs and
the Jews, with their long heads pure and unmixed
saved the wreckage of the Old World for the long
head peoples being newly born in the west. After
the war. when peace is secured, will the long heads
of Western Europe and America, invite or permit a
migration of the mixed or broad head skull types?
If so, in the centuries of retrogression which are to
follow, the mighty problem, will again be handed
to the Jews. God's chosen people, whose very relig-
ion is to continue as an unmixed race.
REFERENCES.
I. GUSHING and GOETTESCH: Hibernation and the Hypo-
physis, Journal of Experimental Medicine, 1915. 2. JOSEPH
MARCUS: New York Medical Journal, December 8, 19 17.
SYPHILITIC JOINTS.*
By Percy W'illard Roberts, M. D.,
New York,
Associate Professor of Orthopedics, Post-Graduate Hospital; Asso-
ciate Orthopedic Surgeon, Mt. Sinai Hospital; Assistant
Surgeon, Hospital for Ruptured and Crippled.
As a factor in the etiology of chronic destructive
joint disease inherited syphilis has heretofore been
considered of so little importance that the ortho-
pedic textbooks of the day dispose of the subject in
a few paragraphs.
Bone tuberculosis, on the other hand, commands
exhaustive chapters devoted to statistics, symptoma-
tology, surgical and mechanical treatment and the
management of resulting deformities which are
looked upon as the inevitable sequelae of chronic
joint morbidity. The pathological groundwork for
these elaborate discussions has in the main been
handed down from older investigators whose work
was done before the treponema pallidum was dis-
covered thirteen years ago. These men were, con-
sequently, unaware that many of the nodules or
tubercles upon which their conclusions were based
might have been produced by the presence of spiro-
chetes and not by the bacillus of Koch. Modern
pathologists recognize these granulomatous masses
merely as tissue reactions which may be set up by
any one of several organisms, notably the bacillus
tuberculosis, the treponema pallidum and the
bacillus lepra. They are not, therefore, pathog-
nomonic of tuberculosis as the term is com.monly
used, and a differential diagnosis, either from
the gross specimen or by microscopic examination,
*Read before the Medical Association of the Greater City of
New York, February 18, 1918.
io6
ROBERTS: SYPHILITIC JOINTS.
[New York
Medical Journal.
is at times impossible until the invading microbe has
been isolated. Thus the foundation upon which our
clinical conceptions of tuberculosis joint disease has
been erected crumbles, our statistics and bedside
observations on the course and treatment of this
condition are exposed to criticism.
The trcMid of events indicates the necessity for
a radical readjustment of our views on the subject
of destructive joint disease, and points to the wis-
dom of correcting the widely disseminated impres-
sion that every chronic articular disability charac-
terized by gradual onset, the presence of spasm,
atrophy, limitation of motion, limp or alteration
of attitude is due to tuberculosis. In the last few
years osteochondritis of the hip, hemorrhagic osteo-
myelitis (Barrie), and localized infectious lesions
have been removed from their former classification
under tuberculosis, and, as I will demonstrate, the
day is at hand for recognizing that probably forty
or fifty per cent., or perhaps more, of the cases pre-
senting the symptoms described are suffering from
syphilitic infection and not from tuberculosis.
Should this opinion be confirmed by the test of time
it needs no vivid imagination to sketch the benefits
which will accrue. Jt means the period of invalid-
ism in such cases will be immeasurably shortened,
the necessity for surgical interference grow less
and less, and the number of permanent cripples be
visibly reduced. Diagnostic errors in the past were
due to the fact that the recognition of tuberculous
joint disease rests entirely upon symptomatology
and X ray findings, and in this study of nearly two
hundred cases it has been revealed that the symp-
torns and radiological characteristics of joint lesions
due to inherited syphilis are so nearly identical with
those of tuberculosis that upon these factors alone
differentiation of the two conditions is impossible.
The diagnostic sterility of both ordinary clin-
ical and radiographic examination throws upon the
remaining evidence available a role of great impor-
tance, and the problem of differentiation is reduced
to the question of either confirming or eliminating
the presence of inherited syphilis. Indeed, after
my past two years' experience, it seems to me
whollv inadvisable to venture a diagnosis of joint
tuberculosis until hie? has been absolutely disproved.
In the perplexities of the situation our first appeal
is instinctively to the laboratory, yet, while the Was-
sermann reaction is of considerable assistance, it
is not, unfortunately, conclusive, but helpful only
when the test is done with sensitized antigens and
where full recognition is accorded the significance
of Vv'eak positive reactions. With the older technic
negative reports are extremely common, even where
there is a direct family history of syphihs and where
lesions in clinically luetic children clear up under
the influence of mercury and potassium iodide.
Through the generous cooperation of Dr. Cyrus
^^^ Field, a stvidy of this phase of the subject is
now in progress, and the data already accumulated
points convincingly to the value of weak positives
obtained by the more delicate methods.
Inasmuch as the Wasserinann is not wholly de-
pendable, every other means at command for the
detection of an inherited taint should be utilized
to prove the presence of syphilis in a given case.
It IS to our advantage that the disease frequently
leaves a trail of more or less permanent imprints
which careful investigation will disclose. The
search for these signs should include an inquiry
into the family history of father, mother, and grand-
parents, the early physical and mental development
of the patient, examination for ocular and oral de-
fects, skin eruptions, chronic headaches, and any
other possible manifestation of lues. When all this
has been done there still remains a fertile field for
investigation — the teeth. It is the dental stig-
ir.ata of syphilis I wish to specially emphasize, for
in all the cases thus far collected a clue to diagnosis
was obtained by examining the teeth.
When we consider that the maxillae are a favorite
site for colonization of the spirochetes, that the period
of greatest activity of inherited syphilis is during the
last half of gestation and the first few months of
the child's life, and that this interval corresponds
to the time during which the deciduous teeth, the
first permanent molars, and the incisors are formed
and partly calcified, it will not be difficult to un-
derstand why the teeth bear permanent imprints
of mkierited lues. If we go further and reahze, as
Cavallaro has shown, that the syphilitic process in
the dental structures of the foetus results in both
constriction and obliteration of the blood vessels,
thereby interfering with the nutrition of certain
parts of the rapidly growing dental tissues, it will
become evident that deformities of great variety
may appear on the completed teeth.
Two deformities other than Hutchinson teeth an-
pear very commonly in syphilitic children. The
first of these is an abnormal spacing between the
upper incisors, to the diagnostic significance of
which I called attention about a year ago. The
condition exists in varying degrees of conspicuous-
ness. and while it is not pathognomonic of syphilis,
and may obviously be due to other causes, it is so
frequently seen in proved luetics as to constitute a
signal for further investigation when found in a
subject suffering with joint disease.
A second common deformity is one to which the
name "humpy molar" has been given — a term which
well describes the appearance of the malformed
unit without endeavoring to explain its pathology.
The anomaly consists of outgrowths on the nor-
mally smooth lingual surface of the molar, which
mav be so slight as to present merely a ridge which
will catch the point of an instrument passed over
it, or it may take the form of a rudimentary cusp
easily discernible on casual inspection. The clinical
significance is the same in either case. Diagnoses
of inherited syphilis based upon the presence of
humpy molars has so often proved to be correct
that rhe contention of Cavallaro. SabXraud and
others that they are of syphihtic origin seems to be
confirmed. There are many other dental deformi-
ties due to syphilis, among them hypoplasia of the
enamel, .so called erosions of various kinds, pitted
surfaces, white and brown sulci, fissured teeth,
etc., but time will not permit of their discussion.
The important thing is to remember that a clue to
the diagnosis of inherited syphilis — that extremely
common and frequently unrecognized condition
whose influence reaches into all fields of medicine —
July 20, 1918.]
ROBERTS: SYPHILITIC JOINTS.
107
Fir.. I. — Extreme type of widely
spaced incisors. Lateral incisors un-
erupted. Knee case.
may often be gained by examination of the teeth,
and that any dental anomaly, however slight, may
be of diagnostic significance.
It is not to be assumed from this that every dental
defect should be laid at the door of syphilis. On
the contrary, post-
natal influences
should ever be
borne in mind.
However, the anom-
alies described are
the products of in-
trauterine develop-
ment, and cannot be
produced after birth.
They are so common
in the teeth of
proved syphilitics
that, while in the
present state of our
knowledge we can-
not say that they are
pathognomonic of the disease, we are justified in
considering them as an indication that lues may be
present, and to proceed with various tests to either
establish or refute the theory. Of these, it seems
to me the therapeutic test is more important than
the Wassermann, for three reasons. First, a nega-
tive Wassermann does not exclude syphilis ; second,
a child mav have inherited syphilis and consequently
have a positive Wassermann, and yet his joint lesion
may be due to a superimposed tuberculosis ; third,
we cannot ignore the judgment of those able clini-
cians of earlier times, whose powers of observation
were sharpened by the absence of our present day
laboratory refinements.
Perhaps the practical diagnostic value of the den-
tal stigmata will best be illustrated by a few briefly
outlined case reports.
Case I. — Boy (F. K.), age eight. "Tuberculosis" of
hip for fourteen months, wearing plaster spica during this
time. On the evidence of inherited syphilis furnished by
humpy molars he was placed on mixed treatment. At this
time he had only fifteen degrees of motion in the hip
joint, accompanied by pain and spasm. The x ray showed
considerable bone destruction in both the acetabulum and
head of the femur. After two weeks of medication the
pain and spasm had disappeared and the joint was more
freely movable. The plaster spica was omitted. Im-
provement was progressive and in three months the pa-
tient was apparently well except for a limp due to shorten-
ing. He has llexion of the hip to a right angle and in-
dulges in all the boys' games.
C.\si: IJ. — Boy (M. S.), age seven. "Tuberculosis" of
the hip for two years,
wearing plaster casts.
Just before coming
under observation
was advised to have
injections of tubercu-
lin. The classical
symptoms of tubercu-
lous hip disease were
present, and the x
ray showed a lesion
in the acetabulum. He
had widely spaced up-
per central incisors and humpy molars and was therefore
placed on mi.Kcd treatment. Plaster spica removed. In a
month the hip motions had increased from fifteen to ninety
degrees ; no pani, no spasm. In two and a half months he
walked without limp and has never had any sign of dis-
ability since.
Case III. — Boy (C. B.), age eight. For six year had "tu-
berculosis" of the knee, wearing a plaster cast all the time.
When he came under observation he had all the usual
symptoms of tuberculous knee join disease, tenderness,
swelling, no motion, marked limp. The x ray showed a
large necrotic area in the upper end of the tibia. Because
of widely spaced incisors and humpy molars he was placed
on mixed treatment and the cast was discarded. In three
weeks pain and tenderness had disappeared. In three
months he had flexion to a right angle and an x ray taken
five months after the beginning of treatment showed re-
generation of the softened bone. He has had no return
of symptoms and walks without a limp.
Case IV. — Boy (G. B.), age five. An early case and dem-
onstrates how a correct diagnosis may eliminate long
periods of treatment and the usual deformities. Treated
for three months for tuberculosis of the right hip, the
usual symptoms of which were present. The x ray showed
slight changes in the head of the femur. There was
marked sensitiveness and spasm and only forty degrees
of motion in the joint. Taking advantage of the clue
furnished by widely spaced upper central incisors and
humpy molars he was put to bed and placed on mixed
treatment. In two weeks all active symptoms had sub-
sided. In six weeks normal motion had returned, to the
hip, general condition was much improved and the child
was running about and very active. His Wassermann was
])ositive.
Spine cases respond particularly well to medica-
FiG. 2. — Widely spaced incisors with
notched margins in a child of four.
Fig. 3. — Extreme type of humpy molars.
tion. and as there is no means but the therapeutic
test to determine which are tuberculous and which
are syphilitic, it would seem unwise to submit any
of them to operation until the effect of a month or
six weeks of treatment can be noted. One case
which had been grafted, and had gone from bad to
worse, was admitted to Neponsit Beach Hospital
while 1 was in charge. He had profusely discharg-
ing sinuses, had been bedridden for several months,
and was extremely cachectic. Even the fresh air
and good food of Neponsit made no change in his
condition. One day I noticed he had Hutchinson
teeth, and placed him on mixed treatment. From
that time on he began to improve. His sinuses
closed, and before he was taken home he was able
to stand and take a few steps alone.
Case V. — Girl (J. K.), age twelve. Lumbar Potts dis-
ea'^e eight years, wearing plaster jackets or braces all this
time. Four months ago she was a delicate stunted child,
pale and sickly in appearance, unwilling and unable to play
out of doors, always tired, had little appetite, and she had
four profusely discharging sinuses. She had humpy mo-
io8
APFEL: CONGENITAL STENOSIS OF ESOPHAGUS.
[New York
Medical Journal.
lars and was therefore placed on mixed treatment. In
four months she has gained seven pounds in weight, goes
to school, plays out doors and is extremely active. Her
appetite is excellent, color good, and she seldom complains
of being tired. Three of her sinuses have closed and the
fourth is discharging a small amount of thin watery fluid.
Her mother had had almost daily headaches as long as
she can remember. She, too, had humpy molars and was
placed on mixed treatment four months ago and for three
and a half months has not had a headache.
The child's grandmother lost three children in early
infancy.
Cask VI. — Girl (H. K.),age sixteen months. For several
weeks had had typical symptoms of tuberculosis of right
knee and came in with this diagnosis. There was pain,
swelling, spasm, and fixed flexion of the joint. She also
had a dactylitis of the fourth finger of the left hand which
had existed for three months. Patient had widely spaced
upper central incisors and was placed on mixed treatment.
Two weeks later pain had almost disappeared, leg could
be brought to full extension, child was much more active
and did not limp. In two months all symptoms had dis-
appeared from both knee and finger.
This patient was probably a third generation case.
The father gave a history of chronic knee joint
disease in boyhood, and he has a saddle nose. The
grandfather had tabes dorsalis for several years be-
fore his death.
There have been many striking cases under ob-
servation in the course of this work, but in some
respects the next one is more instructive than any
of the others, for it shows the length of time that
symptoms due to inherited syphilis may persist.
Casv. VII. — H. F., age thirty-one. When the patient
was six years old, he developed symptoms in his
left hip. He was treated at the New York Orthopedic
Hospital for a year, wearing a brace during that time.
F'or the following ten years he was a patient at the Hos-
pital for Ruptured and Crippled, wearing braces and plaster
spicas and on three different occasions he was admitted
to the wards for considerable periods because of acute
symptoms.
Finally he was permitted to go without protection to
the hip but he has always been conscious of the joint.
Du'-ing the latter part of 1917 his disability became more
marked and he was obliged to give up his work. When
examined January 2, 1918, the hip was extremely sensitive
and for a week he had not had a good night's rest. The
presence of humpy molars indicated inherited syphilis and
he was placed on mixed treatment. After three days of
medication he slept throughout the night without discom-
fort. In a week he was without pain for the first time in
several months and returned to work.
The results of the therapeutic test is striking evi-
dence that this case, treated for so many years by
some of our most eminent clinicians for tuberculosis,
is one of inherited syphilis. Examination of the
teeth gave a clue to the correct diagnosis. The fam-
ily history, which revealed that this man's mother
had eight children, six of whom died in infancv,
added corroborative evidence to the clue, and a pos-
itive Wassermann, obtained a week after treatment
was begun, confirms the therapeutic test and the
diagnostic value of both dental stigmata and the
family history.
These cases have been selected for the purpose
of illustration, and are typical of the majority in
the series. It should not be assumed, however, that
every patient enjoys a prompt and rapid recovery.
Results will vary according to the type of tissue
invaded, the virulence of the organism, and the co-
operation in treatment which the patient is wiUing
to give. Where there is no bone involvement joint
symptoms of long standing usually disappear in a
fcv/ weeks, and sometimes with astonishing rapidity.
Bone lesions, on the other hand, clear up slowly,
even when the accompanying acute symptoms sub-
side <]uickly. Where regeneration of bone does take
place approximately, a year or more of continuous
treatment is necessary.
In conclusion, let me repeat that there is a large
amount of symptom producing inherited syphilis in
the world, the presence of which is not even sus-
pected, but which should be recognized ; that a
negative Wassermann reaction is not sufficient evi-
dence for the exclusion of syphilis ; and that in the
dental stigmata, especially widely spaced incisors
and humpy molars, we have a clue to the possible
presence of inherited syphilis which is worthy of
serious consideration.
576 Fifth Avenue.
CONGENITAL STENOSIS OF THE ESOPH-
AGUS.*
Case Report.
By Harry Apfel, M. D.,
New Vork,
Instructor in Pediatrics, New York Post-Graduate Medical School
and Hospital; Assistant Attending Physician, Kingston
Avenue Hospital, Brooklyn.
Of all congenital deformities of the organs which
comprise the digestive tract, stenosis of the esoph-
agus is least frequently met with. The condition in
most instances is only of interest from a diagnostic
standpoint, for the prognosis in these cases with
complete stenosis invariably spells death from
starvation and exhaustion ; nevertheless we should
be able to recognize the condition when it does
exist. This deformity may exist in varying de-
grees : one is a complete stricture somewhere along
the lumen of the tube with an absence of the lower
end of the esophagus ; or there may be only an in-
complete stricture which would still permit a nar-
row stream of fluid
to go through and
enter the stomach ;
or it may present a
condition not fre-
quently recognized
until the child is
well nigh grown up,
and that is an in-
complete stricture
of the cardiac end
of the esophagus,
the lumen being
sufficiently large to
transmit even solid
food, but, as a re-
(sult of that stric-
ture, the esophagus
immediately above
it, due to the tend-
ency of part of the meal to remain at that point,
develops a dilatation. A case of such a nature
came under the author's care at the New York
Post Graduate some two years ago. The child was
•Read hefore the Brooklyn Pediatric Society. November, 1917.
Fig. I. — First exposure after barium
sulphate.
July 20, 1918.]
APPEL: CONGENITAL STENOSIS OF ESOPHAGUS.
109
Fig.
later;
ished.
-'. — Second exposure four hours
upper part of shadow dimin-
three years of age and came up in every respect to
the measures of a normal, healthy child, but the
mother brought her for what she called a vomiting
habit. The child vomited every day at least once
or twice after meals, and while it was beyond our
belief that a child
would vomit up to
the third year of
age, every day of
its existence, and
still show no ill ef-
fect from it, an x
ray examination
disclosed a marked
degree of narrow-
ing of the lower
end of the esopha-
gus, with a great
deal of dilatation
of esophagus im-
mediately above it.
l"he case I wish
to report this even-
ing was a case of
Doctor Otis that I
saw with him and
which has the following history :
Case I. — Male child, seven days old, duration of labor
twenty-four hours, birth weight seven pounds, breathed
readily.
The nurse reported on the following day that the baby
vomited after attempts to nurse. Stools were small and
lilack and baby slept poorly and was restless most of the
time. Examination showed a poorly nourished baby,
weight, four pounds. Looked very emaciated, skin loose
and cold to touch. No abnormalities noticed on skin.
Head normal. Fontanelle open and not bulging.
Eyes — normal.
Mouth — showed the usual stomatitis from too frequent
washing and in this case perhaps from starvation.
Heart and lungs — negative.
Abdomen — Flat, and soft, no tumors palpable and no
visible peristalsis noticed after baby had been nursed.
Extremities — normal.
The tentative diagnosis offered was a stoppage
somewhere m the upper part of the digestive tract,
probably at the cardiac end ; for if it were a case of
the usual pyloric stenosis we should be able to get
visible peristalsis after nursing as well as palpable
tumor in the region of the stomach, especially
since this child was so emaciated. To corroborate
such a diagnosis two things were necessary, the
passing of a catheter and an x ray examination.
We attempted to pass a sixteen French catheter,
but could only get it down as low as five inches ;
after that the catheter would coil u]X)n itself in the
mouth. We next attempted to pass a smaller size
tube, with similar results.
We then attempted to get some saline solution
through the tube, but the solution would remain in
the funnel with no change in the fluid level (of
course we made sure the catheter was not plugged).
The child was immediately taken for an x ray ex-
amination.
A barium sulphate feeding was given, an ex-
posure taken, and a second one four hours later,
Avith the result shown in the photographs. Figure i
shows a stoppage of the shadow at about the fifth
dorsal vertebra, with well defined curvature of the
shadow upv.'ard. The .second exposure, figure 2,
four hours later, shows the lower level the same as
in hgure i, but the ujjper part of the shadow is
diminished due to the vomiting soon after the feed-
ing. The child was admitted to the New York Post
Graduate Hospital, and Doctor Peterson did a gas-
trostomy, but the child died two days later from
starvation and exhaustion.
327 Pennsylvania Avenue, Brooklyn.
A CASE OF SALIVARY CALCULUS.*
By Max Nisselson, M. D.,
New York.
I present this subject not because of the rarity of
its occurrence, but because the condition was not
recognized for a long time, though seen by many,
Fig. — Salivary calculus.
and because of the size and the pretty shape of the
stone. Wharton's duct is the inost common place
for a stone to occur.
Case.^E. F., forty-three of age, came to me with the
fpllowing history: For the last two years, intermittently
at first, then at longer and finally at shorter intervals he
had pain on the right side of the tongue. The floor of the
mouth on this side would become swollen and there would
also be a swelling beneath the jaw. This would gradually
subside. He was seen by many physicians and was given
numerous mouth washes without benefit. For two months
previous to my seeing him, it bothered him more than be-
fore. The swelling persisted without any letup ; the pain
was constant, increasing when eating. Examination showed
a long" swelling 011 the floor of the mouth on the right side
beneath the tongue which was very tender. Bidigital pal-
pation revealed a hardened mass ; pus was seen coming
from Wharton's duct, which was dilated. Upon inserting
a probe grating could be felt. After thorough cocainiza-
tion and locating the stone, I made a longitudinal incision
o\er it and the stone popped out. The stone was twenty-
five millimetres long, nine millimetres at its widest part and
tapering to a point.
Salivary calculi are composed of either organic
or inorganic matter. The inorganic consists of the
phosphate and carbonate of lime, potash, and tnag-
nesium. The organic consists of bacteria and epi-
thehal debris. More than half of the calculi are
said to be found in the submaxillary glands, the
balance being about equally divided between the
sublingual and parotid. According to various au-
thors, calculi occur more frequently in males than
in females, mostly in middle life, and are rarely met
with in children. The most common predisposing
causes are : the entrance of foreign bodies into the
ducts which act as nuclei ; and microorganisms
around which the salts are deposited. The calculi
should be promptly removed, on account of pain, and
because of the liability to abscess formation.
'Read before the Alumni of Lebanon Hospital, April 2, 1918, and
the Bronx County Medical Society, June 19, 1918.
Med icine and Surgery in the Army and Navy
IMPREGNATION OF THE UNDERWEAR AS
A MEANS OF CONTROLLING THE
CLOTHES LOUSE.*
By William Moore,
St. Paul, Minn.,
Head of the Insecticide Department, Division of Entomology, .
University Farm.
In view of the conclusion arrived at by the British
Commission that trench fever was conveyed by lice,
the control of the louse becomes a very important
matter in the trenches. Therefore, a thorough
study of the subject was made.
The control of the clothes louse was attempted by
four different methods. The underwear was, in the
first series of experiments, impregnated with oil ;
then with oil carrying certain toxic substances ; with
the toxic substances without the oil, and with non-
organic chemicals.
Losing mineral oil it was found that the lice were
destroyed with a minimum dose of one c. c. of oil
to four square inches of a medium piece of under-
wear. With a larger quantity of oil the destructive
action was more apparent until the saturation point
of the underwear was reached, one c. c. to one
square inch. When the amount of oil was reduced
to about one c. c. to eight square inches, when the
garment was just visibly oily, the killing quality of
the oil disappeared to a great extent. Mineral lubri-
cating oils were used, such as petrolatum, vaseline,
paraffin, and chlorcosane, and crude oils from Penn-
sylvania, Kansas, and Oklahoma. In using animal
and vegetable oils the results were no better than
with mineral oils, but if the oil was rancid its
killing qualities were, in general, increased. The
presence of oil, equal to one c. c. to four square
inches, slightly retarded egg laying; at the rate of
one c. c. to eight square inches egg laying was not
retarded ; nor was the hatching of the eggs inter-
fered with.
In the second phase of the work toxic substances
were used with the oil. Of the organic acids used,
valeric was the only one giving good results, but
owing to its volatility, soon disappeared. Among
the iodine derivatives, iodoform was very good;
phenyl iodide, although killing at first, lost these prop-
erties within twenty-four hours. Thymol iodide failed
to kill. The akaloids were uniformly of little value,
but this may have been due to their insolubility in
the oils used. Crude anthracene was effective and
retained its effectiveness for ii8 hours. Some im-
purity in the crude anthracene was responsible for
the killing of the lice, since neither commercially
pure, nor chemically pure, anthracene killed. Di-
phenyl destroyed the lice within twenty-four hours
and retained its killing qualities for as much as 280
hours. A ten per cent, solution of naphthalene in
lubricating oil destroyed 100 per cent, of the lice in
twelve hours, but twenty-four hours later failed to
kill the lice. Alpha naphthylamine, which was just
as effective, still killed 100 per cent, of the lice with-
•Abstract of a paper read at the Annual Meeting of the American
Medical Association. Pul)lishcd with the approval of the Director
as Taper No. 12^ of the Journal Series of the Minnesota Agricul-
tural Experiment Station.
in twenty- four hours. Sulphonated naphthalene
tetrachlor naphthalene, chlorinated naphthalene,
and dichlorinated naphthalene were all more or less
ineffective. Alpha naphthol killed slowly and its
killing qualities lasted for 360 hours ; beta naphthol
was, however, but slightly toxic.
Of the aromatic compounds heliotropine or pip-
eronal was the most effective compound tried, killing
ICQ per cent, of the lice within twelve hours, even
after a period of 528 hours had elapsed.
The phenol compounds, creosote and tricresol,
were effective, while guaiacol carbonate and phenyl
salicylate were nontoxic, the latter even at a con-
centration of twenty-five per cent. Tribromphenol
was toxic to the lice, but would not last longer than
192 hours.
Chemicals to have lasting qualities must have a
boiling point of less than 300° to 350° C. ; the most
toxic compounds were those with boiling points of
265° C. or lower. The most favorable compound,
heliotropine, has a boiling point of 263° C.
The third series of experiments carried out was
to determine if the organic compounds retained their
toxicity when no oil was used. The compounds
showed no reduction in toxicity while some of them
killed even better without the oil.
In the fourth series with inorganic chemicals mer-
curic chloride was the only one that gave favorable
results. A saturated aqueous solution killed within
twelve hours. Sodium fluoride, which is effective
against the chicken louse, gave negative results.
The two most favorable compounds were creosote
and heliotropine. A ten per cent, solution of creo-
sote in lubricating oil used at the rate of one c. c.
to eight square inches of underwear was effective
for twenty-four hours ; after this period it lost its
toxicity.
Heliotropine used with oil is effective for but
forty-eight hours when the clothing is worn, since
the oil is absorbed by the other clothing, weakening
the dose to a point where it is no longer effective.
L^sed without oil heliotropine soon crystallizes out
and is rubbed off. Some other oily compound which
is too viscous to be absorbed rapidly by the under-
wear must be used with the heliotropine. A five
per cent, solution of heliotropine in ether, to which
one half gram of fat or wax was added remained
effective for seventy-two hours. Heliotropine was
found to be most soluble in cocoa butter. Using the
proportions of one gram of heliotropine to three
grams of cocoa butter dissolved in ether per
forty-eight square inches of underwear, the under-
wear could be worn for 168 hours without losing its
toxicity.
One hundred and sixty-eight hours is then the
maximum time that an effective compound will re-
main in the underwear in sufficient quantities to kill
the lice quickly. The use of a less volatile compound
will result in a diminishing toxicity that is an in-
crease in the time required to kill the lice.
The author wishes to express thanks to Dr. A. D.
Hirschfelder for his interest in the problem and
his cooperation by the preparation of a number of
the chemicals used in the experiments.
July 2Q, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
Ill
HEART CONDITIONS IN RECRUITS.
Investigation of Ten Thousand Recruits With
Doubtful Heart Conditions*
Preliminary Report.
Ill February, 1916, by desire of the British War
OfBce, the honorary medical staff of the National
Hospital for Diseases of the Heart undertook to act
as expert referees on all cases of doubtful cardiac
conditions referred to them by the various recruit-
ing boards of the metropolitan area.
Methods! Employed. — In every case an exhaustive
medical history was taken, inquiry was made into
subjective symptoms complained of, and the ordin-
.iry clinical examination by inspection, palpation,
percussion, and auscultation was undertaken. In
addition to this, the urine of every recruit was ex-
amined, the pulse, blood pressure, and the respira-
tion was taken in the recumbent position before and
immediately after a standardized piece of exercise,
and again after three minutes' rest in the recumbent
position. Each case was electrocardiographed, and
the heart was examined by means of the x rays. As
the result of these vai-ious methods of examination
a diagnosis was arrived at, and the medical boards
were advised as to the category for service for
which, in the opinion of the examining physician,
the recruit was fitted, the responsibility for the
actual classification adopted necessarily resting with
the medical boards.
Special Nature of Cases Investigated. — It is nec-
essary to bear in mind the general character of the
cases dealt with. They are not, and cannot be, an
average sample of the population. All recruits pre-
senting themselves had been, in the first instance,
examined bv boards of competent medical advis-
ers, cases where the heart was obviously normal
having been passed by them, if suitable in other re-
spects, as fit for service, and also most of those
who showed well marked and definite diseases hav-
ing been rejected. Consequently, the men referred
to the Heart Hospital were only cases about whose
fitness there was some doubt, or cases of cardiac
disorders in regard to whom there was difficulty
in deciding in which category they should be placed.
These cases, therefore, may be considered a fair
example of the difficulties encountered by the prac-
titioner in cardiac medicine. It is in this fact that
their value, as a subject for investigation, lies.
Up to January 14, 1918, 10,000 recruits were
examined, as well as 181 men already in the army,
who were referred for opinion by army medical
officers.
In order to ehminate, as far as possible, the
personal equation, and to promote a uniform stand-
ard, for some months every recruit was examined
independently by two physicians, the two working
together being varied from time to time. The aver-
age time that each individual recruit was actually
tmder examination was a little over an hour. The
taking of histories, x ray examination, urine exam-
ination, and exercise test of about the first thou-
sand was carried out by the examining physicians.
'Conducted at the National Hospital for Diseases of the Heart,
London, by C. Chapman Gibbes, R. O. Moon, S. Russell Wells,
P. flamill, F. W. Price, and J. Strickland Goodall.
\fter that, these j)ortions of the examination were
made by trained assistants. The actual examina-
tion by the physician then averaged a quarter of
an hour per recruit. When over 2,000 had been
examined conjointly, and there was a probability
of a general consensus of oj)inion having been estab-
lished, on account of the time retjuired and of the
number of recruits, each was examined by one physi-
cian only.
As time went on, fewer and fewer fit men were
seen No doubt this is partly due to the fact that
the absolutely fit joined the army early, and that by
this time the general standard of the population to
be drawn on was lower ; but another factor of great
imi)ortance, so far as these returns are concerned,
is that the later numbers contain an ever increas-
ing proportion of men who had previously been
rejected by medical boards and were called up for
reexamination. It also seemed to the examining
physicians that the medical boards increasingly re-
ferred to them men whom they proposed to put in
some of the lower categories, but who themselves
were desirous of being placed still lower, and prob-
ably in this way the hospital performed a useful
function in convincing many discontented recruits
that their cases had been adequately investigated,
and their category only decided on after full in-
vestigation.
The full service men on a new classification from
August 8, 1916, to January 14, 1918, fell to 11.6
per cent. The total rejections remained fairly con-
stant, being 4.4 per cent., as opposed to 5.4 per cent.,
while those considered capable of some form of
combatant service fell from 51.8 per cent, to 40.1
per cent., and the labor and clerical class rose from
13.8 per cent, to 43.9 per cent.
Classification of occupations. — Considerable dif-
ficulty was experienced in arriving at a suitable ba-
sis of classification of the various occupations. It
was, therefore, decided to adopt a vertical classi-
fication of indoor, partly indoor, and outdoor oc-
cupations, subdividing these into sedentary, semi-
sedentary, and active, the active being again sub-
divided into light, medium, and heavy, with
reference to the amount of muscular work entailed,
while a transverse or cross classification was made
dependent upon professions and trades.
Preponderance of cases among those in certain
occupations makes it seem legitimate to conclude
that there is, on the whole, a greater proportion of
doubtful heart cases in some employments than in
others. This, however, still leaves it open to ques-
tion whether this greater incidence is due to men
with defective hearts naturally drifting into light
occupations, such as that of a clerk, or whether such
occupations themselves lead to any particular form
of heart weakness. This point can only be decided
by a detailed examination of the incidence of the
various forms of cardiac derangement in the vari-
ous occupations. An attempt to do this will be
made later.
A hospital group of one story pavilions has just
been completed at the naval training camp at Pel-
ham Bay, N. Y., providing facilities for 750 pa-
tients and accommodations for hospital corps, etc.
THE SPECIAL BRITISH MEDICAL MISSION
TO AMERICA
Colonel Herbert A. Bruce, Consulting Surgeon to the British Armies in France; Siir
IVilliam Arbuthnot Lane, Consulting Surgeon to the Queen's Hospital, Sidcup, England,
and Sir James Mackenzie, Consultant in Heart Conditions in the British Military Hospitals,
constituted a special medical mission sent by the Government of Great Britain to meet the
leaders of the medical profession in the United States and to confer unth them regarding
medical and sanitary zvork on the ivestern front. After being enthusiastically received at
the various large centred of medicine and of zvar industry, these distinguished visitors bade
farewell to America on the evening of June 26th at the Metropolitan Club of Nezv York
City, where some fifty physicians and surgeons were gathered at a banquet in their honor,
hurriedly arranged through the courtesy and foresight of Dr. Wendell C. Phillips and Dr.
J. J. McPhee, as orders for their immediate return made impossible a more general gather-
ing, as had been planned.
Dr. Walter B. James, president of the New
York Academy of Medicine, at the conclusion of
the dinner addressed the visitors in a brief but feel-
ing tribute to the services which had been rendered
to the cause of liberty by the navies and armies of
Great Britain and France, and more particularly by
the medical men of those forces. He introduced
each speaker in turn in a particularly suitable and
happy manner.
THE PROBLEMS OF MILITARY MEDICINE IN FRANCE
Colonel Herbert A. Bruce, F. R. C. S., A. M. S.,
first entered the war in the Canadian Army IMedi-
cal Service and has for the past year and a half
acted as consultant for the Imperial Forces, cover-
ing the entire line from the North Sea to Switzer-
land. Before taking up the medical problems of the
army he referred in a most appreciatixe manner to
the services rendered by American surgeons in car-
ing for the wounded, mentioning particularly the
Presbyterian Hospital Unit, which is in his area, and
which had lost one medical director after another
by promotion, Major George E. Brewer, Major
William Darrach, and Major Fordyce St. John hav-
ing each in turn been advanced from the post of
director of the Hospital Unit to other fields of use-
fulness, leaving Major J. A. McCreerey as the pres-
ent director with ample material to draw on with
such names as Majors Stevens and Swift, Captains
Parsons, Neuhof, Pappenheimer, Casamajor, Ray-
mond, and Cunningham and many others still with
the unit. He also paid tribute to the work of Cap-
tain Dunning, the dental surgeon of the unit, and
to the services rendered by the nurses.
With regard to the general medical problems of
the army, some of the greatest advances that had
been made lay in the direction of hygiene and sani-
tation, a number of which had resulted from the
necessity of meeting new conditions and overcoming
them. This had a value other than military for it
would result in enormous benefit to the citizen popu-
lation of the civilized world after the war. In all
previous wars the chief wastage had been from dis-
ease, but that was no longer the case. Owing to
improved sanitary methods and inoculations with
various vaccines, epidemics which formerly deci-
mated armies were unheard of, and now practically
the only wastage was from wounds. Typhoid fever
was almost entirely stamped out. In May there
were only twenty-seven mild cases of typhoid in an
army of millions of men, a condition which could
only be attributed to the protective influence of ty-
phoid vaccination which was compulsory with the
troops.
Trench fever had been a source of some trouble,
but a commission was appointed by the British
Government for its investigation with the result
that the louse was convicted as being responsible for
its transmission, since which time strenuous efforts
had been employed to eliminate as far as possible
what the soldiers called "the pilgrims of the night,"
and their ravages had been materially curtailed by
increased bathing facilities in the field and delousing
establishments.
A few words might be apropos of the gas which
the Hun was throwing over in such large quantities.
Three kinds were being used, chlorine, mustard, and
phosgene, the last being the most deadly. A great
deal had been written on this subject so it was not
necessary to go into details, but the pleasant fact
might be mentioned that they had now in the British
service a mask that was absolutely impervious to
any form of gas, so far employed, and the Ameri-
can troops were also using these masks. The
mustard gas was the least dangerous, but it was
troublesome, particularly in consequence of its ac-
tion on the eyes. In some offensives the gunners
and infantrymen were obliged to wear their masks
for twelve to twenty-four hours at a stretch. Prac-
tically all .the casualties from gas now were due
to the fact that the men did not put on their masks
quickly enough through failure to realize that gas
was being used. Arrangements were now being
made for a sufficient number of field ambulances at
the front for the early treatment of these cases, who
would be admitted to a tent where their clothing
would be removed and a shower bath given, fol-
lowed by washing out the eyes with a soda solution.
Ninety per cent, of the cases so treated returned to
their units in three or four weeks.
The method of disposal of casualties had been
developed to a fine point. The wounded were col-
lected at certain predetermined points, called regi-
mental aid posts, brought there by stretcher bearers,
and were carried thence to the advanced dressing
stations two or three miles back where they received
a field dressing. From these they were formerly
taken by horse drawn ambulances to a casualty
clearing station far in the rear, but there were now
in use a large number of light cars which got the
July 20, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
113
wounded back with great speed and a reasonable
amount of comfort. The casualty clearing stations
were really the most advanced hospitals with ex-
cellent facilities for taking care of the wounded and
here all the serious cases were operated upon. The
operating rooms had eight tables, sometimes ten,
and were in use day and night. In order to in-
crease the operating capacity of these hospitals in
time 01 emergency mobile surgical teams had been
organized, which could be moved from hospital to
hospital. Each consisted of a surgeon, anesthetist,
nurses and orderlies. During a strafe twelve to
fourteen teams worked during the entire twenty-
fcur hours and at times they had taken care of two
to three thousand wounded in a single day at one
casualty clearing station. Adjoining was a rail-
road and from here the patients were taken to the
base hospitals in ambulance trains. In the British
service there were forty of these trains with a ca-
pacity of 500 beds each, which gave them a mobile
hospital of 20,000 beds. Each
train was equipped with op-
erating rooms, doctors, nurses,
and orderlies so that the pa-
tients could be cared for at the
same time they were being
transported to the rear to a
base, or to a hospital ship for
transfer to England.
This brought up the sub-
ject of life in the casualty
clearing stations under pres-
ent conditions. At one of
these hospitals, during a time
when Colonel Bruce was
there, they were bombed every
night for six nights. Opera-
tions were carried on in rooms
from which no glimmer of
light escaped and all the huts
containing patients were in
darkness. In the beginning of
the war no possible thought
had been given regarding pre-
cautions as to lights, but they
soon discovered that the lights
which the Geneva convention
fixed as the distinguishing fea-
tures for designating places of
refuge for the wounded simply
became a target for the Hun. So all these signs were
removed from the hospitals. At times they waited
with lights extinguished and when they heard the
hum of the German Gotha they took to the dugouts,
carrying such patients as could not walk. The
patients were evacuated from these hospitals as
quickly as possible, but the doctors and nurses had
to remain and many and varied were their expe-
riences. One night while lifting two or three pa-
tients to a place of safety they heard a crash in the
adjoining casualty clearing station and knew it
had been bombed. One of the surgeons whose
sleeping tent had been hit had been on his way to
rest after a strenuous day when a group in another
hut called to him to join them and being a man of
great amiability he assented and thereby probably
COLONEL HERBERT A I ,h\ .\ X DEK BRUCE,
M. B., L. R. C. P., F. R. C. .S. (England) ;
Temporary Colonel and Consulting Surgeon tn the Brit
ish Armies in France; Associate Professor of
Clinical .Surgery, University of Toronto,
since 1897; President, Ontario Med-
ical Association; etc.
saved his life for his tent was demolished. This
was very fortunate for the service for the man was
Major Darrach. Miss McDonald was less for-
tunate. A splinter of shell caused the destruction
of one of her eyes, but a Parisian doctor made an
artificial eye for her so skillfully that it could not
be disting^iished from the other. They tried to
send Miss McDonald back to America, but she re-
fused to give up her work [applause] and was now
at the front with Major St. John, who has been
appointed chief of a mobile operating unit in the
American Expeditionary Eorces. There were some
twenty-five of these mobile units in the American
service, and they were similar to the French auto-
cliirs. They were really advanced dressing stations
and consisted of an operating room with equipment,
including x ray apparatus, etc., carried on two or
three trucks.
There was a little to be said regarding new meth-
ods. As was well known, practically all wounds
received in the present war
were infected. Various stages
had been passed through in
the treatment of such wounds
and now it might be said that
one technic was similarly em-
ployed in the French, the
British and the American
services. In a word, this con-
sisted of the thorough me-
chanical cleansing of the
wound, the excision of all in-
fected and damaged tissue and
primary closure in cases op-
erated upon at a sufficiently
early period. Where condi-
tions did not permit of this,
then either the delayed pri-
mary closure or secondary
closure took place at the base.
The results obtained were
very striking and they had
had ninety per cent, of suc-
cesses. This was an enormous
saving in time and lives and
man power.
Transfusion of blood was
being resorted to much more
freely than heretofore, and in
the casualty clearing stations
a number of donors were selected and held
in readiness, properly grouped. In addition to
this, a quantity of Group IV citrated blood
was kept in cold storage to be available in periods
of rush, and this blood remained good for a month.
As a rule thirty pints of blood were kept all the
time in an ice chamber in each casualty clearing sta-
tion. During the ofifensive at the end of March
one of these hospitals was lost. Fortunately none
of the wounded, doctors or nurses, fell into the
hands of the enemy, but they mourned the loss of
thirty pints of citrated blood. It was to be hoped
that the Germans employed this blood with their
own men and that it would have a purifying effect.
[Laughter.]
There seemed to have been some misunderstand-
114
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
ing regarding the part the colonies had played in
this war, and there had evidently been a purpose in
the German propaganda to make Great Britain suf-
fer by comparison with the rest of the Empire. Re-
cently a member of the House of Commons pub-
lished some interesting figures in this respect.
Among the six million men of the British Army en-
gaged on fourteen fronts, an entire fifty per cent,
was composed of Englishmen. Wales had con-
tributed about ten per cent, and Scotland about fif-
teen per cent., and the part they had played was
known to all, although the wonderful achievements
of the Fifty-first Division might be recalled during
that terrible time in March when part of the line was
held by them, fighting with their faces to the enemy
continuously for four days and nights without rest,
and it was owing to their heroic deeds that this part
of the line was held during the most critical time
of the war. Ireland had contributed about eight
per cent., in spite of the Sinn Fein, and very nobly
had they fought. The colonies, Canada, New Zea-
land, Australia, and South Africa, had contributed
fifteen per cent. As a Canadian, Colonel Bruce
said he took second place to no man in his appre-
ciation of what the Canadians had done in this war,
but the achievements of the mother country had not
been surpassed even by the brilliant deeds of her
daughters.
The trip, just completed, had taken the members
of this special medical mission through many of
those centres where the people were working day
and night to equip the fighting forces. It was not
necessary to enumerate all that had been seen of
the marvelous and efTective program America was
carrying out upon so colossal a scale and with such
astonishing precision, but it might be said that the
members of the mission had been greatly heartened
at what they had seen, as would be those in Eng-
land to whom they would report on their return.
It was very gratifying to know that America could
come so satisfactorily to the assistance of her allies,
enabling them to secure a complete and final victory
which would lead to the only kind of peace that they
would ever be willing to accept. [Applause.]
PLASTIC FACIAL SURGERY.
Sir William Arbuthnot Lane said that as it
was in the interest of America as well as Great
Britain, he had no hesitancy in talking shop for a
few moments. Early in the war, one of the de-
partments started by the British medical service was
for injuries of the jaw and face. At the commence-
ment that department was small, but it increased in
size as the work improved after the appointment at
Queen's Hospital at Sidcup of a man named
Thomas, who was a great artist and very successful
in his management of these unfortunate fellow crea-
tures whose plight seemed to be the most pitiful of
all those afiflicted by the misfortunes of war. The
personnel of the staf¥ consisted of the greatest plas-
tic and dental surgeons that the service possessed,
nurses and orderlies, a large corps of mechanics,
and this artist whose keen eye visualized at a glance
the former appearance of these poor creatures whose
faces had been so torn by explosives or burned by
flames as to possess little or no resemblance to
human beings. It was hard for the imagination to
compass their sufferings. The man wounded in
the body or the extremities had no such mental
anxiety as the one who felt that on his return home
those most dear to him would involuntarily shrink
at the sight of his disfigured face. Many of them
had destroyed themselves in their despair, but there
was no need any longer for a hopeless outlook, for
the treatment of these cases turned out to be very
satisfactory. Under the discerning eye and gentle
hands of Thomas the work assumed a very high
quality. The progress and development of his work
resulted in about 500 patients being sent to him ;
this represented a small percentage of the wounded.
A certain proportion had other wounds also. The
department grew wonderfully and the Red Cross be-
came interested, and the work went on steadily im-
proving. It was planned to get in those wounded
m this way from the troops of the Dominion of
Canada, of Australia, and of New Zealand. At first
the idea was not received as warmly as one could
wish, because each had little bases in which they
kept these men, but they finally agreed to send their
patients and the best of their surgeons and dentists.
It had seemed a pity America should not take a
hand in it, and so the speaker started a movement
in that direction but without much success at first.
At last Captain Dunning, of the Presbyterian Hos-
pital unit, arrived at Sidcup, and he was delighted
with the work being done. In a little while he was
called away, but shortly afterward twelve American
surgeons turned up. They were very warmly wel-
comed and they sent their assurances of the tremen-
dous value of this experience to them and their be-
lief that it would be of very great advantage to the
United States forces. Among the patients there
were not only Britishers, but a number of Ameri-
cans. It had been a struggle to achieve the desired
aims and the results had been very gratifying, but
the cost was very great, and financial support was
needed. A promise had been made to lay this mat-
ter before the proper authorities here and induce
them to send patients to this hospital and also the
means for their support and treatment. It really
did seem a pity that the American medical service
should go through the mistakes of experimentation.
It would be better to send the American soldiers
there and let them have the advantages of accumu-
lated experience. It might prove to be a slight dif-
ficulty that money would have to be provided, be-
cause the hospital had not the means of accommo-
dating these people, with its slight resources, but
they must be supported somewhere, and their treat-
ment must be undertaken somewhere, and it was
very probable that at the present time, at any rate,
more could be done for them there than anywhere
else.
Some of the work done at Sidcup was marvel-
ous. It was to be regretted that some of these re-
constructed faces could not be shown here. The
improvement in the eye work was especially fine
ever since a method had been devised of making
a cartilage eye in which the glass eye was enclosed
so that there was perfect movement, and no one
would realize that the eye was artificial. The bone
graft work was exceedingly good, the finished result
of a new nose or a new jaw being extremely grati-
fying both to patient and surgeon. Any number
July 20, igiS.l
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
of ears were built up. Sir Arbuthnot was anxious
for America to take a hand in this, not only to train
the surgeons but that American patients should go
there and get the full benefit of friendly competi-
tion, for the men who did the best work on the nose
were given the cases requiring work on the nose ;
those doing best work on the mouth were given the
mouth cases, and so on, and this competition led to
a vast pride in superior work. It would not be fair
to the men from the United States to let them fall
into the hands of those experimenting in nose work
and mouth work when they could be given the ben-
efit of the most highly developed talent and experi-
ence, for all these soldiers who had suffered in de-
fense of a high principle deserved the best that could
be given them.
As Dr. Walter B. James concluded his introduc-
tion of Sir James Mackenzie, a distant strain of
bagpipes was heard, growing gradually clearer until
suddenly through the open doorway appeared Pipe
Major James Cooper, leader of the New York Scot-
tish Highland Pipe Band, dressed in the Mackenzie
tartan, and skirling madly on his pipes a salute to
the chieftain. He marched around the hall, a pic-
turesque and romantic figure, ribbons flying and
figure swaying, and was recalled twice before the
audience settled down to listen with attention and
aftection to the man who has done so much to ad-
vance the world's knowledge of cardiology.
THE SPIRIT OF ENGLISH MEDICINE.
Sir James Mackenzie said that one of the rea-
sons the Special British Medical Mission had been
sent here was to bind closer that growing fellowship
and unity between America and Great Britain and
also to convey certain hints that might be of value.
especially by their failures. The people here had
taken up their work so well and intelligently that
the speaker would not waste time telling them what
to do, but he would try to say one or two things that
might have a bearing on the future.
Sir James said he had always dej)lored the old
colonel SIR WILLIAM ARBT'THNOT LANE, C. B. 1917,
M. B., M. S., F. R. C. S. (England),
Consulting Surgeon, Guy's Hospital, London, and to the Hospital
for Sick Children, London, and Queen's Hospital, Sidcup, Eng.
Sir Arbuthnot had tried to convey the necessity of
knowing how inuch could be saved by trying to ben-
efit by the experience of those long in the war, and
SIR JAMES MACKENZIE, M. D. (Edinburgh), F. R. S.,
F. R. C. P., LL. D. (Aberdeen and Edinburgh),
Physician to Royal College of Physicians, London Hospital.
idea of Americans that progress in medicine was
only to be found in the Teutonic school. If a young
man in this country had a few months to brush up
his medical knowledge, he hastened to a German
city and took an intensive course in his favorite
study, and went home with the idea that he had
done the proper thing. What it should have taken
years to do he tried to do in six months. The spirit
of English medicine had not been understood. The
English school studied the living subject. The
German went to the autopsy room and to the labor-
atory, while the English believed the laboratory
should be the servant, not the master. Medicine
was a science, and true science was always pro-
gressive. Medical science progressed through the
liberty to give birth to new ideas as civilization ad-
vanced. The same ideals that attained to the high-
est form of civilization necessarily lent pace to
progress. It was the growth of ideas and their cul-
tivation that influenced the spirit of a nation. There
was a community of ideas between America and
Great Britain ; they both had the same qualities of
breadth, imagination, vision, and the highest form
of cultivation ; never brutal, never vulgar, never de-
generate : and both countries loved liberty. The
lover of liberty was the investigator, the promulga-
tor of ideas. The true conception of clinical in-
vestigation should be to make the recognition of a
new fact a step to further knowledge. This was
recognized in theory, but it was not always put into
practice. CHnical medicine in Germany dealt with
the later stages of disease, seeking for physical signs
of disease and the changes in the tissues after the
disease had damaged the organism. The continua-
ii6
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
tion of progress depended upon another conception.
How could a German assess, for instance, the value
of an irregular heart when he began his study at
the terminus? lingland's conception of research in
clinical medicine showed a distinct advance. This
was due to a fuller appreciation of the importance
of symptoms and the necessity of more accurate in-
vestigation into these symptoms. This required ex-
haustive observation of individual cases for long
periods oi time in order to note the progress of the
disease and to recognize associated signs and symp-
toms. In cardiology one should be able to assess the
value of an irregularity and to differentiate one that
had significance from one that had none. It was
essential that one should recognize the early stages
of a disease. If one was to be able to ascertain the
significance of murmurs actually caused by a valve
defect, he must turn his attention to the careful in-
vestigation of the symptoms of the disease, know
ihe life history of the subject, watch similar cases
during the illness causing the damage, and note the
gradual changes that ensued during the remainder
to say a parting word to the distinguished guests of
t'le evening, and to express to them, and through
them to the people of Great Britain, the good feeling
of the medical profession and people of the United
States. He referred at some length to the causes
of the misunderstandings that had come down from
the past and the various influences that had favored
their perpetuation and dissemination, but declared
that their hold had been growing less for a quarter
of a century, and that now that the two countries
had come together to fight for the same principles
that caused their differences in the eighteenth cen-
tury, these misunderstandings had disappeared and
were replaced by a strong feeling of kinship. He
thought it could be truly said that all Americans had
come to see the old land in a clearer and better light,
and to look u{X)n her after all as the background of
our liberty and one of the greatest influences for
good in our civilization. He hoped that America
would have the honor of receiving more such dis-
tmguished visitors bearing the good will of their
people and the knowledge gained in the tremendous
Gl.ESTS AT BANQUET GIVEN TO THE MEMBER.S OF THE SPECIAL BRITISH MISSION AT THE
METROPOLITAN CLUB, JUNE 26, 1918.
I, Dr. Walter B. James; 2, Sir William Arbuthnot Lane; 3, Sir James Mackenzie; 4, Colonel Herbert A. Bruce; 5,
Lieutenant Colonel Franklin Martin ; 6, Dr. Charles L. Dana ; 7, Dr. Virgil P. Gibney ; 8. Dr. Leland E. Cof er ; 9, Dr.
Wendell C. Phillips; 10, Dr. Thomas H. Halsted; 11, Dr. William F. Campbell; 12, Dr. Charles W. Pilgrim; 13,
Dr. Frederick Peterson; 14, Dr. Reginald H. Sayre ; 15, Dr. William B. Coley; 16, Major John A. Hartwell ; 17, Dr.
Edward L. Partridge; 18, Dr. Francis Carter Wood; 19, Dr. J. Bentley Squier; 20, Lieutenant Colonel C. A. Warren;
21, Mr. Victor Ross; 22, Dr. Louis L. Seaman; 23, Dr. Edward D. Fisher; 24, Dr. John S. Thatcher; 25, Dr. John E.
Weeks; 26, Dr. Arthur B. Duel; 27, Dr. Waher F. Chappell ; 28, Dr. L. Emmett Holt; 29, Dr. Walter E. Lambert';
30, Dr. Arthur F. Chace ; 31, Dr. Howard C. Taylor; 32, Major Graeme M. Hammond; 33, Dr. Floyd M. Crandall ;
34, Dr. Frederic E. Sondern ; 35, Dr. Carlos McDonald; 36, Captain Henderson; 37, Dr. John S. Waterman; 38, Dr.
J. J. McPhee; 39, Dr. Walter Lester Carr ; 40, Dr. George D. Stewart; 41, Dr. Joseph B. Bissell; 42, Mr. Louis Tracy;
43, Dr. A. R. Lamb; 44, Dr. Walton Martin; 45, Dr. Ernest Fahnestrock ; 46, Dr. Frederick S. Lee; 47, Major Charles:
L. Gibson; 48, Dr. Lewis F. Frissell ; 49, Dr. William K. Draper; 50, Dr. Austin Flint; 51, Dr. Seth M. Milliken.
of life. All these things could be studied, and more
of practical value could be obtained from such study
in three weeks than in six months by the German
method. The British idea was probably the most
helpful of all, for turning to English medical liter-
ature one would find breadth of outlook, philosophic
thought, and always sanity of judgment.
Dr. George D. Stewart, vice-president of the
New York Academy of Medicine, was called upon
experiences of nearly four years of war. He real-
ized the advantage to both countries of seeing and
understanding more of each other. He was very
glad to acknowledge that he had learned much from
what they had said about the work in their respec-
tive fields and had no doubt the American medical
military service would be most happy to avail itself
whenever possible of the advantage of association
with their British brethren in the splendid work they
July 20, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
117
were doing for the wounded. These visitors could
carry back with them the assurance that the people
of the United States appreciated the stand Great
Britain had taken in the war, admired her undaunt-
ed spirit, and acknowledged what they and the world
owed her for her heroic sacrifices. And he thought
there now would be an end to all misunderstandings,
and that all would come to see and realize their
mutual interests in the trying fires of war, and there
would, as a result of their common sacrifices, come
a diflferent outlook and a binding friendship that
would mean much for the good of both countries.
MEDICAL NEWS FROM WASHINGTON.
Training for Military Surgeons at Fort Oglethorpe, Ga.~
Promotion of William J. and Charles H. Mayo to
the Rank of Colonel. — Propaganda Against Typhoid
Prophylaxis.
Washington, July 15, igi8.
In order that the wounded of our army may have
the best obtainable surgical treatment, the army
medical department not only has obtained the serv-
ices of many of the best known surgeons of the
country, but it also is taking many promising physi-
cians of lesser experience and training them for
surgical work in the field and base hospitals.
The work of education is entirely practical. Sur-
geons taking the course themselves wear from
twelve to twenty-four hours the splints, dressings,
etc., that they must put on others, so that they may
learn the feel of them and where and how they hold
and bind. The surgical division of the Surgeon
General's Office has collected all the best practice
into a 300 page digest, which it distributes to the
schools and hospitals. To supplement this, and to
give the latest methods learned from experience at
the front, a monthly review of sixty-four pages is
published. This is necessary, methods having so
changed since the early days of the war that, where
formerly nearly all wotmds became more or less
infected, now more than ninety per cent, of the
wounds are healed without infection ; where at the
outset of the war most of the wounded were held
in hospitals for weeks and months, now a far greater
number return to the ranks in two to four weeks.
This marked improvement is due largely to the
Carrel rriethod of wound treatment, which was little
known when war was declared and must be taught
to most of the surgeons from civil life, for they
usually had not been brought to face such conditions
in private practice.
Special schools of instruction in these methods of
treatment have been opened in about ten of the lead-
ing cities, but the great training centre for surgeons
in military practice is at Fort Oglethorpe, Ga.
There Major Edward Martin, Medical Reserve
Corps, formerly professor at the University of
Pennsylvania, is organizing a surgical school that
will supplement the general instruction given medi-
cal officers at the medical training camp at Fort
Oglethorpe. He will have a corps of associate in-
structors, who will conduct courses in wounds, ex-
cision of tissues, the use of antiseptics, splints, etc.,
and other subjects with a view to making the civil
surgeon conversant with the latest methods of prac-
tice in military surgery.
Major Martin also has been made chief of the
base hospital at Fort Oglethorpe, and the hospital
and school will work in close cooperation. He is
assisted by Captain Edsall Lee, Medical Reserve
Corps, who recently returned to this country after
a year's service in France.
Majors William J. and Charles H. Mayo, Medi-
cal Reserve Corps, the distinguished surgeons of
Rochester, Minn., have been promoted to the grade
of colonel in the Medical Corps of the National
Army. Colonel William J. Mayo has been relieved
from duty in the office of the Surgeon General of
the Army at Washington and directed to proceed to
Rochester for duty as instructor for officers, nurses,
and enlisted men of the Medical Department at the
Mayo Clinic.
Some propaganda, apparently pro-German, di-
rected against typhoid prophylactic treatment as ap-
plied in the army and navy, has come to light.
People from many sections of the country have
been writing to the Secretary and Surgeon General
of the Navy imploring them not to permit the use
of the antityphoid serum for officers and enlisted
men, alleging that it is poisonous, liable to corrupt
the blood, and that it really only is used at the in-
stance of certain manufacturers of vaccine, who,
they say, are making millions from its manufacture
and sale to the Government.
These statements, of course, are so far from the
truth that apparently they have been inspired by
evil motives. If they have pro-German origin, it
should be known that the Germans, who are not
habitually doing anything to injure their own troops,
are understood to be repeating the vaccine treatment
every six months in their armies.
The only serum used as prophylaxis against ty-
phoid in our army and navy is made in the labora-
tories of the Army Medical School at Washington,
without a cent of profit to any manufacturer. So
far as conveying a taint is concerned, the answer is
that it msut be absolutely sterile to have any pro-
phylactic value ; and, to insure this condition and
by way of safeguard against the possibility of con-
taminating the serum, it is submitted to three sepa-
rate chemical tests, difl:'ering radically in character.
Probably the most fatal disease among troops up to
1914 was typhoid, but the disease has been almost
entirely prevented in our army and navy by the pro-
phylactic treatment and sanitary precautions, the
treatment having been commenced in our service in
191 1. In the short period of the Spanish- American
War, out of 20,738 cases of typhoid reported
among the troops, 1,580 men died, and more cases
occurred in the United States camps than in Cuba.
In the two campaigns of our army on the Mexican
border, there were only about six cases of typhoid,
of which only two were fatal.
With the million and more men in the past year
suddenly taken from civil life to camp and canton-
ment, although under conditions where meningitis,
measles, and pneumonia occurred, the cases of ty-
phoid have been negligible, and for the most part
they were where men had escaped inoculation or
had contracted typhoid before inoculation.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. db M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, JULY 20, 1918.
THE RECONSTRUCTION OF THE
DISABLED.
Already we have with us men who have been
maimed in the war. The story of the first blinded
soldier is told by himself in the first number of a
new publication Carry On, issued by the American
Red Cross for the Surgeon General of the United
States Army. This man is being educated for self
support at United States General Hospital No. 7,
at Evergreen, a beautiful country estate at Roland
Park, near Baltimore, which has been loaned to the
Government by Mrs. T. Harrison Garrett for hos-
pital purposes, and is being used as a hospital school
for the blind. This interesting little publication,
edited by Lieutenant Colonel Casey Wood and a
board under the direction of Colonel Frank Billings,
brings out strongly the essential fact that the spirit
as weH as the body of the maimed soldier must be
built up. If an injured soldier is allowed to become
dependent his future is hopeless. Therefore, the
work of reconstruction begins as soon as the patient
reaches the base hospital. The fact is firmly fixed
in his mind that regardless of the character of his
disability he is not to become a beggar; that he is
not to sacrifice his personality and his independence
and that he will be kept under the care of the Gov-
ernment until he has been taught some remunera-
tive occupation, and until a place is found where he
can resume his status in society as an independent
wage earner.
We are fortunate indeed in having this serious
task taken up in such an efficient manner by the
division of physical reconstruction in the office of
the Surgeon General with Colonel Frank Billings
as the director. But this is not the only agency at
work in this particular field. The Red Cross In-
stitute for Crippled and Disabled Men, which was
established nearly a year ago through the gener-
osity of Joseph Millbank, of New York, has already
done most valuable work through the publication
of a series of monographs giving complete informa-
tion regarding the organization of this phase of war
service in Germany, in France, and in England.
These monographs have been prepared by specialists
who have studied the situation thoroughly, and are
full of valuable data for the guidance of our own
workers.
Still another agency has been organized under the
presidency of Dr. W. Gilman Thompson in the form
of a clinic for disabled soldiers and sailors on Liv-
ingston place, New York. This is, we believe, the
first clinic of its kind in practical operation. This
clinic is intended to pave the way for the work of
the Red Cross Institute for Crippled and Disabled
Men by giving special forms of treatment to the
wounded which will prevent distortion and deform-
ity, so far as is possible, through the application of
special forvns of treatment. Dr. R. Tait Mackenzie,
of the University of Pennsylvania, who delivered an
address at the opening of this clinic during the past
week, has installed there a number of special appli-
ances devised by him as a result of his study of
the work done in Canadian hospitals, which have
been very successful indeed in diminishing the un-
toward results of war wounds. This particular
clinic is associated with Cornell University Medical
College, whose faculty will serve in the clinic and
whose students will profit by the opportunities it
aft'ords for observation. No doubt similar institu-
tions are now being organized in other medical cen-
tres. There is no field in which the effort put forth
is productive of such excellent results, for through
such agencies as have been named above, thousands
of maimed soldiers will be saved from the ranks of
dependents and given a place once more among self-
supporting men.
July 20, 1918.1
EDITORIAL ARTICLES.
119
MUSTARD GAS AND ITS EFFECT UPON
THE SKIN.
The carrying on of modern warfare largely-
through the use of poisonous gases necessitates a
full understanding of their nature and effect:
their constitution and manufacture are matters
for Government concern. Their effect' upon the
body tissues and the means of combating or
avoiding these rests with the medical arm of
Government service. Mustard gas or dichlor-
ethylsulphide is the gas which is used in greatest
quantity and produces most disastrous results ;
therefore this is being submitted to experimental
investigation in the laboratories of the University
of Michigan. Dr. Aldred Scott Warthin and Dr.
Carl Vernon Weller [The Pathology of the Skin
Lesions Produced by Mustard Gas (Dichlor-
ethylsulphide). Journal of Laboratory and Clinical
Medicine, May, 1918] have reported their work
upon the skin lesions produced by this gas, re-
serving for another paper the study of the respi-
ratory lesions and of conjunctivitis.
Their experiments were made with animals and
upon human material through autoapplication,
amputation material with consent of the patient,
and accidental chemical laboratory lesions. They
had therefore opportunity to study the lesions
throughout and made careful microscopic, patho-
logical examinations, their results differing some-
what from conclusions reached a number of years
ago through experimental work, and even from
those reported by English and French investi-
gators since the use of the gas in warfare.
Mustard gas proves itself an escharotic, acting
upon the epidermis and tissues of the corium,
particularly the endothelium of the vessels.
There is great damage to the vessels in the af-
fected area, with collapse and some local anemia.
There is no hemorrhage nor thrombosis, but a
distinct fluid exudation and also emigration of
leucocytes. The result of this injury to the ves-
sels with the relatively slight leucocytic demar-
cating infiltration probably accounts for the slow
healing of the lesions. In animals there is slight
hemorrhage by diapedesis.
The burn is a chemical one, unlike that pro-
duced by heat or electricity, or even ordinary cor-
rosives. It is most like that of hydrochloric acid,
and, in its slow healing, resembles the injury pro-
duced by the x ray. The necrosis proceeds very
slowly, not reaching its depth for five or ten days
after application. The writers explain this in
part by contraction and death of the vessels, re-
sulting in anemia in the injured area. The edema
in animals was strikingly intense and deep and
different from that in the human skin. In the
latter, necrosis of the epidermis is usually evident
in two hours and reaches no further than the
papillary layer in the early stages. There is also
early vesicle formation, but, in animals, this was
not observed. The deep penetration of even a
small quantity is another peculiar characteristic.
It enters apparently through the hair follicles, se-
baceous, and sweat glands. The lesions are marked
also by absence of pain, probably due to the
edema and degeneration of nerve endings at the
site of the lesion. The intensity of the effect of
the gas seems to be increased by humidity, and
therefore among the soldiers lesions are usually
found on the covered parts, and because of the
greater moisture of these parts, more severe in the
axilla, between the fingers and toes, around the
genitals, and between the thighs.
These investigators refute the statement of
some observers that the admixture of water in-
creases the escharotic action. They find that if
the oil, the form in which the gas is utilized, is
immediately washed away, the lesion is rendered
much less severe. They advocate washing within
two minutes with tincture of green soap as an
entirely effective preventive measure. At the
most but a slight hyperemia would result. While
this would be difficult to carry out under condi-
tions of warfare, it could be used as a preventive
measure wherever the gas had to be handled, as
in laboratories, factories, and munition depots.
THE DISPENSATORY.
The Dispensatory of the United States has been
so intimately associated with the progress of thera-
peutics that it may almost be taken as its index.
The volume has changed very materially since the
first edition made its appearance with a preface
dated January, 1833, but the principles upon which
the work was based have been followed throughout
and the excellent foundations laid by the authors of
that first edition have been built upon most success-
fully by their successors. The original authors,
Dr. George B. Wood and Dr. FrankHn Bache, would
indeed be gratified if they could see what a colossal
compendium has grown out of their comparatively
modest volume. Even that first edition, however,
was no mean contribution to the medical literature
of that day, for it contained over a thousand pages.
The present, twentieth, edition, which has recently
been issued by the J. B. Lippincott Company, of
Philadelphia, contains more than 2,000 pages and
the type being smaller and more concise, has more
than three times the matter contained in the first
edition.
In its latest form, the United States Dispensatory
contains so much that is new in order to keep it
120
EDITORIAL ARTICLES.
[New York
Medical Journal.
abreast with the extraordinary advances which have
been made in medicine and pharmacy that the book
has been ahnost entirely rewritten. This required
the cooperation of seven men distinguished in their
particular fields. The senior editor, Prof. Joseph
P. Remington, chairman of the committee of re-
vision of the United States Pharmacopeia, who
had been one of the editors of the work since 1880,
died just before its appearance. Associated with
him in this work were Dr. Horatio C. Wood, Jr.,
Prof. Samuel P. Sadtler, Prof. Charles H. La Wall,
Prof. Henry Kraemer, and Dr. John F. Anderson.
All these men are members of the committee of re-
vision of the United States Pharmacopoeia and
speak with authority in their own special depart-
ments.
The new volume contains much that has not here-
tofore been included in the dispensatory, such as an
index of diseases, the text of the federal food and
drugs act, abstracts of federal food inspection de-
cisions, Lhe Harrison narcotic act. with the regula-
tions promulgated for its enforcement, and much
information regarding the more recent additions to
the materia medica ; for instance articles appear on
the so called vaccines and on the various serums
which have come into such general use during the
past few years.
Notwithstanding the spread of therapeutic nihil-
ism, we are still large consumers of drugs. It is
well, therefore, for the physician and pharmacist to
have in such a convenient and accessible form an
abstract of the available information concerning our
materia medica. In the good old days, so often
foolishly deplored, the study of materia medica con-
sisted largely of a study of the United States Dis-
pensatory from "absinthium" to "zingiber." Now
we have all sorts of predigested knowledge laid be-
fore the student in convenient handbooks and the
dispensatory has been relegated to the category of
reference books. As such, however, its value can
hardly be overestimated and a copy of the latest edi-
tion should be in the library of every practising
physician.
THE INTERRELATION OF THE DUCT-
LESS GLANDS.
Since the pioneer work of Claude Bernard with
the ductless glands there has been opened to
medicine almost a trackless field of research. The
functions ascribed to the ductless glands have
been extended, however, to include other glands
which have external secretory functions. It is
found now that such glands as the pancreas,
ovaries, kidneys, cardiac, pyloric, and fundic
glands have both an internal and external secre-
tory action. But the term "endocrinous glands"
refers rather to the glands with only an internal
secretory function, and include the pituitary,
thyroid, parathyroids, the adrenals, and, most
likely, the spleen. The whole range of glands
having internal secretory function is better desig-
nated as a system because of their close interac-
tion. All are so closely bound to each other that
a disturbance in one will throw out of gear or
out of action all the others. Not only do these
glands secrete material which controls certain
phases of the organism, but in order that this
control shall be in harmony they secrete material
for the control of the action of the others. This
control may be inhibitory of the action of the
otiicrs or stimulating. It is either antagonistic
or supplemental. Oversecretion of one gland
soon becomes toxic to the organism, and it is the
function of the others to control this. The an-
tagonistic action of one over the other not only
prevents the overactivity of the others, but keeps
the line of action pulled taut. That even the dis-
turbance in one gland may have dire results can
be seen from the fact that the action of these glands
is concerned with the control of such vital pro-
cesses as the vasomotor system, nutrition, circula-
tion, digestion, etc. Indeed, there is no phase
which they do not control and disturbances
may become manifest even with disturbance
of one gland. It is for this reason that in condi-
tions thought to have origin in this form of dis-
turbance gland medication, organotherapy, con-
templates the giving of the extracts of many
glands, a sort of polyvalent gland extract.
Whether the theoretic basis for this action is
correct or not, better results do in fact follow the
use of polyvalent extracts.
But, while the whole system is strongly bound
together, some of the glands are more closely re-
lated in their action to each other than to other
glands. The thyroid and the adrenals control
each other's action antagonistically — that is, in-
hibiting the overaction of the other. The pitui-
tary, on the other hand, seems to reenforce the
action of the thyroid. However, the thyroid
seems to be the most versatile, having a direct in-
lluence on all of them. The thyroid has, more-
over, a very definite control over the ovaries and
their generative and menstrual functions. The
thyroid and the adrenals are probably most con-
cerned in the control of the sympathetic, al-
though all of the glands are concerned in
the maintenance of the equilibrium of this
nervous system. Gland disturbances may be
either in the production of deficient or of hyper-
activity. Probably such indefinite conditions as
July 20, 191S.]
EDITORIAL ARTICLES.
121
neurasthenia, malnutrition, sexual neuroses, and
allied conditions, and, more specifically cretinism
and dwarfism are produced by deficiency, while
goitre, acromegaly, gigantism, diabetes, gastric
and duodenal ulcers are caused by hyperactivity.
These are but a few of the illustrations of the
wide range of gland activity. There can be no
doubt that many of' the obscure and vague condi-
tions will soon be included among those condi-
tions caused by disturbances of the glands of in-
ternal secretion, and amenable to the same treat-
ment.
ALOPECIA AREATA AND PAIN.
In two cases shown recently before the Royal
Society in London there was rapid and almost
complete baldness completed, in one case, in six
weeks. Both patients were laboratory attendants.
The only possible common factor was microscopical
work and eyestrain, and cases have, been recorded in
which errors of vision have caused alopecia areata.
Sonic cases have recently been attributed to air
raids, and one eminent dermatologist said pain was
a very potent factor. He mentioned a doctor with
an unusual growth of hair on the abdomen who suf-
fered from renal stone and had acute pain in
"Head's area" oji one side. At the seat of greatest
pain there was an area of quite smooth skin. It is
a well known fact that there is a tendency to alo-
pecia areata over the point of pain in neuralgia of
the head. The fact of hair turning white after great
pain or shock does not seem to have any direct
bearing on the cause, as the hair, though changed in
hue often remains as thick as ever.
OUR BRITISH ATSITORS.
It was a fortunate inspiration which prompted the
sending of a medical mission to America by the Brit-
ish government, and a happy choice was made in the
selection of the members of this mission. Sir James
Mackenzie, the senior member of the mission, has
contributed probably more than any other single
scientist to our knowledge of the heart, its functions
and its diseases. The address which he made on
the spirit of English medicine at the farewell dinner
given to the members of the mission by New York
physicians is an admirable exposition of the basic
differences which exist between the methods of teach-
ing in Great Britain and these followed in Germany
and Austria. Colonel Sir William Arbuthnot Lane,
a veteran of the Zulu, the Egyptian, and the Boer
wars, who is an authority alike on surgery of the
bones and surgery of the intestines, made an earnest
plea for a closer coordination of the work of the
surgeons of all the Allies and told of the wonderful
results which have been achieved in plastic facial
surgery at Sidcup. Colonel Herbert Alexander
Bruce, of Toronto, who is now consulting surgeon
to the British army in France, spoke with charm and
enthusiasm of the excellent work being done by our
American hospital units. All three of the distin-
guished guests have spoken to representative gather-
ings of physicians in Cincinnati, in Chicago, in Ro-
chester, in Detroit, in Cleveland, in Pittsburgh, and
in Philadelphia. Wherever they have spoken, they
have won the enthusiastic friendship of their hearers
not only for the speakers individually but for the
cause which they represent and for the service of
which they form so notable a part.
JEAN .SAMUEL POZZI.
It would almost seem as though doctors were
attaining to kingly and presidential distinction in
being assassinated. The general idea used to be
that their errand of healing guarded them safely
in civilian life and the Red Cross in the battle-
field, but now we are finding that they are just
like other mortals, including kings. The blood of
Jean Samuel Pozzi, shed bv his murderous
patient recently, crimsoned the Atlantic and
caused a wave of indignation and sorrow to break
upon our shores. It is not long since he himself
was here, charming all and fascinating the elect
of our profession with his operative dexterity and
calm reasoning in solving gynecological prob-
lems. He was a welcome guest in all the large
cities and ec[ually enjoyed seeing and discussing
art treasures, old books, curios, or interesting
pathological specimens. An imconscious actor,
he posed even in the operating room, and went
unwrinkled through his sixty-eight years because
he never touched too closely with the crowd yet
took great interest as they filed before him in his
busy life. Although death is now such a frequent
visitor that we, unafraid, leave the door ajar
nor shudder at his knock, yet the tragic outgoing
of a great surgeon, a great healing power, will
leave us all a little poorer, a little sadder, because
Pozzi has gone.
HIGHER RANK FOR MEDICAL OFFICERS.
The President has signed the army appropriation
act which carries with it a large number of changes
in the military establishment of the United States.
The act appropriates $12,085,000,000 which is an
increase of $44,000,000 above the aggregate author-
ized in the PTouse bill. Among the changes intro-
duced by the bill is an increase in the Medical De-
partment which includes one assistant surgeon gen-
eral, for service abroad during the present war, with
the rank of maior general, and two assistant sur-
geon generals, with the rank of brigadier general, all
of whom shall be appointed from the Medical Corps
of the regular army. The President is also author-
ized to appoint two major generals and four briga-
dier generals in the Medical Department of the na-
tional army. As the law was finally en-
acted, only half the number of generals were pro-
\ided for the national army asked for in the Owen
bill. A- very important change is that which au-
thorizes the promotion of members of the Medical
Reserve Corps to the rank of colonel. Heretofore,
they could not be given a higher rank than that of
major. In the course of the hearing before the
Senate Committee on MiHtary Affairs, Surgeon
General Gorgas said that the most essential feature
of the Owen bill was that which provided for an
increase in rank to colonel in the Medical Reserve
Corps and this has been covered in the amended
measure.
122
NEWS ITEMS.
[New York
Medical Journal.
. News Items.
American Hospital Bombed. — On the night of July
I5tli, Oerniaii aviators droiiped bombs on the American Red
Cross Hospital at Jouy, France. Two enlisted men were
killed, and nine of the personnel were wounded, including
Miss Jane Jeffrey, a Red Cross nurse from Dorchester,
Alass.
Rockefeller Foundation Mission to Ecuador. — An
American sanitary commission arrived at Guayaquil,
Ecuador, July 9th, to cooperate in wiping out yellow fever
in that country. The commission, which was sent by the
Rockefeller Foundation, includes four doctors and six
nurses.
Doctor Jacobi Honorary President of the Friends of
German Democracy. — Dr. Abraham Jacobi has accept-
ed the office of honorary president of the Friends of Ger-
man Democracy, an organization of Americans, mostly of
German descent, who favor the destruction of Hohenzol-
lern rule.
New Officers of the American Surgical Association.
— At the annual meeting of the association, held in Cincin-
nati, June 6th to 8th, the following officers were elected :
Dr. Lewis S. Pilcher, of Brooklyn, president; Dr. George
W. Crile, of Cleveland, first vice-president ; Dr. Edward
Martin, of Philadelphia, second vice-president; Dr. John
H. Gibbon, of Philadelphia, secretary; Dr. Francis T.
Stewart, of Philadelphia, assistant secretary ; Dr. Charles
H. Peck, of New York, treasurer; Dr. Charles N. Dowd,
of New York, assistant treasurer.
Examination for Surgeons in Naval Medical Corps.
— An examination of candidates for appointment as sur-
geons in the regular Medical Corps of the Navy will com-
mence on September 2d. It will be open only to members
of the Medical Reserve Corps of the Navy who were in
service prior to March i, 1918. At present there are 326
vacancies in the regular Naval Medical Corps, but it is not
expected that all of them will be filled as a result of the
forthcoming examination. However, those candidates that
do not qualify will continue in their present status in the
reserve force.
Additions to Naval Hospitals. — Much additional hos-
pital construction for the Navy is contemplated, and some
of it is already under way. The Naval Hospital at Ports-
mouth, Va., is to be extended by forty buildings of the
pavilion type and a power house, at a cost of about $1,250,-
000. The same amount will be expended on a two story
structure on Ward's Island, East River, New York. Addi-
tions are being built at the existing naval hospitals at Chel-
sea, Mass.; Newport, R. I.; New London, Conn.; Brook-
lyn, N. Y.; League Island, Pa., and Philadelphia, and
extensions are being made to the emergency hospitals at
Charleston and Paris Island. S. C.
Hospital Donations. — John W. Sterling, a New York
lawyer, left a fortune of $20,000,000. Of this $7,500
was given to the Presbyterian Hospital, of New York,
$10,000 to the Bridgeport Hosnital,. and $1,000,000 to the
Miriam A. Osborn Memorial Home at Rye, N. Y. After
numerous specific legacies, Yale University is made the
residuary legatee. It is estimated that the university will
receive about $15,000,000. This is the largest single bequest
ever received by a university, excepting that left by James
Campbell to the St. Louis University, which has been esti-
mated at from $20,000,000 to $40,000,000, but which does
not become available until after the death of Mr. Camp-
bell's wife and daughter.
Treatment of Tuberculous Soldiers.— Difficulty may
be met in holding tuberculous soldiers indefinitely. A time
limit of three months may be placed upon compulsory
treatment in the army sanatorium and the soldier there-
after discharged upon his own request. A tuberculosis
sanatorium will be connected with the special hospitals or
reconstruction units, of which there is to be one in each
of the sixteen military divisions of the country. The gov-
ernment sanatoria for tuberculosis, to be located at Den-
ver, Colo.; Azalea, N. C, and Otisville, N. Y., are now
under construction. There are more than 700 patients at
Fort Bayard, N. M. ; the receiving hospital at New Haven,
Conn., is in full operation, and Whipple Barracks, Arizona,
is being rapidly put in shape by Major Holmberg as a
receiving station.
Officers' Equipment for France. — A notice has been
issued by the chief of stalf as Bulletin 31, War Department,
giving a list of the arms, equipment, and clothing which
would be required for officers going to France. The depot
(piartermaster at New York will furnish on application a
list of manufacturers of clothing and equipment who will
sell these to officers at wholesale cost.
Industrial Hygiene Research at Harvard. — Plans have
been made to give courses of instruction in industrial hy-
giene at the Harvard Medical School, and, through the
cooperation of an advisory board of business men, facili-
ties will be offered for studying occupational diseases and
methods of improving the conditions of labor. The presi-
dent of the university has appointed a committee on indus-
trial hygiene, which is composed of the following mem-
bers: Dr. M. J. Rosenau, professor of preventive medicine
and hygiene, chairman ; Dr. C. K. Drinker, assistant pro-
fessor of physiology, secretary ; Dr. David L. Edsall. pro-
fessor of clinical medicine ; Dr. Reid Hunt, professor of
pharmacology ; and the professor of chemistry. According
to present plans new departments in medicine, physiology,
and chemistry will be created, and courses will be de-
veloped in the pharmacological, sanitary, and social phases
of industry. For information regarding the course apply
tn Dr. C. K. Drinker, Harvard Medical School, Boston,
Mass.
The Army Nurse Corps. — The new military law,
which has been made a part of the army appropriation act,
provides among other things for an increase in the medical
department, which is referred to editorially, and provides
for some changes in the nurse corps, which will hereafter
be known as the army nurse corps. There will be a super-
intendent of the corps with a salary not exceeding $2,400;
assistant superintendents, with a salary of $1,800 each: a
director and two assistant directors for each army or sep-
arate military force beyond the U. S. continental limits,
with salaries of $1,800 and $1,500 respectively; and as many
chief nurses, nurses, and reserve nurses as may be ordered
by the Secretary of War. The chief nurses are to receive
$120 in addition to the pay of nurse. The nurse would re-
ceive $720 a year for the first two years, $780 for the sec-
ond, $840 for the third, $900 for the fourth, and $960 after
twelve years' service in the corps. The reserve nurses re-
ceive the same pay as the nurses, and all members of the
corps receive $10 a month add'tional for service beyond the
continental limits of the United States, excepting Porto
Rirn and Hawaii.
Clinic for Functional Reeducation. — A clinic for the
functional reeducation of disabled soldiers, sailors, and
civilians was opened at 5 Livingston Place, Stuyvesant
Square, New York, on Monday, July 15th. Dr. W. Gilman
Tliompson, the president of the clinic, made a brief address
regarding the organization and function of the clinic. Dr.
R. Tait Mackenzie, of the University of Pennsylvania, de-
scribed the work which was to be undertaken by the crnic.
While established primarily as a war service and for the
treatment of the mutilated men of the army and navy, and
to afford instruction for medical officers, it is intended to
make it a permanent institution. The clinic is affiliated
with the Cornell University Medical College and its staff
includes many members of the teaching faculty. The
buildings have been leased from the New York Infirmary
for Women and Children. The clinic will be open daily,
Sundays and holidays excepted, from 9 to 5. About forty
beds are provided for patients who are unable to walk.
Treatment is offered free to the poor, but the well to do
and those receiving the benefit of war risk or other insur-
ance are expected to pay. The officers of the clinic are :
President, Dr. W. Gilman Thompson ; vice-president, Gi-
raud F. Thomson; secretary. Miss Gertrude Parsons;
treasurer, Mrs. Carlos M. de Heredia ; directors, Mrs. J.
Nicholas Brown. Mrs. Carlos M. de Heredia, Dr. Victor
G. Heiser, Mrs. C. D. MacDougall, Miss Gertrude Parsons,
Dr. W. Gilman Thompson, and Giraud F. Thomson. The
following are the members of the staff: Major Charles L.
Gibson and Major John A. Hartwell, consulting sureeons ;
Dr. Charles L. Dana, consulting neurologist; Dr. Charles
H. Stockard, consulting anatomist : Dr. Charlton Wallace,
orthopedic surgreon ; Dr. William H. Sheldon, vis'ting phy-
sician; Dr. William C. Thro, clinical pathologist: Major
John C. A. Gerster, assistant orthopedic surgeon ; Dr. Wal-
ter H. Brundage and Dr. Edward Miltimore, assistant
physicians.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
SOME NOTES ON DRUGS AND
TREATMENT.
A Review of Recent Progress in Therapeutics.
By Mark S/Vdle.r, M. D.,
Montreux, Switzerland.
L
THE TK£ATMEi\r OF GONORRHEA. CEREBROSPINAL
MENINGITIS, POLYNEURITIS, AND MYELITIS.
Gonorrhea is a general infection, and this should
be always remembered. It may give rise to mani-
festations in the various systems of the body, and
the neuraxis is particularly liable to become in-
volved, so that cerebrospinal meningitis, polyneuritis,
and myelitis may develop during a clap. Whether
or not these complications of the cerebrospinal axis
are due to the gonococcus or its toxins is a question
that experimental work has not as yet determined,
but the clinical evolution of these processes and
simple reasoning should plead in favor of their gon-
ococcal origin. Consequently, the treatment should
take its inspiration from the pathogenesis and com-
prise two indications, namely, general indications
directed against the lesion and gonococcemia ; there-
fore, disinfect the primary focus of the infection
with injections of electrargol or coUargol and
Wright's serum ; and the special indications relating
to each of these nervous complications.
The general indications are those directed not
only against the urethritis itself, but more especially
the gonococcemia. Leaving aside the treatment of
urethritis, since each physician has his own meth-
ods, I would only say that subcutaneous injections
of collargol or electrargol may sometimes render
unexpected results when internal and local urethral
treatment has been of little avail, as occasionally
occur in stubborn cases with marked involvement
of the posterior urethra and adnexa. I would even
advise the use of intravenous injections of these
products if the case is urgent, particularly when
there is evident generalized infection.
As to antigonococcic sera (no reference being here
made to that of de Christmas, since its author has
not employed it in man because of the necessarily
large dose), some good results are to be obtained
with that of Wright and some of those now upon
the market.
Special therapeutic indications. — In gonorrheal
cerebrospinal meningitis the treatment is quite the
same as in the epidemic variety. Stimulants and
tepid baths are useful, but the principal treatment
should be repeated lumbar puncture, which is un-
questionably successful in amelioration. To con-
trol the pain of polyneuritis, rest and exhibition of
analgesics are to be employed. On account of the
present conditions in Europe, one can no longer
obtain pyramidon salicylate, which is unquestion-
ably of great service ; but an almost perfect substi-
tute is now manufactured in Switzerland, called
amidoantipyrin salicylate. The dose is from thirty
to rifty centigrams, several tunes daily, and has no
depressive cardiac action. Some of these cases
will require subcutaneous injections of morphine, or
pantopon, which we in Switzerland much ])refer.
The latter is given hypodermically, two centigrams
or even three centigrams if pain is severe, and, as
well known, some forms of polyneuritis are ex-
cessively painful. For the resulting paralysis,
strychnine has its field of usefulness, but more reli-
ance is to be placed in electricity, massage, and re-
education of the movements, which have given ex-
cellent results.
In gonorrheal myelitis, besides revulsion applied
along the spine, and electricity and massage during
convalescence, the treatment above all should be
prophylactic from the viewpoint of secondary com-
plications. Bed sores are to be carefully guarded
against, the patient being frequently turned from
side to side and a perfect condition of cleanliness
maintained. The use of a water mattress is clearly
indicated. If the catheter is required for retention
of urine, the strictest asepsis is necessary.
RECENT OBSERVATIONS IN DIGITALIS
THERAPY.
By Louis T. de M. Sajous, B. S., M. D.,'
Philadelphia.
{Continued from page 80.)
Among the most recent contributions to the study
of the arrhythmias are those having to do with the
recognition of auricular flutter as a distinct type of
irregularity. Whereas in auricular fibrillation co-
ordinate contraction of the auricle is suspended
through irregular stimulus production at many dif-
ferent points in this structure, with resulting gross
irregularity of ventricular contraction, in auricular
flutter the contractile impulses are thought to arise
in a single focus of the auricular tissue. As in
simple paroxysmal tachycardia, the point of origin
of the contractile impulses is probably an unnatural
one, /. e., separate from the normal pacemaker of
the heart ; in flutter, however, the frequency of the
auricular beat is even greater than in paroxysmal
tachycardia, the line of separation between the two
being arbitrarily placed at 200 per minute because
beyond this rate special, new characteristics of the
heart action, not observed in paroxysmal tachy-
cardia, begin to appear. The auricular rate in flut-
ter— usually from 260 to 320 per minute — is such
that the ventricle is rarelv able to follow the suc-
cessive auricular beats. Partial heartblock almost
invariably sets in as a natural beneficent factor
under these difficult circumstances, and lowers the
rate of the ventricle usually to one half that of the
auricle, /. e., to from 130 to 160; sometimes to one
fourth that of the auricle, i. e., to a normal rate of
approximately seventy-five. Even complete heart-
block is occasionally present. Often the rhythm of
the ventricle is regular ; sometimes it is irregular.
124
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Flutter occurs usually in patients advanced in
years, often in conjunction with arteriosclerosis,
and almost always in the presence of some signs of
myocardial degeneration. In many instances the
condition can be detected without special instru-
ments— in particular, the electrocardiograph. "A
regular and persistent ventricular action of 130 to
160 per minute in an elderly subject," states Thomas
Lewis, 1916, "is a most suspicious circumstance."
If such tachycardia continues a month or more,
without modification of rate upon change of
posture, rest, or exercise, flutter almost certainly
exists. Occasionally during emotion or exertion,
however, the rate of the ventricle suddenly rises to
that of the auricle ; the resulting diminution of the
cardiac outjnit is so marked that temporary syn-
cope results.
Digitalis and its allies are almost as effectual in
auricular flutter as in auricular fibrillation, men-
tioned in the preceding issue. In full doses, they
have been found regularly to lower the excessive
ventricular rate in these cases, and the efifect con-
tinues as long as use of the drug is kept up. In-
deed, in many instances not only is a beneficent
partial heartblock produced, but the auricular con-
dition itself is influenced, the flutter being replaced
by fibrillation and the ventricle, now well protected
from excessive auricular impulse production by the
partial block, being allowed to assume a rate of con-
traction approaching the normal. According to
Lewis, if the drug is now withdrawn the fibrillation
itself in most instances vanishes and the heart re-
turns to a normal rhythm. In a case reported by
Halsey, 1918, however, it was only by energetic use
of digitalis — not its withdrawal — that the restora-
tion of normal rhythm was obtained. In this patient
the ventricular rate had been 160, and that of the
auricle in flutter, 320. Tincture of digitalis in thirty
minim doses every four hours was given. Two days
later the auricles showed fibrillation instead of
flutter ; the ventricular rate was 104, and later de-
scended to seventy-six. Nausea led to temporary
discontinuance of the remedy, but upon resumption
-of digitalis the auricle itself returned in four days
to a rate of seventy-two, with regular beats, the
whole heart being thus restored to a normal sequen-
tial rhythm. In another, similar case, the heart rate
was gradually brought down to and maintained at
eighty-five, but the auricular fibrillation persisted.
As Halsey points out, the giving of such doses of
digitalis as those mentioned should be undertaken
only with hesitation where one is not sure of the
cause of the abnormal pulse frequency. Signs of
cardiac insufficiency accompanying auricular flutter,
such as venous stasis, edema, and dyspnea, disap-
pear almost immediately as the normal rhythm is
restored by digitalis. Here, then, is another condition
in which the effect of this drug upon the rhythm and
rate of the heart is all important in accounting for
the benefit produced ; the degree of benefit it might
be exerting by directly increasing the contractihty
of the heart muscle seems slight or even nil in these
cases. In the remaining forms of cardiac arrhythmia
at present recognized, digitalis is less frequently of
benefit. In sinus arrhythmia, the irregularity is due
to disturbed action of the normal pacemaker of the
heart, which instead of initiating the impulses of
contraction regularly, exhibits an alternate waxing
and waning of rate. The condition is considered
due to alterations of vagus tone, which periodically
becomes excessive, thus slowing the heart. The
irregularity is removed by any factor which decid-
edly increases the heart rate, e. g., exercise or fever.
Digitalis, tending to stimulate the vagi and to slow
the heart rate, is manifestly not of service, and
besides, the arrhythmia itself is, in contrast with
auricular fibrillation and flutter, a harmless condi-
tion.
In premature contraction or extrasystole, ab-
normal, ])remature contractile impulses arise either
in the auricle, the ventricle, or the intervening
tissues, and result in anticipated contractions of the
ventricle. Since, however, plenty of time is given
for recovery and preparation of the succeeding beat,
extrasystoles even when frequent cause but little
embarrassment of the circulation. DigitaHs itself is
capable of inducing premature contractions, appar-
ently through increase of excitability of the heart,
and in so far as any direct influence on extrasystoles
is concerned, is therefore contraindicated in this
condition.
In heartblock, conduction of the impulse of con-
traction from auricle to ventricle is impaired or
completely interrupted. Digitalis itself, as already
noted, tends to impair conduction and has therefore
been held by some to be contraindicated in partial
heartblock, though possibly of service as a direct
tonic to the ventricular muscle in complete heart-
block. As Lewis has emphasized, however, even
complete heartblock is not incompatible with good
circulatory eiriciency, and in many cases of partial
heartblock with impaired cardiac function due to
disease of heart tissues other than the auriculoven-
tricular bundle, digitalis will do more good by re-
lieving dilatation and edema or other symptoms than
it will do harm by increasing the block. Yet this
rule has not been without its unfortunate excep-
tions, and some caution in the administration of the
drug seems advisable.
In alternation of the heart, a prognostically un-
favorable condition characterized by alternate strong
and weak ventricular contractions, without disturb-
ance of impulse production or conduction, digitalis
appears to have no direct influence in overcoming
the alternation, though it might conceivably be bene-
ficial indirectly by improving the nutrition of the
myocardium. Alternation has been known to ap-
pear under large doses of digitalis.
(To be continued.)
Treatment of Puerperal Septicemia by Serums
and Vaccines. — Josue A. Beruti (Boletin de Medir-
cina c Hygiene, Barranquilla, Colombia, November,
1 91 7) concludes from experience that non-specific
serum therapy by the intravenous method gives re-
sults equal to, or better than those obtained with
specific sera, providing the dose per injection be not
more than twenty c. c. Further, the local applica-
tion of nonspecific serum is a rational procedure in
early localized puerperal infections ; and the normal
horse serum possesses indisputable powers of pro-
ducing leucocytosis.
July 20, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
125
Improved Postoperative Mastoid Treatment. —
Daure (Bulletin dc 1' Academic de medccine, March
19, 1918) strongly recommends the use of Bnrthe
de Sandfort's paraffin mixture in mastoid after-
treatment. A special plastic technic in the mas-
toid operation is followed which permits of enlarg-
ing the meatus to any desired size without leaving
any raw surface there. The wound behind the ear
is sutured and all dressings conducted through the
enlarged meatus. An aseptic wick of gauze having
been inserted into the cavity to dry it, the paraffin
mixture, previously sterilized in a flask at 120°
C, is poured in through a nasal speculum
until the cavity is half full. Before it solidifies the
end of a sterile piece of stout cotton cord is passed
into the paraffin. This first paraffin dressing is
allowed to remain five or six days, and the later
dres-sings two or three days. The external dressing
of gauze is renewed about the third day, and there-
after daily, the inner surface of the external ear
being each time washed with ether. In renewing
the paraffin dressing, the block of paraffin is easily
and painlessly withdrawn by pulling on the cotton
cord. The cavity is then merely dried with hot air
or cotton. All the steps should be carried out asep-
tically. The paraffin dressings can be continued up
to complete recovery, though at times, after the
third week, washings with alcoholic boric solution
or powder insufflations are substituted. In all cases
with threatening or already established complica-
tions, or even where there is merely a long standing
disease with pronounced infection, the author em-
ploys the Carrel treatment for a time before begin-
ning the paraffin dressings. Into the adductor tube,
passing through the meatus, are introduced about
ten mils of Dakin's solution every two hours. After
a variable period, the duration of which depends on
laboratory studies if such are practicable, and aver-
aging about a week, the first paraffin dressing is
installed. By these methods complete epidermisa-
tion was obtained, in ten cases, in an average period
of five weeks ; in some cases on the thirty-third and
in one even on the twenty-sixth day. The proce-
dure combines the advantages and obviates the dis-
advantages of the different postoperative treatments
hitherto commonly employed.
The Bad Habit of Vaginal Douching. — W. E.
Fothergill (British Medical Journal, April 20,
1018) points out with emphasis that vaginal douch-
ing has become a fad among physicians and a com-
mon practice among the laity without physicians'
orders, and that its practice does vastly more harm
than good. The vaginal lining is not mucous mem-
brane, but is one of stratified squamous epitheHum,
is not quite impermeable to water and has no secre-
tion other than exuded serum with which leu-
cocytes and epithelial debris are mixed. Mucus
comes from the cervix and uterus. Nomially the
reaction of the vaginal secretion is acid due to the
presence of beneficial organisms, and is therefore
protective against most infectious bacteria.
Chronic douching with medicated solutions washes
the normal protective fluid away, destroys the pro-
tective acid forming bacteria, kills the superficial
layers of cells, irritates the deeper layers, promotes
hyperemia, increases the amount of secretion, and
favors menorrhagia, congestive dysmenorrhea and
intermenstrual pain. Antiseptic douching for in-
trauterine or endocervical infections is useless, and
vaginal infections are very rare and are usually
cared for nomiallv by the vagina if untreated.
Douching for gonorrheal infection of the vulva,
where it is primarily located, merely serves to
spread the infection to the uterus. Very hot
douches to control menorrhagia and other forms of
uterine hemorrhage are seldom taken hot enough
for the purpo.se and usually increase the bleeding
due to the congestion produced. Antiseptic and
medicated vaginal douches are useful in the pallia-
tive treatment of cancer of the uterus to prevent
the foul discharge and as a preliminary prepara-
tion of the ulcerated and prolapsed vagina or
cervix for operation. Warm, normal saline
douches are of value in the convalescence from
pelvic cellulitis to promote the absorption of the
inflammatory exudates through the production of
some congestion.
The Treatment of Advanced Prostatics. —
Frank S. Crockett ( Urologic and Cutaneous Re-
viczv, June, 1918) states that the patient who has
sudden retention should have a nurse for the first
twenty-four or forty-eight hours. The bladder
shovdd never be emptied suddenly. Every two or
four hours a small quantity is withdrawn, t)referably
two to four ounces. Later, if it is found that the
kidney secretion replaces the amount withdrawn, the
quantity can be increased to six or eight ounces : water
should be freely given. The alimentary tract should
receive attention mineral oil being given in a routine
way, coupled with arsenic and iron when the hemo-
globin is low. The two stage operation should be
performed. The second stage should be performed
when the kidney sufficiency increases ; when
pressure efifects on the deep abdominal vessels and
lower bowel disappear ; digestion, respiration, and
heart action improved and when the prostate can be
felt to have shrunken to about half its size.
Fractures of the Elbow in Children. — Mayet
(Presse medicaie, January 7, 1918) disapproves
of the customary immobilization of elbow fractures
in children in plaster casts for a period of three
weeks, and asserts that reduction and fixation can
nearly always be effected more easily, completely,
and rationally in the extended position. The latter
is also highly advantageous in permitting of ready
reduction of lateral disolacements and even of co-
existing dislocations. By allowing the soft parts,
and especially the ligaments, to heal without short-
ening or retraction it facilitates subsequent recov-
ery of the complete range of movements at the
elbow. Care to avoid ankylosis in extension is, of
course, essential. But the line of fracture in these
cases is generally through the zone of epiphyseal
union and bony growth, and consolidation takes
place so rapidly that in ten days flexion can be
substituted for extension and the joint then im-
mobilized again for a period of ten days. By thus
utilizing in succession both of the opposed posi-
tions, complete mobility of the elbow is preserved
and recovery of function hastened. The author's
procedure was carried out successfully in a series
of thirty-five cases of elbow fracture.
126
MODERN TREATMENT AND PREVENTIVE MEDICINE.
fNEW York
Medical Journal.
Nonunion of War Fractures of the Mandible. —
Percival P. Cole {Lancet^ March 30, 1918) says that
the fundamental principle of treatment is the res-
toration of the normal arch and the maintenance
of accurate occlusion. The functional test is the
only one by which results can be judged. In about
eleven per cent, of the cases of fractures of the
mandible nonunion results and the treatment of this
condition is of great importance. Both plating and
wiring may have to be adopted under certain cir-
cumstances, but neither is specially satisfactory. The
best results are secured by bone grafting. Of this
there are two methods. The first consists in uniting
the fragments, after freshening, by means of a free
autogenous graft cut from the patient's tibia and
held in place by a plate at each end. The results are
usually good. Still better, though less widely appli-
cable, is the practice of pedicle grafting by which a
living bone graft is assured. This pedicle graft can
be taken from the lower border of the ramus of the
jav/ with a pedicle consisting of the deep cervical
fascia and the platysma myoides. The graft is
placed in contact with the freshened fragments and
held by passing a silver wire over each end and
through the bored fragments. In both types of
grafting the immobihzation and alignment of the
mandible must be secured and maintained by means
of upper and low^er metal cap splints which are
cemented to the teeth before the operation. The
details of both methods of grafting the mandible are
given.
Important Phases of the Allen Treatment of
Diabetes. — Albert H. Rowe (_N or t Invest Medicine,
March, 1918) emphasizes the need of observing
certain important matters in the conduct of this
method of treatment if the best results are to be
obtained. In the first place a complete physical
examination should be made to discover all ab-
normalities associated with diabetes or which may
influence the results of treatment. Thus all foci of
infection should be eliminated before treatment is
started, the Wassermann test should be performed
to determine the presence or absence of syphilis,
tuberculosis should be sought for, and the circula-
tory system should be examined carefully. In the
second place it is absolutely necessary that the treat-
ment be individualized for each patient. In severe
cases residence in hospital with the care of a com-
petent nurse is essential at the beginning. In less
severe cases daily visits to the physician's office are
essential during the fasting period and the urine
must be examined daily, a twenty-four hour speci-
men being used. In general alcohol and soda should
not be given, but sometimes one or the other may
be helpful. Patients must be taught to approximate
the caloric values of the foods which they eat and
to know the approximate content of each in fat,
protein, and carbohydrate. Continual use of the
proper foods within the limits of tolerance is the
most important of all factors. The weight of the
patient should be kept below normal, but not more
than fifteen ])er cent, below. Excess of food of any
form is harmful and a daily intake between 1,600
and 2,000 calories is usually sufficient. Frequent
careful determinations of acidosis are essential.
Physical exercise is extremely important to shorten
the period of fasting and to restore and increase
the patient's strength and tolerance. Self denial
and will power should be encouraged and the pa-
tient's environment, habits and mental attitude de-
serve investigation and control. Work should be
limited to "eight hours daily and an abundance of
rest assured.
Incarcerated Sepsis. — Albert E. Morison (Lan-
cet, April 13, 1918) recalls the frequency with
which incarcerated sepsis is encountered and infec-
tions from it are lighted up as the result of manipu-
lations or operations. He recommends a very
simple method discovering and dealing with such
incarcerated septic foci preparatory to undertaking
operations. Every previously wounded patient,
even though the wounds are healed and apparently
quite sound and normal, is given ten minutes' treat-
ment daily with radiant heat of from 150° to 250°
F. for a period of a week to ten days. If there is
incarcerated sepsis the scar becomes inflamed in a
few days, fluctuation develops, and some pus can be
evacuated. The wound is then permitted to heal, and
from two weeks to three months after the healing,
depending upon the severity of the secondary in-
fective process, the radiant heat treatment is again
given. If there is no reaction after a week of this
treatment it is safe to operate. Using this method
the author has secured aseptic healing in all cases
of secondary operation. A lesser advantage of the
treatment is also evident in the fact that the scars
become healthier and thinner under the influence
of the radiant treatment.
Trigeminal Neuralgia. — Charles H. Frazier
(Journal A. M. A., May 11, 1918) concludes from
an experience of over 300 cases of this disease that
there are only two forms of treatment which are of
any value whatever, namely, alcohol injection as a
palliative measure and avulsion of the sensory root
of the gasserian gangHon. The alcohol injection
requires a high degree of skill and has to be re-
peated at intervals averaging nine months. It is
not free from dangers, especially to the eye, and is
usually finally followed by the operation of avul-
sion. This operation is truly curative and is not
fraught with any more danger from complications
than is alcohol injection. The ganglion should be
approached through a trephine opening under a flap
incision above the middle of the zygoma. Through
a skull opening the size of a half dollar the dura is
slowly separated from the margins of the bony aper-
ture. When the foramen spinosum comes into view
it is plugged with some convenient material such
as cotton or wax and the middle meningeal artery
divided. The foramen ovale is next exposed and
the dural reflection over the mandibular division of
the nerve is cut as the nerve enters the foramen.
V>y blunt and sharp dissection the posterior third
of the upper aspect of the ganglion is freed of dura
and the sensory root is reached at the apex of the
petrous bone. This is then completely isolated,
caught up on a hook, and severed from its central
connections by gentle traction. The wound is closed
by four layers of sutures. During convalescence
sensory and motor disturbances may appear, but
they are relatively slight and are unimportant.
July 20, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
127
Treatment of Tuberculosis. — Colonel G. E.
Bushnell {Medical Record, May 11, 1918) em-
phasizes the importance of rest in the treatment of
tuberculosis, that is, rest in bed, not sitting up
which is not rest but exertion. Periods of com-
plete relaxation with or without sleep are desirable,
best obtained by assuming the supine posture with
eversion of the arms and legs. While fresh air
is of the utmost importance, the difference between
the air of a well ventilated room and outdoor air
is not sufficient to justify the disturbing of very
sick patients to get the outdoor air. As to exer-
cise, it should be forbidden when the maximum
temperature habitually exceeds 99.5, which tem-
perature calls for bed. Overfeeding is n6t advis-
able as patients become tired of it after a time and
it causes heaviness, acidity of the stomach and a
bad temper. The rest of the treatment is sympto-
matic ; patients with cavities should be taught to
empty the cavity at least once a day by assuming a
position which favors drainage into the bronchi.
Tuberculin is most helpful in those cases which
need it least, namely, the early cases. Advanced
cases are made worse by it and its use is not to be
advocated in the hands of the average phvsician.
The Modem Treatment of Tuberculosis. — H.
F. Gammons {Boston Medical and Surgical Jour-
nal, April 18, 1918) says that the general physician
of today and the past has overtreated his tubercu-
lous patients, and has used the methods of treat-
ment— good, bad, and indifferent — that any or all
authors have advocated. Tuberculin fell into dis-
repute on account of this very reason. Many doc-
tors give tuberculin to all of their tuberculous pa-
tients, regardless of the indications, and push them
nearer their graves. Gammons believes in the use
of tuberculin, but only in the hands of the specialist.
The general physician not being able to interpret
the effect of different treatments, should not use
them except in cooperation with the specialist. As
soon as the diagnosis is made the general physician
should institute treatment, which is, as a rule, rest,
and should educate and guide his patient contin-
uously. He should not give general and superficial
advice, but should see that his patient has rest in
bed, fresh air, a well mixed diet of moderate
amount, sunshine, optimism, and freshness. He
should not give tuberculin, vaccine, artificial pneu-
mothorax, creosote, or exercise, unless by direction
of the tuberculosis specialist.
Fasting in Intestinal Disorders in the Tubercu-
lous.— C. D. Spivak {Colorado Medical, April,
1918) regards rest as the most valuable of all
therapeutic agents and fasting as the only form of
rest available for the gastrointestinal tract. Hav-
ing found partial fasting or short periods of total
fasting to be of great value in the relief of various
gastrointestinal disorders, he has tried it for the
relief of the digestive disturbances so common in
the tuberculous and lias secured the most gratify-
ing results. He recommends that a patient who
vomits a given meal daily should omit that meal
entirely for several consecutive days ; that one
who has no appetite should omit one or more meals
daily until his appetite returns ; that one who has
pain after eating should fast for several meals, etc.
The practice of these recommendations has led to
very marked improvement in practically all cases
and has never proved in the least harmful. It is
also suggested that, since the general bodily func-
tions are diminished in the tuberculous, the diet
should be adapted to the reduced capacities of the
individual and the practice of forced superalimen-
tation should be abandoned as illogical and harm-
ful.
Artificial Pneumothorax in Private and Dis-
pensary Practice. — Alvis E. Greer {Journal A.
M. A., May 25, 1918) reports his very favorable
experiences with the use of artificial pneumothorax
in a series of thirty-two ambulatory cases in private
and dispensary practice. Eight of the patients were
either untreated because of extensive adhesions or
failed to continue treatment and of these all but one
have died. Of the twenty-four receiving adequate
Treatment by pneumothorax all but one are living, the
fatal case having been in a patient with advanced
third stage involvement of a hopeless type. Eighty
per cent, of the treated cases were greatly improved,
more than half having been arrested. The improve-
ment was very rapid and included the prompt fall
of temperature to normal or thereabout, cessation
of night sweating, diminution in sputum, and gain
in appetite, weight, and strength. No ill effects were
observed in any of the patients from the treatment.
It was found preferable to give frequently repeated
small amounts of nitrogen — ^300 to 500 mils — rather
than to give larger amounts less often. The ad-
ministration was made with the Floyd-Robinson
apparatus, the track of the puncture having been
anesthetized with procaine and epinephrine. The
treatment proved of greatest value in first stage
cases, cases with unilateral involvement, those with
only slight involvement of one lung with more ex-
tensive process in the other, cases of acute pneu-
monic tuberculosis, and those with hemorrhage.
Treatment of Cancer of the Rectum. — Charles
J. Drueck {American Medicine, April, 1918), con-
siders that abdominal operation is best in case where
the cancer is limited to the colon or movable sigmoid
and is entirely surrounded by peritoneum. Where
it extends below the promontory of the sacrum a
complete removal through an abdominal incision is
attended with many difficulties and mishaps and the
combined abdominal perineal operation is uncjues-
tionably best. With perineal methods the danger of
recurrence is greater, secondary growths occurring
in the pelvic peritoneum, the pelvic mesocolon and
the lymph nodes situated over the bifurcation of the
left common iliac artery. The following points are
considered essential : the establishment of an arti-
ficial anus , the whole of the pelvic colon must be
removed because its blood supply is contained in the
zone of upward spread ; the whole of the pelvic
mesocolon below the point where it crosses the
common iliac artery, together with a strip of peri-
toneum at least an inch wide on either side of it,
must be cleared away ; the lymjjh nodes over the
bifurcation of the common iliac artery are to be
removed ; the perineal portion of the operation
should be carried out as widely as possible so that
the lateral and downward spread of the cancer may
be effectively extirpated.
Miscellany from Home and Foreign Journals
Meningeal Hemorrhage in War Practice. — G.
Guillain (Bulletin dc I' Academic dc medccine, April
2, 1918) points out that in penetrating wounds of
the skull, nearly all the primary symptoms, as well
as the immediate prognosis, are dependent upon
meningeal hemorrhage. Indications of it are early
coma, epileptiform seizures on the first day, pupil-
lary disturbances, bradycardia, and hyperthermia.
In all cases of penetrating skull injury which suc-
cumbed to shock the author noted both clinically
and at the autopsy the presence of meningeal hem-
orrhage. Inhalation anesthesia and lumbar punc-
ture are attended with danger under such circum-
stances. Even in simple contusions of the skull,
without fracture, due to war projectiles, meningeal
hemorrhage is much more frequent than is gener-
ally supposed. It is marked by slight mental con-
fusion, headache, slow pulse, anisocoria, etc. ; lum-
bar puncture yields a pinkish or yellowish cerebro-
spinal fluid. Subdural hematoma may follow ; yet
its clinical signs — blindness, hemianopsia, aphasia,
paralyses, etc. — may later completely disappear,
either spontaneously or after repeated lumbar punc-
tures. In 191 5 attention was called by the author
to meningeal hemorrhage from nearby explosive
detonations, in the absence of an actual wound. In
addition to the frequently present diagnostic signs
of meningeal hemorrhage, viz., headache, neck rigid-
ity, Kernig's sign, bradycardia, etc., Guillain finds
diagnostically significant a state of cerebral excita-
tion with mental confusion, the contralateral flexion
reflex by pressure on the femoral quadriceps, true
defensive reflexes such as those of the frog, and
pupil disturbances. In a few cases there was noted
a massive albuminuria or a cholemic tint of the skin.
Agglutinin Diagnosis in Triple Inoculated
Persons. — H. Marrian Perry (Lancet, April 27,
1918) points out that prophylactic inoculation with
triple vaccine (T. A. B. — typhoid, and paratyphoids
A and B) has wrought material changes in these
diseases. The clinical form of the enteric infec-
tions is wholly aberrant, and the symptoms have be-
come so modified, or so many are absent which were
diagnostic, that the clinical diagnosis of enteric in-
fection has become very difficult. From the labor-
atory side the condition is similar ; the mortality has
been so reduced that a necropsy on a victim of
enteric infection is now very rare ; the recovery of
the infecting organism from the blood, urine or
feces is now the exception rather than the rule. The
agglutinin test has also been greatly modified, but
it still remains the one method of making a reason-
ably certain diagnosis. As the result of a very
large experience with this test in triple inoculated
subjects the author presents the following conclu-
sions as to its value and the method to be used. The
technic of Dreyer and Walker, of quantitative deter-
mination of the agglutinins for each of the three
organisms against standard agglutinable cultures is
the method to be used, but it must be carried out by
an experienced worker if its results are to be of
value. The test must be repeated at regular inter-
vals to obtain the curve of each of the three agglu-
tinins. Where there is a positive result this is
shown by a rise in the agglutinin curve for one, or
at times two, of the organisms amounting to 100 to
200 per cent. This rise develops in a regular curve
and reaches its maximum between the sixteenth and
twenty-fourth days of the disease. The occurrence
of such a rising curve is diagnostic of infection by
the organism, or organisms, whose curve is affected.
In some cases all three curves may rise and fall in
this manner, and one cannot then make a diagnosis
as to the infecting organism. Negative agglutinin
tests in clinical cases of enteric infection may be due :
I, possibly to the mildness of the infection as a re-
sult of the inoculation, so that few agglutinins are
produced ; 2, to the fact that the infecting organism
is a feeble producer of agglutinins, such as the B.
paratyphosus A; 3, possibly to exhaustion of the
power of producing agglutinins through the admin-
istration of typhoid vaccine prior to the use of the
triple vaccine. Finally, the specificity of the positive
test is shown by the fact that there is seldom any
material rise in the agglutinin curve of any of the
three organisms as the result of other febrile con-
ditions.
A Study in War Nephritis. — John P. Peters,
Jr., and A. Raymond Stevens {Journal A. M. A.,
June 8, 1918) studied 155 cases classed as war ne-
phritis with a view to determining whether or not
there was such a distinctive clinical entity which
might be regarded as a disease per se. Of the 155
patients, forty-seven per cent, were found to be suf-
fering from recurrence of symptoms of chronic car-
diac or renal disease. Of the remaining eighty-two
patients, forty -nine were suffering from definite
acute nephritis, usually indistinguishable from that
seen in civil practice. Eight had typical trench
fever with evidences of nephritis and four had pan-
urinary infections with pyuria. A group of fifteen
patients stood out from the rest in presenting a pe-
culiar and characteristic clinical and pathological
picture. In most the onset was sudden, but some
had mild prodromal symptoms. The constant and
predominant symptoms were profuse hematuria,
frequency and urgency of micturition, and a vari-
able and irregular fever. In the febrile stage the
patients gave the picture of an acute infection ; later
the chief appearances were pallor and debility. A
few showed slight edema or puffiness of the face
and slight dyspnea on exertion. Heart and lungs
were normal, as was the blood pressure. Blood and
urine examinations and cultures for organisms were
negative. In addition to gross hematuria all but
one of the patients showed casts in the urine with
albumin which could be accounted for by the blood.
The phenolsulphonephthalein output was generally
somewhat reduced. The typical physical sign was
found on cystoscopy, being the occurrence of a vari-
able number of submucous hemorrhages in the blad-
der, varying from the size of a pin point to one centi-
meter in diameter. In most cases fresh, fluid blood
was also seen coming from the ureters. Pathological
examination of tissue removed from the bladder at
the site of the hemorrhages showed no inflamma-
July 20, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
129
tion, there being merely a transudation of whole
blood. The nature and cause of this peculiar con-
dition, which constituted fifteen per cent, of all of
the acute nephritic cases, was not determined. The
evidence seemed to point to its being in part a renal
affection. The work is being continued.
The Inorganic Elements in Nutrition. — Thoma?
B. Osborne and Lafayette B. Mendel {Journal of
Biological Chemistry, April, 1918) prepared a num-
ber of salt mixtures in which one or more of the
inorganic elements was omitted and replaced by in-
crements of the remaining ones so as to maintain the
acid base balances as nearly as possible. The foods
were all carefully analyzed, and all contained small
measured contaminations of the elements which it
was desired to exclude. The animals were given
distilled water to drink. With diets low in calcium
and phosphorus there was a characteristic slowing
of growth of the animal, which was quickly altered
when calcium in the inorganic form was added to
the diet. With diets low in sodium, potassium,
magnesium, or chlorine, growth was not inhibited,
though when both sodium and potassium were de-
creased at the same time growth ceased, and recom-
menced when only one of the elements was missing.
No conclusions were reached with the magnesium
free diets. They conclude it is not necessary to con-
sider the presence of calcium, phosphorus, and iron
in natural foods to the degree that is generally be-
lieved, as their experiments show that the growing
animal can supply its need of these elements from in-
organic sources. Under ordinary circumstances it
is possible to supply any shortage of an essential in-
organic element iDy the use of its salts. In feeding
farm animals, where there is a lack of calcium and
phosphorus in their grain, the authors say that the
fact that complete nutrition can be attained upon
diets in which the inorganic ingredients are sup-
plied in the form of their commercial salts has a
significance just beginning to be appreciated.
The Nutritive Value of Maize Protein: Phos-
phorus and Calcium Requirements of Healthy
Women. — H. C. Sherman, Lucile Wheeler, and
Anna B. Yates {Journal of Biological Chemistry,
May, 1918) studied the nitrogen, calcium, and phos-
phorus balances in two healthy women during seven
consecutive periods of four days each, using in the
first series a diet of wheat bread, butter, peanut
butter, milk, meat, apples, and grape juice, and m the
second series with one subject a diet which included
200 grams of corn meal a day, about one-third
of the protein thus being derived from maize, and
with the other woman a diet largely made up of
wheat bread for twenty days, and then for eight
days corn meal was substituted for much of the
wheat flour used in the bread and also for part of
the sugar previously used, so that about one-fifth
of the protein of the last period was derived from
maize. Unless eggs or milk were used plentifully
in cooking it was difficult for one unaccustomed to
eating maize to live on the diet without a
disturbance of appetite or digestion. How-
ever, the conditions of the experiment were
very severe, so that the authors regard the
results as very favorable to the use of maize pro-
tein in normal adult nutrition, because on a con-
tinued low protein diet, where forty-seven per cent,
of the total protein was from wheat flour and thirty-
one per cent, from corn meal, the latter was used
efficientlv in maintaining the nitrogen equilibrium,
and also because when maize protein was substituted
for wheat protein to an extent affecting one-fifth
of the total protein intake, there was no unfavorable
effect on the nitrogen balance. The minimum out-
put of phosphorus per day of 0.71 to 0.69 gram
in these subjects, who weighed sixty and fifty-four
kilos respectively, would correspond to the minimum
requirement of an average sized man per day (0.83
and 0.89 gram respectively in a man weighing
seventy kilos). In both subjects there was a con-
stant negative balance for calcium and nc tendency
to equilibrium.
Influences of Extrarenal Factors on the Renal
Functional Test Meal.— W. G. Lyle and H. Shar-
lit {Archives of Internal Medicine, March, 1918),
in studies in normal and nephritic subjects, found
that extraneous influences might modify the results
of the meal test for renal function in the form sug-
gested by Mosenthal. Two such factors definitely
identified were : the state of water reserve in the
tissues and chilling of the body surface. These
influences affect chiefly the fluid element in the test
meal reaction, mainly because the skin and lungs
make a preferential demand on body fluids, while
the excretion of soHds by the skin and lungs is prac-
tically negligible. They are sufficient to demand
caution in judging of the renal functional efficiency
on the basis of Mosenthal's method of test meal in-
terpretation, especially : on the basis of a single test
meal ; in individuals well enough to be about and
who are exposed to the diverse influences of tem-
perature, humidity, and rate of metabolism ; where
no strict control of the dietary of the test meal is
attempted. Early diagnosis of renal insufficiency
by this test meal method is hazardous unless fre-
quent tests consistently show renal involvement.
The Renal Function in Cardiac Insufficiency.
— Achard and Leblanc {Presse medicale, March 14,
1918) note that in cases of heart disease with dim-
inished output of urine, urea often tends to accumu-
late in the blood, lessening, however, when diuresis
is started. Ambard has ascribed the urea accumu-
lation directly to the reduced output of urine ; the
kidneys are held still capable of concentrating urea
without difficulty, but the outflow of fluid is in-
sufficient. The authors have found that so simple
an explanation of the condition does not always
answer, for upon fractionating the urine one sees at
short intervals the urea being eliminated in very
different degrees of concentration, the latter in-
creasing progressively as the output of urine rises
and the degree of albuminuria falls. These facts
can be explained on the basis of variations in the
circulation of blood through the kidneys ; stasis,
when it becomes accentuated, temporarily lowers
the power of the kidneys to concentrate urea. After
the onset of polyuria, on the other hand, one can
observe an increase of the concentrating power to
above normal. Similar observations may be made
in acute diseases.
130
MISCELLANY FROM HOME AND FOREIGN lOURNALS.
[New York
Medical Journal.
Relation between the Tetanoid Symptoms of
Guanidine Administration and the Condition of
Acidosis. — C. K. Watanabe in this, his third,
study (Journal of Biological Chemistry, April,
19 [8) administered sublethal doses of guanidine
hydrochloride to rabbits, with a resulting marked
acidosis, as evidenced by the increased hydrogen
ion concentration in the blood, and the decrease in
the alkaline reserve. After the injection the rabbits
showed symptoms of tetany. A hypoglycemia was
also produced, as a secondary phenomenon of guani-
dine poisoning. No parallelism between the severity
of acidosis and hypoglycemia appeared to be pres-
ent. The injection of guanidine produces symptoms
analogous to those of tetania parathyreopriva, so
that the assumption that guanidine plays an impor-
tant role in the development of tetany would appear
to be strengthened.
The Basis of Measurement of Antagonism. —
W. J. V. Osterhout {Journal of Biological Clicm-
istry. May, 191 8) says that in order to measure
antagonism it is necessary to know the additive ef-
fect, which he defines as the effort which would be
found if no antagonism existed. He discusses and
illustrates by means of diagrams methods of de-
termining the additive effect and of measuring an-
tagonism. When it is impossible to determine the
additive efi^ect with sufficient accuracy to be of value
one may only be able to determine whether antago-
nism exists where it can be shown that the effect
of any combination of substances is less than that
produced by the most strongly acting substance in
the absence of the others and at the same concen-
tration at which it exists in the combination. If
the elfect is greater than this it may be due to an-
tagonism, additive effect, or the opposite of antag-
onism.
Cardiac Disturbances in Scarlet Fever. — Flo-
rand and Paraf (Bulletins ct mcmoircs de la So-
'ciete mcdicale des hopitaux dc Paris, February 7,
1918) report that in a series of twenty-seven cases
of scarlatina seen in the Val-de-Grace Hospital since
August, 1917, no less than fourteen developed un-
mistakable cardiac complications. In a few in-
stances the heart sounds were observed to be distant
and muffled upon admission, i. c, on the second to
the fourth day of the disease. Usually, however,
the cardiac disturbances appeared only from the
fourth to the eighth day. Evidences of impaired
cardiac function were, as a rule, absent or but shght,
only three patients complaining of precordial distress
and slight dyspnea. Thus, as in rheumatic fever,
cardiac trouble in scarlatina can be satisfactorily
traced only by daily auscultation. The mitral valve
was that chiefly affected ; in fact, none of the four-
teen cases showed any aortic involvement. The
physical signs were precisely those met with in rheu-
matic fever, the initial muffling of the heart sounds
being followed by the appearance of murmurs, often
irregular, with or without lengthening of the first
sound and reckiplication of the second. Likewise,
as in rheumatic fever, the murmurs often disap-
peared from one day to the next, and returned per-
manently, in a few cases, only in the terminal stage.
In four cases the condition passed into a chronic
mitral insufficiency or double mitral lesion. The
remaining cases left the hospital merely with tachy-
cardia and instability of the pulse. During the
course of the heart disturbance the pulse always re-
mained good, and was often accelerated. There
were never any arrhythmia nor signs of myocardial
fatigue, though in one instance bradycardia was
present for a few days.
A Case of Anaphylaxis. — G. H. Waugh {British
Journal of Children's Diseases, January-March,
1918) reports the case of a girl, aged seventeen, who
presented the clinical picture of diphtheria. The
mother stated that the child had had diphtheria ten
years previously and the injection had made her
very ill. She was given 4,000 units of antitoxin and
died within five minutes. The visible effects at the
time of death were : deep cyanosis ; great difficulty
in breathing; frothing at the mouth. At autopsy
the only condition found was a general stasis with
well marked congestion of the lungs. The girl was
a catarrhal subject but had never had asthma.
Intermittent Fever from Meningococcal Septi-
cemia.-— Arnold Netter (British Journal of Chil-
dren's Diseases, January-March, 1918) concludes
that meningococcal infection may assume the clini-
cal appearance of typical intermittent fever, quotid-
ian, or tertian. The attacks often coincide in such
cases with the appearance of an eruption, such as,
erythema nodosum, erythema multiforme or pur-
pura. These eruptions, which might arouse atten-
tion, are often absent. In the majority of cases
symptoms of cerebrospinal meningitis succeed these
febrile attacks but they may not appear for one or
two months or more. Meningitis may be absent
altogether. The diagnosis must be made by bac-
terial examination. Blood cultures and cultures
from the nasopharynx will supply valuable informa-
tion. The intermittent attacks give way rapidly to
serum treatment. Serotherapy may cause an
alarming reaction soon after the first injection. In-
trathecal injection is less dangerous than intra-
venous.
Gastric Secretion during Fever. — J. Meyer,
S. J. Cohen, and A. J. Carlson {Archives of Internal
Medicine, March, 191 8) studied this question in dogs
with Pawlow accessory stomachs, producing fever
by intravenous injection of sodium nucleate or a
killed culture of B. prodigiosus, feeding meat with
water five or ten minutes later, and then observing
and testing the gastric secretion. Striking and con-
stant results were obtained. The gastric secretion
during fever was found to be diminished in volume
and in total and free acid. The percentage of
chlorides is constant or only slightly reduced, and
the pepsin relatively increased. The secretion is
ropy and mucous in character. External heat, when
sufficient to raise the temperature by from 2 to 4° F.,
was found to cause the same changes in the gastric
juice as are produced by fever. Both in fever and
in temperature elevation due to external heat, gas-
trin— a product which when injected subcutaneously
causes a definite secretion of gastric juice in which
psychic factors play no role — proved incapable of
inducing gastric secretion. The authors suggest
that during fever toxins are elaborated having a
direct depressor action upon the secretory cells of
the stomach.
Proceedings of National and Local Societies
MEDICAL SOCIETY OF THE STATE OF
NEW YORK.
One Hundred and Twelfth Annual Meeting, Held
at Albany, May 21, 22. and 2^, ipiS.
The President. Dr. Alexander Lambert, in the Chair.
Etiology of Nephritis. — Dr. CI^ARLES Jack
HuxT, of Clifton Springs, presented a study of
342 cases of nephritis, sixty of whicli were studied
by the methods outlined by the author. Of these
sixty, forty-seven were submitted to corrective and
dietetic measures and were subsequently restudied.
The longest period of observation was two years
and the shortest twenty-six days, following cor-
rective measures. Correspondence with the home
physicians of the groups secured replies from the
majority of them or from patients, and in a few
instances from both. Of the twenty-three cases un-
corrected, three had died from nephritis and six-
teen reported advance of the disease or no improve-
ment ; four were not noted. Of forty-seven cases
submitting to corrective measures, nine had not been
noted, six reported little or no change, and thirty
were much improved or apparently as good as ever.
The latter quotation, "much improved," appeared
frequently enough to be used as a general state-
ment.
The group of nephritics in whom no other etio-
logical factor, except bacterial toxins, formed chronic
foci, were studied by recognized renal functional
tests under control diet both before and after re-
moval of discoverable foci. Culture study showed
the streptococcus mucosus as the principal patholog-
ical evidence. Of forty-seven cases restudied, other
bacterial forms, in the order of frequency, were
a diphtheroid organism, bacillus mitis, streptococ-
cus candidus, streptococcus viridans, and pneumo-
coccus. Thirty-six were reported prior to the pre-
sentation of the paper. Of these thirty were im-
proved and had resumed normal modes of living.
Of twenty-three cases not corrected, nineteen were
reported, three having died, and sixteen showing
advance of the disease.
The work in chemistry was carried out person-
ally by MV. Roger S. Hubbard ; that in bacteriol-
ogy by Mrs. C. Brogden and Dr. M. S. Woodbury.
The management of diets and the technical clinical
work was entirely under the direction of Miss Lil-
lian Bradley, to whose assistance the author was
indebted for the detail of such work, requiring as
it did both time and patience.
Dr. Charles G. Stockton, of Buffalo, stated
that he did not know just how carefully or how rad-
ically Doctor Hunt classified his cases of nephritis,
but it did not seem to make very much difference,
because as these cases were seen they were either
primarily from infection alone or from a mixture
of infection and metabolic defects, and in the man-
agement of all cases it was up to the practitioner
to get rid of infection and correct the metabolic
defect. The paper was very important, and the
author's view of nephritis ought to be verv thor-
oughly appreciated and methods carried out such as
had been described. It was surprising to find
how much benefit might come in some appar-
ently hopeless cases. He had seen rather acute
types of nephritis, with marked metabolic disturb-
ances following infection, the infection producing
anasarca and cerebral symptoms of a grave charac-
ter ; yet he had seen those disturbances pass off
without any apparent effect on the kidney remain-
ing. He had in mind a woman who went safely
through a gestation, who at one time seemed to
be a hopeless nephritic. In her case he felt con-
vinced the reason for relief was the removal of
the tonsils, and subsequently the careful regulation
of diet and studies of the blood.
The Diagnosis of Nephritis. — Dr. Albert A.
Epstein, of New York City, stated that on the basis
of our present knowledge a diagnosis of nephritis
was confronted with two distinct problems ; first,
the determination of the pathological processes in-
volved ; and secondly, the evaluation of the kidney
function. An accurate diagnosis of nephritis, there-
fore, entailed a circumspect and complete analysis
of all the morbid conditions present ; the probable
etiological factors involved, the disturbance in
function, and other disorders which arose there-
from. To regard nephritis as an independent con-
dition was a fallacy.
The problem in the diagnosis of acute nephritis
was essentially different from that of chronic ne-
phritis. In acute nephritis there was acute damage
to normally functioning organs, which having been
previously sound were again more or less quickly
restored to nonnal, provided they were not over-
whelmed by the destructive agent. In the diag-
nosis of acute nephritis or subacute nephritis, a
consideration of the etiological factors involved was
very important ; they were usually bacteria or their
toxins, or as he believed to be the case with cer-
tain subacute types, constitutional disorders of meta-
bolic or endocrinous origin.
The existence of acute nephritis, excepting, of
course, the chemical nephritides and the types oc-
curring in pregnancy, therefore pointed usually to
an antecedent infection. But renal disorders with
urinary signs frequently occurred in febrile diseases
of all kinds, which did not represent true nephritis,
and thus the problem of diff'erentiation often arose.
In this latter group of cases, of course, the signs
usually were not so pronounced. There was an al-
buminuria, at times, with casts. Functional disor-
ders also arose. But there was not as a rule that
marked evidence of renal involvement such as was
found in the true cases of nephritis, nor did the
disturbance last much beyond the duration of the
febrile state. The difference, perhaps, was arbitrary
and one of degree only.
In the matter of chronic nephritis, the problem of
etiology as a source of information was much more
difficult. No doubt, in a certain number of cases
a history of acute nephritis or recurring infections
might be elicited, and a diagnosis made, but the
connection between the two was not always clear.
Chronic poisoning, tuberculosis, or syphilis might
132
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
be contributory factors, and required consideration
in the diagnosis. There was one difficulty that pre-
sented itself from the clinical side in investigating
the question of the connection between acute, sub-
acute, and chronic nephritis, and that was, that
acute and subacute nephritis might appear during
any infection without the development of symptoms
other than the urinary signs. Furthermore, in the
chronic nephropathies it was the possibility and the
frequent occurrence of compensatory processes that
created difficulty in arriving at a diagnosis. This
was particularly true when the question was viewed
from the functional standpoint.
In the application of functional tests in the diag-
nosis of nephritis, two points should be borne in
mind, namely, that a number of the different func-
tional tests should be made, and that they should
be repeated in each and every case. As a pre-
requisite to the proper interpretation of the results
obtained by functional tests, extrarenal factors
which were capable of modifying or influencing
them should be definitely excluded.
Nephritis was rarely an isolated or independent
condition. The accurate diagnosis of nephritis in-
volved the consideration of many different factors
which entered into the production of its clinical
manifestation. Improved methods of investigation
permitted us to get a much more comprehensive
analysis of the disease, and enabled us to under-
stand its menace and variable features. Reliance
should not be placed on any one method of analysis
or investigation ; all of them should be used to at-
tain the one end, namely, a proper diagnosis. At-
tention was called particularly to the heretofore
unrecognized importance of changes in the protein
and lipoid composition of the blood as a means
of diagnosis of certain types of renal disorders.
Pathology of Nephritis. — Dr. Herbert U.
Williams, of Buffalo, stated that the pathology of
nephritis was in a rather confused state. Efforts
were now being made to connect the diseased con-
ditions that were found and their structures with
the causes of these diseased conditions on the one
hand, and on the other hand, to connect these dis-
eased conditions with changes in substance. He
passed over those cases of nephritis that were due
to obvious focal infections such as were found in
an ascending pyelonephritis or in tuberculosis.
These by rather common consent were omitted in
a consideration of this character. Taking up ne-
phritis in this sense, the old fashioned classification
was simple, but it had been considerably modified in
the course of time to secure a more exact classi-
fication, and almost every one divided nephritis into
tubular or glomerular subdivisions. The chronic
form of glomerular nephritis was by many held
to be identical with chronic interstitial nephritis.
There was great difficulty in separating these from
the arteriosclerotic kidney, which resembled it
closely in many cases. As a matter of fact, it was
exceedingly difficult to draw a hard and fast line
between the different types of nephritis, not only
clinically, but anatomically. To be perfectly safe,
one should call a case of nephritis, diffuse, in almost
all instances. The epithelium of the tubules under-
went j)ostmortem change. The kidney of a normal
subject which had had time to undergo postmortem
changes frequently showed alterations that it was
quite difficult to differentiate from what was usually
called cloudy swelling. The epithelium of the con-
voluted tubules was exceedingly sensitive, and in va-
rious conditions of bacterial toxemia or in poison-
ing by metals and other agencies there were marked
degenerative changes in the epithelial cells. Albu-
minous degeneration of the epithelial cells, fatty
degeneration, desquamation, were seen frequently
in this class of cases. It was seen in mercuric
chloride poisoning, in the acute toxemias like diph-
theria and septicemia, in acute yellow atrophy of
the liver, and so on. In many cases there were clear
evidences of inflammation in the form of exudation
into the tubules, and frequently leukocytes in and
around them, and sometimes blood. Many of these
cases would show alterations in the glomeruli at
the same time. The moderately pure type of this
form of nephritis was more common than glomeru-
lar nephritis.
In recent years there was a tendency to attribute
the granular contracted kidney to earlier attacks of
glomerular nephritis. The formation of new fibrous
tissue in a kidney, leading to chronic interstitial
nephritis, seemed more and more to be attributed
to the formation of fibrous tissue in response to
a loss of substance rather than as a result of irri-
tation.
We were not able at the present time to connect
the pathological anatomy very closely with changes
in function. The classification of nephritis into
glomerular, tubular, the late glomerular, the chronic
interstitial, and the arteriosclerotic was quite gener-
ally adopted, and the most interesting point was
that of determining the relation of focal infection
to glomerular nephritis by ascertaining that it was
actually caused by bacterial emboli and not entirely
through the agency of toxins. Finally, a number
of very high authorities (Stengel, Mallory, and
Ophuls) were of the opinion that granular con-
tracted kidney was closely connected with the
arteriosclerotic kidney, and difficult to distinguish
from the latter, and was very largely the late results
of an earlier glomerular nephritis, possibly repeated
attacks of glomerular nephritis. He quoted Mallory
as saying that a patient who recovered from his
toxemia and from his acute attack might suffer
almost equally from the reparative changes which
occurred in the kidney.
Treatment of Chronic Nephritis. — Dr. John R.
Williams, of Rochester, stated that the most com-
mon type of kidney disease seen was that of the
middle aged adult who complained of some or all
of the following symptoms : tiring easily, occipital
headache, shortness of breath, high blood pressure,
with little or no physical evidence of kidney dis-
turbance except frequent and excessive urination at
night. The blood was commonly low in urea, cre-
atinine and phosphates ; the blood sugar might be
high. Edema was usually not present. Death was
rarely caused by uremia, rather by cerebral hemor-
rhage or failing heart. This was the well known
cardiorenal type.
The next most frequently seen type was the mid-
dle aged or even younger adult who might have
July 20, igi8.]
PROCEEDINGS OF SOCIETIES.
133
pronounced eye symptoms, edema, low or high blood
pressure, very little kidney reserve, urine loaded
with albumin and casts, blood containing two or
three times the normal amount of urine, a high
blood sugar, increased blood creatinine and phos-
phate retention. Death was commonly preceded by
convulsions and the phenomena associated with
uremia.
The last and much less frequently seen type was
that of the young or middle aged adult who com-
plained chieHy of edema, weakness, and pallor, with
no albuminuria ; blood urea and sugar would be
found low, perhaps lower than normal. The choles-
terin content of the blood might be greatly in-
creased ; edema might or might not be influenced by
the salt content of the diet. The functional ca-
pacity of the kidney was fairly normal tO' the usual
clinical tests. The patient suffered very little from
headache or from other symptoms commonly seen
in failure of the kidneys.
The first and one of the most important steps in
the treatment of any type of kidney disease was to
rid the body of all focal infections. The investiga-
tion of suspicious tonsils, crowned teeth, and dis-
eased prostates could not be overemphasized.
In the treatment of the cardiorenal type, if it
was certain that the patient was not harboring in-
fection, the most important measure was rest, both
mental and physical. If the patient had a good
functional kidney capacity he should be put on a
low general simple diet. All chemical irritants in
the way of spices, mineral acids, alcohol, and foods
containing quantities of animal extractions, bacteria,
and bacterial products should be excluded from the
diet. The patient should be allowed to have some
meat and eggs.
The second clinical type demanded quite a dif-
ferent therapeutic regime than did the cardiorenal
type. In severe cases the best internal measure
was to put the patient at rest and give him a lim-
ited milk fluid diet as first suggested, by Karell.
The author prescribed for the first few days one
quart of milk, one pint of water, and either another
pint of lime water or some salt of calcium, either
the carbonate or lactate in half gram doses several
times daily. The tincture of iron or ferrous car-
bonate in liberal doses was also given.
In the third and last common type of chronic
kidney disease the diet should be more liberal, and
should contain a large amount of protein. As
many as eight to ten ounces of meat might be very
helpful. Fluids should be restricted. If there
was evidence of salt retention its use should be
curtailed, otherwise it might be sparingly permitted.
Discussion. — Dr. Arthur F. Chace, of 'New
York, agreed with Doctor Jones relative to treat-
ment, that in parenchymatous nephritis physicians
now -gave a larger protein diet than formerly. His
experience confirmed that of Doctor Epstein, that
in these cases, weakness, anemia, and deficiency of
the blood could be overcome by large amounts of
egg, meat, and albumin. A radical change had
taken place in the treatment of parenchymatous
nephritis. He had been surprised how few cases
of parenchymatous nephritis he had come in contact
with. He did not see them as a sequel of organic
disease or blood retention, and he did not give a
large protein diet owing to the number of cases of
mixed types. In the interstitial type of nephritis,
where there was considerable retention of products
of nitrogen metabolism in the blood, a low protein
diet should be given to maintain body strength.
There had been great danger in the treatment of
diabetes as well as in nephritis, in giving too low
a diet. The i)endulum had swung too far in ef-
forts to eradicate sugar from the tirine quickly, and
by lowering too quickly the amount of protein in
the blood. For this reason he did not agree with
Doctor Williams in giving too low a diet, because
one must consider the patient's bodily strength.
There was a distinct advantage in giving mineral
salts. A patient with interstitial nephritis should
take a large vegetable diet, with an ample amount
of mineral salts in the right proportion, both anti-
scorbutics and vitamines, to overcome the tendency
to anemia. In this type of cases profound anemia
was not given suf¥icient attention. The reason the
general practitioner did not give heavy vegetables
in nephritis was because the patient would not take
them, but vegetables that were pureed, thoroughly
mashed, and put through a colander could be given
an intelligent patient. In this way a large vari-
ety of vegetables could be used. The speaker gave
calcium in adequate quantities to eliminate phos-
phates.
Dr. a. a. Jones, of Buffalo, said that in discuss-
ing the pathology of nephritis the changes which
occurred in the kidney in cases classified clinically
as purely interstitial, purely cardiorenal, or purely
parenchymatous, must be kept in mind. Some years
ago we were apt to disregard the glomerular ele-
ment in chronic nephritis, and to look upon the car-
diorenal cases as primarily interstitial cases. The
glomeruli did not suffer early from the changes
occurring around the tubules. The interstitial
changes followed cellular changes in the glomeruli,
and there was destruction of many of the glomeruli
before an abundant interstitial new formation oc-
curred. In the treatment one should include care-
ful consideration of the causes of the disease if
they could be discovered ; so that focal infections
should receive attention just as carefully as dietary
regulations.
Captain Thomas W. Jenkins, of Albany, stated
that they had had several cases of acute nephritis
among the soldiers. One patient, who died follow-
ing an attack of mumps, had only albuminuria. His
kidneys did not show any marked change. One case
which interested him more than any other was a
man who, fatigued by intensive training for a
commission, became ill after paratyphoid inocu-
lation, and developed one of the worst cases of
nephritis he had ever seen. His urine was loaded
with epithelium, and he died in the second week of
illness.
Dr. Albert E. Larkin, of Syracuse, said that
many of these patients were affected in more than
one part of the kidney, and for that reason each
case was a demand for treatment according to the
case in hand. It was difficult to lay down any
hard and fast rules to treat these cases of nephritis.
The best treatment for these cases of nephritis was
134
PROCEEDINGS OF SOCIETIES.
[New York
Medical Journal.
the same as for arteriosclerosis, namely, preverition
of the disease before it has formed. Along this
line we were probably going to accomplish a great
deal more by taking care of cases of acute infec-
tion, and cases of overeating, and overwork, and
guarding against putting extra strain on the circu-
latory and renal apparatus. In this way we would
eradicate many of the diseased conditions.
Dr. Joseph R. Wiseman, of Syracuse, said that
the work of Doctor Hunt was particularly praise-
worthy in attempting to find out in advance whether
a partictilar tonsil or other focus was apt to be the
cause of the symptoms in a given case, or whether
they might not be coincident. The technic of per-
fectly drying the tonsil and painting it with iodine,
and aspirating from the tonsil contents, and mak-
ing cultures from the material obtained was excel-
lent. In those cases in which a streptococcus was
found Doctor Hunt thought that the tonsil was a
dangerous one and should be taken out, and accord-
ing to his case reports he had achieved splendid
results, although most practitioners had been dis-
appointed after removing foci of infection that
looked like etiological factors. Sometimes in pa-
tients with chronic nephritis and diseased tonsils
the removal of the tonsils was not followed by im-
provement. Other patients with similar conditions
would improve remarkably following the removal
of the tonsils.
Dr. M. S. Woodbury, of Clifton Springs, said
there were certain individuals who were susceptible,
but looked as though they could carry a certain
amount of infection as long as their resistance was
good, but when their resistance was lowered they
began to show evidences of arthritis or hyperten-
sive symptoms which indicated the possibility of the
presence of toxic material. He had yet to discover
an individual who did not believe in the possibility
of damage from infection and who had been able
to give him a satisfactory reason for the conserva-
tion of pus. He did not believe there was any
good reason for conserving pus, and if there was
no objection to getting rid of it, it should be re-
moved.
Dr. J. Wejnstein, of New York, was always
under the impression that nephritis, like a degenera-
tive process in any other organ, was due to some
infection. He had noticed that certain diseased
conditions of particular organs seemed to run in
certain families. In two or three generations of
one family one would find that the ofYspring were
apt to suffer with nephritis, as if there was a spe-
cific liability of some particular tissue to disease.
With regard to diet, he had put patients on a rather
low protein diet and was never afraid of using meat.
He allowed a patient to have good steak or poultry,
provided it was not taken in excessive quantity.
The Kareli diet was a well established therapeutic
procedure in cases of nephritis with edema. In
cases with high blood pressure one should not for-
get to employ digitalis in spite of the high blood
pressure.
Dr. Albert A. Epstein, of New York, in
closing, stated that there was uniformity of opin-
ion regarding the type of renal disease in which
the disturbances were purely metabolic. There was
no reason why the renal function should not be con-
comitant with the metabolic disorder ; so that there
were cases in which there were mixed conditions.
In such cases the method of treatment must be some-
what different from the one set down originally.
Dr. Herbert U. Williams, in closing, stated
that with regard to the influence of syphilis in
nephritis, he knew of the work of Stengel, pub-
lished in the Journal of the American Medical As-
sociation some three or four years ago. He (Sten-
gel), however, furnished no proof in the way of
hndings. In cases of congenital syphilis the body
was found riddled with organisms, and there were
gummata in the kidney. With reference to focal
infections, one method of great value which might
be used to prove the importance of focal infection
would be to examine carefully the urine for long
periods for organisms.
Dr. John R. Williams, in closing, said that he
attached a great deal of importance to the removal
of infection wherever found if it bore any rela-
tion to the disease in question. All foci of infec-
tion did not exist in the mouth. A diseased process
in the cervix or in the cervical glands might account
for the trouble.
The Clinical Significance of Congenital Ano-
malies of the Kidney and Ureter ; with Notes on
the Embryology and Fetal Development of the
Kidney. — Dr. Joseph R. Loske ?nd Dr. Henry G.
Bugbee, of New York City, described the develop-
ment of the organs of the upper urinary tract in
man, and traced their relationship to various anoma-
lies. Among the tw^enty-two cases of anomalies
reported by the authors were one case of single
kidney, one case of calculus obstruction of the ure-
ter, three cases of horseshoe kidney, one case of
fused kidney, one case of duplication of the kidney
pelvis, and one case of incomplete duplication of
the right kidney pelvis and colon bacillus infection.
Cases of anomalies of position of the kidney were
reported. In one case the right kidney was low,
and had not rotated. In another case the kidney
had migrated to the opposite side. Cases of anoma-
lies of the ureters had been reported.
The surgical treatment consisted in relieving
pressure, placing the kidneys in their normal posi-
tion, removing any obstruction to renal drainage,
and removing the diseased kidney, when destroyed
beyond repair, if the opposite kidney was able to
carry on its function. If it was not possible to
make a positive diagnosis of the extent of the le-
sion before operation, operation should include ex-
ploration of both kidneys.
Congenital Hydronephrosis. — Dr. John T.
Geragiity, of Baltimore, said there was a group
of cases which had been puzzling practitioners for
years. He referred principally to so called primary
hydronephrosis. The term primary had been used
in these cases because there had been no etiological
factor that could be easily determined as the cause
of this kind of hydronephrosis. Many of the cases
had been considered congenital, and the opinion
had been held until recently that most of the cases
in which we could actually determine any cause for
this extreme process were congenital. Recent
studies, however, had shown that this was incor-
July 20, 1918.]
PROCEEDINGS OF SOCIETIES.
135
rect. There were two types of aberrant vessels which
were most apt to cause hydronephrosis. In one
instance the vessels arose from the aorta behind
the ureter and entered the lower surface of the
kidney at its lower pole. In the second case the
vessel arose from the vena cava, crossed the ante-
rior surface of the ureter, and entered the pos-
terior surface of the kidney. These two conditions
gave rise to a condition which produced obstruc-
tion. In a series of fifteen cases, in only two was
he able to find aberrant vessels as the cause of hy-
dronephrosis. The vessel crossed at the ureteropel-
vic junction, but further studies showed that this
()Ossibly was merely a coincidence. Marked kinking
of the ureter or pressure of a vessel crossing over
the ureter was not sufficient to produce hydrone-
piirosis. However, in some cases of unusual mo-
bility, where the kidney dropped down over the
aberrant vessel, that vessel might play an important
role. Even though aberrant vessels were found, it
was well to bear in mind that they might not be
the primary cause. There might be other factors
that played a causal role. Renal mobility was put
forward as a common cause, and most urologists
gave it first place. In the author's experience it had
been the most common cause of hydronephrosis.
In the series of fifteen cases, in ten nephrectomy
was performed. The tissues were studied, and suf-
ficient of the ureter was removed to study the cause
of the hydronephrosis. In three cases plastic pro-
cedures were carried out, and in two cases aberrant
vessels were divided. In a study of these ten cases,
with one exception, there was found at the uretero-
pelvic juncture, or in the upper part of the ureter,
an inflammatory infiltrate. Most of these cases
were previously considered congenital, but sections
through the ureter in studying the pelvis showed
varying amounts of infiltration. Hunner, he said,
had called attention to pyogenic infiltrations in the
lower ureter, and he had found them common in
women in the region of the broad ligament. These
infiltrations of the ureter caused dilatation of the
ureter and pelvis which were frequently seen, and
which Doctor Braasch had considered an inflam-
matory dilatation. It represented a narrowing
rather than a definite stricture, with obstruction
rather than dilatation of the process in the kidney
and ureter itself. Inflammation did not give rise
to dilatation, but rather a contraction.
The diagnosis of hydronephrosis was not diffi-
cult. With the methods now at our command it
was possible to make a diagnosis of hydronephrosis
by pyelography and to demonstrate the exact point
where the hydronephrosis began. In most cases the
kidney was destroyed when the patient was first
seen. At any rate, it was either badly infected or
the kidney was destroyed. Nephrectomy was the
proper treatment.
The Prognosis in Surgical Renal Tubercu-
losis.— Dr. Wtlli.\iv[ F Braasch. of Rochester,
Minnesota, stated that in considering nephrectomy
for early unilateral tuberculosis the factors to be
considered were age, sex, coincident tuberculosis in
other organs or tissues, the duration of the symp-
toms, the severity of the infection of the urinary
tract, and whether there was or was not bilateral
involvement. The stati-stics of the Mayo clinic were
given. Age was a factor of considerable importance
in the diagnosis. The incidence of renal tubercu-
losis was from twenty-five to forty years of age.
Beyond the age of sixty or seventy years renal
tuberculosis was of rare occurrence. They had
operated in three cases up to ten years of age. In
the meantime they had seen forty cases in children
up to ten years of age, and these had not been
operated upon, because renal tuberculosis in chil-
dren was very frequently a part of a general tuber-
culosis. The children on 'whom they had operated
were seen early and tuberculosis was not found
present elsewhere. It was not customary to operate
on children at once because the majority of cases
sooner or later showed other evidences of tubercu-
losis and their resisting power v/ould be low.
As to the time to operate, it was between twenty-
five to forty years of age, as the mortality increased
steadily with the advance in years. The greatest
mcrtality occurred in patients from fifty to seventy
years of age. The lowest mortality from operative
intervention occurred in patients from fifteen to
twenty.
The influence of complications on the mortality
was important. The majority of cases had evi-
dences of tuberculosis in other organs of the body.
In only five per cent, was the renal tuberculosis
complicated by acute pulmonary tuberculosis. Ninety
per cent, of the cases of renal tuberculosis had
evidences of an old pulmonary tuberculosis. Of
the cases of pulmonary tuberculosis complicated by
renal tuberculosis, twenty-one in number, forty per
cent, died, which was twice as high as the mortality
from renal tuberculosis uncomplicated by pulmon-
ary tuberculosis. However, if they had not oper-
ated on patients with both j)ulmonary and renal
tuberculosis all would have died. It was incon-
ceivable to think of a spontaneous cure of renal and
pulmonary tuberculosis.
The removal of the epididymis when enlarged or
markedly inflamed, with secondary infection, was
unquestionably advisable following nephrectomy.
It was their experience at the Mayo clinic that the
caseating kidnev ofi'ered a much better prognosis
and a lower mortality than miliary tuberculosis.
In miliary tuberculosis scattered over the surface
of the kidnev the mortality was higher than where
caseation was present. It was almost twice as high.
Discussion. — Dr. Benjamin S. Barrtnger, of
Nc\y York, pointed out the importance of not
operating on the kidney without the previous
use of the cystoscope. He had cystoscoped
every patient that came for operation for the
last two or three years, and recalled only one case
in that tii!ie in which he had operated without
cystoscopy and that patient had but one kidney.
Tlie fact that one often saw enormous vessels of
the kidney and comparatively infrequently observed
hydronephrosis, showed there was something wrong
with the anomalous vessel theory.
Dr. Ern£.st Watson, of Buffalo, stated that the
pyelogram with a shadow casting substance was the
only measure we could rely on with any certainty in
making an absolute diagnosis. It was well to make
tnore extensive use of shadov/ casting substances,
136
BOOK REVIEWS.— BIRTHS, MARRIAGES. AND DEATHS.
[New York
Medical Journal.
the pyelogram and ureterogram, in these cases,
particularly if they did not show evidence of infec-
tion. Often a dilated ureter and dilated pelvis
would not give evidence without examination of the
ureter.
Dr. George Stark, of Syracuse, believed that a
ureter that was bent over an artery or was kinked
by ptosis of the kidney produced thickening or in-
duration of the ureter. He recalled sixty cases of
renal colic with hydronephrosis that had been cured
by dilatation.
Doctor Braasch, in closing, said that so far as
ptosis was concerned, very few of their cases of
renal ptosis had a large hydronephrosis. He was
under the impression that they did not find the large
hydronephroses described by Doctor Geraghty.
Frequently slight dilatations of the pelvis of the
kidney were found with ordinary renal ptosis.
Trench Fever. — Major Alexander Lambert,
of New York, read this paper, an abstract of which
will be published in the Journal.
The Psychology of the War. — James M. Beck,
LL. D., of New York, delivered a scholarly address
on this subject. He selected the play of Hamlet
and by analogous reasoning each principal char-
acter represented a nation. An abstract of the ad-
dress will appear in the Journal.
^
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.']
Radiologic dc Guerre. Lc Rcpcragc des Projectiles. La
Collaboration radio-chirurgicale. Par Louis Delherm,
Chef du Laboratoire d'Electro-Radiologie de I'Hopital
de la Pitie, radiologiste expert d'une Armee, et J.
RoussET, Licencie es-sciences physiques manipulateur.
1.34 figures. Paris : A. Maloine et Fils, 1918. Pp. viii-
355-
This book is a veritable encyclopedia of the localization
of foreign bodies, not only by the x ray but also by means
of the electromagnet, the electrovibrator and the tele-
phone. And not only is the localization studied in dis-
tance and direction from a definite mark upon the sur-
face of the body, but valuable tables are given showing
in just what organs a foreign body lies for each geomet-
rical location. One principle of x ray localization con-
sisting in marking, under fluoroscopic observation, sur-
face points of entrance and exit for two rays passing
through the foreign body at widely different angles but
in the same vertical plane. The foreign body manifestly
lies at the intersection of these two lines. Several dif-
ferent apparatuses are described for making the x ray ob-
servation to actermine the proper place for the surface
markers, and for calculating or expressing graphically the
position at which the two lines intersect and where the
foreign body must lie. Various "compasses," frames with
arms of adjustable length and an indicator which shows
the distance and direction of the foreign body, may be
placed upon the patient at the time of"^operation in a po-
sition determined by the previous x ray localization.
Another prmciple is that of making two radiographs
with the patient and the plate in the same position but
with the tube shifted a definite distance and direction,
in a plane parallel with the plate before the second ex-
posure. Of course the foreign body lies at the place
where a line from the first position of the anticathode and
the image resulting from the first exposure intersects the
line representing the second exposure. Numerous appar-
atuses are described for making the radiographs and cal-
culating the .position of the foreign substance in distance
and direction from a mark upon the surface of the body,
or by representing the position graphically, by crossed
wires for example. Various compasses are useful at the
time of operative removal.
Stereoscopic radiography is descriljed and so is Taul-
eigne-Maio's radiostereometer, a special apparatus which
enables one to measure anteroposterior distances in a
pair of stereoscopic radiographs. The electrovibrator is
a powerful electromagnet, originally activated by an alter-
nating or an interrupted current of sixty amperes, but now
by resonance witli only ten amperes. It is held close to
the skin and the nearer one comes to the location of the
foreign body, the more the finger held upon the surface
feels tlie ■viliration of the foreign body under the alter-
nate attraction and repulsion of the electromagnet. Iron
and steel give the best results but most metals respond
to some extent. The modern telephonic test detects me-
tallic foreign bodies at a distance while the telephonic
bullet probe invented by the late Doctor Girdner, of New
York, long before the discovery of the x ray, only recog-
nizes the presence of the bullet upon actual contact with
it. The book is complete and most practical.
A Diabetic Manual for the Mutual Use of Doctor and
Patient. By Elliott P. Joslin, M. D., Assistant Pro-
fessor of Medicine, Harvard Medical School; Consult-
ing Physician, Boston City Hospital ; Collaborator to the
Nutrition Laljoratory of the Carnegie Institution of
Washington, in Boston; Major, M. R. C, U. S. Army.
Philadelphia and New York: Lea & Febiger, 1918. Pp.
ix-187. (Price, $1.75.)
To quote the author's opening sentence in the preface, "for
one diabetic patient who knows too much about his dis-
ease there are unquestionably ninety-nine who know too
little." It is to aid the physician in imparting the desired
knowledge to the ninety and nine that the present manual
has been written, and it is admirably adapted to the work.
While intended primarily for lay perusal, the volume con-
tains so much thoroughly modern information and the
manner of presenting it is so suitable for use in dealing
with patients that it will undoubtedly prove extremely
popular with medical readers also. The development of
the modern therapy of diabetes has involved such demands
on the intelligent cooperation of the patient that there has
been a great need of just such a book as this — not so long
or so technical as to affright the layman, but yet sufficiently
detailed and authoritative to furnish a reliable guide.
There are four parts to the manual. The first covers the
general idea of the nature of diabetes and the principles to
be followed in its treatment. In the second the details of
the treatment are described at greater length. The third
gives cooking recipes and menus suitable for diabetics, and
in the fourth the more important laboratory tests required
in following the course of the disease are described. There
are many ingenious and helpful diagrams and tables.
Epideniologia: Datos Historicos Sobrc La Pestc Bubonica.
Por Antonio Butron y Rios. Delegado Especial del
Consejo Superior de Salubridad Para Combatir las Epi-
demias de Peste Bubonica en el Estado de Sinaloa, etc.
Afexico: Andres Botas, 1916. Pp. xvi-270.
This volume of 270 pages consists of a very detailed ac-
count of the epidemic of bubonic plague occurring in the
State of Sinaloa, Mexico, in 1902 and 1903. The prophy-
lactic measures employed, as well as the histories of a con-
siderable number of cases, are given at much length, and
the favorable results of treatment with Yersin's serum are
reported.
• ®
Births, Marriages, and Deaths.
Died.
Drury. — In Asbury Park, N. J., on Tuesday, July 9th,
Dr. Alfred Drury, of Princeton, aged forty-six years.
Gray. — In Worcester, Mass., on Sunday, July 7th, Dr.
George R. Gray, aged fifty years.
Lank. — In Boston, on Friday, July 5th, Dr. John G.
Lane, aged sixty-four years.
McAviNNUE. — In Lowell, Mass., on Sunday, July 7th,
Dr. Frank McAvinnue, aged sixty-five years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII, No. 4. NEW YORK, SATURDAY, JULY 27, 1918. Whole No. 2069.
Original Communications
MODERxN OBSTETRIC TECHNIC.
Compared %uith the Teacliiiiy of Tzventy Years Ago.
By George L. Brodhead, M. D.,
New York.
Within a short time .after the completion of two
years of general hospital training, I had the good
fortune to spend two years, 1895 to 1807, as resident
obstetrician in the Sloane Maternity Hospital, the
best service to be had at that time in the country,
the college and hospital instruction being given by
Dr. James W. McLane and Dr. E. A. Tucker. Two
years' service under the teaching of Doctor Tucker
was an experience for which i shall always be very
grateful, and, many times in the past few years, in
thinking over the technic used at the Sloane twenty
years ago, I have thought it might prove interesting
to compare the methods then in vogue with the
present ones.
Thinking first of the antepartum or prenatal
work : There was no daily routine more rigidly in-
sisted upon or supervised than the careful, sys-
tematic examination of the pregnant woman. In-
creasing experience completely justified the pains-
taking examinations, which included palpation,
auscultation, and pelvimetry. In the conduct of
normal labor, during my earlier months, at the
Sloane Hospital, no sterile gowns were used, and,
even in 1897, rubber gloves were unheard of. At
the present time, both gown and rubber gloves are
worn, and many of us wear a cap and face mask,
as in general surgery. The greater the precaution
taken, the less the danger of septic infection. At the
Harlem Hospital and in our private work the rectal
examination is used in all cases, unless there is very
good reason for entering the vagina. We believe
that far more harm than good results from vaginal
examinations, and, in my opinion, there should be
clear indication for making a vaginal exploration.
Presentation and position can usually be determined
by external examination, and a large number of our
hospital and private patients have been delivered
with no internal examination, except per rectum.
For the rectal examination, no preparation of the
patient is necessary, the gloves need not be sterile,
thereby saving much time and with a little experi-
ence, a vast amount of information is obtained. In
border line cases, where Ca^sarean section may be
the ultimate operation, the rectal examination is
almost a necessity. I can almost hear some of vou
say, "Yes, but how about prolapse of the cord?"
This is a rare obstetrical complication, and, unfor-
tunately, a frequently fatal complication, in spite of
any treatment, but in many patients the vertex is
engaged at the beginning of labor, and the cord
cannot prolapse ; but in cases where the membranes
rupture, the head being unengaged, the vaginal ex-
amination should be made principally and practically
only to ascertain if the cord has prolapsed. Upon
careful consideration, it must be admitted by all
open minded men that the vaginal examination is
frequently unnecessary, and even with thorough
preparation forms a possible channel of infection.
At the end of the labor, after the expulsion of
the placenta, it was our rule to administer ergot,
and such is the teaching of many obstetricians to-
day. We believe with Hirst and others that ergot,
if given, should be administered at the moment of
birth, and for many years we have done so, with
only good results. In other words, the drug must
be given in time to control hemorrhage, by contract-
ing the uterus before the bleeding is likely to occur,
so we give it immediately after the child is born,
without waiting for the placenta to be expelled.
It was our custom to invade the uterus for re-
tained membranes. During my last year there re-
tained membranes were left in the uterus, and so
satisfactory were the results that I have never ex-
plored the uterus for retained membranes since.
The retained portion will come away in small pieces,
or perhaps in one large mass, and I see no reason
to attribute hemorrhage or sepsis to the mere reten-
tion of chorion. During the puerperium, the pa-
tient was catheterized every eight hours if she
could not void spontaneously. This I feel was a
great mistake, for as a rule, patients need not be
cathe<:erized, if a longer time is allowed, or one c. c.
of pituitrin be given hypodermically, or the woman
be allowed to sit up on the bedpan or chamber, or
even allowed to get out of bed on a commode.
Sometimes an enema will produce the desired re-
sult, and, when there is no distention, the patient
may be allowed to wait eighteen to twenty-four
hours with no discomfort, and no bad results.
Pituitrin is one of the most valuable additions to
the obstetrical armamentarium. Used in postpartum
hemorrhage and before Csesarean section, it is in-
valuable, and as a substitute for forceps, in properly
selected cases, has no equal. We have also admin-
istered it successfully in small doses, two to five
minims. to accelerate a slow and tedious
labor. For the induction of labor, we have
Copyright, 1018, liy A. R. Elliott Publishing Company.
1
i
BRODHEAD: OBSTETRIC TECHNIC.
(New York
Medical Journal.
had, as a rule, very unsatisfactory results.
Personally, I believe with the head at the outlet,
the forceps, in sUillful hands, is a safer pro-
cedure than the use of pituitrin. We have also used
pituitrin in cases of inevitable and incomplete abor-
tion with satisfactory results in a fair number of
cases. There is merit also in the suggestion made
by Furniss that pituitrin be given before performing
curettage in abortion, with the idea of contracting
the uterus, and lessening the hemorrhage. This
gives excellent results.
Before taking up the operative phases of modern
technic, just a reference to puerperal septicemia.
In our hospital and consultation work we still see
many cases of sepsis and I am sorry to say that, in
my opinion, we shall always have more or less of
the condition to deal with. Lack of personal clean-
liness in the patient, combined with careless and
ignorant vaginal examination, will always account
for a certain number of cases. Conversely, the
cleaner the surroundings, and the greater the care
taken by the accoucheur, the less will sepsis be met
with. The patient who is infected, will have a
much better chance for life, if treated conserv-
atively, with good drainage, good food, and an
abundance of fre.sh air.
Taking up operative procedures ; one of the
smallest, episiotomy, was never performed during
my service at the Sloane, but a few years later, I
was impressed by its value, and have been using it
ever since. It has not received the degree of at-
tention it deserves, yet it is so simple, so devoid of
danger, and so successful, that we believe it is per-
formed far too infrequently. The late Professor
Jewett, said that episiotomy substitutes for a
posterior laceration, which is often difficult of com-
plete repair, incisions through less important struct-
ures which can easily and perfectly be closed by
sutures, and that "no method yields better results
for the ultimate integrity of the pelvic floor than
episiotomy rightly timed and properly executed.
The ultimate condition of the pelvic floor after the
0])eration, correctly performed, is even better than
after many natural deliveries in which the parts
escape rupture." Among indications for the opera-
tion, are : rigidity of the perineum, so common in
elderly primiparas, edematous soft parts which we
know are easily torn ; cases in which large fetal
heads must pass through small vulvar outlets ; any
condition such as the passage of meconium in vertex
presentation, or a rapidly failing fetal heart necessi-
tating speedy delivery through a small outlet ; cases
in which there is a large amount of cicatricial tissue
in the perineum, and, finally, and of great impor-
tance, the operation is -ndicated as a prophylactic
mcasiu'e in breech presentation.
The operation is performed by making two in-
cisions, one on either side, at a point about one third
of rhe distance from the fourchette to the anterioi
commissure. An ordinary straight blunt pointed
scissors may be used and the incision should be
made horizontally, about one half to fln-ee quarters
of an inch in depth. The skin should be pulled out-
ward so that the incision will be largely through
the mucous membrane. Occasionally one lateral in-
cision is sufficient. The incisions are easily re-
paired with catgut sutures, and usually heal readily.
I attribute the fact that 1 have never had a complete
laceration of the perineum in a vertex case, to the
beneficial result of episiotomy, without which, in
many cases, I feel certain that the sphincter would
have been torn. The writer confesses, however, to
a considerable number of complete lacerations of the
perineum in breech cases, but he can remember
no instance in which the sphincter was torn
after an episiotomy. During the past few years,
I have performed the operation, in a number
of instances, as a prophylactic measure in breech
cases, where the child was evidently of large
size, and the outlet small, and I believe that, in these
cases, the operation will not only facilitate the in-
troduction of the hand in order to bring down ex-
tended arms, but will save the patient in nearly
every instance from a complete laceration. The
operation is harmless, and so very useful that I
urge its more frequent performance for all the in-
dications mentioned, believing that complete or
severe laceration of the perineum will seldom occur.
Median perineotomy consists in incising the peri-
neum, in the median line down to, or down toward
the sphincter, thus gaining a considerable amount
of room. I have only a limited experience with the
median line operation, but men who have used it
frequently, claim that it is far superior in that the
incision is single, more easily repaired, and there is
less probability of tearing up into the vagina. The
bilateral operation would naturally give more room
in breech presentation, and would be preferable.
My last median operation resulted in a tear, through
the sphincter in spite of very careful extraction and
at present I am inclined to advise the bilateral
episiotomy only.
The low forceps operation has steadily increased
in favor, while the high has been performed less
frequently in recent years, owing to the prominence
given to Ca^sarean section. With the head low in
the pelvis, the cervix completely dilated, and failure
to advance within a reasonable time, the low forceps
operation is safe, and will save the patient, in some
cases, at lea.st, hours of unnecessary pain. The high
forceps operation in former years was attended by
so great fetal mortahty, and such serious maternal
morbidity, that Qcsarean section was hailed as a
solution of the problem of what to do when the
head remained above the brim. No doubt the ab-
dominal operation is performed needlessly at times,
but there can be no question of the brilliant results
obtained, where formerly we were doomed to
failure when using the high forceps operation.
The instrumental rotation of persistent occipito
posterior positions of the vertex, scarcely known
twenty years ago, but insistently taught by Tuckei
has become a recognized obstetric procedure of the
greatest value. Version still remains an exceed-
ingly valuable and necessary operation, the advan-
tages of which it is unnecessary to enumerate.
Craniotomy has been performed far less fre-
quently than formerly, because of th-* good results
obtained in Ca;sarean section, but it is my belief
that craniotomy should be done much more than it
is. We still hear of many deliveries being com-
pleted by the high or median forceps operation, or
by podaiic version, where craniotomy would have
been a much safer operation. This is partly due to
July 2;, igiS.]
JEl.LIFFE: EPILEPTIC ATTACK IN DYNAMIC PATHOLOGY.
139
the fact that general practitioners are as a rule not
provided with a cephalotribe, and. hesitating to call
a consultant, will continue to attempt delivery by the
nonniutilating methods, often to the very great
detriment of the patient, who could have been more
quickly, easily and safely delivered by craniotomy.
In placenta previa, great advance has been made
in the use of the De Ribes bag. followed by forceps
or version, or in selected cases by C'aesarean section.
The writer recently reported to the Slcane Alumni
Society, a case of Cesarean section for complete
placenta previa, and he is confident that in years
past he could have saved many more babies had this
been done. In preparing a paper on C?esareaii sec-
tion in placenta previa, we have collected records of
thirty-five operations, with the loss of four infants,
three of whom were seven months, i mortality of
eleven per cent., which is extremely low for the
condition. The maternal mortality was fourteen
per cent., the five deaths in desperately sick patients.
Contrast these figures with statistics of nineteen
cases of placenta previa, occurring in the service of
the New York Post-Graduate Hospital, collected
for me by my associate Dr. George H. Pierce, which
show a maternal mortality of 10.5 per cent., but a
fetal mortality of 62.5 per cent.
]3uring mv two years at Sloane, Csesarean was
never performed, but in recent years the operation
has come to occupy a prominent place in obstetric
technic. Among the indications have been, con-
tracted pelvis, relative disproportion between head
and pelvis, placenta previa, toxemia of pregnancy,
eclampsia, accidental hemorrhage, and contraction
ring dystocia. It is impossible in this short paper
to go into the merits of the operation for these
different conditions, but the writer is convinced that
there is an important field for the operation in
primiparse at or near term with eclampsia. The
fetal mortality will be very much smaller, and the
maternal considerably less. We have recently col-
lected a series of nineteen Caisarean operations for
eclampsia, seventeen of which were in primiparae,
with two maternal deaths, 10.5 per cent., and no
fetal mortality. Recently the writer had a unique
experience in which he performed a Ccesarean for
a breech presentation with contraction ring dystocia.
The patient, a orimipara at term, had dilated her
cervix completely, and after an hour and a half of
frequent hard second stage pains had succeeded in
forcing the frank breech into the brim, where ad-
vance ceased. Thinking that it would be an easy
matter to seize a foot, and extract the child, an at-
tempt was made to do so under deep anesthesia, but,
at about the level of the internal os, a thick tight
constriction ring was found, through which it was
impossible to pass the hand. Caesarean section was
performed successfully, and the mother left the
hospital with her baby, both in good condition.
Vaginal section, unheard of twenty years ago.
has been extensively performed, and has been found
invaluable in properly selected cases. From the
third to the seventh month, when it is necessary to
interrupt pregnancy for cardiac, renal, hepatic, pul-
monary, or other pathological condition, it is fre-
quently the easiest, quickest, and best mode of de-
livery. In eclampsia, it has not been conchisively
proven in my opinion to be the best form of treat-
ment, but in many instances we have used it with
very satisfactory results. Nitrous oxide, to relieve the
pain of the first stage, has become a great boon, and
marks a great advance in modern obs:etrics. Great
relief can be given, and in competent hands, the
method appears to be safe and extremely useful.
I have touched but lightly on the many subjects
of interest which have come to mind, but present
day obstetrics, with its numerous surgical aspects,
is a field of greatest interest, and well worthy our
conscientious endeavors.
50 West Fokt\ -eighth ."^tkeet.
THE EPILEPTIC ATTACK IN DYNAMIC
PATHOLOGY.*
r.v .Smith Ely Jelliffe, M. D., Ph. D.,
New York.
The analysis of the epileptic attack has begun to
yield results, and a practical working basis for its
understanding is slowly evolving. So long as the
human organism was considered a thing unto itself,
an independent unit, capable of explanation of and
by itself, in terms of perversion of the functions of
its individual organs, no advance was possible. This
limited view has led to the search for disease as an
entity in this or that organ and the naive remedy of
trying to cut it out. as though it were something
encysted and wrapped up in an ovary or an eye, or
in the stomach, or intestine, or what not. As the
dynamic view of man's function as an energy trans-
former grew — -as it was recognized that man like
all other living things, captures his energy from the
cosmic energy of the known universe, transforms it,
and then discharges it in function ; be that metaboHc,
reflex action, or human behavior — then only and
for the first time, flashed the idea that the faulty
energy discharge, which is termed the epileptic at-
tack, is a function of the entire human being, and
not that of any isolated organ or part of an organ.
The environment immediately takes on a new aspect
so soon as this dynamic view is conceived. Living
now becomes, not a special series of processes of the
individual organs, but a series of interactions be-
tween the individual and the environment, in which
the environment supplies the energy, man the means
for capturing it, transforming it, and releasing it.
What does the organism get out of this release?
Teleology says satisfaction ! Satisfaction exists at
all kinds of levels. L'ndoubtedly the concept can be
stretched to include the idea that when the sugar
molecule falls into a regular crystalline shape, an
inherent law of form is satisfied. The pure
mechanists, as Loeb for instance, see it that way.
All of the physicochemical processes follow this gen-
eral type of law, and satisfaction is undoubtedly the
teleological answer at the physicochemical level.
Physicochemically man is a melange of such dis-
persed solutions — protoplasm an enormously com-
plex colloidal factory with the tools of countless
centuries lying about ready to be used if the envir-
onment supplies energy material which it can utilize.
A practical working basis for the understanding
of the epileptic attack has ever been an aim of
*Abstract of clinical lecture, Post-Graduate Medical School, Febru-
ary, 1915.
140
JELLIFFE: EPILEPTIC ATTACK IN DYNAMIC PATHOLOGY.
[New York
Medical Journal.
medical effort. Throughout the whole history of
medicine there has been a vain groping for efficient
therapeutic measures really applicable to this mal-
adaptive discharge of purposeless motor effort. And
still it remains obscure in nature and causation, for
the most part inaccessible to cure or amelioration —
a puzzle to the physician, whether he seeks knowl-
edge of it in anatomical lesions, metabolic disturb-
ances, or what not. Much emphasis has come of
late, because of the failure of so many of these ex-
planations of the disturbance, or of efficient attack
upon it through these channels, to be laid upon
])sychogenic elements as contributing factors in
producing the classical symptoms and the necessity
for including this aspect of the patient. Through
this mode of approach it is thought to gain a larger
view of the conflicts with his surroundings and the
regulation of these to suit his more limited capacity
or constitutional peculiarities, or defective anatomi-
cal substratum.
Yet even this psychological approach, which be-
gins to discern certain potent factors at work in
producing health or disease, fails of success and is
not truly illuminating of this baffling malady unless
it is a psychology which enters ^vithin the psychical
life. It may even in its zeal exclude other factors
w^hich have been long recognized in playing their
part and which cannot be denied but await illumina-
tion from the right kind of interpretative investiga-
tion and treatment. There must be therefore be-
hind and through all future work upon epilepsy an
insistence upon the energy concept. This viewpoint
alone serves to unify the heterogeneous factors pres-
ent throughout the literature and stressed in theory
and in treatment, now to the exalting of this one,
now of that, with the resultant neglect of others
perhaps equally important or perhaps much more
potent and responsible. The energy concept not
only unifies these conflicting data but it also directs
to the point of attack in the very stronghold of the
disordered activity and finds as well further unrec-
ognized manifestations in which it expresses itself
in lesser degree. Therefore the adoption of some
such concept is imperative if we are ever going to
advance to the position of understanding and con-
trol of this menace to the health of a vast number
of individuals whose wellbeing and social useful-
ness is threatened with the utter isolation and
oblivion which is the final goal of an unchecked
epileptic deterioration.
A word then about ourselves in terms of energ}^
This is a very simple concept after all. Viewed
from the standpoint of structure, the nervous sys-
tem consists of receiving organs designed to come
into contact with the outside world. Out of the
combined information derived through these receiv-
ing organs a knowledge of reality is built up. More
however is accomplished. These receptors, extero-
ceptors as they come into contact with environment
outside ourselves, proprioceptors as affording com-
munication between the different parts of our own
organism, obtain and transmute cosmic energy,
which is manifested in the variety of ways which we
know as, heat, electricity, gravity, chemical energy,
sound, etc. There is no new energy for the nervous
system or for human activity. There are properly
speaking no energy reservoirs, save from the stand-
point of structural memories, etc. The ganglion
cells should not be viewed as energ}' containers, or
condensers, if thereby is meant an autonomy within
the cells themselves. There is rather but an appro-
priation and redistribution of energy constantly
streaming in from the external world which may be
utilized for the needs of the human organism. The
nervous system is merely the transmitter and trans-
muter of such energ}^ This system is further ex-
tended through efl'ectors to enable the body to act
upon reality through muscles and glands and con-
tinue the individual's life and accomphsh his life
purpose.
Both the incoming stimuli and the outgoing activ-
ities are diverse and multitudinous. What con-
stitutes the health of the individual is to be able to
distribute the outgoing energy in a harmonious
'series of activities adjusted to life's demands. This
involves the three levels of activity, or of energ}^
distribution, the physicochemical, the vital, and the
psychical. On the first level we have the distribu-
tion in metabolic processes, where the hormone acts
as the chief energ\' carrier. The vital distribution
of energy manifests itself in sensorimotor activity
through the reflex, while the psychical transforma-
tion of energy takes place through the symbol.
Under such a concept we have at last some rea-
sonable explanation of the variety of epileptic
phenomena and the predominance sometimes of
one, sometimes of the other, which has led to the
exclusive adoption of any one of the end products
of faulty distribution as the cause even of the en-
tire disturbance. The exaltation of eye strain,
prolapsed stomach, adhered clitoris, or any other of
the naive but actually adopted attempts to explain
and work a cure becomes impossible when through
the energy concept one enters upon a search for the
misdirected energy and the reason for its harmful
distribution.
No one level is therefore likely to be involved
alone, nor can there be successful therapy in an
exclusive effort to lop off one of these end products
which perhaps results in checking artificially this
particular energy manifestation and thus driving
back, "repressing," the explosive force for a fresh
onslaught from its secret gathering places. The
problem becomes a far more comprehensive and a
much more rational and effective one, if we ap-
proach it from the dynamic side. Thus it may be
seen how even the psychological approach, broad as
it may seem in comparison with more limited phys-
iological attempts, is incomplete except in the light
of this all inclusive grasp of the situation.
Psychological description of inadequate reaction
to difficulties becomes, therefore, but a small part
of the problem, and lacks practical therapeutic
value. It has gone a long way toward suggesting
a suitable watchful regime, for example in institu-
tional life, and forms a certain intelligent back-
ground for the social and therapeutic handling of
the epileptic. It receives its chief value, however,
as it has been carried further into a psychological
interpretation involving the shifting of the patient's
interest, and understanding of his extreme egocen-
tric attitude, the limitation and hampering of his
July -':
igiS J
JELLIFFE: EPILEPTIC ATTACK IN DYNAMIC PATHOLOGY.
141
interest through this, and the pecuhar measures
which must be employed to seek out and entice this
interest from its hiding places and guide it to a
broader reality which means health. It is to the
studies and the practical clinical work of Clark and
AlacCurdy that we owe such a setting forth of the
problem and such a practical approach to it.
This is but a beginning, however, of the more
extensive occupation with epilepsy to which the
medical profession must direct its energies. These
men have proved it worth their while to devote to
the psychical aspect the effort which still knows not
where to attack efficiently upon the basis of physio-
logical symptoms. Other investigators also have
thrust in opening wedges to a better understanding
of the reaction which makes for epilepsy and of all
the psychic character which underlies it. These are
all, however, but indications as to where we must
press forward. They guide us in the direction of
the search for the energy gone astray. They sug-
gest that only a thorough analytic research into the
epileptic's psychical nature will discover the wrong
adjustment of that energy, the reason for a reac-
tion at odds with the real world. It is necessary
to discover why the symbol carrier of this energy
is other than that which would so distribute it that
in the physicochemical sphere, the vital sphere, and
the psychical there would be perfect harmony and
efficiency. Therefore, there is fond reason to hope
that what Freud has so concisely designated "the
most exhaustive occupation with the complexes, and
making them fully conscious" will prove itself the
ideal for obtaining knowledge of this deeply
grounded epileptic reaction, and for releasing the
victim from a fate of inevitable deterioration to a
life of usefulness and health.
This will mean the following of no royal road
of easy and quick discovery any more than of a
ready substitution by the patient of a well directed
life for one sorely at odds with his environment.
It will not necessarily result in the complete well
rounded life. The peculiarity of the epileptic con-
stitution which has chosen its mode of reaction is
too far reaching, perhaps, for that. But it does aim
at a very workable adjustment, not the least, per-
haps, because the method of psychoanalysis is sucli
a thoroughly cooperative one on the part of the pa-
tient and makes the most reasonable and highest
demand upon the guiding and controlling of his emo-
tional and instinctive life by an intelligence whicli
even sets this at a new value.
There is promise, therefore, both to patient and
to the profession in this approach. It will involve
infinite patience and the willingness to evaluate and
handle details of psychic investigation and respon-
sive aid on the part of the physician as circumstan-
tial and minute as is the content of the epileptic
thought and life. It necessitates, further than this, a
keenness of attention and an alertness to the fasci-
nating shiftings and interchangings of energy, which
we are corning to realize do actually exist in this
complex mechanism which we call the interrelation
of body and mind. That, as has been stated, must
never here, at any rate, be left out of account. The
chief manifestation of epilepsy is the sensorimotor
attack. No less actual, although less uniformly fre-
quent, are the disturbances of metabolism, while
behind these is always the possibility of the organic
lesion which is perhaps the original mark of the
insufficiency of the organism for its task, or which
may later accompany the distinct psychic inade-
quacy. These, as we have said, represent the vari-
ety of manifestation of the imperfect energy dis-
tribution, the very concrete pathways of its faulty
discharge, as well as the results of it. Impairment
or lack of development offer easy pathways of dis-
charge for the equally imperfect, undeveloped wish.
For with our knowledge of the unconscious and
the harboring there of infantile wish impulses and
immature tendencies seeking expression in a world
of reality to which they do not belong, we cannot
be surprised to find in the iield of our search not
only a strong infantile wish tendency fighting for
fulfilment, but a complex entanglement of such
wishes in the case of the epileptic, even more in-
tensively and exclusively egoistic than we have
come to recognize generally in the investigation of
the unconscious mental life. The profundity of the
unconsciousness in the classical epileptic convulsion
is an indication of the depths of the ego uncon-
sciousness to which the impulse of the psyche drives
the patient, and which not only exercises periodi-
cally such an overwhelming power over conscious
control, but which colors all his modes of acting,
speaking, and thinking, even those which might be
accounted trivial and unimportant in a superficial
estimate of the personality.
It seems well worth while, then, to submit the
epileptic's problem to the investigation and therapy
of psychoanalysis. Peculiar difficulties will be met
with in the way of accomplishing a thorough analy-
sis, but we believe also that peculiarly important
results will be obtained. The approach to the
heightened egocentricity of the epileptic personal-
ity is not a ready one, or, superficially and apparently
easy, it is found to be based upon an openness on the
part of a shallow egoism which makes a quick, but
meaningless rapport with the superficial features of
the environment. There is a certain offhandedness
which bespeaks a superficiality of affect as well as
a limitation of interest to the egoistic point of view.
This is not alone a trait of advanced epileptic de-
terioration, but impresses one when the patient is
yet fairly active in his environment and the disease
has not made itself manifest beyond the periodic
attack. This demands of the psychoanalyst greater
expenditure of interest or libido on his part in order
to stimulate and maintain interest, as well as to
create for himself enthusiasm in his research, and
in his attempt to rouse the patient to cure. There
is not the same readiness toward the transference
as found in other conditions, and which forms so
important a recognized factor in the psychoanalytic
treatment.
This, on the other hand, by no means signifies
that there is no emotional content to be reached
here. There is just as great complexity of the af-
fect life, with its strivings for expression, conflicts
which this creates, and compromise attempts at so-
lution as is found in the building up of other psychic
disturbances, but within it all the ego centre mag-
nifies itself to the shutting out of other interests
JELLIFFE: EPILEPTIC ATTACK IN DYNAMIC PATHOLOGY.
[N'ew YoBK
Medical .Tournal.
which might aflford healthful occupation for the
hbido, and to the causing of an inabihty to follow
the avenues which would afford a saving contact
with reality. It does not form a phantasy world
which holds a satisfying substitute for reality, as
in certain psychoses, but, thwarted in its ego, reac-
tions must retire deeply within an unconscious world
which probably corresponds rather to the earlier in-
fantile condition where even phantasy formation is
not yet exercised in any great measure of variety.
Maeder in particular has pointed out in detail how
this poverty of the aft'ect life is yet accompanied
by an apparent eft'ulgence of emotional life, but at
the same time he reveals the lack of depth and
reality in these manifestations. So that religiosity
and not religion, effusive piety instead of sincere
morality become marked characteristics. A com-
pulsive form of epilepsy evinces a concern for elabo-
rate devotion to the detail of confession and of
ceremonial prayer, is an excessive devotee of these
external forms of the Church, measures everything
according to its formal standards of "sin," but man-
ifests no evaluation of actual workable moral val-
ues. The manner of life is one of strict observ-
ance and rigid morality, but there is no sense of
a duty which would involve an outgiving of self
in service toward others. Indeed, the compulsive
form of religion, closely bound with the attacks,
both grand mal and petit mal, so occupy the patient
and so incaoacitate her for an active life that she
is kept quite dependent upon the support and min-
istrations of her family.
The love life, as Maeder also shows in his dis-
cussion, manifests the same traits. There is an
excess of infantile activity in all of its forms, but
not that depth toward which, according to Freud,
the various stages of development of the love life
must contribute. The adult goal of a profound
channeling of love into a life of creative service
is not the epileptic ideal. Hence the infantile en-
thusiasm which expends itself again in the super-
ficial expressions of .love and erotic enjoyment, not
only selfcentred and autoerotic, but incapable of
seeing beyond the horizon of such pleasure, win-
ning into the mutual relationship which adult love
requires. Maeder has called attention to some of
the grosser manifestations of the various forms of
the infantile erotic as they appear in those patients
advanced to a greater or less degree in their de-
mentia. Some of the cases which present them-
selves for analysis long before such a stage is
reached present a less gross, but no less significant
illustration of these same tendencies. Indifference
to serious marital difficulties, in one patient, exclu-
sive emphasis upon the pleasant externalities of love
with another, an excessive childish pleasure in mo-
tor activity, and more an extravagance of urinary
enjoyment, a veritable urinary megalomania, in
dreams, and in actual practices, are some of the
superficial forms of enjoyment which seem to have
usurped the place in which normally deeper more
adult pleasure should have come to its own.
The unsatisfactoriness of such libido outlets in
the face of a hard reality with its demands for
something of far greater abiding depth already
grants an insight into the reason why only the re-
mote unconscious goal of the profound attack pro-
vides a sufficient refuge for such infantile seeking.
It forms a yielding background to the inevitable
conflicts of life, conflicts multipHed and rendered
less supportable by such an infantile nature. It is
necessary, however, to discover more in detail in
just what the conflicts themselves lie.
Here once more we shall find that we are deal-
ing with the universal unconscious. There is no
sharp distinction, clinically considered, to be made
between one class of persons and another. Per-
haps, after all, it is merely this constitutional dif-
ference of the exaggerated ego and the shallowness
which that spreads over the personality, which sep-
arates the epileptic reaction from that of the forms
of reaction in other psychic disturbances or in those
we call normal. "\\'e all have traces," MacCurdy
says, ''of the epileptic reaction when we give way
to temper, choose the easier oath, or allow our ego-
tism to sway our judgment." Still more might we
say that we all have the same conflicts arising out
of the impulsive and instinctive tendencies of the
(unconscious) affect life, and the effort of the con-
scious to control these for useful and social pur-
poses. Though the epileptic's form of reaction may
be peculiarly his own in its absolute control by the
unconscious, at times, of his sensorimotor and even
metabolic processes, we can best understand the
reason for this absolute power on the part of the
unconscious and its increasing domination toward
final dementia if we examine by detailed analysis
each individual set of complexes and conflicts as
each individual patient presents them. Only thus
can we come to a better knowledge of the epileptic
reaction itself, and finally to a control over it.
Various writers have recognized the emotionally
jisychical character which underlies the disease man-
ifestations. Flournoy has reported in detail the
emotional history of a patient who repeated in her
attacks the details of a scene of violence with her
husband, who was the precipitating cause in the
first place of the epileptic disturbance. He believes
from the unconscious material discovered in hyp-
nosis that the crises "represent in the beginning,
like so many other emotional manifestations, cer-
tain reactions of defense." Flournoy separates out
thus, a special form of epilepsy which he distin-
guishes as "emotional epilepsy," and discusses a
liysteroepilepsy or epileptiform hysteria, and also
the possibility of a mixed form. Stekel likewise, who
has published some very instructive analyses of epi-
leptic convulsions due to psychic conflict, believes
"that a goodly number of so called epileptics are
doubtless only neuroses and hysterias." Other au-
thors show the same tendency to designate the epi-
lepsies which prove themselves thus unmistakably
psychogenic as hysterias rather than true epilepsies.
This distinction seems not well founded, and, in-
deed, needless, in the full acceptance of the energic
concept. For this necessarily recognizes the psy-
chogenic basis for the epileptic condition (as the
most essential thing), and may perhaps in time
prove it for all genuine epilepsy, while at the same
time it admits of a complexity of reaction. From
the point of view of the complex psychogenic de-
terminants one could not even look for a simple
July 27, 1918.]
BRAV: CLINICAL VALUE OF PUPILLARY CHANGES.
143
form of symptom phenomena, but should rather ex-
pect that variety of emotional reaction which is met
in practically every psychoneurosis.
Besides, for the practical purposes of an analytical
investigation and therapy, this distinction is of little
moment. The problem remains the same, namely,
whetlier or not such a method of "exhaustive oc-
cupation with the complexes" is going to discover
and redirect the wrongly distributed and applied
energy, and it is here that the valuable detailed re-
ports of just such work, under whatever name, come
to our aid and point the way that we must follow.
Jung and others have utilized the association
tests for an approach to the epileptic character, while
Maeder, Sadger, Stekel, Riklin and other psycho-
analysts have subjected the same character to de-
tailed observation and analysis. The results which
they have reported emphasize the egocentricity, its
diffusiveness and the consequent superficiality of
emotional states even in their apparent extrava-
gance, and the poverty of interest in external
objects. The epileptic seizure reveals itself as a
substitute for deeply concealed impulses of an in-
fantile and asocial nature. In Stekel's cases a
strong criminal tendency reveals itself through the
analyses. Strongly repressed from consciousness it
had therefore created the disturbance of the un-
conscious which resulted in seizures. The analyses
brought to light murder instincts or incest wishes
for which compulsive thoughts and actions had to
atone in consciousness ; or a strpng sadistic maso-
chistic nature was revealed which also defended
itself in part by a symptomatic manifestation.
When the entire complex, however, was strong
enough to break through, an epileptic seizure was
the result.
In some instances the convulsion represents a di-
rect flight into sexuality, the loss of consciousness
being comparable to an orgasm, a conclusion which
has long been held and which is further confirmed
by Maeder's studies in the sexuality of the epileptic.
These particularly stress the infantile character of
the sexuality of the epileptic, with whom any one
of the infantile undeveloped forms of the psycho-
sexual hfe are exaggerated and form a barrier to
adult development and reveal his difficulty in attain-
ing to the normal sexual Hfe or to a subhmation
of^it.
64 West Fifty-sixth Street.
Blood Pressure in Gout. — Jacob Rosenbloom
{Journal A. M. A., June 29, 1918) says that there
are few data in the literature relative to the blood
pressure in gout, although it has been fairly well
established that certain of the purin bases are hy-
pertensive in action. The general understanding is
that there is high blood pressure in gout, with an
increase during the acute attacks, while hypotension
develops in the later stages with cachexia, cardiac
weakness, and acidosis. Four cases have been
studied frequently during the past ten years and
their blood pressure records show that there was
no hypertension in any of them, except during the
acute attacks. In all the blood pressure was rather
below the normal between the attacks.
THE CLINICAL VALUE OF PUPILLARY
CHANGES.
By Aaron Brav, M. D.,
Philadelphia,
Ophthalmologist to the Jewish Hospital, Philadelphia.
In the study of the pupillary phenomenon we
must carefully observe the following conditions: i.
Form and color of pupil ; 2, size of pupil ; 3, con-
tents of the pupil; 4, asymmetry of the pupils; 5,
reaction of the pupil; 6, associated ocular condi-
tions. By carefully observing in a systematic man-
ner the condition of the pupil, as thus outhned, very
important information can be obtained by the physi-
cian both as to the local condition of the eye and as
to some general constitutional disease. We shall
first consider the form of the pupil and learn of
what clinical value it may be to the physician.
Form of pupil. — It is well to recall the simple
anatomical fact that the pupil is merely an opening
or foramen in the centre of the iris surrounded and
controlled by the .sphincter of the iris. Normally
this opening is round and is situated approximately
in the centre somewhat inward and downward as
seen through the transparent cornea. Any change
in the pupillary form must be accounted for by
alterations in the structure of the iris tissue. This
change may be either congenital or acquired. It
may be due to some trauma, or it may be caused
by some inflammatory process. As long as the iris
is in a normal condition and the sphincter is intact
the pupil will be found to be round. Whenever the
pupil is not circular in form we are dealing with
some anomaly or inflammatory condition of the iris
or some adjacent ocular tissues involving the uveal
tract. Congenital alteration in the form of the pupil
is seen in the socalled cases of coloboma of the iris
in which a portion of the iris is missing. It closely
resembles an artificial iridectomy. The pupil is pear
shaped, the narrow portion pointing toward the
periphery of the iris. In the vast majority of cases,
this coloboma is in the lower half of the iris in con-
tradistinction to the coloboma caused by an iridec-
tomy, which is usually in the upper half. The key-
hole pupil is a coloboma of the iris, but the apex is
much narrower, so that the pupil resembles a key-
hole. From the clinical point of view, however, the
pupillary changes resulting from some inflammatory
process are of more importance than those of the
congenital variety. An irregular pupil is always
significant of some inflammatory or engorged iris
or some multiple tears in the iris.
During an inflammatory process the iris, as a re-
sult of some exudation, becomes adherent to the
lens capsule in various places ; the form of the pupil
takes a clover leaf shape especially so after the
instillation of atropine. This is of special diagnostic
value and is the chief and only reliable symptom in
difrerentiating iritis from acute glaucoma.
A pear shaped pupil, not congenital in origin, is
always indicative of either some trauma that caused
a perforation of the cornea or some perforated ulcer
of the cornea where the iris is caught in the perfo-
ration and becomes adherent to the corneal tissue.
Some alteration in the form of the pupil is also
seen in arteriosclerosis, increase in the intraocular
144
BRAV: CLINICAL VALUE OF PUPILLARY CHANGES.
[New Yokk
Medical Journal.
pressure, as well as in ophthalmic migraine. In
these conditions the pupil is found often to be more
or less oval and eccentrically situated ; the associ-
ated ocular and other symptoms are essential for
diagnosis. In iridodialysis where a rupture of the
iris has taken place the form of the pupil neces-
sarily undergoes some change depending upon
whether the radial or horizontal fibres of the iris
have been torn. Such a pupil is apt to have the
shape of a half moon. The same may be said of
tumors situated in the anterior chamber and on the
iris where the pupillary opening loses its rotundity.
Color of the pupil. — Normally the pupil is black
in color and appears as a dark round circumscribed
spot when seen through the cornea. Changes in
the pupillary color indicate some deep seated trou-
ble. In glioma of the retina the pupil appears yel-
lowish red in color. A whitish gray pupil is prac-
tically always the result of a cataractous lens. A
slightly greenish pupil indicates a glaucomatous
condition. In fact glaucoma is known among the
Germans as the Griiner Staar. In retinal detach-
ment we also notice a slight grayish pupil with
some light red streaks passing over the detached
retina. A golden reflex around the pupillary
periphery is diagnostic of subluxation of the lens
anteriorly. A red pupil indicates hemorrhage in the
anterior chamber.
Contcnls of the pupil. — In health the pupil is not
only round and dark in color but is also free from
any substance. Under abnormal conditions, how-
ever, the pupil changes in form and color and may
show distinct masses of tissue filling it partly or
completely. The pupillary openmg may be filled
with blood and thus appear red instead of black.
Blood in the pupillary opening always denotes some
trauma either from some perforation, or as result
of a severe contusion where some of the vessels of
the iris have been ruptured. The blood may fill the
anterior chamber, the vitreous, as well as the
pupillary opening. Not infrequently, however, only
the pupil is filled with blood while the anterior
chamber is free from blood. The trauma may be
the result of an accident or it may be the result of
operative interference. The blood may come from
the superficial vessels or it may be deeply seated,
when it is very serious not infrequently necessitat-
ing the removal of the eye ball. Spontaneous hem-
orrhage into the pupil without trauma is rare in-
deed. The pupil may contain a dislocated lens.
This can be diagnosed by the associated symptoms,
especially the circular golden rim around the lens.
This may be accompanied by marked inflammatory
symptoms but often there are no inflammatory
signs. Dislocation of the lens may be traumatic in
origin, may be caused by a blepharospasm during an
operation but it may also occur spontaneously as a
result of some sudden strain.
The pupillary opening may also contain pus.
This can be seen in some form of keratitis or iritis
when the color of the pupil appears yellowish. Oc-
casionally there are some brownish deposits in the
pupillary area as a result of some iritic exudation.
The pupil may also contain a very delicate mem-
brane known as the pupillary membrane ; this may
be congenital or acquired as the result of some iritic
inflammation. The pupil then appears grayish white
and must be differentiated from the pupillary reflex
due to lenticular sclerosis. Occasionally a tumor
or cyst may be seen in the pupillary opening. Such
a tumor is usually attached to the posterior surface
of the iris or ciliary body projecting into the pupil-
lary area or it may be a glioma pushing its way to
the anterior chamber. A syphilitic gumma or a
tubercle or a metastatic abscess encapsulated may
also be seen in the pupillary opening. Of course the
contents of the pupil are only of local diagnostic
significance, excepting perhaps in syphilitic gumma
or inflammatory deposits that are of some consti-
tutional origin. The treatment in some cases is
purely medicinal while in others surgical means
have to be employed to clear the pupillary field. Of
course the syphilitic cases usually yield to anti-
syphilitic measures and do not require operative
procedures. Blood in the pupil and anterior cham-
ber due to some contusion usually disappear. All
that is necessary is to put the eye at rest with
atropine and apply hot compresses to hasten absorp-
tion. Pus in the anterior chamber may also some-
times require surgical means for its evacuation.
Size of the pupil. — The size of the pupil is of
considerable importance in the study of the pupil-
lary phenomenon. Ordinarily the size of the pupil
is about three millimetres in diameter. Hyperopes
have a small pupil, while myopes have larger pupils ;
so that the refractive status of the eyes markedly
influences the size of the pupil. The pupil is some-
what smaller in childhood, becomes larger in the
adult and becomes smaller again as age advances.
The pupillary size is also markedly influenced by
the degree of illumination, so that the pupil is smaller
in the daytime and in bright light than it is in the
evening and in a badly illuminated place. These are of
course physiological variations and must be remem-
bered before pathological causes are considered or
decided upon. We must also bear in mind the fact
that pupillary changes are often artificially pro-
duced either for therapeutic purposes to examine
the eye ground or for mydriatic purposes to correct
some refractive errors. Changes in the size of the
pupil may be accompanied by inflammatory symp-
toms or they may be present without any inflamma-
tory changes and symptoms.
Miosis. — The pupil is not infrequently found to
be small and when accompanied by inflammatory
symptoms it usually points to an engorgement or in-
flammation of the iris. It is also to be found in corne-
al inflammations, especially in those forms that are
usually complicated with iritis. When not accom-
panied by inflammatory symptoms and not the re-
sult of the use of some eserine or pilocarpine it
points to some spinal lesion or some disease in the
cerebrospinal system. Resection of the cervical
sympathetic or traumatic destruction of the same
ganglion will give us a small contracted pupil. It is
also seen in syphilis of the cerebrospinal system,
in tabes dorsalis. Spastic miosis is also seen in
meningitis, especially in children. Paralysis of the
sympathetic also presents a contracted pupil.
Trauma may also be considered as a cause of miosis.
It must be remembered that a contracted pupil is
found in various forms of poison, such as opium and
tobacco. Eserine and pilocarpine produce the great-
est degree of spastic miosis. Miosis caused by
July 27, 1918.]
BRAV: CLINICAL VALUE OF PUPILLARY CHANGES.
145
spinal trouble can usually be distinguished by the
fact that while the pupil is small it does not react
to light but contracts synchronously with accommo-
dation and convergence. Small juipils that do not
react to light are diagnostic of syphilis.
Mydriasis. — The pupil may be found to be dilated
merely as a result of markedly reduced vision. Com-
plete dilatation of the pupil may be artificially in-
duced by the instillation of a mydriatic. A dilated
pupil points to a paralytic condition of part of the
third nerve. Irritation of the sympathetic will pro-
duce mydriasis. The pupil may be dilated as a re-
sult of toxic elements within the blood. This we
see in postdiphtheritic paralysis of the accommoda-
tion. In optic nerve atrophy, partial or total, the
pupil is usually found dilated. Occasionally trauma
produces paralysis of the iris sphincter and hence a
dilated pupil. Dilatation of the pupil is also seen in
.syphilitic conditions of the eye involving the oculo
motor nerve. In acute glaucoma the pupil is par-
tially dilated as a result of pressure upon the sphinc-
ter. Of course in these cases there are associated
symptoms of inflammation and this dilatation of the
pupil is of utmost diagnostic importance. Dilata-
tion of the pupil, when purely local in origin, is
either due to an instillation of some mydriatic or
caused by trauma. Whenever these causal elements
are excluded we must think of the constitutional
conditions that produce some paretic condition of
the oculomotor nerve. Syphilis, diabetes, nephritis,
general paresis are the constitutional conditions to
be considered. Tumors of the brain also give rise
to dilated pupils due to changes in the optic nerve.
We must also remember that the various inflamma-
tory diseases of the retina, choroid and optic nerve
also produce mydriasis.
Anisocoria. — Inequality of the size of the diam-
eters of the two pupils is not necessarily a patho-
logical condition, but should always stimulate dili-
gent search for a cause, although it is occasionally
seen in otherwise healthy persons. It is sometimes
congenital, but more often acquired. It may be the
result of dififerences in the refractive status of the
eyes. It may also be seen in unilateral amblyopia
when the ambliopic eye has a slightly dilated
pupil. Inequality in the size of the pupil may
also be seen in cases where there is a marked
difference in the visual acuity of the eyes.
It may also be seen in unilateral chronic iritis
as well as in unilateral chronic glaucoma or
unilateral diseases of the retina and choroid. Where
local causes can not be demonstrated some constitu-
tional condition must be thought of. Syphilis, tabes,
progressive paralysis, multiple sclerosis, diseases of
the kidney, liver and some nervous condition, as
neurasthenia, may give rise to pupillary inequality.
In studying these cases it is essential to determine
first whether we are dealing with a unilateral miosis
or unilateral mydriasis. This can be determined in
most cases by finding which of the eyes is patho-
logical by studying the reactions. It is necessary to
study the associated local ocular phenomena in
order to enable us to arrive at a proper understand-
ing of the underlying cause. It may be said, how-
ever, that while slight degrees of anisocoria may be
seen in healthy persons, a marked degree of pu-
pillary inequality is always pathognomonic of either
some local or general constitutional disease.
Pupillary reaction. — The most essential pupillary
phenomenon from both the ophthalmological and
general diagnostic standpoint is the pupillary reac-
tion. In healthy and normal eyes the pupil reacts to
the stimulus of light, accommodation, and conver-
gence. In some diseased conditions this reaction
may be either absent or diminished. Any disturb-
ance in the pupillary reaction, however, must be re-
garded as pathological. The pupil may react to light
and remain rigid to accommodation and convergence
or vice versa. Absolute immobihty of the pupil when
not caused by a cycloplegia or by some local in-
flammatory adhesions points to some constitutional
condition. We speak of absolute immobility when
the pupil does not react to either light, accommoda-
tion, or convergence. Relative or reflex immobility
on the other hand means an abrogation of the light
reflex, but reaction to convergence is still present.
This condition of pupillary immobility may be uni-
lateral or bilateral. Absolute reflex immobility
points to syphilis while reflex immobility is diagnos-
tic of tabes and general paralysis. The anatomical
site of the lesion in pupillary immobility and its
various forms is still a matter of discussion, and the
phenomenon must be studied in association with
either miosis or mydriasis. The study of this pupil-
lary manifestation is a valuable aid to the neurolo-
gist and internist. The reaction to light may be
absent in diseases of the optic nerve and optic tract.
Iritis and total posterior synechia gives rise to im-
mobility. In iritis and acute glaucoma there is an
abeyance of the light reflex. It is also seen in
syphilis of the nervous system, nephritis, diabetes.
There is another pupillary change known as the
hemianopic pupillary reflex, where only part of the
optic nerve fibres are involved, so that irradiation of
that part will give no reaction while irradiation of
the unaffected part will be followed by prompt re-
action. This serves to differentiate between cortical
lesions and lesions in the optic tract. These are the
principal pupillary disturbances of diagnostic im-
port.
Associated ocular phenomena. — A careful study
of these incomplete observations on pupillary mani-
festations will soon convince us that the clinical
value of pupillary changes can only be determined
by studying the pupil from various angles, such as
form, size, contents, color, symmetry, and reaction,
and this in association with other ocular symptoms.
It is the combined observation that will give such a
symptom complex as to aid us in diagnosis. For
instance, a dilated pupil alone cannot point to a
definite pathological condition. But a dilated pupil
associated with inflammatory symptoms of the eye
ball, a steamy cornea and reduced vision and high
tension at once points to a definite clinical condition,
i. e., acute glaucoma. On the other hand, a dilated
pupil that does not react to light, not accompanied
by inflammatory symptoms and associated with pa-
ralysis of the internal rectus, and accommodative
disturbances points at once to paralysis of the oculor
motor nerve. A partially dilated pupil with lateral
nystagmus and temporal atrophy of the optic nerve
is pathognomonic of multiple sclerosis. A contracted
146
RAMIREZ AND HOGUET: ILEOCECAL INSUFFICIENCY.
[New York
Medical Journal.
pupil that does not react, associated with inflamma-
tory symptoms of the eye is diagnostic of acute
iritis, while a contracted pupil that does not react
to light, which is slightly irregular and shows signs
of adhesion accompanied by a diminution of vision
is indicative of chronic iritis. On the other hand a
contracted pupil that does react to light, but is round,
whether associated with a reduction of vision or not,
is practically always diagnostic of cerebrospinal
syphilis. I could multiply examples to show the
necessity of studying the pupillary changes in asso-
ciation with other ocular phenomena. This is, how-
ever, not the place and I feel that these few ex-
amples chosen are sufficient to demonstrate the idea
expressed in this paper.
917 Spruce Street.
ILEOCECAL INSUFFICIENCY.
By M. a. Ramirez, M. D.,
New York,
AND J. P. HOGUET, M. D.,
New York.
The object of this paper is to draw attention to
a condition within the abdomen which is one of
considerable importance and a definite clinical entity
more or less overlooked up to the present.
Ileocecal insufficiency or incompetency is a con-
dition characterized by a dilatation of the ileocecal
valve, thus allowing a regurgitation of cecal and
colonic contents into the ileum, and in marked
cases, even further. As the small intestine pos-
.sesses a greater absorbing capacity than the colon,
it is logical to conclude that the regurgitation of
colonic contents into the small intestine is bound to
be accompanied by the absorption of some of the
end products of digestion which normally are ex-
creted.
Among the more common causes of this condi-
tion are repeated attacks of appendicitis with the
formation of adhesions and bands involving the
ileum and cecum ; trauma to the valve during opera-
tions in this region seems to be an important factor,
as about ninety per cent, of all cases of ileocecal
insufificiency are to be found m patients who either
have a chronic appendicitis or have undergone a
laparotomy. The remote causes are intestinal atony
associated with marked anemia, rapid emaciation,
relaxed abdominal wall, following frequent jxirturi-
tion or advanced age, lesions distal to the cecum
causing reverse peristalsis, or interference with the
normal emptying of the small intestine.
Normally, the ileocecal valve is fonned of two
semilunar segments, an upper and a lower, which
project into the large intestine. These segments
are formed by a reduplication of the mucous mem-
brane, and contain circular muscle fibres. When
the valve is incompetent, these segments disappear
and the ileum empties directly into the colon by a
large funnel shaped opening which allows of the
passage of intestinal contents in both directions.
Associated with this condition there is always a
dilatation of the terminal ileum and of the cecum,
accompanied by a moderate degree of passive con-
gestion, the extent naturally depending on the se-
verity of the individual case. 7he local clinical
manifestations usually consist of a burning pain in
the right iliac fossa and moderate tenderness in this
region. The abdominal walls are usually very
flabby and allow of easy palpation of the ileum and
cecum, which are generally found to be distended
with flatus. Occasionally patients also complain of
pain in the left iliac fossa. Alternating attacks of
diarrhea and constipation is probably the most
constant of the general manifestations. Persistent
pains in the various articulations and muscles,
severe and frequent headaches, dizziness, general
malaise, weakness, lassitude and tympanites are
among the more common general symptoms.
A positive diagnosis may be established by
rontgenographic examination. All cases presenting
symptoms suggestive of incompetency of the valve
or of chronic intestinal absorption, especially if as-
sociated with a history of repeated attacks o^ ap-
pendicitis or occurring some time after a laparot-
omy, should be submitted to a careful rontgen ex-
amination, which consists in injecting a certain
amount of bismuth or barium into the rectum and
determining the height to which this passes. Nor-
mally, it should not pass the ileocecal valve.
All cases of ileocecal incompetency should be
subjected to proper medical treatment before re-
sorting to operation. After a careful trial of vari-
ous methods of treatment we believe that the most
satisfactory form of medical treatment consists in
repeated intestinal lavages by means of the duo-
denal tube. The tube is slowly inserted up to the
third ring mark, with the patient in the sitting
posture. The patient is then instructed to recline
on a table or sofa on his right side in order to
facilitate the passage of the tube into the duodenum.
It is necessary that the stomach should be empty
at the time of the treatments. After four or five
minutes, an aspirating bottle is attached to the distal
end of the tube in order to determine whether or
not it has passed into the duodenum. The aspira-
tion of a stringv or bile stained fluid usually sufifices
to establish the position of the tube in the intestine.
After it has been determined that the tube is in
the proper place, it is connected with an irrigating
funnel and the desired solution introduced directly
into the duodenum. The solution used varies with
the individual case, but ordinarily, a solution con-
taining sodium chloride, sodium sulphate and about
thirty drops of a saturated alcoholic solution of
phenolphthalein is used. The total quantity used
also varies, as some patients will tolerate more than
others, but ranges from six to twenty ounces or
more.
The tube is then carefully withdrawn. The fluid
introduced into the duodenum passes quickly
through the intestinal tract, flushing it out com-
pletely and patients usually have from one to three
or more copious watery movements of the bowels
within one to two hours after the treatments. The
frequency of these transduodenal lavages depends
naturally on the individual case, but varies from
two to three times a week. It is also necessary to
give associated attention to the diet and general
health of the individual. Adrenalin administered in
July 27, 1918.]
RAMIREZ AND HOGUET: ILEOCECAL INSUFFICIENCY.
147
the form of the nucleoprotein seems to produce
beneficial results, by increasing the intestinal as well
as the general body tone. In selecting the diet for
individual cases, it is essential to determine whether
the products of carbohydrate or protein metabolism
are at fault.
The restoration of the true mechanical function
of the valve can only be accomplished by a plastic
operation. This operation, which was originally
suggested by Dr. Lewis Gregory Cole, is really a
reconstruction of the valve by invagination of the
ileum into the cecum and is performed as follows :
The abdomen is opened by a right rectus incision at
the level of the cecum. The appendix is removed,
if this has not already been done at a previous
operation. The fat is dissected away from the
ileocecal junction for about three quarters of the
circumference of the bowel. When this is done,
there is revealed the termination of the ileum which
can always be detected by an elliptical white line
which runs transversely across the left side of the
cecum. The ileum is then invaginated into the
cecum for a distance of about three quarters of an
inch and held in place by Lembert sutures of Pagen-
stecher which are placed above, below and on the
anterior wall of the ileocecal junction, running from
the wall of the cecum to that of the ileum, about
three quarters of an inch from its end. It has been
shown by rontgenograms, taken after operation that
this proceeding gives excellent mechanical results,
but, of course, enough time has not as yet elapsed to
prove these results permanent.
The following is a brief report of a few of the
cases that have come under observation :
Casf I. — J. C, male, thirty-five years old. Was operated
on for chronic appendicitis six months before onset of
present sjmptoms. Complained of persistent headaches,
pains in the shoulders, burning pain in the right iliac
fossa, eructations of gas, and frequent attacks of diarrhea
alternating with marked constipation. Had lost fifteen
pounds in six months. Rontgenograms showed a moderate
degree of insufficiency. Urine contained a marked trace
of indican. Physical examination negative, except for
slight tenderness over the terminal ileum and cecum and
flaccid abdominal walls. Transduodenal lavages were
given three times a week and patient was put on a care-
fully selected diet. Under this treatment he gained nine
pounds. Weakness, malaise, and pains in the body disap-
peared and headaches became less frequent. Bowels
moved regularly and urine showed only a faint trace of
indican.
Case II. — M, J., female, thirty-four years old. Operated
on for chronic appendicitis eight months ago and made an
uneventful recovery. For the past six months complained
of a constant feeling of weakness and inaptitude for work,
persistent headaches, constant pain in both right and left
iliac fossre, but chiefly in the right. Bowels constipated
and urme showed a faint trace of indican. Physical ex-
amination was negative, except for slight tenderness in the
right iliac fossa. Transduodenal lavages were given twice
a week at first, then once a week for three months. Her
symptoms have completely disappeared and the patient now
leads a normal life, except that she must pay careful at-
tention to her diet, eliminating meat as much as possible.
In the following cases the patients have been
operated upon :
Case III. — E. R., female, twenty-six years old. Three
years ago began to have attacks of pain between the shoul-
ders and in the epigastrium. This was followed shortly
afterwards by vomiting after each meal. At this time pa-
tient remained in a hospital for three weeks under treat-
ment for appendicitis. After this her symptoms disap-
peared, but began again three months later. By July, 1916,
the pain had disappeared from the shoulder region but
there was a burning and severe epigastric pain occurring
about two hours after meals. This was immediately fol-
lowed by vomiting. She was very constipated and had
lost about twenty pounds in weight in the last year. From
a rontgenographic examination, at this time, Dr. L. G. Cole
reported that there was a minute punctate ulcer on the
lesser curvature of the stomach, about four inches from
the pylorus, a definite veil or membrane involving the
cecum and ascending colon, and a moderate degree of in-
competency of the ileocecal valve.
She was operated upon August 1, 1917, at the French
Hospital, by Doctor Hoguet. The appendix was removed,
the valve repaired, as described above, and the gastric
ulcer excised. She made an easy recovery and reported
in January, 1918, that she had no discomfort whatsoever
after eating and was not troubled at all with constipation.
She had gained twenty pounds in weight. Rontgenograms
made at the time showed that the barium passed all the
way back to the cecum, the left side of which was flattened
and the indentation of the ileocecal valve was distinctly
seen ; there was no evidence that any of the barium had
passed into the ileum, indicating that the valve was com-
petent and that its repair had been complete.
Case VI. — Aviator, age twenty-eight years. This young
man had been perfectly well up to within two months of
the time when he was first seen. He then began to com-
plain of burning pain over the right iliac region and of a
diarrhea Vyfhich seemed uncontrollable. He had from three
to ten large, watery movements a day. Physical examina-
tion was practically negative. Radiographic examination
by Doctor Cole showed that there was an incompetency of
the ileocecal valve with an influx of colonic contents into
the ileum. The left side of the cecum seemed to be very
irregular. He was operated upon September 17, 1916, at
the French Hospital. A long, slightly kinked appendix
was found and the valve easily admitted the tip of the
index finger. The appendix was removed and the valve
repaired as described above. The patient's recovery was
uneventful and the diarrhea stopped immediately. When
seen in May, 191 7, he reported that since the operation he
had but one or two stools daily and complained of no ab-
dominal discomfort whatsoever.
Case VII.— E. E. V., medical student, male, age twenty-
six years. For the last two years had had attacks of
cramp like pains in the right iliac fossa. These attacks
were at irregular intervals, not associated with fever or
abdominal tenderness, and seemed generally to be brought
on by indiscretions in diet. Patient was exceedingly con-
stipated and was forced to take cathartics almost daily.
Radiographic examination in February, 1917, by Doctor
Cole, showed that there was an incompetency of the ileo-
cecal valve with a moderate regurgitation of the colonic
contents into the ileum. There was also some deformity
of the left side of the cecum. He was operated upon Feb-
ruary 26, 1917, at the Hospital for the Ruptured and Crip-
pled. The appendix, which was rather thick and long, was
removed. The valve, which easily admitted the tip of the
index finger, was repaired in the usual manner. The pa-
tient made an easy recovery, his bowels moving without
cathartics on the second day after operation. In De-
cember, 1917, he reported that his bowels moved daily,
that he had no abdominal discomfort whatsoever, and that
his physical condition was improving rapidly.
Conclusions. — i. Ileocecal insufificiency is much
more frequent than is ordinarily recognized and
should be suspected in all cases presenting symp-
toms of chronic intestinal absorption. 2. It is an
indication of local enfeeblement of the intestine and
is usually associated with a chronic inflammatory
process in the ileocecal region. 3. The most char-
acteristic symptoms are burning pain in the right
iliac fossa, alternating periods of constipation and
diarrhea, headaches, lassitude, and arthritic mani-
festations. 4. General hygienic, dietetic, and tonic
treatment phis frequent duodenal lavages, in the
most satisfactory method of medical treatment. 5.
Surgical intervention is often necessary.
148
FOWLER: SURGICAL DIAGNOSIS.
[New York
Medical Journal.
SURGICAL DIAGNOSIS.
By W. Fr.\nk T'owler, M. D.,
Rochester, N. Y.
Difficulties of diagnosis are too well recognized
to merit extended comment. They have been strik-
ingly demonstrated by the published necropsy re-
ports of the Massachusetts General Hospital. Yet
the decreasing proportion of diagnostic error re-
vealed by these reports indicates, perhaps, the salu-
tary influence of routine postmortem examination.
The present discussion is concerned with various
phases of surgical diagnosis, in an endeavor to de-
termine who is best quahfied, in each instance, to
recognize such pathology, and, having recognized
it, whether further diagnostic effort is essential.
The acute traumatic cases which come into the
wards ordinarily present no serious diagnostic
problem to the surgeon. We must except, however,
in cases of gunshot and stab wounds, and blows
or falls upon the abdomen, that there may be doubt
in regard to visceral injury or hemorrhage. 1 re-
cently saw such a case in consultation. A bullet
had entered the chest wall at the level of the eighth
rib in front, slightly external to the nipple line, and
emerged at a corresponding point in the back. The
pulse was 120, the lips were blanched, and the urine
smoky. On the other hand, there was no restless-
ness nor air hunger, the conjunctivje were not ex-
cessively pale, and the pulse was of fair quality.
Operation was deferred, and the patient recovered,
unoperated. The surgeon in charge of this case,
a man of wide experience, said to me: "Whatever
is done here is good judgment if this patient gets
well, and poor judgment if he dies."
The diagnostic value of lumbar puncture in ob-
.scure head injuries, as pointed out by Wyeth and
Sharpe (i), and the emphasis placed by Elsberg
(2) and Kearney (3) upon the importance of ex-
amining the eye grounds in fractured skull should
not be forgotten. The term "diagnosis" should be
broad enough to include not only a recognition of
the lesion itself, but also the effects of such lesion.
For example, in fractured skull the examination of
the eye grounds, just noted, indicates whether or
not intracranial pressure is increasing and helps
decide for or against operation.
Another type of acute case, the so called "acute
abdomen," if considered as such, offers few difficul-
ties in diagnosis, it is so obviously surgical. A
specific preoperative determination of the underlying
pathology, however, is usually difficult and often
impossible. The surgeon merely recognizes the ex-
istence of some intraabdominal catastrophe demand-
ing immediate surgical intervention. The perfora-
tion of a typhoid ulcer exemplifies this class of
surgical emergency. Here we recognize the diag-
nostic importance of a sudden sharp rise in blood
pressure, but we must not be deceived by its ab-
sence. Even in the diagnosis of acute cases the
surgeon cannot be entirely independent of medical
aid.
Mistakes in diagnosis are more frequent, how-
ever, in chronic conditions. Take, for example, a
definite case cf flatulent dyspepsia. To the surgical
mind gastric or duodenal ulcer, cholecystitis, appen-
dicitis or pancreatitis suggest themselves. In the
case under discussion the gastric distress came on
immediately or soon after eating. There was no
tenderness over the appendix nor any history of
attacks, and the symptomatology was not suggestive
of ulcer. The flatulent dyspepsia was of the type
encountered in gallbladder disease, and, although
there had been no pain or tenderness in the gall-
bladder region, the surgeon, nevertheless, consid-
ered the probability of cholecystitis. The internist,
on the other hand, made a diagnosis of functional
gastric disorder, proved to be correct, which sub-
sequently led to improvement under dietetic meas-
ures. Undoubtedly, the diagnostic judgment of the
internist is much freer from bias than that of the
surgeon.
The internist, however, either through actual dis-
taste for, or mere indifference to, surgical work,
too rarely visits the operating room, where the op-
portunity would be afforded him to check up pre-
operative symptomatology and diagnosis with opera-
tive findings. The writer believes that the actual
increase in diagnostic ability gained thereby, and
the added confidence which the surgeon could place
in that ability, would amply compensate the intern-
ist for the time consumed. The surgeon learns
diagnosis to a degree, by reasoning backward from
the "living pathology," so called, to the symptom-
atology. The internist considers the symptomatol-
ogy first. The method of the latter is the more
logical, but cannot be thoroughly efficient unless
supplemented by operating room observation. Sur-
geons have contributed largely to the sum total
of diagnostic knowledge, as evidenced by the say-
ing of Moynihan that duodenal ulcer can be diag-
nosed by correspondence. Although not to be taken
literally, Moynihan thus gives us an unforgettable
reminder of the unique value of subjective symp-
tomatology in ulcer diagnosis. The simultaneous
occurrence of gastric or duodenal ulcer, cholecystitis,
appendicitis, or pancreatitis, or mistaking the one for
the other before operation, is too frequent to re-
quire discussion, althougii typical of diagnostic dif-
ficulty. In a restricted sense, therefore, most diag-
noses are tentative and the majority of laparoto-
mies exploratory.
Peterson (4) indicates the value of the diagnostic
incision by his statement that, during the course
of 1906, in abdominal sections undertaken primarily
for gynecological conditions, gallstones, unsuspected
in all but a few instances, were discovered inci-
dentally 135 times, or in 12.66 per cent, of the cases,
^fayo (s) states that cholecystitis without gall-
stones may be recognized after the abdomen is
opened by the presence of enlarged lymph nodes
along the cystic duct.
This fact, the diagnostic nature of laparotomies,
has unfortunately led to ill advised operations has-
tily undertaken upon insufficient evidence. Lichty
(6), as an internist, and Connell (7), from the
surgical standpoint, among others, have noted the
frequency of error in the diagnosis of chronic ap-
pendicitis. We recall how often the excised appen-
dix has been opened, seeking justification for opera-
tion in those hemorrliagic areas of the mucosa which
Moscowitz (8) tells us are not pathological, but
are the result of operative trauma. Nevertheless,
it must be borne in mind that occasionally symp-
July 27, 1918.]
FOWLER: SURGICAL DIAGNOSIS.
149
toins suggestive of appendicitis are entirely relieved
by appendectomy although the appendix shows no
definite lesion.
The surgical significance of pain is predominant,
and therefore prone to overaccentuation. Its reflex
and referred nature is recognized, but may be mis-
interpreted and lead to erroneous diagnosis if re-
lied upon exclusively. In this connection Elsberg
(9) reports several cases previously operated upon
for appendicitis or ovaritis, without relief, in which
the lesion was a tumor of the cord pressing upon
the nerve roots. A simple neurological examina-
tion determined the diagnosis. Again, Braash and
Moore state that when the pain of stone is localized
to the area of the lower ureter, particularly on
the right side, it may so closely simulate appendi-
citis that, given a normal urine, "an exploration
of the appendix might be justifiable without pre-
liminary rontgenographic examination."
Noble (10), referring to the indications for gyn-
ecological operations, reminds us that "it is in the
study of the psychic functions of woman and their in-
fluence, and more especially of the influence of emo-
tional states upon the health of women and in the
causation of functional sexual disturbances, that the
general surgeon and the average family doctor fail
in comprehension and insight, as to whether partic-
ular symptoms have a local morphological basis, or,
on the other hand, are caused by morbid emotional
states, acting through the sympathetic nervous sys-
tem and through the ductless glands."
Of course, operation should never be undertaken
upon the sole indication of pain in the female pelvis.
This occurs occasionally, however, either because
of overaccentuation of the pain symptom, pre-
viously mentioned, or through lack of confidence in
the negative findings of bimanual examination. If
one who has acquired a fair degree of manual
perception is doubtful whether he feels something
abnormal in the pelvis he had best accept that doubt
rather than subject his patient to the chance of
negative exploration. On the other hand. Wall
(11) warns us that pelvic varicocele, for example,
is frequently overlooked. The symptoms are few
and the soft broad ligament tumor may escape
detection entirely unless examination is made with
the patient standing. Many of these women, ac-
cording to Wall, are classed as neurotics. The
gynecologist and the general surgeon appear to be
best equipped to make gynecological diagnosis.
Neurological diagnoses, however, had best be in-
trusted to the internist, neurologist, or neurological
si;rgeon rather than to the general surgeon. In this
connection Wytth and Sharpe call attention to the
point that in epilepsy "the patients operated upon
are selected ones only, according to the presence of
a marked increased intracranial pressure and with
definite localizing signs."
It must not be assumed from the foregoing that a
determination of the more or less obvious complaint
is anything more than a partial solution of the diag-
nostic problem or that any specialist is diagnostically
selfsufficient even in his own field. Nevertheless,
the evident difficulties of diagnosis are not to be over-
emphasized, but, rather, stress should be laid upon
the means of overcoming them. Bevan (12), in
discussing the problem cf intestinal stasis and its
surgical relief, states that the cooj^eration of the
internist, the neurologist, the physiologist, the j>a-
thologist, the rontgenologist, and the surgeon is the
essential factor. In group diagnosis then, as
evolved from modern hospital practice and speciali-
zation, lies the remedy for minimizing diagnostic
error. Unfortunately, an extremely large class of
patients are neither rich enough nor poor enough to
enjoy the full benefits of this efficient plan. Pos-
sibly a solution of the difficulty may be found in the
diagnostic clinic as described by Birtch (13). Here
individual examinations are made by each staflf
specialist with subsequent consultation of all ex-
aminers including the family doctor who referred
his patient to the clinic. A moderate fee is charged.
It is perhaps superfluous to state that the success
of any group plan depends necessarily upon a dis-
criminating use. The assignment of ward cases by
the senior house officer is undesirable. Every ward
case should receive a routine examination some time
during his hospital stay from each attending staff
specialist. The diagnostic system should be auto-
matically thorough. The internist, of course, is
better qualified to assume charge of surgical diag-
nosis (hence diagnosis in general) and coordinate
the diagnostic talent of other specialists than is the
surgeon, for the internist is, essentially, a diag-
nostician and the surgeon should be, essentially, a
technician. It is manifestedly unscientific and un-
fair both to the patient and to the surgeon to charge
the latter with sole responsibility for the diagnosis
and treatment of some surgical lesion which may be
only one of several factors contributing to the pa-
tient's ill health. On the other hand, the surgeon
cannot shift the responsibility for undertaking a
surgical procedure to the shoulders of a colleague.
The recent evolution of specialization with the con-
sequent refinement of diagnostic methods has rele-
gated the diagnostic activities of the surgeon to a
position of secondarv importance, but it has not
eliminated him from the scheme of diagnostic team
W-""^- REFERENCES.
I. J. A. WVETH and W. SHARPE: The Field of Neurological
Surgery in a General Hospital, Surgery, Gynecology, and Obstetrics,
January, 1917. 2. C. A. ELSBERG: The Indications for and Re-
sults of Cerebral and Cerebellar Decompression in Acute and
Chronic Brain Disease, Surgery, Gynecology, and Obstetrics, Au-
gust, 1916. 3. J. A. KEARNEY: The Value'of Eyeground Observa-
tions in Recent Cases of Fracture of the Skull, Journal A. M. A.,
October 27, 1917. 4. R. PETERSON: Gallstones in 1.006 Abdom-
inal Sections, Surgery, Gynecology, and Obstetrics, March, 191$.
5. C. H. MAYO: The Relative Merits of Cholecystostomy and
Cholecystectomy, Surgery, Gynecology, and Obstetrics, March, 191 7.
6. J. A. I.ICHTY: Appendicitis as Seen by the Internist, Report
Based Upon About 700 Cases, Pennsylvania Medical Journal, Jan-
uary, 1915. 7. F. G. CONNELL: The Chronic Abdomen, Surgery,
Gynecology, and Obstetrics, December, 1914. 8. ELI MOSCO-
WITZ: Pathologic Diagnosis of Diseases of the Appendix, AnnaU
of Surgery, June, 1916. 9. C. A. ELSBERG: Recent Advance in
Our Knowledge of Spinal Disease and Its Surgical Treatment,
Read Before the Rochester Medical Association, Rochester, N. Y.,
February 7, 1917. 10. C. P. NOBLE: The Constitutional Factor in
Gynecology and Obstetrics, Surgery, Gynecology, and Obstetrics,
January, 1917. 11. J. A. WALL: Pelvic Varicocele, Surgery, Gyn-
ecology, and Obstetrics, July, 1916. 12. A. D. BEVAN: Problem
of Unnecessary Operations and of Incompetent Surgeons, Journal
A. M. A., July 21, 1917. 13. F. W'. BIRTCH: A "Group Study"
Plan for a Diagnostic Team Acting as a Laboratory for the Pro-
fession, Journal A. M. A., May 27, 1916.
183 Alexander Street.
Physicians who have joined the army are becom-
ing accustomed to make use of clinical laboratory
reports to an extent to which few have been accus-
tomed in private practice, and when they return to
civil life they will demand the laboratory service
the value of which they will learn in the army.
FINKELSTEIN: DIAGNOSIS IN GASTROINTESTINAL DISEASES.
[New York
Medical Jouknal.
DIAGNOSTIC HINTS IN GASTROINTES-
TINAL DISEASES.
By Reuben Finkelstein, M. D.,
Brooklyn.
In an orderly examination observation of the
patient is the first and most important step to diag-
nosis. Observing does not mean merely looking at
a patient in an absent or careless manner, but close
attention to his demeanor, gait, nervous stability,
obesity, emaciation, and color. Very often a patient
will come in complaining of gastric disturbances and
observation will show the laborious breathing and
cyanosis of a cardiac condition. In these cases you
may confine yourself almost at once to his heart and
discard all other symptoms. As a student I re-
member seeing a case at dispensary tretited by a
good physician. Because the patient complained of
gastric disorders, the doctor sent her to the stomach
department ignoring the casual observation that she
was slight in build and rather emaciated and had a
proportionately large rounded abdomen. She was
promptly sent back with a diagnosis of ascites with
advanced cardiac disease.
We must not forget to find out a man's occupa-
tion, age, and address. Occupation will often give
a clue to symptoms. For instance, lead colic and
aniline dye poisoning are very important diseases
under present industrial conditions. Again, does
the patient's occupation demand constant sitting or
standing? Does he travel or is he confined to a
small dingy oftice? Age is an important factoi.
While most of the gastrointestinal diseases are
usually classified as to certain ages, these ages often
overlap and some diseases that should normally
come in old age are often seen in the young. I
have seen a case of gastric carcinoma in a girl
nineteen years of age, proved at autopsy. The
family history in cases of gastrointestinal troubles
is not an essential element. It is not necessary to
go into detail as it is in nervous or mental diseases
Heredity plays an important part in this class of
cases. The only interesting facts are whether the
parents were syphilitic, alcoholic, or perhaps tuber-
culous and thus transmitted a lessened resistance to
their offspring. A more important part is the
previous history of the patient — the influences to
which he was subjected as a youth, his general
mode of living, diseases of youth and adolescence
and how far back his present complaint began. The
fact that his history began a number of years ago
may rule out many diseases. Even the fact that the
patient suffered with frequent attacks of conjuncti-
vitis, pharyngitis, or laryngitis may show that at
those times there was a toxemia probably dependent
upon an intestinal stasis.
I remember a case where a careful taking of a
previous history might h&ve saved a man's life
through necessary operative interference. The pa-
tient was treated by a number of eminent physicians
and specialists for what seemed an obscure gastric
condition and eventually died of multiple abscess of
the liver. About two weeks before his death, on
carefully going over his previous history, we found
definite evidence of cholelithiasis. In his youth he
suffered for some time from intense upper ab-
dominal cramps which would be reheved only by
hypodermic injections. This put us on the right
track, but too late for an operation. Even where
the present history obtained is confused because of
a variety of complications and the inability of an
ignorant patient to differentiate the finer points, the
history of pain or discomfort of previous years may
be given correctly and easily recognized.
There is a possibility of trauma, which may mean
nothing more or less than a constant irritation due
to hot and highly spiced foods or constant intake of
very rough and indigestible ones. Last, but not
least, do not forget to make special inquiries of
previous infections, not only syphiHs, but typhoid,
influenza, pneumonia, or any bacterial infection. I
have a patient now under observation who has been
treated for all kinds of gastric troubles ; when one
line of treatment did not produce results another
was taken up. The patient was really sick. A
course of salvarsan and mercury seemed to relieve
him. His Wassermann reaction is at present nega-
tive and the stomach symptoms have disapf)eared.
Now we are ready to hear the patient's story. As
a rule I allow him to tell his story in his own words.
It takes a few more moments, but I get an idea of
the ailment and am able to question him more in-
telligently.
He will tell you first that he suffers pain, but pain
being a subjective symptom and only a relative term
I closely question him. He is, say, about thirty-five
years of age, bright and well fed, and is beginning
to take up abdominal corpulence that is common to
men of that age who eat well and do very little
physical work. He states that after an indiscretion
of diet about ten years ago, he had a sudden attack
of abdominal pains located for the most part in the
centre of the abdomen. He was in bed for one day,
was given an enema, and never had a recurrence of
the pain. He felt well for a number of years. For
the last five years, however, he has complained of
bad taste in his mouth and pain across the abdomen.
Now we ask as to the relation of the pain to his
meals. It may come before, during, or after meals,
or at an indefinite relation to them. Let us under-
stand the causes of pain in gastrointestinal diseases.
Pain in the gastrointestinal tract is caused by in-
creased tension of the muscular wall either by dila-
tion or spasm (i). Hence we can see that any
spasm of the pylorus from whatever cause will
produce pain in the upper abdomen. The degree of
spasm and its time relation to meals will therefore
determine the character and time of the pain.
Glassner and Kreuzfuchs, quoted by Carlson, have
shown that, while the pylorus may contract suddenly
in spasm and cause pain, the fundus may be atonic
and quiescent (2). Pain is also produced in peri-
toneal irritation. The visceral peritoneum is
insensitive to pain but the parietal peritoneum is
very sensitive (i). The mucous membrane of the
stomach and intestines is insensitive to pain. Ex-
periments by Carlson on himself and others sub-
stantiate this (2). A 0.5 per cent, solution hydro-
chloric acid causes no pain if introduced even at
the seat of an ulcer. Hence the number of latent
ulcers and also the absence of pain in the Dieulafoy
ulcers. When, however, the ulcer is caused by in-
fection, as has been proved by Rosenow in many
instances, then the resulting toxemia will cause a
July 21, .918.] FINKELSTEIN: DIAGNOSIS IN GASTROINTESTINAL DISEASES.
hyperexcitability of the sensory nerve endings. This
will cause the spasm with its pain signal. Now,
when the ulcer has penetrated further into the
peritoneum, and, through irritative exudates, has
attached itself to the parietal peritoneum we get
irritation pain. Remember, also, that similar irrita-
tion is the cause of pain in visceroptosis ; it is simply
the pulling upon the parietal peritoneum. There is
pain due to spinal causes and referred to the
stomach and abdomen. Any disease of the seventh
to tenth dorsal segments may be referred to the
stomach. Another cause of gastric pain in disease
is the so called hunger pain. The feeling of wanting
to eat is designated as hunger. It is nothing more
than the hunger contractions of a normal stomach.
This hyperexcitability is caused by inflammation
due to a gastric or duodenal ulcer and in chole-
lithiasis to the spread of bacterial toxins along the
branches of the vagi nerves (2).
To return to the patient : his pain is indefinite but
has a tendency to come on about three to four hours
after meals, also at times immediately after meals.
The pains are so indefinite that he does not give a
clear history of hunger pain. Another fact that we
nmst take into consideration is that he has never
vomited and so does not know whether it would
relieve his pain. He has taken soda to reheve the
burning but has never learned to take food for his
pain as is sometimes done in uncomplicated duo-
denal ulcers. Food does not increase his pain im-
mediately. There is no difficulty in swallowing. A
very important fact is that when he takes physic,
has a movement, and expels gas, he feels relieved
and the pain practically disappears for some time.
He does not complain of pain or pressure under his
chest but does complain of precordial pains espe-
cially when suffering with gas distention. Another
very important fact is that the pain does not radiate
to his shoulder. The patient does not vomit nor is
he ever nauseated. He is constipated for weeks in
succession, having a bowel movement only on taking
physic. During the time when he is not constipated,
his appetite is good. Stool is of normal consistency
and there is no pain on defecation. Urine is normal
in color and amount, although very red, and there is
no pain on urination. He does net arise at night to
urinate.
In an examination for a suspected gastrointestinal
disease always take the blood pressure first. Arterio-
sclerosis and chronic nephritis are by no means rare
even at the age of our patient. Again tuberculosis,
myocarditis, gastric carcinoma, and diseases result-
ing in hemorrhage will often give a low blood press-
ure. Simple intestinal toxemia may give a high
blood pressure. Our patient has a blood pressure
of 126 systolic and seventy diastolic. His eyes arc
clear, color good, no enlarged glands about the neck
or throat, thyroid normal in size, heart and lungs
negative.
Now comes the abdominal examination. We may
have an idea of our patient's trouble, but should
not jump at conclusions, but examine that part of
the abdomen suspected. In this connection observa-
tion again comes to the fore. First he is put in the
upright position, then in the prone. In this way one
can often diagnose a tumor, ascites, pregnancy, or
prolapsed viscera.
Now we come to palpation, which should be done
in an orderly manner. I usually go over the abdo-
men lightly at first to feel any special resistance or
tumors of any kind, then more carefully. With
deep palpation, my usual routine is to examine the
left lower quadrant, the left upper quadrant, the
epigastrium, the right hypochodrium, the right
lumbar region, the right lower quadrant, and finally
the special points. Our patient presents no patho-
logical signs upon observation. The entire abdomen
moves freely with respiration. Percussion elicits
nothing exceptional. The liver is normal. The
stomach percusses to the umbilicus. Percussion of
the colon seems normal, perhaps a little tympanitic.
Light palpation shows no resistance and no tume-
faction. Deep palpation shows some tenderness
over the sigmoid ; the spleen is not enlarged ; there
is tenderness over the epigastrium ; the liver is not
tender ; gallbladder is not felt ; right kidney is not
felt. I also look for the left kidney but only as a
matter of routine as it is rarely prolapsed. There
is an indefinite tenderness over the right lower
quadrant. There is some tenderness over McBur-
ney's point. Morris describes tender points in dif-
ferentiating chronic appendicitis. They are situated
in a line drawn from the umbilicus to the anterior
superior spines of the ilia and about one and a half
inches from the umbilicus. This falls over the right
and left lumbar gangHa of the sympathetic. He
states that in chronic appendicitis the right point
alone is tender. When the right and left points
are tender it would prove to be a pelvic disease.
When neither is tender, the trouble would be
cephalad from the pelvis and the appendix (3).
This sign is good when present in uncomplicated
cases. Our patient has no tenderness over these
special points. Robson's point, midway between the
ninth costal cartilage and the umbilicus, is negative.
This sign is usually present in gallbladder diseases.
In testing for these special points of tenderness be
on the lookout in thin patients where the spinal
column comes right up. In those cases tenderness
will be elicited all over. A very important diag-
nostic point when present is the localization or Head
zone. Ordinary pinching of the skin is not painful.
In disease of the internal viscera we often get a
hypersensitive condition of that portion of the skin
having nerve connection to the same segment of the
cord as the affected viscus. Our patient does not
show it. Much has been said of the Boas point in
cases of upper abdominal disease, but it is so in-
constant and so easily mistaken for general spinal
tenderness always present in neurotics that I place
no reliance upon it.
Sometimes where tumors are suspected or where
a gastroptosis is present we will wish to make out
the exact boundaries of the stomach. Pump a little
air into the stomach or blow it up with a seidlitz
powder, and the tumor, if present, will then become
more palpable. Perhaps for the boundaries it is
better to give the patient one or two glasses of
water to drink and then percuss the outline accord-
ing to the Conheim method (4), but not in this
patient because his symptoms do not point that
way. As he sits up we will make sure of his
patellar reflexes and shin tenderness which will tend
to exclude tabes or syphilis. Do not forget to pal-
152
FINKELSTEIN: DIAGNOSIS IN GASTROINTESTINAL DISEASES.
[New York
Medical Journal.
pate the abdominal rings for hernia; often a right
inguinal hernia may give rise to abdominal symp-
toms similar to chronic appendicitis. The final step
of physical diagnosis should be a rectal ex-
amination. Osier has stated that the difiference
between a general practitioner and a specialist is
that the specialist examines the rectum.
Laboratory findings are very important. By this
time we have excluded many diseases, but we must
complete our examination. A gastric test is at once
suggested. This should be divided into two parts.
The empty stomach secretion should be extracted to
show a hypersecretion, and then the regular test
meal to show the hyperacidity. I have my patient
come in the morning on an empty stomach. I ex-
tract any secretion present, and then give him a test
breakfast, a roll and two glasses of water. One
hour later I extract again, and tes*-. The inter-
pretation of the results is very important. The first
extraction is examined for free hydrochloric acid,
Opler-Boas bacilli, and lactic acid ; the second for
free hydrochloric acid, total acidity, blood, lactic
acid, when hydrochloric acid is absent, and occa-
sionally for pepsin, rennin, and bile.
Microscopically we examine the solid portion and
note the findings. The different tests can be found
in any good textbook on clinical medicine. A very
important point should be cleared up; that is, that
the presence of the Opler-Boas bacilli does not al-
ways mean carcinoma. It may be present m any
case of lactic acid fermentation due to stagnation.
Again, carcmonia may exist without the Opler-Boas
bacilli, because no stagnation is present. Also, sar-
cini simply mean stagnation without destruction of
the secreting cells, i. e., hydrochloric acid must be
present for their development. Stasis can easily be
detected by asking the patient to eat a handful of
raisins the evening before the test meal is given.
Their presence in the extraction of the fasting stom-
ach would indicate retention. On finding occult
blood, make sure that it is not due to injury of the
delicate mucous membrane caused bv the stomach
tube. As a rule, gastric tests should not be made
during the menstrual period because the chemism of
the stomach contents at that time varies from the
normal. No examination of the gastrointestinal
tract is complete without examination of urine and
stools, but, as a matter of fact, the urine should be
examined in every case of chronic disease, because
the body chemistry is more or less changed, and
the urine gives the first sign of these changes. T
have a little patient under treatment now who has
been complaining of symptcms diagnosed as chronic
appendicitis, but a careful history of the pains and
an examination of the urine discloses evidences of
renal disturbance, probably caused by a stone in the
pelvis of the kidney. She also had definite tender-
ness in the right costovertebral angle, a very good
sign in differentiating kidney disturbances. The
feces should be examined for occult blood and un-
digested material. Never forget to look for ova,
for intestinal worms will often give symptoms of
more serious diseases.
On extraction nothing is recovered from the fast-
ing stomach of our patient, and it is well known
that the fasting stomach may contain ten to fifteen
c. c. of acid fluid and be normal. Rhefus, Bergeim,
and Hawk assert that they have proved that the
normal stomach may contain as much as lOO c. c. of
fluid (5). This patient's stomach secretion was ex-
tracted one hour after his test was given ; the free
hydrochloric acid showed a value of sixty and a
total acidity of seventy-six. The presence of hy-
drochloric acid precluded testing for pepsin or
rennin as they are always present with hydrochloric
acid. Occult blood was not present. Microscopi-
cally nothing was seen but a few starch granules.
The urine was negative except for a large amount
of indican. The stool, was negative as to blood,
ova, or undigested material. The examination of
our patient's blood showed a normal leucocyte count
and the hemoglobin was eighty-five per cent. The
Wassermann test was negative. The man had no
hemorrhage, hence we did not take a red cell count.
It is almost impossible to make a final definite
diagnosis of any chronic disease of the gastroin-
testinal tract without a complete x ray examination.
Carman reports about eighty-five per cent, diag-
nosis of duodenal ulcers and ninety-five per cent, of
gastric carcinomas with the aid of the x ray. The
findings in the Brooklyn hospitals are not so high,
but are high enough to warrant an x ray examina-
tion for every patient giving symptoms of gastric
ulcer or cancer. Even in cholelithiasis, where the
stones may not always be seen, evidences of ad-
hesion or position of the stomach may prove their
presence. In order to be of any value it must
be thorough and complete, merely taking a few
plates after a six hour meal is not sufficient. The
actual working of the stomach must be observed
under the fluoroscope ; plates should then be taken
to help in the diagnosis and for record purposes.
A practice to be decried is the sending of a patient
for an x ray examination without making any other
physical or laboratory examinations, simply be-
cause he complains of stomach trouble. The x ray
alone is of no value and is of diagnosing import in
gastrointestinal diseases only when an entire exam-
ination as outlined above has been made.
Our patient was thoroughly x rayed. First in the
upright position we found a slight retention after
a six hour meal. The bismuth filled the entire
ascending and transverse colon showing a hyper-
activity of the entire tract. After a full meal the
gastric and duodenal outline shows no defect, but
the stomach shows a hyperperistalsis, that is, it
works too fast. In the horizontal position we also
find bismuth in the appendix. Twenty-four hours
later we find the entire colon filled and the appendix
still visible. Forty-eight hours later the colon is
empty except for some bismuth in the rectal ampulla,
but the appendix still shows bismuth retention. In
the entire history this is the first real definite evi-
dence of his trouble, but this is fortunate for vis
because in all cases we do not get such direct
evidence.
Here is the summary and diagnosis: i. We no-
tice that while his pain is periodic, that is, coming
on at definite intervals of a few months, there is at
all times some epigastric burning and feeling of
fullness, especially after meals. He has frequent
attacks of constipation lasting for two or three
July 27, 1918.]
BEHREND: SURGICAL PROBLEMS.
153
weeks at a time, and at those times suffers with
loss of appetite and belching. 2. While his pains
come on two or three hours after meals there is
always a blending or overlapping from time to time
and no definite history of pain before meals. 3.
Food does not relieve his pain, as it would in duo-
denal ulcer, nor does it increase pain, as it would
in gastric ulcer. 4. There is entire relief of sym-
toms after a bowel movement. 5. The gastric find-
ings are not conclusive. The acidity is too high for
a duodenal ulcer and is rather indicative of a nervous
dyspepsia or irritation from an outside source. We
must not forget that in chronic appendicitis we may
even get occult blood in the stool. This, however,
is not so in our case. 6. The urine shows an in-
creased amount of indican which means intestinal
stasis. After the hyperperistalsis, the muscular
walls are tired out and hence stasis results. 7.
Direct x ray evidence shows inability of the ap-
pendix to empty itself in forty-eight hours. We
may conclude, therefore, from the foregoing evi-
dence, that our patient has chronic appendicitis.
George and Gerber claim to have visualized the
appendix in about seventy per cent, of their cases.
Another method is the indirect one. The insuf-
ficiency of Bauhin's valve or the presence of ad-
hesions about the appendicular region will give us
the correct diagnosis. In this connection a very
important observation by Brown, Moynihan, and
Finney (6) cannot be too strongly emphasized. "In
all cases of gastric dyspepsia of long duration espe-
cially if they show an exacerbation from time to
time with no success in treatment as nervous, the
underlying cause is chronic appendicitis without
local manifestations."
It is not often that a physician is called upon to
use all these stratagems in order to make a diagno-
sis of chronic appendicitis. In fact, a few careful
observations will rule out a number of diseases,
but, when a patient comes into my office for the
first time, I canript tell what the ailment is until
I make some investigation. Very often from the
patient's brief history and incomplete description
you wonder whether you are dealing with a case of
tabes dorsaiis or, perhaps, a Meckel's diverticukim,
until further examination proves the contrary.
Again, not at all times are we able to make a cor-
rect diagnosis even with all the means at our com-
mand. However, in the majority of cases by care-
ful study of the patient's history and a subsequent
study of findings we can arrive at a definite diagno-
sis. Even in duodenal ulcer it is not true, as
Moynihan has said, that the diagnosis can be made
from the history alone. We must make a study of
the clinical findings and a careful x ray diagnosis.
The man who makes an incorrect diagnosis after
exhausting every means should not be censured.
Such errors are excusable and the physician making
them will be benefited. The man who is doginati-
cally positive and jumps at conclusions without due
deliberations is the man who deserves censure (7).
257 Utica Avenue, Brooklyn.
references.
I. Monographic Medicine, i, 172. 2. CARLSON: Control of Hun-
ger in Health and Disease, p. 102. 3. KEMP: Diseases of the\
Stomach, Intestines, and Pancreas, 1917 Edition. 4. CONHEIM:
Diseases of the Stomach and Intestines. 5. RHEFUS, BERGEIM,
and HAWK: Journal A. M. A.. Ixiii, 11. 6. FINNEY: New York
State Journal of Medicine, xvii, 207. 7. LYNCH: International
Clinics, 1912, iii.
SOME SURGICAL PROBLEMS AND PRIN-
CIPLES.*
By Moses Behrend, M. D.,
Philadelphia.
Certain elementary principles of surgery are of
great importance to the general practitioner. Often
greater success is obtained by bringing minor con-
ditions to a speedy and favorable issue. The edu-
cation of the profession in these minor principles
is, however, still deficient. Although the experi-
ence of two men may not be identical, both may be
correct if the same result was obtained in sim-
ilar cases. One often hears, too, discussion of sim-
ilar symptoms and diseases when upon careful in-
vestigation there may be no resemblance at all. The
title of this paper allows wide latitude of discus-
sion, but there are a few salient points derived
from experience that I hope may be of interest.
While some of the topics may seem trite and not
sufficiently technical, these points have been of
great assistance in bringing to a final cure many
cases under my care.
Probably the one aid in surgery that has been
most often misused and misapplied is gauze in daily
routine. It has been, and is still, the universal
custom to pack abscess cavities and infections day
after day for weeks and months ; this keeps them
open and prevents their iiealing, thus unnecessarily
postponing the ultimate healing. The first principle,
then, is that gauze does not drain. It dams up
secretion and prevents healing. An ischiorectal ab-
scess, after the first four or five days, requires no
packing at all. The best method of treating these
cases is to pass cotton with the solution of choice
on an appHcator to the bottom of the wound. It
effectually prevents healing from the top, and the
medicament is carried to the depths of the wound.
The wounds heal more quickly and the patient is
relieved of the much dreaded and painful gauze
packing. The time required to heal any infection
depends on its size and situation, but the course
of treatment is much shortened by this method.
It also applies especially to abscesses in the right
iliac fossa following an operation for acute appen-
dicitis. In this region I have often noted that the
discharge was encouraged and the wound prevented
from healing by prolonged packing. It is with
the greatest difficulty that resident physicians can
be kept from stuffing these wounds daily with
gaur.e, thereby disturbing healthy granulations.
When I entered my service a few days ago at the
Jewish Hospital two cases of compound commi-
nuted fracture of both bones of the leg were brought
to my attention. They had become infected and
had been packed every day. The packing was
stopped at once, and the following day, upon inquiry,
I was told that the discharge had been practically
nil. It is very poor technic to pack infected bones
and joints. Joints that have been packed will be-
come ankylosed. Infected joints should never be
drained. They require a Buck's extension appa-
ratus to keep the joint surfaces separated.
The first few days after operation in appropri-
ate cases, however, there is an undoubted field for
*Read hefnre the Ex-Residents' Association of Mount Sinai Hos
pital, February 6, 1918.
'54
BEHREND: SURGICAL PROBLEMS.
[New York
Medical Journal.
gau.'.e packing on account of its hemostatic action.
After gall bladder operations where many adhesions
have been encountered, especially after secondary
operations, gauze placed over and packed around
denuded surfaces, which cannot be ligated, is a
welcome hemostatic. The same may be said of
difficult pelvic cases with adhesions where raw sur-
faces are left oozing.
The treatment of pus in any situation has been
revolutionized by the use of dichloramin-T. It has
demonstrated that gauze packing of abscess cavi-
ties is of less utility than ever. There is no ques-
tion that the chlorine compounds have an especial
affinity for pus. They have the power of decreas-
ing the quantity of pus by diminishing the virulence
of the germs and finally destroying them. These
controls have been demonstrated by us in the lab-
oratory with the able assistance of Doctor Ruben-
stone. A smear of the discharge is placed on a glass
.slide each day, and the number of bacteria in a given
field or fields is counted. Thus when the number
o-f bacteria in given field reaches fifty or sixty the
wound is not yet ready for further treatment. When
the fields under the microscope show from four
to five bacteria to a field we may then sew these
wounds without compunction. It takes consider-
able courage to sew palmar abscesses and infected
abdominal wounds, for instance, long before it is
time for the skin edges to close these spaces by the
prolonged and natural processes of repair, but with
this scientific method of observation and the per-
fect cooperation of surgeon and laboratory no fear
need be felt as to the failure of the procedure just
mentioned. A new epoch has been attained by the
introduction of this new Dakin compound, and the
chapter on the treatment of infections will have to
be rewritten.
It is not possible to discuss this oily compound,
dichloramin-T, without referring to the Carrel-
Dakin watery solution. The former is to be pre-
ferred in the large majority of cases because no
elaborate method of application is necessary. With
the oily solution one treatment a day is sufficient,
whereas with the Carrel-Dakin solution the nurse
must be ready every two hours to irrigate the
wound. The Carrel-Dakin solution will irritate the
skin more readily than the oily solution. The lat-
ter does not irritate imless free hydrochloric acid
has been evolved. This can be detected by the
formation of crystals in the bottom of the container.
One objection to the chlorine compounds is the ease
with which they disintegrate into other chemical
constituents.
We now come to the consideration of fractures.
They are first seen in the majority of cases by the
general practitioner. They cannot be reduced prop-
erly without an anesthetic. The best anesthetic is
ether, although nitrous oxide gas, on account of its
safety and ease of administration, may first be tried.
An X ray is then taken, and if the fragments are
not in apposition ether should be given to insure
perfect relaxation of the muscles. The treatment
of fractures is not the simple proposition that it
seems. Many suits for malpractice are due to the
poor results and the poor restoration of function
following fractures. In the treatment of fractures
splints may be used the first few days, until the
swelling has subsided. Afterward a plaster of
Paris cast or a moulded plaster splint is to be
preferred. All plaster casts should be cut down
the centre after they are appHed. This serves a two-
fold purpose : i, it allows freer circulation and venti-
lation of the part bandaged ; 2, the cast can be easily
removed, and the parts inspected from time to
time and massaged. The same cast is then replaced.
Massage and passive motion of the fractured part
should not be done until the first two weeks have
elapsed, and then every four or five days there-
after. Much harm can be done by too much and ill
advised massage, but if gently done no hami can
follow, provided the fragments are in apposition
and union of the fracture has taken place. The
X ray and the fluoroscope are indispensable in the
treatment of fractures. At times the x ray picture
is at variance with the position of the bones as
derived by the examination of the parts involved.
In other words, if the x ray shows the bones not
in perfect line, and physical examination reveals
that function will not be disturbed, it is justifiable
to allow the fracture to unite in this p>osition. If
the deformity is too great, however, and the frac-
ture cannot be reduced, then an open operation is
permissible.
While I wish to avoid technicalities as far as
possible in presenting this subject to general prac-
titioners, the open operation for fractures must be
briefly considered. I am old fashioned enough not
to treat any fracture by the open method when a
good result can be obtained without it. The main
indications for the open method are inability to
keep the fragments in line, and a fracture that
will not unite within a reasonable time. Open op-
erations should not be performed unless the sur-
geon has been trained perfectly in the no contact
technic. By this I mean that his fingers must
never touch the wound or the fractured ends. This
is all important if one wishes to avoid infection.
Remember also that an instrum^t once used must
be resterilized. These precautions are taken because
bones have a peculiar susceptibility to infection.
There is a tremendous field for the treatment of
fractures, but less than one per cent, are treated
by the open method. Excellent results are ob-
tained by the conservative methods outlined.
In gynecological practice dysmenorrhea forms a
considerable percentage of the numbers of cases
seen by the physician and surgeon. It may be due
to many causes, such as maldevelopment, blood
dyscrasias, faulty position of the uterus, and occlu-
sion of the cervix. One cause of dysmenorrhea,
rarely described in the textbooks, is a condition
of varicose veins of the broad ligaments, which
cannot be diagnosed by vaginal examination. After
the abdomen is opened, the veins are seen to stand
out like cords and feel not unlike a varicocele in
the male. A ligature is placed above and below
the course of the veins, the intervening section is
excised, and then the free ends are tied together.
I have performed this operation on two virgins for
severe dysmenorrhea ; in one the symptoms were so
agonizing as to cause fainting spells at the time
of menstruation, while in the other the symptoms
compelled the patient, a school teacher, to lose sev-
eral days each month. On vaginal examination in
July 27, 191S.I
BEHREND: SURGICAL PROBLEMS.
155
both of these cases the condition found was a retro-
version. Upon opening the abdomen, in addition
to the retroversion, enormous veins were noted in
the left broad ligaments. These patients were oper-
ated upon, respectively, in May and October of last
year, and up to the present time they are enjoying
perfect health.
Surgeons are often asked whether a patient suf-
fering from adhesions following an operation will
be benefited by a secondary operation. As a rule,
one can advise operation and promise success even
if secondary adhesions are formed. In many cases
adhesions do not reform. It has been my good for-
tune to have operated in cases for other conditions
following a secondary operation for adhesions. In
two cases absolutely no adhesions were found at
the third operation. The formation of abdominal
adhesions with the subsequent symptoms is a most
annoying complication. It is a fact that has not been
satisfactorily explained that after a severe gallblad-
der operation the patient often suffers less from
adhesions than from those following a one inch in-
cision for the removal of a chronic appendix. The
great mass of experimental work done on adhesions
has not cleared the situation as to their prevention.
One great class of cases has interested the pro-
fession comparatively recently since many diseases
formerly treated by the internist have been rele-
gated to the surgeon. These borderline cases nat-
urally require in many instances a consultation be-
tween the internist and the surgeon. Although
these conferences in the main have not been neg-
lected, there ought to be a closer affiliation be-
tween the internist and the surgeon in the study
of their respective cases. Borderline cases may be
divided into those that are purely surgical and
those that may be considered medical and surgical.
A group of pure borderline cases that occupy the
attention of surgeons alone are the many cases of
breast tumors, the majority of which are found in
women. It requires the finest judgment to differ-
entiate between the apparently benign tumors and
those bordering on malignancy. It may be stated
that tumors of the breast in women over thirty
years of age may be looked upon with suspicion,
although malignancy may occur in individuals much
younger. Cysts with clear fluid are benign, but
those that contain a brownish or muddy liquid are
malignant. Here the radical operation should be
done. In a rather large experience with breast tu-
mors it has always been my rule where doubt exists
to have the pathologist present at the operation,
so that a frozen section can be made of the tumor.
This is done while the patient is still under the
anesthetic. The pathologist's report guides the sur-
geon as to the character of the operation to be
performed.
Exophthalmic goitre is a type of a medicosurgical
borderline group that has elicited considerable dis-
cussion in the past few years. The internist be-
lieves that these cases should be treated with
rest, bisulphate of quinine, thymus gland, and a
host of other drugs. Medically, the disease may
be arrested for a time, but ultimate cures cannot
be recorded. The surgeon believes that with very
cautious surgical procedures the patients can be
greatly benefited and many cures obtained. In these
cases the surgeon must first classify his patients
very carefully as to the degree of toxemia present.
Toxemia varies in each case, and the kind of
operation, whether a ligation of one or both
superior or inferior thyroid arteries or lobec-
tomy, depends on the amount of toxic material in
the system. The best results in my experience are
obtained by the primary ligation of the superior
thyroid artery, and then three to six months later,
if the patient has gained sufficient weight, and he
usually will have gained from fifteen to twenty-
five pounds, a lobectomy may be performed with
greater safety.
In conclusion, certain anemias have opened a field
in surgery at which a few years ago the internist
would have looked askance. These patients pre-
sent great difficulties to the surgeon on account of
the existence of degeneration in the cardiorenal sys-
tems, in addition to the poor quality of blood. The
best results have been obtained in the syndrome
called Banti's disease, .splenomyelogenous leucemia,
and pernicious anemia. Medicine has failed to cure
these diseases; the surgeon has often arrested their
progress and prolonged the lives of these patients
by a timely splenectomy.
In closing, the main points that I wish to empha-
size are that infected wounds must not be packed
indefinitely with gauze ; that the chlorine compounds
exert a specific influence on pus ; that with the lab-
oratory controls infections can be treated scientific-
ally and the wounds may be actually closed by
suture. In the treatment of fractures an anesthetic
is important in reduction and, while nitrous oxide
gas may be used, ether is preferable on account
of the thorough relaxation procured from its use.
Plaster of Paris is superior to the wooden splints
universally used. The open operation should not
be used unless the fragments are in poor position
or there is no union at all. Secondary operations
for abdominal adhesions are often curative. Bor-
derline cases should always be studied thoroughly
by both internist and surgeon.
1427 North Broad Street.
Cuneiform Fracture of the Upper Extremity of
the Tibia. — Bee and Hadengue {Paris medical,
April 13, 1918) report the case of a soldier with a
history of twisting of the right knee in falling into
a hole. The parts were swollen and pressure caused
pain especially at the outer aspect of the upper end
of the tibia, which seemed distinctly broadened.
X ray examination revealed a cuneiform or vertical
fracture at this point, splitting off about one half
of the right articulating surface of the tibia. The
fibula was intact, doubtless owing to its elasticity.
The portion of bone split off was, however, adher-
ent, as in most similar cases hitherto reported, to
the epiphysis of the tibia and the head of the fibula
owing to the fibroperiosteal sheath and the joint
capsule. This is the first case of this type met with
by the authors among thousands of fracture cases
examined since the beginning of the war. Before
the discovery of the x ray such fractures were mis-
taken for sprains of the knee.
156
NIES: FOOD VALUE OF MEAT.
[New York
Medical Journal.
THE FOOD VALUE OF MEAT *
; By Edward H. Nies,
New York,
Associate Editor of Hotel Gazette.
The essential in increasing meat value is to make
it go further. It gradually became the custom to
economize on expenditure for food in restaurants
by buying only meat. This, together, with bread,
which was gratis, constituted a meal. Vegetable
and farinaceous foods were absolutely ignored.
When meats were cheap this was practicable, but
now that they have so risen in price and diminished
in portion, while in addition bread must be paid for,
other expedients must be employed in order to re-
tain even a memory of meat flavor.
The entrance of women into the industries, their
disinclination to cook, and the pernicious poisoning
of the chain lunch rooms, undermined the good
habits of our people by making it possible to get
along and keep alive without all the labor and ex-
penditure of time that must be devoted tO' healthful
cooking. And moreover the disordered lives so
many of us live with the pretense of keeping up
app>earances beyond our means have led us into the
error of cheating our stomachs which are invisible,
in favor of gaudy clothes, automobiles, and rainbow
drinks in cabarets. These and other practices,
equally destructive, have resulted in our deserting
the straight and narrow path of systematic and
orderly living, and our lack of moral stamina.
As a result of this mode of living we are face to
face with a food problem, since that supplied in the
lunch rooms and mediocre restaurants is becoming
so meagre, tasteless, nonsatisfying, and inferior in
•quahty. Many of us who lack means would, Hke
the prodigal, fain fill up on husks. Our poor wives
and mothers at home try in vain to make ends meet.
Lacking the necessary information they turn to
those false prophets, the hall room epicures of the
woman's page and household journals, who reward
their confidence by a dinner of dead sea fruit. To
follow their regimen would chain us to the cooking
stove forever and test the resources of Park &
Til ford to fill their recipes. The diet they have
evolved, the mock duck, bean roast beef and alfalfa
croquettes, if persisted in, would incite the land to
rebellion. Their constant succession of reheats,
starch repeats and their advocacy of robbing the
baby's milk bottle of its top milk to furnish cream
for adults can but result in disaster to ourselves,
and degeneracy to our children, whose milk they
rob of its butter fat. Recourse must be had to
other means if we would be well nourished and
healthy. TIow can we do this? I think my method
may help. I do not claim for it any great origin-
ality. It is employed abroad and was in our homes
■before the low cost of meats lured us to the delica-
ftessen store.
There are a thousand and one dishes of which
each one is in Hself a well balanced meal, and in
addition is appetizing and nourishing. They can,
even at the present high costs, be prepared for a
reasonable price. They are made by a combination
•An address delivered to the Municipal Employees, New York,
May 22, 1918, under the auspices of the Municipal Civil Service
..Commission, L. F. Fuld, Assistant Chief Examiner.
of a small portion of meat with a larger c[uantity of
grain, cereal, or other farinaceous substances, or
vegetables. They are flavored from their essential
ingredients so that their preparation requires no
high order of culinary skill. With a judicious use
of the ordinary fireless cooker they can be prepared
in the morning, put in the cooker, and taken out
ready to serve when the family returns in the
evening- ; thus releasing poor women from the bond-
age of the cook stove, and, in addition, providing
the family with better food than could be prepared
by the old hurryup way, which is so wasteful of
material, and consumes so much time.
These dishes are prepared so that all the sub-
stance of each ingredient is conserved for consump-
tion. The shrinkage instead of evaporating into the
air is absorbed by the parts of the combination and
saved to the consumer. The pleasure which is de-
rived from eating, is established first by sight, sec-
ond by taste and smell, and lastly by the feeling of
satisfaction after eating which brings with it relaxa-
tion of mind and body. If our food can be so
prepared tliat it brings about all these things, and
that with the homely means at the command of
every housewife, much can be saved by thus abolish-
ing the necessity of dining at restaurants and
spending money, which economized, purchases
many better and perhaps more needed things.
Let us take simple and well known combinations,
found in the sunny south where the struggle for
existence is not so keen and every woman learns
how to cook : Hopping John or Jomblyla, the vari-
ous Creole Gumbo, and many other savory Creole
di.shes. A little further afield in Persia and Ar-
menia, we find Pilaff, a dish made with rice or
cracked wheat combined with meat, fish or vege-
tables. It is most substantial, appetizing and nour-
ishing, and it can be prepared in an infinite
variety of ways.
We all know how appetizing macaroni, spaghetti,
or noodles is when properly cooked in broth, and
then combined with the flavor or gravy of meat.
Stews largely com.posed of potatoes and various
vegetables with only enough meat used to flavor
them are better than meat stews. Potatoes cooked
a la Boulangere with bacon, and sliced onions con-
stitute a meal in themselves. Go into this idea thor-
oughly, and see how much you can improve your
diet, and cut down your meat bill. A small part
of meat or fish will give relish or flavor to the sat-
isfying and nourishing cereal. The farinaceous or
vegetable dinner will save you money and health.
Adjusting Rations. — The English doctors will
themselves certainly need extra rations if they are
so incessantly called upon to decide as to sufficient
rations for invalids, working men, school boys, and
the rich. They have also just had to decide con-
cerning emergency food supplies for the air raided.
Supplies, overriding ration rules, are to be available
for air raid sufl^erers. An instruction is issued that
district committees or executive officers can now
provide food cards or take such other actions as may
be necessary to meet an emergency, and it is pointed
out that where a national kitchen is accessible food
can be obtained there under oilficial authority.
Medicine and Surgery in the Army and Navy
MEDICAL iNOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London; etc.
DIABETES AMONG THE TROOPS.
I send you some notes regarding the treatment
of diabetes as carried out in the Austro-Hungarian
troops. It would seem that the number of cases
has been remarkably small in their military hos-
pitals. Soldiers so afflicted are sent to hospitals as
soon as the affection is recognized, and after thor-
ough examination they are sent to the rear or em-
ployed in office work or some similar occupation.
The Austrian physicians appear to find it difficult
to decide to what extent corporal or psychic dis-
turbances resulting from warfare enter into the
genesis of diabetes.
According to von Noorden, whose experience has
been confirmed rather more in Teutonic countries
than elsewhere, the present war has not increased
the number of diabetics. If this prove true from
experience gained in all armies, the traumatisms
of warfare cannot be placed among the etiological
factors of this process.
As far as I can learn, Lenne is the only Hun
authority who sustains an opposite point of view,
but the analogy which he puts forward with car-
diac affections would seem to be contradicted by
the frequency and the high percentage of these le-
sions. However, even if psychic traumata be rec-
ognized as etiological factors, it does not seem quite
legitimate to admit a "war diabetes" on this foun-
dation alone, as he would have it.
Therefore, as Roth points out, it is much simpler
to divide diabetic soldiers evacuated from the front
into two groups, viz. : light cases with unsuspected
disease, and healthy subjects who are sent to the
rear with what Albu terms a "diabetic predispo-
sition," and who simply offer the symptoms of the
affection
The first group only composes light cases, because
they do not offer subjective phenomena for the rea-
son that the process is not advanced. Likewise,
in the second group a certain percentage belong to
mild cases.
Regardless of all this, the Austrian physicians
have discovered a striking fact, namely, that the
number of serious cases are far in excess of the
mild or medium, to sixch an extent that Lenne re-
cords 152 serious cases as against ninety-nine mild
ones. I note that in the statistics offered by Roth,
out of a total of thirty-one cases sent from the front
there is not a single mild case. This may be ex-
plained from the fact that some of the men had
a latent diabetes at the time they were enrolled,
and the process then rapidly developed in a predis-
posed soil. The lack of proper diet may unques-
tionably act on the metabolism of the carbohydrates,
especially when it is recalled that diabetic soldiers
continually receive more foodstuffs containing sugar
than they can usually tolerate. The psychic fac-
tors invoked by Lenne may also participate in the
physical failure of these subjects. But it appears
from all accounts that a most striking fact is elic-
ited in the case histories of these soldiers, which
cannot be accounted for by the above explanation.
The majority of them state that they have been
principally fed on meat, white bread, vegetables and
carbohydrate substances have been given in small
quantity. In the mild cases, which appear to have
been more frequent at the beginning of the war, it
might naturally have been supposed that, on account
of a restricted diet, a tolerance would occur, yet
nevertheless, the majority of patients entered the
base hospitals in a bad general condition, and even
with acidosis. At the Rozsahegyer Heilaustalt, at
Budapest, it was found that the disappearance of
sugar from the urine and an increase in tolerance
was much more difficult to obtain than in medical
practice in peace time. It was, therefore, thought
that albuminoid foodstuffs, particularly animal,
might be, to a certain extent, the causative factor
in the tenacity of the phenomena.
The experiments carried out by Roth in 1913
seem to have confirmed the nefarious influence of
animal albumins, as opposed to vegetable albumins,
on tolerance, and this unfavorable effect may pos-
sibly be connected with the different chemical make-
ups of these albumins, and not to the extractive
matter of meat, because in the above mentioned ex-
periments Roth was unable to demonstrate that a
similar effect could result from the simultaneous
exhibition of vegetable albumins and extractive
matter.
Therefore, in similar cases he was tempted to
decrease the amount of animal albumin and to re-
place it by the vegetable. This done, he found that
when the sugar could not be expelled by a meat diet
with the addition of some carbohydrates, the sugar
could be made to disappear when the meat was elim-
inated and replaced by vegetable albumins, upon the
condition that the amount of carbohydrates was the
same as with a meat diet. The tolerance increased
slowly after the meat was cut out, and a complete
disappearance of the sugar was finally obtained.
I cannot do better than offer the following case
as an illustration : Soldier, aged thirty-three years,
had been at the front for six months. He had lost
weight regardless of a good appetite and a tremen-
dous thirst. He had been treated in various hos-
pitals for five months. Finally, when he returned
home he was so. weak that he could hardly walk.
Under proper diet, as outlined above, he improved.
Roth has been able to show quite conclusively,
I think, that in almost all cases the elimination of
animal albuminoids is essential, both in mild as well
as serious cases. It is well known that in some
few instances a better utilization of the carbohy-
drates can be obtained by decreasing the albumin in
the diet, although von Noorden looks upon such cases
as exceptional. In these circumstances one is deal-
ing with what the Huns call "sub jects sensitive to
albumins," who, according to their way of looking
at it, react more to an increase of albumin in their
diet than to an increase of carbohydrates.
158
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
According to Rubner, the cause is to be found in
the specific effect of the albumin on metaboHsm,
and inore particularly on sugar metabolism. It
would, however, appear that this property belongs
rather more to animal than to vegetable albumin.
In serious cases it may very well be questioned if
the favorable result is not due to the exhibition of
a special category of carbohydrates, such as veg-
etables, potatoes, farinaceous food products, and the
like, but one cannot exclude the fact that in these
patients the absence of animal albumin has quite as
favorable an action. The explanation of this phe-
nomenon is for the time being, at least, purely hypo-
thetical, and even Teutonic "kultur" does not seem
to be able to enlighten its benighted professional
brethren of other less civilized countries than its
own.
The Germans admit that the intestinal flora be-
comes more flourishing when a carbohydrate diet is
allowed, and brings about a better utiHzation of
these substances, because the sugar is transformed
by the fermentative activity of the intestinal bac-
teria as well as by an oxidation product which can
be utilized by the diabetic organism, so that the
sugar is utilized as such.
This theory is backed up by the fact, discov-
ered by Baumgarten that mucic acid given
per rectum is assimilated by the organism, while
according to Boer and Blum gluconic acid is com-
pletely utilized.
Besides these reasons, it is possible that the ani-
mal albuminoids possess a specific dynamic action,
but, though all these questions are unsettled, that
which seems to be certain is the imfavorable ef-
fect of animal albumin on the tolerance of these
patients. It is with this factor that one must deal
especially when soldiers are fed on an exces-
sive meat diet, and in these circumstances more
complete results may be obtained by the use of veg-
etable albumin.
Such, Mr. Editor, are the reigning opinions on
the other side of the Rhine and in Austria. I offer
them without comment as they actually are. In
my next letter I shall endeavor to give you some
idea of the work done in Germany and Austria in
the question of the trench kidney, or, as they term it,
"kriegsnephritis."
DIAGNOSIS OF ACUTE STAPHYLOCOCCIC INFECTION.
1 will conclude this letter by giving a few details
on the diagnosis of acute staphylococcic infection, a
process which is uncommon, but during a year in-
stances have occurred in the French army, and as
the affection is not generally known what is to fol-
low may not be devoid of practical interest. All
things considered, the symptomatology of staphylo-
coccemia enters into the symptomatic picture of bac-
teremias in general. It is the early diagnosis of this
generalized septicemia, without any marked pre-
dominance in any particular viscus, that gives rise
to very great diagnostic difficulties.
All these patients offer a typhoid aspect, and with
the headache, high temperature, general malaise, and
abdominal meteorism one is quite likely to suspect
typhoid rather than a general infection. However,
the analy.sis of the various .symptoms will allow one
to differentiate between the two processes. In
staphylococcic septicemia there is one big chill, the
temperature chart offers an irregular curve with
marked oscillations, the affection undergoes its evo-
lution quickly, while the patient's general condition
rapidly becomes serious. The pulse soon reaches
1 80 to the minute and the temperature ranges be-
tween 103° to 104° F. In typhoid the initial chill is
lacking, the temperature is quite characteristic, and
the pulse corresponds with the temperature. The
appearance of rose spots will remove all doubt. In
epidemic cerebrospinal meningitis the headache,
vomiting, and constipation may simulate those en-
countered in acute staphylococcic septicemia, but in
the latter there is no strabismus nor unequal pupils,
photophobia, or convulsions. When some viscus is
particularly involved in staphylococcic septicemia
the diagnosis becomes somewhat easier. In this case
the general symptoms, the infectious character of
the visceral lesions will be the means of attributing
them to their just cause.
In cases of secondary staphylococcic septicemia
the process may be overlooked, because during the
evolution of a disease, or during convalescence from
some affection, the secondary septicemia will be re-
garded as a recrudescence or relapse of the original
disease. There is, however, an excellent diagnostic
sign that may not be generally known to your read-
ers, namely, that when a secondary staphylococcic
septicemia is about to declare itself during some in-
fectious disease, the temperature first falls to the
normal, or even below, and this sudden deferves-
cence is far from being a good sign because within
a few hours it is followed by a rapid rise of tempera-
ture, which is also accompanied with profuse sweat-
ing and a tendency to collapse.
A septicemia, be it primary, consecutive, or sec-
ondary, having been diagnosticated, it remains to
discover what bacterium is at the bottom of the
process. Since the clinical signs are not characteris-
tic in any of the various septicemias, a diagnosis can-
not be made with any degree of certainty, so that
recourse must be had to bacteriology.
The only proper way to carry out this examina-
tion is to aspirate about ten c. c. of blood from a
superficial vein of the arm with a suitable syringe
and needle and drectly inoculate gelose, gelatine, and
potato, which will give rise to the development of
characteristic growths of staphylococci in twenty-
four to thirty-six hours, if this organism be the
etiological factor of the process.
Aviators and Blood Pressure. — Dr. W. Hirsch-
loft', speaking at a medical meeting at Konigsberg,
said (Lancet, May 25, 1918) that the blood pres-
sure was raised after a flight, particularly in men
over thirty. The amount of hemoglobin and the
number of the red cells were invariably found to
be increased in men who had been flying for some
time. The lymphocytes also were more numerous.
Flying provoked no organic changes in the heart
other than those associated with athlete's heart.
y\nother speaker suggested that the reason why
mountain climbing might induce certain symptoms
at an altitude of only 3,000 metres, whereas the
airman did not suffer till he had reached a consid-
erably greater altitude, was that the airman had
not exerted himself much in getting to this height.
July 27, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
159
THE PSYCHOLOGY OF THE WAR *
By James M. Beck, LL. D.,
New York.
Doctor Beck selected the play of "Hamlet" in
Shakespeare and by analogous reasoning each
principal character represented a nation. Among
other things Mr. Beck said: "Obviously, the
usurping king of Denmark is Prussia. It was
Prussia who, on July 31, 1914, found the whole
world sleeping in the garden of civilization on an
afternoon when there was general fraternity and
peace between nations. Little did we think we were
on the eve of this war! It was a time when two
great conventions had been held at The Hague in
which forty-four sovereign nations participated, in
which there was greater fraternity between men than
ever before and less cause for international fric-
tion. Yet at that moment, when the sun of uni-
versal peace seemed to beam upon the earth and
hold it in its fructifying rays, Prussia swept down
on sleeping civilization and offered the juice of
cursed henbane. While the world was absolutely in
ignorance that its peace would be torpedoed by sub-
marine diplomacy, the masters of Potsdam had
worked out in infinite detail this most brutal, this
most treacherous scheme against the peace of the
world, which has already cost, at least ten millions
of men, women, and children in its awful work of
destruction. If Prussia is this Claudius, wicked, un-
conscionable, who is Queen Gertrude in this stu-
pendous world tragedy? It is Germany as distin-
guished from Prussia. Who is Laertes? It is
Austria. When the whole history of this war comes
to be written, what a pitiful object Austria will be.
Austria, like Laertes, has been the toolmaster of
Prussia, and like Laertes, it has perished on its own
poisoned foil. Who is Polonius? The Polonius of
this world tragedy is Russia. There crept into Rus-
sia those wise maxims and phrases that were the
undoing of Polonius. It was peace without annexa-
tion and indemnities ; down with capital ; universal
freedom ; no order or discipline ; peace without vic-
tory. All these specious phrases ran through the
heart of Russia like poison. What was the result?
This mighty Colossus of the north crumbled as no
nation ever crumbled. Who is Horatio in this
tragedy ? I but anticipate your thoughts when I say
France. The French people are so noble, so trans-
figured in the glory of selfsacrifice, that words are
powerless to say what you and I think of France.
Ophelia, caught in the vortex of this world tragedy,
is obviously Belgium. Relgiuxn can say with Ophe-
lia, 'we know what we are, but we know not what we
may be.' The Belgians with an army of 100,000
men against 750,000 Germans held the gate as the
Greeks did at Thermopylae, and it required the Ger-
man army sixteen days to go through Belgium
where its schedule prescribed six.
"Who is Fortinbras? England. On the night of
August 4, 1914, England said she was not con-
cerned with the Belgium quarrel ; that she was
obliged to wait for something definite to take place.
But when Belgium through the words of its noble
'Abstract of an address delivered at the annual meeting of the
Medical Society of the State of New York, held in Albany, May
21, 22, and 23, 1918.
king appealed to the king of Great Britain for aid
against the threatened invasion of the Germans,
think of what that meant to England. There was no
possible direct benefit to her in entering the quarrel,
the ultimate outcome of which no human being could
foresee. But England never hesitated when the
king of Belgium sent an appeal to come to her aid.
She sent her reply to Berlin that unless by midnight
of August 4th she had a positive revocation of the
order she would fight at all hazards. War began on
August 4th and by August 8th, England had nearly
100,000 men crossing the channel. Who are Rosen-
crantz and Guildenstern ? Bulgaria and Turkey.
Who is Hamlet? America is the Hamlet of na-
tions. America has all the virtues of Hamlet and
some of his faults. One can take all that is said in
the phrases of "Hamlet" and in some aspects of our
national life we will find it worthy of our own
country. On the other hand, this country has the
fundamental failing of Hamlet. It may not be true
in the future because our country will be profoundly
changed in character by this war. There 'has been
a profound awakening on the part of the American
people. We are not the same people we were three
months ago. We have put aside our provincialism
and are now taking a world view of affairs and all
the latent power that is within us is struggling to
take part in this Great War for the rights and free-
dom of mankind. I firmly believe that when the
war is over, when our cause has triumphed, no fact
can be more certain than that the United States is
going to take the moral leadership of the world.
It is not going to be by anything that is said, because
words do not count in this world crisis. We will be
judged by what we do on the fields of Picardy and
Flanders, and if, as I believe, we are to be the
determining factor in the battle in France, so surely
will the kingship of Hamlet be recognized."
TRENCH FEVER.*
By Major Alexander Lambert, M. D.,
New York,
Medical Corps, U. S. Army; President-elect of the American
Medical Association.
Major Lambert, said that early last summer
Commissioner Murphy informed him that it was his
desire that he (Doctor Lambert) should build up as
good and scientific an organization as possible. He
therefore formed a research committee. He ob-
tained an appropriation of $100,000 and said that
they could use as much of this amount as in their
judgment seemed best, without restrictions, and
asked them to decide on what was best to be done.
He obtained the cooperation of the Medical Corps
of the British Army and of the French Army, and
the three Medical Corps had met every month as a
research medical society, and had given to the
American, British, and French surgeons their best
experience and ideas in the last three or four years
and had placed our men in a position to go on with
research work in medicine and surgery in 1918.
Since, otherwise, they would have had to work out
and struggle over the same problems that the French
'Abstract of a paper read at the annua] meeting of the Medical
Society of the State of New York, May 21, 22, and 23, 1918.
i6o
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
and British had dealt with before. This cooperation
had been of the greatest help and was one of the best
things they could have done to solidify the Medical
Corps and give aid to the army and to the surgeons
that needed it.
As to trench fever, its transmission and origin had
been solved. Trench fever was a curious breakbone
fever that had a sharp, shooting temperature. The
temperature rose to 103° and 104°, with aches of an
intense character in the insertion of the muscles, and
then it dropped down. Again, it went up for four
or five days later and took on the character of a
regularly recurring fever. It could not be dififer-
entiated, except by blood cultures, from the recur-
rent infectious fever of Weil. No organism had
been found for it. The disease had not yet been
successfully transmitted to animals. All animals,
even monkeys had been used and the fever had
not yet been produced in any. Volunteers were asked
for. A curious thing was that some of the men who
worked with General Gorgas in Cuba in connection
with yellow fever and were volunteers there, were
with them. Colonel Ireland, who was on the re-
search committee, worked out the line of research
in conjunction with General Wood, and Colonel Mc-
Coy was chief of staff. Colonel Ireland took the
necessary orders and asked for volunteers. Of the
500 men who offered to go, sixty volunteers were
accepted, and within six weeks from that time
through experimental work it was found out that
trench fever was transmitted by the bites of body
lice. Body lice in the trenches were used and per-
fectly tame and virtuous lice secured from London,
whose habits and previous conditions of health were
easier, and the problem was worked out with every
possible method of control. Trench fever was the
cause of ten per cent, of the English army in the
last year being on the sick list when they ought to
have been in the trenches. No man died of the
fever, but it knocked him out for two or three
months. This discovery of the mode of transmis-
sion had solved the question and it saved from eight
to ten per cent, of the active force of the army.
Credit must be given to the Red Cross for this
achievement.
Nervousness in Soldiers. — Foster Kennedy
(Journal A. M. A., July 6, 1918) deprecates the
use of the term "shell shock" to indicate a concrete
and quite novel condition resulting from experi-
ences of unimaginable horror. In its place he em-
ploys the term "nervousness" as less likely to play
upon the suggestibility of the victims and more in
harmony with his conception of the nature of the
condition and its mechanism. In the vast major-
ity of persons the capacity of adaptation to an
existence in novel and abominable surroundings
has been excellent, but in a certain number this
adaptabilitv has been less complete. The emotions
of fear and pain make up our machinery of self
preservation and in normal conditions of civil life
but little call is made upon them. Constant ex-
posure to imminent destruction in war, however,
causes a constant strain on the nervous system.
The instincts of self preservation do not often be-
come conscious realizations — the nervous system
may be said to be frightened in great danger, but
the man is honestly unaware of the fear. The
normal submersion of these powerful forces below
the threshold of consciousness is due to several
causes, among which there is the powerful factor
of morale. This morale is an expression of the
herd instinct, of the willingness of the individual to
sacrifice himself for the benefit of his kind and for
the ideals of his countrymen and himself. It is an
active component of the soldier's conscious life,
while shrinking from loss and the fear of death are
rarely scrutinized in their realities since they are
antisocial in trend. These facts offer a clue to the
genesis of the neuroses found in soldiers. It is
commonly agreed that generalized psychoneuroses
are almost never seen in soldiers who are also suf-
fering from physical wounds. This is explicable
on the grounds that the receipt of a wound is fol-
lowed by a period of mental rest and relaxation ;
the man is for the time being honorably freed from
his obligations to others and from his fear of
death. The converse situation is found in those in-
stances in which a man is subjected to stupefaction
and profound bewilderment from the bursting of a
heavy shell and yet suft'ers no wounds. Here the
obligation of self-preservation remains, coupled
with a prospect of indefinite repetitions of the ex-
perience, culminating in death or horrible mutila-
tion after a time. Under these conditions the later
developed qualities of conscious morale and ideal-
ism are overweighed by the rising desire for self
preservation and life and his whole organism is
surrendered to the phenomena of fear. He be-
comes an automaton both mentally and physically,
impelled by a single emotion. This is the suggested
mechanism of the condition which has been called
shell shock, but which may result from a variety
of harrowing experiences acting upon partly ex-
hausted nervous systems.
MEDICAL NEWS FROM WASHINGTON.
TNT Poisoning With High Explosive Shells. — Promotion
of Temporary Assistant Surgeons in the Navy. — Refit-
ting Stations for Volunteers. — House Objects to Con-
sultant Physicians for the Army. — Naval Hospitals Now
.Sufficient. — Government Aid for Disabled Soldiers.
Washington, D. C, July 22, igi8.
Special consideration lately has been given by
medical officers of the navy to the increasing num-
ber of cases of poisoning resulting from the han-
dling of trinitrotoluol in the loading of high ex-
plosive shells. The danger of poisoning is equally
great with the new shellfiUers in which seventy-
five to eighty per cent, of the TNT is replaced
by ammonium nitrate.
Reports received by the bureavt of medicine and
surgery from certain stations indicate that the
simple precautions that experience has shown nec-
essary are not being taken with sufficient thorough-
ness to protect the naval personnel. Of one detail
of fifty-four men no less than thirty-seven showed
symptoms of TNT poisoning within a few weeks,
and more recently eight cases were detected in one
day, of whom it was necessary to send three to the
hospital. In view of the increasing number of men
July 27, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
161
engaged in handling the explosive, it is considered
important that the precautions that are at all times
practical should be urged by medical officers.
Among these may be mentioned careful selection,
in place of indiscriminate detail, for the work.
Blondes are peculiarly susceptible and negroes very
resistant to TNT poisoning, and men with any acute
or chronic skin lesions should not be engaged in
handling the material. Early detection and prompt
removal of men showing headache and gastroin-
testinal symptoms should be practised. Compulsory
change of all clothing, thorough cleansing of the
body with soap and abrasive, with careful attention
to finger nails after a day's work, are very impor-
tant.
Temporary assistant surgeons in the navy holding
commissions dated January 19th, last, or before, are
to receive temporary promotion to passed assistant
surgeon, with the rank of lieutenant, from July ist.
It is probable, however, that some of these officers
may not receive official notification of promotion at
once, owing to pressure of work.
A report, recentlv made available, of the physical
examination of 20,000 volunteers for enlistment in
the army bv Major Clarence L. Cole, Medical
Corps, and Captain E. W. Loomis and First Lieu-
tenant E. A. Campbell, Medical Reserve Corps,
states that fifty per cent, of all volunteers have im-
portant physical defects. A large number of these
men could be cured of their ailments and made
available for military service if proper provision had
been made for refitting stations. The conclusions
of the medical officers show the necessity of physi-
cal training and supervision of school children by
government agencies. These are their findings: i,
practically fifty per cent, of all candidates volun-
teering for military service — 20,000 men examined
— have physical defects that incapacitate them for
military service entirely or reduce efficiency ; 2, the
present method of examination requires acceptance
of many defective men or rejection of many men
that can be made capable of performing military
service ; 3, estabhshment of refitting stations with
properly organized staff for medical treatment and
military drill would af?ord time for observation of
men before discharge or afford an opportunity for
treatment of curable defect; 4, the number of men
available for military service would be increased ;
5, the military efficiency of the forces would be in-
creased through the bringing of all men to a higher
physical standard ; 6, more efficient intensive training
could be given at training camps through reducing
the number of men admitted tO' camp hospitals for
physical defects existing at the time of enlistment ;
7, many physical defects 'exist in young men of
mihtary age that could have been corrected, by
proper inspection and physical development, while
the individuals were school children, if provision
had been made for such procedure in our public
schools.
The provision of a Senate amendment to the
army appropriation bill authorizing the employment
by the Surgeon General of the Army of consultants
was opposed by the House conferees, and it does
not appear in the measure as finally enacted into
law. Objection to appointment of physicians to act
in that capacity was the possibility of great abuse
in such special contracts. It was believed by those
who opposed the proposition that the only purpose
such a contract could serve would be in the case of
a soldier separated from his particular unit and
where no army physician was available.
Those who were interested in the provision had
in mind the fact that there are a great many medi-
cal men in the country that would be glad to devote
a certain period of time to the Government service,
but who were not willing to give their entire time
thereto and thus neglect their private practice. By
appointing such men consulting physicians the
Government would have opportunity to call them
for specific purposes at any time.
:^ zlfi ^ :^ ^
For some time the navy has availed itself of the
facilities offered in civil hospitals, particularly in
large cities contiguous to naval stations, for the
care of naval patients that could be accommodated
readily in the naval hospitals. Owing to the vari-
our war activities in civil life, which have greatly
increased the working population in some communi-
ties, it has become more and more difficult to
utilize the facilities of civil establishments. Now,
however, there is a reserve of beds in practically all
the naval hospitals, due to recent extensions, and,
as the health of the navy is excellent at this time,
there is no lack of accommodations anywhere.
Therefore, it is unlikely that the navy will have to
rely on civil hospital facilities in the near future,
unless there should be a great naval battle with an
unexpected number of injured, as it is thought that
the present and projected facilities will be sufficient.
Several departments of the Government are pre-
paring to extend aid to soldiers disabled during the
war. The Surgeon General of the Army has made
elaborate plans for physical rehabilitation, and
mental reconstruction will go hand in hand with
the distinctly medical work. The federal voca-
tional board will give aid in cooperating with the
medical authorities, and the Interior Department
will have land ready for prospective settlers.
Many well-intentioned individuals have offered
to take crippled soldiers into their service as watch-
men, messengers, and in positions of similar char-
acter. While the spirit of these offers is appre-
ciated, they conflict with the policy of the medical
department of the army. From the time a wounded
soldier is taken to the field hospital he is encouraged
to understand that the seriousness of his wounds
will not render him worthless for useful work.
The work of reconstructing him both physically
and mentally is carried on simultaneously.
At the present time there are many soldiers in
the army hospitals in this country who have been
crippled in the course of duty. In many cases these
men are receving the preliminary training that will
be finished by civil boards authorized to continue
the work begim by the Surgeon General. They will
receive a training that will make them competent in
the trade or profession they elect to follow.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY.
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5; Foreign Postage, $7; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, JULY 27, 1918.
THE PROTEINS IN THE CAUSATION OF
DIABETES.
Whatever the dietetic errors that provoke the
diabetic condition it now seems certain that it is
not the carbohydrate alone that is at fault. Pri-
marily diabetes occurs only in an individual
whose metabolic organization is very weak, but
it will not occur unless provoked by some gross
and persistent dietetic abuse. Perhaps overeat-
ing is the most potent factor in its causation. On
the other hand, in races that consume large quan-
tities of farinaceous food with only a minimum of
proteins or fats diabetes is very rare. Neither
underfeeding nor poverty is a cause; it is rather
a disease of the rich.
When the expensive proteins are consumed in
large quantities by those who can afford them
and by those who lead a sedentary life, diabetes
is likely to follow. It is more than likely that
even without a proper balancing of the food, a
reduction in the total quantity of food consumed
would in itself reduce the incidence of diabetes.
It is the protein element that must be curbed
rather than the carbohydrates in diabetes. In
the newer understanding of this disease this is
realized, and far from withdrawing the carbo-
hydrates they are often advocated as a cure for
diabetes. It is from this that the socalled oat-
meal cure received its reputation. Heretofore
the dietetic treatment of diabetes contemplated
an almost unlimited supply of proteins and a
complete withdrawal of the carbohydrates. Yet
it was understood that the threatening of an acid
condition was a sign for the restoration of the
carbohydrates, in spite of the increase of the
sugar output.
Overindulgence is perhaps the most important
factor in the production of a systemic hypoalka-
linity. The taking of food in which the proteins
predominate increases the acid production and
increases the hypoalkalinity. The proteins, in
fact, are acid foods. It is pernicious in any
glycosuria to allow an excessive meat diet. Very
often a marked limitation or even abstinence for
a period will of itself cause the disappearance of
the sugar. Moreover, the defective utilization of
the sugar is not nearly as ominous to the organ-
ism as an increase in the acid state of the body
as a result of protein intoxication or excess. In-
deed, it is because of the defective utilization
where only a small amount of sugars can be oxi-
dized at one time out of the amount supplied,
that the sugars must be pressed so that at least
this small amount can always be carved out of
the total supply. There is no harm in the pres-
ence of sugar in the urine. It is merely an index
of the condition. The amount of sugar only
shows how much of it the system could not uti-
lize.
Before much improvement in the carbohydrate
utilization can occur the nitrogenous equilibrium
must be reestablished. The prescribing of a meat
diet in this weakened metabolic organization but
increases the nitrogenous inequilibrium. Those
individuals who exist on the diet heretofore pre-
scribed for the diabetic — that is, high protein and
low carbohydrate — are the ones most likely to be
attacked with diabetes. Diabetics get along
much better on a normal well balanced diet than
on any special diabetic dietary that has not the
balancing as its chief purpose. Because the basic
cause of diabetes is a weak metabolic organiza-
tion the diet must be at a minimum in order to
tax the metabolic process least, but the diet must
favor the carbohydrates rather than the proteins.
The diet is the provoking element in a damaged
July 27, 1018.]
EDITORIAL ARTICLES.
organization. With normal metabolism no one
can foretell how much abuse the organism can
stand without injury. If organotherapy has any
value in the treatment of diabetes it is because
the basic metabolic weakness in diabetes is prob-
ably of glandular origin. It is most probable that
not only the pancreas but also the other glands
of internal secretion are concerned, and the
gland extracts usually administered supply a de-
ficiency that the defective glands cannot.
CONTINUED TACHYCARDIA.
Continued tachycardia is an affection of adult
life and appears to be unknown in childhood. The
affection may be looked upon as the result of a
bulbar or bulbospinal neurosis and some cases are
undoubtedly of thyroid origin. However, the patho-
genesis of the affection is most obscure.
The symptoms of continued tachycardia must be
distinguished from those of the paroxystical type.
The symptoms belonging to continued tachycardia
are two, namely, acceleration of the beats and a
lowered blood pressure. The acceleration of the
beats is certainly considerable, but never reaches
the number occurring in the paroxystical form, the
pulse averaging from 140 to 150 pulsations, with a
maximum of 185.
While the intensity of the cardiac contractions
produces vibrations of the thoracic walls in paroxys-
tical tachycardia, in the continued form the apical
shock remains perfectly perceptible and there is
neither thoracic vibration nor thrill, the contrac-
tions maintaining their accustomed force. More-
over there is usually no cardiac murmur, the heart
sounds remaining normal and with no change in
their duration.
The other element in all cases of continued
tachycardia is the lowered arterial tension, a dis-
tinctive symptom. The pulsations can hardly be
felt, the pulse oft'ering rather an indistinct undula-
tion so that the cardiac contractions cannot be
counted. Another distinctive feature is the absence
of paroxysms, the affection being continued with-
out variations once the maximum number of cardiac
contractions has been attained.
The heart is often dilated and very marked
venous pulsation is observed in the cervical region
that may be mistaken for arterial upon a merely
superficial examination. This dilatation of the
right heart rarely causes death and even after the
tachycardia has lasted for some time no albumin
can be detected in the urine. There is little stasis
in the various viscera, little or no peripheral edema,
and an absence of an hepatic pulse.
There may be fever present for some time. Other
general disturbances are unequal pupils or myosis ;
occasional nausea or vomiting, and vasomotor dis-
turbances, such as profuse sweating or high color-
ing of the skin, particularly of the face. The dis-
ease may culminate in asystolia, but this seems to be
less common than a spontaneous recovery.
Rest is the first element in treatment. The most
important cardiac indication is to sustain the heart
against fatigue and to prevent the advent of asysto-
lia. Digitalis is the most important in this respect,
but caffeine, sparteine, and ether have their indica-
tions. Quinine at the dose of one to one and a half
grams daily has given good results and some writers
have advocated ergotine.
GLYCOGENIC FUNCTION AND THE
VEGETATIVE NERVOUS SYSTEM.
Investigations undertaken at various times and
places have concurred in establishing the nervous
regulation of the glycogen function of the liver
through separate fibres belonging to the two divi-
sions of the vegetative nervous system. These
prove to be the fibres of the sympathetic which
exert the secretory influence and those of the
craniosacral [autonomic] division, that is in this
instance of the vagus, which inhibit this action.
The Gazzetia dcgh Ospcdali dellc Clhiichc [Regu-
latory Nerves of Hepatic Glycosuria], May 5,
1918, devotes several columns to a discussion of
these experiments and their mutual confirmation
of results.
Reference is made to Langley's hypothesis
that the centrifugal nerve fibres of the vegetative
nervous system controlling the involuntary mus-
cles and the internal secretions belong not only
to those of sympathetic origin but also to the
craniosacral or to what is also known as the auto-
nomic system. This includes the oculomotor
fibres which go to the intrinsic muscles of the
eye, the vasomotor and secretory fibres of the
fifth, sixth, seventh, and ninth and the centrifugal
fibres of the vagus of the heart, bronchi, and di-
gestive organs, and the sacral centrifugal fibres
to the rectum and urogenital apparatus. In gen-
eral the action of the one system is opposed to
that of the other and the two systems respond in
opposite manner also to the action of certain defi-
nite drugs.
The school of Von Noorden base certain con-
clusions in regard to hepatic glycogenesis upon
this theory supported both by clinical and phar-
macological experience. They believe that this
function is promoted by the sympathetic and in-
hibited by the vagus. They find that adrenalin,
which excites the organs supplied by the sympa-
164
EDITORIAL ARTICLES.
[New York
Medical Journal.
thetic fibres, produces hyperglycemia and glyco-
suria, irrespective of the diminution in the con-
sumption of glycogen and that this glycosuria
can be arrested by pilocarpine, which is stimu-
lating" to the organs supplied by the autonomic
system, here the vagus. Moreover, in some" cases,
the uncertainty being apparently dependent on
individual variation in tone, sympathetic or auto-
nomic glycosuria can be caused by the adminis-
tration of atropine, which acts to paralyze the
organs supplied by the vagus.
Researches definitely applicable to the glyco-
genic output of the liver have been made
first by Vasoin and later confirmed by Farini,
and again, with possible source of error re-
moved, by Berti and Roncato. These experi-
ments were made upon frogs in which in one
group the vagus was cut, in the other it remained
normal. At hibernating temperature in the frogs
with cut vagus there was no evidence of change
in the amount of glycogen retained in the liver
or in the weight of the liver after several days'
observation. In those frogs, however, which were
roused from their dormant condition and kept in
a higher temperature for twenty-four or forty-
eight hours — both periods of time were tried —
there was a marked difference. In those with
severed vagus the diminution in the amount of
hepatic glycogen was much greater than in the
normal frogs. Also the weight of the liver in the
vagotomized frogs diminished in far greater pro-
portion than in the normal ones.
These experiments served to establish the the-
ories of the inhibitory action of the vagus upon
this function of the liver. The vagus inhibited
the transformation of hepatic glucose, which was
promoted by increase of temperature. Evidently it
contains glycoinhibitory fibres.
THE MAYO IDEA IN MEDICINE.
Dr. William J. Mayo and his brother. Dr.
Charles H. Mayo, have won an enviable and very
deserved reputation as surgeons. As authors
they have a remarkable gift for clear, concise,
and illuminating description of their operations.
For their work in these fields alone their names
will be remembered long after they are gone, but
their greatest achievement lies in another direction :
that of the coordination of the work of other
experts with their own. The experience at the
Mayo clinics of Major John A. Hornsby, ed-
itor of The Modern Hospital, is told by him in
lighter vein in a recent issue of his journal. The
reader cannot but be impressed, as was the au-
thor, with the tlioroughness of the clinical exam-
inations and with the extreme to which speciali-
zation is carried. Even in so simple a thing as
the use of a stomach pump a specialist has been
developed, and in the hands of this specialist the
stomach pump lost much of its horrors to the
patient. Happily Major Hornsby had nothing
more serious than a slight excess of adipose tis-
sue and the treatment prescribed was one easily
followed.
The salient feature of the Mayo idea in medi-
cine, as observed by Major Hornsby and by thou-
sands of physicians whose ailments have been
helped at the Mayo clinics, is the employment of
every possible means of insuring accurate diag-
nosis and the use of highly trained experts in their
application. Experts alone are employed to make
an x ray, analyze a test meal, or insert a stomach
pump. With the data accumulated by such ex-
aminations the skilful surgeon is able to operate
with intelligence and assurance. The use of
these agents by no means detracts from the bril-
liancy of the work done by the Mayos and their
associates in medicine and surgery, for even
these most complete diagnostic reports are use-
less except as a basis for the work of a master
mind in medicine. The work of these experts,
however, does clear the field of cumbering de-
tails and leave the mind of the surgeon armed
with the fullest possible information free to at-
tack the problem of correct diagnosis. Hitherto
the surgeon has depended too much upon per-
sonal observations ; he devoted valuable time and
thought to the accumulation of detailed informa-
tion on points which modern methods relegate to
specialists. It is the problem of the physician
himself to correlate the findings of these special
observers and to deduce from their observations
the real significance of the phenomena observed.
The Mayo idea in medicine is not wholly new.
It has been carried out to a certain extent in
other clinics, but they have developed the idea to
a greater extent, have been more liberal in the
employment of experts, and have achieved such
remarkable results that we feel justified in speak-
ing of it as the Mayo idea in medicine. Along
these lines the greatest results are to be achieved
in the practice of medicine.
UNION AND REPRESENTATION.
Harley Street and the Royal Colleges of Medicine
and Surgery in London have been awakened from
their habitfial somnolence and solemnity by a cry
from the younger members of the profession for a
union — in fact, a Trades Union — among themselves
and for greater representation in Parliament. The
censors of the Royal College of Physicians already
shudder, but as pointed out in The Medical Press
July 2-, 1918.]
NEWS ITEMS
165
and Circular, the unrest in the profession requires
an outlet. Those in the service may not speak ;
those outside the service are too tired and disheart-
ened to protest. True, a few of the universities
may elect a doctor, but the only way for medical
men to obtain seats enough to make the medical
profession felt is to have a really strong trades union.
The proposal is to increase the strength of the
Medico Political Union, an organization which came
into being because a few doctors who took service
under the insurance act, could get no hearing of
their grievances from the British Medical Associa-
tion, and, realizing their utter helplessness vis-a-vis
government departments, determined to band them-
selves together for corporate action. American
physicians cannot realize what an uprooting of tra-
dition the following sentence from a doctor means
in England : "If we are not content to sink into
the position of slaves to the proletariat and their
underbred bureaucratic masters, then we must
buckle on our armour to defend our elementary
rights. It is the duty of every sclfrespecting mod-
ern medical man to join a trades union. Let the
fogeys of the College of Physicians fuss and fuddle
in their futile feudaHsm. The future is with the
present generation." We are afraid the infusion
of American ideas by the United States doctors who
have gone over to the mother country will render
the potion redder in that goblet which the revolu-
tionary doctors are preparing for their conservative
early Victorian confreres to drink.
ASSUMING VICES.
Though tremendously extolling the virile en-
ergy and perseverance which woman has brought
to bear on the masculine work she is doing, there
are those, particularly French doctors, who ex-
press anxiety because she is sometimes assuming
the minor masculine vices, such as excessive cig-
arette smoking, drinking, swearing, and an irrev-
erence for chastity. Such women pay men a high
compliment in imitation, but the price is heavy.
It would not matter so much if they had started
out into the world of men with no special vices of
their own, but to add the masculine weaknesses
to their own emotional shortcomings, their cun-
ning, their macroscopic view of microscopic tri-
fles, spells abnormality to type of a rather sad
nature. The doctors regard the menses and preg-
nancy as most useful ballast to stay her too rapid
flight into masculinity. One she may refuse, and
that is often disadvantageous to her real growth,
but the other is her heritage and not at her own
disposal. With regard to a possibility of her tak-
ing to fighting with talon instead of tongue, the
muscular ^may prove to be a wholesome substitute
rather than a vicious procedure, and researches
into the relative strength of the normal man and
woman have shown that there is no real differ-
ence as regards the "strength factor," though
desuetude of certain muscles has made a differ-
ence, but one which may be overcome, and will
be overcome, now that woman is doing field and
other manual labor. Periodic disability, in women
without organic disorder, does not lessen their
racial e^^iciency^ As to swearing and slang, their
powers in these are merely repressed, though per-
haps their terms are not quite so varied in expres-
sion as that of sinful man, still, being more emo-
tional and imaginative, she may even come to
excel him. "War is hell" and Paradise is closed,
where will Eve stand when peace comes once
more ?
OFFICERS' UNIFORMS AT COST— AFTER
A WHILE.
A general order has been issued by the War De-
partment adopting standard materials for officers'
uniforms and providing that the cloth for these uni-
forms shall be supplied by the quartermaster corps
at cost. Furthermore, the quartermaster corps will
make contracts with tailors to make uniforms for
ofBcers. These contracts will require a guarantee
that the garments shall fit. Any changes or altera-
tion required to make them fit will be made at the
expense of the contractor. The cost of the uniform
to the officer will be the contract price plus the cost
of the cloth. The officer will pay the local quarter-
master, who will in turn pay the contractor. Should
the officer prefer, he may have the uniform made
by a private tailor, at his own expense, of course,
but in any case he must use cloth furnished by the
quartermaster corps, which will be charged to him
at cost. While the order has been issued, the supply
of cloth is not sufficient as yet to put it into effect
nor have contracts been made with the tailors. It
is stated that several months may elapse before it
is practicable to put the order into effect. In the
meantime, officers will have to purchase their uni-
forms from private tailors as heretofore.
News Items.
American Nurses for American Soldiers. — The Amer-
ican Red Cross Society has issued a notice to the effect
that a Red Cross nurse's aide speaking both English and
French has been assigned to every American Red Cross
Hospital to act as interpreter to any American soldiers
who may be received.
Two New Orthopedic Wards in Army Hospital.—
Two new surgical wards for orthopedic patients were
opened on July 12th at U. S. General Hospital No. 2,
Fort McHenry, Md., and are under the care of Major
Samuel C. Baldwin, Medical Reserve Corps, U. S. Army.
Each of the wards will accommodate thirty-six patients.
Infantile Paralysis at Dubuque.— Dr. Edward C.
Rosenow, with laboratory equipment from the Mayo
Foundation, Rochester, Minn., arrived in Dubuque on July
gth, to aid the local health authorities in the work of
checking the spread of infantile paralysis which is epi-
demic there. Since July 4th forty-two cases, with ten
deaths, have been reported.
Combating Venereal Disease.— The War Department
has issued a statement to the effect that owing to measures
taken for the prevention of venereal diseases, the soldiers
of the Expeditionary Force show a smaller rate of illness
per thousand from these diseases than has ever been
recorded heretofore for American troops. The figures
of the United States are even better than those in Europe.
NEWS ITEMS.
[New York
Medical Journal.
Sisters of Charity Organize Base Hospital.— The
Loyola Unit, known as Base Hospital No. 102, has been
organized by St. Vincent's Hospital, of Birmingham, Ala.
The sisters will wear the habit of their order, but other-
wise follow Red Cross rules.
Army Hospitals on Philadelphia City Farms.— Ten
hospital buildings which will furnish accommodations for
five thousand wounded soldiers are to be erected on the
farms of the city of Philadelphia. The buildings will be
of the type used in the army cantonments.
Political Activity Forbidden to Red Cross Workers.
— Under a ruling made by the War Council the officers
and workers of the American Red Cross will not be al-
lowed to run for any public office in the coming general
election or be active in the interests of any candidate.
Unification of Phj^ical Tests. — The Surgeon General
of the United States Army has announced that the stand-
ards for acceptance of men in the army will hereafter be
uniform in all its branches. The changes involved in this
are expected to prevent the occurrence of men being reject-
ed for training camps and later being accepted in the draft.
Women Wanted for Student Nurse Reserve. — The
government wants 25,000 young women to join the
U. S. Students Nurses Reserve and to hold them-
selves ready in training for service as nurses. The stu-
dents must be between the ages of nineteen and thirty-tive.
They will receive their board, lodging, and tuition free,
and a small salary sufficient to cover the cost of books and
uniforms. Enrollment may be made at any of the recruit-
ing stations established by the Woman's Committee of
the Council of National Defense.
Rehabilitation Work in Philadelphia. — In common
with similar institutions all over the country, the hospitals
of Philadelphia are doing good work in rehabilitating men
who have been rejected for military service on account of
minor defects. At Jefferson Hospital alone preparations
have been made for the treatment of 300 selected men
turned down by draft boards on account of remediable
physical defects. This work is already under way, and the
men will be treated as rapidly as the facilities of the hos-
pital permit. This applies also to those who in future may
have the same experience with the examining boards.
All Doctors to Be Enrolled. — ^At a meeting held in
Washington on July 17th, the members of the committee
of the Medical Section, Council of National Defense for
the States of New York, Pennsylvania, New Jersey, Dela-
ware, Maryland, Virginia, and the District of Columbia,
plans were formulated for enrolling every doctor in some
one of the organizations for tnedical service, either the
Medical Reserve Corps of the Army, the Medical Reserve
Corps of the Navy, or the Volunteer Medical Service
Corps. The latter organization intends to take in men who
are above the age of fifty-five and therefore are not avail-
able for service in either of the other corps.
Personal. — Dr. Horace Russell Allen, formerly pro-
fessor of orthopedics in the University of Indiana, now a
major in the Medical Reserve Corps, U. S. Army, has re-
ceived the honorary degree of doctor of laws from Little
Rock, Ark., College.
Dr. William Coon, of Haverhill. Mass., has been ap-
pointed director of health and sanitation for the United
States Shipping Board. He will have liis headquarters in
Philadelphia and will have charge of health and sanitation
in all shipbuilding yards in the country.
Dr. Lewis S. Pilcher, of Brooklyn, was elected senior
commander of the New York State Department, G. A. R.,
at its annual meeting on June 27th.
Dr. Henry Jackson, of Boston, and Dr. William C.
Quiinby, of Baltimore, have been elected president and sec-
retary-treasurer, respectively, of the Harvard Alumni
Association.
Major Albert E. Halstead, of Chicago, Medical Reserve
Corps, U. S. Army, has been promoted to the rank of
lieutenant colonel and placed in charge of Base Hospital
No. 5.3, France.
Dr. Henrietta A. Calhoun has been appointed assistant
professor of otology and bacteriology at the University
01 Iowa.
Dr. George F. Butler has resigned as medical director
of Mudlavia and accepted a position as medical director of
the North Shore Health Resort at Winnetka, 111. He will
take up his active duties there September ist.
A Drug Commission Asked For. — Senator Freling-
huysen has introduced into the U. S. Senate a resolution
providing for the appointment of a commission of three
to examine into the subject of narcotics and habit form-
ing drugs and appropriating $50,000 for the expense of the
commission.
American Association of Medical Jurisprudence Dis-
solved.— A petition in the Supreme Court for the disso-
solution of the association has been filed by a majority of
the members. The membership has decreased from 200
to twenty-three members, and there is a general lack of
interest in the organization.
Openings for Physicians in State Institutions. — Ex-
aminations will be held on August 31st by the New York
State Civil Service Commission for the position of as-
sistant physician, regular or homeopathic, in State hos-
I>itals, and for positions of a similar nature in various
State and county institutions. The salary in State hos-
pitals is $1,200 a year, increasing $100 a year to $1,600,
with maintenance. The examination is open to both men
and women who are licensed medical practitioners in the
State. An examination will also be held on August 31st
for the position of resident physician. State Agricultural
and Industrial School, Monroe County, open to men only.
The salary is $1,500 to $2,000 a year, with maintenance.
The appointee will not be required to live in the institu-
tion. For full particulars address the State Civil Service
Commission, Albany, N. Y.
U. S. Mobile Hospital Units Ready to Sail at Any
Time. — The mobile hospital units ready to sail now
include base hospitals, evacuation hospitals, evacuation
ambulance companies, railroad hospital trains, convalescent
camps, and medical supply depots. All these are in addi-
tion to the regular medical department units with each
army division. Each hospital train is composed of sixteen
cars ; each train has a capacity of 400 patients, with ope-
rating rooms, kitchens, personnel car, etc. Each base hos-
pital comprises the personnel and equipment for a hospital
of 1,000 beds; the personnel consists of thirty-five medical
and sanitary officers, 100 army nurses (women), and 200
enlisted men. The evacuation hospitals have about the
same capacity as the base hospitals, but because of their
greater proximity to the fighting line there are no women
nurses. To each evacuation hospital is attached an am-
bulance company with twenty ambulances and a personnel
of one officer and thirty-seven men. The convalescent
camps are each designed to care for 10,000 patients. Each
camp includes a 1,000 bed hospital with a personnel of
ten officers and ninety enlisted men. At the convalescent
depot, with its capacity of 5,000 beds, those men will be
taken care of in whose recovery time is the principal
element.
Vacancies in the State Health Department. — Among
the positions for which the New York State Civil Service
Commission will hold examinations on August 31, 1918,
are the following lin the State Department of Health, Bu-
reau of Venereal Diseases :
Chief of bitreau; $3,600; men only; preferred ages, thirty to fifty
years. Applicants must have the degree of M. D. from a recognized
medical school and fundamental scientific training in medicine, with
knowledge of serology, and should also have had experience in
administrative work, preferably in some branch of public health
work, and must possess ability to address audiences in a convincing
manner; they should also be familiar with health conditions in the
larger communities of the State.
Consultant in venereal diseases; $3,000; men only; preferred ages,
thirty to fifty years. Applicants must have the degree of M. D. from
a recognized medical school, and they must also have had special
training and experience in the diagnosis and treatment of venereal
diseases, including the taking of blood for the Wassermann test,
and other specimens required for the diagnosis of venereal diseases,
and the methods of administering salvarsan intravenously and intra-
spinously.
Hospital and dispensary organiser and inspector; $2,500; men
only; preferred ages, thirty to fifty years. Applicants must have
the degree of M. D. from a recognized medical school and practical
experience in the treatment of venereal diseases. The appointee to
this position will be required to organize venereal disease dispensaries
in various parts of the State and to advise as to their proper admin-
istration when established.
Lecturer on social diseases; $2,500; open to both men and
women; preferred ages, thirty to fifty years. Applicants must have
the degree of M. D. from a recognized medical .school and be con-
vincing public speakers with ability to address mixed audiences;
they should also be able to write brief articles acceptable to the
public press. Preference will be given to those having a general
knowledge of venereal diseases.
For full particulars and proper application blanks ad-
dress the State Civil Service Commission, Albany, N. Y.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
SOME NOTES ON DRUGS AND
TREATMENT.
A Review of Recent Progress in Therapeutics.
By Mark Sadler, M. D.,
Montreux, Switzerland.
II.
THE USE OF MORPHINE AND PANTOPON IN PERTUSSIS.
Wolkenstein has shown morphine to be the agent
which most diminishes irritation of the superior
laryngeal nerve by discovering, in the first place, its
reflex power by measuring the time separating the
excitations of the reflexes. Therefore, it is not
unusual that morphine has been advised in whoop-
ing cough, an afifection which is regarded, since its
etiology is still unknown, as a neurosis of the re-
spiratory apparatus, particularly involving the su-
perior laryngeal nerve, although naturally this is not
of necessity the specific causal factor.
Although the profession in general attribute to
morphine an elective action on this symptom, they
take good care not to advise it as a drug to be
employed indiscriminately for whooping cough.
This analgesic must not be allowed, by dulling
the respiratory reflexes to too great a degree, to
suppress a cough which, when moderate, is an
excellent means of pulmonary defense. There-
fore, the use of pantopon or morphine should
be restricted to cases where the paroxysms are fre-
quent and prolonged, and to those in which laryngeal
complications, spasm of the glottis, etc., occur, just
as in croup or asthma. In other words, the use
of morphine should be restricted to the dangerous
spasmodic periods of whooping cough. In these
particular cases, Marfan has noted that there is,
firstly, a decrease in the intensity of the paroxysms,
and, afterwards, in their frequency, and this like-
wise applies to the polypnea and tachycardia.
Therefore, morphine may shorten the duration of
the period of severe paroxysms in some cases.
Triboulet and Boye have even maintained
that in cases of uncomplicated whooping cough,
morphine, after a few injections, will trans-
form the characteristic double cough of the disease
into a simple paroxysm. Triboulet even says that
it is astonishing to see a whooping cough sud-
denly cease with morphine when it had been
supposed that the case would continue for
some time. Given these statements, it appears
to me a settled question that morphine has a dis-
tinctly sedative action on the paroxysms, and per-
haps on the duration of the afifection as well, and
also on both respiratory and cardiac rhythms.
Vomiting is an epiphenomenon of the paroxysm.
Experimental physiology teaches that the gastric
mucosa is the principal emunctory of morphine. And
still more, considering the great frequency of vom-
iting in adults following injections of morphine, it
would seem, a fortiori, that this alkaloid would in-
crease, or, at least, facilitate vomiting. But such is
not the case, and, regardless of the emetic action of
morphine, vomiting is almost always diminished or
completely controlled, an evident advantage because
it allows the general health to recuperate.
A more serious complication of pertussis is bron-
chopneumonia, which darkens the prognosis in very
young children. But as I have already remarked,
morphine, by calming the cough, destroys the salu-
tary effect which is to disengage the pus contained
in the small bronchi and pulmonary alveolje. As
a symptomatic medication, baths and revulsions are
to be preferred. Therefore, the use of the alkaloid
is to be prohibited in pulmonary complications with
a defective defense of the lungs. There are other
contraindications of a more general kind. Since the
integrity of the excretory organs is a condition of
success in the struggle against all disease, the con-
dition of the renal gland must be ascertained, and
whenever there is a renal edema or a small amount
of urine the alkaloid must never be given. As Tri-
boulet and Boye advise, it is always well to look
for albumin before prescribing the drug. Early life
is not a contraindication ; it is well tolerated in quite
young children, but in an infant, say, eight months
old, the dose should never reach beyond two miUi-
grams. Lust, of Brussels, has even stated that the
newly born are much more tolerant to morphine
than the adult, particularly when the morbid phe-
nomena are very distinct.
Morphine is a simple and stable medicament, al-
ways identical in itself, and with a perfect toler-
ance at present unquestionably demonstrated and
admitted. There are three ways of administration,
viz. : by the mouth, rectum, and hypodermically.
The latter is by far the modus facicndi of choice.
Lesage and Cleret employ a ten per cent, solution
of morphine hydrochlorate, this representing one
centigram of the alkaloid in each cubic centimetre.
According to these writers, the dose to be employed
is as follows :
One third cubic centimetre of a one per cent, solution
during the first year.
One half cubic centimetre of a one per cent, solution
during the second year.
Two thirds cubic centimetre of a one per cent, solution
during the third year.
One cubic centimetre of a one per cent, solution above
the age of three years.
For an infant, have a i/i,ooo solution made, and
of this give one or several hypodermic injections of
one c. c. every twenty-four hours.
Mouriquand prefers the rectal route, and gives
the following formula:
TyL Morphine hydrochlor 0.05 ;
Aq. laurocerasi 2.00;
Aq. dest., q. s. ad 10.00.
Each cubic centimetre contains a half a centigram
of the drug, and, according to the dose to be given,
one c. c. is added to sixty or eighty c. c. of tepid
water to be given per rectum. I recall the rule of
the old Berlin therapeutist, Miiller, to begin with
one sixtieth of a grain and increase to one fortieth
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
or one thirtieth of a grain until the commencement
of narcotism is noted.
It is difificult to fix the size of the doses of mor-
phine in children. The doses employed by Lesage and
Cleret were extremely variable for children of the
same age on account of the intensity of the symp-
toms that were to be controlled. The dose of one
centigram above the age of three years is a strong
dose applicable in violent paroxysms of laryngism.
Lust's method seems to me more exact. He ad-
vises giving the morphine in relation to the body
weight, and not to the age of the child. Begin
with one half milligram for each kilogram, in
twenty-four hours, by the mouth ; or one quarter
milligram in an enema of about thirty c. c. Hypo-
dermically, begin with one tenth milligram per kilo-
gram of body weight. After a few hours another
dose can be given without danger if necessary.
Lust says that children rapidly acquire immunity
against the drug, and, if it is continued for some
time, there is no danger of accumulation.
As to the maximum quantity of morphine that
may be with safety employed in a series of injec-
tions, each one must be guided by his own judgment,
but the child must be carefully watched for the early
signs of intoxication. For this, the pupil is the
surest guide, and if it contracts the administration
of the drug must be stopped, and when the miosis
has disappeared it can again be given.
RECENT OBSERVATIONS IN DIGITALIS
THERAPY.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
(Continued from page 124.)
The influence of digitalis exerted clinically in the
presence of a rapid heart rate or of one of the
various forms of arrhythmia recently recognized
has been discussed in the preceding instalments.
Our inquiry showed the necessity of careful difter-
entiation between individual cases in this connection,
some instances, whether of increased rate or definite
arrhythmia, responding appreciably or remarkably
to the remedy, while in others digitalis fails or may
be actually prejudicial. We are next concerned
with the influence of digitalis in simple weakness of
the heart muscle.
The view generally held on this subject is sum-
marized in Sollmann's conception, 1917, of the
service clinically rendered by the drug as "restoring
the tone and contractions of an exhausted, fatigued,
but otherwise normal heart muscle, to healthy ef-
ficiency." Where, as is sometimes the case, an ex-
cessively rapid rate of contraction or an irregularity
creating mechanical conditions unfavorable to a
sufficient cardiac output coexists, the drug may at
times, in view of the eff'ects it is capable of exerting
on these latter types of disturbance, be of marked
help indirectly by slowing and regularizing the heart
and thus actually reducing the energy expenditure
required of it. The importance of such indirect
corrective actions in the clinical benefit yielded by
the drug is being increasingly recognized. Indeed,
the degree and manner of direct digitalis action on
the heart muscle in various abnormal states is as
yet far from certain; strangely enough, there seems
to be less unanimity of opinion on this long talked
of subject than on the influence of digitalis in the
recently discovered arrhythmias. While most ob-
servers continue to believe in an increase of tonicity
or contractile power as accounting at least in part
for the benefit from digitalis in cardiac insufficiency ;
Sutherland, 1917, has put forward the claim that
digitalis "has no action whatever in medicinal doses
on the cardiac tissues." As well known an observer
as Vaquez, 1918, while recognizing a direct cardio-
tonic influence on the part of the strophanthins —
and in particular ouabain — asserts that digitalis clin-
ically is powerless to improve the tone of the myo-
cardium, and agrees with Potain and Merklen that
in cases of marked cardiac dilatation this drug may
not only fail to relieve the symptoms but do actual
harm by slowing the rate, thereby forcing the hearr
to overfill in diastole and gradually yield owing to
its deficient tonicity. Mackenzie considers the dila-
tation of the diseased heart to be due to failure of
tonicity, but Henry and Smith, 1918, state, referring
to cardiac dilatation, that "the function of tonicity
remains quite as dark as the formerly accepted
theory of muscle exhaustion." Cohn, 191 5, has
interpreted certain changes in the T wave in the
electrocardiogram witnessed by him under the in-
fluence of digitalis as indicating a direct action of
the drug on the heart muscle, and speaks of an
"alteration of the contractile substance" in this con-
nection. That digitalis may, even in small amounts,
increase to some extent the excitability of the heart
muscle seems possible in view of the evidences of
markedly increased excitability — extrasystoles in
particular — which frequently appear from large
dosage.
On the whole, the subject may be said to be still
in a somewhat confused state. Granting that in a
certain proportion of heart cases digitalis has no
opportunity to be of service by slowing an inor-
dinately high rate or correcting arrhythmia, some
other action must be exerted in such cases if any
benefit accruing from the drug is to be accounted
for. For the present it seems wisest to continue
to recognize some sort of a direct strengthening
action on the heart muscle, similar to but less pro-
nounced than that already definitely shown to occur
in experimental work with large doses. If varia-
tions in the extent of this strengthening appear to
exist in different types of cases, we may, perhaps,
explain them as arising through differences in the
state of nutrition of the heart muscle in these va-
rious types, such differences possibly causing varia-
tions in the effect of digitalis on the muscle. Ac-
cording to Bernoulli, 1913, digitalis fails to alter the
reaction of the normal — and, we may add, properly
nourished — heart to heavy work ; nor does it change
the time required for complete return of the heart
thus fatigued to normal. On the other hand, where
the pathologically crippled heart becomes overbur-
dened— and failure of compensation is generally
ascribed to failure of cardiac nutrition — digitalis
does seem to exert a direct beneficial influence.
Miller, 1918, observed experimentally that digitalis
enables the heart to tolerate a greater degree of
coronary obstruction, i. e., a greater reduction of
nutrition from the blood than it could otherwise
July 27, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
169
withstand. Again, Cushny and his coworkers, as
already tiientioned, have recently presented evidence
to the effect that whereas digitalis remedies the ef-
fects of auricular fibrillation in the well nourished
heart by depressing conductivity through vagus stim-
ulation, in the poorly nourished heart, including that
of cardiac disease in man, it produces this result
by direct action on the heart muscle. Thus, cardiac
nutrition and the action of digitalis would seem to
bear to each other some relationship, the precise
nature of which, however, is not as yet clear.
Whatever uncertainty may still prevail regarding
the mode of action of digitalis on the myocardium,
the variations in benefit from the drug in different
cases can at least partly be accounted for by varia-
tions in certain influences secondary to the direct
myocardial effect. Assuming that some form of
strengthening action on the heart muscle does occur
under clinical therapeutic doses, such secondary in-
fluences as the increase in coronary circulation due
to augmented cardiac output under digitalis and the
removal of blood stasis and of the corresponding
functional impairment in the lungs, digestive organs,
and other viscera previously crippled through circu-
latory stagnation, are factors liable to marked varia-
tion in different cases and which help to explain
differences in the amount of benefit yielded by the
drug. Thus, in chronic myocarditis, the amount of
functioning muscular tissue having become greatly
reduced; these secondary benefits can hardly be as
marked as, e. g., in cases of valvular disease with
thick cardiac parietes consisting of functionally ef-
ficient muscular tissue, well able to respond to what-
ever direct myotonic action digitalis may exert. On
the other hand, recent experience has not sustained
the view formerly held by some that digitalis is a
dangerous drug in chronic myocarditis. According
to Abrahams, "patients with myocarditis can stand
fifteen drop doses of the tincture three times a day
very nicely. It does them a great deal of good."
The possibility that myocardial changes may predis-
pose to heartblock should, however, be borne in
mind in these cases.
{To be continued.)
Glandular Laryngovestibulitis. — A. Robin and
J. Renaut {Bulletin dc V Academie de medecine,
January 8, 1918) have observed that the loose
cough of ordinary acute laryngotracheitis often
passes into a much more annoying form of cough
characterized by violent efforts to expel what ap-
pears to the patient as a foreign body tenaciously
adherent to the laryngeal mucous membrane. At
times, loosening of the foreign material, which is
apt to produce a sensation as of a body that has
■'gone down the wrong way" in swallowing and
become impacted, is finally accomplished only by
sneezing. This material is actually an exaggerated
secretion of the glands of the laryngeal vestibule,
i. e., that portion of the larynx situated below the
inferior vocal cords. In mild cases, where acute
or subacute, the phagocytic and air purifying func-
tions of the secretion are unimpaired, but in in-
tense forms phagocytosis becomes greatly reduced
or even abolished and there is some risk of de-
scending bronchitis or pulmonary congestion as a
complication, as well as of pain from overwork of
the diaphragm in coughing and of myocardial
weakening— the latter possibly of toxic origin. In
the treatment, primary infection of the naso-
pharynx or mouth, or abuse of tobacco, must be
eliminated. Where these measures fail to bring
complete or even partial relief, the condition may
be said to have become definitely established, and
local treatment is required, viz., inhalation four
times daily of the following preparation, which the
patient sprays into his mouth continuously for
three successive periods of one minute at each sit-
ting:
Sodii salicylatis, 25 grams;
Antipyrinae, 5 grams;
Glycerini 80 grams ;
Aquae laurocerasi / i? s a •
Aquae aurantii florum, ) ^ '
Aquae destillatae, i litre.
Fiat solutio.
This procedure generally overcoilies the condi-
tion in three or four weeks. Recovery is acceler-
ated by simultaneous internal use of a mixture of
tincture of aconite, fifteen drops ; tinctures of
bryonia and belladonna, of each, eight drops, and
distilled water, 150 grams; dose, one tablespoonful
four times a day.
Intravenous Injections of Arrhenal in Relaps-
ing Fever. — Dumitresco-Mante {Presse medicate,
March 21, 1918) uses a solution of three grams of
arrhenal in sterile distilled water, enough' to make
ten mils. Giving this large amount of the drug in-
travenously in a single dose was found entirely safe,
no early or late ocular complication or other toxic
effect save a slight, evanescent headache being no-
ticed in any case. Among eight who were given this
dose during the first paroxysm of fever, six were
freed of the second paroxysm, the temperature soon
descending permanently to normal. In the seventh
case, the second paroxysm appeared nine days after
the first, but was very mild, and no spirilla could be
found in the blood at the time. In the ninth case
the temperature rose to 40° C. nine days after the
beginning of the first paroxysm, but descended to
36° on the next day. No spirilla could be detected.
In this case the second rise is believed to have prob-
ably not been due to the infection itself. The
average time between the injection and the return
of temperature to normal in the eight cases was
twenty-six hours. The sterilizing action is thus
slower than with neosalvarsan, but seems none the
less sure in most cases. Using neosalvarsan the
author found that the second febrile paroxysm some-
times did appear after it, even where 0.45 or 0.5
gram had been given. In one case, moreover, only
0.15 .gram of neosalvarsan proved sufficient to in-
duce rather alarming cardiac disturbance. In no
case receiving three grams of arrhenal had any
cardiac difificulty resulted. Studies of the red blood
cells, coagulability, and leucocytes, and of the renal,
hepatic, and pulmonary functions revealed no dele-
terious effects of the drug. The known contra-
indications to arsenic, viz., insufficiency of the liver,
heart, or kidneys, as well as hemorrhage from the
bowel or lungs, should doubtless apply in the use of
arrhenal. Doses smaller than three grams proved
therapeutically insufficient.
170
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Hepatitis: a Constant Accompaniment of
Cholecystitis. — Evarts A. Graham (Surgery, Gyne-
cology, and Obstetrics, May, 1918) states that in
thirty cases of bihary tract disease which have come
to operation a distinct enlargement of the Hver has
been present in twenty-six or eighty-seven per cent.
In the remaining four cases there has been definite
gross evidence of previous or existing pathological
change in the liver other than an enlargement. Dur-
ing the course of the operation small pieces of liver
tissue have been removed for bacteriological and
microscopical study. The result of these examina-
tions may be epitomized as follows : In cases of acute
or subacute cholecystitis there has been constantly
found in the liver microscopical evidence of inflam-
mation. The hepatic inflammation is characterized
by leucocytic infiltration of the interlobular or peri-
portal sheaths ; in the more severe types of inflam-
mation the infiltration may involve also the paren-
chyma at the peripheries of the lobules and be asso-
ciated with more or less edema, slight necrosis, and
moderate fat infiltration. Cultures from both the
liver tissue and from the bile in the gall bladder
have usually revealed the same organism from each
of the two different sources. In chronic cholecys-
titis the liver microscopically often presents a
similar condition to that of an early case
of cirrhosis. The inflammatory reaction appears
to be chiefly a pericholangitis. The gross enlarge-
ment of the liver is probably due chiefly to edema.
The enlarged livers in this series have always dimin-
ished markedly or returned to normal size after
appropriate surgical treatment. INIarked cirrhotic
changes have been shown to occur in the liver even
when there has been a stasis of bile. The import-
ance of these findings in relation to the pathogenesis
of cirrhosis of the liver in general is discussed.
From the standpoint of the diagnosis of obscure or
doubtful cases of biliary tract disease the presence
of an enlarged liver is of the greatest importance.
Treatment of Puerperal Eclampsia. — ^F. A.
Dorman {American Journal of Obstetrics, April,
1918) says there is no type of sickness in which
the indications for treatment are so clear cut as in
eclampsia. First and most important is to get rid
of the source of the poison by emptying the uterus
with the minimum of shock. If there be a dilated or
dilatable cervix one should proceed to deliver; if
not, and the fetus is small, vaginal hysterectomy is
a good method. In a case near term the condition
may permit of temporizing by the introduction of a
bag, to be followed by operative delivery after a
few hours. In other cases the urgency of the
symptoms may demand an abdominal Cesarean sec-
tion. The second indication is to sustain the heart
and respiration by diminishing the convulsions and
relieving the blood pressure. Temporary control
of the convulsions may be secured with a dose of
morphine. If the pulse is rapid and strong, fluidex-
tract of veratrum viride, four minims, may be given
hypodermically and repeated in four hours, with
careful watching in the meantime. Chloral hydrate,
thirty grains by rectum, then ten grains every three
hours, seems to have a quieting elTect. Nitroglyce-
rine, l/ioo grain hypodermically every hour, is also
beneficial as regards the blood pressure. No anes-
thetic will stop the eclamptic seizure once it has
begun. In this emergency, prevent injury to the
tongue, keep the patient from falling ofif the bed or
table, and see that respiration is resumed. Early
administration of oxygen is of some assistance in
overcoming the cyanosis. The third and last in-
dication is to stimulate excretion. As soon as pos-
sible wash out the stomach and introduce by tube
five grains of calomel with half an ounce of mag-
nesium sulphate or one ounce of castor oil. This
should be followed up by colon irrigation with saline
or sodium bicarbonate solution, to be repeated as
often as three times a day. Bleeding followed by
intravenous saline injection may be practised in
sthenic cases. The tendency to pulmonary edema
should be remembered and the amount of solution
introduced limited. A moderate degree of bleeding
at the time of delivery usually serves the purpose of
a blood letting. AfteV twenty-four hours the hot
pack or hot air bath is valuable ; used earlier it
seems to depress the heart. Giving oxygen at inter-
vals is very beneficial. If coma persists, one must
catheterize every six hours. The heart action
should be watched and any necessary stimulation
given. Beginning pulmonary edema demands active
treatment, with dry cupping over the chest. As
soon as the patient becomes partly rational she must
be urged to drink water freely.
Management of Breast Feeding. — Howard
Childs Carpenter (Pennsylivania Medical Journal.
May, 1 91 8) maintains that encouragement of the
mother is of great importance. The anxious mother
should be told that she has nothing to fear. If the
child fails to gain in weight it should be examined
carefully for any underlying condition present, such
as syphilis, pyelitis, or adenoids. Little reliance
.should be placed on a chemical analysis of the milk,
as many babies thrive on milk shown to be deficient.
The breast fed baby should not suck the nipples
alone but should be taught to grasp as much as pos-
.=:ible of the areola. The intervals should be four
hours and not two or three, and the best method is
to feed the child five times daily — at 6 and 10 a. m.
and at 2, 6, and 10 p. m. The diet of the nursing
mother should remain about the same as before
pregnancy. The food should be rich in calcium,
cheese, milk, yolk of eggs, spinach, peas, and beans.
A diet containing 2,500 to 3,000 calories per twenty-
four hours is the best. If the baby has difficulty in
nursing its throat should be examined, especially
for adenoids. If artificial food is necessary, as de-
termined by the weighing, it should be given im-
mediately following the nursing and should vary
with the age, size, and digestive ability of the infant.
Vomiting is frequently due to handling the baby
too much or having it assume faulty positions. Colic
may be treated by turning the child on its abdomen
or applying heat ; if it persist the breast milk must be
diluted, which is done by giving warm water or
barley water in a nursing bottle before feeding, add-
ing two to five grains of sodium bicarbonate to each
bottle of diluent, or, if there is a tendency to con-
stipation, five to ten drops of magnesia. When the
baby is gaining in weight it should not be weaned.
This is true, irrespective of vomiting, diarrhea or
colic.
July 27, igi8.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
171
Feeding in Hyperemesis Gravidarum. —
Charies S. Bacon {journal A. M. A., June 8,
1918) holds feeding to be one of the most impor-
tant of all measures in the treatment of hypereme-
sis gravidarum. The condition usually passes off
when the uterus rises out of the pelvis, and there-
fore every effort should be bent to nourishing the
patient until that time arrives. Of the three non-
oral modes of feeding, the rectal is the most com-
monly available, and is the easiest. By it all the
essential factors of the diet can be supplied, carbo-
hydrate, protein, salts, and vitamines. Since the
rectum has not the power of digesting either pro-
tein or carbohydrate, the former should be supplied
in the form of its constituent aminoacids and the
latter in the form of glucose, which is absorbed as
such. The protein is best provided by the dialysate
of artificially digested meat or milk. The vitamines
can be secured in an extract of the pancreas, and
the salts can be added as desired. Sodium bromide
can often be made to replace sodium chloride and
provide the necessary sedative. Alcohol in dilute
form, and in an amount not to exceed 100 grams
daily, is an excellent food, and is well absorbed and
completely utilized. From 300 to 500 mils of the fol-
lowing mixture should be given three times a day
at the rate of one drop a second. It should be
warmed by passing the tube between warm sand-
bags placed close to the buttocks. The solution
consists of fifty grams of glucose, fifty grams of al-
cohol, three tenths gram of calcium chloride, three
grams of sodium bicarbonate, four grams of sodium
chloride or bromide, a sufficient quantity of pan-
creatic vitamine, and distilled water to make 1,000
mils. Fifteen hundred mils of this provide 825
calories. Under this treatment, carried out in hos-
pital with the patient in bed, the vomiting stops in
two or three days, thirst disappears, and the nitro-
gen loss is promptly checked. It is seldom neces-
sary to interrupt pregnancy.
Intravenous Injection of Chlorine Solutions in
Typhus Fever. — O. Danielopolu {Bulletins et
memoires de la Societe medicate des hopitaux de
Paris, December 13, 1917) found that a solution
containing 6.5 grams of sodium chloride and 0.4
gram of chlorine per litre merely agglutinates the
red and white blood cells in vitro, without destroy-
ing them, and can thus be administered intraven-
ously without the dangers that would attend a
similar use of Dakin's solution, which is strongly
hemolytic. Over 1,000 injections of the chlorine
saline solution, never exceeding 500 mils at a dose,
were administered without mishap, the only un-
favorable effect being a chill, v.'hich occurred al-
most constantly" m the subjects treated. The treat-
ment was tried only in severe typhus cases, with
intense delirium, prostration, great facial conges-
tion, a pulse of 120, and a systolic pressure of
eighty or ninety millimetres of mercury, with cya-
nosis and coldness 6f the extremities. Patients
with such symptoms who did not receive the intra-
venous chlorine saline treatment showed a mortal-
ity of ninety-two per cent., while among sixty
grave cases which did receive the treatment the
mortality was only ten per cent. Injections were
given daily. After one or more injections, normal
consciousness returned, cyanosis disappeared, and
the excessive number of leucocytes was soon re-
duced to normal, rising again later, however, upon
discontinuance of the injections. In exceptional
cases in which the leucocytosis continued pro-
nounced, increasing the number of injections to
two a day generally brought about the desired re-
sult. On an average, two to eight daily injections
proved sufficient. The measure probably acts
indirectly as an antiseptic and antitoxic agent,
as was indicated by the consequent rapid improve-
ment in the general condition, disappearance of
tachycardia, and subsequently, the restoration of
normal arterial pressure. The typhus cases which
succumbed in spite of the treatment were nearly
all over forty years of age, and in four out of the
six that died secondary streptococcic infection was
the lethal factor.
Selection of Abdominal Cases for Operation. —
Owen Richards {British Medical Journal, April 27,
1918) says that in military wounds of the abdomen
the value of early operation and the best technic
are fairly well agreed upon, and the mortality is
fairly constant. There is, however, a material dif-
ference between successful cases and profitable
cases. The only profitable cases are those in which
an otherwise fatal injury is cured by operation, and
it is upon the proper selection of cases for operation
that the proportion of profitable cases depends.
Even if the operation does no harm, it is a waste of
valuable time to operate upon cases which would
recover equally well without of>eration, and it is a
similar waste of time to operate upon such as offer
no hope of recovery even after operation. In both
instances we are depriving other men oi profit-
able operations. Patients with wounds limited to
solid viscera, with no progressive hemorrhage and
no large retained missile, seldom need operation,
and those with other grave injuries of head, chest
or extremities are usually not fit to withstand opera-
tion. In the others it can usually be determined
that the abdomen has been penetrated, but the na-
ture and extent of the abdominal injury remains un-
known, hence the decision regarding operation must
be based upon those facts which can be determined.
While no rule can be laid down with certainty, the
proportion of profitable operations is very high in
those operated upon within the first twelve hours;
the same is true to a less extent for those treated in
the first twenty-four hours, but after this interval
the proportion is very small, since most who then
survive would have lived without operation. The
pulse rate is the second guide of value, for those
with a pulse of 120 or more have less than half the
chance of survival of operation of those with a
pulse below that rate. Those with rapid pulse
should be operated upon, however, if their condition
is as good as it is likely to be, if they have a chance
of recovery, and if the time taken does not prevent
the proper treatment of more hopeful cases. In
times of great pressure the men should be selected
and arranged in the order of the likelihood of the
operation's being profitable, if the maximum sur-
gical help is to be given to all. Finally no surgeon
should be allowed to do this work who is not rapid
and gentle in his technic
172
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Simple Arthrotomy in Suppurative Arthritis. —
Willems {Prcssc medicale, March 28, 1918) re-
ports five wound cases with diplococcic, staphylo-
coccic, or streptococcic joint infections, some with
and some without intraarticular fracture, in which
simple opening of the joint and immediate active
mobilization was followed by good results. In no
case was any other means of drainage instituted or
the joint irrigated. Drainage was perfect in every
case. The temperature rose but little above normal
and the general condition remained good. The in-
fection seems to have continued limited to the
synovial membrane, little or no atrophy could be
detected, and joint mobility was completely pre-
served. These cases are held to prove that simple
arthrotomy is far superior to either primary or sec-
ondary joint resection. The latter should now be
abandoned in suppurative arthritis.
Bactericidal Properties of Chlorine Yielding
Solutions. — Weissenbach and Mestrezat (Presse
medicale, February 14, 1918) sought to ascertain
the relative bactericidal power of various hypo-
chlorite solutions, all containing equal amounts of
chlorine but in different combinations. Solutions
acid, neutral, and alkaline to phthalein were in-
vestigated, including the Dakin-Daufresne solution
and solutions containing sodium bicarbonate and
alum, respectively. Tests in vitro with the Staphy-
lococcus aureus, Bacillus pyocyaneus, Bacillus para-
typhosus. Bacillus perfringens, and the spores of
Bacillus sporogenes showed that, weight for
weight, the chlorine of hypochlorite solutions acid
to phthalein acts twice as strongly as bactericide as
the chlorine of alkahne solutions. This is appar-
ently accounted for by the readiness with which
hypochlorous acid decomposes in acid media, with
liberation of four parts of oxygen to every two
parts of chlorine. The action of nascent oxygen
is thus added to, or perhaps may even completely
replace, that of the chlorine.
Method of Citrated Blood Transfusion. — Os-
wald H. Robertson {British Medical Journal, April
27, 1918) points out the fact that transfusion of
citrated blood requires a careful technic if reac-
tions are to be avoided, and that if properly carried
out it is a method of great value, especially since
the whole process can be completed by one man.
The apparatus that is used consists of a short, broad,
open mouth glass bottle fitted with an inlet glass
tube of six mm. internal diameter, to which a bleed-
ing needle of large bore — 1.5 to two mm. — is con-
nected by rubber tubing eight cm. long. The outlet
consists of a smaller glass tube, angulated so as to
reach the lowest part of the bottle and connected
to a smaller bore needle by a length of rubber tub-
ing and a short connecting glass piece placed close
to the needle. Pressure or suction within the bottle
is provided by a reversible rubber syringe bulb. The
bottle is marked at levels indicating 660, 760, and
860 mils, corresponding to 500, 600, and 700 mils
of blood. For use the bottle is cleansed carefully
and i6o mils of 3.8 per cent, solution of sodium
citrate, made with freshly distilled water, are placed
in it. It is then stoppered with cotton in gauze,
and sterilized. To draw blood from the donor's
vein the citrate solution is forced up into the in-
take tube to fill it and the needle without air The
needle is then inserted into the donor's vein through
a small nick in the skin, and blood is drawn di-
rectly into the citrate, entering below its surface.
Every few minutes the bottle is rotated to insure
mixing. When the desired amount is drawn, the
intake tube is clamped to leave it filled with blood
and the needle withdrawn. For injection into the
recipient the outlet system is filled with the citrated
blood by air pressure, the detached needle and glass
connection is inserted into the recipient's vein, and
when it fills with blood the tube from the bottle is
attached. The injection is made slowly by air pres-
sure, and should take at least ten minutes. During
the administration the bottle should be immersed
in water at body temperature.
Cultivation of the Meningococcus Under Par-
tial Oxygen Tension. — M. B. Cohen (Journal A.
M. A., June 29, 1918) cites the well known fact
that it is often a difficult matter to obtain cultures
of the meningococcus in sufficient quantity for rapid
agglutination. The reason for this was found in
the fact that this organism is microaerophil ; that
is, it does not grow well in the presence of full
oxygen pressure. On this basis a simple, rapid,
and satisfactory method for culture has been de-
vised. It consists in sowing a tube slant of human
serum ghicose infusion agar with the culture, or
suspected culture, and connecting this tube by a
piece of rubber tubing with a second sown with
B. suhtilis. The subtilis grows rapidly and reduces
the oxygen tension in both tubes. The same meth-
od can be applied to Petri dish cultures by inverting
them and connecting the two by a short piece of
tubing.
Entameba Histolytica Carriers. — S. Shepheard
and D. G. Lillie {Lancet, April 6, 1918) investi-
gated the value of infusions of the several portions
of the plant, "chaparro amargosa" in the treatment
of persistent carriers of the Entameba histolytica,
testing the drug on a series of patients who had
proved resistant to at least two courses of emetine
bismuth iodide. They used infusions of the root,
of the root bark, and of the twigs and leaves, and
correspondmg amounts of the isolated, crystalline
bitter principle. All infusions were made fresh and
they were given orally and also by rectum. The
latter method of administration was combined with
the oral, but seemed of little or no value. The drug
had some tendency to produce nausea, vomiting,
abdominal pain, and diarrhea in some patients, the
latter two symptoms appearing only in those who
had free amebas in their stools. No case was cured
by the use of the isolated bitter principle, but the
infusion cured from thirty-six to fifty-seven per
cent, of the cases in which they were used, there
being but little difference in the efficiency of the dif-
ferent portions of the plant. The administration of
a second course of treatment to patients who were
not cured by the first course did not increase the
proportion of cures. Simaruba bark was also tried
in the form of fresh infusions, it yielding a similar
bitter principle and being closely allied to chaparro.
It gave about the same results. In no case having
free Entameba histolytica in the stools was a cure
effected.
Miscellany from Home and Foreign Journals
Diagnosis of Abdominal Aortitis. — A. Mougeot
(Bulletins ct memoircs dc la Socictc medicate dcs
hdpitaiix de Paris, February 7, 1918) compares by
the graphic method the time of the radial pulse
with that of the femoral artery — the latter taken
just below the crural arch. In all patients with
aortic lesions not involving the abdominal portion
of tlie vessel, and at any level of blood pressure,
the normal synchronism of the pulse in these two
situations was found preserved. In nearly all cases
of abdominal aortitis without aneurysm, however,
the femoral pulse was found to precede the radial
by one fortieth to one twentieth of a second. In
the presence of the interval last mentioned the dis-
crepancv can be made out merely by careful palpa-
tion. To detect briefer intervals a recording
apparatus is required. I'hat an aortic aneurysm
situated below the point of origin of the left sub-
clavian artery or involving the abdominal aorta
causes retardation of the femoral pulse as com-
pared to the radial was already known. The au-
thor's recent observations in about fifty cases have
shown that the opposite state of affairs, retarda-
tion of the radial as compared to the femoral, indi-
cates sclerotic changes in the abdominal aorta.
Diagnosis of Cholecystitis. — W. H. Bodenstab
{Journal A. M. A., July 6, 1918) contends that the
profession at large is not sufficiently strongly im-
pressed with the importance of early operations
for the relief of inflammations of the gallbladder
and their results. Cholelithiasis and active chole-
cystitis deserve special attention on account of the
suffering which they cause and because many of
their serious consequences as cancer of the gall-
bladder or ducts, rupture of the bladder with septic
peritonitis, empyema of the bladder, suppurative
cholangeitis, hepatitis, abscess of the liver, pancrea-
titis, etc., can all be prevented by early diagnosis
and prompt operative treatment. With the aim of
facilitating early diagnosis the author presents the
results of an analysis of the clinical features of a
series of 500 cases, 340 with stones and 160 with
cholecystitis but without stones. The most con-
stant symptom was tenderness in the gallbladder
region, being present in eighty-six per cent of cases
with stones and ninety-four per cent, of those with-
out. The sensations of bloating and upward
pressure, relieved only by belching of gas were
found in eighty per cent, of stone cases and in
sixty-seven per cent, of those without stones.
Vomiting, due mainly to the regurgitation of bile
into the stomach, was found in eighty per cent, of
the stone cases and forty-seven per cent, of those
without stones ; and it was found to be a good rule,
when there was an upper abdominal lesion
without pyloric obstruction to cause the vomiting,
to look to the gallbladder. Radiating cramps in the
form of sudden, severe epigastric pain shooting to
either costal arch, through to the back, or to one
or the other shoulder, and bearing no relation to
food were typical of gallstones and were found in
seventy-two per cent, of the cases with stones and
only thirt3'-eight per cent, of those without. In
the absence of stones the attacks were less severe
than in their presence. Marked shortness of
breath was very common during the attacks of
pam. Reflex symptoms suggesting digestive dis-
turbances were very common and should always
be investigated with reference to the state of the
gall bladder. The presence of bile in the urine was
also very common in the early hours after an at-
tack. Jaundice mentioned in tlie patient's history as
having followed an attack of radiating epigastric
pains made the diagnosis practically certain.
Finally the sex incidences of cholecystitis and
stones were of importance ; thus there were nine
women to one man in the stone cases and three
women to one man in the cholecystitis cases without
stones. The cardinal symptoms of cholelithiasis
could be stated as: i, radiating pains; 2, vomiting;
3, belching ; 4, dyspnea ; and 5, prostration. The
relative frequency of their occurrence in various
combinations in both cholelithiasis and cholecystitis
cases is shown in the subjoined abbreviated table.
Cholelithiasis Cholecystitis
Groups of symptoms. Per cent. Per cent.
I and 2 59.0 21.2
I, 2, and 3 SS.6 18. i
I, 2, 3, and 4 50.9 13.8
I, 2, 3, 4, and 5 24.1 4.5
I, 2, and 4 50.6 16.2
I, 2, 4, and 5 24.1 5.6
I, 2, and 5 24.1 5.6
The Relation of Cellular Changes of Age to
Tumors. — Ernest William Goodpasture {The
Journal of Medical Research, May, 1918) bases his
extensive report on the autopsy findings in fifty old
dogs, each of which contained multiple tumors, either
benign or benign and malignant, in more than one or-
gan. The large number of sections studied showed
that senescence is accompanied by multiple degenera-
tive cellular changes in many organs and tissues, and
apparently as a direct result of these changes, there
occur the benign and malignant tumors, which in
old dogs are usually multiple. He explains the
changes which are observed in old age, together with
the formation of tumors, in the following way:
Progressive cellular differentiation eventually leads
to senescence by the constant accumulation in the
protoplasm of more or less stable structural sub-
stances. It may then be possible that a disturbance
in assimilation or metabolism of cells may result
in the accumulation of injurious metabolic sub-
stances within either the cytoplasm or the nucleus,
so that many of the cells die, while others become
dedifferentiated. The latter then possess potentiaH-
ties for groM'th and differentiation in varying de-
grees. Some of these dedifferentiated cells may not
attain their former degree of specialization, and so
are not perfectly adapted to the needs of the organ-
ism. In the simplest form of dedifferentiation the
cell is regenerated, and possesses the power of adapt-
ing itself to specialized function. In other cases the
regenerated cells are only capable of a partial re-
sumption of function, and finally, this capabilitv
may be destroyed altogether, although there is still
formative power dominant in the life of the cell,
whose continued growth may arise in tumors.
174
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Milk a Source of Watersoluble Vitamine. —
Thomas B. Osborne and Lafayette B. Mendel (The
Journal of Biological Chemistry, June, 1918) found
that in order to promote growth it was necessary
to add a much larger proportion of milk to the diets
fed rats than had been reported by Hopkins. The
optimum amount seemed to be about twenty-eight
per cent, of proteinfree milk. In trying to explain
the discrepancy between their results and Hopkins',
the authors thought that heating the dried protein-
free milk might have caused deterioration in the
vitamine factor. Accordingly, fresh milk was used,
which gave results similar to those obtained when
an approximately equivalent amount of proteinfree
milk was employed. At least sixteen c. c. of fresh
milk must be supplied with the food mixture to
produce a normal rate of growth in rats. In view
of the fact that their rats needed much more milk
than was reported by Hopkins, the authors advise
for the present the use of liberal amounts of milk
when this is depended on to supply an appreciable
proportion of the watersoluble vitamine in the diet.
A practical point in connection with this is the cus-
tom of reinforcing the supply of calories by diluting
the top milk and adding milk sugar. Here the food
contains a relatively smaller proportion of the water-
soluble vitamine than was originally present in the
cow's milk, so that while the child's appetite is nor-
mal, the supply of vitamine may be sufficient, but
if the food intake is reduced, the vitamine supply is
lowered, and endless dietary trouble may set in.
The suggestion is offered that this is what happens
in artificially fed children, and that it may be pos-
sible to obviate this by supplying this important
factor of a proper diet, as has been done in feeding
animals.
Renal Elimination, Normal and Pathological.
— Ambard {Presse medicale, April 25, 1918)
points out the futility of expecting that additional
information as to renal function in the individual
case can be obtained by using new compounds,
without threshold of elimination, as test substances.
The reason for this is that all substances without
thresholds — substances apparently useless in cellu-
lar life, such as urea, ammonia, glycerin, iodine,
methylene blue, and salicylic acid — have the same
coefficients of secretion in a given case. Which-
ever of these substances, including also phenol-
phthalein, is employed, the result is the same, if it
can be accurately read. Substances with thresh-
olds, such as glucose and chlorine, have lately been
shown to have the same coefficients as the sub-
stances without thresholds ; but here a variable
'factor comes in in the changeability of the thresh-
old at different times. A subject with satisfactory
coefficients ni general may be able to excrete iodine
perfectly while showing retention of chlorine ; in
such a case the chlorine threshold is too high.
Studies of the mobility of the threshold can be con-
ducted with the aid of phloridzin, which lowers the
glucose threshold, and of theobromine, which
lowers the chloride threshold by increasing chloride
elimination. As regards the technic of blood urea
estimations Ambard lays stress on proper shaking
of the contents of the ureometer — ten to twelve
times in the course of fifteen minutes — in order to
obtain the best possible results with the hypo-
bromite method. To obviate injury to the skin in
closing the outlet while shaking the ureometer, a
rubber cot should be used. Thirty mils of blood
should, if possible, be collected for the estimation.
Where smaller amounts are obtained, a greater
yield for the test cai2 be secured by rendering the
blood incoagulable with 0.2 to 0.3 gram of sodium
fluoride, centrifugating, and using the plasma thus
obtained instead of serum. The time otherwise re-
quired— several hours — for the serum to separate
is also saved by this method. The urine collected
should be product of 13/2 hours if the catheter is
used and of 23/2 hours if not, preferably obtained
in the morning between nine and noon. Clinically
the ureosecretory coefficient is especially important
where the blood urea is below 0.5. Between 0.5
and one it is to some extent serviceable, but above
one is superfluous.
Distribution and Elimination of Zinc and Tin
in the Body. — William Salant, J. B. Rieger, and
E. L. P. Treuthardt {Journal of Biological Chem-
istry, May, 1918), after administering zinc mtra-
venously to rabbits, found that the gastrointestinal
tract was the chief organ of elimination, as from
one third to one half of the amount given was re-
covered from its contents and the feces in two to
three days. Appreciable amounts of zinc were re-
covered from the liver, and the amounts demon-
strated in the skin indicate that the metal may be
either stored here or eliminated. Subcutaneous in-
jection of zinc showed its elimination likewise main-
ly by the gastrointestinal canal. The kidney is not
an important factor. The behavior of tin in the
body is somewhat difiPerent, smaller amounts being
found in the liver, and more eliminated by the kid-
neys, although its elimination also occurred chiefly
through the gastrointestinal tract. Both metals
were demonstrated in the skin and bones.
Study of Foiu- Hundred Post Mortem Wasser-
mann jReactions. — Stuart Graves {Journal A. M.
A., June 8, 1918 )presents the results of this investi-
gation as part of a series of over 6,000 Wassermann
reactions performed during life or post mortem. He
finds that in ninety-seven per cent, of a series of
sixty-eight cases the post mortem reaction agreed
with the antemortem test. A positive reaction agreed
with the anatomical and clinical findings when
done sixty hours post mortem, and a negative reac-
tion twenty-two hours after death agreed with the
reaction found during life. Only two and a half
per cent, of the serums obtained post mortem were
anticomplementary, or otherwise unsuitable for the
test, which compares favorably with 1.14 per cent,
found in antemortem specimens. The reaction
was positive in the blood post mortem in over
ninety-one per cent, of the cases in which there were
anatomic lesions of syphilis and positive histories.
Negative reactions were obtained in only 2.6 per
cent, of cases showing anatomic lesions of syphilis.
No evidence was obtained for the belief that acute
infections or malignant growths caused positive re-
actions. The conclusion was reached that the Was-
sermann reaction performed on blood obtained post
mortem was essentially as reliable as when done on
blood from the living patient.
July ^:
MISCELLANY FROM HOME AND FORLICN JOURNALS.
Method for Determination of Sugar in Normal
Urine. — Stanley R. Benedict and Emil Osterberg
{ Journal uf Biological Cliciiiistry, April, 1918)
found that the Myers adaptation of the Lewis-
Benedict method gave results at least 100 per cent,
too great in some cases, partly due to the imperfect
removal of the creatinine. They have evolved a
method by which the preliminary precipitation of
interfering substances from the urine is accom-
plished before the final determination of sugar in
the filtrate. The first step is calculated to remove
the creatinine completely, the polyphenols almost so,
and the total nitrogen and glycuronic acid as com-
pletely as possible. This is done by a single pre-
cipitation with excess of mercury nitrate in the
jiresence of a slight excess of sodium carbonate.
After removing the mercury with zinc dust the
filtrates are waterclear. The sugar is then deter-
mined by the modified Lewis-Benedict method.
Spirochetes in the Kidney. — Yutaka Kon and
Tomomitsu Watabiki {Journal A. M. A., May 25,
1918) call attention to the fact that others have ob-
served spirochetes in the urine and renal casts in
cases of typhus fever and have regarded them as the
causative organisms. Still others have found spiro-
chetes in the tirine in other conditions and have
(juestioned the fact that they are characteristic of
typhus fever. The authors examined the kidneys of
fifty miscellaneous necropsy cases and those from
twenty-six operative cases in which one kidney was
removed. In the fofmer group they found spiro-
chetes in twenty-five, in the latter in fifteen kidneys.
Three difl'erent types of spirochetes were found.
The spirochetes were found in the hyaline casts and
hyaline bodies in the renal tubules and occasionally
in the so called cysts of retention in contracted kid-
neys. The occurrence of the spirochetes bore no re-
lation to the disease from which the patient had
sutfered. The nature of the spirochetal bodies could
not be determined and requires further investigation
and the same can be said of their significance.
Blood Dextrose as Affected by Morphine and
Morphine with Ether Anesthesia. — Ellison L.
Ross (Juunial of Biological Chemistry, May, 1918)
using the variations in blood dextrose as an indi-
cator, conducted experiments on dogs to determine
whether morphine increases or decreases the unbal-
anced physiological condition produced by anes-
thesia. In the first series of experiments, eleven
dogs were given ten milligrams of morphine per kilo
of weight hypodermically. A calculation of the
averages for blood sugar showed that half an hour
after the administration of the morphine the dex-
trose content was increased fifty-nine per cent, of
the original value ; after forty-five minutes it was
increased sixty-six per cent, over the original, and
after ninety minutes there was an increase of
seventy-seven per cent, of the blood dextrose before
morphine. The second series of animals was given
the same amount of morphine as the first. Half an
hour later they were bled and immediately an-
esthetized. In the third series the dogs were an-
esthetized and, later, given the usual dose of mor-
phine. After the animals had been under ether one
hour and were still under the influence of morphine,
the average dextrose content showed an increase of
twenty-one per cent, before ether. Ross finds that
morphme does not produce as great an increase in
the blood sugar when acting with ether as when
acting alone. The increase of the blood sugar re-
sulting from the action of ether anesthesia after the
administration of morphine was much less than
without morphine. The final degree of hyper-
glycemia is practically the same, with or without
morphine.
Agglutination of Human Red Cells by Horse
Serum. — Herbert U. Williams and Harold A.
Patterson {Journal A. M. A., June 8, 1918) tested
the agglutinating power of nineteen samples of horse
serum for various specimens of normal human red
cells, and found that twelve of the serums agglu-
tinated more than half of the samples of red cells.
The serums used included normal serum with and
withotit preservative, and such therapeutic serums
as antipneumococcic, antistreptococcic and antidys-
enteric serums. The agglutination occurred at
varying strengths of serum from i :20 to i 1500, and
varied with a given serum for different samples of
red cells. The significance of the results were ren-
dered somewhat problematical since various ex-
traneous factors, such as temperature, etc., were
found to infiuence the occurrence of agglutination
to a marked extent. It seemed probable, however,
that the results might throw some light on the oc-
currence of more or less marked symptoms follow-
ing the use of such serums, especially when given
intravenously. It was suggested that serums for
therapeutic purposes should be derived from horses
which had been previously tested and found not to
agglutinate with human red cells.
Bacteriological Studies in Bacillary Dysentery.
— BezanQon, Kanque, Senez, Coville, and Paraf
(Bulletin dc I' Academic de inedccine, March 26,
1918), in studies of 300 stools during an epidemic
which broke out simultaneously in several small
foci in a certain military district in the late summer
of 1917, were able to establish clearly the role of
Shiga's bacillus in the more severe and clinically
typical cases, while in the mild the Shiga organism
was generally wanting and was replaced by aberrant
bacilli of the dysentery group. The Shiga bacillus
was isolated in large nimibers from forty-three
cases, and in dishes of lactose litmus agar at times
almost completely replaced the normal intestinal
flora, no colonies of colon bacillus being found. In
twenty-six milder cases were found a number of
different forms of organisms which did not corre-
spond to any of the classical types of dysentery
bacillus and never occurred in the severe or fatal
cases. These atypical organisms are divided by the
authors into five separate classes, according to their
respective behaviors with indol and various sugars
and their susceptibilities to agglutination by anti-
.Shiga and anti-Flexner serums. In each focus of
dysentery the organisms responsible for the mild
cases were of a single type. In one focus, however,
the examinations revealed, in addition to the Shiga
bacillus in five cases, the A paratyphoid organism
alone in four cases and the typhoid organism alone
in one case, in spite of the fact that the symptoms
were those of dysentery. In no case in the series
was the Flexner or the Hiss bacillus encountered.
Proceedings of National and Local Societies
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held March 21, 1918.
The Second \ ice- President, Dr. Edwin B. Cragin, in the
Chair.
Physical Reconstruction. — Major Paul B.
Magnuson, of the Surgeon General's Office, Wash-
ington, D. C, said there was no subject of greater
interest today than the conservation and physical re-
constrttction of men. There was nothing particu-
larly new about reconstruction ; it was simply a co-
ordination of many things that had been done in-
dividually over a considerable period of time. The
reconstruction problem had been talked about as if
it were a new thing, but many industries had been
carrying on this work for the last ten or fifteen
years.
Suppose a man in the trenches to have a joint in-
jury. He was taken to the first dressing station
just behmd the lines ; the wound was dressed and he
went thence to the evacuation hospital some distance
behind. In the first station were men trained in
schools for special work; there were four or five
schools in this country training men to take special
care of special conditions. So in this first station
expert attention was given to the injured joint which
was placed in fixed position to prevent suffering and
shock from the jolting over the roads to the evacua-
tion hospital. That was the first step in reconstruc-
tion and began immediately, as soon as the patient
was picked up in the field. The evacuation hospital
was equipped to do surgery; there the wound was
cleansed, fragments of bone put in apposition, a more
permanent form of dressing put on, and, after
twenty-four hours, the patient was taken back to
the base hospital.
The Surgeon General's Office was divided up into
different specialties, eye, ear, head, orthopedic sur-
gery, medical service, genitourinary surgery, tuber-
culosis section, and so on, not forgetting the general
surgeon. The general surgeon, apparently, would
not seem to have much left to him, but in reality he
had plenty to do. The man skilled in general sur-
gery easily became the skilled specialist, so he was
trained in one line, preferably that which appealed
to him. In the evacuation hospital the cases went
through regular channels. A record was kept of all
patients and of those who treated them, and when a
man failed with many cases his head came off be-
cause the ultimate good of the soldier was the only
goal.
The soldier at the base hospital, if judged to be
totally disabled, came back to the United States at
once. The term, unfit for military service, meant
unfit for front line duty. There were many duties
a man partially disabled could perform ; orderly duty
or clerical work. Such men would be kept in the
service and assigned to duty within their ability to
carry out. The aviation service had use for a great
many men in stretching goods on aeroplane wings
alone. They planned to establish schools in connec-
tion with supply stations where these men were con-
centrated and supply themselves with men disabled
for front line duty, which would release a great
many ablebodied men for front line work. Some of
them couid be drillmastcrs and some teachers of
bomb throwing. So because a man was wounded
was often no reason for discharge from the army.
The plan of distribution of the arriving wounded
to this country was to send them as near their homes
as possible, first taking into consideration the num-
ber of men at the various reconstruction hospitals.
Reconstruction did not mean only bone and joint
work ; it meant making over every class of cripple,
whether from a medical or surgical cause. Tuber-
culous cases could be trained as well as those having
amputations, in the hospital to which they were
finally sent.
At the head of the hospital would be the best men
that could be secured for medical and surgical work.
Here would begin the repairs on the man which
were all that was formerly known of reconstruction.
If the man had had an amputation at the front he
might need a secondary amputation here, and an end
bearing stump was tried for, there being many ad-
vantages in it, so it was being advocated at this time.
Within three or four weeks of the time of the sec-
ondary amputation the man would be fitted with a
jointed pegleg and then would be taught to walk.
While he was learning, his permanent leg would be
made. A wonderful artificial leg had recently been
devised by an army medical officer which was far
ahead of anything so far in use, and cost only one
fourth the price of the best previously sold. This
leg would be fitted as soon as the man learned to
balance himself on the pegleg and he would thus be
started on the road to his education.
As soon as the surgical disability was corrected
■sufficiently for the patients to move around they
could be given work to do because they were per-
fectly healthy except for their disability. It was the
plan of the Surgeon General to start their education
the minute they were able to do anything, and, to
that end, bedside occupations had been instituted. A
consultation was held with the patient himself, the
doctor, and the vocational officer as soon as the pa-
tient was able to be up. In these schools there would
be vocational teachers of all kinds, bookkeeping,
stenography, the trades, farming, etc. At the con-
sultation many factors would be employed, many
things considered ; it might be necessary to persuade
the man to take up a certain line of work ; he might
prefer work which he was not able to do. He must
be started on something in which he would have an
interest and in which he could make a living, a field
in which there would be a market for his labor. The
fact that he could sell his labor for a price would
also stimulate his interest. The consultation ended,
the man would enter the vocational school or the
shop or wherever it had been decided he should go.
From there a one hundred per cent, man would
eventually emerge. This was a statement to be em-
phasized to industries ; these men when they were
sent back to industry would be one hundred per
cent, men in that industry ; they would not be in-
capacitated ; they would do good work and compete
equally with men who had not their disability. A
campaign should be started to teach this fact among
July 27, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
177
manufacturers. Another telling point lay in the fact
that a man trained to do certani work to which he
was compelled to stick was the better workman and
more valuable to his employer than the man who
could go out and get half a dozen jobs any time he
wanted to.
In the base hospitals moving pictures would be
shown these men, just newly crippled, of men in-
jured as they had been and performing all sorts of
work and daily services for themselves. This would
have a potent psychic effect. A book was being
written for cripples teaching them how to care for
the stump, how to use artificial limbs, how to repair
them, etc., which would be of inestimable value.
The reconstruction hospitals would have every fa-
cility for doing high class work, including hydro-
therapy, electrotherapy, massage, and a little gym-
nastic apparatus, though not much made for the
curative workshops would be used for exercises. A
lathe worker with his foot operating a jigsaw would
have his attention focused and at the same time ex-
ercise his stiff ankle as well as if with a piece of
gymnasium apparatus. A massage treatment lasted
for one half hour ; a patient's interest could be bent
on some form of work with machinery so arranged
with some device as to administer massage for long
periods of time ; the patient became so absorbed in
his work that the pain was forgotten.
It was planned to have these hospitals form large
institutions, for they would need many of the most
skillful physicians, and many small units scattered
all over the country would take away too many sur-
geons and medical men from the civil population.
There was a lesson for industry in these plans for
the rehabilitation of cripples. Industry had paid too
little heed, as a rule, to the value of proper medical
service and supervision of its workmen and scarcely
any at all to the possibility of getting valuable serv-
ice from the work of men who had been crippled in
their employ, if properly trained. If the medical
profession made good in this vast work it was doing
for the Government, industry would be forced to a
realization of it, for there would be a labor shortage
after the war and it would be necessary to save every
man available.
The Technical or Educational Side of Curative
Work in Military Hospitals. — Major Michael
W. Murray, Sanitary Corps, National Army, classi-
fied the cases for curative reeducational work and
grouped with them the types of work for which
they would best be fitted. The problem could be
broadly stated as one of reestablishing the soldier's
citizen morale and of returning him to civil life
with such powers that he might again take his place
as an independent wage earner. It was impossible
to make a sharp distinction between the medical and
the educational phases of the problem. At the very
beginning it was wholly medical and surgical ; at
the end it had become in most cases entirely educa-
tional. The educator could perform a double serv-
ice in the work of reconstruction: First, assist the
medical officers in providing means of occupational
therapy ; second, readjust the soldier or sailor to the
requirements of civil life so that he might return to
independent wage earning with the brightest possible
future. Generally speaking, the best therapeutic
work would be that which aimed most directly and
most visibly at increasing the man's wage earning
capacity and at giving him a sense of increased
power in his social and occupational relationships.
The nature of the problem could best be illus-
trated by describing a few concrete cases of men
who had already returned from the front, and sug-
gesting a few of the things which could be done for
men while they were under medical and surgical
care. While the men were lying in bed thinking
about their future was the best possible time to
arouse their ambition, make them realize that more
would be accomplished by persistent effort than by
talent, and that there were diff'erent lines of en-
deavor in one of which each could accomplish all
he would. The following class of cases had been
discovered. Case I. Illiterate, native-born Ameri-
can, laborer, with latent talent to learn, who would
not in the future be able to accomplish any heavy
work. It was essential that this man should learn
the fundamentals of the three R's and this could
be started while he was still in bed. Case II.
Illiterate foreigner or native-born of foreign par- \
ents, laborer, low grade, apparently no desire to
learn. It should be. determined if he is subnormal
and, if not, every effort should be made to get him
started on the right road. Case III. Man with
less than common school education, formerly em-
ployed in unskilled or slightly skilled trades. Fair
native talent, realizing the need of more training,
desiring to learn and able to profit by opportunity.
Case IV. Man with common school education, be-
fore enlistment having begun in trade promising
advancement ; intelligent, willing to learn and physi-
cally able to progress in his old occupation. These
men could either be improved technically for their
own line of work, if physically capable of following
it, or they could be prepared for some other occupa-
tion related to it. If the cases so far surveyed were
any indication there would be no serious problem
of labor adjustment. Men unable to follow a trade
or technical occupation could most profitably be
trained for some clerical, commercial, or technical
occupation connected with it, thus not interfering
at all with labor conditions in those occupations.
Case V. The highly trained electrician, electrical
engineer, mechanical engineer, men who had held
positions of large responsibility. Some of the best
therapeutic work would be to allow such men to
teach and help their fellows in Class IV. With the
development of vocational, technical and tradr
schools in the country, men doing such work would
have gotten their first taste of teaching and many
teachers for these schools could be recruited from
this class. Case VI. The boy who left school at
fourteen and engaged in odd jobs as elevator run-
ner, messenger, etc. He needed to realize that he
must have more education to fit himself for a man's
job. This was a case for practical vocational guid-
ance. Case VII. The farmer or farm hand with
a common school education caring for no other oc-
cupation, but unable to do much of any farm work.
They could make a good living on their own farms
or as superintendents for others when trained to
use their heads instead of their hands and backs,
through study of the scientific side of agriculture,
simple practical farm accounts and business man-
agement.
178
I'KOCEEDIXGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
These were fair examples of the principles which
would have to be followed in these classes of men.
The educated man provided no such problem ; he
naturally worked more with his head than with his
hands and followed some line of commercial work,
accounting, salesmanship, teaching, and the other
professions. It would be seen from these cases that
the work presented a great human problem which
neither the medical man nor the educator could
solve alone. It was a continuation from the point
at which the public school work had left off. It was
not, however, a simple matter of continuing public
school education, as it was ordinarily understood.
There would be needed for such work occupational
therapeutists who had a wide knowledge of all
phases of education, acquaintance with industrial de-
mands and opportunities, familiarity with labor con-
ditions, knowledge of educational means and possi-
bihties, wide experience in educational administra-
tion, especially with the newer phases of education,
as commercial, agricultural, vocational and technical,
knowledge of psychology, pedagogy, and the realiza-
tion that in a broader sense the work was all part of
the medical problem and that the soldier was not
truly cured until he was back at work.
Dr. W. Gii^i- W'ylie expressed his particular in-
terest in the work outlined this evening because of
his recollections of the effect of the Civil War. It
had been stated that the needs of this war being met
by the work and resourcefulness of the medical
profession would redound to the benefit of the civil
population after the war. After the year 1865 there
was certainly an improvement in the condition of
the sick and poor through the sanitary laws which
grew out of that conflict. A little later came an
end of the habitual bad work done in the hospitals.
Antiseptics were just beginning to be known and, up
to that time, there had never been an ambulance to
bring the sick to the hospitals. While the speaker
was still an intern in Bellevue the State Charities
.A.id Association was formed, and that was the be-
ginning of a training school for nurses in this
country ; not only did it enhance the value of the
hospitals in caring for the sick, but the presence of
highly trained, efficient, and refined women vastly
im])roved the morale of the entire atmosphere. From
that time their beneficent influence had been at work.
Dr. Reginald H. Sayre alluded to the fact that
a certain number of corporations, particularly a
large railroad with a terminus in this city, had made
a practice of caring for those workmen crippled in
their employ, by giving them work well within their
ability to perform and paying them the same wages
as men not so disqualified received for the same
duties. They earn their living and did their work
in as satisfactory manner as any one else. There
would have to be a change in the workmen's com-
pensation laws, and this was of vital importance be-
cause, at the present time, many corporations were
doubtful about giving positions to any one with any
disability or illness because they felt if he got sick
or injured in their employ the disability he had to
start with would add to the employer's financial
responsibility. The subject of changing these laws
would doubtless have to be considered very soon.
That which Doctor Wylie had said about condi-
tions after the Civil War was true. The speaker
remembered as a bo}- that it seemed to him every
street corner had an armless or legless man grinding
an organ, the pennies he collected forming his living.
The work that was referred to by the speakers of
the evening would prevent that. The idea was an
excellent one of giving these cripples work to do
that at the same time acted in lieu of curative gym-
nastics. It was in line with that plan so frequently
resorted to of giving children with spastic paraplegia
jackstones to plav with ; with mind absorbed and oc-
cupied with accomplishing something, there was no
drudgery attached to the exercise.
Captain S. A. Knopf expressed his particular
interest in the very difficult problem of finding suit-
able work for the tuberculosis patients to do.
Lieutenant Russell, of Port Jefferson, said that
most of the young men joining the army had been
haunted by what they had heard of crippled soldiers
and sailors after the Civil War and were conse-
quently discouraged. It would seem a very desira-
ble idea to publish this plan widely so that those
young men thinking of enlisting would have oppor-
tunity to know what the Government intended to do
for them in case they were disabled. It was an ex-
cellent development and it encouraged a recruit to
know that if he lost his life, his people would be
provided for ; if he did not lose his life, but became
disabled, the Government would aid him in every
way to return to civil life a self respecting, self sup-
porting, efficient, and valuable member of the com-
munity.
Major P. B. Magnuson replied to Captain Knopf
that the reconstruction of a tuberculous man was
considered just as important by the Government as
of one who had lost his arm or leg. The tubercu-
lous would not be given anything to do that was not'
v-onducive to cure ; but would be sent to a special hos-
pital in a suitable climate ; there to work under the
supervision and guidance of a man familiar with his
needs, preferably out of doors. There was at pres-
ent some idea of keeping these patients quietly rest-
ing out of doors all the time for a while, using no
energy whatever and not until the case could be con-
sidered to be arrested would the patient be given
work and then he would be tried out very slowly.
There would be two outcomes of this Govern-
mental plan ; there would be no cripples from the
ranks playing hand organs on the corners and it was
to be hoped no more turning out of industrial plant
cripples with a few thousand dollars which would
be taken away from them in a year or two leaving
them a burden on the State or begging their daily
bread. The war would come to a close, but industry
would go on. There was no reason why industrial
cripples should not be cared for. They were in the
ser\'ice of the Government as well as the soldier and
sailor, they produced the things they ate, the things
they wore and used every day, and the slight cost
of reeducating them was their due.
Major M. W. Murray in closing wished to em-
phasize that this reeducational work should be begun
very early, as soon as the doctors pronounced the
man able to do something sitting up in bed. A great
deal could be done at that time with proper hospital
apparatus. Starting with that thin edge of the
wedge the education could be increased under medi-
cal supervision.
July 27, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
179
PHILADELPHIA COUNTY MEDICAL
SOCIETY.
Regular Meeting Held April 34, ipi8.
The President, Dr. Frank C. Hammond, in the Chair.
SYMPOSIUM ON THR ANEMIAS.
The Recognition and Treatment of the Anemias.
— Dr. Alfred Stengel said that when we summed
up all cases of anemia there would be relatively few
of the socalled primary anemias and a great many
of the form termed secondary anemia. The second-
ary anemias or the simple anemias, analyzed from
the standpoint of cause, might be grouped under:
I, infections; 2, those following hemorrhage, mani-
fest or concealed ; 3, those due to some form of in-
toxication. While lead was the recognized form of
poisoning, in these days new poisons were being
encountered, and cases, such as had been termed
pernicious anemia, might be due to TNT poison-
ing ; 4, parasitic anemia ; 5, anemias that were ex-
pressive of some deep seated, perhaps, overlooked
neoplasm.
Infection was probably the cause of the great
majority of anemias that we saw in ordinary prac-
tice and those cases were mainly important where
the infection was not manifest. Young boys and
girls who were anemic were treated with iron and
arsenic ; they improved, only to relapse. Was there
here a constitutional tendency to anemia ? W^e had
failed to recognize the cause of the anemia in these
cases. We could recall cases of anemia in young
women and boys with valvular lesions of the heart.
They had a chronic infection and they literally ate
iron and were thus kept in a reasonably good condi-
tion of health. Young persons with large cystic in-
fected tonsils were constantly relapsing to an anemic
condition because the infection was allowed to re-
main. The attitude of practitioners had been all
wrong in this connection.
In the posthemorrhagic anemias there were the
open and the concealed hemorrhages, and in the lat-
ter instance a mistake in diagnosis was not unlikely
to be made. The longer an anemia lasted the more
it approached in its clinical appearance a pernicious
and aplastic anemia. The bone marrow became ex-
hausted and the patient's appearance was that of
pernicious anemia. In such a case, although the
cause of the anemia might be removed, the patient
did not get well ; the anemia habit was established ;
the blood regenerating function was absent, and
while the blood did not show the characteristics of
pernicious anemia the patient was anemic until he
died. The question of treatment was not so much
concerned with the form of iron and arsenic that
was used as in finding and removing the cause ; sur-
gically, if focal. Transfusion was indicated in acute
anemia due to loss of blood. Splenectomy was one
of the most valuable adjuncts that had been discov-
ered in the treatment of certain types of anemia. It
was, however, a very serious procedure.
The Value of Splenectomy in the Treatment of
Some of the Anemias. — Dr. John B. Deaver said
that the leading indication for splenectomy was
probably traumatic injury. Inspection would soon
indicate whether or not the organ should be removed.
Injury to the hilus without doubt demanded removal.
A slight wound of the cortex might be treated con-
servatively by some .surgeons, but if there was any
doubt, removal was the safer course. Neoplasms
of the spleen were rare, but they demanded splenec-
tomy, unless there was evidence of metastasis. Wan-
dering spleen was often associated with splenic en-
largement. It might be treated by s])lenopexy or
splenectomy, according to the case.
A more common condition of enlargement was
that due to Banti's disease. While we did not defi-
nitely know its etiology, we did know that remov-
ing the spleen had obtained a cure in a great many
instances. Some recoveries had been reported by
operation in the later stages of the disease, but the
operation was attended with great risk ; early opera-
tion had been attended with such good results that
it should be resorted to without hesitancy.
The mortality appeared to be about eleven per
cent. We were told that the best results of splen-
ectomy were obtained in the treatment of hemolytic
jaundice. Eliot and Kavanel in forty-eight cases
collected in 191 5 reported only two deaths, a mor-
tality of 4.2 per cent. Krumbhaar in 1916 had col-
lected 156 cases of pernicious anemia treated by
splenectomy with thirty deaths. The Mayo Clinic
reported thirty-one splenectomies for ])ernicious
anemia up to April i, 1916, with three deaths, or
9.7 per cent, mortality. Of the survivors, twenty-
two, or seventy-eight per cent., showed continued
improvement ; of sixteen followed up for six
months, eleven continued to improve and three had
relapses. From the experience of the Mayo Chnic
it appeared that splenectomy for the relief of per-
nicious anemia should be considered in youthful and
middle aged subjects showing good general resis-
tance and where splenic enlargement was moderate
and there was evidence of hemolytic action. The
degree of hemolytic activity was estimated by the
blood pigments, urobilin and urobiHnogen in the
duodenal contents. A comparison of the degree of
hemolysis with the severity of the anemia seemed
to indicate the degree of productive power of the
bone marrow. Hemoglobin below thirty-five per
cent., with erythrocytes less than 1,500,000, increased
the operative risk. An improvement in the blood
picture and in the general condition might be ob-
tained by preoperative blocxi transfusion. In a few
instances blood transfusion for postoperative re-
lapse had been successfully employed in the Mayo
Chnic, but it had not been adopted as a routine pro-
cedure.
The treatment of pernicious anemia by splenec-
tomy was still on trial and was apparently merely
palliative. There was, however, reasonable hope
for improved results. In the aplastic type of the
disease splenectomy was contraindicated. Splen-
ectomy was also contraindicated in leuceniia. In
at least one operated case of Banti's disease the pa-
tient had lived comfortably for several years, dying
later of hematemesis. Operations in late Banti's
cases in the presence of ascites had been attended
with good results. The few cases of jiernicious
anemia which had been operated, had shown the
same fluctuations of improvement and relapse which
seemed to characterize the condition.
Blood Transfusion in Infants. — Dr. Harry
Lowenburg called attention to a method of blood
l8o LETTERS TO THE EDITORS.— BOOK REVIEWS. „ [New York
'■'^ Medical Jourkal.
transfusion in infants. Within the last month he
had on three occasions effectually done a transfu-
sion in the longitudinal sinus through the inferior
fontanelle. In one referred case the child was six-
teen months of age with a hemoglobin of thirty i>er
cent, and 1,560,000 red cells. The case was studied
along the lines suggested by Dr. Stengel. The baby
had had bloody stools for about a year. It was not
determined whether this condition was responsible
for the anemia or was caused by it. As a last re-
sort transfusion was tried. The hemoglobin had
been raised to sixty-five per cent, and the erythro-
cyte count to 4,800,000. The child had had no
bloody stools since the first transfusion. Attention
was directed to the procedure as a valuable but much
neglected means of intravenous medication.
^
Letters to the Editors.
EIGHT HOUR DAY FOR PHYSICIANS.
Bar Harbor, Maine, July 17, iQiS.
To the Editors:
The Labor Board deserves credit for establishing as
law, a great democratic principle : the right of the lowest
grades of self supporting men to fix minimum hours for
a day's work. Doubtless this board will further distin-
guish itself by fixing the maximum wage for the smallest
output.
By such acts is progress encouraged? Especially for
preparedness for war? The dominant political group has
always made that their chief objective. To be sure the
nation might well expect some such action since rumors
are rife of strikes, for no valid reason, to prepare the
public mind.
Why should not the profession of medicine collectively
take steps to limit their hours of work? They would be
amply justified since the young and robust physicians are
■"volunteering rapidly and the older men must kill them-
selves in behall of ailing humanity. This obligation, how-
ever, they cheerfully accept. Why is patriotism confined
to professional groups and (practically) repudiated by la-
borers— except they be able "to get away with it" by rea-
son of overwhelming power of voting? Who encourages
them in this? J. Madison Taylor, M. D.
^
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Interpretation of Dental and Maxillary Rbntgeno grams.
By Robert H. Ivy, M.D., D.D.S., Major, Medical Re-
serve Corps, United States Army; Associate Surgeon,
Columbia Hospital, Milwaukee ; Formerly Instructor in
Oral Surgery, University of Pennsylvania. With 259
Illustrations. St. Louis : C. V. Mosby Company, 1918.
Pp. I.J4.
Following an illustrated section on the anatomy of the
jaws and the accessory pneumatic sinuses and their nor-
mal X ray appearances, there is a most valuable section
descriptive of oral diseases and injuries. Stereoscopic
dental radiography is very well explained and also a con-
venient device for viewing the two films in a stereoscope.
Localization bv means of a comparison of two radio-
graphs made from different directions is explained.
This method is often useful in determining the position
of an uneri'iited upper canine. .A. single radiogram does
not always enjihle one to say whether the canine lies at
the palatal or the labial aspect.
A special feature of the book is seventy-three pages of
radiographs illustrating normal and pathological condi-
tions and classified regionally. Each radiogram is accom-
panied by a description of the diagnosis and in prac-
tically all cases the author had an opportunity to con-
firm t!ie diagnosis operatively. This section includes sev-
eral radiogr;;ms made with the plate at the side of the
face and showing especially unerupted or horizontally
impacted v.isdom teeth and fractures of the jaw. All of
the text is valuable and well expressed. Many of the
illustrations are excellent and even in those not quite so
clear, the reader is al>le to verify the accompanying diag-
nostic notes.
The book forms a handsome volume, and while it does
not enter into x ray technic except as noted above, it does
afford an admirable guide to diagnosis based upon dental
radiograph}'.
An X Ray Atlas of the Skull. By A. A. Russell Green, M.
B. , B. S. (Lond.), M. R. C. S. (Eng.), Captain, R. A. M.
C. (T.) ; Radiographer to Birmingham Skin Hospital
and Birmingham Board of Guardians, etc. With Five
Colored Plates and a Table Showing Relations Between
Displacement of Shadows and Distance of Bodies
Throwing Those Shadows. New York, Bombay, Cal-
cutta, and Madras : Longmans, Green & Co., 1918. Pp.
x-27. (Price, $3.50.)
A slender but most attractive book and especially useful
as a guide to the x ray localization of diseases or injuries
of the skull, pneumatic sinuses, or brain, and the localiza-
tion of bullets or other foreign bodies. A valuable table is
given showing the distance of the foreign body from the
surface as indicated by the displacement of the image
when two radiographs are made from a tube distance of
fifty centimetres and a tube displacement of ten centi-
metres. Radiographs of the living head from a number
of standard directions are given, and then follows the dis-
tinctive feature of the book. This is a set of radiographs
of the dried skull in which one side is empty and the other
has been so treated as to demonstrate the anatomy with
extraordinary clearness. Sutures are outlined with wire,
some structures are covered with tinfoil, the sinuses are
injected with a mixture of paraffin wax and bismuth, and
in the fresh specimen the blood vessels have been injected
with mercury. The resulting radiographs are printed in
about eight colors and form charts which combine beauty
with utility.
^
Births, Marriages, and Deaths.
Died.
Day. — In Port Norris, N. J., on Friday, July 12th, Dr.
F. Thomas Day, aged fifty-eight years.
DoYLi;. — In Philadelphia, on Saturday, July 6th, Dr. John
J. A. Doyle.
Hoi.T.--In Webster, N. Y., on Monday, July 8th, Dr. N.
Curtice Holt, aged sixty-five years.
Karniol. — In New York, on Monday, July 15th, Dr.
William Karniol, aged forty years.
Kappas. — In France, on Monday, June 24th, Major Mor-
ris Jacob Karpas, Medical Reserve Corps, U. S. Army, of
New York, aged thirty-eight years.
Mi-NDKL. — In New York, on Saturday, July 13th, Dr. A.
A. Mendel aged fifty years.
MicRCKK.L. — In New York, on Tuesday, July i6th. Dr.
Gottfried Merckel, aged fifty-one years.
Mi RLDiTH.— In Philadelphia, on Friday, July 12th, Dr.
Samuel C. Meredith, aged sixty-three years.
MoRAssf;. — In Norwich, Conn., on Sunday, June 30th,
Dr. Louis Ovid Morasse, aged fifty-nine years.
Mi'RRAY. — In Bellows Falls, Vt., on Thursday, July 4th,
Dr. George G. Murray, aged forty-two years.
M^ i RS.— In Milwaukee, Wisconsin, on Tuesday, July 2d,
Dr. Albert William Myers, aged forty-six years.
Rathiu'N. — In Washington, D. C, on Tuesday, July
i6'.h. Dr. Richard Rathbun, aged sixty-si.x years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journahht Medical News
A Weekly Review of Medicine, Established 1 843
Vol. CVIII, No. 5. NEW YORK, SATURDAY, AUGUST 3, 1918. Whole No. 2070.
Original Communications
OP.HTHALMIC CHANGES IN TABES AND
PARESIS.
Recent Pathology and Diagnosis, With Reference
to Cerebrospinal Syphilis; 122 Cases.
THE LUCIEN HOWE PRIZE PAPER.*
By I. S. Wechsler, M. D.,
New York,
Instructor in Neurology, Columbia University; Chief of Clinic,
Second Neurological Division, Vanderbilt
Clinic, New York City.
(From the Department of Neurology, Columbia University.)
INTRODUCTION.
The great amount of study which has been de-
voted to the ophthahnic disturbances in tabes, gen-
eral paresis and meningovascular neurosyphilis and
the voluminously compiled facts observed as to
symptoms, incidence, etc., seemed to make the subject
a closed chapter. So well, in fact, have statements
come to be accepted that it would have seemed naive
heresy, for instance, to question the primary, purely
degenerative nature of the optic atrophy in tabes.
But, as far back as 1902, Keraval and Raviart
pointed out that optic atrophy in tabes and general
paresis was not a simple, primarily degenerative
process, while Marie and Leri, 1904, sought to bring
this conception a step further. The work of both
fell on unreceptive soil. Stargardt, in 1913, ex-
haustively studied the subject and not only con-
firmed the work of Marie and Leri but altogether
denied the existence of purely degenerative pro-
cesses in tabes and paresis. Schoenberg in this
country in 1916 called attention to the above in-
vestigations and added his own study, pointing to a
newer concepti'on. I shall refer to their work in
greater detail later.
Other events served to alter in part our concep-
tion of syphilis of the nervous system and the neu-
rology of the eye. The discovery of the spirochete
and the synthesis of arsenobenzol revolutionized
etiology and therapy, while to the work of Schau-
dinn and Ehrlich was added the intraspinal treat-
ment initiated by Swift and Ellis. The routine
examination of the spinal fluid made possible by the
work of Quincke, and, later, the epoch making re-
searches of Wassermann, followed by the investi-
gations of Ravaut and finally Lange-Szigmondi,
added to the refinement of diagnosis. The investi-
gations of Moore, Noguchi and Levaditi fixed the
'Awarded the Lucien Howe Prize by the Medical Society of the
State of New York, at Albany, May 20, 1918.
guilt upon the heads of the spirochetes as the direct
etiological culprits in tabes and paresis. The lucid
distinction of Head, in 1914, on embryological
grounds, that is, parenchymatous and interstitial or
vascular involvement, or ectodermal and meso-
dermal lesions, also served to clarify the subject.
riTE PROBLBM.
In view of recent investigations it is evident that
the pathology of optic changes in tabes and paresis
does not present the finality which, for instance,
Uhtofl: and Wilbrand and Saenger give to it. There
are three questions to be considered: i. Are the
pathological changes in tabes and paresis giving rise
to ocular manifestations fundamentally different
from those occurring in interstitial meningovascular
syphilis ? and 2, are the lymphocytosis, plasmocytosis,
and other inflammatory changes absent in tabetic and
paretic eye palsies and optic atrophy and present
only in so called cerebrospinal syphilis? 3. Is the
process on the one hand primarily degenerative and
on the other consequent upon inflammation? To
all these questions a negative answer must be given.
There is an etiological identity and pathological
similarity in all syphilitic processes, be they paretic,
tabetic or so called cerebrospinal syphilitic, and an
attempt will be made to prove this in the discussion
of the pathology.
In the opinion of the writer, syphilis is one con-
tinuous disease, and while for convenience of clas-
sification one may speak of a primary, secondary,
tertiary, or even quaternary, or the old meta and
parasyphilitic stages, from the standpoint of pa-
thology there is no fundamental difference between
them. The difference, if any, lies in the reaction
of the structures of the body at various periods
after infection or in the varied action of the spiro-
chete after numerous vicissitudes in the body. It
may safelv be argued that the underlying patholog-
ical process of any syphilitic lesion, whatever its
chronological manifestation, is essentially of one
character, differing only in degree at various times
and under various conditions, and depending upon
the structures involved. Thus, while in socalled
cerebrospinal syphilis the vascular, inflammatory,
exudative process overbalances the degenerative
changes, in tabes and paresis the latter is more
marked and often completely overshadows the
former.
As the term cerebrospinal syphilis is often mean-
ingless and frequently confusing, I shall employ the
term interstitial or meningovascular neurosyphilis.
Copyright, 1918, by A. R. Elliott Publishing Company.
1 82
WECHSLER: OPHTHALMIC CHANGES IN TABES AND PARESIS.
[New Yoric
Medical Journal.
The terms paretic, tabetic, meningovascular or dif-
fuse, etc., neurosypliilis, as classified by Southard
and Solomon are much better. To avoid confusion,
however, it will be necessary occasionally to employ
the common designation, cerebrospinal syphilis.
The object of this paper, of course, is not to
discuss the whole subject of the pathology of
syphilis but only that part which bears on the neu-
rology of the eye. While, unfortunately, I have
no original pathological sections, I have brought
together facts recently gathered and shall discuss
the ophthalmic changes in tabes and paresis from
the point of view of more modern pathology. I
have collected 122 clmical cases and, in reviewing
their various ocular symptoms, will compare them
with previously gathered data, at the same time lay-
ing stress on the diagnostic dififerentiation from eye
changes occurring in cerebrospinal syphilis.
Enough has been said to outHne the aim of this
essay, but it may be well to point out that the influ-
ence on therapy will be far reaching if the opinion
is confirmed that the optic changes in tabes and
paresis are primarily inflammatory and degenerative
only secondarily.
OPHTHALMIC CHANGES IN TABES AND PARESIS.
With few notable differences, the eye symptoms
in paresis are practically similar to those occurring
Robertson pupil, while the average in cases culled
from literature is given as sixty-seven per cent. Nat-
urally, the per cent, incidence rises and falls with the
stage of tabes under observation, and a rigid pupil
as the only symptom may precede the onset of tabes
by years. How early pupillary changes are seen in
tabes is difficult to decide, some authors claiming
to have observed them even in the first year of the
infection. Mott gives 73.5 per cent. Argyll Robert-
son out of a series of 150 cases; three per cent, of
his cases gave unilateral Argyll Robertson, 3.7 per
cent, were sluggish to light and fifteen per cent were
inactive to light and accommodation. In my series,
3.2 per cent, showed internal ophthalmoplegia and
4.3 per cent, of cases had normal reaction while 8.7
per cent, gave sluggish reaction to light. In twenty
per cent, there is said to be a want of parallelism
in the intensity of rigidity in both pupils. The
Argyll Robertson pupil is said to be found in ten
per cent, of cases of interstitial neurosyphilis. Many
authors (Erb, Dejerine, Uhtoff, Oppenheim, Spil-
ler, and Camp) deem this in cerebrospinal syphilis
really due to a coexisting tabes. Loss of consensual
reaction runs parallel with rigidity to light, and
sometimes, loss of convergence accompanies rigidity
to light (in about twenty-five per cent.). Inter-
mittent pupillary rigidity has been claimed to exist
in tabes ; more Hkely it is due to interstitial syphilis
Size of pupil
Miosis
Thirty cases=32.6%
Anisocoria
Twenty-eight cases= 30.4% Three cases=3.3%
Mydriasis
Four cases=4.3%
Pupillary reaction
Argyll Robertson
Seventy cases=76%
Sluggish reaction
Eight cases=8.7%
Double internal oph-
thalmoplegia
Five cases=:5.4%
Unilateral internal and Normal size
external ophthalmo- Thirty-three cases=36%
plegia
One case=i%
One pupil A R and the
other normal
Two cases=:2.2%
One pupil A R and the other
internal ophthalmoplegia
Two cases=2.2%
Normal reaction
Four cases=4.3%
TABLE I (NINETY-TWO CASES OF TABES).
Showing Per Cent. Incidence of Eye Symptoms.
Shape of pupil Muscle palsies
Irregular Unilateral oculomotor
Thirty-six cases=39.i% Four cases=4.3%
Only one pupil irregular Unilateral abducens
Normal shape
Fifty cases=54.3%
Two cases=2.2%
Unilateral ptosis
One case = i-|-%
Optic atrophy
Complete bilateral
Twelve cases=i3%
Partial bilateral
Three cases=3.3%
Nystagmus
True nystagmus
One oase=i + %
Nystagmoid
Two cases=2.2%
in tabes. Thus, while one may get visual disturb-
ances in paresis due to involvement of the cortical
centres, a picture never seen in tabes, the main
character of the symptoms, their underlying patho-
logical condition, and their manifestation, are the
same in both diseases. Taboparesis, juvenile tabes
and juvenile paresis also show almost identical
clinical pictures and only minor characteristics will
have to be alluded to to show wherein they differ.
THE PUPIL.
Reaction. — While the Argyll Robertson pupillary
phenomenon very rarely occurs in other conditions,
it is practically pathognomonic of tabes ; its absence
however does not altogether militate against the
diagnosis. Seventy-six per cent, of my cases showed
the phenomenon bilaterally and four per cent, uni-
laterally (Table i). Of 300 cases quoted by
Uhtoff seventy-one per cent, showed the Argyll
or intoxications. Absence of accommodation and
the presence of light reaction has been observed in
tabes (Dejerine) but this is seen more often in
general paresis, meningovascular syphilis of the
nervous system and tumors of the colliculi.
"Springing mydriasis," that is alternating miosis
and mydriasis occurs rarely in tabes and is seen
more often in paresis. The socalled paradoxical pu-
pillary reaction has been observed in tabes and paresis
(Mott), although its existence is doubted by some
(Uhtoff). Piltz found contraction of the pupil on
forcible contraction of orbicularis in forty-one to
forty-three per cent, of cases of tabes. Hippus is
said to occur in tabes, but is neither common nor
diagnostic, and has significance only in a rigid pupil.
Its pathology is given as either cortical or quadri-
geminal irritation (G. Ludwig). Loss of reflex
sensory dilatation is common and early in tabes.
All the foregoing pupillary signs are much less
August 3, 1918.]
WECHSLER: OPHTHALMIC CHANGES IN TABES AND PARESIS.
183
common in paresis. In my cases of paresis only
36.7 per cent, showed an Argyll Robertson pupil,
thirty per cent, gave a sluggish reaction and twenty
per cent, were normal in both eyes. One case 3.3 per
cent, showed bilateral and one, 3.3 per cent., uni-
lateral internal ophthalmoplegia, while 6.7 per cent,
showed one pupil sluggish and the other normal
(Table II.).
per cent, of tabes and forty per cent, of paresis
showed normally shaped pupils. Besides irregular-
ity in shape, the pupil may be oval or eccentrically
situated. The explanation of the underlying pa-
thology of pupillary irregularity is neither sufficient
nor clear, thougli it is known that irritation of the
long and short ciliary nerve fibres (Pilt;',) gives
irregularity of outline.
TABLE II (THIRTY CASES OF GENERAL PARALYSIS).
Showing Per Cent. Incidence of Eye Symptoms.
Size of pupil Shape of pupil Muscle palsies Optic atrophy
Miosis Irregular Partial oculomotor Total bilateral
Four cases=i3% Fourteen cases=47% Onecase = 3.3% Onecase = 3.3%
Pupillary reaction
Argyll Robertson
Eleven cases=36.7%
Sluggish reaction
Nine cases=30%
Bilateral internal oph-
thalmoplegia
One case=:3.3%
Unilateral internal oph-
thalmoplegia
One case = 3.3%
One pupil sluggish and
other normal
One case=3.3%
Normal reaction
Six cases=2o%
Anisocoria
Nine cases=3o%
Normal size
Eighteen cases=6o%
One irregular and one
normal
Four cases= 13%
Normal shape
Twelve cases=40%
Partial bilateral
(temporal)
One case=:3.3%
Nystagmus
Nystagmoid
One case:=3.3%
Sisc. — The miotic pupil is very common in tabes
but is only significant in connection with rigidity. I
need only mention the arteriosclerotic pupil to show
how common it is in other conditions. Miosis
occurs in from twenty- four per cent. (Uhtoflf) to
fifty-two per cent. (Erb) of cases. In my series it
was found in 32.6 per cent. There need be no
parallelism between miosis and rigidity. The pa-
thology is not quite clear. Some think it is due to
a disturbance in the paths from the spinal centre ;
others to an irritating process in the fibres to the
sphincter pupilkie. (One can, of course, only sug-
gest that it is a vagotonic reaction of an irritative
character, as there is very good ground to believe
so from the general vagotonic reactions so com-
monly observed in tabes.) Anisocoria is equally
common and significant with miosis : it occurred in
30.4 per cent, of my cases of tabes. While in my
cases of paresis, miosis occurred in only thirteen per
cent., anisocoria occurred in thirty per cent. My-
driasis occurred in 4.3 per cent, of the tabes cases.
I found normal .-lize pupils in thirty-six per cent, of
tabetics and sixty per cent, of paretics. In so called
cerebrospinal lues the miotic pupil does not espe-
cially belong to the clinical picture. Inequality is
probably more common in paresis but altogether is
not of very great value ; it is seen in neurotics and
in diseases of the lungs, heart, and chest. Ob-
viously, unilateral involvement of the sympathetic,
from whatever cause, will give inequality of the
pupil.
Shape— -An irregular pupil is probably as fre-
quent in tabes as in paresis or general syphilitic in-
volvement of the nervous system. In fact, it is said to
be common in the very early stages of diffuse neuro-
syphilis. One must make sure, however, that an iritis
or an old synechia is not behind the phenomenon.
I observed irregular pupils in 39.1 per cent, of cases
of tabes and forty-seven per cent, of paresis. In
3.3 per cent, of tabes and thirteen per cent, of paresis
cne pupil only was irregular, the other normal ; 54.3
Pathology of pupillary reactions. — Some believe
that the pathological process causing light rigidity
lies in the gray substance of the third ventricle
(Pineles, Siemerling and Boedeker, von Monakow).
Marina found degeneration in the ciliary ganglion
and secondary degeneration of the short ciliary
nerve in all cases of pupillary rigidity. Uhtoff says
that, although nothing is certain, the probability is
thcit there occurs some break in the centripetal paths
to the oculomotor and accommodation nuclei. Fer-
rier in his "Lumleian Lectures : Tabes," as quoted
by Mott, says, "The probability is that the condition
which blocks the path of reflex pupillary contraction
blocks also that of psychoreflex dilatation." The
conscious voluntary accommodation occurs by
virtue of the central asscH:iation with the muscles of
conveigence through the impulse from the cortex
to the motoroculi. . The Edinger-Westphal nucleus
supplies the sphincter and the ciliospinal supplies
the dilator pupillse. The seat of the pathological
process may be in the synapses in the ciliary gan-
glion or there may be an interruption in the reflex
path to the Edinger-Westphal nucleus. The degen-
eration may be in the optic fibres (it is known that
there are -separate fibres for light reaction, some of
which cross in the chiasm) , or in their terminal arbor-
ization in the superior coUiculi, or in the associating
neurones from them to the Edinger-Westphal
nucleus (Mott). The anatomicopathological back-
ground of the pupillary phenomena is still ill under-
stood, as the existence of an accommodation centre
is only guessed at, not known.
A discussion of the histopathology will be de-
ferred for later consideration in the general treat-
ment of the pathology.
THE OPTIC NERVE.
Perhaps not so important from the standpoint of
diagnosis but surely more so from that of pathology
are the optic nerve changes in tabes and paresis.
So called pure, white, simple optic atrophy is said
WECHSLER: OPHTHALMIC CHANGES IN TABES AND PARESIS.
[New York
Me«ical Journal.
to be the badge of parenchymatous syphilis, and
every case of optic atrophy is the forerunner of
tabes, even if it takes twenty years (Charcot) to
develop.
Optic atrophy. — Tabetic optic atrophy is more
ccmmon in men. It is said to occur in ten to fifteen
per cent, of all cases of tabes. In my series of cases
I found 13.3 per cent, complete bilateral and 3.3
per cent, partial bilateral atrophy, that is, 16.6 per
cent, in all. It is more common in juvenile tabes.
Wilbrand and Saenger collected thirty-nine cases
from the literature, of which nineteen had optic
atrophy. Gowers mentions twenty-six cases of
optic atrophy out of 400 cases of syphilis, t. e., 6.5
per cent. Mott states that paresis shows four per
cent, of optic atrophy. Some claim that one never
finds this in pure cases of paresis, only in such as
are complicated by tabes, i. c, taboparalytics. I
found 3.3 per cent, complete and 3.3 per cent, partial
bilateral optic atrophy in paresis, or a total of 6.6
per cent.
Optic atrophy sets in most commonly in the pre-
ataxic stage (fifty per cent. — Wilbrand and Saen-
ger), and, when it does occur, usually is the first
symptom. In fact such cases of tabes usually run
a milder course. The so called formes friistes
(Charcot) or forme; bcnigncs (Babinski) belong to
this class. Some think that the advent of optic
atrophy and blindness stops the progress of tabes
(Benedict, Charcot, Gowers, Dejerine, Spiller,
Mott). Other authors disagree with this view
(Marie), but careful serological examination ought
to throw light on this point. Mott believes that
tabetics who develop optic atrophy are apt to de-
velop paresis, but Oppenheim and Wilbrand and
Saenger controvert this.
Fields. — One eye usually precedes the other in
loss of vision, though the fact is often not discov-
ered until the second is involved. Most authors
assert that pure hemianopsia is never seen in tabes,
though symmetrical degeneration may simulate the
picture; the periphery of the other half is usually
also involved, though Stargardt denies this dogmatic
statement {v. ?'.). It is claimed that whenever a
hemianopsia is found in tabes an interstitial lues
involving the chiasm or tract complicates the picture.
Central scotoma are rare in tabes, and, when found,
are the result of complications, such as interstitial
syphilis, toxic amblyopia, etc. (UhtofY). Stargardt
quotes fourteen cases from the Breslau Clinic,
showing the presence of scotoma in tabes. Fuchs
reported thirty cases of scotoma (quoted by Star-
gardt). There is generally found first, peripheral
contraction of fields for colors, first for red, then
green, blue, and yellow and finally for white, and
secondly, cases which show partial defects of the
field with other parts perfectly normal.
Course. — The progress of the optic atrophy is
usually slow and gradual. The visual disturbances
usually begin with defects in color perception, de-
fects in fields of vision, and diminished central
vision. At first there is blurring, cloudiness, flashes
of light, seeing red and green. The patient may be
unaware for a long time of his condition. One eye
may precede by months the blindness in the other,
and, in many cases, vision is much better after the
eye has been completely rested for hours in the
dark; possibly because the few healthy retinal
ganglion cells have a chance to renovate the visual
purple. Sudden blindness in tabes is probably due
to destruction of the masculopapillary bundle
(Mott). It usually takes two or three years for
complete blindness to set in : the minimum is said to
be two to three months; the m.aximum twelve years
(Uhtoff). Dejerine gives the time as six to eighteen
months for completion of the optic atrophy. Tabetic
optic atrophy "always ends in blindness" (Uhtofif).
While this may have been true in the past there is
reason to believe that it will not be so in the future.
Ophthalmoscopic findings. — The disk is grayish
or whitish, the vessels are usually normal, the mar-
gins sharply outlined. There may be atrophy of the
disc and no visual or field disturbances for some
time, but less often disturbances without opthalmo-
scopic changes. Neuritic changes are not found in
tabetic atrophy, though they have been reported
(Wilbrand, Oppenheim). The cupping of the
disc is not a significant sign (Uhtoff). Neverthe-
less, there may be no disc changes, despite positive
disturbances of vision and irregularities in fields.
Wilbrand and Saenger quote ten cases (with au-
topsy) which showed no objective findings during
life and yet revealed degeneration on microscopic
study.
EYE MUSCLES.
It is difficult to determine the incidence of muscle
palsies in tabes and paresis. Most tabetic eye muscle
paralyses are fleeting, their existence often brought
out only through a history of double vision. Uhtoff
speaks of twenty to twenty-two per cent, of tabetics
having disturbances of eye muscles, Erb gives thirty-
eight per cent., v. Leyden and Goldscheider forty
to fifty per cent., and Mott about fifteen per cent.
In my series of cases I found only 7.5 per cent., and
if to this is added 7.6 per cent, of complete internal
ophthalmoplegia then the series shows 15.1 per cent
The oculomotor is most commonly involved (Erb,
Fournier, Charcot, Gowers, Wilbrand and Saenger,
Mott, Nonne), either partially or completely, thus
earning for itself in tabes also the deserved appella-
tion, la signature de la verole, given to it by Fournier
and Ricord. The abducens is next most common and
trochlearis last. As for the fourth nerve, it may be
remarked that detection of its involvement is par-
ticularly difficult and often escapes detection by the
neurologist, if not the ophthalmologist. Palsies are
by far less common in paresis ; in my series only
3.3 per cent. Kraepelin speaks of eighteen per cent,
of transitory palsies.
Clinically, the palsies are partial, incomplete, fleet-
ing, and changing, while total third nerve paralysis
is uncommon. Usually it is unilateral; if bilateral,
one thinks rather of a basal meningitic involvement.
The levator palpcbr^e is the most common single
muscle afifected. Ptosis is more common in the
early stages. In paresis, ptosis is relatively uncom-
mon compared to internal ophthalmoplegia (Wil-
brand and Saenger), which is equally true of other
eye muscle palsies in paresis. Incidentally, atrophy
of the optic nerve with psychic symptoms, in tabes,
is more common in connection with eye muscle
palsies than without them. Isolated ptosis and ab-
ducens paralysis are said to be common. Complete
external ophthalmoplegia alone is not common. Ab-
August 3, 1918.]
WECHSLER: OPHTHALMIC CHANGES IN TABES AND PARESIS.
185
ducens paralysis is usually transient, rarely bilateral,
always nuclear. Transient ptosis is not rare in
early tabes, while palsies of associated movements
are rarely, and according to Oppenheim never, seen
in tabes. Diplopia, of course, is a common symptom.
Most muscular palsies occur early in tabes (Char-
cot, Gowers, Westphal, Wilbrand and Saenger,
Uhtoflf, Mott, Nonne) and are fleeting; those that
remain stationary come later (Oppenheim). Re-
curring paralyses are not uncommon. The duration
of the palsy may be from hours to days, months, or
even years.
Pathology. — All authors agree, and stained sections
show, that we deal with a nuclear degeneration.
The roots are said to be secondarily degenerated, al-
though they and the nerve may be primarily degen-
erated (Dejerine). Spiller demonstrated the pres-
ence of inflammation in the nerves in tabetic eye
palsis, and found lymphocytic infiltration in the pia
of the nerves. Thickening of the ependyma over
the aqueduct and fourth ventricle without nuclear
degenerations has been observed in tabetic muscular
palsies. Microscopically, the ganglion cells are
broken down in varying degrees, some cell bodies
disappear, others are small and shrunken and with
broken endings. Some cells show vacuolization.
The fibres gradually disappear. There is an in-
crease in neuroglia. Vascular changes are rare
{v. i.). In the nerve the myelin sheath is found
broken down and axis cylinder very thin, and both
may be completely atrophied. The connective tissue
is increased, the nuclei proliferated. (Despite
which, Uhtoff says there is no proof of an actual
neuritic process.) The transitoriness of the paraly-
ses is explained by some on circulatory grounds,
while Wilbrand and Saenger are of the opinion that
there is actual restitution of destroyed substance.
Nystagmus. — Actual nystagmus is very rare in
tabes, and, when found, should always suggest com-
plication. Nystagmoid movements are more com-
mon and supposedly are due to weakness of the eye
muscles. I found 1+ per cent, nystagmus and 2.2
per cent, nystagmoid movements in tabes, and 3.3
per cent, in paresis. Mott gives four per cent, in
tabes. Charcot spoke of an ataxia of the eye mus-
cles, but Uhtofif denies this. The anatomical se.at
of the lesion, if there be any, is not known.
Keratitis and ophthalmia ncuroparalytica arc
very rare in tabes, and, according to Uhtofif and
Wilbrand and Saenger, hardly ever found. The
same is true of herpes zoster ophthalmicse. Sensory
changes in the region of the trigeminus are not
common, nor are neuralgias. The pathology of
keratitis ncuroparalytica is a degeneration of the
descending sensory root in the bulb, or the sensory
nucleus and the nerve roots. Epiphora occurs, but
is rare in tabes, thougli it may come on in crises,
this probably due to irritation of the fifth and, pos-
sibly, the seventh. Paralysis of the branches of the
sympathetic have been observed. All of the above
symptoms are, of course, to be found more com-
monly in interstitial neurosyphilis.
OPHTHALMOPLEGIA.
Isolated chronic progressive ophthalmoplegia is
most commonly found in tabes and next often in
paresis. Unlike muscular paralyses it is usually not
recessive. Total ophthalmoplegia — that is, internal
and external — according to Uhtoff, occurs in two per
cent, of cases, according to Wilbrand and Saenger in
seven per cent. I found unilateral internal ophthal-
moplegia in 3.2 per cent, of cases, bilateral internal
ophthalmoplegia in 5.4 ])er cent., and complete in-
ternal and external in per cent, in tabes,
while in paresis I found 3.3 per cent, unilateral and
3.3 per cent, bilateral internal ophthalmoplegia.
Optic atrophy accompanies the ophthalmoplegias in
thirty per cent. The very presence of primary optic
atrophy occurring in ophthalmoplegia speaks for
tabes or paresis. Pupillary changes in shape, size,
and form frequently accompany ophthalmoplegias,
also occasional facial and trigeminal paralyses.
Very naturally, accompanying bulbar symptoms
speak rather against tabes and paresis and for dif-
fuse neurosyphilis.
Pathology. — Degenerative changes have been
found in the nuclei and nerve roots supplying the
eye muscles as well as the peripheral nerve
branches. It is said that degeneration begins in the
nuclear regions, or, at least, is more intense there
than in the roots and nerves. Sometimes, however,
the peripheral nerves alone are degenerated and not
the nuclei (Oppenheim, Dejerine, Spiller). The
cells in the nuclei are shrunken, granular, degener-
ated, or vacuolated. The fibres arc rarefied and the
glia is increased. Small hemorrhages and diseases
of bloodvessels have been found to account for the
degenerations. Ependymal changes in the aqueduct
and the floor of the fourth ventricle are rarely en-
countered. Peripherally the nerve fibres are found
atrophied, the sheath and axis broken down. Lym-
phocytosis has been found in the nerves. The con-
nective tissue may be increased. The muscles them-
selves show atrophy of fibres, degeneration, in-
crease of nuclei, and at times even hypertrophy of
some fibres (Oppenheim.).
A few eye symptoms are found in paresis which
are never seen in tabes. In epileptiform seizures,
so common in paresis, one occasionally sees con-
jugate deviation of the eyes. So, too, paretic mi-
graine may be accompanied by transitory hemi-
anopsia, transitory strabismus, ptosis, and diplopia,
and while it may be difficult to demonstrate, a
paretic lesion of the calcarine fissure, occipital lobe,
or optic radiation may give homonymous hemi-
anopsia. Alexia may result from a lesion in the
angular g}'rus. These symptoms may occur in
gumma of those regions and indeed the difficulty of
diagnosis may be very great. The .symptoms ac-
companying parenchymatous neurosyphilis as con-
trasted with those occurring in interstitial neuro-
syphilis will, however, serve to help in the diflferen-
tiatioiL Visual hallucinations may be mentioned as
occurring in paresis and. though rarely, even in
tabes and taboparesis.
DTAGNO.SIS.
In attempting to dififerentiate tabetic eye symp-
toms from other conditions one usually considers
meningovascular neurosy]>hiHs (cerebrospinal lues),
pseudotabes, alcoholic amblyopia and pseudotabes
alcoholica, combined sclerosis of the posterior and
lateral columns, hereditary ataxia and syringomyelia.
Leaving out those of lesser importance, I shall
limit the dififerential diagnosis to tabes and so called
cerebrospinal syphilis.
186
WECHSLER: OPHTHALMIC CHANGES IN TABES AND PARESIS.
[New York
Medical Journal.
Although rare, tabes may supervene on an inter-
stitial, vascular neurosyphilis, making a mixed clini-
cal picture so far as the eye symptoms are con-
cerned, which renders the diagnosis somewhat more
difficult. In such cases the general neurological
signs, particularly those referable to the cord, will
have to be taken into consideration. Generally
speaking, the clinical picture of tabes comes on late
in the infection — eight to fifteen years; interstitial
lues more commonly early in the disease — one to
three years. In tabes, optic atrophy is more com-
mon, and the condition usually progresses to com-
plete blindness. Total bilateral optic atrophy hardly
ever appears in interstitial vascular neurosyphihs
(Uhtoff, Mott, Wilbrand, and Saenger). In the
latter we always deal with an active retrobulbar,
inflammatory, neuritic process causing so called de-
scending optic atrophy.
The visual fields in tabes differ from those found
in optic neuritis. Central scotoma due to direct
involvement of the maculopapillary bundle are very
common in neuritis, and so is hemianopsia ; while
irregular or concentrically contracted fields are the
rule in tabes. Bitemporal hemianopsia does not at
all belong to the picture of tabes. Optic neuritis
is not infrequently unilateral throughout the course
of interstitial neurosyphilis. Ophthalmoscopically,
vascular changes and an inflammatory condition of
the disc in neuritis, and a sharply defined margin
and normal vessels in tabes, are often found.
Of course, a syphilitic meningitis behind the
chiasm (optic tracts, etc.) will not give any in-
flammatory disc changes even in neuritis. Visual
disturbances without ophthalmoscopic findings are
not uncommon in cerebrospinal lues, and are ex-
ceptional in tabes. Isolated optic neuritis without
complications is rare in interstitial syphilis, while
optic atrophy alone, even for years, is not uncom-
mon in tabes. Complications of the basal cranial
nerves and other localized affections point away
from tabes. Choking of the disc caused by a
gumma, obviously, is never encountered in the latter.
Paralysis of the eye muscles are said to be far
less common in tabes, and involvement of the other
cranials is practic&lly unknown. It is difficult to
determine the exact incidence, as patients often give
a history of diplopia and show no palsies. Not
only are disturbances of eye movements less com-
mon, but they are not so complete, being transient
and fleeting; they show nuclear paralyses, isolated
palsies. As we deal with a basilar vascular menin-
gitis in interstitial neurosyphilis we often have
double paralyses of the third nerve, involvement
of all the branches, greater degree of paralysis, and
combination with visual disturbances not peculiar
to tabes. A superior crossed hemiplegia (Weber's
syndrome), symptoms referable to gummatous or
other involvement of the brain, of course, do not
belong to tabes.
Miosis is rare in cerebrospinal syphilis and pupil-
lary rigidity, that is, a true Argyll Robertson phe-
nomenon is said not to occur except in tabes and
paresis. Where the Argyll Robertson is found it
is justifiable to suspect a superadded tabes. Ac-
commodation is usually affected together with light
rigidity in interstitial lues, while the internal oph-
thalmoplegia not infrequently is accompanied by
involvement of other cranials. Involvement of the
trigeminal is very rare in tabes, and keratitis neuro-
paralytica is altogether wanting, and Horner's pu-
pillary sign is never seen. Wernicke's sign is also
unknown, as are symptoms referable to involvement
of the coUiculi or geniculate bodies.
Practically, the same conditions hold true in pare-
sis as in tabes. The cerebral conditiops caused by
gumma giving psychic symptoms, which may remind
one of paresis, will be diagnostically differentiated
by signs and symptoms peculiar to each condition.
Ataxia, of course, is not seen in interstitial neuro-
syphilis and spastic paralysis is not observed in tabes,
while loss of memory, gutting of the personality,
and euphoria are not seen in either. Finally, serol-
ogy offers an aid to diagnosis which is always
available. The blood is more often positive and the
cerebrospinal fluid more often negative in inter-
stitial syphilis than in tabes, while in paresis the
fluid is nearly loo per cent, positive. A colloidal
gold reaction, of course, goes with paresis and
speaks against interstitial neurosyphihs. All in all,
while cases occasionally do come up which offer
diagnostic problems, in the vast majority careful
analysis will make differentiation fairly simple.
PATHOLOGY.
Before discussing the more recent conceptions of
the syphilitic changes in tabetic and paretic optic
alrophv it may be well to review briefly the orthodox
pathology : Macroscopically, the nerve appears gray,
thin and slack ; on cross section the periphery may
be gray and the centre of the nerve white. Micro-
scopically, there is fatty degeneration and absorp-
tion of the myelin sheath, breaking down, varicosity,
and disappearance of the axis cylinder. The atro-
phic process begins primarily in the retinal gan-
glion cells and in the retinal fibres, and progresses
secondarily, but little, to the optic, chiasm, tract,
thalamus, superior quadrigeminal, and external gen-
iculate body. It never begins in the basal ganglia
to descend to tract, chiasm, optic, etc., although
Uhtofl' thinks it may begin in the optic fibres. The
changes are similar to those found in the poste-
rior columns of the cord. The connective tissue
and neuroglia tissue changes are secondary to the
fibre changes, and not due to sympathetic or vas-
cular changes. The interstitial connective tissue
and neuroglia undergo secondary changes, but there
is no scar formation and proliferation or infiltra-
tion of cells as in neuritis. There is atrophic scle-
rosis of glial and interstitial tissue and sclerosis of
the small vessels. Later, there is an increase of
glial cells. In old cases there is atrophic sclerosis
of the retinal vessels. The neurogliar increase is
secondary to the atrophy of the nerve fibres (Wei-
gert). The theory has been put forward (WTiarton
Jones) that the tabetic optic atrophy is due to the
influence of the sympathetic which is affected in the
spinal cord, but it has been denied on the ground
of the absence of vascular changes. In paresis
the central neurones are degenerated, and in tabes
the peripheral one.
From the abbreviated description just given we
gather that in tabes and paresis, more particularly
August 3, 1918.] WECHSLER: OPHTHALMIC CHANGES IN TABES AND PARESIS.
187
in optic atrophy, the process is a purely degenera-
tive one, the existence of which is postulated on
the theory of toxins. The presence of an inflam-
matory process is not considered, and is even de-
nied. As far as the toxic theory is concerned,
it seems to have been fairly well disposed of by
the discovery of spirochetes in tabetic and paretic
lesions, and, while they have not yet been demon-
strated, it is not too speculative to assume their
existence in the optic paths as well. Further, as
has been fairly well established, exudative foci are
found in tabes and paresis, and the pathological
process is not at all like that found in toxins such
as tobacco, methyl alcohol, fiHx mas, etc.
In 1902 Keraval and Raviart microscopically ex-
amined a number of atrophied nerves taken from
tabetics and paretics and found neuritic processes.
They found an endo and perivasculitis as the cause
of the atrophy ; likewise a thickening of the pia-
arachnoid around the optic paths. In 1905 Marie
and Leri also found signs of inflammation and
thickening of the pia and arachnoid covering the
optics and chiasm. They described signs of oblit-
erated vessels in the septa of the nerves, and stated
that there are two phases in optic atrophy : First,
the inflammatory, phase d' irritation, and second,
phase d' obliteration. It is in the second stage that
the fibres disappear. Marie and Leri also found a
disproportion between the atrophy of the retinal
ganglion cells and the optic fibres, a condition which
ought never to exist if it be true that the degenera-
tive process in the latter always follows a disap-
pearance of the former. They concluded, therefore,
that destruction of the optic fibres may go on in-
dependently of the destruction of the retinal gan-
glion cells.
Stargardt, however, seems to have demonstrated
conclusively the exudative, inflammatory process in
tabetic and paretic optic atrophy. He examined
twenty-four specimens taken from tabetics and pa-
retics, and investigated separately the retina, optic
nerves, chiasm and tract, external geniculate body,
and parts of the gray matter adjacent to those struc-
tures. To make sure that no cadaveric changes in-
terfered with his investigations, he obtained some
of his specimens within a few minutes after death.
The Retina. — His investigations showed chro-
matolysis and degeneration of the ganglion cells
which could only have been secondary to degenera-
tion in the optic paths. In many cases of paresis
where the optic fibres were found normal the reti-
nal ganglion cells, too, were found intact. On the
other hand, he found normal retinae in cases where
the brain suffered intensely, and he asks the ques-
t:on : "If the degeneration of the gangHon cells is
due to a toxin, how is it that they altogether escaped
destruction when the brain sufl'ered so extensively ?"
In four cases where the ganglion cells were de-
generated in part it corresponded to degeneration
of the optic fibres. He also found quadrant degen-
eration in the retinal cells, and asks, "How can
this be explained on the assumption that the pro-
cess begins in the retina?"
Changes in the optic nerves. — Stargardt found
two pathological processes in tabes and paresis : exu-
dative and degenerative. Characteristic of the first
was the presence of lymphocytes and plasma cells,
but no round cell infiltration. Characteristic of the
second was the breaking down of the axis cylinder
and myelin sheath, and replacement by glial tissue.
The exudative and degenerative processes were
found side by side. The plasma cells were found
mainly in the pia and septa along the perivascular
lymph spaces in the optic nerve. There was also
inflammation of the endothelium and proliferation
of vessels. In some cases mast cells were to be
seen.
Changes in the chiasm and tract. — In the chiasm
[;rimary degeneration was most commonly seen. By
primary degeneration is meant the presence side by
side of both exudative and degenerative processes ;
by secondary is meant the absence of an exudative
process. In the optic tract the changes were usually
secondary, and only rarely were exudative ones
seen.
Changes in e.vternal geniculate body. — In some
were found exudative processes in the pia, with
deposit of plasma cells and secondary degeneration
;n the gangfion cells, while similar pathological
changes were found in the tuber cinerium and the
gray matter of the anterior perforated space, third
ventricle, basal part of the cortex, the olfactory
and oculomotor nerves, and the hypophysis — all
structures adjacent to the intracranial visual paths.
As to the oculomotor, both exudative and degenera-
tive changes were found, and in several cases of
ptosis none were i'otmd in the third nerve nuclei.
In all cases the plasma cell infiltration was in the
vessels of the nerve and in the mesodermal tissue,
plways having stopped short of the ectodermal struc-
tures {i. e., the nerve fibres).
His conclusions were as follows : "There is no
fibre degeneration if there is not an exudative pro-
cess somewhere in the course of the nerve. The
exudative process, according to this, belongs to the
picture of optic nerve atrophy just as it does to
that of tabes and paresis. The main seat of the
exudative process is in the intracranial portion of
the optic nerve, in that lying in the bony canal, and
in the optic chiasm. The orbital optics, the tract,
£nd external geniculate body are only rarely in-
volved. There is no regularity in the localization
or extent of the exudative process. In paresis the
exudative process extends from the brain structures
to the visual paths ; in tabes the exudative process
begins in the visual paths, apart from those in the
spinal cord, and may extend to the brain. Here,
too, there may be all possible variations. In all
cases the exudative process precedes the degenera-
tive changes."
Stargardt also believes that there is a nonguni-
matous syphilitic process in cases of tabes and pare-
sis comparable to gummatous changes seen in in-
terstitial syphilis, and that the histopathological
changes in the former take place by preference in
the optic nerve and chiasm, and more rarely in the
tract, etc., just as they do in the latter. He denies
that no scotoma are found in tabes, quoting Fuchs
{v. s.\, and that no hemianopsia is seen, quoting
Gowers. Both of these pictures may follow, though
rarely, the primary exudative-degenerative process
in the retrobulbar optic paths.
i88
WECHSLER: OPHTHALMIC CHANGES IN TABES AND PARESIS.
[New York
Medical Journal.
Schoenberg, who has done some interesting work
on intravital staining of the optic nerve, also holds
the opinion "that this type of optic atrophies is due
to the presence of spirochetes in the sheaths and in
the interior of the optic nerves, that in the begin-
ning these microorganisms are localized at the pe-
riphery of the nerves, mostly in its sheaths, and that
only in a later stage (do) they migrate into the
nerve bundles and between the fibres. . . ." In a
later essay on the intracranial treatment of optic
atrophy the same author confirmed his previous view
that the tabetic optic atrophy is the result of an ac-
tive inflammatory process, and he has even suc-
ceeded in arresting, if not improving, the condition
in advanced cases.
Spiller has made microscopic studies in tabetic eye
palsies, and has demonstrated the presence of in-
flammatory changes. In one case showing bilateral
internal and external ophthalmoplegia he found
lymphocytic infiltration of the oculomotor nerve and
nuclei, as well as of the trochlearis and abducens.
The nerves were atrophied and the fibres degener-
ated. The degeneration in the left abducens was
greater than in the right, and the lymphocytic infil-
tration was also more extensive in the left than in
the right. Although the case was clinically one of
tabes, pathologically it could not be differentiated
from cerebrospinal syphilis. He also found lymph-
ocytic infiltration in the pia and the pial vessels in
eleven cases of tabes. Dejerine has described ac-
tual meningitis in tabes, while others have observed
inflammatory changes in the septa and the intersti-
tial supporting tissues. Still others have shown the
presence of lymphocytes and plasma cells in the
lymph sheaths in cases of tabes and paresis. Bre-
sowsky (as quoted by Spiller) found meningitis in
forty cases of tabes. In half those cases the men-
ingitic process was of a severe form.
Warthin, as the result of intensive study of 300
cases of syphilis by means of microscopic sections,
definitely states that it is the gummatous process
that exists in places where there were no inflamma-
tory lesions. Doing post mortems with the micro-
scope instead of the scalpel, he demonstrated the
presence of spirochetes in places where there were
no inflammatory lesions, but simple degeneration or
necrosis — a condition analogous to so called primary
degeneration of the optic paths. It is his opinion
that all nerve syphilis (and optic atrophy is nerve
syphilis) begins in the secondary stage, and that
"every syphilitic is a little tabetic and paretic."
Fordyce, in speaking of optic atrophy, says that
"in syphiHs the optic nerve may be primarily or sec-
ondarily involved, more often the latter," that is,
there may be direct involvement of the nerve or ex-
tension to it from the meninges. Further, he be-
lieves that optic atrophy in tabes which gives a posi-
tive fluid reaction, bespeaks an inflammatory process
and therefore makes the case amenable to treat-
ment.
CONCLUSION.
After study of the more recent investigations con-
cerning the pathology of neurosyphilis, particularly
witli reference to optic changes, I have gained the
impression that there is no fundamental difference
between tabetic neurosyphilis and so called cerebro-
spinal or, better, difi'use neurosyphilis. It seems
evident that an inflammatory process is behind every
form of syphilitic involvement, and that the spiro-
chete is at the bottom of the reaction. Obvioilsly
the inflammatory reaction is in direct proportion to
the kind of tissue involved. There is every reason
why the meninges should respond more violently
than the parenchyma of the brain. The reaction,
too, of vascular, interstitial structures will be of a
different nature than that of parenchymatous tissue.
But lymph and plasma cell infiltration and mast
cells are the fundamental characteristics of syphilis.
This picture occurs in tabes, paresis, and optic atro-
phy just as it does in interstitial neurosyphilis or,
say, aortitis. There is therefore no valid reason
for calling a protean clinical picture cerebrospinal
syphilis. In the first place, tabes and paresis are
anatomically just as cerebrospinal, and secondly, the
pathology is based in all cases on a similar reactioii
to the same agent. I have, therefore, without being
too consistent, used the term interstitial or diffuse
neurosyphilis instead of cerebrospinal lues.
The same argument seems to hold true when we
come to the pathology of special structures, sucli as
the optic nerve. Evidently very careful examina-
tion has revealed inflammatory reactions even in
very old cases of optic atrophy. It would seem ad-
visable, therefore, to drop the term primary optic
atrophy, or, rather, employ it in the sense that the
atrophy takes place pari passu with the inflamma-
tory, exudative process. It is equally descending
with an inflammatory neuritis, though the vascular
.changes are not nearly so violent. The deductions
to be drawn are quite obvious. Without attempt-
ing to deal with the subject of therapy, it may be
well to point out that if the inflammatory character
of optic atrophy will come to be recognized, we may
be able to attempt rational and possibly hopeful
treatment in cases hitherto the despair of thera-
peutists.
REFERENCES.
I. KERAVAL and RAVIART: Archives de Neiirologie, 1902, xvi.
2. MARIE and LERI: Nouvelle Iconographie de la Salpetriere. 3.
STARGARDT: Ueber die Ursachen des Sehnervenschwundes bei
der Tabes und der Progressiven Paralyse, Archiv fur Psychiatric,
1913. 4. W. G. SPILLER: The Pathology of Tabetic Palsy with
Remarks on the Relation of Syphilis to the So Called Parasyphilitic
Diseases, Journal of Nervous and Mental Diseases, 1915, xlii. 5.
WILBRAND and SAENGER: Neurologic des Auges. 6. W.
UHTOFF: Graeffe-Saemich Handbnch der Cesainten Augenheil-
kunde, 2 Aufl. 7. H. HEAD: Brain, 191 4. S. F. W. MOTT:
Syphilis of the Nervous System; D'Aarcy Powers, A System of
Syphilis. 9. MAX NONNE: Syphilis und Nervensystem, 1909.
10. M. T. SCHOENBERG: Intracranial Treatment of Syphilitic and
Parasyphilitic, Optic Nerve Affections, Journal A. M. A., June, 1916,
Ixvi. J I. M. J. SCHOENBERG: Remarks on Intracranial Treat-
ment of Syphilis of the Optic Pathways and Optic Atrophy, New
York State Journal of Medicine, February, 191 8, xviii. No. 2. 12.
A. S. WARTHIN: Harvey lecture. Academy of Medicine, New
York, December 12, 191 7. 13. W. G. SPILLER: The Amaurotic
Form of Tabes, Tabes Arrested by Blindness, Philadelphia Medical
Journal, November, 1902. 14. PILTZ: Ueber neue Pupilenerschein-
ungen, Ncurotogisches Zentralblatt, 1899. No. 6. 15. E. SIEMER-
LING: Beitriige zur Pathologischen Anatomic der isolierte, etc.,
Augenmuskellahmung, Archiv fiir Psychiatrie, 1905, xl, No. i. 16.
J. DEJERINE: Semiologie des Affections du Systeme Nerveux.
17. H. OPPENHEIM: Lehrbuch der Nervenkrankheiten. 18.
GOWERS: Syphilis and the Nervous System, Lettsotnian Lectures.
19. FOURNIER: Les Affections Parasyphilitique, 1894. 20. BA-
BINSKI and NAGEOTTE: Lesions Syphilitique des Centres Ner-
veux, etc., Nouvelle Iconographie de la Salpetriere, 1902, No. 6.
21. E. ELSCHNIG: Zur Anatomic der Sehnervenatrophie bei Er-
krankungen des Centralnervensystems, Wiener klinische Wochen-
schrift. 1899, No. II. 22. W. G. SPILLER and D. C. CAMP:
The Clinical Resemblance of Cerebrospinal Lues to Disseminated
Sclerosis, American Journal of the Medical Sciences. 1907, cxxxiii.
23. HUGH F. PATRICK: The Somatic Signs of Brain Syphilis,
Journal A. M. A.. 1901, xxxvii. 24. E. E. SOUTHARD and H. C.
SOLOMON: Neurosyphilis, Boston, 1917.
212 East Twelfth Street.
August 3, 1918.]
VOORHEES: CHRONIC INFECTIONS OF RESPIRATORY TRACT.
THE SUCCESSFUL TREATMENT OF
CHRONIC PATHOGENIC INFECTIONS
OF THE LOWER RESPIRATORY
TRACT.
Bv Irving Wilson Voorhees, M. S., M. D..
New York,
Assistant Surgeon to the Chappell Clinic, Manhattan Eye, Ear, and
Throat Hospital.
I wish to point out some salient facts in the diag-
nosis and treatment of certain infections of the
lower respiratory tract, the larynx, trachea, and
bronciii, as distinguished from the upper tract about
which so much has been written during the past
few years.
Any person who has more than a passing interest
in respiratory diseases must have been impressed in
an increasing degree by the large number of so
called chronic conditions of the larynx, trachea, and
lungs whicii are met with not only in daily clinical
experience, but outside of the consultation room
and hospital ward. It is fairly impossible to be-
come one of a public assemblage, such as the theatre
or opera, and not be more or less annoyed by vol-
leys of coughing, scraping the throat, or other
noises peculiar to respiratory disturbances. In
fact this becomes so common that it often passes
unnoticed unless it is near to us and of a particu-
larly aggravating character. Doubtless many of
these cases are acute and are destined to recover
spontaneously, but a very large number, at one time
acute, are now chronic, and because of neglect or
im.prof)er or unskillful treatment have gone on to
such marked pathological change that they go about
seeking relief where none is found and become the
bane of many a practitioner.
It should be understood that I am speaking here
of infectious processes only and not of conditions the
result of tumor, such as aneurysm, or the chronic
passive congestion of valvular heart disease, or
structural changes found in such incurable entities
as emphysema and advanced tuberculosis.
There is undoubtedly a rather large group of
respiratory patients who are suf¥ering from an un-
recognized infection of the mucous membrane, not
merely a surface infection, but an infection where
the bacteria live, thrive, and grow deep down in the
submucosa, causing there, in time, abundant con-
nective tissue proliferation and complete functional
change. Such patients are in the light of present
day knowledge carriers of certain types of micro-
organism attenuated in virulence, to be sure, but
culturable on satisfactory media, again becoming
lethal when used experimentally. It is remarkable
how resistant the body becomes to the ulterior ef-
fects of such a chronic infective process, and even
a superadded acute infection such as that caused
by the pneumococcus does not always destroy the
life of the host, contrary to what might be expected.
Many such cases recover from the acute process
only to have for the remainder of their lives the
annoying symptoms of the old chronic condition.
The profession at large has been slow to learn the
nature of infection of the respiratory mucous mem-
brane save in pneumonia and tuberculosis which
have been studied assiduously. For example, a
sputum is sent to a health laboratory for exanilna-
tion, the specimen is reported as containing or not
containing the tubercle bacillus although it may
have swarmed with myriads of other organisms
which are regarded as simply incidental — a mixed
infection, if anything is said about it at all. The
pneumococcus is recognized as a potent enemy, but
it is only within a very short time and as a result of
academic rather than actual clinical interest at the
Rockefeller Institute that the pneun;ococci have been
classified into four distinct groups according to their
virulence and prognostic importance. It' is now
known that every case of pneumonia falls imder one
of the four headings according to what the labor-
atory specialist has to say about the sputum ; and.
consequently, we have had placed in our hands a
specific sei-um for each type according to the
identity of the enemy we are fighting. Work of this
kind is not only farreaching but epoch making in
that it gives us a wider acquaintance with our
bacterial enemies, and afi'ords a constructive plan of
battle out of which we have greater reason to ex-
pect victory than ever before.
Without meaning to offer any drastic criticism it
is only fair to say that no class of disease is more
unskillfuUy treated by the average medical man
than infections of the lower respiratory tract, and
especially so if they l^e chronic. Fortunately the acute
cases have a remarkable tendency to recover whether
they be accorded all, any, or no treatment what-
ever, and it is undoubtedly due to this fact that the
family practitioner makes light of a simple cold and
considers his duty well performed if he prescribes
just to make the patient feel that something is be-
ing done. This is, in the last analysis, the fault not
of the doctor but of medical teaching. In all of
these diseases indirect treatment has ever been the
rule. Too much attention has been paid to the
bowels ; the liver and the kidneys ; to the temper-
ature, pulse and respiration ; to calomel, squills,
ammonium chloride, ipecac, rhinitis tablets and the
compound tincture of benzoin; and not enough at-
tention, may one say, no attention at all, to the
microorganism causing the difficulty and how it may
be combated.
It has not been emphasized that cough medicines
do not cure but only increase or diminish the secre-
tions and stop the tickling through the beneficial
action of some paralyzant such as heroin, which
constipates and may set the stage for the entrance
of that arch villain, opium, who has probably de-
stroyed more lives than he has ever saved.
A few simple rules stand one in good stead in
working with these respiratory infections. One
should have at his right hand the skilled services of
a trained bacteriologist who must be cooperative
and interested in the clinical side of his work as well
as in the test tube and microscope. In every case
the sputum should be obtained, and cultures taken
from the nose and throat whenever symptoms are
referable to these organs. It should be a standing
order that the culture is to be saved with the pur-
pose of making a vaccine if this be deemed neces-
.sary.
The organisms most commonly found are some
member of the streptococcus or staphylococcus
190
VOOkHEES: CHRONIC INFECTIONS OP KESPIRATOKY TRACT.
[New York
Medical Journal.
family and the micrococcus catarrhalis. Some
attempt should be made to determine the site
of bacterial growth. Not infrequently the voice
is normal and the larynx looks healthy, but just be-
low the vocal cords the mucous membrane looks
swollen and red and the tracheal rings cannot be
counted. If a tracheitis is present, the patient when
asked whei-e he feels the tickling will point to the
episternal notch, to the area directly behind the
collar button. Plaques of mucopus, mucus, and
blood streaks are often seen, especially when the
streptococcus mucosus is present. A continuous
desire to scrape the throat indicates the presence of
mucus on the vocal cords, and not infrequently the
patient cannot speak distinctly until this mucus is
shaken off by the scraping or "hemming" process.
In chronic tracheitis one often finds the mucous
membrane over both true and false cords covered
with crusts. There is a dry, hard cough which be-
comes easier when the crusts soften and can be
coughed out. The secretion in all of these cases is
very viscid in character owing to an excess of
mucin, consequently Avhen dried it becomes very
firmly attached to the epithelium and on coming
away leaves a raw, bleeding, eroded surface. The
voice is very husky, and at times there is aphonia.
Such a condition may be limited to the trachea or
may extend downward into the larger bronchi.
In one case, upon examination of the right superior
bronchus with the bronchoscope we entered a small
abscess cavity which had apparently been encapsu-
lated. Culture showed a staphylococcus organism.
In those cases of socalled chronic bronchitis with
copious, fetid discharge, one must always keep in
mind the possibility of a foreign body in a bronchus.
One such patient, the son of the president of a
great mercantile company, had been the rounds in
Europe before the great war, and a diagnosis of
pulmonary tuberculosis had been made by several
eminent physicians. An x ray plate showed an
encysted collar button far down in the right bron-
chus which had been there for about eleven years.
This was successfully removed by Dr. Chevalier
Jackson, then of Pittsburgh, and the patient recov-
ered, although it required several months for all
of the active symptoms to subside. This is by no
means unique, as several bronchoscopists have re-
ported similar experiences.
The method of procedure in all cases is as fol-
lows : A careful history, especially as to how the
condition began ; its probable origin ; whether fol-
lowing pneumonia, grippe, etc. ; question of asso-
ciated disease, heart, kidneys ; duration ; local symp-
toms ; character of cough, worse at night or when
lying down; what periods of ease if any; efifect of
climatic or barometric factors ; amount, character,
odor, color, and consistency of sputum ; and the
kinds of treatment that have been already employed.
In the local examination the nose and naso-
pharynx must be studied for obstruction and the
presence of pus. Occasionally the patient com-
plains of coughing and gagging, which we find to
be the result of a chronic nasal sinus disease with
postnasal discharge and dried secretion which gets
down into the hypopharynx, drags on the epiglottis
and rinia glottidis, and sets up .severe spasms of
choking until the of¥ending discharge is loosened
and spit out. The larynx and trachea must be
studied with the laryngeal mirror, and it is often
necessary to cocainize quite thoroughly with twenty
per cent, cocaine before we can get a view of the
region below the cords. In case this indirect meth-
od fails, we can proceed with the direct speculum
and inspect the trachea and bronchi by broncho-
scopic methods. In every case a specimen of secre-
tion must be secured, either during the examination
or when the patient coughs it out. This is cultured
and carefully gone over by the laboratory man who
furnishes a full report of the bacterial flora.
X ray examination of the nasal sinuses, and of
the chest may be essential in a given case, and a
Wassermann may throw surprising light on a baf-
fling problem.
Physical signs do not afford any great help except
as to the location of the lesion — that is, which lung
and what part of the lung is affected. In our ex-
perience, physical signs even when determined and
recorded by an expert examiner are not of nearly
so much value as the x ray, although this latter is
also capable of being misread.
Naturally the entire question of treatment resolves
itself into two factors : the improvement of the pa-
tient's general resistance, and the destruction of the
bacterial parasite. The former has been the chief
weapon of the lung specialist these many years, and
is too well known to need mention here. A newer
phase of treatment which does require special men-
tion is the use of vaccines. These have proved so
successful .in my hands in increasing the general
bodily resistance that it is surprising how many men
seem opposed to their use. There must be some-
thing in the way the vaccines are made which af-
fects their efficiency. Personally, I do not favor the
stock variety for several reasons, and always use
the autogenous kind whenever possible. Dr. T. S.
Schlauch, of this city, has made these for me for
some years and I cannot testify too strongly to
their value. This excellence probably lies in the
fact that he does not destroy the bacteria by heat
in making the vaccine, but uses cresol or a very
mild carbolic solution. Heating is capable of ex-
erting some lipoid change which renders the vaccine
inert or at least ineffectual, and it is entirely un-
necessary. The vaccine is counted as 500 million
in one cubic centimetre. We begin with fifty mil-
lion in most cases and wait for the reaction, both
local and general, to subside before giving another
dose. Quite often one can increase a half c. c. at
each dose. Whenever a too marked or a violent
reaction is obtained we usually discontinue vaccine
treatment temporarily and watch for recurrence of
old symptoms or absence of them as the case may
be. A vaccine does two verj' helpful things, it in-
creases the appetite and makes the patient sleepy,
and is therefore a better tonic than most of the
commonly used drug combinations.
If a drug combination seems desirable, the French
ampoules of Clin & Cie. (No. 627) are excellent.
These contain glycerophosphates of iron and soda,
arsenate of soda, and sulphate of strychnine. One
of these sterile ampoules is used hypodermatically
twice a week, rarely three times. After the third
August 3, 1918.]
KLOTZ: ASPARAGUS DURING GONORRHEA.
191
dose the patient will often say that he feels much
improved.
As for the destruction of the microorganisms by
direct treatment, this is a matter which has been
sadly neglected. Even the nose and throat special-
ist has not always made the most of his opportuni-
ties in applying bactericidal medication, chiefly be-
cause most agents have acted severely on the normal
body cells as well as on the bacteria, and thus the
patient has been made worse instead of better. Sil-
ver nitrate has been the old standby, and when ju-
diciously used it is very helpful. It should not be
swabbed on with an applicator as that method is
very disagreeable, and by bruising the soft tissues
may engender a reaction which does more harm
than good. With a De Vilbiss atomizer (No. 52)
it can be sprayed directly into the trachea, or if it is
desirable to reach the bronchi it can be dropped
in with a laryngeal syringe. A two per cent, solu-
tion is sufficiently strong, about five minims at each
instillation. Recently a preparation known as silvol,
an analogue of silver nitrate, has given good service
in the hands of several men at the Manhattan Eye,
Ear, and Throat Hospital. Occasionally where di-
rect medication of a given bronchus has been de-
sirable, we have passed the bronchoscop>e under local
anesthesia and have instilled our antiseptic through
a soft rubber catheter passed through the lumen
of the bronchoscopic tube.
The silver preparations are especially helpful
where one has to do with crusting, for they increase
all secretions to a marked degree, render them less
viscid, and by stimulating the mucous glands help
to remove from the submucosa great masses of
bacteria which have been intrenched there.
Much is to be looked for from the new dichlor-
amine-T of Carrel-Dakin. This is now made up
with an oily base known as chlorcosane and is fairly
stable as compared with the earlier solutions which
were readily .spoiled by contamination and decom-
posed by light and had to be made up fresh every
day. Either a one per cent, or a two per cent, solu-
tion may be used in the trachea and bronchi by
instillation or spraying. In beginning treatment of
those cases where there is much discharge or crust-
ing it is better to use a silver preparation for a few
days, and then change to dichloraniine-T when one
can be sure that this agent will come directly into
contact with the infected surface.
One reason why treatment of this class of pa-
tients has failed in the past is because neither pa-
tient nor doctor has realized the importance of per-
sistent and repeated applications of bactericidal
agents. Inhalations such as the compound tincture
of benzoin, while of value in certain acute cases, are
not usually concentrated enough in action and not
frequently enough applied. Bacteria grow at an enor-
mous rate on the respiratory mucous membrane
where heat, moisture, and absence of direct sunlight
make cultural conditions ideal ; therefore, ammuni-
tion must not be frugally used, but a nearly continu-
ous barrage fire must be maintained to win the battle
against such overwhelming propagation. It is use-
less to administer a treatment by direct instillation
and tell the patient to come back the day after to-
'-"lorrow, for by that time the efTect of the bactericide
has long since been lost. These patients must be
treated at least once every day. In private practice
tlie efifect is so marked that they do not at all object
to coming in morning and evening and thus shorten
the time of" convalescence very markedly. Twice a
day is the rule in all severe, chronic cases and in all
of the acute ones with active symptoms or tendency
to complications in the ears and sinuses. The grati-
tude of these sufferers more than repays the phy-
sician for the time and patience he is obliged to
give to them.
Conclusions. — From an intimate and intensive
study of a large number of cases of chronic, chiefly
pvogenic, infections of the larynx, trachea, and bron-
chi, both in hospital and private practice, it would
seem that such infections are seldom diagnosed in
the acute stage. Questioned as to previous treat-
ment, nearly all of these patients said that they had
taken much medicine by mouth without seeing any
permanent benefit, and that the activities of the
physicians whom they had consulted were limited
to chest examination, sputum tests, and a negative
report as to the presence of pulmonary tuberculosis.
In many cases the patients had been carefully ad-
vised as to diet, fresh air, exercise, etc., but almost
none had received any kind of local treatment other
than inhalations to be carried out at home, and an
occasional swabbing of the pharynx and larynx with
a silver or iodine preparation.
In the light of such evidence it would seem wise
for those who make a specialty of throat and lung
disease to enlighten the profession as to the method
of procedure in the diagnosis and treatment of cases
manifesting chronic hoarseness and disturbing
cough. Especial emphasis should be placed upon
the importance of systematic and thorough treat-
ment in all acute respiratory infections with a view
to decreasing the number of chronic cases now so
frequently seen in all branches of medical practice.
14 Central Park West.
WHY IS ASPARAGUS FORBIDDEN DUR-
ING GONORRHEA?
By Hermann G. Klotz, M. D.,
White Plains, N. Y.
The idea that the ingestion of asparagus is to be
avoided, at least during the acute and subacute
stages of gonorrhea, seems to be widespread not
only among the members of the medical profession,
but also among that portion of the laity which
furnishes the greatest contingent of the patients
affected with the disease. In quite a number of
older and newer books on the subject in which the
dietetic management of gonorrhea has been more or
less fully considered, and also in the periodical liter-
ature, asparagus appears most frequently among
the forbidden articles of food, and sometimes con-
spicuously as the arch offender. During an ex-
tended practice in the treatment of gonorrhea I had
frequently the opportunity for the examination of
urine -v oided within a short time after the ingestion
of asparagus and the experience gained thereby
soon made me look somewhat skeptically upon the
correctness of the interdiction of asparagus, the
192
KLOTZ: ASPARAGUS DURING GONORRHEA.
[New York
Medical Journal.
more so as I was not able to detect in the literature
any (Iclinite statement of the reasons for the elim-
ination from the diet of an article of food, which
from its character is not only considered a whole-
some one in general ( i ) , but rathef seems to
promise a favorable effect upon the congested state
of the mucous membrane of the urethra during this
period. So I have become somewhat suspicious
that, like not a few other doctrines, the ban on as-
paragus, of obscure origin, passed without any close
investigation through conventional tradition into the
medical literature and into the mind of the profes-
sion. Therefore in practice I usually have not pro-
hibited the eating of asparagus and the result has
not changed my opinion, and, while probably it is
not a matter of much importance, I have felt justi-
fied in brmging it before the profession in order to
have the truth established.
Having gone over a large part of the literature
in search of definite statements of convincing rea-
sons for or actual proofs of the injurious effect of
asparagus I shall refer to a few authors. One of
the most outspoken adversaries, the younger Zeissl
in his numerous publications on the subject (2),
usually applying exactly the same phrases and
words, says that the patient should be allowed a
moderately nourishing diet, if possible entirely
vegetable, particularly milk, vegetables, fruit.
Celery, asparagus, caviar, black coffee should be
avoided, or briefly all articles of food or stimulants
which increase the secretion of the kidneys and
cause erections. Contrary to the opinion of most
other authors Zeissl insists that frequent evacuating
of the urine irritates the inflamed mucous mem-
brane of the urethra. Lydston (3), considers a
restricted regimen necessary, not only because of its
beneficial effects from an antiphlogistic standpoint,
but for the purpose of diminishing the waste prod-
ucts excreted by the urine. It is on the amount and
character of these waste products that the irritating
properties of the urine depend and there is nothing
so efficacious in diminishing its acidity as attention
to diet, the ideal regimen being bread and milk.
Stimulants of all kinds, such as alcoholics, tea, and
coffee should be interdicted. The more closely a
vegetable diet is adhered to, the better, providing a
bread and milk regimen be not acceptable. Aspar-
agus and tomatoes, however, are to be avoided. R.
W. Taylor (4) says that careful attention to diet is
an important consideration. It should be light and
plain, and in moderate quantity. All highly sea-
soned foods, salads, gravies, soups, and condiments
should be absolutely interdicted. Coffee, cocoa,
beer, alcoholic liquors, ginger ale, and asparagus
should be avoided. In a more recent publication R.
Guiteras (5) advises avoidance of all foods which
give rise to irritating compounds in the urine, such
as asparagus, tomatoes, rhubarb, and all sour,
pickled and spiced dishes, especially the condiments,
pepper, pepper sauce, catsup, chile sauce, etc. In an
article entitled. Scientific Knowledge Logically Ap-
plied to Acute Gonorrhea of the Male Urethra (6)
G. S. Peterkin among other things forbidden spe-
cially mentions bananas, rhubarb, tomatoes, and
asparagus.
From these citations, which easily could be
multiplied, it apf)ears that the reason for the re-
strictions of the diet is the increase of the volume
of the urine secreted. This theory of Zeissl is
strongly opposed by Guiteras and Peterkin who in-
sist on the ingestion of large quantities of water, or
in case of considerable acidity of the urine, of
alkaline mineral waters or solutions or salts of po-
tassium. Other factors are the causation of erec-
tions and the furnishing of irritating waste products
excreted in the urine. The latter are to be referred
to the crystals of oxalate of lime in the case of
tomatoes, rhubarb, celery, and possibly coffee, tea,
and cocoa, but not asparagus. I have not been able
to find any evidence that asparagus increases the
tendency to erections, which is generally acknowl-
edged to exist in a more or less pronounced degree
in the majority of cases owing to the congested con-
dition of the urethra and surrounding tissues.
Under these circumstances it would be very difficult
to decide in a single instance upon the participation
of asparagus in the sexual irritation. However, to
answer the principal charge, the production of
chemically injurious substances in the urine, it will
be necessary to carefully scrutinize the chemical
con.stituents of the plant asparagus.
Although in France the shoots are used for the
preparation of a syrup, the root is really alone
officinal in the shape of a tisane which is prescribed
as a diuretic in cases of dropsy associated with dis-
eases of the heart, but its medical value is consid-
ered problematical. In this discussion we have to
do only with the shoots as the real article of food.
Like the root they contain, besides sugar, albumin,
mucus and the alkaline mineral salts which are
found in varying quantities in all vegetables articles
of food, principally asparagin or aminosuccinamic
acid (C4HsN203-f HjO), an amido derivate of
succinic acid, containing 21.2 per cent, of nitrogen.
It forms transparent lustrous, rhombic prisms, of
1,519 specific gravity, soluble in forty-seven parts
of water at 68° Fahr., and in acids and alkalies ; it
is physiologically inactive and its medical properties
are doubtful. Discovered first in 1805 in the shoots
of Asparagus officinalis and named after this plant
it has gradually been traced in the widest distribu-
tion over the vegetable kingdom. Though the
amounts are smaller than in asparagus it is found
in considerable quantities in the leguminous vegeta-
bles, peas, lentils, beans ; among the cereals in oats ;
and in much larger quantities in potatoes and sugar
beets. It is always found in the greatest quantities
in sprouting plants ; in the potato it may furnish as
much as forty per cent, of all nitrogen. That
asparagin owes its origin to the disintegration in the
sprouting plants of albuminous bodies becomes evi-
dent from the fact that the albumin in the sprouting
plants becomes diminished in proportion to the in-
crease of asparagin ; it remains in the sprouting
plant for a short time if exposed to light, being
regenerated into albumin.
Asparagus, when young and tender, is very easily
digested, even by invalids. Though not of high
nutritive value, there is very little doubt that its use
leads to a true economy of food during digestion, in
other words to a healthy assimilation of food prin-
ciples, and more particularly of proteins. Experi-
August 3, 1918.]
KLOTZ: ASPARAGUS DURING GONORRHEA.
193
ments on herbivorous animals place asparagin, as a
nourishing substance, in line with the gelatines,
having the effect of saving albumin and thereby
allowing of the formation of albumin during a de-
ficiency. In carnivorous and omnivorous animals,
however, addition of asparagus to the food did not
result in a reduction of albumin metabolism, but
rather in an increase of the disintegration of albu-
min. This stimulus to the disintegration of protein
in the intestines during digestion leads to the pro-
duction of an organic sulphur body known as
methylmercaptan, which is absorbed and becomes
responsible for the well known pecuHar disagreeable
odor of the urine. There is no evidence that the
presence of this substance in the urine is in any way
irritating.
Substances producing purin bodies and excess of
uric acid are present in asparagus to an extent
which perhaps cannot be entirely neglected,
although in smaller quantity than in oatmeal, pea-
meals, beans, and particularly in all kinds of fish
and meat. It is probable, however, that the alkaline
salts present in asparagus as in all vegetable foods,
would compensate any uric acid forming tendency
and keep the blood sufficiently alkaline to prevent
the formation of insoluble urates.
There remains to be considered the condition of
the urine itself after the ingestion of asparagus. It
is usually of normal specific gravity and of light
color. The chemical reaction may be slightly acid,
amphoteric, neutral, or more frequently alkaline.
The urine may be clear immediately after being
voided, but commonly it is at once more or less
deeply clouded. This cloudiness, at first uniform
through the entire quantity, cannot at once be dis-
tinguished from that caused by the presence of pus
or of mucus, but gradually it begins to thin, showing
many minute clear areas and small whitish flakes
which soon begin to sink and to settle at the bottom
of the vessel as a white, gray, or even yellowish
sediment. The settling proceeds much more rapidly
than that of mucus or pus. On heating or boiling
the cloudiness increases, but immediately and en-
tirely disappears when some acid, preferably acetic
acid, is added, sometimes with the development of
small gas bubbles. The sediment principally con-
sists of the neutral and basic phosphates of the alka-
line earths, calcium and magnesium, which nor-
mally are kept in solution as acid salts if the urine
contains a sufficient quantity of phosphoric acid and
soluble combinations of phosphoric acid with the
alkalies sodium and potassium, but are precipitated
as neutral or basic salts whenever the acidity of the
urine is diminished. Therefore the cloudiness is not
at all restricted to asparagus, but also appears after
rhubarb, horseradish, beans, various kinds of cab-
bage and copious drinking of milk, and alkaline min-
eral waters, with great individual varations. In
fact the condition of such urine is almost identical,
except for the pecuhar odor, with one purposely
produced by the administration of solutions of some
potassium salts, as particularly recommended by
Guiteras. Under the heading of Alkaline Diluents,
he says that the alkaline salts of potassium and
sodium are administered for the purpose of reduc-
ing the acidity of the urine, thus making it less
irritating to the urethra. The potash salts, while
not so well borne by the stomach, are more effective
as diuretics and for rendering the urine alkaline ;
they are the acetate, the bicarbonate and citrate of
potassium in doses of fifteen to thirty grains. The
action of all these salts of sodium and potassium is
to reduce the acidity of the urine. They escape by
the kidneys as carbonates. The acetate is the most
efficient, but is not as well borne by the stomach as
the citrate.
The sediment generally is of a grayish white color,
sometimes it feels soft, like dust, sometimes slightly
gritty or sandy ; under the microscope one meets
mostly the amorphous, dustlike elements of the
basic salts of the alkaline earths which resemble the
salts of uric acid, but occasionally the spear or
wedge shaped crystals of the neutral phosphate of
lime are found, or the coffin shaped crystals of the
ammoniated phosphate of magnesia, when the alka-
line reaction of the urine is due to the decomposition
of urea. Altogether the asparagus urine practi-
cally represents a physiological phosphaturia with-
out any increase of the phosphates themselves,
which, outside of ingestion of certain substances
into the digestive organs, occurs under various
conditions, particularly under some nerve in-
fluences. Ordinarily it does not cause any sub-
jective symptoms and probably for that reason
escapes observation, but in the case of asparagus the
peculiar, often strong odor is more likely to attract
attention and lead to examination.
While at the present time one must not insinuate
that a physician would be satisfied with a mere in-
spection of a patient's urine. I know that not so
very many years ago patients with phosphaturia
were treated for weeks and longer for catarrh of
the bladder ; also that the cloudiness on heating and
the sediment have been mistaken for albumin ; in
fact I have seen patients of mine refused life insur-
ance until the attention of the examining physicians
had been directly called to the presence of phos-
phaturia. With such an experience one may well
feel justified in assuming that in years back similar
mistakes originally led to the condemnation of
asparagus as injurious in gonorrhea, and that this
erroneous impression has gradually been accepted
without much further investigation. Exacerbations
of gonorrhea certainlv are likely to- occur subse-
quently to an ingestion of asparagus, but that is no
proof that it is really caused by it, and before judg-
ing one ought to carefully investigate what else had
been eaten or drunk with the asparagus. It seems
improbable that of the many substances of similar
composition asparagus alone should have an inju-
rious influence.
REFERENCES.
I. Annotations in the Lancet, May 6, 191 1, p. 1222. 2. ZEISSL:
Diagnosis and Therapeutics of Gonorrhea, 1903. 3. BANGS-
HARDAWAY: America^n Textbook of Genitourinary Diseases, 1898,
p. 117. 4. R. W. TAYLOR: Genitourinary and Venereal Diseases
and Syphilis, 1904, p. 58. 5. R. GUITERAS: Urology, 1912, ii, 370.
6. G. 'S. PETERKIN: Scientific Knowledge Applied to Acute Gon-
orrhea, Medical Record, January 16, 1915.
43 ROCKLEDGE AVENUE.
A new treatment for chronic cases of malaria
with enlarged liver and spleen consists in the in-
travenous injection of basic colloidal quinine.
194
LANDSMAN: INTERESTING RECTAL CASES.
[New York
Medical Journal.
SOME INTERESTING RECTAL CASES.
With Comments on the Lessons They Teach.
By Arthur A. Landsman, M. D.,
New York,
Deputy Surgeon, Diseases of the Rectum, Out Patient Department,
New York Hospital; Attending Rectal Surgeon Philantropin
Hospital; Associate, Department Rectal Surgery, Post-
Graduate Medical School and Hospital.
The immediate objective of the physician in his
treatment of the sick, is obviously, the cure of the
patient, and his restoration to his accustomed place
in the social scheme. But this is by no means his
sole duty, for he must so utilize the knowledge, ex-
perience, and skill thus gained, as to enable him to
prevent disease m others, when possible, modify its
course, shorten its duration, and ward off its compli-
cations. Unless this has been attempted, consist-
ently, earnestly, and diligently, the doctor has fallen
short of what is expected of him, for he owes a duty
to the community no less than to the individual.
To the credit of the medical profession be it said,
that it has always upheld this enlightened view of its
responsibilities, indeed has at all times been found
in the forefront of every educational effort to urge
a higher standard of the obligations of the physi-
cian to society as a whole. Its best ideals, noblest
impulses, and loftiest aspirations have been at all
times centred on efforts to diminish the sum total
of human suffering, by stamping out preventable
illness. It is in furtherance of this thought that
clinical observations are made, and interesting or
unusual cases recorded, for as the lessons they
reveal today become crystallized into the solid
scientific achievement of tomorrow, they furnish
weapons with which medicine is enabled to forge
ahead in its campaign against ignorance and disease.
it falls to the lot of the proctologist to be con-
sulted by patients whose cases present features
which must possess a special interest to the physi-
cian. This arises from the fact that disease of the
lower rectum and anal canal may bring about such
varied changes in the neighboring organs, and such
profound alterations in their functions because of
reflex and other disturbances, as to make it neces-
sary for the physician to be thoroughly familiar
with their manifestations, in order to understand
their causes, combat their symptoms, and overcome
their ill effects.
The proctologist is frequently consulted in cases
in which local symptoms dominate the picture, not-
withstanding that the disease is in other parts of the
body, conversely, with manifestations which point
to foci in adjacent organs, the sole cause of the dis-
ease may be found in the anorectal tissues. Indeed,
rectal, or perirectal disease has been known to
simulate constitutional conditions so closely, as to be
mistakenly treated for it, at least for a time.
Prolonged suffering, and even serious disability
may result from comparatively slight local trouble,
often controllable by minor surgical procedures ; on
the other hand, conditions which are a grave menace
to the life of the individual m.ay, at the outset, cause
no alarming changes, and the unsuspecting medical
attendant may be lulled into a fancied security,
though the patient is already the victim of a formid-
able malady. It is because of these premises that
these cases have been singled out from daily prac-
tice, and concrete examples presented of features
which may be helpful in avoiding errors.
Case I. — E. E., twenty-five, unmarried, suddenly became
ill after her day's work, with excruciating pains in the
rectum and anal canal, radiating into the lumbosacral
region and thighs, and with cramplike sensations over the
lower abdomen. The patient had no history of previous
illness or attacks, no constipation, vomiting, menstrual or
urinary disturbances. The temperature was ninety-eight,
the pulse ninety-four. The muscles of the pelvic outlet
were in a state of marked spasm, the sphincters and levator
ani tightly contracted ; those of the abdomen were rigid,
with no localized tender points that could be ascertained.
No satisfactory rectal examination was possible at this
time, but digital examination was negative, beyond the find-
ings noted above. Two general possibilities were consid-
ered : local trouble in anal canal and rectum, such as a
foreign body, fissure, acute invagination with strangula-
tion of a portion of the rectum or pelvic colon ; or some
abdominal disease. After four or five hours the pain and
rigidity diminished, permitting a rectoscopic examination,
which was negative ; on digital exploration of the rectum,
however, marked tenderness was elicited on the right side
of the pelvis, in the region of the pararectal fossa, over
what seemed a boggy mass. The abdominal muscles being
less tense, a decidedly tender point could be made out in
the right iliac fossa, but there were no other signs of ap-
pendicitis. The patient was removed to the hospital the
next day, with a diagnosis of a possible appendicular ab-
scess, which was confirmed by the attending staff. Tem-
perature one hundred, pulse eighty-four, total white blood
cells 15,000, oolynuclears sixty-nine per cent. At operation
the peritoneal cavity was found to contam a quantity of
bloodj' fluid, coming from a ruptured cyst of the corpus
luteum of the right ovary, which was still bleeding. Ap-
pendix normal.
It must seem clear from the above, that the dis-
ease need not necessarily be in the rectum even if
the most prominent subjective symptoms point
toward it ; the pain in the rectum, and the rigidity
of the muscles in this case, were reflex phenomena,
excited by the irritation of the lesion communicated
to adjacent parts of the cord, and deflected to the
anorectal tissues. A proctoscopic examination
brought out at once negative findings in the recttun.
and a clue to the location of the disease, though not
its nature. We know of a case of appendicitis with
rectal symptoms, in which the patient barely
escaped operation of the rectum, because the condi-
tion was mistakenly attributed to rectal trouble ; on
the other hand we recently operated on a physician
in like circumstances, but with symptoms less in-
tense, in whom a sliver of wood, 1 34 inches long
and one quarter inch wide, was lodged transversely
in the anal canal.
Case II. — D. P., a married woman under forty, was re-
ferred to the Rectal Clinic of the New York Hospital, fol-
lowing an operation for the correction of flat foot four
weeks before, made necessary to relieve the patient of
lumbosacral pains radiating to the thighs, heavy, dull feel-
ing in the lower back, weakness of the feet, and inability
to attend to her usual duties. She had been troubled with
increasing constipation, straining at stool, and occasional
bleeding from the rectum; all of which continued un-
changed after her operation. Proctoscopic examination
revealed a mass, the size of a small apple, pressing upon
the anterior rectal wall, reducing its lumen considerably.
With the patient in the squatting position, the mass could
be readily outlined about four inches from the anal mar-
gin, conveying to the examining finger the impression of an
irregularly round, somewhat nodular body, apparently con-
nected with the fundus uteri. A diagnosis of a probably
malignant neoplasm was made, and an operation was ad-
vised, but was declined by the patient. Here we have dis-
ease of the genitorectal apparatus, which in its subjective
symptoms resembles flat foot closely enough to have been
mistaken for it, even to the extent of surgical remedies
August 3, 1918.]
LANDSMAN': INTERESTING RECTAL CASES.
195
being carried out to cure it. We must bear in mind, too,
that the presence of one disease does not necessarily ex-
clude another. A patient with flat foot (for indeed she
had it) may become the victim of carcinoma just as readily
as one without it. Further than that, only a thorough local
examination of the parts could reveal the seat of the real
trouble, for most of the subjective symptoms might easily
have been caused by the flat foot; that is, all except the
bleeding, which did not fit into the picture at all, and for
which a satisfactory explanation should have been sought.
If that had been done, the patient's condition might have
been diagnosed at least four weeks earlier, an interval, it
must be assumed, which would have made an appreciable
difl^erence in the management, if not in the treatment, of
the case; for a diagnosis of malignant tumor is of but little
value, if the disease is already inoperable.
Case III. — This case has been reported in detail else-
where (New York Medical Record, November 18, 1916),
and will only be briefly featured. A married woman of
twenty years of age had been complaining of obstinate
constipation, which had grown progressively worse, until
there was only one bowel movement in nine days, in-
variably accompanied by much distress. She was subject
to attacks of vertigo, headaches, cramplike abdominal pain,
tenderness in the right iliac fossa, and tympanites. Men-
struation and urination were normal ; there was no fever,
vomiting, or loss of weight. Her condition was attributed
by her doctor to a chronic appendix, and an abdominal
section was advised. When she came under observation
by the writer, he was struck with the thickened, hyper-
trophied sphincters, which surrounded the anal canal very
tightly, interfered with a proper digital examination, and
seemed to act as a decided cause of obstruction to a nor-
mally formed fecal movement. She was therefore advised
to permit a division of the muscles, before consenting to
the more serious abdominal operation ; to this she agreed,
and it was performed under local anesthesia, followed by
gradual dilatation with Wales bougies. The result proved
striking; the subjective sensations were relieved promptly,
completely, and permanently, with the return of a daily nor-
mal movement, and she was able to return in a few days to
her regular duties. Case III illustrates the obverse of
Cases I and II : inasmuch as symptoms which pointed to a
serious abdominal condition were found to be due to dis-
ease of the anal canal ; furthermore, but for the local ex-
amination, and its correct interpretation, the patient might
have felt necessary to submit to an abdominal operation,
involving invasion of the peritoneal cavity, which would in
all probability have aff^orded no relief.
Case IV. — N. K., male, twenty-five, previous history
negative, with no history of venereal disease, was taken ill
one week before he came under our observation with fever,
severe headache and backache, constipation, dysuria, and
pain in the rectum. All other examinations, including the
genitourinary tract, being negative, his trouble was diag-
nosed provisionally by his family physician as grip, and
treated expectantly. His rectal and urinary symptoms,
however, became worse, and he was removed to the
writer's service at the Philantropin Hospital, where under
general anesthesia a fluctuating, sausageshaped mass was
made out on the under surface of the pelvic diaphragm,
pressing forward toward the membranous urethra and in
the general direction of the urogenital triangle. This was
found to be due to an abscess. The abscess was incised,
its contents evacuated, and the cavity drained, resulting in
the recovery of the patient.
We know that deep abscess of the pelvirectal tissues is
a grave infection, liable to result in rupture into the peri-
toneal cavity, or when localized anteriorly, into the blad-
der or urethra ; hence its treatment must be prompt and
radical. Infections of this character may give rise to
constitutional symptoms for a longer or shorter time with-
out any focal signs; hence in every obscure fever the
pelvirectal tissues should be carefully explored, especially
in the presence of urinary symptoms for which no satis-
factory explanation can be found.
Cask V. — The patient was a married woman of twenty-
six, referred to the Rectal Clinic at the New York Hos-
pital by Doctor G., with a complaint of obstinate consti-
pation, and straining at stool, as far back as she could re-
member. She had a feeling as though the bowel did not
completely empty itself, and an annoying sensation as of
a foreign body in the anal canal, which made her return
to the toilet necessary again and again after defecation.
In addition to this, she had developed in the past three
years protrusion and bleeding from the bowel, which were
attributed to piles ; as a matter of fact, she was sent to
the hospital for operation to remove them. Inspection
showed that she had indeed some small piles, but when the
buttocks were well separated, and an attempt was made to
introduce the finger into the rectum, the true cause of her
trouble quickly became apparent ; it was due to the pres-
ence of an obstructive band, one fourth of an inch wide,
extending from one side of the anus to the other, bisecting
it into two unequal halves, and preventing the expulsion
of a normal sized fecal mass. In the absence of any his-
tory pointing to an inflammatory condition of the parts, or
any operation upon the anal canal, it may be safely as-
sumed that the trouble was of a congenital origin. The
lower portion of the rectum is formed by the union of the
caudal end of the enteron with the proctodeum, an invagi-
nation of the ectoderm at the anal site ; these grow toward
each other, and when they finally meet, the membrane be-
tween the two becomes absorbed, and a continuous tube is
formed. At times, owing to some unknown fault in de-
velopment, the membrane between the two persists, either
in whole or in part, causing a varying degree of obstruc-
tion to the fecal current. The remedy in this case was
simplicity itself, and its application resulted in a prompt
cessation of the troublesome symptoms.
The lesson to be derived from this case appears to be
clear enough, but it might not be amiss to repeat, at this
point, that a careful examination of the anal canal of the
newborn child should be made by the obstetrical attendant
as soon after birth as possible. The anus should not be
merely inspected, but a well oiled finger ought to be passed
into the canal, one inch or more upward. A deep anal
dimple may be the only evidence of an anal canal, as in one
of our cases; at any rate, the discovery of a malformation
of the parts at this time may be the means of saving years
of sufi'ering, if not life itself.
Case VI. — An unmarried woman, under thirty, had been
suffering from loose stools, containing mucus and pus, and
protrusions from the bowel, a number of years. Her appe-
tite and general condition were good, she had not lost any
weight, and was able to attend to the demands of a rather
strenuous occupation. However, she decided to consult
her doctor, and was under treatment for four months with
bismuth internally, starch enemata, and regulation of the
diet, which gave her only temporary relief. She was re-
ferred to the writer, and on proctoscopic examination an
ulcerated bleeding mass three inches from the anal margin
was found, which partially surrounded the circumference
of the bowel. The pathologist's report showed it to be an
adenocarcinoma, and an amputation of the rectum was
done by the vaginal route ; the treatment, however, failed
to save her life. There is one symptom in this case which
should have put the doctor on his guard at once : the pres-
ence of bloody stools containing mucus and pus, which
are never a part of the picture in bleeding from hemor-
rhoids. The age of the patient, and absence of loss of
weight, are merely negative symptoms, which do not count
in the presence of positive signs. Four months were spent
in temporizing with a condition which should have received
medical treatment immediately, and which a careful local
examination would have disclosed at once.
The material presented furnishes food for
thought and contains facts which cannot be disre-
garded. It could serve no useful purpose to cite
any more cases ; enough have been recorded to
convey an adequate idea of the subject to the gen-
eral practitioner, and even the specialist ; enough to
demonstrate how much depends upon a careful,
svstematic, and thorough examination of the parts.
Mistakes will continue to be made, because the
human mind with all its wonderful attributes is an
imperfect instrument ; but it is one thing to arrive
at an erroneous conclusion after a full consideration
of all the facts, and quite another to fall into error
because we have failed to gather the best evidence
obtainable to make out our case.
17 East Thirtv-eighth Street.
196
BOWERS: HOW TO GET ENOUGH SLEEP.
[New York
Medical Journal.
HOW CAN WE GET ExN'OUGH SLEEP?
Bv Edwin F. Bowers, M. D.,
New York.
On an average most healthy persons require
about nine hours' sleep in order to be thoroughly
recuperated. Women need and should have a
half an hour to an hour more than men of the
same age.
But this is entirely a matter of the individual's
power to recuperate — to restore his oxygen bal-
ance, eliminate or burn up his fatigue poisons,
and to replace his wornout cells with fresh tissue
pabulum. All of which depends largely upon the
depth of sleep. If the sleeping chamber is stuffy
and poorly ventilated no amount of sleep is going to
produce the rested feeling that should come from
sound sleep taken under hygienic conditions.
Of course, these hours of sleep do not apply to
children. The rules governing their sleeping
must be much more flexible than those applied
to adults. Children growing rapidly need more
sleep than those of slow growth. Children require
and should get more sleep in winter than in sum-
mer. And vigorous children need less sleep than
delicate children. At a rough estimate it might
be said that babies can use fifteen to eighteen
hours out of every twenty-four very profitably in
sleeping. This period gradually declines, until
at the third year the child requires about twelve
hours. By the sixth year, if left to his own in-
stincts, he takes about ten hours. Up to the
eighteenth or nineteenth year this ten hour ne-
cessity persists. Growth being by this time at-
tained, the sleep requirements drop an hour or
more, and remain there until the advent of that
second childhood, age — which reduces the period
of reconstruction because the reconstructive fac-
ulty has been reduced.
To make children get up before they have had
enough restful sleep to thoroughly refresh them
is a foolish, health destroying crime against the
child, and an insult to Nature. There's nothing
we could possibly do^ — unless it would be to
frighten them with bedtime tales of ghosts or
hobgoblins — -that reacts more disastrously on the
nervous systems of children or youths of either
sex than to deprive them of needed sleep. And
nothing that will sow the seeds of future nervous
instability more surely.
The best time for sleeping is that time that will
favor the greatest degree of relaxation. With
most people this is soiiif- time during the hours
of darkness, when there isn't so much going on to
distract the senses of sight and hearing. Just
what hours should be devoted to sleeping is not
as important as that there should be enough of
them. The socalled beauty sleep, achieved dur-
ing the hours preceding midnight, is a fact only
because it adds to the number of hours which,
under ordinary conditions, we might be supposed
to spend in bed. Most of us get up at about the
same time every morning — no matter how early
or how late we've gone to bed the night before.
So there isn't a word of truth in the old fable
that one hour of sleep before midnight is worth
any two hours after. Sleep is sleep, provided
only that it is sound, restful sleep — whether we get
it at eight o'clock in the evening, two o'clock in the
morning, or one o'clock the next afternoon. If
we can get our sleep undiluted by disturbance so
much the better.
In this connection it may be of interest to ob-
serve that we physicians are at last awakening to
the fact that it is a job similar to the one made
famous by the industrious Sisyphus to attempt
to cure a neurasthenic who isn't permitted to
sleep. We are beginning to realize that sound
sleep isn't obtainable in a bed that rattles or
squeaks or that shocks the nerves into semi-
wakefulness by unusual slippings of the springs
or unexpected creakings. The advent of the sep-
arate bed and the banishing of th§ double bed
into the limbo of warming pans and night caps is
a distinct advance from the standpoint of hy-
giene, sanitation, and more rational sleeping hab-
its. When separate beds, or, better still, sepa-
rate sleeping chambers, are in universal use, men
and women, especially nervous men and women
— and delicate children, will get a good deal more
sleep than they do at present; they'll derive more
benefit from the sleep they do get. All this will
make it easier for them to do with considerably
less sleep than they now require.
225 West End Avenue.
HIRSCHSPRUNG'S DISEASE WITH EVEN-
TRATION OF THE RIGHT HALF
OF THE DIAPHRAGM.
By Edward A. Aronson, M. D.,
New York,
Adjunct Atttnding Physician, Mt. Sinai Hospital; Chief of Clinic,
Department of Gastroenterology, Mt. Sinai
Dispensary, New Yorlc.
Hirschsprung's disease is synonymous with mega-
colon congenitum, idiopathic dilatation of the colon.
By it is meant a marked dilatation of the whole sig-
moid colon with hypertrophy of all the coats of the
colon, particularly the muscular. The case I wish
to report is unique, because of the coincident occur-
rence of such a dilated colon with a marked eventra-
tion or elevation of the diaphragm.
Case. — B. G., age twenty; saleswoman, Russian; was
admitted to the first medical service of Dr. N. E. Brill,
August 22, 1917, and discharged September 21, 1917. The
chief complaint was pain in the right hypochondrium for
the past two years. Family history was negative. Past
history was negative, except that just prior to the begin-
ning of her complaint she fell from a car, striking her
right side.
Present history: For two years she has complained of
pain in the right hypochondrium and chest, cramplike in
character, increased by taking food, usually one hour after
meals; nausea after meals; and frequently vomits, induc-
ing same for the relief of epigastric distress and disten-
tion She has frequent eructations of no particular taste
nor odor; no jaundice nor hematemesis ; is constipated ; has
frequent attacks of pain at night, but no cardiac or res-
piratory disturbance, and no genitourinary symptoms. She
has frequent headaches, some loss of weight, and has had
several fainting spells.
Summary: Cramplike pain in the right hypochondrium
and right chest, nausea, vomiting, eructations, constipation,
headaches for two years.
August 3, 191 8.1
ARONSON: HIRSCHSPRUNG'S DISEASE.
197
Physical examination: Her general condition was fair,
she was anemic, and had spots of pigmentation on the
abdomen. Respiration was increased and, at times, there
was slight dyspnea ; the nodes small, cervical, axillary and
cpitrochlears palpable. Head, ears and mastoids were
negative. Eyes were normal. Mouth, teeth and gums
were in fair condition ; mucosa was negative ; tongue moist
and coated ; throat negative. Neck showed no rigidity.
Thyroid was normal. Heart apex was in the sixth space
in the anterior axillary line. Right border was at the left
parasternal line ; action was slow and regular ; no mur-
murs ; pulse of a normal tension.
Lungs: There was dullness above the right clavicle, be-
low it became tympanitic and continued so to the costal
margin. On the left side there was normal pulmonary
resonance. On the right side in the supraclavicular region
the breathing was rough and loud. Below the breathing
became diminished and finally absent. At the end of in-
spiration there was occasionally heard a metallic tinkle.
Posteriorly there was dullness over the right suprascapu-
lar region, below the shoulders, tympanitic. Over the up-
per portion the breathing was rough and loud, below it was
gradually diminished. On pressure in the epigastrium, or
over the right hypochondrium, musical gurgling sounds
were heard. On the left side, posteriorly, there was rela-
tive dullness and the breathing was somewhat rough.
Abdomen: The abdomen was perfectly flat. There was
resistance in the right hypochondrium ; the liver was not
palpable, nor could its position be elicited by percussion.
The spleen edge was fully two fingers below the costal
margin. Kidneys were not palpable ; no masses were felt
anywhere. Extremities were negative. Summary : Loss
of weight, palpable lymph nodes, cardiac displacement,
pulmonary signs, palpable spleen.
Blood examination: Hemoglobin, 85 per cent.; red blood
corpuscles, 4,000,00c; whit? blood corpuscles, 10,000; poly-
nuclears, 60; small lymphocytes, 26; large lymphocytes, 10;
transitional i; eosinophiles, 2; basophiles, i.
Stomach contents: Fasting, 15 c.c. ; gray-yellow; no
food residue; small amount of mucus; congo positive;
total acidity, 23; free hydrochloric acid, 8; test meal, 150
c.c; of a brownish color; total acidity, 46; free hydro-
chloric acid, 20. Blood pressure — systolic, 90 ; diastolic, 70.
Urine negative, stools negative.
Report from the Rdntgenological Laboratory: The
Rontgen examination of the chest showed almost complete
absence of the lung markings on the right side. At the
level of the second rib anteriorly there was seen travers-
ing the chest a linear shadow, the convexity of which was
upward. Above this shadow there apparently was nor-
mal lung. Below this shadow the lung structure was ab-
sent and was replaced apparently by air. The linear
shadow described was the diaphragm, which was displaced
upward by the intestinal viscera. The heart and the medi-
astinum were displaced toward the left. Fluoroscopic ex-
amination showed the diaphragm on the right side to be
motionless in respiration. The Rontgen appearance indi-
cates probably a diaphragmatic hernia or eventration.
The differentiation between these two conditions is almost
impossible.
The Rontgen examination of the gastrointestinal tract
showed the following: No abnormality was seen in the
esophagus. The stomach was situated vertically, displaced
to the left and moderately ptosed, its lower pole in the
erect position reaching about two inches below the crest
of the ilium. Gastric tone was good and peristalsis was
normal. The duodenal bulb was small, but regular in
contour and not tender. The food started to pass at once
through the pylorus, and the stomach seemed to be empty-
mg rapidly. An examination made three hours post cibum
showed almost the entire food in the jejunum and ileum;
there was a moderate quantity still in the stomach. At
the six hour observation there was a very tiny residue
still in the stomach and the rest of the food was in the
jejunum and the ileum. The entire colon was distorted
and displaced to the right. It was difficult to determine
exactly its different portions. An observation made forty-
eight hours post cibum showed most of the colon out-
lined. The examination of the colon by means of a barium
enema showed a markedly distended colon, not all of it
outlined, and it was difficult to distinguish its different
portions.
The patient was discharged from the hospital and, in a
short time, began to have several attacks characterized by
pain referred to the right chest and right hypochondrium,
accompanied by vomiting, loss of appetite, marked con-
stipation and weakness. On account of the frequent re-
currence of these attacks, each of which would last for
about three days — the intervals between such attacks be-
ing extremely short — the patient demanded some relief,
even though surgical interference were required. Acting
upon this demand the patient was readmitted to the gastro-
enterological service (Dr. A. A. Berg, Chief) of the hos-
pital, and further study was then made of the abdominal
condition. Particular attention was paid to the rontgeno-
logical examinations of the colon. In view of the rare
findings during the preceding stay in the hospital, in which
evidence was noted of the eventration of the right half
of the diaphragm with marked displacement of the colon
high up on the right side, it was decided to further this
study by means of barium enemata. Five and a half
quarts of the barium enema were found necessary to dis-
tend her colon — one and a half quarts being the usual
amount required. X ray findings showed a huge disten-
tion and dilatation of the complete descending and trans-
verse colons with a protrusion upwards to the chest, be-
neath the marked elevation of the right half of the dia-
phragm.
On November 17, the patient was operated upon by Dr.
A. A. Berg. Laparotomy was performed and, immedi-
ately, the distended gut presented itself through the ab-
dominal incision— the gut having a circumference about
as large as a stout person's thigh. With the extrusion of
the gut the patient temporarily ceased breathing, in all
probability, due to a partial return of the heart to a more
normal position, and to a descent of the diaphragm, with
a sudden expansion of the right lung. About three feet
of this distended colon was resected, and a side to side
anastomosis was performed. Doctor Berg, after resection, on
inserting his hand into the right upper quadrant, found
that the diaphragm had descended, possessed respiratory
motility, and that a hand's breath space existed between
the diaphragm and liver. The patient made an uneventful
recovery ; the respiratory signs in the right lung ap-
proached much nearer the normal; subjectively, the symp-
toms improved considerably ; the gastric symptoms disap-
peared ; and constipation gave way to a normal bowel
movement.
The patient was discharged from the hospital. Prior to
discharge, however, a rontgenological examination of the
thorax showed that the right half of the diaphragm had
descended to the fourth rib. The shadow caused by the
liver was very distinct, and a space of about three fingers'
breadth persisted between the diaphragm and the liver.
The left half of the diaphragm was somewhat higher than
in the preceding examination, and the heart had assumed
a position considerably more to the right. Fluoroscopic
examination showed that there was respiratory motility
on the right side, but the respiratory excursions there
were much more limited than on the left side. There was
no paradoxical respiration to be noted.
An analysis of the case made us appreciate that
we had to deal with a marked dilatation of the colon,
coincident with eventration of the right half of the
diaphragm — a truly unique condition. There was
no evidence to prove that the colonic condition was
other than a congenital one. In reviewing the his-
tory we note that, while the constipation was some-
what of an obstinate one, it was never so marked
as one expects to find in Hirschsprung's disease,
where one of the cardinal symptoms is a most ob-
stinate constipation. The curious feature was that
the dilatation was coincident with eventration of
the diaphragm on the right side rather than on the
left. There must have been some pathological lesion
of the right half of the diaphragm to permit of its
marked displacement upward by the dilated colon.
The puzzling factor was to account for the right
sided eventration. The only etiological factor which
198
ARONSON: HIRSCHSPRUNG'S DISEASE.
[New York
Medical Journal.
miglit have some influence on the right sided lesion
was that the symptoms persisted for only two years,
and were felt directly subsequent to the injury re-
ceived by the falling from the car and striking the
right side. This injury caused her, at the time,
to remain in bed for two weeks, and, according to
her story, she was considerably shaken.
Eventration of the diaphragm has been regarded
as synonymous with several other conditions, and
has been known ever since F. L. Petit reported a
case in 1790. In 1849, Cruvellhier gave his con-
ception of this condition under the same term. Some
have used the terms dilatation, relaxation, muscular
insufficiency, high position, elevation. Others have
used the same terms to describe a pathological con-
dition of the diaphragm, permitting the abdominal
viscera to be displaced upward. The diaphragm,
as a result, is greatly thinned as well as distended,
but its three layers remain intact. In this respect,
the condition is different from hernia of the dia-
phragm, which, whether tnie or false, is dependent
on the presence or absence of a hernial sac, consist-
ing of an opening in the sheet of the diaphragm
through which the abdominal viscera pass into the
thoracic cavity. All the terms mentioned are par-
tially descriptive, though none are satisfactory. As
its multiplicity of names suggests, eventration is one
of the rarer lesions of the diaphragm. As to its
frequency, Eppinger, in 191 1, published the follow-
ing comparison :
Type Right side Left side
True hernia 21 53
False hernia 34 527
Eventration 2 15
This gives a total of 635 cases, in which there
were seventeen eventrations ; the ratio of eventra-
tion to hernia being one to thirty-seven. Bayne-
Jones collected a larger number, and the number of
eventration cases has now risen to forty-six.
Bayne-Jones added a third case of right sided even-
tration, occurring in a man of fifty-two who began
to complain of gastric symptoms five years before
admission to the hospital. The above described
case makes the fourth of right sided eventration in
the literature. Diaphragmatic hernia with protru-
sion of the stomach or other abdominal viscera into
the thoracic cavity and a relative condition — eleva-
tion of the diaphragm — though not common, are of
practical importance. Both may give rise to
marked gastric symptoms. The former is an actual
rupture of the diaphragm, the latter is not ; al-
though the term eventration, which is frequently
used as a synonym, implies a rupture. While the
right half of the diaphragm may be affected, nearly
all the cases reported have been left sided. Eleva-
tion is usually, if not always, congenital. Hernia
may be either congenital or acquired. The clinical
symptoms and the physical signs of the two condi-
tions are not essentially different, and the rontgen
examination affords the most effective means of
exact diagnosis and of differentiating the one from
the other.
The diaphragm depends for its nerve supply upon
the phrcnics which arise from the fourth cervical
and connect with fibres from the third, and even
from the fifth. Along their course to the dia-
])hragm they connect with fibres from the brachial
plexus. In the etiology of the condition, apart from
being congenital, it may occur in diseases of the
motor columns of the cervical cord, c. g., anterior
poliomyelitis, tumors — such as tubercle, gummata,
lepra tubercles — in diseases of the cervical vertebra,
fracture and dislocation of ihe midcervical vertebra,
involvement of the anterior horns (hematomyelia)
or into the m.eninges surrounding the same, mostly
traumatic. We see it, also, in Duchenne-Erb
paralysis ; in tumor compression of the phrenics ; in
tuberculosis caused by a compression of the thoracic
glands; as a neuritis; in infectious diseases, such
as diphtheria ; in alcoholic, lead, chronic arsenical,
carbon dioxide, and opium poisoning; in acute and
chronic inflammation in the vicinity of the phrenic
or diaphragm — for example, pleuritis ; in tabes ; in
progressive muscular atrophy ; and both hysterical
and rheumatoid forms have been described.
120 West Seventieth Street.
Treatment of Sprained Foot in Military Prac-
tice.— Audion (Paris medical, April 20, 1918) com-
ments on the large number of cases of pes equinus
or equinovarus which have followed mere sprains
among soldiers. Surgeons have been allowing men
with such sprains to walk as soon as they feel able
to, just as has been the custom in civil practice. The
soldier, however, instead of resting as soon as the
muscle concerned begins to be fatigued, finds so
much pleasure in walking about and is so hardened
to fatigue that he does not rest the parts sufficiently.
The muscles fail to recover their mobility complete-
ly during rest, and the faulty attitude of the limb
assumed in locomotion to minimize pain becomes
fixed by contracture and retraction of the over-
fatigued muscles. All these sprain cases should be
put to bed when admitted and the condition of the
foot examined carefully the next day. Where the
patient is able voluntarily to flex the foot so that the
sole forms an angle of 75° to 80° with the axis of
the leg, he can be allowed to walk two hours every
day provided he avoids external rotation of the foot
and keeps the heel down normally at each step. If
he cannot walk thus, he should remain in bed longer,
or better, a plaster boot should be applied with the
foot flexed — a procedure facilitated by the sitting
position, the knee being flexed and the chair moved
forward slightly in relation to the affected foot rest-
ing on the ground. Where voluntary flexion of the
foot proves impossible at the first examination, pas-
sive flexion should be attempted. If it can be ac-
complished, the patient may walk, but not as long
as the preceding group of cases ; preferably he
should be allowed to walk only to the table and the
latrine, remaining in bed the rest of the time. If
even passive flexion is impracticable, a plaster boot
should be applied with the foot in the best position
in which the patient can walk without distress. The
boot should be used for ten days to two weeks. The
patient must allow the boot to harden for twenty-
four or thirty-six hours before he begins walking.
To prevent any tendency to external rotation by
pivoting on the heel in walking, the patient should
be told to bend the knee as soon as the heel meets
the ground.
Med icine and Surgery in the Army and Navy
EXAMINATION OF RECRUITS FOR
TUBERCULOSIS *
A Plan for the Special Examinations of Conscripts
at the Place of Mobilij^ation zmth Particular
Reference to Tuberculosis.
By Ralph C. Matson, M. D.,
Portland, Ore..
Major, M. R. C, United States Army, Tuberculosis Specialist,
Ninety-first Division; President, Tuberculosis Examining
Board, Camp Lewis, American Lake, Washington.
Conscripts upon arrival at this camp are regis-
tered in the receiving camp and are assigned to the
depot brigade, where they enter quarantine for
three weeks, during which time they are clothed,
vaccinated, and drawn for special physical examina-
tion. This examination is carried out uaider orders
issued by the mustering officer to the commanding
oflicer of the organization or organizations to
which the conscripts belong, directing them to re-
port to the supervisor of the special physical ex-
amining boards.
The special physical examining boards act in an
advisory capacity to rhe mustering officer. They
are under the direction of the division surgeon and
supervised by the president of the tuberculosis ex-
amining board. These boards comprise the tuber-
culosis examining board, cardiovascular board, or-
thopedic board, and the neuropsychiatric board. They
occupy a regulation barrack (plans A and B). The
lower floor houses the orthopedic and cardiovascu-
lar boards, the x ray rooms, the reexamination
rooms, supervisor's office, and laboratory. The up-
per floor houses the tuberculosis and neuropsy-
chiatric boards, stenographers, and clerks. These
boards are organized to handle 1,500 men daily, but
^v^th an additional force they can be expanded to
take care of 2,000 men daily.
The conscripts report for examination in charge
of a noncommissioned officer as follows : approxi-
mately 250 at 7.30 in the morning ; 200 at 8.30 a. m. ;
150 at 9.30 a. m. ; 150 at 10.30 a. m. ; 250 at 12.30 p.
m. ; 250 at 2 p. m., and 200 at 3 p. m. In this way
large numbers of men are not kept waiting. On
the day preceding the examination the mustering
officer sends a duplicate of each man's form loio,
issued by the local board to the supervisor of the
special physical examining board, together with a
copy of the order to report for examination and the
roster. The lOio forms are arranged in the same
order as the names on the roster, and the men are
lined up single file outside the barrack building in
the same order. The receiving is in charge of three
clerks (enlisted men). All enlisted personnel of all
the boards is in charge of one noncommissioned offi-
cer. The clerk at the entrance calls out the names,
and each man enters the building as his name is
called. He is handed his form loio and told to look
at the name. As he enters, he states his age, which
is written behind his name upon the roster, serving
as a check indicating that the man has appeared for
examination and has been given his form loio. The
*Published by permission of Board of Publication, office of
Surgeon General.
man passes into room i-A (see plan), and hands
his form loio to a second clerk, who asks the man
his name and compares it with the loio. He then
copies the man's name on form 88, and passes 88 and
lOio across the table to the third clerk, who copies
the name upon a blank reference card. These are
returned to the conscript, who passes on and is in-
structed by an orderly to completely undress and
place his clothes upon the mess table (i), which
runs down the middle of the room, dividing the or-
thopedic space into two parts in such a manner that
after the examination the men secure their clothes
from the opposite side of the table, thus obviating
the necessity of going back after them and inter-
fering with traffic.
After completely undressing, the men take their
place in line, single file, and pass to the orthopedic
board, which consists of three medical officers and
two clerks. Each man motmts on one end of the table
(see plan 2) and approaches the orthopedic exam-
iner (Plan A. — Fig. 3), who is stationed at the other
end and conducts the foot examination. Note is made
of their foot posture, the amount of disability, and
the presence of congenital or acquired deformities.
A statistical record of the finding is made on ortho-
pedic form I. The man passes on for the general
examination. For this general examination two ex-
aminers are utilized (4). The recruits are lined
up on the floor three feet apart in rows of six,
each man standing on a mark painted on the floor
(X). fie places his papers in front of him on the
floor ; the various joints of the body are then exam-
ined for deformities and tested for limitation of
motion, special attention being given to the spine and
to general body posture. Upon completion of the
examination the recommendation of the board is
stamped on form 88 and the blank card, and a record
is made of those accepted for full military duties,
those accepted for special and limited service, or do-
mestic service only, and those rejected. (No writ-
ing is placed upon form lOio; it is only to determine
what action was taken by the local or medical ad-
visory board.) In case of rejection or acceptance
for special or limited military service, orthopedic
board form 2 is filled in and kept by the board as
the board's record, and a note is made upon form 88
of the cause of the rejection, or the reason for spe-
cial or limited military service ; or, if accepted, with
abnormalities, a record of the abnormahty is made
and recorded on form 88, after the word "accept."
The orthopedic board stamps its recommendation on
the second line from the bottom on form 88. In
case of rejection or domestic service only (special
or limited military service), the board's clerk records
the reason for such action on form 88, but if ac-
cepted with abnormalities for full military duty, the
clerk places the number of the abnormality as it ap-
pears on the Surgeon General's office list. The exit
clerk refers to the list and writes in the abnormality
after the conscript has given up his paper ; thus the
conscript has no knowledge of the existence of an
abnormality. The three papers (form loio, form
88, and blank card) are returned to the man, who
200
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
passes on down the side of the mess table opposite
to his entrance; he removes his clothes therefrom
and dresses to the waist, except shoes. An orderly
stationed in this dressing space calls out constantly,
"Dress to the waist quickly, except shoes ; carry
your shoes and remaining clothes on your left arm.
Be sure you pick up your right papers and all your
belongings. You cannot return." The man passes
upstairs to be examined by a member of the cardio-
vascular board (room 2-A) for enlarged thyroid,
which, if found enlarged, is indicated by placing a
T upon the conscript's chest with a skin pencil. An
orderly stationed at the head of the stairs first re-
quires each man to examine his papers again and
make certain that they belong to him, lest in dress-
ing he may have picked up another man's papers.
The man then passes on to the tuberculosis exam-
iners, consisting of twelve examiners, each given a
number which is written in lieu of signature on form
88 and on the blank card. The examiners are dis-
tributed at convenient places around the room ; they
are selected for the most part from infirmary sur-
once ; after the man leaves the base hospital, a sec-
ond examination is made one month later, and a
third one made three months after the first.
The tuberculosis examiners verbally interrogate
each man regarding his family, past and present his-
tory along the lines indicated in circular B, this
board, and according to the special blank form i,
this board. The physical examination is then made
along the lines described in circular A,^ this board,
circular 20 S. G. O., and Colonel Bushnell's "Mani-
fest Tuberculosis."
The principles contained in these circulars have
been thoroughly mastered by the tuberculosis exam-
iners. If the examiner has reason to suspect tuber-
culosis, either from the patient's family history, past
history, present history, or the results of the phys-
ical examination, he is required to write a history
of the case on blank form i. In any event, a history
is required, and the conscript must be referred to
the X ray department under the following circum-
stances: I. History of prolonged contact with, or
death of a single member of the family from tuber-
ENTRANCe
STA. WHERE FORM88 AND BLftNK CARD 15 MAD^OUT.[
5TATION WHERE FORM lOlO IS GWEN TO CONSCRIPT.
-STA WHERE
F0RM68 6I0I0
]AI!S COLLECTED
AND STAMPED
QK.CflR04V.yi
^ CLERKS.
© ORDERLIES WHO DIRECT CONSCRIPTS.
.RAILINGS.
Plan A. — Lower floor, physical examination unit: orthopedic and cardiovascular boards and x ray rooms.
ENTRANCE AND EX\T
FOR DEFFERED CASES.
EXIT
geons in the camp, few of whom have had any re-
cent training, and none of whom have had any spe-
cial training in physical diagnosis. An effort is
made to get officers from every organization who
are especially interested in the work, so that there
will be at least one officer in every organization who
will have some special knowledge of the diagnosis
of tuberculosis. This plan has proved advantageous,
in that these oflicers are constantly on the alert for
suspicious cases in their organizations. Approxi-
mately one third of these officers are detached from
the organizations that are not full ; they are as-
signed to the depot brigade for duty on the tuber-
culosis examining board. The other medical offi-
cers go back to their organizations during the quiet
period. When insufficient infirmary surgeons are
available, the deficiency is made up by the addition
of contract surgeons. During the quiet period the
"board conducts reexaminations of men who have
had measles, influenza, pneumonia, and broncho-
pneumonia. These examinations are carried out at
culosis. 2. Inability to work because of ill health.
3. Every case of well defined history of previous
pleurisy, pneumonia, frequent or protracted colds,
typhoid fever, or any other past illness of a pro-
longed character, which could have been tuberculous,
such as prolonged cough and expectoration, hemor-
rhage from lungs, or expectoration of bloody spu-
tum, loss of weight or strength, night sweats, fa-
tigue, etc. A sputum examination will be request-
ed in every case wherein cough or expectoration is
claimed, or rales of any description are heard on
auscultation. 4. Existing, cervical adenitis, tuber-
culosis of the bones and joints, or rectal fistula. 5.
Every asthenic and all cases wherein a man's physi-
cal condition is manifestly below par or lacking in
stamina or resistance to disease. 6. All cases of
chest deformity, scoliosis, kyphosis, funnel chest,
pigeon breast, flat chest, and barrel chest. 7. All
cases wherein physical examination reveals (a) im-
'The text of circulars, A, B, and C will be given in the second
instalment of this article.
August 3, 1918.1
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
201
paired resonance on percussion. (b) Increased
transmission of voice sounds over areas where it is
normally not increased. (c) Abnormal breathing,
such as sharpened vesicular or rough inspiration,
with prolonged expiration, over areas where it is not
physiologically normal, even though no rales are
found. (d) All cases presenting rales, (e) Fix-
ation of lung borders or Turban shading.
A copy of the above is given each examiner and he
is required to follow it carefully. When the exam-
inations noted above are distinctly negative, and the
examiner is of the opinion that there is no evidence
of disease of the lungs, pleura, or mediastinum, he
accepts and indicates the acceptance by placing his
number with a lead pencil at the beginning of the
fifth line from the bottom on form 88. He also
places his number on the blank reference card in
the space assigned to the tuberculosis board. The
tuberculosis examining board not only examines
for lung abnormalities, but notes cardiovascular and
neuropsychiatric defects. If a neuropsychiatric or
cardiovascular defect has been observed or suspect-
ed, an N or C or both are placed upon the man's
chest with a grease pencil, the man then passes on.
If he bears an N, the orderly directs him to the
neuropsychiatric board (room 3), otherwise he goes
downstairs. In case positive evidence of tubercu-
losis is obtained as a result of the investigation under
I, 2, 3, 4, 5, 6, or 7, the examiner is obliged to fill
in the important data on form i, with remarks per-
taining thereto. He also fills in the result of the
physical examination. In case of abnormal physi-
cal findings, the examiner is obliged to record the
results of inspection, percussion, and auscultation,
as outlined in circular C, this board. This nomen-
clature was adopted to prevent the use of careless
and meaningless phrases. While it does not cover
all physical phenomena noted in physical examina-
tions, it is sufficiently broad to cover all important
findings, and at the same time to standardize our
methods. A diagnosis is also required if a lung
abnormality is noted. If tuberculosis is diagnosed,
the character, location, extent and activity of the
lesion must be indicated. In other lung diseases
sufficient evidence must be given to justify the diag-
nosis. For instance, if uncomplicated chronic
bronchitis is diagnosed, we expect the examiner to
give the evidence on which the diagnosis has been
made. W^e would expect a history of cough and ex-
pectoration for more than three months' standing ;
no alteration in percussion resonance ; certainly a
prolonged expiration over the lower lobes with non-
resonating mucous rales. If emphysema is diag-
nosed, we would expect him to demonstrate a pro-
longed expiration with the lung border standing
below the twelfth dorsal spine behind and below the
seventh rib in the midmamilliary line in front, with
mucous nonresonant rales, etc. The examiner then
checks for sputum examination, providing the con-
script claims cough and expectoration, or if any kind
of a rale is heard on auscultation. He then writes
his recommendation to the president of the board
and the reason the case is referred to the x ray de-
partment, such as "family history, past history,
present history, physical findings, chest deformity,
asthenia, etc." The examiner finally signs the blank
and in addition places his number on form 88 and
the blank card. In the latter instance, he places an
H after his name, indicating that a history has been
written. The papers are then returned to the con-
script, who passes downstairs, providing, of course,
that he does not bear an N. Silence is maintained
in the tuberculosis examining room by four order-
lies, who see to it that the examiners are constantly
supplied with men to examine. Inasmuch as the
men are in their stocking feet, there is no noise due
to movement about the room. Upon arriving down-
ART^CWS INPICATH COURSE TAKEN BY CONSCRIPTS FOR EVAyriNATlONS-
I /
I /
□ D O O □ □
3 T B. f XAMINATION ROOM
1 THOSE REQUt»lN& SPECIAL EXAM ARE
MARKeO ON WITM LE1T£RS TO INQ'CATF f
Q n □ □
□ no
/ t r /
J N p. EXAMINATION ROOM
VJ
3TENOGRAPMEPS.
□ □ □ a □
Plan B. — Upper floor, physical examination unit; tuberculosis
and neuropsychiatric boards.
stairs in room 4 A, the man confronts an orderly
(four orderlies are used to direct traffic in this
room), who observes whether the man has a his-
tory blank, a C or a T upon his chest. If none is
present, the man is instructed to dress completely,
4 C, and pass on to the exit, where he gives up
all papers to the exit clerks (three in number), who
now stamp form 88 and the blank reference card
"T. B. Exam. Bd. ACCEPT," behind the examin-
er's number. On the line below this (fourth from
the bottom) he stamps "No N. P. defects noted by
the T. B. Exam. Bd." In case an N. P. defect has
been noted, this space will have been stamped by
that board. On the third line from the bottom on
form 88 and the blank reference, the exit clerk
stamps "No C. V. defects noted by the T. B. Board,"
which, if noted, is stamped by the cardiovascular
board. The orthopedic board has already stamped
their action. If a history has been written, the man
is instructed to put on his shoes and pass on without
further dressing to the history clerk (four in num-
ber), who complete the history and direct the man
to the X ray waiting room (Room i B).
The X ray equipment consists of two fluoroscopic
outfits, equipped with Coolidge tubes, three medical
officers, twO' stenographers and one clerk, and three
orderlies to direct traffic and maintain order. Each
rontgenologist fiuoroscopes 200 to 250 men daily.
The fluoroscopic work begins in the morning as soon
as a sufficient number of men accumulate, and con-
tinues until the last man has passed through. Each
day's work is thus finished the same day. The men
are brought into the x ray room in groups of ten,
lined up single file, and as each man steps in front
of the screen he gives his name. The findings are
dictated as the examinations proceed, the stenog-
rapher recording them in the dark. In case of neg-
ative findings, the rontgenologist dictates simply
"negative," whereupon the stenographer turns on
the ruby light, gives the man an O. K. card ; the next
man steps in promptly and the light is turned out
again. In case of abnormal findings, the dictation
is made as brief as possible, and the rontgenologist
202
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
places an R upon the man's chest with a grease
pencil. After all have passed under the screen, the
light is turned on and the men pass out, those having
O. K. cards complete their dressing and pass on to
the exit clerk, where the card is given up and the
man joins his company waiting outside. The men
with R's upon their chest and without O. K. cards
are directed back to the waiting space for reexam-
inations (4D).
TUBERCULOSIS EXAMINING BOARD, CAMP LEWIS, WASH.
FORM I.
Name Rank.... Org Bat Co
Date Drafted from Inducted in service
Occupation Working steadily? Why not?
Age.... Single.... Married.... Nativity mother Father
Family History.
Father. Alive.... health dead Cause
Mother. Alive.... health dead Cause
Brothers. Alive.... health dead Cause
Sisters. Alive.... health dead Cause
Remarks
Past History.
Severe or prolonged illness (Nature — Date — Duration)
Pneumonia Pleurisy Typhoid
Take cold easily last long.... weeks.... cough or spit blood.
Remarks
Present History.
Cough how long Raise from lungs how long
Height.... Highest Wt when.... Present Wt L. due to..
Tire easily Time of day how long sweat at night...
Remarks
Examination.
General condition Habitus Attitude.
Physical Findings:
X Ray Findings:
Diagnosis:
Sputum Recommendation
Referred to because of
Their diagnosis Final disposition
T. B. Examiner's name
FORM II.
Camp Lewis, American Lake, Wash.
Date 1918.
From: The President of the Tuberculosis Examining Board, Camp
Lewis, American Lake, Wash.
To: The Commanding Officer:
Organization Co
Subject: Tuberculosis Examinations:
You are requested to require the following named persons to
report to
Date at for the purpose of a
Re-examination
FORM III.
Camp Lewis, American Lake, Wash.
Date igi8.
From: The President of the Tuberculosis Examining Board, Camp
Lewis, American Lake, Wash.
To: The Commanding Officer:
Organization Co
Subject: Tuberculosis Examinations:
You are requested to require the following named persons to
report to (The orderly room, for example)
Date, June 24, at 5 a. m., for the purpose of coughing and expec-
torating from lungs, into sputum cup in the presence of an attendant.
It is requested that the sputum cups so obtained shall be labeled,
showing Name, Organization, Rank, Company, Age, and same should
be sent to Laboratory Building No. 33, H. A. Section.
Each sputum cup so obtained should be wrapped separately in
order to avoid contamination of one specimen by another.
FORM IV.
Camp Lewis, American Lake, Wash.
Date 1918.
From : The President of the Tuberculosis Examining Board, Camp
Lewis, American Lake, Wash.
To: The Commanding Officer:
Organization Co
Subject: Tuberculosis Examinations:
You are requested to require the following named persons to
report to the x ray laboratory,
Date.
at for the purpose of an x ray examination.
After approximately fifty men have passed
through, for about one hour, the rontgenologist and
stenographer alternate with another rontgenologist
and stenographer. The stenographer secures from
the exit clerks the papers of the men upon whom
he has taken dictation, and records the x ray find-
ings at once upon the history blanks, which are then
handed to the clerk of the assistant of the president
of the board. The assistant reviews the evidence
recorded, namely, the complete history, physical ex-
amination, diagnosis made by the examiner, the :^
ray evidence dictated by the rontgenologist. He then
sends for the man, reexamines him (4 E), and de-
cides the case, if possible. If in doubt, he sends
the man into the room of the president of the board
(4 F) with the accumulated evidence. The presi-
dent then decides the case. The president of the
board sees, in addition to such doubtful cases, every
reject and every case given limited service. The
men's cards are then stamped and turned over to
the exit clerks.
The fluoroscopic O. K. records are gone over by
the assistant. If he cannot accept from the evi-
dence recorded or is in doubt, he sends out form 2
by orderly and has the man brought back for re-
examination at once. He will, in any event, send
for the man, irrespective of x ray findings, if the
examiner has diagnosed a tuberculosis, or if there
is anything suggestive of tuberculosis, either from
the history or the results of the physical examina-
tion, in spite of the negative fluoroscopic findings.
If it is evident that the man is an accept, his form
88 and blank card are stamped and returned to the
exit clerk. If the sputum examination is checked
on the history, form 3 is made out, and together
with a sputum cup sent to the man's company com-
mander, the latter has the specimen returned to the
laboratory, where a micrcscopic examination is
made at once. The laboratory is in charge of one
medical officer and two technicians. However, the
man's disposition does not await the results of the
sputum examination. In case it is desired to repeat
the x ray examination, form 4 is sent to the man's
company commander. These four forms are also
used in cases of all reexaminations. Those cases
sent into the assistant or president's room for re-
examination are given O. K. cards after the exam-
ination has been completed. These cards indicate
that the man may leave the building, and that he has
given up his papers.
In case a man is referred to the cardiovascular
board (4 B) in addition to the x ray, he is sent to
the cardiovascular board with a copy of the x ray
findings after the tuberculosis board has acted upon
the case. The rontgenologist fluoroscopes every
heart case, and notes any heart abnormality that is
present in cases referred by the tuberculosis board.
Thus, if the tuberculosis examiners follow instruc-
tions regarding case?, they are obliged to refer to
the X ray ; approximately one man out of every four
will fall into one of the groups, i, 2, 3, 4, 5, 6, or 7,
and thus not only will almost every case of tuber-
culosis be weeded out, but it serves as a check on
missed heart cases. To check the tuberculosis ex-
aminer, the exit clerk is instructed to send every
man without history that passes through between
August 3, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
203
certain hours to the x ray room. In other in-
stances, every case passed by a certain examiner
without a history is sent to the x ray room, a differ-
ent examiner being checi<ed each day, and while it
is known to them that the check is being run, they
• do not know upon whom, or in what manner it is
r being carried out. This control fluoroscopic work,
as well as part of the other fluoroscopic work, is
carried out by the president of the tuberculosis ex-
amining board, who not only must be a clinician but
a rontgenologist, and thus in a position to interpret
properly the findings of both the tuberculosis exam-
iners and the rontgenologists, serving as an arbitra-
tor and preventing undue enthusiasm on the part
of either.
In order that the control cases may be kept sep-
arate from the other x ray cases, the exit clerk gives
the man a slip of paper upon which has been stamped
an X and the examiner's number, as the man gives
up his papers. The man gives his papers to the clerk
(the stenographer of the president of the board)
in the x ray room as he steps under the screen. If
0. K., the clerk marks O. K. upon the slip and re-
turns it to the man. who gives it up at the exit. If
an abnormality is noted, an R is placed upon the
man's chest with grease pencil, and he is directed
to the waiting place for reexamination and thence
to the reexamination room, where he is historied and
examined by the president of the board. If a tuber-
culosis has been overlooked, the man is sent back
to the original examiner for review. As an addi-
tional check on the alertness of the examiner, cases
of manifest tuberculosis detected are sent through
several examiners without their knowledge. In case
of disagreement, the examiners are assembled after
the day's work is finished, and the case reviewed
by the president of the board. If a case of tuber-
culosis is missed by the examiner, but sent to the
x ray room because of any of the conditions under
1, 2, 3, 4, 5, 6, or 7, with an incorrect diagnosis and
found under the screen to present an abnormality
which reexamination determines to be tuberculosis,
the case is sent back to the examiner with the re-
sults of the reexamination for review.
Every conscript rejected on account of tubercu-
losis is given a short talk by the president of the
board, who explains to the conscript the reason for
rejection, and advises him to get in touch with the
antituberculosis association of the state in which he
resides. He is also given a booklet issued by the
National Association for the Study and Prevention
of Tuberculosis, entitled "What You Should Know
About Tuberculosis."
The board keeps a record of the local and med-
ical advisory board examiner who passed the case.
The forms 88, stamped with all the board's recom-
mendations, together with the forms loio, are sent
to the mustering ofticer at frequent intervals, who
summons the men for mustering or furnishes them
with a discharge, according to the information con-
veyed on form 88. The supervisor of the special
physical examination units keeps the other blank
reference card which contains the same information.
These cards are in charge of a clerk and kept for
future reference, so that in case the man breaks
down from tuberculosis or from other causes, it may
be traced back to the board and the examiner held
responsible for having passed the man. The
tuberculosis examining board reports to the S.
G. O. through the Division Surgeon each Satur-
day on blank 987 S. G. O., setting forth the details
of each rejected case on the card form 986 for con-
scripts and form. 440 S. G. O. for cases of tubercu-
losis arising after having been mustered.
{To be concluded.)
MEDICAL NOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
DIAPHRAGMATIC HERNIA.
An interesting lesion occasionally met with,
caused by bursting shell in most cases, is diaphrag-
matic hernia of the stomach. In these cases, feed-
ing is possible when the subject is lying down,
impossible when sitting, because the patient vomits
all the food taken, and thus an advanced cachexia
rapidly occurs. This symptom is so distinct that a
diagnosis can be made before radioscopy has been
done.
Absence of thoracic symptoms is the rule ; there
is no pain on percussion, while the stethoscopic
signs are vague and generally attributed to the re-
mains of the pleuropulmonary reaction following
the wound. If, in some cases, particularly in dia-
phragmatic gastric hernia, local complications are
uncommon, the same cannot be said when with the
stomach a bit of either large or small intestine is
pinched in the diaphragmatic opening. In these cir-
cumstances, the phenomena of acute or chronic
strangulation arise, and a perforation of the strang-
ulated gut may take place if surgical relief is not
forthcoming. As an example : A soldier received a
through and through thoracoabdominal bullet
womid which quickly healed, but, six months later,
he entered the hospital with abdominal symptoms of
partial occlusion and important left thoracic symp-
toms consisting of dullness at the base, edema of
the thoracic wall and a temperature of 104° F.
Puncture of the pleural cavity withdrew a fearfully
fetid liquid and a free pleurotomy gave issue to
fecal fluid. After this, the temperature dropped
and the symptoms of occlusion subsided. The
patient went normally to stool but a little intestinal
liquid continued to come from the drain in the
pleural cavity. The temperature remained normal
and, at last report, the general condition was good.
If the fistula does not close spontaneously a high
laparotomy will be done to effect a cure.
I would say that such cases are not exceptional,
and that Gaudier and Amenille have reported
similar ones.
As to the surgical treatment of gastric diaphrag-
matic hernia, it is fairly well decided that laparot-
omy is the operation of choice, because it offers a
large operative field and one can operate the reduc-
tion of the abdominal viscera which have passed
through the diaphragmatic opening into the thoracic
cavity. By the abdominal route, drainage of the
subdiaphragmatic area is easily accomplished in
cases where an infection is possible from contamin-
ation by septic pleural fluid. As to suture of the
204
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
diaphragmatic opening, it is, of course, better to
close it directly by total suturing but this will un-
doubtedly be found difficult in the majority of cases
on account of the rigidity of the edges, so that the
surgeon must be content with occluding the aperture
by suturing some omentum over it.
Now for the question of unilateral arthrotomy
with immediate total suture in wounds of the knee
joint. This procedure has been successfully carried
out in numerous cases, particularly by Barnsby. In
these cases a very early interference is ideal, but
excellent work can be accomplished if the case is
seen within the first twenty-four hours following
the receipt of the injury.
The site of the entrance opening is the guide to
the incision, but the data obtained by radioscopy
and above all, the location of the missile dictate
whether the incision is to be made on the right or
left. Circumstances permitting, the incision should
circumscribe the entrance opening, otherwise the
orifice and track are excised after the joint has
been closed. The incision should be made a good
centimetre behind the edge of the patella and not
more than from four to five centimetres to begin
with. This is enough to explore the joint, clean it
out and remove the missile when stuck in the syno-
via or cartilage, [f a limited condyle or patellar
lesion is encountered, the incision is enlarged with
scissors at each end, but when the diagnosis of
lesion to the bone is evident before operation, the
incision, which is vertical, should be made long at
the start in order to freely expose the parts.
In cases of comminuted fracture of the edge
of the patella, or even one half of it, exploration
when the limb is extended, is easy. The bone can
be everted with ease by the use of Farabeuf's re-
tractors and the interference rapidly carried out.
If there is much damage to a condyle the limb
should he flexed. When both condyles are involved
it will usually be better to make a U incision, with
division of the tendon of the patella, and it is only
when the osteocutaneous flap is thrown back that
the fracture focus can be thoroughly cleansed, ex-
cepting in those cases where excision of this sesa-
moid bone is indicated. The same applies in cases
of severe injury to the tibial plateau. The loss of
bone tissue may be filled with bits of cartilage but
this is not always necessary. A complete hemostasis
by compression with gauze, lasting from five to ten
minutes, is usually obtained and will not be followed
by a hemarthrosis. The joint cavity is washed out
with ether, first in flexion, then in extension. The
suture of the incision is made in three layers without
drainage. Now, the particular novelty in the treat-
ment is that the limb is simply placed in a fracture
box and mobilization of the joint is begun on the day
following removal of the sutures. A stirrup of sur-
geon's plaster is applied ; a cord passing over a pulley
carries a weight of from two to six pounds. The
patient begins his movements himself, ten minutes
morning and evening, increasing the time himself,
as well as the maximum of flexion, and he soon
reaches a seance of one hour twice daily. When the
maximum point of flexion is attained a large pillow
is put under the knee and maintains the joint in this
position for about fifteen minutes. In the majority
of cases flexion at a right angle was reached by the
twenty-sixth day. The results have been really as-
tonishing and deserve the attention of American sur-
geons.
It is unquestionable that there are many advan-
tages in early secondary suture of war wounds. The
technic should be scrupulously carried out as fol-
lows :
Wait for the disappearance of every symptom of in-
flammation and the elimination of all necrotic tissue. Cir-
cumscribe the ulcerated surface by an incision in healthy
skin, at least five millimetres from the wound edges, and
carry the knife down to the aponeurotic layer, removing
en masse, just as one would excise a neoplasm, the entire
ulcerated surface. Next, disinfect the field of operation
with ether and change gloves, instruments, and towels sur-
rounding the operative wound. If union of the edges of
the operative wound causes the slightest tension, the bor-
ders are to be freely mobilized by dissection with knife or
scissors, as far as is required in order to attain an easy
and even approximation. When the wound is wide, the
deep layers are to be approximated with catgut. This
suture completes hemostasis, which should always be com-
plete. Besides, it facilitates the skin suture.
The integuments carefully approximated are sutured
with silk-worm gut, particular care being taken at the
angles of the wound. In the case of the limbs, the line
of suture should follow the long axis and if necessary to
accomplish this a supplementary incision to free the struc-
tures should be made.
During postoperative treatment the temperature
should be closely followed and the first change of
dressings should be made in forty-eight hours. In
some cases, the latent infection being more seriotis
than the clinical aspect of the case would lead one to
suspect, two possibilities may occur, i. The middle
sutures tend to develop an inflammatory process
around them and tend to give way. In this case
they are to be supported by adhesive plaster. 2. A
small focus of suppuration forms. All that is neces-
sary is to remove the sutures at this point and after
emptying the collection, dress the resulting wound
with a little ether daily.
As an example of what can be accomplished I
here give the statistics of forty cases recorded by
Barthelemy, Morlot, and Jeanneney.
In twenty-six cases union per primum occurred in
less than a fortnight. In eleven cases union was
rapid in spite of a suppurating stitch or the develop-
ment of a small pus collection, and was perfect at
the end a month. Twice the results were only fair,
due to a technical error, the sutures having been
placed perpendicularly to the axis of the limb. And,
lastly, one case was a failure because approximation
of the wound edges was not preceded by excision
of the infected tissues. A second interference un-
dertaken a few days later with a proper technic
was followed by perfect union.
In a general way, it may be said that a complete
recovery ensues in from a fortnight to four weeks.
Early secondary wound suture can be undertaken in
most cases within a fortnight after the patient is in
hospital and from the date of the receipt of the
wound, the number of days in hospital will average
about forty. The resulting cicatrices are solid, non-
adherent and soft. The technic is simple, and in
the majority of cases, can be done with local or
regional anesthesia.
In closing, let me say to you, that surgery at the
front is a far different matter from that of our
August 3, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
205
well furnished hospitals, a fact that must be remem-
bered by the American surgeons who have as yet
had no practical experience near the firing line.
Even those who have been in France and seen the
American Ambulance and other American hospitals,
must not for the fraction of a second imagine they
are to be professionally mollycoddled in that way.
These institutions are luxuries and cannot be com-
pared in any way to the real surgical outfits at the
front. If they do indulge in such hopes, disaster
faces both them and their patients.
MEDICAL NEWS FROM WASHINGTON.
Coming Promotion of Brigadier General Ireland as Major
General, M. C, U. S. A— Reduction of American Hos-
pital Records in France by Use of Charts.
Washington, D. C, July 2g, 1918.
An interesting situation has arisen in connection
with the new places with the rank of major general
and brigadier general provided for the Medical De-
partment of the army by the new army appropria-
tion act, with the almost certain prospect that
Brigadier General Merritte W. Ireland, Medical
Corps, national army (colonel, Medical Corps, reg-
ular army), who is on duty in France as chief
surgeon on the stafif of General Pershing, will be
raised to the rank, one way or another, of major
general in the Medical Department of the regular
army.
The appropriation act authorizes the increase of
the Medical Department of the regular army "by
one assistant surgeon general, for service abroad
during the present war, who shall have the rank of
major general, and two assistant surgeons general,
who shall have the rank of brigadier general, all of
whom shall be appointed from the Medical Corps
of the regular army."
It also authorizes the President to "appoint in the
Medical Department of the national army, by and
with the advice and consent of the Senate, from the
Medical Reserve Corps of the regular army not to
exceed two major generals and four brigadier gen-
erals."
Geneial Ireland is the officer most frequently
spoken of in connection with the promotions to fill
these places, and it seems certain, under the circum-
stances that have arisen, that he will be advanced
to the rank of major general. However, it is un-
certain at present exactly what method will be pur-
sued in advancing that officer.
It is understood that the Secretary of War has
decided to recommend to the President that Gen-
eral Ireland be appointed to fill the place of assistant
surgeon general with the rank of major general in
the Medical Department of the regular army. In
view of the fact that all proposed promotions in
the personnel under General Pershing are referred
to that officer for his approval before they are made,
the departmental recommendation in the present
case has been referred to him before sending the
nomination to the senate for confirmation.
Another angle is given to the case by the fact
that practically all of the medical personnel in
France, of all ranks and classes, are strong in their
desire to see General Ireland appointed Surgeon
General of the Army to succeed Major General
William C. Gorgas, when that officer retires for age
on October 3rd, next ; and it is understood that
General Pershing favors the appointment, notwith-
standing his reluctance to lose General Ireland as a
member of his staff. This situation has been made
known to the authorities at the War Department.
It has been decided that it would be contrary to
law to continue General Gorgas as Surgeon General
after his transfer to the retired list. It is suggested,
however, that, if General Ireland is appointed Sur-
geon General, and, if it is desired to keep him on
duty in France, General Gorgas might be retained
at the head of the Medical Department as "acting"
Surgeon General, provided he is willing to continue
on active duty after retirement from the active list
of the army.
Moreover, this course would afford opportunity
to have two major generals of the regular Medical
Department in France — General Ireland as Surgeon
General and some other officer of the regular corps
appointed to fill the place of Assistant Surgeon Gen-
eral with the rank of major general.
All together, the situation is an interesting one,
with something more than probability that General
Ireland will be advanced to the rank of major gen-
eral in one or the other of the ways described.
Reduction of red tape and the elimination of un-
necessary paper work are being practised in our
army hospitals, particularly those in France, where
the demands upon the hospital personnel are in-
creasing constantly. A system has been put into
operation whereby two thirds of the volume of
paper work is saved.
The S3'Stem, which is based upon one followed in
the British hospitals, was put into force just prior
to the flow of wounded from the fighting near
Chateau-Thierry, at a time when the former cum-
bersome system doubtless would have added greatly
to the confusion.
The key to the new system is a field medical
card, a simple cardboard chart, which folded twice
will fit into a note envelope. This chart begins at
the first point at which a patient is received, be it
ambulance, field hospital, or evacuation hospital,
and it is fitted by wire to his clothing similar to an
identification disk. W^herever the patient goes, the
chart follows him, even back to America. At each
stopping place entries are made on the card, with
the treatment admmistered.
Under the former ponderous methods, each hos-
pital executed its own voluminous records, which
were filed away with elaborate detail ; and, if it be-
came necessary suddenly to transfer several hun-
dred patients, the regulations required that a com-
plete transfer card be filled out in each case. Often
the convoys would be made up with such a rush that
there was no time to prepare the transfer cards,
much less a transference of clinical records, etc.,
and the physicians and surgeons into whose hands a
patient later might come were without information
as to what had been done before.
Another improvement that has been made is the
reduction of involved terminology and the elimina-
tion of unnecessary family history.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. dh M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, AUGUST 3, 1918
SOME QUESTIONS REGARDING
PENSIONS.
The subject of pensions will soon be a serious
one again for our Government. Workman's in-
surance is calling into service the immeasurable
advance made in methods of diagnosis, in greater
surety of prognosis based upon a much clearer
and a better defined separation and distinction
among various diseases and traumatic conditions.
So the vast addition to knowledge and experience
gained on the battlefield and in the war hospitals
should furnish also a broader and more assured
background on which to adjust the matter of
pensions. It is the members of the medical pro-
fession who should be the agents for lifting this
from a mere political basis of degrading injus-
tice, favoritism, and dependence to a scientific
plane based upon actual conditions of health and
ability.
A few practical suggestions along this line in
the field of mental and nervous disabilities are
made by R. Benon [Mental and Nervous Mala-
dies and the Law Regarding Military Pensions,
La Pressc Mcdicalc, April 18, 1918]. Four points,
he says, must be considered. These are, the
previous state of the individual before the injury;
the contradictory reports of examination ; special
dispositions to be made in regard to the pensions
of those placed in an asylum for the mentally
diseased, and the social situation of the wife of
the man thus interned. The first point comprises
several etiological considerations. These are
whether, though the patient may have been in
the best of health, he belongs to a family men-
tally and nervously afHicted ; whether the patient
has presented symptoms of constitutional dis-
turbance either in character or intelligence,
though there are no cases in his family of mental
or nervous disturbances ; whether disturbances
on the part of the patient have appeared when
there are others in the family afflicted with men-
tal or nervous disturbance; whether there is evi-
dence of syphilis, chronic alcoholism, or other
such disease in the patient, and, finally, whether
the patient had any mental or nervous malady
before he entered the army. These considera-
tions are all, however, of less weight if the patient
has served a long period at the front and been
under a great strain there. Moreover, the theory
of a mental degeneracy is too obscure and unsci-
entific to sustain much weight at present. In
regard to general paresis, syphilis is only one of
a number of factors which must be taken into
account in the incidence of the mental condition.
By no means do all syphilitics develop general
paresis. The contradictoriness in reports of exami-
nation Benon considers inevitable, but it empha-
sizes the need of greater precision in medicine.
Special dispositions in regard to these pensions
have already been resolved upon in France. These
grant to the wife of a patient suffering from a
mental disease, which necessitates his sojourn in
an asylum, the pension equal to that given to a
widow. Here, too, the question of antecedent
causes fo» the disease may have to be considered.
Another complication arises if the patient improves
and can be given his liberty and yet must be sup-
ported by the family. His support and, perhaps,
extra care must be provided for him, and this the
pension law should provide. The same question
arises in cases of blindness or other permanent
disability. Another consideration has been
brought forward, which may become a very prac-
tical one in the conditions which war has forced
upon Europe, and that is the revising of the di-
vorce laws for practical and moral interests, in
August 3, 191 8.]
EDITORIAL ARTICLES.
207
order to permit greater freedom for divorce to
those women whose husbands are permanently
secluded in the asylums for mental diseases as a
result of their wounds or illness contracted dur-
ing service.
Benon's very practical suggestions are such
that they should arouse us to think of this com-
plicated problem, which is even now arising as a
result of the war. And even as political organi-
zations should be better prepared to deal with
such a situation than in the past, so should medi-
cine be far more able to throw light upon its in-
tricacies. At the same time the unprecedented
numbers among the wounded and disabled, the
far greater variety and seriousness of the injuries,
largely evident in mental and nervous results, to-
gether with the far greater complexities of mod-
ern life, make the whole question one which can
be adequately handled only with all the help
which scientific experience and consideration can
give to it.
"BOTTLEISM" IN TORONTO.
By the terms of the Ontario Temperance Act
which became effective in September, 1916, phy-
sicians were permitted to keep ten gallons of
alcohol in their lockers at any one time, write
orders for quarts in either the shape of whiskey,
or ale and other malt liquors, and carry around
a quart bottle of "hard stuff" for the benefit of
their patients. All has been going on compara-
tively well during the last year and a half, with
the exception of a sporadic abuse here and there
on the part of some too generous physician, who
should have known better and should have had
some consideration for the honor and standing
of the faculty. Some believed in prescribing
quite generously, even, in several cases, lavishly.
Coincident with the annual meeting of the On-
tario Medical Council in that city, June 24th to
29th, a Toronto physician was summoned to the
police court charged with having on four spe-
cific occasions unlawfully prescribed liquor for
patients, or pseudopatients. He was convicted
on one charge, pleaded guilty to the other three,
and was fined $300 on each count, the total there-
fore amounting to $1,200. It was discovered that
this physician had written 1,274 orders on vend-
ors of liquor — there were two such in Toronto —
in eleven days, as many as 122 prescriptions hav-
ing been issued in one day.
The law having been satisfied by the handsome
addition to the city's exchequer, the Medical
Council took the matter in hand. Dr. Edmund
E. King, the retiring president, found that his
Toronto confreres had been prescribing liquor
to the extent of at least 4,000 prescriptions from
June 1st to nth. His brethren in Toronto, about
525 not yet drafted for overseas, wrote as many
as fifty-two prescriptions, fifty-three, sixty-two,
sixty-seven, sixty-eight, seventy-three, ninety-
nine, and 215 each — that is, some of them. At
least 275 of them had given one prescription, and
nearly one third of that number had given ten ;
while four had issued twenty-four each; three,
fifty-eight each; two, ninety-nine each. Fur-
ther scientific and alcoholic search revealed
the fact that in the month of April 5,369 prescrip-
tions had been issued in Toronto ; but as the
warm weather drew on apace, these figures
swelled to 9,255 prescriptions in May. Now the
whole profession in Toronto have been dubbed
Physician Bartenders, or, to be exact, those who
are entitled to write the above quoted figures after
their names. Should they not be known by their
numbers?
It has not yet come out if any physicians have
availed themselves of the provisions of the act in
stocking up to the extent of ten gallons, and
keeping stocked up. Nor has any information
been forthcoming as to whether any doctor has
been in the habit of dispensing his own liquors.
What has resulted, however, is that the Medical
Council promises to ask the Ontario Government
to cut the quantity down to eight ounces; and
that hereafter the body charged with the admin-
istration of the Ontario Temperance Act will re-
quire vendors to make returns of prescriptions
issued by physicians for liquor, not later than the
tenth of each and every month.
Liquor, of course, has been always a much de-
bated and a very complicated question; but it
would seem to be a wise provision on the part of
the Government of Ontario, or any government
elsewhere, to appoint to the administrative body
a physician of standing, to vise all prescriptions,
so that physicians may not be needlessly sum-
moned to court in this or that prosecution. The
law is the law, and there is no question that cer-
tain physicians in Ontario have abused their
privilege; and the profession as a whole now
rests under the stigma, perhaps inadvertently
placed upon their shoulders by unthinking and
too easily persuaded members.
WTaat is the physician in Toronto, in Ontario,
and other places where such acts are in force, to
do? Can physicians be assured, if they give pre-
scriptions for diseased conditions, that they will
not have to appear in court to defend themselves
against a charge of having done so wrongfully?
Is an administrative board, upon which sits no
208
EDITORIAL ARTICLES.
[New York
Medical Journal.
physician, to be the ultimate authority in saying
whether liquor should be prescribed for asthma,
rhinitis, constipation, atonic dyspepsia, etc.?
Would it not be better to consider that every
man or woman who applies to a physician for
liquor should be treated as diseased? Then the
physician would be obliged to state on his pre-
scription that his disease was alcoholism pure
and simple, and should so treat him to ef¥ect a
cure. There is here a fine chance for the physi-
cian to carry on an efifective temperance cam-
paign. Let him prescribe his liquor to be taken
according to usual directions, as is done in treat-
ing other diseases. If the patient abuses that^ —
does not follow directions, swallows it all in two
or three drafts, the doctor has the remedy in his
hands to deny him more. The physician should
not be held accountable, any more than he is held
accountable in other drugs, if the patient swal-
lows the whole bottle and poisons himself. If
liquor is to be dispensed at all. it should be dis-
pensed for disease — and surely alcoholism is a
widespread disease — and physicians should feel
it incumbent on them to treat and cure, if possi-
ble, the craving for alcohol, as they do in under-
taking to treat and cure, if possible, any other
disease.
Under the Ontario Temperance Act the condi-
tions in that province looked to be ideal. Un-
happily, several physicians have not recognized
their responsibility in the matter; but it would
seem a more just arrangement if delinquent prac-
titioners had their prescriptions in some way
vised by one of their own profession, who could
better determine whether a given prescription
were justifiable and recognized treatment for any
disease for which it had been issued.
THE STARVATION TREATMENT OF
DIABETES.
Perhaps no other form of treatment has given
such good immediate results both in reduction
of the sugar content of the urine and improve-
ment in the general condition as the starvation
treatment carried out according to the plan of
Allen. This form of treatment is consistent with
the newer theories as to the causation of diabetes,
at least as regards the part tliat excessive eating
plays in the disease.
It is no longer held tliat only the carbohydrates
are a factor in the causation of the sugar malas-
similation. In all likelihood the proteins are as
important a factor as the carbohydrates. In the
gradual return to the stationary diet, after star-
vation, it is possible to determine which of the
two, carbohydrate or protein, is at fault, by not-
ing the influence each has on the appearance of
sugar in the urine.
It is a remarkable fact that in spite of the star-
vation there is practically no loss in weight. In
these patients a little loss in weight is rather de-
sirable. In the obese diabetic, who usually loses
no weight under this treatment, it is impossible
to eliminate all the sugar from the urine while his
weight continues high. There is never any dan-
ger that the starvation will cause acidosis and
coma, as is caused by the long continued with-
drawal of carbohydrate from the diet of the dia-
betic. In this connection it is to be remembered
that the amount of ammonia in the urine is an
index of the degree of acidosis. Acidosis is
marked if the ammonia output reaches three or
four grains in a day.
As a prerequisite to the starvation treatment
the patient must be kept in bed during the treat-
ment, and until he is sugar free. While the wa-
ter intake is not restricted he is allowed no food
except cofifee and whiskey. One ounce of whis-
key in the black cofifee is allowed every two hours
between the hours of 7 a. m. and 7 p. m. The
total amount of whiskey consumed during this
period is six ounces and the total caloric value is
800. The patient, it must be remembered, is not
really without food because alcohol can take the
place of food for short periods. The administra-
tion of sodium bicarbonate,, while sometimes ad-
visable with marked acidosis, is not really essen-
tial.
The starvation treatments are carried out in
two day series, never more than four day series.
At the end of two days the patient is usually
sugar free. Then he is allowed a diet of vegeta-
bles, cooked three times, in which the carbo-
hydrate content does not exceed five per cent.
Some fat in the form of butter may, however, be
added. On the whole, the amount of carbo-
hydrates allowed must not exceed fifteen grams.
Allen has two dietaries from which to draw. One
contains ten grams of protein, seven grams fat
and fifteen grains carbohydrate, with a total cal-
oric value of 200; the other contains seven gi-ams
protein, six grams fat, and fifteen grams carbo-
hydrate, with a caloric value of 150. Allen's
vegetable diet tables include string beans, aspara-
gus, carrots, spinach, cucumbers, celery, cabbage,
and onions.
This abbreviated vegetable dietary is main-
tained for a few days, whereupon the dietary is
made gradually more generous. The proteins
and the carbohydrates are added one at a time
and watch is kept to see the addition of which
August 3, 1918.]
EDITORIAL ARTICLES.
one first causes the sugar to reappear. Which-
ever element it is that one must be materially
reduced. A fairly generous dietary for a diabetic
to maintain who has taken the starvation treat-
ment contains fifty grams each of carbohydrate
and protein and 200 grams of fat. If in spite
of this reduced dietary sugar reappears, the
starvation course of treatment must be repeated
from time to time. However, the point to be
remembered in this aftertreatment dietary is that
in order to maintain the sugar free urine obtained
by the starvation treatment it is necessary to
continue to live on a very low diet as to quantity
in order that the organism may never be taxed in
the assimilation and elimination of large quanti-
ties of food.
ERYTHEMA AND TUBERCULOSIS.
The striking fact in the reported cases is that
the attack of erythema occurring in tuberculosis
often preceded death only by a few days or
served as a precursory sign of a tuberculosis
which had been in a latent state; and it would
also seem that the maculopapular form preceded
death, while the nodose type of the eruption was
the forerunner of an acute outburst of the latent
disease.
This is not, of course, a fixed rule, and it does
not necessarily follow that every time an ery-
thematous eruption is met with in a tuberculous
case, the prognosis is serious. But, at all events,
it may be said that this eruption generally coin-
cides with an acute outbreak of tuberculosis, in
the phase of acute tuberculization. The erythema
is due, not to the tuberculosis but to the specific
bacillus. Therefore, it is during the granulia that
the erythema appears and also in the acute out-
breaks occurring in chronic tuberculosis, when
a superproduction of bacilli has taken place, and,
as a consequence, an overproduction of microbic
toxins.
As to the nodose form of erythema in particu-
lar, its importance is considerable as a premoni-
tory symptom of a latent tuberculous infection,
and when a case is encountered where the nature
of the eruption remains obscure, it will be pru-
dent to suspect tuberculosis. Therefore, the
prognosis of these erythemata should be guarded,
because they are often the index of an acute out-
break in a chronic tuberculosis or of the evolu-
tion of an unrecognized bacillosis.
The pathogenesis of these erythemata may be
explained by an angioneurotic process. The tox-
ins of the tubercle bacillus act upon the vasomo-
tor centres by the intermediary of a vasodilator
substance called ectasine. A vasodilatation is
the result, and this is accompanied by diapedesis
and the production of exudates, the underlying
phenomena of erythemata.
The diagnosis is important when an erythema
occurs in a tuberculous subject. For example,
one must not mistake a macular erythema for
erysipelas, or for variola at its outset, or a pur-
pura ; a vesiculobulbous erythema for pemphigus
or herpes ; a nodose erythema for luetic or tuber-
culous gummata ; lupic erythema for numerous
cutaneous manifestations which have many
points of resemblance to it and which are too
long to enumerate.
Once the diagnosis of erythema is made, one.
should ascertain if it is not due to some common
cause and not to the tuberculosis, because it does
not necessarily follow that, because the patient is
tuberculous, every symptom offered is bacillary
in nature.
Above all, it must be remembered that there
are erythemata due to external causal factors,
such as the sun's rays, erythema intertrigo, ery-
thrasma, etc. The fact that gastrointestinal
disturbances or medicaments may cause ery-
thema must not be overlooked ; among the latter
antipyrine, quinine, opium, arsenic, and ergot
hold an important place.
Finally, when all causes of mistake can be set
aside, there still remains the question whether or
not the bacillus of tuberculosis is to be incrimi-
nated or if the eruption is not due to some con-
comitant infection, such as diphtheria, typhoid
fever, infectious endocarditis, syphilis, or gonor-
rhea.
THE AGE OF A MINISTERING ANGEL.
The Secretary of War was quite convinced that
when pain and sickness wrimg the brow woman
was a ministering angel, but not quite sure at
what age she ceased to be "uncertain, coy, and
hard to please," or whether these failings might
sometimes hinder the "ministering" when she was
at the Front with her sisters where tactful coop-
eration and loyal obedience would tremendously
influence all the work. So he wrote to General
Pershing, giving him the casting vote concerning
the age of women allowed to go over in connec-
tion with relief work. This age has been fixed
as twenty-five, and the decision at once brought
into evidence the very failing — want of self con-
trol— which the "angels" under twenty-five would
have been the first to deny. They certainly con-
sider themselves ill used — and say so in unangelic
terms — because this new ruling has been added con-
cerning any relief work to that regulation about the
nongoing of any wife, mother, sister, or daughter of
soldier or sailor or member of the Red Cross or
Y. M. C. A. or any such societies.
2IO
NEWS ITEMS.
[New York
Medical Journal.
News Items.
The British Medical Mission. — Tlie four photographs,
illustrating the article on the New York visit of the Spe-
cial British Medical Mission to America, published in the
j'uly 20th issue of the Journal, were furnished through
tile kindness and courtesy of Lieutenant Badgley, of the
liritish Pictorial Service, 511 Fifth Avenue, New York.
Forty Bed Hospital Erected in Record Time. — Under
the direction of the Construction Division of the Army a
forty bed addition to General Hospital No. 10, at Fox
Hills, Statcn Island, was erected recently and made ready
for occupancy in exactly ten hours and thirty-eight min-
utes. The building is a one story frame structure, with a
l)orch, and has in addition to the ward a diet kitchen, sur-
gical dressing room, linen room, and bath. The finished
building was fully wired, the lights ready to be switched
on, water running in the pipes, and all the radiators set.
The Construction Department is prepared for similar
\vork in all cantonments should the necessity arise for in-
Aireased hospital facilities.
Women's Motor Corps Uniforms. — In order to save
khaki cloth, the War Department has requested the 6,000
women of the American Red Cross Motor Corps Service
to discard their khaki uniforms and to adopt the Red Cross
Uniform of oxford gray. Commanders will wear three
silver diamonds embroidered on their shoulder straps ;
captains will wear two silver diamonds, first lieutenants
one, and second lieutenants a gilt diamond. Pearl gray
tabs on the collar will indicate staff officers. Cars will be
designated by a white metal pennant bearing a red cross
and the words "motor corps." The independent service
in the principal cities has been amalgamated with the Red
Cross Corps.
College Students to Be Trained for Medical Depart-
ment Officers. — The Medical Department of the Army
will shortly issue an appeal to American colleges and uni-
verfities urging them to alter their curriculum so that
third and fourth year students may receive special train-
ing which will enable them to qualify as officers and for
other work in the Medical Department. The appeal will
be sent to all the principal colleges and universities in the
country, and the request is made that all directing heads
of such institutions write to either Dr. Richard M. Pearce,
of the National Research Council, Washington, or to the
Division of Laboratories, Ofifice of the Surgeon General,
Washington, for details of the proposed plan.
Safeguarding the Health of Soldiers at Sea. — Strict
medical and sanitary precautions are taken to safeguard
the health of American soldiers on the transports going
to France. Before embarking a thorough examination of
troops is made by army medical officers to eliminate the
sick. Within five days of sailing the commanding officer
of troops submits to the senior naval surgeon a statement
that all his men have received protective vaccinations ;
and if any have not, he designates the men to be vac-
cinated. After embarkation all troops must spend at least
an hour and a half daily on deck, each man bringing his
blankets to be aired. Commanding officers must see to it
that their men receive thirty minutes of physical exercise
during this period. The men are expected to stay in the
open a? much as the weather will permit. All men and
their effects must be inspected twice weekly by medical
and commanding officers to detect the sick and make sure
that the men are observing the rules of hygiene. Men
are not permitted to close the ventilators or other-
wise interfere with the flow of air. They -are not per-
mitted to eat food in berth spaces. Food is not served in
rooms or other unauthorized places unless so ordered by
the senior naval surgeon in case of sickness. Guards are
stationed day and night at drinking fountains and other
points to enforce cleanliness. Spitting on deck is strictly
forbidden. Every man must take a shower bath daily and
change his underclothing at least once during the voyage.
These and other regulations were promulgated by the
Surgeon General of the Navy. The senior naval surgeon
is made responsible for the sanitation of the ship and for
the routine care of all men who are sick enough to re-
quire treatment other than first aid. Arrangement is
made for the cooperation of the medical officers of the
army aboard and members of the army hospital and
sanitation corps.
Epidemics in Germany. — According to cable de-
spatches from Amsterdam, dated July 29th, tetanus has
broken out to a serious extent in the German army. The
Netherlands Export Company has agreed to send a large
consignment of antitetanus serum to Germany. Typhus
fever is said to have appeared in epidemic form at Ber-
lin, and malaria in Baden. Influenza continues to spread,
and it is said that the health of the troops has been seri-
ously afi'ected by the epidemic.
Appointments to the Harvard Cancer Commission. —
Dr. Robert B. Greenough will act as director of the com-
mission and as surgeon in charge of the staff of the Collis
P. Huntington Memorial Hospital. Dr. Chann'ng C. Sim-
mons will continue as his secretary, and, with Dr. Edward
H. Risley, will serve as surgeon at the hospital. Other mem-
bers of the commission are : Dr. James H. Wright, patholo-
gist, in charge of diagnosis service; William Duane, re-
search fellow in physics ; William T. Boyle, research
fellow in biology; Dr. Henry Lyman, research fellow in
chemistry, and Clarence C. Little, research fellow in
genetics.
Status of Contract Surgeon. — According to an opin-
ion rendered recently by the Judge Advocate General of
the Army, a contract surgeon is not a military officer and
has no military rank; he is not a part of the military es-
tablishment but merely a' civilian in the employ of the
United States by contract for his personal services as a
medical attendant to the troops. Accordingly he is not
entitled to the benefits of the war risk insurance act of
October 6, 1917 ; nor is he an officer within the meaning of
section 9 of the selective draft act of May 18, i9i7._author-
izing the examination of officers by boards appointed to
determine their fitness for service.
National Medical Association. — The twentieth annual
meeting of this association will be held in Richmond, Va.,
August 27th, 28th, and 29th. The officers of the associa-
tion and the Richmond Medical Society are endeavoring
to make this session the best in the history of the_ organ-
ization. A programme of unusual interest, embracing im-
portant stibjects in medicine, surgery, dentistry, and phar-
macy, has been arranged ; surgical clinics will be held at
the Richmond Hospital ; medical clinics will be held in
conjunction with the regular programme; motion picture
clinics will be held in practical dentistry; pharmaceutical
demonstrations have been arranged. The scientific ses-
sions will be held at Virginia Union University. Dr. J. H.
Blackwell, 14 East Thirteenth Street, Richmond, Va., is
chairman of the local committee of arrangements, and
Dr. W. G. Alexander, 14 Webster Place, Orange, N. J.,
is secretary of the association.
Child Health Organization. — As the result of a study
of war time problems of childhood, undertaken in New
York some weeks ago by a group of specialists in chil-
dren's diseases, the Child Health Organization came into
existence. An important revelation made by these studies
was the extent to which malnutrition existed in school
children and its steady increase due to the rising cost of
food. The Secretary of the Interior, to whom the matter
was referred, urged the formation of a national commit-
tee, composed of lay and medical members, to study the
problem and devise means for its solution, and as there
were already a number of committees working along these
lines, it was decided to affiliate with the National Qiild
Labor Committee. Accordingly an organization to pro-
mote the health of school children has been formed as
one of the branches of the Child Labor Committee. The
proposed lines of activity as outlined by the committee
include the following: To teach health habits to children
and to secure adequate health examinations for all chil-
dren in the public schools of the country; to consider the
urgent problem of malnutrition among school children;
to safeguard the health of children in industry; propa-
ganda to awaken the public to the necessity of conserving
the health of the school child as a basis of national secur-
ity and stability ; to promote, or cooperate with other
bodies in securing legislation for the attainment of these
objects. Among the members of the executive committee
are the following physicians : Dr. L. Emmet Holt, chair-
man ; Dr. Samuel McC. Hamill, Dr. Godfrey R. Pisek,
Dr. Victor G. Heiser, Dr. Bernard Sachs, and Dr. Thomas
D. Wood. The headquarters of the organization is at 289
Fourth Avenue, New York.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
RECENT OBSERVATIONS IN DIGITALIS
THERAPY.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Conchided from page I59-)
Recent clinical and experimental work with digi-
talis has served to emphasize the benefit which this
drug may yield by correcting the rate and rhythm
of the heart. On certain cases at least, its direct
action in enhancing the contractile activity of the
heart muscle is apparently no longer of such ex-
clusive importance clinically as was formerly
thought. Yet, in whatever way this may be ac-
complished, it is generally recognized that the di-
lated heart decreases in volume, as a rule, under
digitalis. In some valvular conditions, in particular
mitral and tricuspid insufficiency, the drug is cred-
ited with power to reduce regurgitation by toning
up a relaxed mitral or tricuspid ring, thus enabling
valve leaflets previously unable to meet during
systole to become more closely approximated.
.Similar assistance in valve closure may be afforded
through removal of dilatation of the ventricular
walls in their portions nearest to the mitral or tri-
cuspid valve. T. W. King showed experimentally
many years ago how much a complete closure of the
tricuspid orifice depends upon adequate tone of the
right ventricular muscle ; the opportunity for bene-
fit from digitalis in this particular manner is thus
correspondingly enhanced.
Poor quality of the blood supplied to the heart
often results indirectly from impairment of the
cardiac function itself, insufficient circulation
through the lungs, alimentary tract, and other
viscera causing an imperfect renovation of the blood
which reacts upon the nutrition and contractile
power of the heart muscle. Under such conditions
digitalis should be extremely efTective, for by what-
ever process it may increase the output of blood
from the heart and relieve venous stasis, the cir-
culation through the coronaries and the viscera in
general is thereby increased and cardiac nutrition
improved.
Studies of the viscosity of the blood under both
normal and abnormal conditions have been made in
recent years by Martinet, of Paris. Increased vis-
cosity, by augmenting the resistance to the passage
of the blood through the vessels, tends automatically
to raise the blood pressure and increase the work of
the heart. Martinet observed no important effect
of digitalis on the viscosity, the latter remaining
stationary during the earlier stages of digitalis ac-
tion but rising sharply as the diuresis waned and
the absorption of edematous fluid was completed.
Some other observers, however, have reported a
diminution of viscosity at the height of digitalis
diuresis.
Digitalis and the blood pressure. — On this subject,
clinical investigations of the last decade have led to
a pronounced modification of former views, based
on experiments in animals. Potain's observation
that digitalis diuresis sometimes occurs simultane-
ously with a distinct reduction of blood pressure
was one of the earlier indications that the prevailing
explanations of the action of digitalis were at fault.
The actual effects of the drug on the blood pressure
in cardiac cases appear to be those stated in 1914 by
.\fartinet, viz., the systolic pressure may be either
unchanged, raised, or lowered, but the diastolic
pressure is regularly lowered. Indeed, according to
this author, the degree of effect on the diastolic
pressure is of prognostic value, those cases being
most hopeful in which this pressure is most re-
duced. Such reduction increases the differential or
pulse pressure, and this increase appears to improve,
in most instances, the blood flow through the vari-
ous organs of the body. Martinet found in many
instances that small doses of digitalis, such as o.i
to 0.25 milligram of the French digitalin (mainly
or wholly digitoxin), suffice tO' lower the diastolic
pressure. Evidently this may be included among
the earliest effects of the drug in a large proportion
of cases.
.A. corollary of the findings just referred to is
that digitalis may be administered without harm to
patients with high blood pressure. Not only is it
unnecessary to combine nitrites with it to prevent
any injtirious rise of pressure, but the drug has fre-
quently proved highly useful in cases of high blood
pressure with beginning cardiac failure. According
to Norris, 1914, digitalis lowers the blood pressure
with especial frequency in heart cases with high
pressure stasis and in patients with hypertension
due to retained toxic material through renal impair-
ment. Lawrence states that digitalis may be safely
given to patients suftering from arteriosclerosis or
angina pectoris in the presence of cardiac decompen-
sation, and Riesman has advised its use in hyperten-
sion cases attended with cardiac hypertrophy.
On the other hand, in cases in which cardiac im-
pairm.ent is accompanied by subnormal blood
pressure, digitalis tends to raise and restore the
pressure. Bishop, 1914, advocates continuous use
of digitalis in many instances of the later stage of
arteriosclerosis, in which the preexisting hyperten-
sion gives way to a level of pressure below the line
of compensation.
Digitalis and the kidneys. — The last of the major
effects of digitalis which have been more or less
elucidated by recent observations is that concerning
the renal function. The former view that digitalis
diuresis depends mainly or exclusively on an in-
crease of systolic blood pressure has proved erro-
neous. Clinically, diuresis and a diminution of sys-
tolic pressure frequently coexist. An increase of
the differential or pulse pressure, on the other hand,
whether due to digitalis (Martinet) or artificially
produced (Gesell, 1913), is, in most instances at
least, attended with diuresis. Martinet foimd digi-
2\2
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
talis diuresis especially pronounced when the in-
crease in pnlse pressure resulted mainly from a fall
in the diastolic pressure rather than from a rise in
the systolic pressure.
Again, Loewi and Jonescu in 1908 presented ex-
perimental evidence to the effect that digitalis in
therapeutic doses tends to dilate the vessels of the
kidneys while constricting those of other abdominal
A'iscera. This constitutes another process by which
digitalis may promote diuresis.
Thus, the indications from recent studies of the
question are that digitalis causes diuresis not in one
but in several different ways, viz., by increased
pulse pressure, which enhances the blood flow
through the kidneys ; by reduction of pressure in the
renal veins through increased flow of blood from
the great veins into the heart ; by dilatation of the
renal vessels and a consequent increase of blood flow
through the kidneys at the expense of other abdom-
inal viscera, and probably also, at times, through
hydremia resulting from absorption of edematous
fluid into the blood stream. Doubtless it is because
of the combined action of these several factors that
diuresis, in appropriate cases, is so pronounced a
feature in the action of the drug.
Intraspinous Arsenobenzol Treatment. — Bev-
erley R. Tucker {Virginia Medical Monthly, May,
1918) believes this form of treatment justified both
by experimental work and clinical evidence. It is
attended with little or no danger if ordinary care is
exercised in preparing the serum. Neosalvarsan
should never be used. Many late and apparently
hopeless cases were arrested by this treatment, and
besides, relief of pain and improvement in the blad-
der condition were noticed. Arsenobenzol intra-
venously is very efficient in superficial nervous in-
volvement manifested by headache, slight cranial
nerve palsy, and luetic vascular conditions ; but in
the resistant affections formerly termed metasyph-
ilis, the intraspinal method, systematically and judi-
ciously employed, is far superior. Ogilvie's tech-
nic is used by the author, but the dosage never
exceeds 0.5 milligram, and is preferably limited to
0.3 milligram. The serum should be used immedi-
ately, or certainly not later than three hours after
its withdrawal. No spinal fluid is withdrawn un-
less it is under considerable pressure. The patient
is kept in bed without pillows and with the foot of
the bed elevated for twenty-four to thirty-six hours.
The treatment is repeated until the Wassermann
is negative and the cell count and globulin normal.
After apparent cure these tests should ^be renewed
several times a year for a number of years ; any
slight positive tendency indicates further treatment.
The author reports six cases, including two of early
paresis, in which the treatment resulted in clinical
and serological recovery. Advanced paresis is
rarely benefited by any measure. Intravenous treat-
ment is chiefly beneficial in central nervous syphilis,
giving both a positive blood and positive spinal Was-
sermann ; often it is advisable to administer both
intravenous and intraspinal therapy. Mercury and
iodide should be included in the treatment of central
nervous syphilis.
Treatment of Malignant Measles. — Ribadeau
Dumas and E. Brissaud (Bulletins et memoires de
la Societc medicate des hopitaux de Paris, Febru-
ary 21, 19 18) report the case of a man in a grave
condition from measles, with temperature of 41°
C, a confluent eruption with ecchymoses, dry mouth
and tongue, subsultus, albuminuria, and finally col-
lapse, anuria, incontinence of feces, and toxic dys-
pnea. Death in coma threatening, transfusion of
citrated blood from a man who had recovered a
week before from uncomplicated measles was re-
sorted to. Two hundred mils of the donor's blood
were received in twenty-five mils of water contain-
ing one gram of sodium citrate, and about one hun-
dred mils of the mixture were administered. Within
a few hours there occurred not only a temporary
fall in temperature but a complete transformation in
the patient's general condition. The temperature
dropped to 38.4'^ C, the pulse to ninety-eight,
micturition occurred, and patient went quietly to
sleep. Next day rales were noted and the tempera-
ture rose to 40° C. A second, similar transfusion
was given. The injection being more rapid than
before, a slight chill and temperature reaction took
place. After this the patient gradually gained, and
an unexpected recovery followed. The sudden im-
provement taking place after the first transfusion
seemed definitely caused by the latter. In a case of
equal severity in the future the authors would ad-
minister a more copious transfusion.
Proctitis and Sigmoiditis. — Charles J. Drueck
{Chicago Medical Recorder, March, 1918) says that
the treatment of acute proctitis varies with the
exciting cause and therefore a very thorough ex-
amination should be made first under general or
local anesthesia. The former is preferred, as it
permits complete stretching of the sphincter and
the removal of any local trouble at once. Impacted
feces or foreign bodies if present must be removed
carefully to avoid injury to the mucosa. A saline
cathartic should be given to remove decomposing,
infectious, or irritant material, and the dose should
be large enough to cause good flushing of the in-
testine. Then the bowel should be irrigated sev-
eral times daily with normal salt solution at 1 10° F.
This is followed by the injection of about eight
mils of 1-5,000 silver nitrate solution which is to
be retained. A thirty milligram grain) opium
suppository may be used for the relief of tenesmus.
This treatment is continued as long as there is any
discharge of mucus or pus. If the rectal wall is
ulcerated, the ulcers should be wiped clean and
touched with pure ichthyol or five per cent, silver
nitrate. The diet should be absorbable and non-
irritating and should produce soft stools. Milk
should not be given. Eight glasses of water should
be taken daily and a glass of flaxseed tea every
night. This tea is made fresh daily by boiling five
tablespoonfuls of whole flaxseed in a quart of water,
straining while hot, and flavoring with licorice,
lemon, oil of peppermint, or wintergreen and sugar
before cooking, or with wine after it has cooled.
The patient should be kept in bed as long as there
is pus or blood in the stools. Chronic proctitis, due
to rectal causes, requires the same treatment plus
irrigations of extract of krameria.
August 3, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
213
Potency of Antipneumococcic Serum. — N. E.
Wayson and G. W. McCoy {Journal A. M. A., June
1918) point out the desirability of having all
supplies of antipneumococcic serum tested in one
official laboratory, the Hygienic Laboratory of the
U. S. Public Health Service. They present a num-
ber of protocols of tests of serum for type one,
in which they show that the method of testing gives
somewhat irregular results, even with desirable
modifications in its technic. The results, neverthe-
less, give a valuable measure of the potency of the
serum when controlled. Tests of a number of com-
mercial and noncommercial serums showed that the
former were of as high potency as the latter.
Ozonized Chlorinated Oil of Eucalyptus. — J.
Thompson Schell ( Medical Record, May 11, 1918)
describes a preparation which would seem to be
better than Uakin's solution or dichloramine-T. It
is made by the direct application of ozone and
chlorine to oil of eucalyptus. Ihe ozone oxidizes
the oil, destroys impurities, and makes it more
readily chlorinated while the chlorine is obtained
from sodium chloride by electrolysis and is passed
into the oil until a twenty or thirty per cent, solu-
tion is made. This oil can be diluted with oil or
even water, it is nonirritant, stable even when
long exposed to air, does not injure metal and no
cumbersome apparatus is required for its use.
Wounds may be washed with the watery solution
(.02 per cent."^ and then painted with a fifty per
cent, solution of the oil in paraffin. An ointment
of the eucalyptus oil one half to one dram in one
ounce of vaseline is valuable in burns and crushed
wounds ; the watery solution may be made by
putting one dram of the oil in a gallon of water.
An Abduction Splint for the Femur. — Dennis
W. Crile {British Medical Journal, April 27, 1918)
says that fractures in the upper third of the
femur, especially when complicated with extensive
wounds of the hip and buttock, present great diffi-
culty in treatment with the Thomas or other avail-
able splint. Abduction and extension must be pro-
vided, the wounds should be accessible for dressing,
and the splinted patient should be easily transported
without disturbing the immobilization of the frac-
ture. To meet these requirements a splint has been
devised, modeled on the lines of the Thomas. The
ring of the Thomas splint is transposed to the sound
side, taking the ischial tuberosity of that side as a
base for the extension. The inner rod of the splint
is attached to this ring, an ofifset being made for the
genitals. The rod is continued into the outer rod
which ends above in an iliac pad which fits just
below and parallel to the crest of the ilium on the
fractured side. This pad is continued in a well
protected broad band which passes around behind
the pelvis fitting snugly into the sacral hollow and
ending in a leather strap in front. At the front of
the splint the iliac pad and the ring are connected
by an iron rod which runs transversely across the
body and to which the leather strap is also attached
by means of a buckle. The outer and the trans-
verse rods are provided with screws and nuts for
adjustment for length. The plan of the splint is
shown in a number of illustrations. Abduc-
tion is secured by the tilting of the pelvis through
pressure on the ischial tuberosity of the sound side
and extension by weight and pulley or by a gradu-
ated spiral spring. Flexion at the hip can be se-
cured by bending the splint or elevating the foot.
The splint is light, inexpensive and easily carried.
Ethylhydrocupreine (Optochin) in Lobar
Pneumonia. — H. F. Moore and A. M. Chesney
{Archives of Internal Medicine, May, 1918), in
clinical studies in seventy-five cases, found ethylhy-
drocupreine hydrochloride to fulfill at least some
of the requirements of a chemotherapeutic agent.
Even in high dilutions it kills the pneumococcus in
the presence of body fluids. It is absorbed from
the gastrointestinal tract, and when injected into the
muscles may pass into the blood stream. When a
sufficient amount is given by mouth — 0.024 to 0.028
grami per kilogram of body weight every twenty-
four hours — the blood serum becomes pneumo-
coccidal in vitro, and when such a condition obtains
in the blood, the pericardial fluid also becomes pneu-
mococcidal. The necessary amount cannot always
be given with safety, for in one instance of the series
total blindness lasting six days resulted, and in eight
others there occurred visual symptoms of sufficient
gravity to demand discontinuance of the drug. From
the standpoint of the efifect of the drug on the dura-
tion of the disease, extension to previously unin-
volved lobes of the lung, the pneumococcemia, and
the mortality rate, the results did not afford much
support for routine use of the drug. The main
reason it has not yielded more striking results seems
to be that its toxicity is such as to keep the limits
of dosage below the limits of effectiveness.
Bloodless Repair of Cervix. — A. Heineberg
{American Journal of Obstetrics, April, 1918) finds
marked advantages in a bloodless method of repair.
After introducing a selfretaining speculum in the
vagina, he grasps the anterior lip of the cervix in
the median line with an ordinary double tenaculum
and dilates the cervix moderately, mainly to deter-
mine the exact location and direction of the canal.
The cervix is then drawn to one side and a special
angulated tenaculum forceps, with a pedunculated
metaUic ball attached to the outer aspect of each
blade above the angle, is applied to the cervix well
above the level of the proposed amputation or de-
nudation. Next the cervix is drawn to the other
side and a second angulated forceps applied opposite
the first. The ordinary tenaculum is now removed,
the handles of the two special forceps brought to-
gether, and a rubber ring, such as is sometimes em-
ployed to hold together the tops of umbrella ribs,
stretched over the forceps and carried up on the
cervix to a level ?bove the balls on the forceps. The
handles of the forceps are then separated and hand-
ed to an assistant, thus acting also as lateral retrac-
tors of the vagina. Finally the repair operation is
proceeded with, care being taken throughout not to
tear the cervix by excessive traction on the forceps.
When the vagina is long and narrow or the cervix
cannot be easily drawn down, forceps provided with
balls but with a long curve instead of an angle can
be applied more easily than the angulated forceps.
Where it is desired to remove the forceps and rub-
ber ring before tying the repair sutures, the ring
is simply cut through.
214
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Drainage of Deep Thigh Wounds. — W. Samp-
son Handley and P. J. Hanlon {Lancet, May 25,
1918) suggest that the special gravity of infected
deep thigh wounds hes in the enclosure of the struc-
tures in the inelastic sleeve of the fascia lata. This
leads to extensive spread of the inflammation under
great pressure. Hitherto the methods of drainage
have been very inadequate, but a study of the an-
atomy of the thigh in cross section reveals that the
most important intermuscular space is that between
the vastus externus and the crureus, which also
communicates with many other intermuscular spaces
and extends the whole length of the thigh. This
space is very readily opened by a longitudinal inci-
sion in the line of the external intermuscular septum
at the posteroexternal aspect of the thigh. The in-
cision runs for two thirds the length of the thigh
and the separation of the tissues is made along the
plane between the hamstrings and the external in-
termuscular septum. When the linea aspera is
reached the external intermuscular septum is cut
through along its attachment. This gives free open-
ing, good drainage, and does not endanger any im-
portant structure.
Influence of Treatment on Bacterial Flora of
War Wounds. — Kenneth Goadby {British Medi-
cal Journal, May 25, 1918) draws his conclusions
from three years of study of the bacterial flora of
war wounds as seen in home hospitals and finds that
the mass infection of wounds has shown progressive
diminution while the persistence of anerobic organ-
isms in the wounds has not undergone a similar re-
duction. The use of the two common antiseptic
dressings — Bipp and hypochlorite — has not mate-
rially diminished the anerobic flora. Of the various
methods employed in the immediate treatment of
wounds at the front, early, complete excision of the
damaged tissues seems to be the only one which has
materially reduced the anerobic wound flora. The
question of latent infection as contrasted with per-
sistent infection is of great importance in relation
to the performance of subsequent operations. Since
the organisms in latent infection are found in close
proximity to healthy tissue, they are likely to be at
the site of the subsequent operation. Finally, it is
found that bone fragments split ofif at the time of
the original injury invariably become sequestra,
probably due to the proteolytic action of the bac-
teria.
A Vaccine for Bronchial Asthma. — J. Morrison
Hutcheson and S. W. Budd {American Journal of
the Medical Sciences, June, 1918) prepare their
vaccine in the following manner : One c. c. of
washed sputum is incubated in ten c. c. of broth and
one or two drops of guineapig scrum for forty-eight
hours. The culture is then standardized and killed
by heat of 60° C. for a period of two hours.
Further decomposition is prevented by adding
carbolic acid until a one per cent, solution re-
sults. This is cultured ouc to ensure sterility of the
suspension. The vaccine is then diluted with nor-
mal saline until each cubic centimetre of the sus-
pension contams 500,000,000 to i ,000,000,000 organ-
isms. The initial dose is five minims ; each subse-
quent dose is increased by one minim up to a max-
imum of fifteen minims. This amount is not in-
creased, though the treatment may be continued sev-
eral weeks. The authors report the following re-
sults obtained in twenty cases of typical bronchial
asthma. Complete relief in twelve after one to five
injections. Longest period of freedom from symp-
toms, sixteen months ; shortest, six weeks. Distinct
improvement in five cases. No effect was observed
in two patients, one an elderly man with emphysem-
atous lungs and a history of asthma for over twenty
years, the other a case in which asthma followed in-
jury to the chest and the x ray showed ununited frac-
tures of several ribs. In one case the vaccine
seemed to Increase the intensity of the paroxysms ;
the explanation seemed to be that too long a time
was allowed to elapse between injections. Injcc-
lions in most cases were made twice a week, but
the writers think that a shorter mterval would prove
more desirable.
Chronic Septicemic Endocarditis with Spleno-
megaly.— David Riesman {Joiifnal A. M. A., July
6, 1918) calls attention to the fact that the spleen is
practically always enlarged in cases of chronic sep-
ticemic endocarditis, and points out that the spleen
is well known to be a filter for bacteria in the blood.
The organisms filtered out by the spleen may not
be destroyed, but may multiply there, throw large
quantities of toxins into the circulation, and keep
up the infection even after the primary focus has
ceased to exist or to be active. On the strength of
these views and since the use of autogenous vac-
cines, transfusions, drugs and other measures failed
to avert death, splenectomy was thought of as a
possible measure of value. One case was submitted
to this operation after preparation by blood trans-
fusions, and during the month of the man's subse-
quent life his general condition and blood picture
showed decided improvement. Death resulted acci-
dentally from an intercurrent abscess of the larynx.
Effect of Phosphorus on Growing, Normal, and
Diseased Bones. — D'. B. Phemister {Journal A. M.
A., June 8, 1918) says that since the researches
of Wegner, in 1872, phosphorus has been used in
disorders of ossification, but there has been little
evidence brought out as to just what changes it
produces. From a careful rontgenological study of
three cases Phemister finds that, given alone, phos-
phorus stimulates markedly the production of bone
and calcium accumttlation in the normal zones of
growth in healthy children. The stimulant effects
on endochondral bone growth are particularly
marked, and the overproduction of bone in juxta-
epiphyseal regions of the shafts of the long bones
continues for some time after the administration
of the drug has been stopped. In diseased bone
there are certain dififerences in eflfect ; thus in the
florid stage of rickets there is no x ray evidence of
increased bone growth, due probably to the loss of
power of lime deposition. During the healing stage
the drug should stimulate bone growth. The pri-
mary union of fractures is aided by phosphorus,
but union is not promoted in cases of nonunion
after the normal reparative processes have been ex-
hausted. In osteogenesis imperfecta bone growth
is greatly stimulated. The entire subject of the ef-
fects of phosphorus on bone growth and repair de-
mands much detailed investigation.
August 3, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
215
Corpus Luteum Extract in Repeated Abortion.
— John Cooke Hirst {American Journal of Obstet-
rics, April, 1918) refers to a type of case — the "ir-
ritable uterus" — in which the uterus will stand dis-
tention up to a certain point, usually three or four
months of pregnancy, then expels its contents.
There is no apparent cause, such as uterine dis-
placement, lacerations or erosions of the cervix, or
pelvic adhesions, and the Wassermann is negative.
In the case of a patient just beginning her seventh
pregnancy, previously attended several times in
abortion about the third month, the thought present-
ed itself to the author that the cause of the rniscar-
riages might have been a premature absorption or
blighting of the corpus luteum of pregnancy, the re-
lation of which to pregnancy is well known. Upon
this basis, intramuscular injection of corpus luteum
extract was instituted, one mil of the extract, rep-
resenting twenty milligrams of the dried substance,
being administered once daily. Thirty-six injec-
tions were given in the course of two months. The
patient had never before gone beyond the fourth
month and one week of pregnancy, but this preg-
nancy resulted in a living child delivered at term.
A second patient had had five miscarriages, never
going beyond three and one half months. In the
sixth pregnancy corpus luteum was begun when she
was seven weeks pregnant. She was also delivered
at term. A third patient had a similar history and
was successfully treated. Further experience by
various observers will be required to establish defi-
nitely the value of the procedure. Intramuscular
rather than oral use of the extract is recommended.
Forced Feeding and the Nitrogen Equilibrium
in Pernicious Anemia. — Herman O. Mosenthal
(Bulletin of the Johns Hopkins Hospital, June,
1918) in order to study the question of whether
forced feeding has any influence on the assimila-
tion of protein in pernicious anemia and allied dis-
eases, observed three cases so treated, . and an
additional one of secondary anemia, as a control.
The criteria by which the results were judged were
the production and maintenance of a positive ni-
trogen balance, and an improvement in the blood
picture. The patients were put on high diets of
as appetizing food as possible, conforming to their
individual tastes, and selected without any attempt
to maintain a definite proportion of proteins, fats,
or carbohydrates. They were kept in bed, and the
only medication given was dilute hydrochloric
acid. In one instance the patient was transfused
twice. In all of the cases a positive nitrogen bal-
ance was obtained by this forced feeding, and a
rise in the red cell count and hemoglobin was ob-
served. One of the patients retained 3.4 grams of
nitrogen a day for twenty-eight days, another 3.4
grams a day for thirty-two days, and the third 6.8
grams a day for thirty-six days. In the first case
the hemoglobin rose from thirty-six to forty-eight
per cent. ; in the second, from twenty-five to sixty
per cent., and in the third from seventy to seventy-
seven, with a corresponding increase in red blood
cells. The case of secondary anemia, treated in
the same way, except that no hydrochloric acid was
given, showed a positive balance of 8.7, a rise of
hemoglobin from twenty to fifty-five per cent., and
in red blood cells from 912,000 to 3,056,000. While
this may have been accidental, it is interesting in
that, as Mosenthal says, it suggests that the ele-
ment of protein destruction does play a consider-
able role ill pernicious anemia. In considering the
improvement in the blood picture, the tendency to
remissions which occurs in pernicious anemia, must
be considered, so that it is impossible to say just
how great a factor the forced feeding was in this
instance.
Treatment of Deep Facial Scars. — A. Poulard
(Presse medicale, April 25, 1918) asserts that com-
plete removal with the knife is justified only in su-
perficial, elevated scars. In deep, depressed scars
adhering to the underlying bone, complete removal
may lead to great difficulties by reawakening deep
infectious processes that had subsided. Often the
scar is acting as a stopper in an opening leading into
one of the sinuses or the skull cavity, and its remo-
val is useless and dangerous. Poulard makes a
deep incision in the healthy skin around the scar,
then removes with the knife the superficial epi-
dermal layer covering the scar, leaving, however,
the main fibrous mass of the latter behind. The
margins of healthy surrounding skin are then freely
loosened, brought together, with a thick layer of
adipose tissues, over the cicatricial mass, and sutured
there. Esthetically this procedure obviates the tm-
sightly depression left after complete excision of a
scar. The scar itself fills up the base of the depres-
sion, and the thick, healthy tissues brought over it
suffice to form a level surface. The sutures should,
of course, be skilfully placed to secure the best
esthetic results.
Treatment of Malaria. — C. A. Johnston {Brit-
ish Medical Jomrnal, May 25, 1918) describes a
method of treatment with subcutaneous injections
of quinine which has given him uniformly good re-
sults in years of use in malarial regions. The
method of giving the injections must be followed to
the finest detail if it is to prove satisfactory. The
materials required are : A sterilized, all glass, twenty
minim hypodermic syringe with stout needles ; half
per cent, sterile saline solution ; sterile three inch,
wide mouthed test tube ; five per cent, phenol in oil ;
pure quinine bisulphate. The patient's flank be-
tween the iliac crest and the last true rib is prepared
by cleansing with soap and water and smearing
with the phenol in oil. Four grains of the quinine
bisulphate are put into the test tube and twenty
minims of the saline are squirted in from the syr-
inge. Bring to the boiling point over an alcohol
lamp, fill the syringe with the solution, dip the needle
into the phenol in oil, and when the solution of qui-
nine has cooled to about 100° F., pick up a good
lump of cutis vera of the prepared flank between
the fingers, plunge the needle in to its hilt, sweep
its point from side to side through the connective
tissue to break down small trabeculae, and inject the
solution. Withdraw the needle quickly and massage
the spot with some cotton containing the phenol in
oil. Repeat daily for five consecutive days in alternate
flanks. The patient should also take for one month
a daily dose of one twentieth grain of arsenious
acid and five grains of quinine, well diluted, the
latter being taken in the morning.
Miscellany from Home and Foreign Journals
Acute Meningitis in Congenital Syphilis. — Hu-
tinel {Presse nicdicale, April 22, 1918) states that
attacks of meningitis in the presence of congenital
syphilis are by no means rare. Some are insidious
and latent in type ; others, occurring among older
children, may simulate tuberculous meningitis, at
times so closely that confusion is practically un-
avoidable. The condition should be borne in mind
especially when the clinical picture in a case of men-
ingitis presents unusual features, when the child
shows suspicious evidences of syphilis, when his
heredity is doubtful, and especially, when recovery
occurs. Even in the presence of what appears to
be a tuberculous meningitis, running a regular course
and the diagnosis of which is almost certain, it is
wise not to render a definite diagnosis too soon, for
such a diagnosis implies a fatal termination. When-
ever any doubt is felt, specific treatment should be
at once instituted, beginning with mercurial inunc-
tions while awaiting the opportunity for more vig-
orous measures. Such inunctions have no preju-
dicial influence in tuberculous meningitis, and may
cause rapid improvement in syphilitic meningitis,
thus revealing the nature of the disturbance.
Splenic Enlargement in Malaria. — R. Porak
{Presse medicale, April 22, 1918) calls attention to
cases of malarial splenic enlargement occurring in
the absence of all fever. This condition doubtless
often escapes notice. In two of the author's sixteen
cases the patients came under treatment for dis-
orders other than malaria, and the attack of splenic
enlargement was only discovered by chance. In six
cases they complained of more or less severe pain
in the splenic region, sometimes with added reflex
disturbances such as colonic spasm, incessant cough,
and pain in the loins. Six others were admitted
because of their general condition of pallor, emacia-
tion, and lassitude, together with headache and di-
gestive disturbances. Finally, in two cases a rare
manifestation of malaria was the initial disturbance,
viz., a diffuse erythema in one instance and sciatica
in the other. In some of these cases of splenic en-
largement the organ is merely sensitive to percus-
sion or palpation. A single observation of an en-
larged spleen is without diagnostic value ; the organ
must be found to have increased in size upon re-
peated examination. The temperature in these
cases shows, in general, an undulating curve, with
a tendency to hypothermia and a range of one to one
and a half degrees centigrade; it is not periodic.
Slight tremor of the fingers occurs when the tem-
perature is rising. The general condition is one of
asthenia with dififuse muscular pains. Anorexia,
diarrhea and atrophy of muscular tissue are other
accompanying manifestations. The diagnosis must
be confirmed by blood examination. The author
looks upon the splenic enlargement as an evidence
of defensive activity on the part of this organ
against the malarial parasites. Healthy carriers of
the parasites are kept healthy by the protective ac-
tion of this organ. In malarial districts all illnesses
are accompanied by marked enlargement of the
spleen, in the absence of all manifestations of ma-
laria ; in such cases the splenomegalic form of ma-
laria has evidently run its course unnoticed by either
patient or physician. In splenic enlargement occur-
ring as the initial evidence of malarial infection,
quinine sulphate in large doses rapidly reduces the
organ and leads to a gain in body weight. In sec-
ondary malaria, however, in which gametes have
already been formed, quinine is incapable of effect-
ing a complete sterilization of the organism, and
must be supplemented by measures calculated to
augment the resisting powers, such as rest, good
food, open air treatment, and arsenic. Even after
apparent recovery the patient must be kept under
observation. Prophylactically, a search for and
treatment of gamete carriers is as important in this
as in other forms of malaria.
Experiments Outlining the Limitations of Op-
erations on the Abdominal Aorta. — Charles
Goodman {Journal of Experimental Medicine,
May, 1918) reports the results of various operations
on five dogs with such satisfactory results that he
concludes that injuries of the abdominal aorta maybe
corrected with subsequent perfect restoration of the
continuity of the vessel. Even when the aorta is
completely occluded for thirty minutes there need
not necessarily be serious consequences. Where it
is necessary to resect part of the aorta, it is safe
to use an arterial segment taken from another ani-
mal as a transplant. When the aorta is completely
severed the safest operation is to transplant a seg-
ment, for while it is possible to reestablish the con-
tinuity of the severed aorta by a circular suture,
the method entails so much difficulty to approximate
the cut ends that thrombosis is likely to occur. It is
fairly safe to use an arterial tube of increased
calibre made of the smaller vessels, e. g., the carotid,
as a transplant to the severed aorta, while fascial
transplants can be employed to correct defects in
the aorta with a minimum danger of thrombosis.
Megacolon. — Charles Greene Cumston {British
Journal of Children's Diseases, January-March,
1 91 8) describes this condition as one of extraordi-
nary size of the colon. It may involve the entire
colon or one of its segments. The walls of the in-
testine are not thinned. It may be present in
the newborn and manifest itself by retention of the
meconium. Two symptoms predominate : obstinate
constipation and abdominal distention. Vomiting is
present in about thirty-three per cent, of the cases
reported. In children tetany is often seen, unques-
tionably the result of an intoxication due to intes-
tinal putrefaction. Fever is rarely seen. The final
symptoms are extreme cachexia, short rapid respira-
tion, small pulse and cold and clammy extremities,
and coma. This condition is to be differentiated
from rickets, tuberculosis of the peritoneum or of
the mesenteric lymph nodes. A rise in temperature,
the presence of ascites, etc., will eliminate mega-
colon. Prognosis is serious as medical treatment is
usually useless. Colostomy has given a mortality
of thirty-five per cent. Colopexy has been used. A
simple enteroanastomosis is said to produce atrophy
of the useless colonic segment.
August 3, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
217
Intermittent Claudication Following Ligation
of Main Artery to Lower Extremity. — Babinski
and Heitz (Pres'se mcdicale, March 28, 1918),
among fourteen wounded men in whom ligation of
the femoral or popliteal artery had been carried out,
observed intermittent claudication in five instances.
Pain compelled these patients to stop after they had
walked a distance varying from a few steps to a
few hundred metres. The condition was still pres-
ent months after the operation. In no cases were
there pulsations in the dorsalis pedis or posterior
tibial arteries. The oscillations shown by the
Pachon instrument when applied above the malleoli
were greatly reduced and failed to increase upon
immersion of the extremity in hot water. Of the
nine patients who did not show intermittent claudi-
cation, six could only walk slowly with crutches be-
cause of contractures or deep injury of the sciatic
nerve. In the remaining three, collateral circula-
tion had been largely reestablished so that the oscil-
lations were almost as large on the affected as on the
normal side.
Preservation of Complement. — B. W. Rhamy
(Journal A. M. A., June 29, 1918) finds that the use
of sodium acetate is ideal for preserving the com-
plement for the Wassermann reaction for the follow-
ing reasons : l, it is not hemolytic ; 2, it is not anti-
complementary ; 3, its solutions can be sterilized ; 4,
in solution in physiological saline it has the same
hydrogen ion concentration as the blood ; 5, it pre-
serves and stabilizes the complement for from two
to three months at icebox temperature ; 6, it can be
used in any strength from five to fifty per cent., or
even in crystal form ; 7, its action is not antibac-
terial ; 8, it is anticoagulant when added to whole
blood in certain strengths ; and, 9, it will preserve
human complement. The best method of obtaining
and preserving guineapig complement is to bleed
the pig by severance of both carotids, gently break
up the clot as soon as it has formed, centrifugalize,
pipette off the serum, and dilute it to forty per cent,
with twelve per cent, solution of sodium acetate.
This is then preserved in the icebox. This serum
loses only about 0.02 unit of complement per week
when kept cool. The complement must be titrated
against every new batch of red cells, owing to the
variability in the latter.
The Nutritive Value of Maize Protein: Phos-
phorus and Calcium Requirements of Healthy
Women. — H. C. Sherman, Lucile Wheeler, and
Anna B. Yates {Journal of Biological Chemistry,
May, 1918) studied the nitrogen, calcium, and phos-
phorus balances in two healthy women during seven
consecutive periods of four days each, using in the
first series a diet of wheat bread, butter, peanut
butter, milk, meat, apples, and grape juice, and in the
second series with one subject a diet which included
200 grams of corn meal a day, about one-third
of the protein thus being derived from maize, and
with the other woman a diet largely made up of
wheat bread for twenty days, and then for eight
days corn meal was substituted for much of the
wheat flour used in the bread and also for part of
the sugar previously used, so that about one-fifth
of the protein of the last period was derived from
maize. Unless eggs or milk were used plentifully
in cooking it was difficult for one unaccustomed to
eating maize to live on the diet without a
disturbance of appetite or digestion. How-
ever, the conditions of the experiment were
very severe, so that the authors regard the
results as very favorable to the use of maize pro-
tein in normal adult nutrition, because on a con-
tinued low protein diet, where forty-seven per cent,
of the total protein was from wheat flour and thirty-
one per cent, from corn meal, the latter was used
efficiently in maintaining the nitrogen equilibrium,
and also because when maize protein was substituted
for wheat protein to an extent affecting one fifth
of the total protein intake, there was no unfavorable
effect on the nitrogen balance. The minimum out-
put of phosphorus per day of 0.71 to 0.69 gram
in these subjects, who weighed sixty and fifty-four
kilos respectively, would correspond to the minimum
requirement of an average sized man per day (0.83
and 0.89 gram respectively in a man weighing
seventy kilos). In both subjects there was a con-
stant negative balance for calcium and no tendency
to equilibrium.
Heat Production. — Soderstrom, Barr, and Du
Bois {Archives of Internal Medicine, May, 1918),
in ten experiments on five subjects, administered
small breakfasts of bread, butter, sugar, and milk,
each totaling 222 calories. In the first hour the
heat production increased seven per cent., in the
second and third hours, two per cent., while in the
sixth to eighth hours the metabolism was slightly
lower than before the breakfast. Only during the
fir,st hour could absorption of food have been suf-
ficient to produce a "metabolism of plethora." The
experiments seemed to indicate that taking five or
six small nieals a day instead of two or three large
ones would result in a saving of five or ten per
cent, of the basal metabolism, or about 200 calories
a day. Practically, however, this would be of little
importance, and one must remember the waste of
time in taking frequent meals and the tendency to
overeat.
The Influence of Parathyroidectomy on the
Gastrointestinal Mucosa. — G. A. Friedman,
{Journal of Medical Research, March, 1918),
was able to produce gastric or duodenal lesions
after parathyroidectomy in eleven out of four-
teen dogs, and in two dogs appendicitis lesions
were present, in one associated with a duodenal
ulcer, and in the other with a gastric ulcer. Similar
results were obtained with rabbits, so ihat Friedman
believes the initial lesion of peptic ulcer and appen-
dicitis may be produced by a disturbance in the
thyroid secretion. These lesions did not show a
tendency to heal because of the continued thyroid
disturbance. As the degree of thyroid insufficiency
in man is less than that produced experimentally in
animals, there is the likelihood that the anomalous
constitution created by lack of thyroid secretion may
be corrected, but if this does not happen, through
the irritation of food and the effect of excessive
secretion of hydrochloric acid, the acute ulcers may
become chronic. It therefore appears that the thy-
roid, and perhaps the parathyroids and adrenals,
may be responsible for the association of peptic ulcer
and appendicitis.
2l8
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Circulatory Reactions to Graduated Work. —
Theodore B. Barringer, Jr. (American Journal of
the Medical Sciences, June, 191 8) concludes that the
occurrence of a delayed rise in systolic blood pressure
after work indicates that the preceding work has
either overtaxed, or is on the point of overtaxing the
heart's reserve power. The presence of a delayed
rise can be determined by the infrequent method
of plotting the pressure curve with almost as much
certainty as by the frequent method. A small num-
ber of experiments upon normal people and upon
patients with cardiac insufficiency showed that no
definite relation existed between the time required
for the pulse rate to return to normal and the con-
dition of the cardiac reserve power.
Bordet-Wassermann Reaction of the Cerebro-
spinal Fluid in General Paralysis. — J. A. Sicard
and H. Roger (Bulletins ct memoires de la Societc
medicale des, Jiopitaiix de Paris, February 21, 1918)
obtained a positive reaction in the spinal fluid in
100 cases of paresis, and maintain that a negative
reaction in a suspected case, especially if the test is
twice repeated at weekly or fortnightly intervals
with the same result, excludes a diagnosis of this
affection. Such differentiation is now of especial
moment, as certain concussional states more or less
closely reproduce the symptoms of chronic diffuse
meningoencephahtis. High albumin content of the
spinal fluid generally accompanies a positive reac-
tion ; the albumin varies independently of treatment
and depends upon the congestive attacks sometimes
clinically noticeable in these patients. The Bordet-
Wassermann reaction of the blood was positive in
about ninety-five per cent, of the cases before treat-
ment and in only thirty-five per cent, after vigorous
intravenous arsenobenzol therapy. On the other
hand, the same reaction in the case of the spinal
fluid always remained positive after treatment, even
when doses of arsenobenzol so large as to cause se-
vere intoxication were used.
Comparative Activity of Local Anesthetics on
Sensory Nerve Fibres. — Torald Sollmann (Jour-
nal of Pharmacology and Experimental Thera-
peutics, February, 1918) studied the activity of va-
rious local anesthetic agents on sensory nerve fibres
by applying them to the sciatic plexus in the frog
and observing the presence or absence of reflex re-
sponse to stimulation of the foot by dilute hydro-
chloric acid. Cocaine, novocaine, and tropacocaine
were found about equally efficient. Potassium — in
the form of potassium chloride — alypin, quinine,
and urea hydrochloride, and especially antipyrin,
proved less active, and their efficiency ratio in com-
parison with cocaine was lower as regards sensory-
fibres than the author had previously found to be
the case as regards motor fibres. Alkalization by
the addition of 0.5 per cent, of sodium bicarbonate
to the anesthetic solutions was found to increase the
efficiency of the organic anesthetics from two to
eight times. Even this enormous increase was only
about one half that previously noted from alkaliza-
tion in the case of motor fibres. Addition of
epinephrin, one in 10,000, to one quarter or one
eighth per cent, solutions of cocaine or novocaine
hydrochloride failed to increase their paralyzing
action on sensory fibres as it had failed similarly in
the case of motor fibres. Mixtures of cocaine hy-
drochloride with novocaine hydrochloride or with
quinine and urea yielded a simple summation of
activity, without potentiation — a result similar to
that noted with motor fibres. Mixtures of the an-
esthetics with potassium chloride likewise failed to
show potentiation on sensory fibres. This was in
marked contrast to the effects on motor fibres, in
the case of which the efficiency was potentiated
eight times with the potassimn salt. Thus appar-
ently the sensory fibres show some important dif-
ferences from motor fibres in their response to local
anesthetics.
Optic Atrophy and Multiple Neuritis from
Manufacture of Explosives. — Arthur S. Hamilton
and Charles E. Nixon (Journal A. M. A., June 29,
1918) reports in detail the first case so far encoun-
tered of bilateral atrophy of the optic nerves and
peripheral multiple neuritis which has developed as
the result of exposure to binitrotoluene. The pa-
tient was a man thirty-nine years old, of good gen-
eral health and habits and good past and family his-
tories. About a year after beginning to work with
the binitrotoluene he first noticed numbness and
prickling in the feet, extending up to the knees after
five months. After a month at outside work these
symptoms passed off, except from the feet. He then
returned to his former work and after five months
the symptoms began to return and his sight began
to fail. He also became slightly cyanotic and
seemed anemic. After stopping work again his sight
continued to fail rapidly for some time until it was
only 6/200 in each eye. The eye grounds showed
well developed atrophy of the optic nerve and gen-
eral examination revealed a well developed multiple
peripheral neuritis. Under treatment with potassium
iodide, laxatives, and sweating his condition im-
proved and recovery was almost complete from both
the neuritis and the optic atrophy.
Cranial Bone Plates in Cranioplasty. — Sicard,
Dambrin, and H. Roger (Bidletin de I'Academie de
medicine, April 30, 1918) have been resorting suc-
cessfully to this procedure for two years, and have
now operated in eighty-five cases without mortality,
with perfect tolerance of the bone plate, and with
excellent esthetic and protective results. The plate
is obtained from a human cadaver at autopsy and
is taken from the corresponding region of the skull.
It is properly shaped, thinned down, then freed of
fat and sterilized. The few persistent local sinuses
and complications necessitating removal of the plate
in three or four of the earlier cases were entirely
obviated by strict technic in the latter portion of
the series. Of the other methods hitherto used,
metallic plates are open to the objection of ultimately
inducing local irritation. Cartilage and osteoperi-
osteal plates sometimes give way and become ab-
sorbed, even to the point of reappearance of the cer-
ebral pulsations. Cartilage plates placed in blood
or blood serum for a few hours show marked
changes in curvature. Bone plates, on the other
hand, promote subjacent osteogenesis, or rather,
fibrogenesis. While they are similarly susceptible
to absorption, there remain locally very firm filjrous
or osteofibrous residua which continue to serve the
purpose of the plate.
Proceedings of National and Local Societies
NEW YORK ACADEMY OF MEDICINE*
Stated Meeting, Held on May 2, ipi8.
The President, Dr. Walter B. James, in the Chair.
Specific Prevention of Poliomyelitis. — Dr. H.
L. Abramson read this paper which presented only
the salient facts brought out in work extending
over a period of two years, and dealt with efforts
made toward the development of a method for pro-
tection against acute poliomyelitis. The first effort
in this work consisted of an attempt to adapt the
virus of poliomyelitis to the rabbit, but after rather
extensive experience with this animal it was found
to be unsuitable. Attention was then directed to
the use of monkeys of the rhesus variety. This
animal, as had been amply demonstrated in a wealth
of experimental work, was highly susceptible to
experimental poliomyelitis. The virus of poliomye-
litis used was obtained from the Rockefeller In-
stitute and was of such potency that .05 c. c. of the
supernatant fluid of a centrifuged five per cent,
emulsion inoculated into the brain of a monkey
produced a fatal poliomyelitis infection. This virus
had passed through a large number of monkey
generations at the Rockefeller Institute and through
ten additional generations at the Board of Health
Laboratory. It was very reliable and had not yet
failed to produce lethal poliomyelitis in normal ani-
mals that had been inoculated intracerebrally with
.05 c. c. or more of a five per cent, emulsion. It was
decided that the injection material ought to be modi-
fied or attenuated in some manner so as to remove
any possibility of harm from the method itself.
Also, in order to render the emulsion utilizable in
time of epidemic, it was decided that the time con-
sumed in administration of the method ought to be
as short as possible consistent with the production
of a degree of immunity sufficient to protect against
a reasonable exposure to the disease.
The first method tried, an effort to attenuate the
highly potent monkey virus by exposure to forma-
lin, which was later removed by dialysis, was not
satisfactory. Two other methods were tried, the
killed virus method and a method involving the use
of virus subjected to graded heat with a final in-
jection of unheated material. The first produced
some immunity, but not of a high degree. The
second produced protection of considerable degree
against an unusually severe method of testing, the
sera of these animals all containing neutralizing
substances, but in varying degree. The latter
method also produced no ill effects as a result of the
treatment itself : the injection of graded attenuated
material prepared the animal to take care of the
final injection of live virus ; it produced sufficient
immunity to protect animals against a multiple in-
tracerebral dose of a highly potent virus, which was
a hundredfold severer exposure than that to which
persons were exposed in the natural infection ; and
it produced neutralizing substances in the blood in
such concentration as should be amply able to com-
*Program arranged in cooperation with the Laboratory of the
Board of Health, William H. Park, M. D., Director.
bat the comparatively mild infection which might
lodge on the nnicous membrane of persons exposed
to poliomyelitis. Furthermore, the series of injec-
tions were completed in five days, which rendered
it highly practicable in time of epidemic. It could
be easily prepared from the glycerolated virus
which might be kept on hand over a long period of
time without deterioration and required only mod-
erate laboratory facilities.
Pneumococcus Type Determination in Pneu-
monia.— Dr. Charles Krumwiede presented the
results of a successful effort to establish a rapid
method for the determination of the type of pneu-
mococcus. Observations, made in an attempt to de-
termine the earliest time at which precipitable pneu-
mococcus antigen was demonstrable in the wash-
ings from the peritoneal cavity of mice inoculated
with pneumonia sputum, indicated that pneumonia
sputum contained considerable soluble pneumococ-
cus substance. This fact, as well as the knowledge
that sputa of pulmonary origin contained albumin,
suggested the following rapid method for the de-
termination of the type of pneumococcus. If the
sputum was of satisfactory quality, it would coagu-
late if the test tube in which it was poured were
placed in boiling water for several minutes. The
clot was broken up and the fluid separated from it
was added to the type sera. With positive sputa
the readings were usually made within fifteen or
twenty minutes after the receipt of the specimen.
The success of the method depended on the quality
of the sputum submitted. About three c. c. of
sputum was desirable for the test.
Of 183 sputa received in the regular routine of
the department, 129 had been satisfactory for this
method of testing. Of the good specimens, ninety-
nine contained a fixed type and about ninety-five
per cent, gave a promptly positive reaction. Of the
poor specimens, sixteen contained fixed types, but
mouse inoculation was necessary to determine this.
Of fifty sputa containing a Type I pneumococcus,
forty were satisfactory for this method and thirty-
nine gave a positive result. As Type I serum was
available for therapeutic purposes, in these in-
stances it was possible to send the serum back with
the messenger who delivered the sputum which re-
sulted in the serum being administered within half
an hour instead of the usual twenty-four hours,
thus hastening the possibility of the patient's re-
covery.
Technic of Complement Fixation in Tubercu-
losis.— Dr. M. A. Wilson said that in this study
of tuberculosis complement fixation two points of
technic had been found which had increased the
efficiency of the test. The first had to do with the
standardization of the guineapig serum to determine
the value of the complement, and the second dealt
with the advantage of testing the patient's blood sev-
eral days before bleeding. The latter point was
discovered by Doctor von Wedel and would be ex-
plained by him in his paper. The method for
making the tests was as follows : All reagents were
used in one tenth the classic Wassermann volumes.
220
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
Fixation period, one hour, 37° C. The patient's
serum was inactivated for thirty minutes at 56° C.
Two antigens were used ; one was made from
twelve stock cultures of human tubercle bacilli, the
other from a strain used for tuberculin production.
The antigen was standardized to be used in such a
dilution that one c. c. would contain two standard
fixation units and one fourth or less of the anti-
complementary dose. The unit was determined by
titrating varying amounts of the antigen with one
c. c. of a known positive tuberculosis serum and
two hemolytic units of a complement known to be
potent for tuberculosis fixation. These antigens
were not anticomplementary. They had given uni-
form and constant fixation reactions. The tests
showed they were specific and stable. They were
made ten months ago and were perfectly efficient
today.
The complement was obtained from guineapig
serum twenty- four or forty-eight hours old, pooled
from six to ten pigs, the serum from each pig hav-
ing previously been tested for its hemolytic strength,
for antisheep amboceptor, for anticomplementary
reaction and for fixability with the combination of
tuberculosis antigen and tuberculosis serum. This
last test was emphasized as essential if uniform re-
sults were to be obtained with difTcrent lots of com-
plement ; it had been proved beyond a doubt that
although a guineapig serum might react perfectly in
all other respects, it might fail to be fixed by tuber-
culosis antigen and serum. A table, giving the
number of pigs efficient for complement fixation
showed that out of 129 guineapigs only forty-six
were efficient for tuberculosis, 117 for meningo-
coccus and eighty-eight for gonococcus complement
fixation. The conclusions were that all guineapig
serums were not efficient for tuberculosis comple-
ment fixation ; and that the serum from each guinea-
pig should be tested for fixability with tuberculosis
antigen phis tuberculosis serum before pooling the
complement for diagnostic tests.
Clinical Results of Complement Fixation in
Tuberculosis. — Dr. H. von Wedel presented the
preliminary results of a study of the complement
reaction for tuberculosis made to determine the
value of this reaction as a means of diagnosis and
prognosis. In the course of this study he made a
very interesting observation which might possibly
account for some of the wide discrepancies in the
various complement fixation results reported by the
difit'erent workers. The complement fixation results
on sera from positive cases made the first day after
taking the specimens from the patients were in a
very large percentage of cases negative or weak
positive ; while in most instances, seven days later
these same sera gave a strong positive reaction and
continued to give this strong positive reaction week
after week with unvarying regularity. None of the
nontubercular sera gave a positive reaction the
second, third, or fourth week after taking the speci-
men from the patient. The conclusions so far
reached in this study were as follows: i. The
tubercle bacillus antigen used was not anticomple-
mentary in four times the amount necessary to give
positive fixation results with sera from the majority
of active tuberculosis cases. 2. Pooled complement
from at least six guineapigs was used in making the
tests, or the complement from single guineapigs was
tested for its complement fixation value with known
j)Ositive sera. 3. Double the original Wasserniann
amount of patients' sera was used. 4. No report
was made until the sera had been tested after hav-
ing been kept under sterile conditions in the ice
chest for from four to six days, but probably six
days. 5. The results seemed to indicate that if the
aforementioned modification of the original comple-
ment fixation tests were used, 100 per cent, of non-
tubercular cases would give absolutely negative re-
sults; nearly 100 per cent, of the primary and
active cases would give positive results with the ex-
ception of the late cases ; and about twenty-five
per cent, of the partially inactive and negative cases
would give only weak positive results. Before
definite conclusions could be drawn, however, it
would be necessary to make many more tests in a
large number of sera from active, inactive, and in-
cipient pulmonary tubercular cases with a large
number of controlled sera from nontubercular
cases. The results on about 3,000 cases would
probably be reported in the autumn.
The Meningococcus Carrier Problem from the
Laboratory Standpoint. — Dr. Anna W. Wil-
liams said that the investigations in regard to the
detection of meningococcus carriers in the Bureau
of Laboratories had been carried on chiefly from
two standpoints; i. that of developing a method of
making an accurate and rapid diagnosis that could
be of practical use in examining large series of
cases such as occurred when meningitis appeared in
camps, and 2, that of determining the types of
meningococci found in carriers and their relation to
case strains. The work was undertaken because of
a request for aid in the hunt for carriers in certain
camps, aviation fields and ship stations in the vicin-
ity of New York City. First the dififerent culture
media recommended were tested out, and this was
done by using freshly isolated cultures, and these
in one in fifty dilution. Among those tested was
the so called hormone medium recommended by
Lloyds in England and Doctor Hunston in this
country, which had been found to give the best
results but only when a small amount of blood was
added to it. Every lot of this medium should be
tested by planting plates of it containing blood and
plates without blood with a one to fifty dilution of
two recently isolated strains and only those lots
should be used giving at least a moderate growth on
the plates containing no blood. A comparison of
this with other methods showed the time shortened
to twenty-four hours and procedure and apparatus
much modified.
In regard to the second standpoint (the types of
oiganism in these carriers and their relation to case
strains) this part of the work and the more impor-
tant part of helping to decide the necessity of con-
tinued weeding out and isolation of meningococcus
carriers had only just begun. The work had so far
been limited by the inabiHty to determine accurately
the extent of apparent contact. Still, two groups of
cases had been studied in connection with the case
strain in each group which seemed to promise some
interesting data. One of these groups came from
August 3, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
221
an aviation field : the case developed in one of three
carloads of soldiers coming from the south. The
man had given slight symptoms for a day before
arriving and the soldiers from all the cars had
mingled freely at several stops on the way up. The
inunediate contacts of the case, as far as could be
determined, were thirty in number and among these
were eight carriers, or twenty-three per cent. In
the rest of the squadron, numbering 187, twenty-
one carriers, or eleven per cent., were found. The
whole number examined, 217, gave thirteen per
cent, carriers. The second group came from a re-
ceiving ship station. The immediate contacts gave
twenty-four per cent, carriers and the others gave
nineteen per cent. The whole number examined,
293, gave 21.5 per cent, carriers. The difference in
percentage between this group and the one from the
aviation field was significant.
Gordon and his coworkers claimed there were
four distinct types of pathogenic meningococci dem-
onstrated by absorption of agglutinins ; Griffith and
others thought there were only two rather indef-
inite types, and the last Rockefeller division gave
three groups. Gordon stated that those strains that
did not fall into his four types were probably non-
pathogenic and did not need to be isolated; if this
contention was correct it would simplify matters
from the standpoint of an efficient army but it
would increase the complexity of the laboratory
test. In the speaker's study by the method of ab-
sorption it was found that in the first group the
case strain and nearly half the contact strains fell
definitely into Gordon's type I group, one fourth
belonged to type III, those most nearly related to
type I, and the rest either belonged to type IV or
were heterogeneous. These results seemed to bear
out Gordon's claims. The study of the other groups
proved, however, how much study was still needed
to clear up this problem.
Immunization of the Infant against Diphtheria.
— Dr. William H. Park, Director of the Labora-
tory of the Board of Health, said that a number of
the workers at the laboratory had been engaged for
three years on the question of active immunization
against diphtheria, and now a special attempt was
being made to immunize the infant. It was not nec-
essary to go over the history of the development of
this work, but there were several points in connec-
tion with it that might be of interest at this time.
The results obtained during the last three years
showed not only the possibility but the feasibility of
immunizing the child population against diphtheria.
The injections were perfectly harmless. The
tests were carried out on children in institutions.
The children first were given the Schick test and
then immunized. It had been possible to check up
the results, and up to the present there had been no
untoward consequences. Some showed a reaction,
but in none were there any afterefifects. There
had been no cases in which any harm had resulted.
The blood and urine were examined at regular in-
tervals, but revealed no changes. There had been
no local reaction beyond a slight redness and hardly
appreciable swelling. The injection was made in
the arm ; the amount was one half cubic centimetre
in infants, two thirds cubic centimetre in those one
year old, and one cubic centimetre in older children.
Recently one cubic centimetre had been given even
to infants, as there had been no bad aftereffects.
If the injections could be given combined in one
amount, this would simplify the process, and exjxjri-
ments were being made along this line, with a view
to giving two or three cubic centimetres in scattered
regions. At present it was found that three injec-
tions gave immunity in ninety-eight per cent., two
injections in ninety per cent., and one injection in
seventy-five per cent. Most of the work had been
done with three injections.
As to the time, it had been found that no immu-
nity developed for two weeks, but from the second
10 the fourth or fifth week there was rapid increase
in the number that were immune. In the fifth week
three fourths were immune, and in two months all
were immune. All the immunity was tested by the
Schick reaction, and there was in addition the result
that no diphtheria had followed in the immune cases.
In a home for infants, where this immunity had been
produced, they had had no diphtheria for two years.
At birth a child had a positive immunity trans-
ferred by the mother, but this generally disappeared
during the second six months of life, though in some
not until the end of the second year. Therefore one
could not depend on a negative Schick as an indica-
tion of permanent natural immunity until this time.
If after four years of age the child was immune, it
was so through the production of the child's own
cells, and the immunity was permanent. This
brought up the difficulty of knowing what to do in
immunizing infants. I'hey could all be immunized
without regard to the Schick reaction, and that was
probably the best way except in institutions where
regular tests could be made and any change from
negative to positive instantly noted and acted upon.
Outside of institutions it Vv^as best to immunize all
children whether immune or not, and a retest should
be made in six months or a year of all those that re-
acted. It depended on the family and the circum-
stances, but whether the child was immune or not
during its first year, three injections would give ac-
tive immunity, though a little less would develop in
those already immune than in those susceptible.
It was essential to immunize the infant and not
the schoolchild. The statistics of death in New
York City from diphtheria in 1917 showed 133 in
the first twelve months, mostly from two to six
months ; 274 in the second year, 186 in the third
year, 152 in the fourth year, and 97 in • the fifth
year. At the primary school age there were only
twenty per cent, that were not immune, but when
one thought of the deaths that occurred before
school age, the necessity for conferring immunity
was very apparent. The immunity thus induced in
infants lasted probably for life, for once having been
instituted, it was continued as a natural immunity.
It was a question whether the amount of diphtheria
warranted the trouble of giving the injections, but
on the part of the infant and the parents there was
no objection ; there was no wound and no discom-
fort like that of vaccination for smallpox. The de-
partment of health urged upon the general popula-
tion the consideration of the value of this immunity.
Discussion. — Dr. Abraham Jacobi said that after
222
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
listening with intense interest to the account of the
valuable work of the health department, he was
more than ever of the opinion that the health de-
partment, as it had been in existence in New York
for the last few years, was well worth while main-
taining, and it was the duty of every one to see to it
that the department was not changed from without
in any particular in its most important aspects. All
that had been said in defense of the health depart-
ment had been worth while and all should echo it,
not only to the public but in private practice. Doc-
tor Jacobi concluded by declaring that what he could
do to uphold the health department and all those
who had been doing this good work, that he would
do, and he wanted every one to do the same.
Dr. I. L. Feinblrg reminded his hearers that this
city and the health department owed much to Doctor
Park ; that the United States of America and other
countries throughout the world had always hstened
keenly to the scientific pronouncements of Doctor
Park on all of the subjects relating to the bacteri-
ological questions at issue in this municipality. He
recalled the picture presented (a quarter of a cen-
tury ago) of children dying in myriads of diph-
theria, dying of acute meningitis of the most viru-
lent and horrible type, of typhoid that predominated
and spread, and he realized how this picture had
changed in the city, how the death rate from these
diseases had fallen. And yet today one was con-
fronted with the almost incredible fact that the
health department was in jeopardy and that its
scientific department might be annihilated. He
echoed Doctor Jacobi, and in addition moved that
before adjournment the audience arise as a vote of
thanks to Doctor Park and his fellow workers, who
had shown that in the face of misappreciation, of
antagonism, of unwarranted interference, they were
continuing their work for the benefit of their fellow
citizens, and as a token of firm confidence in them
in their ventures for the betterment and safeguard-
ing of the health of the citizens of New York.
PHILADELPHIA COUNTY MEDICAL
SOCIETY.
Meeting held Wednesday, April lo, ipi8.
The President, Dr. Frank C. Hammond, in the Chair.
SYMPOSIUM ON THE MODERN TREATMENT OF BURNS
AND LEG ULCERS.
Treatment of Burns. — A paper by Dr. Walter
Estelle Lee and Dr. William F. Furness was
read, on the treatment of burns by exposure to the
air and the application of dichloramine-T through
paraftined mosquito netting. Doctor Lee said that
Stewart's definition of an ideal dressing for severe
burns was one "that would be i, asceptic or 2,
mildly antiseptic : 3, that would provide free drain-
age ; 4, that would not macerate or 5, stick to the
tissues and 6, would not necessitate frequent chang-
ing." Still another might be added, that 7, it should
minimize tlie abnormal radiation of body heat from
surfaces devoid of the protection of the skin and
subcutaneous tissues. We did not have at the
present time any one method of treatment of burns
in which all these conditions were attained. Am-
brine and the many forms of paraffin films now
used did meet some of the necessary conditions.
The recent interest in paraffin film treatment had
for the time being induced many surgeons to aban-
don a method which for some time had given ex-
cellent results (the exposure of the burned surfaces
to the air). The open air treatment of burns more
nearly met the theoretical requirements of an ideal
dressing than any other that had been proposed.
The following modification of the open air treatment
of bums was suggested: the covering of the entire
burned area and a generous portion of the sur-
rounding skin with a single layer of mosquito net-
ting previously impregnated with paraffin wax. The
paraffin netting might be held in place by single
layers of a circular turn of gauze bandage or by
adhesive strips applied over the netting and the un-
injured skin (never over the burned area). Such
a dressing was aseptic, and the large open meshes
provided perfect drainage for the wound secretions
to the outer surface of the netting. When this scab
formation on the outer surface of the netting inter-
fered in the slightest way with the drainage of the
wound secretions, it was completely and painlessly
removed by lifting the nonsticking paraffin net from
the surface of the wound, usually once in twenty-
four hotu-s. The paraffined netting rarely adhered
to the wound surface and then a generous spraymg
with sterile paraffin oil always loosened it. The
only remaining condition to be met in order to have
the air treatment fulfil all the requirements of the
ideal dressing was the use of an antiseptic. A one
or two per cent, solution of dichloramine-T dis-
solved in chlorinated paraffin wax (after the
method of preparation proposed by Dakin and Dun-
ham) could be used on burned surfaces without
causing any objectionable subjective or objective
irritative phenomena. This oil solution could be
readily applied in the form of a spray (at the room
temperature no heating was required as with the
paraffin films) to the entire burned surface, before
the paraffined net dressing was applied, and subse-
quently, through the meshes of the net on to the
surface of the wound, if for any of the above
mentioned reasons, it was unnecessary to remove
the dressing each day. Doctor Lee and Doctor
Furness had employed this modified air treatment
of burns upon eighty-six cases of bums at the
Pennsylvania and Germantown Hospitals during
the last seventeen months. With it, the doctors
felt that because of the surprisingly small degree of
infection occurring in these wounds, they had
healed more promptly and with more satisfactory
scars than with any other method heretofore used.
(The paper outlined the preparation of the par-
affined raosqtiito netting tised to minimize the stick-
ing of the dressings to, and pemiit the drainage of
the discharges from, the surfaces of the wounds and
extensive burns.)
Dr. Robert Perry Cummins said that in the
steel industry one saw almost every type of bum.
Among the most common were those caused by
molten metal splashes coming in contact with the
tissues, those caused bv setting fire to clothing, and
those due to back drafts from furnaces. In treat-
ment, all burns had to be regarded as infected
August 3, 1 918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
223
wounds ; shock had to be considered and the ques-
tion of the primary dressing; also treatment after
subsidence of the acute inflammatory stage, the
constitutional treatment and the treatment of se-
quelae. For the immediate treatment of shock he
relied more upon the use of adrenalin and ergot
than upon strychnia and digitalis, and would cau-
tion against over stimulation. For the cleansing of
wounds benzine was the best agent. The dressing
should l)e warm sterile boric or normal salt solution
changed once or twice every twenty-four hours, and
continued for three of four days. In the healing
period the ambrine treatment or one of its substi-
tutes, or the open air method, had given the best
results. If the ambrine method was employed
Doctor Cummins advised that its use be suspended
for a few days that the wound might be freed of
pus by the application of an antiseptic such as
dichloramine-T. He was decidedly opposed to the
exclusive use of the ambrme method in bums of
large area ; and he did not use ambrine over a
sloughing area. Exuberant granulations should not
be cauterized : these were soon strangled by the ele-
ments of regeneration of the skin. A very striking
characteristic of the scar of ambrine was the ab-
sence of hard, poorly nourished scar tissues. It
ahnost invariably resembled normal skin. The open
air treatment was more satisfactory in application
if the patient was a hospital case. When scar and
contractures were likely to lead to deformities,
splints, postures, and passive motion formed as im-
portant a procedure as technic and dressing. Im-
portant factors in the treatment of the complicating
toxic nephritis were an abundance of concentrated
Hquid food and water, stimulation, elimination by
every possible avenue. The prognosis presented a
difficult problem ; the outcome was uncertain until
the patient was well advanced toward recovery ; al-
cohoHcs had little chance of recovery in extensive
iuirns. In treatment, careful surgery and technic
were of equal importance with the dressings.
Iodine Fumes in the Treatment of Burns. —
Dr. John J. Gilbride said that about a year and
a half ago he had read in the Journal of the Amer-
ican Medical Association of the satisfactory results
in treatment of ulcers with iodine fumes, and that
he had employed this method in a severe burn of
the leg from a hot water bottle in a patient who
had had his appendix removed. The burn had re-
sisted the ordinary treatment given for a month or
two. At the time of the first application of the
iodine fumes the ulcer was about three quarters its
original size. One subsequent treatment was given
and in a week following the ulcer had completely
healed. Doctor Gilbride said that he had since used
the fumes in four other cases of burn with most
satis factorv results.
The Treatment of Leg Ulcers — Dr. Penn-
Gaskill Skillern, Jr., discussed the principles of
the treatment of ulcer, i, sterilization of the ulcer
and 2, support of the part. Since congestion was
the first stage of inflammation, the patient should
be put to bed and the limb elevated to an angle of
twenty degrees. Sterihzation of the wound should
then be effected, and this was best accomplished by
the use of dichloramine-T. Following the applica-
tion of a twenty per cent, solution of dichloramine-
T, the paraffined widemesh mosquito netting de-
scribed by Doctor Lee was placed over the area and
secured at the edges with adhesive plaster. The
next dressing was made in from twenty-four to
forty-eight hours and consisted of a five per cent,
solution of dichloramine-T. If the ulcer was large
skin grafting might be needed. The best method
had been carried out by Steele in 1870, and utilized
a greater thickness of skin, giving a graft from the
size of a pea to a finger nail. These grafts took
hold and made a more pliable scar. The treatment
after the skin grafting was almost the same as be-
fore, that of the open method. A basket of wire
gauze was placed over the open wound and the
graft allowed to heal underneath. The best treat-
ment for a small ulcer, practically sterile with
healthy granulations, in which the patient was able
to be up and about, was that proposed back as far
as 1776 by an English surgeon and recently revived,
consisting of the application of imbricated adhesive
plaster strips two thirds around the limb from be-
low upward in the direction of the venous current.
These strips supported the edge of the ulcer, com-
pressed it and kept the blood out of the edge, thus
jireventing the granulations becoming edematous.
Discharge was reduced to a minimum by means of
the compression, and calomel powder dusted on
kept the wound dry. If there happened to be a
concavity between the floor of the ulcer and the
surface of the leg, the compression by the adhesive
plaster strips was transferred to the base. In cer-
tain cases of simple ulcer in which this method was
not effective, others had to be used, the simplest of
which was the Nussbaum operation. In addition
to local treatment there must sometimes be expo-
sure of the nerves supplying the ulcerated area. In
the treatment of leg ulcer it was essential to re-
member the underlying congestion and the other
fundamental etiological factors involved.
Discussion. — Dr. Edward J. Klopp said he had
had opportunity to see Doctor Lee's method for
the treatment of burns, and believed it to be the
best. Our experience with the ambrine treatment
had been limited but disappointing. For the re-
moval of the carbonized tissue in the third degree
burn he believed that the dichloramine-T was prob-
ably not necessary. The method formerly had
been the use of salt solution. Most of the text-
hooks recommended the im.mersiiig of the patient
in a tub of warm salt solution at a temperature of
100-105° F. Unfortunately, in the majority of in-
stances the water was not maintained at this temper-
ature and the already shocked patient was further
depressed. To facilitate the removal of carbonized
tissue when the tissue was not removed with the
forceps under anesthetics, the surface was covered
with narrow strips of sterilized gauze separated for
about a quarter of an inch. The surface was then
covered with gauze saturated with warm sterile salt
solution. The dressing could be changed and warm
salt solution added without interfering with the
wound. We had nothing at present to take the
place of the dichloramine-T. Concerning the end
results. Doctor Lee had said that the scar was less
than by previous methods. Sometimes it was sev-
224
BOOK REVIEWS.— BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Journal.
eral years before the maximum contraction of a
scar was attained. In the presence of a large
burned area with hcaUhy surface, skin grafting
should probably be attempted because it expedited
matters. Here, of course, the method of choice
was the Thiersch procedure.
Dr. William L. Clark said that the ulcers which
he saw were usually advanced cases in which ordi-
nary methods had failed, when they were sent to
him with the idea that electricity might be bene-
ficial. The diagnosis of the ulcer was of first im-
portance. Syphilitic ulcer had been referred to him
for epithelioma ; epithelioma, for simple sluggish
ulcer. For the dift^erent types diflferent treatment
was required. We had found that various physical
measures often did good. The principle on which
electricity was used, was first, destruction of the
granulations ; second, sterilization ; third, relief of
passive congestion.
Dr. Kate W. Baldwin had found nothing more
soothmg in cases of burns and more healing than
the application of tlie violet ray of moderate
strength. The value of the treatment was com-
pletely demonstrated in a child brought to the hos-
pital in whom one third of the surface of the body
had been burned. The child had been treated out-
side imtil it was in a septic condition. The child
was placed on the table and without an anesthetic
the moderate current was applied ; the electrode
was in contact before the current was turned on.
The child went to sleep and remained asleep while
the application over the involved surface was made.
Dr. Moses Behrend thought that the treatment
of burns with ambrine had given good results. He
believed, however, that the dichloramine-T was the
better method because of its antiseptic quality.
^
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Normal and Pathological Histology of the Month. Being
the Second Edition of The Histology and Pathohistol-
ogy of thi' Teeth and Associated Parts. Revised and
Enlarged by Arthur Hopewell Smith, L. R. C. P.,
M. R. C. S., L. D. S., Professor of Dental Histology and
Comparative Odontology, University of Pennsylvania.
Volume I : Normal Histology. Five Colored Plates,
Three Hundred and Sixty-two Illustrations. Philadel-
phia: P. Blakiston's Son & Co. Pp. xvii-.i^s. (Price
$4.50.)
This two volume work upon the histology, normal and
pathological, of the mouth contributes important material
to dental practice. TlTe first volume, which we have be-
fore us, deals with the dental tissues, the oral tissues, and
the histogenesis of the teeth of mammals, fishes, and rep-
tiles. A more and more thorough preparation for scien-
tific dental practice will do much to bring this specialty
into its proper relation with the other branches, and this
preparation is obviously and essentially dependent upon
the same careful investigation and research into' the
minute normal and pathological construction of these spe-
cial parts as has been found necessary in other fields with
which it would and should find itself on a par. Doctor
Hopewell-Smith has a singularly direct, thorough, and
scientific style, and his material is well arranged. An
excellent feature of his presentation is the illustrations.
A great number of original photomicrographs, generously
distributed two and more to a page, supplement and en-
rich the text. His avowed purpose, to point out the essen-
tials of a profoundly fascinating science, to indicate some
difficult and apparently irresolvable histological proposi-
tions, to attempt to elucidate, illuminate, and complete
otl'.er recondite and unfinished studies, and to establish
upon a permanent and convincing basis many accepted
l)ostulates and uncontested facts — this complex purpose
has apparently been accomplished. The work should
prove an interesting and stimulating exposition of the
subject.
Applied Bacteriology. Studies and Reviews of Some
Present Day Problems for the Laboratory Worker, the
Clinician, and the Administrator. By C. H. Browning,
M. D., D. P. H. Director of the Bland-Sutton Institute
of Pathology, the Middlesex Hospital. London: Henry
Frowde (Oxford University Press) and Hodder &
Stoughton, 1918. Pp. xvi-291. (Price $2.50.)
This book of only 291 pages represents a good nucleus
of information on some of the special present day prob-
lems in bacteriology. It does not attempt to cover the
whole field but reviews for the most part the latest and
most scientific studies in special departments whose vital
importance has been emphasized by the creation of im-
mense armies and the exigencies of medicomilitary prac-
tfce. These reviews include full resumes, with the editor's
reasoned opinion on conclusions, of the latest work in the
enteric infections; the diphtheria group; Bacillus pyocy-
aneus and the tetanus bacillus ; as well as the general work
upon antiseptics ; the relationship between bactericidal action
and chemical constitution, with special reference to selec-
tive inhibitory action on different species of pathogenic
organisms: the special work upon the isolation of typhoid-
paratyphoid bacilli by enrichment with brilliant green and
telluric acid; and the use of ultraviolet radiation to dif-
ferentiate organisms, etc., etc. Some of the chapters in-
corpo-rate with extended comment material already
published as separate papers, and this is further enriched
Idv full references to further work.
<i>
Births, Marriages, and Deaths.
Died.
Clark. — In Buffalo, N. Y., on Monday, July 22d, Dr.
Joseph C. Clark.
Gray. — In East Orange, N. J., on Monday, July 22d,
Dr. Thomas N. Gray, aged sixty-five years.
Herrick. — In Brent, France, on Sunday, June i6th. Dr.
Henry Burt Herrick, of Cleveland, Ohio, aged fifty-three
years.
Lawrence. — In Flushing, Long Island, on Friday, July
26th, Dr. Enoch P. Lawrence, aged sixty-two years.
Lofton. — In Richmond, Va., on Sunday, July 21st, Dr.
Lucien Lofton, aged forty-six years.
Marvin. — In Albany, N. Y., on Monday, July 22d, Dr.
Frederick Rawland Marvin, aged seventy years.
O'Keefe. — In Boston, Mass., on Tuesday, July i6th, Dr.
Michael Wallace O'Keefe, aged seventy-four years.
PoLHEMus. — In Nyack, N. Y., on Saturday, July 20th,
Dr. Jacob Cutwater Polhemus, aged eighty-four years.
Potter. — In Lisbon, Me., on Thursday, July iith, Dr.
Augustus W. Potter, aged sixty-four years.
Sanders. — In New York, on Monday, July 22d, Dr.
Charles Walton Sanders, aged seventy-one years.
Sanford. — In Centreville, Conn., on Tuesday, July 23d.
Dr. E. W. Sanford, of Johns Hopkins University Medical
Faculty, aged twenty-five years.
Shoi.l. — 1« Birmingham, Ala., on Friday, July 12th, Dr.
Edward Henry Sholl.
Stowell. — In Watertown, N. Y., on Friday, July 19th.
Dr. Olmsby Stowell. aged seventy-two years.
Stuart. — In Boston, Mass., on Wednesday, July I7tli,
Dr. James Henry Stuart, aged sixty-one years.
^'oi;Nf;. — In Batavia, N. Y., on Monday, July 22d, Dr.
Ruth A. Young, aged thirty-two years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol, CVIII, No. 6. NEW YORK, SATURDAY, AUGUST 10, 1918. Whole No. 2071
Original Communications
THE BLOOD AND THE SOUL
In Ancient Belief and Their Relation to the
Evolution in Medicine of Humoral and
Pneumatic Theories.
By Jonathan Wright, M. D.,
Pleasantville, N. Y.
H.
THE BLOOD IS THE LIFE.
We have not had much trouble in tracing the
connection between the pneumatic theory of disease
or its counterpart in its affiliation with the soul in
the beliefs of primitive men, but it is less easy to
take note of the humoral theory as existent in
primitive ideas of the blood. Most of the physio-
logical ideas primitive men arrived at were the re-
sult, apparently, not of consecutive thought and
analysis, but the result of direct observation to
which were applied faulty mental methods, hardly
to be dignified by the term "thought." There is
nothing which could so immediately and impres-
sively influence them in this method of forming
opinion as the observation of the blood. We have
seen that in West Africa, according to Miss Kings-
ley, "the blood is the life," and as Schoolcraft (30)
asserts of the North American Indians, the practice
of the hunters in cutting up the carcasses of the
game evidently gave them some elementary ideas of
the internal bodily functions. "Experience got by
viewing the vital organs would, apparently, inform
them, that the heart is the distributing reservoir of
the blood, and the central point of vitality. Such
their language and experience appear to regard it,
if we examine the etymology of the word denoting
heart. Taking the numerous Algonquin dialects as
the subject for comparison, this is the primary
meaning of the word denoting this organ, although
we have no authority for saying that they have any
just conception of the doctrine of the circulation of
the blood. The liver is called okoon, and the lungs
opun— terms which, as they contain the sign of the
third person, o. lose their elementary character,
meaning, in this form, his liver and his lungs ; a
common feature of Indian lexicography. By okoon,
the softer texture of the liver appears to be de-
noted, compared to the more firm and muscular
structure of the lungs." The Tonga Islanders (31)
"Jiave no clear distinction between the life and the
soul, but they will tell you that the right auricle of
the heart is the seat of life. The liver they con-
sider to be the seat of courage, and they pretend
to have remarked (on opening dead bodies), that
the largest hvers (not diseased), belong to the
bravest men."
After a fatal gush of blood from a wounded
enemy or friend or animal it is natural for the
savage to conclude that the blood is indeed the life.
Crooke (32) speaks in this way for northern India.
Indeed the idea is prevalent everywhere and the ex-
planation is obvious, nor, in this instance, can we
say that it is fundamentally wrong without awaken-
ing our feeling of the impossibility to define "life"
at all. It is interesting, however, to follow some of
the consequences which pantheistic beliefs have
associated or deduced from this natural idea of the
blood. " 'The flesh with the life thereof which is
the blood thereof. . . .' In Cornwall the burn-
ing of blood from the body of a dead animal is
a very common method of appeasing the spirits of
disease and the blood sacrifices prevalent all over
the world are performed with the same ob-
ject. . . . There are many cases where blood
is rubbed on the body as the antidote of disease,"
but the examples the author quotes are chiefly to be
ascribed to the influence of primitive homeopathic
ideas in therapy, though evidently they are remotely
derived from the same trend of thought. The
Emperor Constantine, it is said, gained popu-
larity by refusing to follow a reconmiendation
to bathe in the blood of children, and was
miraculously cured. "In South Africa (33), among
the Amapondo, one of the Kafifir tribes, it is custom-
ary for the chief, on his succession to authority, to
be washed in the blood of a near relative, generally
a brother, who is put to death on the occasion, and
has his skull used as a receptacle for blood." It was a
common belief in the Middle Ages that the blood of
young persons, especially of children, had a benefi-
cial or curative effect upon disease. It is embodied
in many a gruesome tale, frequently associated with
ideas of a mystic or religious character, nowhere
more artistically set forth than in the medieval tale
of Amis and Amiles, in which the father is directed
by the Angel Raphael to murder his children in
order to use their blood to wash his leper friend
clean of his malady, in the performance of which
awful task a miracle brought the story to a satis-
factory conclusion. The persistence of the most
cruel and unnatural practices of old time sorcery
is illustrated by the fact that only a few years ago.
in the Island of Cuba, three women were condemned
to death for murdering a white baby so as to use
the heart and blood as a cure for diseases.
Copyright, 1918, by A. R. Elliott Publishing Company.
226
WRIGHT: THE HI.OOD AND THE SOUL.
[New York
Medical Journal.
The aborigines of north central Queensland (34)
treat various obscure alfections by the smearing of
blood, drawn from the posterior ulnar vein of an-
other man, but not from a woman, over a patient
from head to foot, rubbed in with the flat of the
hand, the massage lasting for a quarter hour. In
addition the patient may drink a portion or all of it.
Among the northern tribes of central Australia
(35' the drawing of blood from the body is of
frequent occurrence, being often used for purposes
apparently not medicinal or magical. Very large
quantities, according to the reporters, are drawn
sometimes, as often as twice a week. "It is a very
common practice to give both men and women blood
to drink when they are ill, and when this is done
blood may be drawn either from a man or from
a woman ; when drawn from a woman it is always
taken from the labia minora. In every case the
idea is to impart to the patient some of the strength
of the blood giver. One morning, at the close of
a consultation of five doctors over a Tjunguri man
amongst the Warramunga who' was so ill that he
died a day or two later, it was decided to give
him some blood drawn from women to drink. This
is only done in very serious cases. Every one left
the sick man's camp except four or five old women
who were his tribal mother's and father's sisters.
The blood was allowed to drain into a jjitchi. and
then some of it was rubbed on his body and some
given to him to drink. In the Kaitish tribe it is
the custom, when a man is ill, for another indi-
vidual who stands to him in the relationship of gam-
mona — that is, daughter's husband — to go to the
sick man's camp, open a vein in his arm, and allow
the blood to .spurtle down into the patient's mouth."
.Among the native tribes of Central Australia (37,
38), as among many other races of savage man,
there are certain rites concerned with the ceremo-
nial letting of blood which may be of some interest
in view of the science of serology which has risen
of late years. I'lood of two individuals mingled
together is suppo.sed to give them a tie of relation-
ship which prevents the possibility of treachery.
Blood drinking is also associated with special meet-
ings of reconciliation which sometimes take ]>lace
between two groups which have been on bad terms.
Moreover, blood is used in a certain ceremony
where young men open the veins in their arms onto
and over the edge of a ceremonial stone, which
thereby acquires certain mystic properties. I have
recently read in an account of the Croats in the
October, 1914, number of the Forinightly Rcvinv,
of a ceremony amounting to a pledge of mutual
friendship which is ])erformed by the individuals
allowing a certain amount of their blood to fall in
a cup and the two drinking it up bv alternating
swallows. This is supposed to give them a blood
relationship. Among the Australians, blood may
be given by young men to old of any degree of re-
lationship and at any time with a view to strength-
ening the latter.
In southeast Australia (39), at Port Stephens the
Koradji treated a sick person by winding round
him a cord of opossum fur, and then around the
body of some female relative or friend, who held
the end of it in her hands, and passed the cord to
and fro ])ctween her Hps, until the blood dro])ped
into a bowl, over which she held her head. It was
believed that the evil magic which caused the dis-
ease passed up the cord into the body of the
operator, and thence with the blood into the bowl.
Some of the Australians are particular that the
blood should never fall on the ground but flow over
the body of another man in a crossing network of
lines (40, 41). Roth says that also in Tasmani?
the blood of another was often employed as a
healing draft. While most of the accounts of a copi-
ous blood therapy among primitive men thus come
from the Australian quarter of the globe, its use is
by no means absent among those in other continentb
for the same purposes. In Lower California, "if
the sick person has a child or sister, they cut its or
her little finger of the right hand, and let the blood
drop on the diseased part." Before passing to
another ])hase of the subject I quote the above to
illustrate what we have already ' just seen for
.Australia, and what may be noted as incidentally
related of practice in Africa and elsewhere — that a
superior virtue resides in the blood of relatives for
therapeutical purposes. This has a curious coin-
cidence with our most recent ideas as to homologous
blood in transfusion and homologous blood sera in
variotis laboratorv reactions. I also draw attention
to the minute directions as to the nonessentials, as
we believe, in the technic, a certain finger of a cer-
tain hand, the network pattern of the flowing lines
of blood, etc. In uncertainties of therapy these
things are of much practical use, since confident as-
sertions as to the beneficial result to be expected,
when they are found not to be fulfilled — may be
justified by careful inquiry to reveal that "the med-
icine was not given as directed."
y\ccording to Doctor Nassau (42) quoting Trum-
bull: "The widespreacl popular superstition of the
vampire and of the ghoul seems to be an outgrowth
of this universal belief that transfused blood is re-
vivifying. The bloodless shades, leaving their
graves at night, seek renewed life by drawing out
the blood of those who sleep, taking the life of the
livmg to supply temporary life to the dead. . .
An added force is given to all these illustrations of
the universal belief that transferred blood has a
vivifying power, by the conclusions of modern
medical science concerning the possible benefits of
blood transfusion. The primitive belief seems to
have had a sound basis in scientific fact."
It is difficult to select from the literature of the
blood beliefs of man to illustrate any one bearing
which they may have without introducing irrelevant
matter, yet from its general trend, despite its
copiousness, it leaves the impression on the mind of
the existence, from the very beginning, of a theory
of humoral pathology. I may venture to transgress
a little further on the patience of my readers, in the
domain of primitive man. In northern India (43)
a "favorite way of counteracting the spells of a
witch is to draw blood from her. This is probably
a survival of the actual blood sacrifice of a witch."
In New Guinea (44) ''pointing at a rainbow, which
is regarded as the blood of the murdered people
rising to heaven, causes axillary abscess." The
Singhalese (45) believe "bleeding should always be
stopped as quickly as possible, because the least ap-
pearance of blood attracts Ririyaka (the devil of
August lo, 1918.]
CUNNINGHAM : ETIOLOGY EN ECHELON.
227
l)lood), who will endeavor to make the patient ill,
in order to obtain more of his blood." A scarcely
more coherent blood idea concerns the function ot
menstruation in women. The physiological reason
for this still remains one of the mysteries of
])io]ogy. Its very mystery must of itself have
always given rise to the usual surmises which attach
to mystery — a divine origin and this allies itself
naturally to the mystery of life itself. In evolution
it is one of the landmarks by which we recognize
that the brute is emerging into man. Nearly all
tribes of primitive men have deduced from it certain
taboos and civilized men continue to build untenalilc
theories upon it.
Although Schoolcraft describes a ceremony of a
naked menstruating woman among the North
American Indians making the circuit of a planted
field at night to insure the protection of the cro])s
from depredating vermin, it was due to the belief
of her being able thus to thwart their plans and it
had no connection with the idea of adding fertility
to the field. Most of the taboos which exist in all
wild tribes ascribed some sort of evil influence to
the menstruous blood, and the idea of the menstru-
ating woman being unclean, which permeated all
the earlier civilizations is found fully developed
among the most primitive men. Though this is
markedly so for the Australians, they, as we have
seen, ascribed many therapeutic virtues to blood
drawn from the labia minora of women. Blood
drawn from the scrotum of the male and from his
navel mingled with the water of a stream causes
the multiplication of fish {46), and in many of their
ceremonies the evidence, according to Frazer, points
to the belief that there i.s a fertilizing virtue inherent
in human blood, wliich we have seen in Africa and
which we will find in Babylonian and Biblical liter-
ature "is the Hfe.'' In Abyssinia the Galla tribe has
a sacred tree which, among other attentions it re-
ceives in veneration, has its roots watered with the
blood of animals (47), and another tribe in East
.Kfrica do likewise, though the idea of fertilization
])erhaps in both cases is confused with that of the
])ropitiation of demons, the smearing of tree trunks
with blood being evident Iv akin to smearing the
door posts of dwellings in Egypt and Palestine and
Babylon. Demons were supposed to reside in the
blood itself, such as the demon of fatigue among the
South American Indians ( 48 ) , but the therapeutical
virtues as evidenced in the practice of manv tribes
and its fertilizing j)roperiies as .svmbolized in manv
ancient cults point unmistakably to the fact that in
the view of many primitive men the blood embodied
the principle of life.
In this and the preceding paper we have thus
noted the prevalence of two sets of beliefs, which
have naturally flowed from phenomena likely to be
earliest impressed upon the attention of primitive
man not only on account of their obvious and strik-
ing character but because of their impMDrtance in his
struggle for existence from the very first. They
exhibit tendencies to unite in some concept common
to both. Subsecjuently in the history of medicine
they appear both as rival and as mutually explana-
tory theories of health and disease.
(To he concluded.)
ETIOLOGY EN ECHELON.
Bv ^\'ILLl.\M P. Cunningham, M. D.,
New York,
Visiting Dermatologist to the Misericordia Hospital; Associate visit-
ing OcrniatoUigisl, New Vorl< C'hililren's Ht)spital
and Schools, Randall's Island.
On superficial examination there would appear
to be a play of cross purposes, a confounding of
etiologies, a contest for approval between several
pathological theories, in some of the more recent
developments of medical science. It is certain that
two truths cannot clash. No matter how divergent
they seem there is a point at which they can be
made to harmonize, if we seek diligently to locate
it. A bar of steel will promptly sink to the bottom
of the sea. ,\ ship constructed of steel will float.
The air contained within the hollow vessel imparts
sufficient buoyancy to overcome the disproportion
in density between the metal and the water. An
aeroplane without a motor obeys the law of gravi-
tation and lies inert upon the ground. The same
machine activated by its cylinders defies the pull of
gravitation and soars into the empyrean. Its
propeller has created a vacuum into which rushes
the eager air that pushes it fleetly onward.
In the domain of pathology, acidosis, endocrin-
opathy and intestinal stasis, put forward their
claims to individual and exclusive efficacy in the
production of many abnormal conditions. It is
(juite the usual thing for the tale of the lethargic gut
to fascinate the student into a belief in its wonder-
ful revelations. There is a completeness about it
that is deeply satisfying. It appeals to our earliest
preconceptions ; for we have always recognized the
evil influence of delayed evacuations. We are pre-
l)ared to believe anything of intestinal putrefaction.
The imagination of the ardent etiologist cannot
carry us beyond our nimble concurrence. Swarm-
ing in the Inibbling broth of noxious nitrogen are
myriads of bacteria capable of inducing every ill
that flesh is heir to. or with which it may become
invested in its stumbling progress through the cen-
turies. There is pathogenesis personified. There
is the source of disease. Microbial mutations de-
pendent on the battle for survival hotly contested in
that ever seething swirl of portentous putrescence,
bring about the many varieties of perverted func-
tion and structural alteration that we denominate
disease in our more or less intelligent nosolog)'.
There is no limit to the possibilities of such per-
nicious activity. C ross breeding induces diversifica-
tion.
This in turn favors fecundation. New types
mean virulent intensiiication. It is thus in the mind
of the ''stasis" advocate that rheumatism, gout, epi-
le])sy. diabetes, cancer, tuberculosis, arthritis de-
formans, psoriasis, dermatitis exfoliativa, et multa
oir.iiis f/riieris originate. The instances are taken at
random from a list as long as human disabilities.
Much is to be conceded to this contention. The
names of those who support it are warrant of
credibility. The results obtained from a practical
application of the theory are very often brilliant. If
short circuiting the intestine has cleared up diabetes
or tuberculosis upon the testimony of grave and
prudent witnesses, we may not disregard this aston-
228
CL'NNIXGHAM : ETIOLOGY EN ECHELON.
[New York
Medical Journal.
ishing contirniation because it runs counter to our
rooted prepossessions. W'e must accept what is
demonstrated and make it coapt with the sum of
our information. Retiring into the shell of a patho-
logical ritual and refusing to discuss a heresy mark
the end of ideation. We have reached the term of
our mental activities. We have become fossilized.
There is no f|uestion then that the statements of
Lane, Bainbridge, and other diligent pioneers in this
field of surgical endeavor, are absolutely trust-
worthy , that their conclusions are based on expert
and painstaking observation ; and that the cures
effected of the diseases involved are unciuestionably
due to the operations performed. Etiology here
would ap])ear to have been established without the
shadow of a doubt.
And yet — the doctrine of acidosis looms contro-
versially in a great shadow of doubt. It disputes
the pretensions of stasis at several important
junctures. It claims rheumatism and gout for its
very own. Urticaria, erythema multiforme and angio-
neurotic edema, are boldly displayed upon its
casualty list. Nephritis and cancer are gloomily in-
sinuated also. And it must be admitted that a tell-
ing case is made out. the men behind the propa-
ganda are of the highest standing and as in the case
of the surgeons their statements must be accepted
as conservative and true. Aside from this appeal to
credibility the inherent strength of the acidosis idea
is considerable. The increased capacity of colloids
to absorb water under the influence of an acid en-
vironment is demonstrated. It explains many
phenomena hitherto perplexing.
It puts in concrete and comprehensible terms
what was hitherto vaguely surmised or utterly mis-
understood. Among our quite remote professional
forebears it was generally accepted that alkalies
were of decided advantage to the maintenance of
health. This idea has survived in some form to the
present day. Now we realize that, while hitherto
incompletely developed, it contained the germ of the
carefully elaborated and minutely demonstrated
doctrine of acidosis. Gravely impressed w'ith the
importance of this condition, and seeking to square
with it many of the diseased manifestations of un-
determined association, we have been confronted
with another factor of immense complexity whose
radius of activity dwarfs all etiological competitors.
Endocrinology rears its massive front in contra-
vention of some of our pet delusions, in confirma-
tion of some of our sage suspicions, in a general re-
apportionment of the whole field of pathogenesis.
The pity of it is that here appear to go by the
l)oard all the conclusions we had based on the sup-
positious efficacy of acidosis and chronic intestinal
stasis. We believed we had certain facts estab-
lished. Now these endocrinous glands standing on
the defensive agamst all the assaults upon our
phvsical integrity upset our calculations, and com-
pel a reconsideration of the entire scheme of dis-
ease invasion.
It has been observed that all truth is comple-
mentary. No matter how apparent the contradic-
tion two verities will dovetail somewhere and har-
monize perfectly. The results obtained by straight-
ening intestinal kinks are just as authentic and just
as valuable as they were before we discovered the
overshadowing influence of hypothyroidism in the
perversion of nitrogenous metabolism. It is of little
consequence whether the patient is poisoned at the
beginning of the process in the intestine (because
of an obstructed channel) or at its completion in
the tissues because of defective enzymes. The net
result is poisoning, i^revention may be applied at
either end ; we may limit the ingestion of the offend-
ing pabulum ; we may hasten its progress along the
intestinal tract by lubricating or mending the road :
or we may supply at the termination of the process
the lack of energy permitting its incomplete con-
version. Thyroid secretion is intimately concerned
in the final disposition of nitrogen. Intestinal di-
gestion is intimately concerned in the initial prepa-
ration of nitrogen for absorption.
It is not contended that stimulating or supplying
thyroid secretion will counteract all the evils of an
inefficient bowel. But where there is question of
the intoxication from animal proteid the remedy
may lie either at the beginning or the end of the
process of conversion. Tims the testimony of the
stasis advocate is found to square with that of
the thyroid advocate ; instead of being contenders
they are really confederates, each having hold of a
difl'erent thread of the argument but both pulling in
the same direction.
-Acidosis enters as a factor in the problem of
proteid intoxication in as much as it is a conse-
quence of the imperfect combustion of nitrogen, and
is revealed by the presence of ethereal sulphates in
the urine. Those who zealously defend the alkaline
surcharging of the blood and lymph, with the object
of neutralization, are just as clearly right in their
attitude as the supporters of the endocrine or in-
testinal therapy. 'J'o prevent proteid intoxication by
cleaning the sewer, to control it by thyroid pressure,
or to neutralize its terminal condition by an antacid
tide are all measures operating in perfect harmony,
and despite the occasional hyperbole of over-
wrought enthusiasm, are equally entitled to the con-
fidence of the practitioner. The main purpose being
to preserve the level of normal assimilation in the
organism, it is a matter of choice where we shall
direct our effort, at the initial disturbance in the
intestine, at the intermediate phase in the blood, or
at the concluding development in the tissues.
Arguments based on the success of all these
methods deserve careful consideration. They
actually involve no antagonism while apparently
establishing a different cause for the same phenom-
enon. It is much as if one said that a certain fire
was due to the presence in a building of inflammable
materials ; and another said that it was due to the
presence of a lighted cigarette ; and still another
that it was due to the absence of available water.
All three hypotheses would be correct. The re-
moval of any one of the factors mentioned would
have prevented the destruction wrought hy the
flames. Undoubtedly the best preventive would be
the removal of the inflammable material. Undoubt-
edly the best preventive of proteid intoxication is
the cleaning out of the source of supply. But those
who favor that conception should view with toler-
ance the equally well sustained opinion of the
August 10, 191S.]
CUNXIXGHAM: ETIOLOGY EX ECHELON.
229
thyroid iherapeutist. All roads U-ad to Rome, it is
lip to the pilgrim which he shall pursue.
A sturdy school of aggressive pathologists at-
tribute rheumatism to dietetic errors. They ignore
the suggestion of microbic infection, and point to
the amelioration experienced upon the exclusion of
animal nitrogen, as the final word upon this topic.
The endocrinologists are as vigorously insisting
upon the deficiency of thyroid secretion and the
consequent failure to dispose of the nitrogen as tlie
necessary prerequisite to the arthritic outbreak.
In the midst of this debate bursts clamorous
acidosis. Is it not perfectly plain that a condition
in which the saliva is acid, the sweat is acid, and the
tears are acid, should come into this etiological
association? With acid oozing everywhere argu-
ment is superfluous. In the whirl of these opinions
how is the bewildered practitioner to choose ? With
little chance for individual investigation how is he
to incline to this or that grovtp of grave and re\ eren(l
teachers? The re.spectabihty of the witnesses is the
greatest cause of confusion. If any weight might
attach to one group over another, decision would be
easy.
In this uncertainty let us apply the touchstone of
common sense and concede that all of these able
contenders may be right ; that the contrariety is only
apparent, and that perfect consonance may be
brought to supplant it. To begin at the end : acid-
osis is so marked a feature of rheumatism that
tradition has carried it down to us through ages
under one designation or another. Uric acid has
been the popular epitome of the prevailing 0]>inion
for a generation past. To be sure uric acid was
only a vague apprehension of the great disturbance
in the alkaline tide of the normal metabolism. But
grasping the existence of such a disturbance, how-
ever incomi)letely understood, cleared the ground
for a rational therapy. But obviouslv acidosis does
not arise de novo. It is an induced condition. Dis-
turbances of nutrition, disturbances of circulation,
overexertion, insufficient exertion, bacterial in-
vasion, various drugs, such as alcohol, ether,
morphia, and cocaine, tend to the reduction of the
normal alkahnity of the tissues, and the production
of the phenomena included in the term acidosis.
Being a consequence of a previously existing ab-
normality, it cannot be put in competition with it
for the distinction of causing rheumatism. \\'hether
't be the consequence of microbial activit}', or of
nutritional deviation, is all one in the reckoning: for
a consequence it is and not a cause. The rheu-
matism may in truth be attacked via the acidosis
iust as water will put out a fire. But the fire, like
the rheumatism, is only the product of the conjunc-
tion of favorable factors.
With acidosis assigned to its proper place in
the sequence of events, we are confronted by the
endocrinologists with the proposition that derange-
ment of the internal secretions is answerable for
rheumatism, since the internal secretions control
metabolism, and faulty metabolism is the cause of
the disease. Here again instead of combating the
idea we are prepared to reconcile it with the broad
!/eneral scheme of etiology en echelon. If the in-
flammable material in the house needs the touch of
the lighted match to set it in combustion, the faulty
diet may need the relaxation of endocrine influence
to permit of its development of poisonous products.
Given the reestablishment of that influence and we
gain control again of the process of metabolism and
insure the perfect disposal of the nitrogenous ele-
ments.
How about the germ? Where does it lit in? If
the bacteriologist is right is not all of this other
speculation the merest empty vaporing? Let us fol-
low our method of deduction and determine how
the germ may be acknowledged without weakening
our position in the least. First of all the germ is
not demonstrated. It is assumed because rheuma-
tism presents so many of the symptoms of infection.
Its presence in the blood would induce derangement
of the adrenals, which are very susceptible to the
influence of infection. This would react at once
upon the thyroid through the agency of the hormone
and the combustion of nitrogenized matter would be
imperfectly performed. Now we are again at the
point where we stood before we postulated the germ.
Furthermore, one of the inevitable results of infec-
tion is acidosis, and we have seen that acidosis is
invariable in rheumatism.
.So the germ may be duly admitted to its share
in the etiology without in any degree weakening the
claims of the other factors mentioned. But now we
come to another ])roblein — whence the germ? If
faulty diet is defended as the cause of rheumatism
and the germ is conceded to be in the same category,
we have reached a fine scientific dilemma in which,
to use the language of tlie street, "we don't know
whether we are coming or going." But clinging
to the supposition of etiology en echelon or etiolog)'
in phases, the mind reverts to that colossal culture
tube of an intestinal canal in which are generated
more varieties of noxious elements than we can, in
the imperfect state of our bacteriological develop-
ment, either classify or conceive. May not the
bacillus rhcumatismi in\oked to explain the phe-
nomena of the disease have come to mischievous
maturity in that sluggish stream of putrefaction?
This admitted and the putrefaction properly attrib-
uted to the indiscreet ingestion of inconvertible pa-
bula, we have rounded out our mosaic of etiological
phases in the production of rheumatism. Herein it
will be noted, that no established fact has been con-
tested ; no reasonable deduction has been disregard-
ed : truths apparently at variance have been brought
into consonance by seeking their points of cohesive
contact. Seeing an object from a different angle,
may give a different picture. But all pictures of
that object (no matter how numerous the points of
observation) are true. Their combined features
represent the complete delineation.
In selecting rheumatism to illustrate the idea of
harmony in our seemingly diverse etiological con-
cepts, it was felt that because of its frequency,
familiarity and controversial prominence it would
be an excellent case in point. Doubtless many other
general conditions will occur to the mind upon the
sHghtest reflection in substantiation of the position
here assumed. But it has been the object of this
paper not so much to multiply instances of this char-
acter as to establish a principle applicable to the
230
CUNNINGHAM : ETIOLOGY UN ECHELON.
[New York
Medical Journal.
elucidation of diseases of the skin. For there \vc
have a big field of disputatious and discoura<:^in,<j
dissension. Attempts to explain many of its gravest
problems have begun and ended in talk. Theory
has set itself against theory and often opi)Osed a
kindred truth. The zeal of the ergoteur has blind-
ed him to the modicum of knowledge possessed by
the nonconformist. Unconsciously employing the
method of the theologian he decides that doubt in
one particular destroys the whole fabric of faith.
He who does not utterly ogree, opposes. So that
he who has grasped a frayed end of eternal verity,
considers that he has become like unto God, and
will tolerate no contradiction and will brook no
participrition. Nothing, as we have seen, is less de-
fensible than this arrogant attitude.
There are several dermatoses more or less cor-
rectly identified with rheumatism, which naturally
arouse the same reflections. There is the interposi-
tion of a word ijetwe'cn the cause and the effect but
the connection is just as perfect. The escai)e of blood
into the tissues variously described as peliosis rheu-
matica, purpura hemorrhagica, diapedesis rheu-
matica, and Schonlein's disease is demonstrably an
acidosis with or without the recognition of the quali-
fying term. Being an acidosis it is due to infection
or protein poisoning or lack of oxygen. In any
case it harks back to endocrine derangement or may
bg traced to the influence of intestinal stasis.
Erythema nodosum is characterized as rheumatic
by all dermatologists. In so far as there may be
unanimity among the brethren it exists in this case.
The disease occurs in connection with constitutional
disturbances and arthritic pains which seem to sus-
tain the accepted etiology. Painful nodes suddenly
appear upon the tibial ridges in successive crops.
The total duration of the attack may be several
weeks. Endocarditis has been noted as a com-
comitant. This gives added weight to the rheumatic
conception. From the character of the lesions and
the pathological relations just enumerated it is ob-
vious that erythema nodosum is an acidosis. The
peculiar propensity of colloids to absorb water while
under the influence of an acid irritant, accounts for
the nodular and abrupt tumefactions of this extraor-
dinary disease. ft may be rationally combated
therefore on this interpretation of its pathology.
As a phase or manifestation of the ideate complex
called rheumatism, it may be met by the therapeutics
sanctified by hoary usage. Carried beyond the name
to the causes of things we may find ourselves grop-
ing about in the pantogenous putridity of the halt-
ing gut. There we may discover the Bacterium
idoneum or, failing that, we may discover the nitro-
genous toxins that, upon absor])tion. defeat the
efforts of the ductless glands to maintain the level of
normal metabolism. It has been warmly advocated
that the efficacy of the salicylates in rheumatism
depends upon their power to stop intestinal putre-
faction. Shutting off the supply of fuel is an excel-
lent way of putting out a fire.
Erythema multiforme is a toxic erythema. Its
source is the incapable intestine. The intermediary
is the overwhelmed adrenal, so readily succumbing
to infection. The progression involves the develop-
ment of acidosis producing the local infiltrations.
In erythema bullosum the process is seen in its full-
est expansion. It will occur to the clinician at once
that this disturbance may be attacked at its origin,
along the route, or in its terminal phase. Active
catharsis, intestinal antisepsis, adrenalin, or alkalies
are rationally indicated. Prudence might suggest
the combining of all these forces in one massed at-
tack. Setting up an academic antagonism between
these several stages of the one disease, and con-
tending for therapeutic preeminence upon any shade
of immaterial opinion, is a stupid waste of time and
energy. It were better to recognize the title of the
dissenting theory to careful consideration and en-
deavor to reconcile the apparent contradictions. It
will --juickly ])ecome manifest that the fact dis-
covered by one investigator cannot run counter to
the fact discovered by another.
Intimately associated with erythema multiforme,
clinically and etiologically, is the bane of the der-
matologist— urticaria. They have been somewhat
fancifully linked as cousins. There are some out-
breaks in which either classification is permissible,
in which capable men take open issue on the ques-
tion. It is habitually and credulously asserted b}-
medical writers that urticaria is readily curable by
stopping certain suspected ingesta and cleaning out
the bowels. This is optimism gone mad. Occasion-
ally such a consummation is vouchsafed us. But
the sober truth is that it is not readily curable at all.
There seems to be some impression made upon the
skin by the effective cause which keeps it in a con-
dition of irritability, even after heroic efforts have
been made to regulate the diet. The sudden vascu-
lar dilatation casts instant suspicion on the adrenals.
The wheal is a product of acidosis. The acidosis
is rationally referable to disordered metabolism.
Disordered metabolism is redolent of intestinal
putrefaction. If it is desired to interpolate rheuma-
tism, between the putrefaction and the acidosis
there will be no substantial alteration in the situ-
ation.
After the ready remedy of sweeping out the bow-
els has failed, adrenalin will be worth a trial ; it is
frequently effective — for a while. Its action proves
the implication of at least one of the endocrine
glands in the pathological process. Inferentially
this brings in the whole chain, because they are in-
timately interdependent in response to disturbing in-
fluences. The hormone derived from the Greek
word <>i'3,'i.ao), "I incite," is a secretion that en-
tering the blood incites the other endocrine glands
to synergistic or antagonistic action. The hormone
balance is delicately adjusted upon the maintenance
in proper proportion and quality of these various
secretions. No untoward influence can strike one
of the endocrine chain without being promptly felt
in the rest. Those that oppose will ht stimulated
to increase their opposition. Those that assist will
be put to it to overcome the handicap. The wheal
being the manifestation of an acidosis, in the opin-
ion of competent observers, demands the exhibition
of alkaline neutralizers.
There is absolutely no conflict of purpose in these
different measures. They are all grounded in fact,
and the soundest of deduction. They are all direct-
ed to the same end and along parallel lines. One
August 10, 1918.]
CUNNINGHAM: ETIOLOGY EN ECHELON.
231
starts from a certain point — far distant from the
wheal — the putrescent intestinal tide, or the pres-
ence in the normal chyle of elements prejudicial to
the individual. Another starts half way on in the
course of the process, namely at the. deranged adre-
nal which permits the vascular dilatation. The last
starts very nearly at the finish ; at the acidosis in-
duced by the foregoing irregularities. While it is
obviously prudent to assail the disease at its origin,
still in the event of indifferent success, it is quite as
prudent to attempt a flank movement on the timor-
ous ally, the adrenal. Failing here also, opening
the dykes and flooding the region with counteracting
alkalies, offers a chance of nullifying the effects of
the preliminary disturbance. Again is it made man-
ifest that the labors of the earnest workers in the
field of etiology and rational therapeutics, harmon-
ize as all truths must. The fruitful method of se-
lection consists in acknowledging the facts of any-
body's offering, and refusing to set them in opposi-
tion to any other facts. Find the points of conso-
nance. The differences will be seen to be illusory.
Pathology has been enriched by the acne bacillus.
Except with regard to the making of vaccines this
has proven a barren possession. And figuring on
the rather episodal efficacy of the vaccine the
bacillus has not been worth the labor of its dis-
covery. However, conceding the bacillus, how does
it operate? All bacteria induce an acidosis. They
interfere with the proper oxygenation of the parts
and the elements of inflammation and effusion
quickly appear. The inflammation with its dilated
arterioles immediately indicts the adrenals. Re-
calling the universally recognized association of
injudicious alimentation, we work around again to
the involvement of the intestinal tract. We all
know that carelessness in eating and drinking and
failure to get adequate fecal evacuations, will
frustrate every attempt to cure the exasperating
deformity. Hence we must give due consideration
to the question of faulty metabolism. Curiously
enough it is not the proteids but certain carbohy-
drates which are proscribed in acne. But it is al-
together likely that the acid fermentation conse-
quent on the ingestion of sweets, interferes with the
proper conversion of the proteids in the intestines.
With flatulence and hyperchlorhydria, digestion
must be imperfect throughout. If intestinal diges-
tion requires an alkaline environment, hampering it
with inordinate streams of acid reaction is certain
to result in a failure of substantial proportions.
When we mention faulty metabolism we embroil the
thyroid. This is effected also by the hormone from
the unstable adrenal. Verification of this hypoth-
esis is seen in the improvement produced in cer-
tain acne cases, by the administration of thyroid
extract. Local applications to the pimples and
comedones prove unsatisfactory, unless reinforced
by measures looking to the general well being. The
Kromayer lamp is a case in point. There is a dis-
position to attribute quasimiraculous powers to this
fonn of radiotherapy possibly because of its spec-
tacular properties. While disclaiming any desire to
belittle the reputation of the violet light, and recog-
nizing that in some dermatoses it is unquestionably
of great advantage, still it must not be forgotten
that acne is from within and nothing of a purely
external nature can have a permanent effect upon it.
Conversely internal measures alone may and often
do rid the patient of the aftfiction.
Bearing this in mind, we resort to the restriction
of detrimental pabulum, to the complete and regular
elimination of waste material, to insistence upon
active exercise, with its salutary circulatory accel-
eration, to the exhibition of alkalies and as already
noted to the speeding up of endocrine activity.
Any of these procedures is wise. None interferes
with the others. The supply of incomplete con-
verted protein is prevented. The unavoidable en-
trance of some of it into the blood is met by the
increased metabolic vigor of the tissue enzymes
stimulated by the artificial thyroid, and the quick-
ened circulation. Contributory acidosis is obviated
by the alkalies and the increased supply of oxygen.
None of the theories of acne causation is here dis-
credited. All are seen to work in unison. Even
the bacillus may be admitted without disturbing the
etiological harmony because if it attacks from with-
out it requires a spot of lowered resistance ; and if
it attacks from within, it is not only under the same
necessity, but probably has developed in the in-
testinal cloaca which we are going to clean out.
Far back in the twilight of dermatology the
puzzle of eczema began. It is one of the most
venerable of diseases because of its great age and
the mystery surrounding its origin. Today its
secret is just as closely kept as it was before the
bacteriologist illumined our clouded understanding.
We do not know the cause of it or the cause of its
manifold manifestations. We are in possession of
certain information regarding its phenomena which
is usually trustworthy. We know that external ir-
ritants will excite it- -in the predisposed. But we
do not know what constitutes predisposition. It
is possible that a germ will be found. When it is
we shall be in exactly the same position as we are
in- relation to acne. The germ will be a useless ap-
pendage if we do not discover what provides its
opportunity. At present we observe that lye, dyes,
acids, soaps, lime, terpenes, wood alcohol, bichloride
of mercury, beer (externally), water, cold, and wind
will bring on an attack after more or less prolonged
exposure. These precipitants are taken at random.
There are many others such as woolly underwear.
Of internal precipitants we may cite beer again;
whisky ; gluttony ; excessive sweets ; oatmeal ; pork,
and veal; tea, coffee, and constipation. Doubtless
there are many others conforming to narrower idio-
syncracies.
It is a fact that any or several of these exciting
causes may be operative without inducing the
cutaneous reaction. Eczema is not as common as
constipation, as dietary indiscretion, as irritating
manual duties. Eczema while a very frequent dis-
ease is in small proportion to the number of people
subject to its accredited provocatives. Clearly there
is something out of gear in the individual who suc-
cumbs. If we could put our finger on that defect
we might be able to devise a remedy. The endo-
crinologists believe that they have found it in the
internal secretions. The idea has much to recom-
mend it. While still only in the humble posture of
232
CUNNINGHAM: ETIOLOGY EN ECHELON.
[New York
Medical Journal.
an hypothesis, it presents possibilities, of a fascin-
ating character. It is undeniable that here, as in
acne, thyroid has achieved some briUiant results.
It is only fair to add that it has also sustained some
dismal failures. But dealing with an extensive and
complicated system of practically unknown secre-
tions, whose potentialities are looming through a
haze of dubiety and surmise, it is possible to miss
the localization of some particular influence. Hence
the method of election will be not to surrender the
quest but to extend it. It is rational therefor to
submit this influence as one of the etiological factors
of eczema and one of the indications for treatment.
If we are drawn into a divided judgment by the
pretensions of intestinal stasis and autointoxication,
we may fairly reconcile the two. If we are bacillo-
philes and must have a microorganism for every
pathological departure, there is no reason why we
may not indulge that propensity also. Imbued with
the enticing doctrine of acidosis we shall be at no
loss to make all taut, as the sailors say. It has been
the purpose of this paper to impress by frequent
repetition that every one of these propositions con-
tains a strain of truth which cannot possibly con-
flict Avith any other truth. All are headed one way
and no mistake can be made by following any of
them. The mistake will be made by rejecting any
of them in a narrow interpretation of the etiology.
When we approach psoriasis we are confronted
by a problem compared with which that of eczema
is trivial. As far as our discernment goes it is
dependent on internal causes. A germ may be discov-
ered but neither that nor any other external factor
has been yet made out. The avocations that excite
eczem.a seem powerless to excite psoriasis. The
palm of the hand, so frequently the site of eczema
owing to its exposure to irritating contacts, is rarely
the site of psoriasis. Delicate regions like the axilla,
breast, and groin are not especially liable to psoriasis.
The prolonged provocation of wet diapers will
readily induce eczema but not psoriasis. An acrid
nasal discharge will have the same result. In-
stances might be multiplied indefinitely in support
of this position. With its recognition, we have to
face the question of internal causation with very
little prospect of a satisfactory outcome. We may
derive some instruction from the circumstance that
a meat free diet seems occasionally to exert a con-
trolling influence over the eruption. This would
suggest that proteid metabolism is somehow at fault
in the psoriatic. Either he cannot take care of the
nitrogen in his assimilative processes, or nitrogen
from animal tissues is in any amount noxious to his
organism.
That other factors may be operative also- is evi-
denced by the failure of abstinence in this regard,
to affect all patients alike. We can all recall how
our promises of immunity have recoiled upon our
heads after a faithful adherence to the regimen
prescribed. Despite these disconcerting exceptions
we may safely cling to the reasonably supported
postulate that animal nitrogen is usually prejudicial
to the patient. This has been assumed to involve
the thyroid, which we have learned by persistent
reiteration, is concerned in the process of proteid
metabolism. The endocrinologist is demanding
psoriasis by right of paternity. He has proved
something and has failed to prove much. His
science being immature may develop some surprises
as progress is made. Those who concede the tox-
icity of animal protein, content themselves as a rule
with forbiddmg its ingestion. But it is quite in
accord with that attitude to seek the support of the
internal secretions. There is no possible antag-
onism between them; nor between them and the
doctrine of acidosis. The latter developing as a
consequence of the preceding abnormality calls for
management along parallel and not diverging lines.
Dermatitis herpetiformis, one of the pests of der-
matology, also known as Duhring's disease because
of the illustrious American who rescued it from the
conglomerate bewilderment masquerading as ecze-
ma, is groping blindly for an etiology. Our infor-
mation on that point is perfect in its incomplete-
ness. We are offered neurosis with unblushing
effrontery by perplexed investigators, who find in
their own nerve the only etymological association.
A neurosis is not a disease, any more than a fever,
a pain, or an itch. It is a symptom. It cannot be
urged as a cause of anything. It cannot be urged
as the consequence of nervous malfeasance, be-
cause that omits the reason for the latter, without
which we are in no better position than he who
should assert that a certain person was irritable
because he was nervous. We are still "shy" on
causes. What is back of this nervous instability
which permits the development of the tormenting
lesions of dermatitis herpetiformis?
Instinctively, by force of a habit often amply re-
warded we turn to the intestinal tract for aid, com-
fort and information. Is there a bacterium or other
materies morhi, evolved in that polygenetic hotbed
of noxious reactions which is capable of bringing
out the peculiar eruption of this obstinate disease?
Shall we find in animal proteid — incompletely
enzymized under the conditions existing in intesti-
nal stasis — the explanation of the perplexing phe-
nomena? Or perhaps we shall be asked to agree
that the inefficiency of the internal secretions pre-
siding over proteid metabolism is responsible. We
have already observed how urticaria may be attri-
buted to incompetent adrenals. From urticaria to
prurigo, from prurigo to Duhring's disease, is a
transition of measured smoothness. It is not at-
tempted to set up a definite etiology for Duhring's
disease in marking this transition, but simply to
illustrate that manifestations, so easy of compari-
son, may be traced to the same or a similar origin.
Infection will perturb the adrenals. Infection will
induce an acidosis. Intoxication from incom-
pletely assimilated or katabolized protein will also
induce an acidosis. Once more we are vizualizing
three correlated and coordinated pathological pro-
cesses, which appear constantly in acute and chronic
cutaneous conditions, of a nutritional character.
This persistent association should indicate the
stupidity of setting these processes in competition
and dogmatically urging the recognition of one to
the exclusion of the others.
Without multiplying instances at the expense
of interest, we may deduce analogies to a great
many others, from the foregoing considerations.
August 10, 1918.]
CUNNINGHAM: ETIOLOGY EN ECHELON.
^33
Any dermatosis not merely of external origin
like scabies — not purely of specific origin like
lupus or ginnma — may be reasonably ascribed to
nutritional disturbance. Aside from the organic
origin of such disturbance, for example cirrhosis
of the liver or chronic nephritis, which will be
elicited upon careful examination, we shall be
driven to the acceptance of one of the vigorously
urged hypotheses here under discussion. It will be
of great assistance to the clinician in choosing his
course to remember that he cannot go astray in fol-
lowing any of the sign posts. He is not at a cross
roads. He is not at head of three divergent paths.
He is facing parallel highways leading directly to
his main objective.
In the heat of animated argument, the stenopia
of the enthusiast may lead him into intemperate de-
preciation of every other conception but his own.
He sees straight to his own demonstration and nat-
urally concludes that all competitive propositions
are sophistical and false. That is the error of the
zealot : he is a one punch fighter ; that punch has
carried him so far that he considers it the only ef-
fective method of attack. He reasons that truth is
single and indivisible. A thing cannot be partly
true. Part of a proposition is true perhaps and
part is false. But the part that is true is utterly
true and the part that is false is utterly false and
the proposition in toto cannot be partly true. This
is the logic of the metaphysician and not that of the
physician. The latter ought to deal only with facts
not with dialectics. He is not considering any
proposition as a matter of faith, to stand or fall
upon the acceptance of all its parts. He is con-
sidering every part of it as a distinct proposition in
itself, the credibility of which in no way depends
upon the credibility of any associated factor.
Exempli gratia, there is a pathological condition
commonly denominated gout. It is attributed usually
to over indulgence in eating and drinking ; to gour-
mandizing in the popular phrase. It is character-
ized by inflammation of the joints (the smaller ones
mainly), by calcification of the arteries, by chronic
interstitial nephritis, by the deposition of tophi in
various situations, and in subacute manifestations
by pains and disabilities of a vague and indetermi-
nate description. The tophi are composed of urate
of soda. They are found in the helix of the ear, the
perichondrium, the periosteum, the periarticular
connective tissue, the tendons and their sheaths,
the spongy texture of bone and bursal sacs. More
rarely these deposits are found in the outer sheaths
of vessels and nerves, the dura of the cord, the
larynx, and the sclera of the eye. When the kid-
neys are affected calcareous dots and streaks are to
be detected there also. Independently of the long-
recognized dietetic provocation of this disease, the
presence of these concretions would indicate the
nutritional disturbance involved. It is plain that
much acid has been demanded for the formation
of the extruded salt. Or to put it another way, it
is plain that much alkali has been drawn from the
tissues by the excess acid developed therein. The
acidosis is unmistakable. The thyroid having to do
with the control of proteid metabolism (manifestly
out of order) is charged with inefficiency.
The ardent supporters of these different doc-
trines do not acknowledge the merit of any but their
own. With visual fields narrowed to purely frontal
perception, they arraign as heresy any hypothesis
not in strict conformity with their point of view.
The dietitian refers to the results of abstinence in
gout as sufficient vindication of his own position
and sufficient confutation of every dissenting
opinion. The interjection of other factors he con-
siders superfluous and mischievous as tending to
weaken belief in the accredited causation, and carry
everything down in a wave of scepticism. The
acidosis propagandists assume about the same atti-
tude. Intolerance of competition and a disposition
to dogmatize mark their presentation of the case.
The endocrinologist, a later comer, has all the
fervor of the missionary, and — some of his repel-
lent bias. Demanding acceptance of his plausible
;)retensions, without qualification, he brooks no di-
vided allegiance, and arrogates to himself the ab-
solute domination of the pathological controversy.
The act of faith must be al3ject and complete. The
dietitian, depending on the uniform confirmation of
his proposition during a long experience, is unable
to explain the occurrence of gout in those who are
undernourished ! The so called poor man's gout
simply takes the legs from under him, and his pa-
tient! But the watchful eye of the rival detects the
crack in the armor and immediately he cries
"Acidosis ! Starvation acidosis !" There is no
question of the effectiveness of that thrust! It
tumbles the "one punch" fighter in the dust ! It
demolishes the whole fabric of his theory! For if
hypernutrition is the cause of gout, how can it oc-
cur in an organism inadequately nourished? Aci-
dosis then proceeds to show that either an over
supply of ordinarily assimilable nutriment or an
under supply of absolutely necessary nutriment will
result in the reduced alkalinity of the tissues bring-
ing about the clinical picture of "gout."
Just as this comfortable adjustment has been ef-
fected and Acidosis has assumed the arrogance of
the successful contender, along conies Endocrinology
with the disconcerting question, "If hypernutrition
induces acidosis and acidosis is the cause of gout
why does not everybody who is overnourished get
gout?" "Idiosyncrasy," retorts Acidosis uncon-
scious of the trap. "Exactly so," triumphantly ex-
claims Endocrinology, "and idosyncrasy resides in
the internal secretions ! All the assaults made upon
the organism would fail completely if they en-
countered a stiff constitutional resistance. It is a
matter of indifference what may be the nature or
the vigor of the invader if normal internal secre-
tions interpose an effective barrier. The last word
therefore is with endocrinology, and it is the only
factor worth consideration since it teaches that the
others are powerless against its commanding pre-
ponderance."
As a matter of sober truth this apparent rivalry
is part of the great jointed correlated scheme of
pathogenesis. All parties to the discussion have
contributed indisputable evidence of sound con-
■ ictions. There should not be question of discrimi-
nation, but of coaptation between them. When
each recognizes that he has only a part of the truth
234
DANZIGER: ACUTE CORYZA.
[New York
Medical Journal.
and is not authorized to issue an index expurgato-
rius stigmatizing every body else (with another bit
of the truth) as a deluded and untrustworthy
teacher, we shall begin to grasp the scope of our
pathological problems, and shall have made a long
stride toward the solution of many of them.
323 West Fourteenth Street.
ACUTE CORYZA.
Its Intranasal Complications, Diagnosis, and
Therapeutics.
By Ernst Danziger, M. D.,
New York.
It is said that acute coryza is a disease that is
more disagreeable than serioiis, and that therapeu-
tical attempts seem to have but little effect in in-
fluencing the cause of the affection.
These statements are not correct. The acute cold
in the head may lead to grave consequences, and
with appropriate treatment not only can the dis-
comfort of the patients be alleviated, but they will
be protected from serious complications. The im-
portance of the subject forced itself upon me dur-
ing recent years when we have been exposed every
winter to epidemics of the grippe.
.\cute coryza has to be regarded as an acute in-
fectious disease caused by the pneumococcus,
streptococcus, or bacillus influenza which are found
chiefly associated with staphylococci. We know
that the nasal secretion contains certain bacteria
normally, but to make one certain germ responsible
for the infection it is necessary to find such germ
in a pure culture with the normally present bacteria
absent.
If a disturbance of the local circulation is pro-
duced by a sudden change of temperature or by
exposing an isolated part of the body to a draft or
moisture (head or feet), pathogenic germs find a
suitable soil for development, and acute coryza
makes its appearance.
Chemical irritating substances may produce an
inflammation of the nasal mucosa, but only tempo-
rarily.
Hay fever is caused by the pollen of plants in the
atmosphere only in subjects who react to it in an
anaphylactic way. There is one other form of
coryza which is not due to infection, but rather to
an irritation of the mucous membrane of the nose
from some metabolic conditions. In certain indi-
viduals, certain substances, spices, alcoholic bever-
ages, will produce the sudden appearance of all the
symptoms of acute coryza, which will disappear
within a day after elimination of the toxic sub-
stances. These are the cases which are controlled
by adrenalin or other medicaments. They would
have disappeared in the same time spontaneously.
We know that in anemic children with a tendency
to rheumatism, sugar or egg albumin might be the
source of a never ending nasal discharge, the treat-
m.ent of which is, of course, self evident.
Acute coryza is ushered in by a more or less
marked feeling of chilliness. In the nose is ex-
perienced the sensation of burning and itching
which leads to repeated attacks of sneezing. In
about twelve hours, the nose starts to discharge a
colorless seromucous secretion which, within a few
days, changes to a thick yellowish greenish mucopus.
This condition improves slowly, and in two or
three weeks, complete restitutio ad integrum takes
place.
But not always is the course so favorable. In
quite a few instances, the secretion from the nose
continues for weeks or months; sometimes the pa-
tient complains of headaches and facial neuralgia ;
the nasal secretion is of such an amount that the
patient cannot carry handkerchiefs enough to re-
ceive it. Occasionally symptoms disappear for a
week, only to return at the slightest change of
temperature.
What are the pathological processes taking place
during an acute coryza? At the onset we find the
mucosa hyperemic, with a bluish red, glassy, dried
appearance. As soon as the second stage of secre-
tion is reached, the mucous membrane is swollen
and edematous, and covered with watery secretion.
It is not so much the seromucous secretion which
prevents nasal breathing as it is the edematous
swelling of the mucosa of the turbinated bones,
Avhich fills the whole nasal cavity. On inspection
we find the lower nasal meatus filled vnth grayish
glairy mucus interfering with expiration. Gradu-
ally the edema of the mucosa disappears, the
amount of secretion diminishes, and normal condi-
tions are reestablished in about three weeks.
The treatment of acute coryza has been the fol-
lowing: During the stage of chilliness and irritation,
urotropin has been given with the idea that by the
secretion of formaldehyde the development of the
coryza can be prevented antiseptically. So far as
T am concerned, the results have been decidedly dis-
appointing. Powders, consisting of aspirin, phe-
nacetin, Dover's powder, and caffeine give the
patient a feeling of well being and relieve the head-
ache. A thorough evacuation of the intestinal tract
with calomel is indicated.
The purpose of local treatment is to remove se-
cretion, to reduce the edematous tumefaction, and
by so doing establish good drainage from the ac-
cessory sinuses. The patient should irrigate the
nose with warm saline solution (say one teaspoon-
ful to a pint) a few times a day with the following
precautions :
1. The point of the nose piece of the syringe must
not occlude the nostril.
2. The stream must be horizontal.
3. If irrigated from a douche bag, same should
not be elevated higher than the ear. In case of dif-
ficulty in starting the flow, remove nozzle from
nose, elevate the bag until fluid starts, lower the
bag to the desired height, and insert nozzle into the
nose.
4. Patient should bend the head forward during
the irrigation.
5. Under no condition should the patient blow the
nose directly after irrigation. When he blows his
nose he must not touch or compress either one or
the other nostril.
It is not the irrigation itself, but the improper
blowing of the nose afterward, which causes ear
complications. After removal of the secretion, the
August 10, 1918.]
DANZIGER: ACUTE CORYZA.
235
patient uses an adrenalin ointment which by reduc-
ing the swelling of the mucosa promotes drainage
from the sinus and enables the patient to breathe
more freely. During the second week, I add to this
treatment a spray with an oil containing one of the
volatile antiseptics.
With such therapeutic measures, the patient feels
much more comfortable, and by the establishment
of better drainage of the accessory sinuses, com-
plications in that region will be avoided to a great
extent.
And now let me speak about the clinically im-
portant complications which the rhinologist sees
very frequently after they have not been recognized
by the general practitioner.
Unless there is a cessation of the nasal symptoms
of acute coryza after three weeks, the question
presents itself : What is the cause of the continua-
tion of the symptoms?
In this connection we have to consider various
etiological points.
1. The presence of enlarged or diseased adenoid
tissue in the vault of the pharynx, for which we
have to look not only in children. With the knowl-
edge that almost all adults still are the more or less
happy possessors of their adenoids, it should not be
a matter of surprise to find even in adults a chroni-
cally diseased Luschka's tonsil as the cause for re-
, infection or long continuation of a coryza. As a
digital examination in acute or subacute infections
is contraindicated, and the inspection with a retro-
nasal mirror is not verv satisfactory, the use of
Holmes's pharyngoscope should supplant any other
method of diagnosis. By means of this instrument
the retronasal space can be examined without hurry,
and the ditference in coloring will often show the
site of some focal infection.
2. We have to consider the jKDssibility of an in-
volvement of the accessory sinuses, which is mostly
caused by interference with normal drainage. Dur-
ing an edema of the nose, the normal ostia of the
sinuses become obstructed, so that proper drainage
is not possible.
The presence of the stagnating secretion of the
sinuses keeps the mucosa in a state of congestion.
And, finally, if the pressure within the cavities in-
creases, trophic disturbances occur and ulcerations
take place. We have then to deal with a serous,
seropurulent, or purulent inflammation of the ac-
cessory sinuses. Retention of secretion will be
brought about much more readily in patients who
suffer from anatomical abnormalities, which make
one side especially narrow, as a deviation of the
septum or a large hypertrophic anterior end of the
middle turbinated bone.
The object of the treatment is to establish normal
drainage, and this often simple procedure will pro-
mote a quick restitution to the normal state.
The intranasal symptoms in these cases are of the
greatest variety and intensity, and are sometimes
entirely wanting, and we have to depend upon other
methods to arrive at a correct diagnosis.
In very acute cases the patient may suffer from
intense pain over the antrum or frontal region,
which, with their periodicity might easily lead to a
mistaken diagnosis of malaria. The cheek with the
infraorbital or supraorbital region might be edem-
atous, or the region of the antrum or frontal sinus
only painful on pressure.
With such symptoms present, there is no doubt
of the diagnosis, and immediate steps should be
taken to establish normal drainage — not necessarily
surgical means, as most cases will readily yield to
a more conservative form of treatment — as the
often repeated application of adrenalin or cocaine
to the region of the infundibulum into which the
ethmoidal cells and frontal sinus drain their con-
tents, and a little further back in the middle meatus
where the nomial ostium of the antrum is located.
At the same time, irrigation with warm saline solu-
tion three to four times a day will prevent the
mechanical obstruction of the normal openings with
sticky mucopus. In case of swelling or severe pain,
the ice bag should be employed. Internal medica-
tion consists in doses of sulphate of quinine, five
grains three times a day, which seems to have a
specific action in these cases.
While the diagnosis of these complications is
simple enough, if the symptoms are as obvious as
in the clinical picture just presented, the reverse is
true in a great number of cases where the only
symptom present is a prolonged nasal discharge ; or
often the frequent occurrence of a headache is the
only indication of something radically wrong. Even
the typical stream of pus between the middle
turbinated bone and the outer wall of the nose,
exuding from one or the other sinus, is often absent.
In these cases we have to take refuge in other diag-
nostic methods which I will enumerate in the se-
quence of their reliability: i, diagnostic puncture
and lavage ; 2, transillumination ; 3, Rontgen pic-
tures. Before entering into the discussion of diag-
nostic puncture, I will dispose of the subject of
transillumination and skiagraphy.
If we find on transillumination a decreased trans-
mission of light on both sides, it is often due to a
thickness of bone which may be normal for that
individual. Even a one sided shadow with dimin-
ished transillumination on the other side has often
led to a diasjiosis of empyema of the antrum which
was not substantiated by lavage. But where we get
intense transillumination on one side with a decided
shadow on the other, the diagnosis can be safely
made.
Nothing has been more disappointing to me than
skiagraphic pictures in connection with the diag-
nosis of affection of the accessory sinuses. Where
the clinical picture of the disease is typical, the
picture will always corroborate the diagnosis and
will show the formation and extent of the sinus;
but in doubtful cases the picture and the interpre-
tations of some of our best rontgenologists have
misled me so often that I have grown quite skeptical
in accepting their diagnoses.
In puncture of the antrum followed by lavage,
we have one method which does not leave any doubt
concerning the diagnosis.
Paracentesis of the nasal wall of the antrum in
the lower meatus, about one half inch back of the
anterior end of the lower turbinated bone through
the membranous portion of the wall, can be done
after thorough cocainization. Lavage will show
236
ALLEN: FOOD VALUE OF BREAD.
[New York
Medical Journal.
either a clear return flow or turbid dirty looking
Huid, or it will contain plugs of mucopus, or some-
times a brown jellylike secretion. The procedure is
harmless and painless. Doctor Coffin and Dr. Har-
mon Smith have tried to supplant the puncture and
lavage by suction and injection of either antiseptics
or astringent remedies into the sinuses after the
production of a vacuum.
Treatment. — In acute cases, where the conserva-
tive treatment has given no relief from the symp-
toms within a few days, I use the puncture followed
by lavage repeated every twenty-four hours, three
or four times, which seems to be sufficient to pro-
duce a cure. The reason that some of the cases do
not yield to the conservative treatment is due to the
fact that sometimes the secretion in the sinus is so
thick that it cannot drain through the natural open-
ing. During irrigation of the antrum the pressure of
the water will often force a big plug of mucopus
through the ostium and empty the sinus completely.
With the suction method of Coffin and Smith — an
injection of medicament — we sometimes do get re-
sults which are due to the passive hyperemia so pro-
duced (Bier method), but by prolonged hyperemia
we also produce a swelling which might easily
obstruct the ostia and prevent drainage.
Whether we irrigate with saline solution or a
stronger antiseptic, is immaterial, as the reason for
the cure is the removal of the secretion. Anti-
septics, and even chlorazine (modification of Dakin
solution) are useless, as the germs are either em-
bedded in the mucus or located deep in the gland-
ular tissues of the mucous membrane.
In some cases where an actually enlarged anterior
end of the middle turbinated bone prevents drainage
from the ethmoidal cells or frontal sinus, if the en-
largement is not due to a temporary edema, the
removal of this obstruction is indicated.
It is the early diagnosis of such afifections, which
travel under the cloak of a prolonged head cold, that
promises the patient escape from a trouble which,
unrecognized, would stick to him for the rest of
his days, even if operated. While an operation
might give him relief and prevent a systemic intoxi-
cation, it will not forestall relapses, and the peculiar
dry feeling in the nose, and in the case of pro-
fessional speakers and singers will undoubtedly
affect the voice.
Prevention, of course, has been attempted by im-
mimization with vaccines made from the bacterial
fauna of the nose — a procedure which in my hands
has been a complete failure, in spite of the enthusi-
astic reports of others. The reason for the failure,
in my opinion, is that the normal bacterial flora
does not represent the pathogenic germs.
285 Central Park West.
Sugar in the Cerebrospinal Fluid. — M.-P. Weil
(Presse medicate, May 2, 1918) asserts that excess
of sugar in the spinal fluid in cases of war concus-
sion is both of diagnostic value and of interest from
the standpoint of pathogenesis. It indicates an or-
ganic element in the eflfects of the concussion and
proves the role of congestion in the production of
the morbid manifestations.
THE FOOD VALUE OF BREAD.*
By Robert McDowell Allen, M. D.,
New York,
Formerly Food and Drug Commissioner of Kentucky; Head of the
Research Department, Ward Baking Company.
Bread is the staple food of all people. It ranges
from ten to eighty per cent, of the total. The daily
garrison ration for the United States soldier con-
tains :
Ounces
Fresh beef 20.
Flour 18.
Baking powder 08
Beans 2.4
Potatoes 20.
Prunes 1. 28
Coffee, roasted and ground 1.12
Sugar 3.2
Milk, evaporated, unsweetened 5
Vinegar .16
Salt 64
Pepper, black 04
Cinnamon .014
Lard 64
Syrup 32
Butter 5
Flavoring extract, lemon 014
Total 68.908
When it is considered that meat contains from
fifty to seventy per cent, water in addition to from
ten to forty per cent, of waste, that potatoes con-
tain about sixty-five per cent, water together with
twenty per cent, waste and that flour contains from
eleven to twelve per cent, water with no waste, it
will be seen that bread is even the soldier's main
food dependence and why there is so much concern
dttring times of war for the adequate production,
transportation and conservation of bread cereals.
CEREAL production.
Somewhere today wheat is being harvested .
somewhere it is being planted. It is the white
man's cereal. He takes it wherever he goes and
adapts it to all climates. It is grown at the equator
in India, and in Canada only 600 miles from the
arctic circle. It has been bred to all conditions,
although it is wild only in the temperate zones. The
ancient Egy^ptians prized their abundance of wheat
even more than their gold. The Roman legions
were strongest when their granaries were filled with
wheat. When the armies march, wheat is the first
food for which there is concern. The bread line is
the source of food for the unemployed. How much
does the world grow ? How much of this is avail-
able through war limited distribution? Is there
enough? Have the greatest wheat producing na-
tions always had the balance of power? Where
wheat lands are kept fertile and acreage production
is maintained and increased there too is a nation in
the full of its great reserve power.
What other cereals have we for bread? In
what combinations can we make an acceptable,
wholesome, and nutritious loaf ?
Bread was the first concern in the food controls
of all of the nations at war. It was Mr. Hoover's
greatest concern in feeding the stricken Belgians
*An address delivered to the city employees on April 3, 1918,
under the auspices of the Municipal Civil Service Commission,
Leonhard Felix Fuld, Ph. D., Assistant Chief Examiner.
August 10, 1918.]
ALLEN: FOOD VALUE OF BREAD.
237
and his first concern in organizing war control of
the food supply here.
rhe agricultural extension service with trained
agents in each county is the system through which
ofificial activities operate. The Federal Department
of Agriculture and the agricultural colleges were
provided for by Congress in 1863, as a civil war
food measure. The states were given blocks of
public land as a nucleus for endowments. The ex-
periment station organized later with experts in
chemistry and biology accumvdated a wealth of
sound facts relating to agriculture and live stock.
The experiment stations have been supported both
by federal fund and state funds. Some five years
ago Congress through the Smitli-Lever Act appro-
priated money for joint cooperation with the states
in sending trained men in agriculture and trained
women in domestic science to take this wealth of
fact to the farm and to the farm home.
The agricultural county agents, backed by experi-
ment station research, are producing results. Where
they have worked they have increased the crop
yields per acre, for corn 15.5 bushels, for oats 14.7
bushels, for wheat 8.1 bushels, for barley 6.5
bushels. They have done this through seed im-
provements, farmers' meetings, field demonstrations
and a close study of the soil and cropping needs of
each locality. Their work was largely responsible
for the increased oat and corn yield last year. Eight
bushels per acre for all the crop would add over
four hundred thousand more bushels to our 191 7
six hundred and fifty million bushels of wheat.
When the war was declared Secretary Houston
had at hand a complete survey of our agriculture.
He called other leaders into conference, outlined a
plan for increasing particularly the 191 7 corn, oat,
potato, sweet potato, bean, and soy bean, and peanut
crops. This organized effort with the backing of
the American farmer gave the nation six hundred
million extra bushels of corn, two hundred and
thirty extra million bushels of oats, twenty extra
million bushels of barley, two extra million bushels
of rye, five extra million bushels of buckwheat and
twenty-three extra million bushels of Kaffir com.
This harvest result relieved the food crisis of our
Allies in Europe.
The United States should have for the coming
year approximately the same amount of corn, oats
and rye and in addition from eight million to one
billion bushels of wheat. With this accomplished
the food supply for our Allies will be more a prob-
lem of transportation than production. As the ship-
ping crisis becomes easier we should import wheat
from Australia into this country rather than have
it shipped direct to England. The Russians, Ger-
mans, Swedes, and Danes have more rye and bar-
ley than wheat. The Russian, Roumanian and
Ukranian situation will make more food available
for Germany, but farming, threshing, elevator, and
transportation facilities are far inferior to those in
the United States and the people of inland Russia
will demand something more than paper money be-
fore they will give up their cereals without force.
AMERICAN FOOD CONTROL.
The federal food control act covers distribution
and sales from the farm through manufacturing,
storage, wholesale and retail distribution, ])rices,
and hoarding. Under this act Mr. Irloover has
brought many of the leaders in food industries into
a voluntary organization, men big in the fields of
buying, manufacturing, and distributing. To this he
has added and is adding experts in food nutrition.
He has asked for and is fast gaining the coopera-
tion of the food consuming public. In outlining
plan and purpose of his administration he states:
There is no force by which conservation could be im-
posed upon the American people. Conservation can be
accomplished in some countries by ironclad law, or by forc-
ing legal limitations on every individual in the country, but
in our country that is not only unfeasible from the govern-
mental point of view but it is against the instincts of the
people. . . . There is the possibility of demonstrating
that democracy can organize itself without the necessity of
autocratic direction and control. If it should be proved
that we cannot secure a saving in our foodstuffs by volun-
tary effort, and that as a result of our failure to our coun-
try we are jeopardizing the success of the whole civilized
world in this war, it might be necessary for us to adopt
such measures as would force this issue, but if we come to
that unhappy measure we shall be compelled to acknowl-
edge that democracy cannot defend itself without com.pul-
sion, which is autocracy and is a confession of failure of
our political faith.
If we can secure allegiance to this national service in
our twenty million kitchens, our twenty million breakfast,
hmch and dinner tables; if we can multiply an ounce of
sugar, or fats, or what not every day by one hundred mil-
lion, we have saved one hundred and eighty million pounds
in a month. If we save a pound of flour per week, we save
one hundred and twenty-five million bushels of wheat per
annum. It is this multiplication of minute quantities — tea-
spoonfuls, slices, scraps — by one hundred million and three
hundred and sixty days that will save the world. Is there
any one in this land who cannot deny himself or herself
something? Who cannot save some waste? Is not your
right to life and freedom worth this service?
The big part of Mr. Hoover's food control task is
a war against waste. There is waste in production,
due to unscientific and uneconomic methods, due to
drought, too much rain, frost, and the spoilage of
butter, eggs, milk, meat, vegetables, and fruit. The
fight of the entomologist and biologist against
blights, bugs, and animal diseases is a soldier's fight
in the war. Not more than two thirds of the animal
and vegetable foods intended for human consump-
tion raised from the earth are saved and consumed
and of that saved there is enough and more, if
mobilized and properly utilized, to feed double our
own population. There is waste in the feeding,
preparation, and distribution. Uninspected and un-
economic slaughtering houses lose valuable food and
fertilizer. There are losses in retail stores. There
is waste in the home kitchen. The known methods
of constructive sanitation organized and applied
through the American public health and pure food
officials can cut down a food spoilage waste amount-
ing annually in this country to more than one billion
of dollars. The domestic science expert has the
remedy at hand against food waste in the home.
In but few homes is there concern to keep the fat
cut from meat, the extra slices of bread and eatable
parts of vegetables out of the garbage pail, and in
but few cities is there systematic effort to conserve
the food in the garbage pail for feeding meat ani-
mals. There is improper eating, overeating, unnec-
essary night eating. Preventable food waste today
is a national crime. There are enough bread cereals
if properly combined in bread making and if waste
238
ALLEN: FOOD VALUE OF BREAD.
[New York
Medical Journal.
is stopped, to handle the situation well until next
harvest.
THE FOOD VALUE OF BREAD.
Wheat stands first among bread cereals. Its pro-
tein and starch and its mineral salts, when balanced
with calcium, are particularly fitted for human nu-
trition. Its protein produces a gluten which gives
more volume and consequently better leavening
properties to the loaf. For this reason, among
others, it is best to distribute wheat all around so
that all of the yeast bread mixtures will contain
some wheat flour. Cereals are not only a staple
food for men but with forage crops the staple food
for domestic animals. Milk, butter, and cheese,
meats, poultry, and eggs are produced from grains
and grasses. Plant foods contain their nutriment
in varying degrees of digestibility. The animal can
take care of the less digestible portions. In this
fi.eld there is opportunity for dividing and conserv-
ing sufficient food for the production of meat and
milk on the one hand and sufficient cereals and
other plant foods for the direct feeding of human
beings on the other. There is, of course, far more
food economy in feeding cereals direct for human
consumption, to the extent that reasonably balanced
rations can be maintained ; there is, further, more
economy in feeding grains for the production of
milk than for the production of meat. But we must
also have meat.
The food needs for both animal and human be-
ings vary. A mixture in which wheat bran pre-
dominated with ground corn, with still smaller
amounts of cottonseed meal, alfalfa hay, or silage
is the proper ration for a dairy cow in full milk
production. Corn can predominate in the fattening
of hogs. Oats and timothy hay constitute the basic
part of the ration for the thoroughbred horse during
the racing period. The fertilization of soils and
the feeding of animals have had more of scientific
direction than has the diet of human beings. The
young and the old, the laborer by hand and the
laborer by brain, with less exercise of muscles, re-
quire different amounts and kinds of food. The
average individual on the football team of the East
consumes daily 226 grams of protein, 354 grams of
fat, and 634 grams of carbohydrates ; while the aver-
age man engaged in professional work consumes
daily 104 grams of protein, 126 grams of fat, and
423 grams of carbohydrates. The soldier on the
battle field or in training needs the football diet.
Proper food for the human system includes: i,
proteins and the proper balance of different pro-
teins ; 2, carbohydrates, including the proper balance
of fats, sugars, and starches ; 3, mineral salts and
their proper balance ; 4, a proper amount of as yet
not fully determined substances which some inves-
tigators refer to as vitamines and other investigators
refer to as protective foods ; 5, freedom from harm-
ful substances which exist in many foods, freedom
from unwholesomeness produced by spoilage or con-
' tamination with disease producing germs; 6, pleas-
ing color, flavor and other similar qualities which
stimulate immediate sympathy from the digestive
juices.
Wheat, rye, barley, and oats add not only carbo-
hydrates but a large supply of proteins to the diet.
Rice and corn have less protein. Beans and peas
are high in protein. Beans were combined with
the corn diet of the American pioneer. Soy beans,
high in protein, are combined with the rice diet of
the Oriental. Peanut and cottonseed flours consti-
tute, with beans, peas, and soy beans, cheap sources
of vegetable protein. Some big results to the food
supply are at hand for scientific and industrial en-
deavor in these vegetable protein fields. Bread
made from wheat, rye, oats, or barley, or combina-
tions of these, is richer in protein than bread made
from corn or corn and wheat flour. One needs to
eat more of beans and meat with bread made from
corn than with bread made from wheat, oats or
barley. But corn looms a great hope to the hungry
world. It is easiest to double its bushels per acre.
The increase of its protein content and the develop-
ment of a corn protein with better leavening proper-
ties is not impossible under modern botanical ad-
vance.
The loaf of bread should not be looked to as an
all sufficient food. It should be kept what it is, a
cereal food.
Widespread attention is being given to the min-
eral salt needs in nutrition. It has for a long time
been observed that the mineral content of soil and
water is at the foundation of progress or poverty
among the human race. As we become better ac-
quainted with the facts there is no reason why the
nutritional advantages of one district should not be
adopted throughout the entire food supply.
Doctor McCallum, formerly of the University of
Wisconsin, now of Hopkins, Doctor Mendel and
Doctor Osborne, of Yale, Doctor Sherman of
Columbia, Doctor Lusk, of Cornell, Professor
Forbes, of the Ohio agricultural experiment station,
and others, have been following the work done in
protein and carbohydrate nutrition by Atwater and
his coworkers with a farreaching investigation of
the mineral salts and other protective food needs in
the diet. The present conclusions are that the
staple foods, including bread, should be supple-
mented with milk, fruits and vegetables, including
the leaves of vegetables. With such additions, the
cereals will continue to take a fundamental place in
the diet.
These studies in human nutrition have been based
upon experiments with animals. Companion ex-
periments in scientific baking have been conducted
with yeast and enzymatic actions. It was for a
long time observed in brewing, distilling, and baking
that the mineral content of both the water and the
grain has an influence on the action of yeast. A
study of the cause has led to some very interesting
results, to a closer control of fermentation, and
already it is being seen that the mineral salt balance
which stimulates yeast and the enzymatic processes
in bread making parallel closely the mineral salt
needs in the human diet.
Milk or milk solids will and should be more and
more included in the loaf of bread. The milk pro-
tein adds a perfect protein balance to the protein of
the cereals for human nutrition and the lime rich
milk supplies in part this recognized, mineral salt
deficiency of the cereals. There is vast opportunity
for the economic consei'vation of milk solids for
August 10, 1918.]
ALLEN: FOOD VALUE OF BREAD.
239
bread making without in any way trespassing upon
the fluid milk supplies for children. Progressive
bakers have already made milk in the form of con-
densed milk or dried milk a staple ingredient in
their bread formulas and the amounts introduced
into the loaf will increase as the public comes to ap-
preciate the increased nutritive value of the loaf.
How much bread shall we eat ? This may be
answered by referring again to the ration of the
soldier. All of us do not need the soldier's ration
and many need only half of it. Until next harvest
we nuist use as little wheat as possible, but there is
no reason why we should stint ourselves in the con-
sumption of other cereals, and baking as regulated
now by the food administration requires sufficient
introduction of other cereals to make up for the
wheat deficiency. Cereals, with milk, vegetables,
and fruit constitute the cheapest way of feeding our
people. We have had some difficulty in organizing
the cereal situation but it is being brought under
proper control, and with the coming harvest there
will be suflficient cereals to meet all food demands,
and suflicient wheat to make the cereals into an
acceptable loaf.
The food value of the protein and carbohydrate
constituents of food has been reduced to units
called calories. The average daily food need of the
individual ranges from 2,500 to 4,500 calories. This
does not mean that we can select all calories from a
particular kind of protein or from a particular kind
of carbohydrate, but is a general measurement. In
reducing food to calories the balance of the protein
with the carbohydrate, the balance of proper proteins
one with the other, the adequate balance of mineral
salts and of other protective foods must be taken
into consideration.
A pound of wheat bread averages from twelve to
thirteen hundred calories of food value. From
twelve to sixteen ounces of bread can be taken as
the average daily need in the diet of the healthy
adult. This is in terms of yeast made bread, but it
can serve as a general measurement for the con-
sumption of cereal prepared in any form.
Hunt and Atwater in Farmers' Bulletin 824 of
the United States Department of Agriculture have
summarized the needs in nutrition, especially from
the standpoint of sufficient protein with reference
to bread as follows :
Since the protein foods include many of the more ex-
pensive foods in common use, and since an adequate supply
of protein is essential to the growth and upkeep of the
body, it is especially important for the housekeeper to know
how much her family needs and to be able to choose the
materials which, in her particular circumstances, will best
provide the proper kind and amount.
Among the generalizations made are the following: The
foods usually classed as rich in protein are: Milk and
cheese ; eggs ; meat, poultry, and fish ; dried legumes, such
as peas, beans, cowpeas, soy beans, and peanuts ; and al-
mond, and some other nuts. Wheat, oats, and some other
cereals also furnish considerable amounts of protein. Milk
is the best source of protein for children. There is about
one fourth ounce of protein each of the following: one
glass of milk, one egg, one and one half to two ounces of
meat, one ounce of cheese, and thirteen ounces of bread.
A man at moderate muscular work is believed to need
about three and one half ounces of protein a day, and a
family consisting of father, mother, and three small children
about twelve ounces a day.
It is possible to plan an attractive and wholesome diet in
which one half of the necessary protein is supplied by bread
and other cereal foods which are relatively cheap. . . .
Cereals stand out as stajjle foods not only because
of the cheap form of carbohydrates which they af-
ford, but also because of their desirable protein and
mineral salt content. There is a great opportunity
ahead of the baker in working to perfect the eco-
nomic, protein value of bread. The consuming pub-
lic can safely turn to the cereals for economic pro-
tein as well as economic carbohydrates.
The food administration has asked for and will
enforce the restriction of wheat in bread and other
cereal foods, at least until the next harvest. It
recommends that not more than two ounces of bread
containing seventy-five per cent, of wheat be served
in the restaurant, at one meal ; which would mean
six ounces a day. This may be raised to four ounces
at one meal, if the bread contains sixty-six and two-
thirds per cent, of other cereals than wheat, which
would mean twelve ounces per day. This is in ad-
dition to the consumption of breakfast foods made
from other cereals than wheat.
Let it be repeated that no one food should be
emphasized as the complete food, to the exclusion
of other needed foods. It can be emphasized, how-
ever, that grain, properly supplemented, forms the
cheapest source of food for human consumption.
Contrary to the prophesy of some economists the
world's cereal crops, except as temporarily aft"ected
by war conditions, show constantly increased pro-
duction. During the last twenty years the bushels
of wheat and oats have increased by about one-
third. Barley and rye show a substantial though
less increase, while it is now possible, through ap-
plied science in seeding and cultivation to practically
double the corn crop at will.
It is not generally known that the baking industry-
is the largest of the food industries. This industry
is now the subject of the closest control exercised
by the Federal and State food administrations. The
food administrations have turned to the baker to
help put oats, corn, and barley into an appetizing,
wholesome and economic form for human consump-
tion. Rakers are meeting the task. Light and nu-
tritious loaves are now being baked from combina-
tions of oats, barley, corn and rice with wheat flour.
A\\ baker's bread is now "Victory" bread.
Simple Wrist Drop Splint. — The Lancet (May
25, 1918) presents, under "New Inventions," a sim-
ple splint for cases of wrist drop which was invented
by G. W. Clyne, of the Surgical Supply Depot of
the Ladies' Needlework Guild of the First Scottish
General Hospital. It consists of a single piece of ten
or eleven gage coppered, mild steel wire, about two
feet long, bent to follow accurately the palmar
aspect of the forearm and hand, and having its ends
inserted into a flat, dome shaped piece of hardwood
nbout 1% inches in diameter to fit the palm. Two
lugs are bent into the wire to hold the strap which
buckles about the forearm, and the protrusions at
the base of the wrist serve the same purpose for the
wrist strap. Any degree of hyperextension can be
secured without pressure on the thenar or hypo-
thenar eminences and with the fingers left free.
240
STALLER: IMMUNITY IN TUBERCULOSIS.
[New York
Medical Journal.
liMMUNITY IN TUBERCULOSIS.
By Max Staller, M. D.,
Philadelphia,
Medical Director, Jewish Consumptive Institute; Visiting Surgeon,
Mount Sinai Hospital.
Immunity is secured by a person having in his
blood certain chemical substances capable of neu-
tralizing a toxin, of producing an enzyme for the
leucocytes which enables them to digest the invad-
ing organism, or of producing a substance able to
destroy the power of the germ to reproduce itself.
In some infections, all these substances are present,
and in others, only one of them. These substances
are attached to a complex molecule of the station-
ary cells and leucocytes as a free ion, and they re-
main inactive mitil a substance known as antigen
apf>ears in the circulation. The antigen is able to
tear away these ions and form a new molecule
which is capable of causing a rearrangement in
either the toxin molecule or the parasite itself by
combining with an ion that is essential to reproduc-
tion, thus destroying in the parasite the main phe-
nomenon of infection and causing a rearrangement
of the entire constitutional makeup of the organism.
Immunity to a certain disease can be acquired
only by those who have suffered with the infection,
either in severe or in mild form. Its duration de-
pends altogether on the stability of the antibody
formed by the antigen. If the antigen is polyvalent,
there will be several immune bodies formed, such
as precipitin, agglutinin, complement and lysin. If
the antigen is monovalent, only one immune body
will be formed, and the immunity, therefore, will
be of only short duration, as in diphtheria. Im-
munity may be produced by the direct action of
living or dead organisms introduced into the circu-
lation either by chance or by artificial means. Vac-
cination in smallpox and typhoid fever is the
artificial introduction of the organisms in order to
create immunity in these diseases. Antibodies can
be formed only in the presence of living and dead
organisms. These organisms sensitize the cells of
the body, which in their turn respond bv introduc-
ing an enzyme or antibody capable of destroying
that parasite or its protein. The mechanism does
not appear so complicated if the physiochemical
facts are borne in mind. Let us analyze certain
facts.
How the organisms are destroyed is of little im-
portance. In order for them to disappear from the
body, the leucocytes must be able to digest the
organisms or break up their complex molecules into
the original elements. Those elements that can be
assimilated by either the stationary cells or the leu-
cocytes are utilized, and whatever is left over is
carried away by the leucocytes into the tissues.
Those elements remaining attached to the cells and
leucocytes act as receptors for the antigen. These
receptors remain for a short or a long period or
in some cases permanently, and constitute the body
defenses to be utilized later. As the original germs
enter, a ferment is formed, which has the power of
digesting the parasites.
Many varieties of bacteria are constantly ready to
gain entrance into the body — saprophytic, patho-
genic or pyogenic ; yet, they do not destroy the func-
tional equilibrium of the bodily organisms. This is
good evidence that they have been destroyed. We
may, therefore, conclude that a slight amount of
immunity is left. It has been proved that leucocytes
yield substances that are bactericidal, on account of
the remaining elements abstracted from the organ-
isms in the course of their migration into the body
in small numbers. Hiss and Zinsser, by injecting
extracts prepared from leucocytes obtained from
rabbits following the intrapleural aleuronat injection
were able to modify the course of staphylococcus
infection and various other diseases, such as pneu-
monia, typhoid, meningitis, and cholera infection in
animals, and in many cases the animals were saved
from a fatal dose of those germs by this means.
Opie also found that otherwise fatal experimental
intrapleural tuberculous infections in dogs could be
made to heal by the introduction of living dog leu-
cocytes. Mainwaring noted a similar protective in-
fluence of leucocytes in experimental tuberculous
meningitis in dogs. These substances need not
necessarily be specific. They simply are able, by
combining, to form a ferment which enables the
leucocytes to digest the parasites or so modify their
toxins as to make them harmless fo'r the body.
Yet not all germ diseases confer immunity.
Pneumonia and tuberculosis rather predispose to
new infection. In pneumonia, however, we assume
that the second attack is caused by a different strain
of pneumococci. This is, however, merely an as-
sumption, as no one, to my knowledge, has proved
with clinical cases a first and a second attack of
pneumonia to be exclusively from different strains.
I have had cases in which I have treated the pa-
tients for pneumonia four times within the last ten
years. Since but one of the four types of pneumo-
cocci which have so far been recognized, is always
fatal, this leaves only three nonfatal types; yet my
patients had pneumonia four times and recovered.
In tuberculous infection, a large number of the
so called arrested cases have been followed by rein-
fection. This, no doubt, is due to the fact that the
tubercle bacilli still remain in the lesion. Until a
short time ago, we had no positive means of de-
termining whether a given case was arrested or
cured. Craig and Miller have adopted a plan, which
has been tested in a number of cases, and which is
valuable as bearing on this subject. It is that the
disappearance of clinical symptoms and arrest of
the activity of the disease do not mean that the pa-
tient is cured. If, however, in the absence of clini-
cal evidence, the patient's blood, when tested for
complement fixation with tubercle bacilli, proves
negative, then we may apply the term "cured" to his
case. If the blood is still positive, in spite of the
absence of clinical evidence, the disease is arrested,
but not cured. He still has tubercle bacilli, either in
the old focus or in a new one whose presence could
not be detected clinically.
We must recognize the universality of tubercu-
losis. If absolute, no immunity to it could be ob-
tained, the whole of mankind and animals would
suffer from either acute or chronic tuberculosis.
The fact that this is not the case is evidence of
immunity. It is true, however, that when an over-
whelming dose of tubercle bacilli gains entrance
August 10, 1918.]
KANTOR: CLASSES IN MALNUTRITION.
241
into an organism predisposed to the disease by
weakness, exhaustion, alcohol, or syphilis, the im-
inunity is lost. In 1915, while in Vienna, I wit-
nessed 1,000 post mortems on the bodies of persons
dying- with diseases other than tuberculosis, between
the ages of eighteen and seventy years, and ninety-
two per cent, of all these showed evidences of
healed tuberculosis of the lungs. I will admit that
these thousand individuals represented the indus-
trial classes, which are more susceptible to the
development of the disease than are the upper
classes. Nevertheless, if this ratio holds good, we
must conclude that immunity to tuberculosis does
exist in a greater or less degree. Resistance to
tuberculosis is due entirely to the cellular system,
which gives the leucocytes the chemical units re-
quired to produce an enzyme when stimulated by
the presence of tuberculosis antigen in the form of
toxins or endotoxins. These vmits are acquired by
the body cells during their lifetime through the en-
trance of small numbers of tubercle bacilli which
are readily destroyed, thus making it possible for
the leucocytes, with the assistance of these enzymes,
to engulf, digest, or break up the molecules of
which the tubercle bacillus is composed, and so
eliminate it as a disturber of the peaceful colonies
of cells making up the animal's body.
How can such an enzyme be produced? Air,
sunshine, sanitation, good food, and rest keep the
cells and leucocytes in good trim and the cells will
destroy the few tubercle bacilli that may enter,
thereby preparing themselves with substances capa-
ble of overcoming a large number of these organ-
isms. The person who does contract tuberculosis is,
to begin with, not up to par. You must, therefore,
give him the diet, sanitary conditions, etc., that the
first individual had, in order that he may resist the
infection. If his cellular system is much below par,
he will succumb before a sufficient amount of bac-
teria are killed to produce the primary elements
essential for the formation of antibodies. If the
entering tubercle bacilli are numerous and virulent,
your dietetics and sanitation and fresh air will be
of no avail ; because the cells are so overwhelmed
by the tuberculous toxins that they must utilize all
their energy m throwing ofif the toxins and main-
taining their own life, and have none left for the
production of antibodies. The tubercle bacilli are
then the victors, because the overwhelming amount
of toxins prevents the moleculization of the atoms
present, to form, with the antigen, the antibodies.
The famous physician, Galen, gave a dictum as
far back as 130 A. D. : "No one can be saved, unless
nature conquers the disease ; and no one dies, un-
less nature succumbs." Radical as that statement
was at the time, it is only lately that it has been
modified on a scientific basis by Sir A. Wright, who
gave the following dictum : "No one recovers from
a chronic or acute bacterial disease unless it be by
the production of protective substances in his organ-
ism ; no one acquires protection against disease
except, again, by the production of protective sub-
stances ; and finally, no one lives in the presence of
infection and repels that infection, except by the
aid of protective substances in his blood." The
elaboration of this theory as applied particularly to
tuberculosis constitutes an entirely new phase in the
treatment and cure of the same.
If we recognize tuberculosis as a bacteriemia, the
local anatomical lesion becomes of secondary, and
the toxemia of primary importance. If the cellular
system is able to produce sufficient protective sub-
stances in time, the local lesion will take care of
itself ; and since these protective substances, known
as antibodies, can be produced in the individual only
in the presence of infection, the amount of toxins
thrown into the circulation at one time plays an
important role in the prevention and cure of the
disease. If the amount is small and is thrown into
the circulation at infrequent intervals, the chances
for immunity or recovery are good. On the other
hand, if the amount of toxins is large and enters
the circulation at frequent intervals, the cells be-
come so overwhelmed that they cannot produce
enough antibodies to neutralize the toxins, because
they are not able to kill enough tubercle bacilli to
make a sufficient number of receptors to form anti-
bodies. In such cases, the results are fatal.
It is, therefore, clear that the principle in the pre-
vention and cure of tuberculosis is the elaboration
of tuberculosis antibodies by the infected individual.
His entire protection lies in their quick and active
production. If he succeeds, he is saved; if he fails,
he is doomed. Up to the present time, no one has
succeeded in producing tuberculosis antibodies out-
side the infected individual. I have, however, suc-
ceeded in producing a serum in an animal body- —
not by means of the tiibercle bacillus, but of the
Bacillus X ( I ) . This serum gives the complement
fixation test positive with living tubercle bacilli, and
also with Craig and Miller's tuberculous antigen. If
the theory of the curative action of specific anti-
bodies is correct, then my serum ought to be capa-
ble of preventing, as well as of curing, tuberculosis
in the pretuberculous state, as well as in incipient
and moderately advanced cases.
REFERENCE.
I. STALLER: Report of Experiment.il Work on the Production
of an Antituberculous Serum, New York Medical Journal, Decem-
ber 22 and 29, 1917.
1310 South Fifth Street.
EXPERIENCE WITH A CLASS IN MALNU-
TRITION.
Work of the Malnutrition Clinic, Bowling Green
Neighborhood Association, New York City.
By John L. Kantor, M. D.,
New York.
The recent growing general interest in the sub-
ject of malnutrition among school children has sug-
gested the publication of the present brief account
of the work done from June through December,
1017, at the Bowling Green Health Centre, 45 West
street. New York City.
material, facilities, methods.
As pointed out in various reports dealing with
the activities of this association, the Bowling Green
district represents a poor residential neighborhood
located in the southwest part of Manhattan Island,
almost completely isolated from the better residen-
tial districts by the interposition of the large finan-
242
KANTOR: CLASSES IN MALNUTRITION.
[New York
Medical Journal.
cial and warehouse sections of New York. Although
this isolation has undoubtedly in the past been re-
sponsible for the neglect and relative backwardness
from whicJi the population has suffered, its very
compactness and what may be called "natural"
boundaries make it so much easier to handle from
the medical and sociological point of view.
The larger portion of the population comprises
those of Slav, Syrian, Irisli and Greek extraction.
The children attend either the one public school or
the parochial school of the district, and in these
schools general medical inspections have been made
by the municipal authorities, and on the basis of
these findings children suspected of being under-
nourished have been referred to our clinic. Before
the opening of the association's building, the clinic
Avas held at the public school, v/hile one class was
conducted at the parochial school.
At present the classes are held in the malnutri-
tion room in the association building, twice weekly.
The examinations are conducted by the physician in
charge and an assistant. A small portable scale is
used for the weighings. New subjects are con-
stantly being added to the class on recommenda-
tion of the association nurses, social workers, school
nurses, and other agencies. The procedure for an
individual child is as follows :
TABLE I.
Classification of Cases Admitted to Clinic.
Number. Percentage.
Class III Ill 53
Class IV 69 33
Class Ilia 31 14
Total 211 100
Cases incompletely studied 141
Total cases with available records 352
Each case is provided with a standard sheet on
which the original and all subsequent findings are
recorded. The child is weighed and comparison is
made between the weight as found and the theo-
retical weight for his age. Similar comparison is
made for the height. If the data are found normal
the child is not admitted to the class but the record
is filed for future reference. Should the child be
found underweight, he is put in the appropriate
class of the Dunfermline scale.
The Dunfermline scale. — According to this
method of marking nutrition, prepared by the Car-
negie Trust at Dunfermline, Scotland, every child
can be put into one of four classes :
Class L Children in superior physical condition
under the best environment. Weight normal or
slightly ai)Ove average.
Class n. Children in passable condition under
ordinary environment. Weight normal.
Class III. Children below weight, requiring ob-
servation.
Class IV. Children below weight (I have se-
lected an arbitrary limit of more than fifteen per
cent, under weight ) re(!uiring special observation.
Naturally, the malnutrition clinic deals primarily
with classes III and IV.
Corrective measures. — At the original examina-
tion the outstanding physical defects are noted.
Children suffering from their teeth are treated at
the association's dental clinic under the same roof,
n'hose with diseased tonsils or adenoids are re-
ferred, pending the enlargement of our own fa-
cilities in this direction, to appropriate institutions
for treatment. The same applies to cases of ocular
troubles. Those suffering from cardiac and other
general diseases are referred to the association's
children's clinic. Cases with spinal curvatures are
sent to the class of corrective exercises.
Constant and repeated individual and class in-
struction is given as to proper dietary habits and
TABLE II.
Analysis of Weights.
No. No. who showed No. who showed Relatively
in group. relative gain. relative loss. stationary.
Boys .... 39 30 or 77% 8 or 20.0% i or 2%
Girls .... 29 23 or 79% 6 or 21.0%
Total... 68 53 or 78% 14 or 20.5% i or 1%
Theoretical or expected
No. who showed actual gain for this number
gain and amount gained, for period of observation.
Boys 36 gained 107.00 lbs. 36 should gain 55 lbs.
Girls 24 gained 82.75 lbs. 24 should gain 61 lbs.
Total 60 gained 189.75 lbs. 60 should gain 116 lbs.
The boys, therefore, gained 1.9 times their expected weight increase.
The girls, therefore, gained 1.4 times their expected weight increase.
The entire group gained 1.6 times their expected weight increase.
hygienic measures in general. Between cHnics,
nurses and social workers are engaged in visiting
the homes of the children and giving advice and
relief where possible. During the summer, selected
cases are sent to the country for a stay of about
two weeks. This is accomplished through coopera-
tion with the various agencies now available for
such relief. Children favored in this way almost
invariably gain in weight. It should be mentioned
TABLE III.*
Weight and
Height Chart.
, Boys-
N
Age
Pounds
Inches
Pounds Inches
Birth
7-55
20.6
7.16
20.5
6 months
16.0
25.4
15-5
25.0
I year
21.0
29.0
20.5
28.7
18 months
24.0
30.0
235
29.7
2 years
26.4
32.S
26.0
32.S
254 years
29.0
28.5
3 years
31.0
35-0
30.3
350
3"^ years
33-0
32.3
38.0
4 years
35.0
38.0
34-2
4/^ years
370
36-1
5 years
39.0
37-9
sVz years
41.0
41.7
39-8
41.4
6 years
43-1
41.6
6!^ years
45.2
43-9
43-4
43-3
7 years
47.4
45.6
7V2 years
49.5
46.0
47-7
45-7
8 years
52-0
51-0
SYz years
54-5
48.8
52.5
47-7
9 years
57-0
55-0
gVi years
59-6
50.0
57-4
49-7
10 years
62.5
60.2
loyi years
65.4
51-9
62.9
51-7
1 1 years
68.0
53-6
66.2
1 1 Yi years
70.7
695
53^8
12 years
73.8
74.1
12!-^ years
76.9
55-4
78.7
S6.i
13 years
80.8
83.7
I3J^ years
84.8
S7-S
88.7
58.5
14 years
90.0
93-5
14^ years
95-2
60.0
98.3
60.4
15 years
101.2
102.5
isY years
107.4
62.9
106.7
6i]6
16 years
1 14. 1
109-5
i6J^ years
121. 0
64.9
1 12.3
62.3
*Used at
the Bowling Green
Malnutrition
Clinic. Compiled
from
the work of
Burk, Holt, and Boas, by Mr. F
rank A. Manny.
that special supervision
can now
be secured
for
cardiac cases insuring against overexertion.
Although no plan of ideal feeding has yet been
attempted, each child is given a glass of milk —
sometimes cocoa in winter — and a few crackers at
each session. This has the additional value of in-
suring regular attendance. No medication in the
nature of artificial foods or fattcners has been ad-
August 10, 1918.]
ABSTRACTS AND REVIEWS.
243
ministered. It seems well, therefore, to point out
tliat so far, our results have been obtained, in a
sense, witli the kinds and amounts of food at the
disposal of the malnourished children themselves.
Accordingly, there is reason to look for greater
gains just as soon as some continuous plan of con-
trolled feeding is adopted.
Working out of the problem. Results obtained.
— A total of 352 children have been enrolled at the
malnutrition clinic. Of these 141 have been set
aside as of normal weight or as having been ob-
served for too short a period to permit of inclusion
in a comparative study. This leaves a group of 211
serving as a conservative basis for this report. Of
this number iii, or fifty-three per cent., belong to
Class III, sixty-nine or thirty-three per cent, to
Class IV, and thirty-one or fourteen per cent, to a
special group which I have designated class Illa.
This group is of sufficient interest to warrant a few
words of explanation :
It was observed early in the progress of the work
that some of the obviously undernourished children
referred to the clinic, when weighed, were found to
equal, and in some cases to exceed, the expected
weight for their age. The solution of the difficulty
was apparent when the height was taken. Such
subjects were found to be too tall for their age, and
their actual weight was invariably found to be less
than the expected weight for their height. In other
words, these children were, in reality, instances of
asvmmetrical development, as opposed to children
who are both under weight and under height for
their age, and who may be spoken of as instances
of symmetrically retarded development. I think
that recognition of these asymmetrically developed
(Class Ilia) children is of real importance because
they seem to be candidates for diseases or condi-
tions associated with ptosis of the internal organs.
Is it not possible that measures taken in early life
woul'd yield far better results than when attempted
later in the career?
Atuilysis of data. — Of the 211 cases above men-
tioned as serving for the basis of this report, sixty-
eight were observed for periods of more than a
month : some for as long as six months. Detailed
statistics are presented in the accompanying tables.
It may be pointed out that seventy-eight per cent,
of the children regularly attending have gained
more than their expected increase in weight during
their respective periods of observation. The boys
did somewhat better than the girls, having gained
1. 9 times their expected weight increase, whereas
the girls gained but 1.4 times their expected weight
increase. Both together gained 1.6 times the normal
amount. Fourteen per cent, of the children showed
a relative loss, i. e., failed to gain weight at a rate
equal to the theoretical weight gain for their re-
spective ages.
General conclusions.-— Child malnutrition is not
merely a poverty problem, or a food problem, or
even a medical problem. It is a problem involving
adjustment between the individual and the environ-
ment in the broadest sense, and can be solved only
by bringing to bear on any one case all the re-
sources of the best medical, educational and socio-
logical teaching. If well cultivated this field bids
fair to offer the richest practical rewards to hygiene
and preventive medicine.
44 West Ninety-sixth Street.
<t>
Abstracts and Reviews.
HOW AMERICA IS HELPING FRANCE
WITH HER TUBERCULOSIS PROBLEM.*
By James Alexander Miller, A. M., M. D.,
New York,
Associate Director of the Commission for the Prevention of Tuber-
culosis in France.
The Commission for the Prevention of Tubercu-
losis in France was sent in July, 1917, under the
auspices of the International Health Board of the
Rockefeller Foundation, with Dr. Livingston Far-
rand, formerly executive secretary of the National
Association for the Prevention of Tuberculosis, as
its director. In February, 1917, Dr. Herman M.
Biggs was requested by .the International Health
Board to make a personal study of the situation and
the sending of the permanent commission was a
direct result of Doctor Biggs's report and recom-
mendation. The results of the studies made by the
commission thus far tend to corroborate Doctor
Biggs's estimate of nearly 500,000 cases of tubercu-
losis in France, though the classification is some-
what modified. Doctor Biggs's classification is as
follows ;
Discharged from army 150,000
Still remaining in the army 45,000
Prisoners of war in Germany 20,000
Civilian refiifrees and repatries 85,000
.A.mong the remaining civilian population 110,000
Tuberculosis listed under false diagnoses, such as
bronchitis, etc 30,000
Total 440,000
It is the opinion of several of the best of the
French clinicians that a very large percentage of the
patients diagnosed as tuberculous in the army did
not have this disease, at least, in active form. That
predisposed cases do well rather than otherwise
under army regime was the expression of opinion
of French physicians in mihtary service. Very few
tuberculous prisoners of war in Germany have been
returned to France. That a goodly number of cases
of tuberculosis are covered under such terms as
chronic bronchitis is most probable. The prejudice
in France against public aclcnowledgment of tuber-
culosis in a family is even greater than in this
country. In Paris, where the mortality is highest,
more than fifty-two per cent, of the deaths reported
from tuberculosis occur in hospitals where the
greatest accuracy in diagnosis and record is to be
expected. Regarding tuberculosis among the re-
maining civilian population an analysis shows that
while the death rate from tuberculosis in France is
high, it has been no higher during the war than
previously ; also that the increase in the death rate
above the average in France is due almost exclu-
sively to the very high figures which obtain in large
cities. Tuberculosis remains, as before the war, a
* Abstract of paper read before the College of Physicians of
Philadelphia, May i, 1918.
244
ABSTRACTS AND REVIEWS.
[New York
Medical Journal.
disease especially oi the civilian poor in large
cities. The food problem has by no means reached
the point of actual want in France, excepting in the
exceptional cases, although the question is a difficult
one. Alcoholism plays a large part and all French
sanitarians hope for some control of the sale of dis-
tilled liquors as a result of the war.
Second in importance to the tuberculosis problem
in France is that of infant mortality and of depopu-
lation. We have found it desirable to link up the
two campaigns through cooperation with the Ameri-
can Red Cross. This has been done by carrying on
the publicity propaganda as one united effort and
by conducting clinics for children in all tuberculosis
dispensaries which we have established. The birth
rate in France is well below the death rate. The
infant mortality rate, however, is distinctly below
that of Germany. Our commission entered into a
working agreement with the American Red Cross
which has exhibited as splendid an example of co-
operation as could possibly exist between two similar
bodies. Our working basis was that the general
outline of the tuberculosis campaign and the policies
involved should be directed by the commission,
which would have direct charge of the establishing
of dispensaries, the training of nurses, and the edu-
cational propaganda; the l^ed Cross assuming tlie
mstitutional care, home relief, and housing. There
was, as a matter of fact, interchange of work and
personnel with complete harmony. We assumed
the entire responsibility for community tuberculosis
work in an arrondissement of about 250,000 inhabi-
tants. Three tuberculosis dispensaries have been
established here and a fourth is under way. The
visiting nurses are domg tuberculosis work and in-
fant welfare work simultaneously.
The housing problem in France is one of the
most difficult to solve The overcrowding and gen-
eral lack of hygiene in the tenement districts exceeds
almost anything with which we are familiar in our
large cities. Mr. Flomer Folks, of the Red Cross,
contracted with the owners of half finished apart-
ment buildings for the Red Cross to finish the build-
ings and to apply the necessary expense toward the
rental upon a three year basis. This has made space
available for several thousand people, some of
which has been used for our tuberculous families.
In order to make our demonstration more complete
we developed a rural section of France along the
lines followed in the arrondissement mentioned.
Hospital supervision has been provided and plans
are under way for the erection of a sanatorium.
The same methods have been employed as in Paris,
including the establishment of children's dispen-
saries, training of visiting nurses, and provision for
home relief. In addition to these two intensive or-
ganizations we have cooperated with existing
French dispensaries. In our various dispensaries
we have over 1,500 new patients in attendance and
1,350 families were under supervision April i, iQiS.
'Until a few years ago the nursing of the sick in
France was entirely in the hands of the nuns, but
since the separation of Church and State schools for
nurses have been developed. We have established a
scheme of cooperation with three of the best schools
in Paris and a fourth in Lyons. While the theoreti-
cal training and the jjractical work given to nurses
in these institutions were splendid, there appeared
to be a lack in training for social work. We have
achieved a common basis for the curriculum and
liave secured courses in the principles of social
work. As all physicians of military age in France
have been mobilized, only the elderly men and wom-
en physicians remain. It has been our policy to
cooperate with them in every possible way. One
important result has been a most interesting and
valuable interchange of knowledge and methods be-
tween the physicians of France and America.
Members of the Faculty of Medicine in Paris and
in Lyons have suggested that we offer a course in
diagnosis to the students of their medical schools.
This undoubtedly will later be done.
Probably the most interesting and successful
feature of our commission has been the educational
propaganda developed under the direction of
Professor S. M. Gunn in cooperation with Mr.
Pratt, of the Children's Bureau of the American
Red Cross. The plan consists in having several
educational automobile units, comprising moving
picture machines, a traveling exhibit, a mass of
printed literature and posters, and lectures on tuber-
culosis and infant welfare, all heralded in advance
and kept before the public by a well organized press
campaign. Three of these units have begun work
and twelve are planned. The success achieved is
already astonishingly great and the enthusiasm has
not only done much to extend the health propaganda
but has aroused a tremendous admiration for
America among the French people. No more stir-
ring experience can be had than watching the effect
of this American effort among the French people.
The very satisfactory beginning of the campaigns
in France against tuberculosis and infant mortality
is due mainly to the cordial spirit of cooperation
manifested by the French themselves, who need the
encouragement and assistance that America has
brought to them to tide them over this present period
of terrible strain and stress. That America has
been able to have a part in the beginning of this
great movement will do much to strengthen the
ties of affection binding these two great republics,
and to those of us who have been privileged to
share in the work, it will always remain one of the
great and deep experiences of our lives.
The Indefatigable Cabanes. — Recently the
Academy of Sciences at Paris was presented with a
new volume by Doctor Cabanes, entitled Chirurgiens
ct blesses a trovers I'histoire, des origines de la
Croix Rouge. The author devotes the first chapters
to the care of war wounded in the time of the
Pharaohs, in India, and the Greek and Roman
armies. He notes the progress made through the
reign of Louis XIII, Louis XIV, and Louis XV
during the revolutionarv wars, down to those of the
First and Second Empires, showing how much w^e
owe to the work of the philanthropist, Dunant. The
International Copyright laws will bring a copy to our
own medical library at Washington, D. C. if any
wish to see a volume whose author's name promises
good reading.
Med icine and Surgery in the Army and Navy
EXAMINATION OF RECRUITS FOR
TUBERCULOSIS.*
A Plan for the Special Examinations of Conscripts
at the Place of Mobilization mith Particular
Reference to Tuberculosis.
By Ralph C. Matson, M. D.,
Portland, Ore.,
Major, M. R. C, United States Army, Tuberculosis Specialist,
Ninety -first Division; President, Tuberculosis Examining
Board, Camp Lewis, American Lake, Washington.
{Concluded from page ^oj.)
At the end of each month an efficiency chart is pre-
pared of the board's work upon which are indicated
curves, representing the number of cases each ex-
aminer has examined, the percentages of histories
written, the percentage of correct diagnoses, the
number of cases of tuberculosis recognized, the
number of cases of tubercvilosis missed, and the
number of tuberculosis cases occurring in the camp
within three months after having been passed by the
examiner. The curve indicating the character of
the work done by each examiner is of a different
color, one for each examiner, and is known to him
only. The chart is posted in the room of the presi-
dent of the board. Each examiner can see at a
glance how his work compares with the others.
This stimulates better individual work, the most ef-
ficient being the curve indicating the largest num-
ber of examinations, largest number of cases diag-
nosed, the fewest missed, and the fewest breaking
down with tuberculosis after having been passed.
By special order of this camp, no officer or man
is discharged on account of tuberculosis without ex-
amination and report of the division tuberculosis
specialist. The president of the board is the divi-
sion tuberculosis specialist, and sees every case of
tuberculosis diagnosed in the camp. Thus by re-
ferring to the blank reference card he is able to
trace the case back to the examiner and determine
whether the man was accepted on recommendation
of the examiner, who found no evidence of tuber-
culosis, either from the family history, past history,
present history, or the result of physical examina-
tion, and thus assumes the responsibility, or whether
on account of the presence of some of the indica-
tions stated above the man was referred to the x ray
department, and thus brought to the attention of the
president of the board through his assistant^ who
then assumes the responsibility. The blank refer-
ence card enables the president of the board to secure
and give information requested by the Camp com-
mander, division surgeon or mustering officer, re-
garding the results of the special physical examina-
tion of any conscript and his disposition. This is
especially valuable, for the reason that countless
communications are received from anxious mothers
regarding the physical conditions of their sons.
The blank reference card shows the action of
all boards at once and whether the man was
historied by the tuberculosis examining board,
thus falling into groups i, 2, 3, 4, 5, 6 or 7,
and therefore x rayed. The form i gives the
* Published by permission of Board of Publication. Office of Sur-
geon General.
history, results of examination, physical and x
ray, the diagnosis of the examiner and the rontgen-
ologist, and the examiner's recommendation to the
president of the board, also the results of the re-
examination, and the final disposition by the presi-
dent of the tuberculosis examining board. All this
information is especially valuable in cases accepted
where tuberculosis was alleged, as means of escap-
ing military service. This scheme is the outcome of
the examination of over 40,000 first draft men and
has proved satisfactory in the examination of over
32,000 second draft men, as well as an additional
2,000 absentee first draft, all of which have been
carried out at Camp Lewis, American Lake, Wash-
ington. The scheme is efficient. Almost every case
is decided the same day. The percentage of rejects
has not been unusually high, and of the last 32,000
men, many of whom have been in camp three months
under intensive training, there have been only two
breakdowns, one a case accepted with what was
thought to be an insignificant healed lesion ; the other
a man of splendid physique, who gave a negative
history, and the examiner found his lungs negative,
so the man was accepted on the examiner's recom-
mendation. But three weeks later he was referred
back because of cough and expectoration, fatigue
and loss of weight. Reexaminations revealed a
chronic, active, fibrocaseous tuberculosis. The man,
through patriotic motives, had purposely misled the
examiner regarding his past history, which, if truth-
fully given, even with the examiner's negative find-
ings, would have brought the man under the x ray,
v/here tliis particular case would no doubt have been
recognized and brought to the attention of the pres-
ident of the board.
The scheme provides intensive training for medi-
cal officers in the diagnosis of tuberculosis. They
are taught the limitations of the x ray, as well as
the physical examination ; at the same time their
value and the importance of making a diagnosis
on the evidence gathered, not only from physical
examination and x ray, but evidence gathered from
a tactfully gotten history interpreted with judg-
ment. These officers, who return to their organiza-
tion, are certain to stimulate a sane interest in tu-
berculosis, to have a well balanced judgment re-
garding its diagnosis, and to exercise their knowl-
edge to the end that tuberculosis arising in their
organizations will be recognized and brought to the
attention of the division tuberculosis specialist or
consultant at the base hospital at a time when
something can be done for the unfortunate man.
The scheme calls for only minor alterations of
the barracks building, and provides a plan whereby
an enormous number of men can be ef?ectively han-
dled without confusion, even when dealing with a
cosmopolitan mass comprising many races and
tongues.
The neuropsychiatric board is composed of three
officers and two clerks. The board examines both
mentally and neurologically cases referred to it.
The sources of cases are :
I. Special tuberculosis examining board. All
cases whose conduct, actions, or conversation, in-
246
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
dicate any nervous disease, psychosis, or previous
psychosis, mental deficiency, or inebriety are re-
ferred by the individual member making the tuber-
culosis examination to this board.
2. Mustering office. All cases in whom no neuro-
psychiatric defect was observed by the tubercu-
losis examining board, but who later present such
'defects, while undergoing examination during mus-
ter, and have not been examined previously by the
neuropsychiatric board are referred.
3. Command. This board acts only in an ad-
visory capacity in these cases, recommending trans-
fer to the base hospital for observation or exam-
ination by the divisional psychiatrist.
4. Other special examining boards, as orthopedic
and cardiovascular. All cases of mental deficiency
are referred to the psychological board for a report
as to intellectual level and their recommendation is
made a part of the findings in the case.
The rules governing are those in general laid
down by the Manual of Instructions, for Medical
Advisory Boards and published by order of the
Secretary of War, February 14, 1918. All reports
of examinations are made on forms as prescribed
and cardiovascular, All cases of mental deficiency
blank card are stamped, indicating the board's rec-
ommendation to the mustering officer. These pa-
pers are returned to the man who passes on down-
stairs entering room 4. The cardiovascular board
is composed of four officers and four clerks. Only
referred cases are examined, these cases being re-
ferred immediately by the tuberculosis examining
board or by the mustering officer.
Type of cases referred :
I. By the tuberculosis examining board :
1. Registrants who claim heart disease, ne-
phritis, syphilis or rheumatism.
2. Registrants in whom the local or medical ad-
visory board detected cardiac disorders.
3. Registrants in whom the tuberculosis board
detected cardiac lesions not noted previously.
IL By the mustering board :
I. All cases not previously passed on by the
cardiovascular board, and who show evidence of
cardiac disease.
Methods of examination :
Instructions as per Manual of Instructions for
Medical Advisory Boards, part 12, February 14,
1918.
All men showing murmurs or enlargement are
placed under the fluoroscopic screen. A laboratory
is equipped for uranalysis in the case of hyperten-
.sion, suspected nephritis or diabetes.
Cases showing irregularities of the pulse have a
polygraphic tracing made when time permits.
In addition to the cardiovascular work, the board
has undertaken a study of endemic goitre. Each
registrant is carefully examined for the presence of
an enlarged thyroid and recorded accordingly on
the form attached. It has long been known that
endemic goitre existed in the Pacific Northwest, but
a comprehensive study of the distribution has not
been made. The survey undertaken includes regis-
trants from Washington, Oregon, Idaho, Montana,
Wyoming, Utah, Nevada, and California. Follow-
ing the preliminary study, further work is planned
to determine what type of cases are liable to break
down under the stress of military service.
Records of the examinations are recorded on
Cardiovascular Record Form B-i, Medical Depart-
ment, U. S. Army, and weekly reports on Forms
B-2 and B-3, Medical Department, U. S. Army.
Form 88 and blank are stamped indicating the
board's recommendation to the mustering officer.
These papers are handed to the man who passes
them on to the exit clerks.
Thanks are hereby acknowledged to Captain W.
J. Kerr, M. R. C, president of the cardiovascular
board ; Captain Arthur P. Calhoun, M. R. C, presi-
dent of the neuropsychiatric board ; Captain John
Carling, M . R. C, president of the orthopedic board,
for notes regarding the procedure of their respective
boards.
TUBERCULOSIS EXAMINING BOARD, CAMP LEWIS.
CIRCULAR A.
Suggestions regarding procedure of chest examina-
tions.— The examination is to include i, inspection, 2, pal-
pation, 3, auscultation, 4, percussion. Inspection and pal-
pation are usually combined.
As the soldier approaches you and takes his position in
front of you observe his general physical condition, mus-
cular development, habitus, and attitude. Three types of
habitus are recognized: i, asthenic; 2, normal, and 3, hy-
persthenic. I, The asthenic has a costal arch of less than
90° ; ribs pursue an oblique direction. The chest may be
pyriform ; shoulders may be broad ;^rms long and swing-
ing. The asthenic usually has more or less scoliosis. The
heart is pendulous and occupies a central position. There
is general ptosis of all organs. These individuals are fre-
quently the sufferers of a latent tuberculosis. 2, The nor-
mal habitus requires no description. 3, The hypersthenic
has a costal arch of more than 90°. The ribs pursue a
horizontal course. Frequently they are sufferers from
asthma and emphysema. The attitude is either active or
passive ; active when a soldierly appearance is presented ;
passive when the individual seeks every opportunity to
arrest or support himself. Instead of standing at attention
in front of you, he stands on one leg. If a table or chair
is handy, he will support himself. Muscles are generally
relapsed.
Having noted these conditions as the soldier approaches
you, now observe the facies, noting particularly the absence
of pallor and flush (general flush of face in acute respira-
tory affections associated with fever). The flush is local,
being confined to the cheeks in chronic tuberculosis, asso-
ciated with fever. Observe the nose for obstructed nasal
breathing, such as polypoid growths. Observe nares, the
direction of septum, etc. The mouth and throat can also
be quickly examined. Note condition of the skin, presence
of operative scars, those of tuberculous adenitis being
usually multiple and over the site of superficial glands.
Simple adenitis scars usually occupy the submaxillary re-
gions and are single. Look for scars of sinuses as a result
of broken down tuberculous glands. These scars usually
show evidence of a healed cutaneous scrofula. Small hard
nodules scattered throughout the neck occur in infections,
but the adenitis of lues is characteristic. General ade-
nopathy oftentimes accompanies vaccination. Observe the
condition of the skin and adipose tissues, not only of neck,
but chest and upper extremities. A rapid disappearance
of fat leaves a loose skin, the shoulders droop and appear
narrowed. Observe and palpate the apex beat. Note its
location and character, whether diffused or circumscribed,
heaving, etc. In drop heart the apex beat may be just
back of the costal margin, but a diffuse pulsation will be
seen just at the right of the costal margin. After having
inspected and palpated the front of the chest, direct the
conscript to turn about, then repeat the same procedure on
the back. Note the position of the trapezius muscle, whether
atrophied or in spasm. Note the position of the scapulae and
whether the angles project. Direct conscript to draw shoul-
der blades together. Observe direction of the line of folded
skin between the scapula; (valuable in detecting slight
August 10, 191?.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
247
degrees of scoliosis). Direct a deep breath. Note whether
apex rises or not. In an old chronic tuberculosis of the
apex or upper lobe, no excursion is noted on the affected
side. A narrow girdle on the opposite side may be due to
scoliosis or contracture of the upper quadrant of the chest
due to chronic tuberculosis. Observe the position of the
trachea, which may be retracted to the affected side in
tuberculosis. Observe the breathing, watching the costal
margins for retarded or restricted respiratory movements ;
at the same time place the fingers in the intercostal spaces.
Note the presence or absence of bulging, narrowing or
retraction. The ribs should separate freely during inspira-
tion, allowing the finger tips to pass between the ribs.
Observe the presence or absence of old emphysema scars.
Now percuss back of chest, determining first the mobility
of the lung border at the height of inspiration and end of
expiration. This is rather important to note. Next percuss
from base to apex, first on one side and then on the other ;
then alternate back and forth for comparison. Mark any
dull or impaired area. Percuss the isthmus of the shoulder
girdle. Now test out the vocal fremitus, preferably with
an Erlenmeyer flask 200 c. c. capacity, which is much more
sensitive than using the hand. It will be more convenient
to auscultate the back of the chest before percussing in
front. First direct conscript to breathe properly. If the
respiration is a little hurried, thirty per minute, it brings
air into the air cells better and saves time. The respiration
must be uniform and quiet. If there is any obstruction
to free nasal breathing, direct conscript to say "ha" and
hold the mouth in that position. The inspiration should
approximate thirty per minute, but you will have to illus-
trate this. Auscultate from base to apex, first on one side,
then on the other; then compare identical spots on both
sides. In going over the first time, note the type of breath-
ing. The purest vesicular is usually heard over base. Pure
bronchial breathing is heard normally on the back of the
neck, below the occiput, and in front over the trachea.
If any question arises regarding the tj'pe of breathing in
the suprascapular region, it is easy to compare with bron-
chial heard over the back of the neck or trachea and vesi-
cular heard over bases. After having determined the
type of breathing, both inspiration and expiration, test out
whispered resonance; direct conscript to take just suffi-
cient air to whisper one, two, three. This gives you a
short, sharp, quick inspiration, during which you will note
again its type and the presence or absence of rales. Dur-
ing the expiration you will note abnormal prolongation,
and the presence or absence of pectoriloquy or egophony
should be noted. At times rales are more distinctly heard
when the conscript forces all air out of the lungs, coughs
once, and breathes in at once (expiratory cough). Note the
type of rales if any are heard. If difficulty is encountered in
determining the type of breathing, it will be found valuable
to listen only to inspirations on first round, removing the
stethoscope at the end of expiration. On the second round,
listen only to the expiration, removing the stethoscope just
before inspiration. After having finished the back, direct
conscript to turn, percuss and auscultate the front of the
chest in the same manner as the back. Percuss lung excur-
sion on both sides in front. Observe the ribs for bulging
or flattening due to scoliosis. If the bulging is due to an
acute angulation, there will be a corresponding- flattening
on the opposite side with compensatory changes in front
of the chest, with checkerboard dullness. Now place the
palms of the hands on the sides over the lower lobes and
direct a deep breath to be taken. Note whether the expan-
sion is equal on each side. There may be a limitation of
motion or the excursion may be fairly good but retarded.
Now place one hand in front in the mammary region, the
palm of the other hand below the spine of the scapula.
Note whether expansion over the upper lobes is limited
or retarded, as from base to apex, first on one side, then
on the other ; compare alternately identical spots on both
sides. Auscultating in front it will be more convenient
to begin at the apices. Since you have already determined
the type of breathing normal for the individual, auscultate
down to the base, first on one side, then on the other, com-
paring identical spots. The procedure of auscultating in
front is exactly the same as that practised behind ; first
determining the type of breathing, presence or absence of
rales; and if present, the kind, whether occurring on in-
spiration, expiration, or both, or only after cough, or
cleared on coughing. Next auscultate the whispered voice.
Finally, determine the border of the heart and auscultate
all valves.
TUBERCULOSIS EXAMINING BOARD, CAMP LEWIS.
CIRCULAR B.
Information Concerning Methods of History Taking in
Examination of Conscripts for Tuberculosis. — These sug-
gestions are placed before you in order to assist you in
eliciting information which will be of value in esti-
mating the true worth of the person's statement regarding
his condition. It must be borne in mind that conscripts
who are trying to evade military service will lie, and those
anxious to serve will deny. It is important, therefore, that
the questions should be so put that the conscript will not
recognize the character or value of the information he im-
parts.
It is important to know whether the conscript has been
working steadily or not; and if not, if his inactivity
was due to ill health. Inquiry should be made into the
health of living members of his imnjediate family, and the
statement that the father, mother, or any other member
of the family has tuberculosis, pneumonia, chronic bron-
chitis, or is "run down," or is in any other condition of ill
health which might be attributable to tuberculosis, should
not be accepted without interrogation which will tend to
reveal the true nature of their illness. If any of the im-
mediate members of the family have tuberculosis, find out
how long they have had it and if the patient was exposed,
1. I'., lived in the same house. If any member of the family
died from tuberculosis, find out the date, length of illness,
and if the conscript lived in the same house. If the cause
of death is given as chronic bronchitis, typhoid fever,
asthma, or any condition which might be confounded with
tuberculosis, inquire carefully into the nature of this ill-
ness in order to satisfy yourself that the patient's statement
is correct. This information should be noted by the exam-
iner under remarks.
Do not accept the conscript's statement regarding the na-
ture of a severe illness without satisfying yourself regard-
ing its true nature. Inquire particularly into his previous
health, mode of onset (slow or sudden), duration, and
whether not complete recovery took place. This is im-
portant in trying to differentiate between typhoid fever and
tuberculosis.
In the so called typhotuberculosis of Landouzy, it may be
very difficult to decide. Many persons who have had really
a tuberculous infection claim that they have had a slow
fever or walking typhoid. The diagnosis in those cases is
usually based upon the fact that the man was run down
and had a low fever extending over a period of time. It is
important in determining the existence of a previous
typhoid infection to know whether there were other cases
in the family, and whether or not it was epidemic in the
community. The onset of typhoid is, of course much more
rapid than that of tuberculosis. When the patient states
that he has been ill, or not feeling well for a long time,
even from three months to a year Ijefore he was stricken,
and when few of the classical symptoms of typhoid fever
were present, one must always be suspicious. Determine
as nearly as possible the height of the fever, its duration,
whether or not he was delirious. The typhoid patient is
delirious if he runs a high fever for any length of time.
The tuberculosis patient is never delirious unless he has
meningeal involvement or is moribund, no matter how long
the fever lasts. In typhoid fever the convalescence is rapid,
oftentimes characterized by a ravenous appetite and rapid
gain in weight. In tuberculosis the convalescence is much
slower, and patient may state that he has never regained his
lost weight. After typhoid fever, the patient is liable to
lose his hair. This rarely occurs in tuberculosis. Nose
bleeds and headaches also are not common in tuberculosis.
In both diseases there is cough and expectoration.
Convince yourself that the pneumonia, so called, was
really pneumonia and not a bad cold or la grippe. Satisfy
yourself by careful interrogation as to whether or not the
so called pleurisy was really pleurisy. If a man has ever
had pleurisy he will not forget the stitch in the side and
the severe lancinating pain which follows coughing or deep
inspiration. This pain usually lasts a few days and sub-
sides as an exudate is formed, or if the case is one of dry
pleurisy, as adhesions are formed. Manv men think they
have had pleurisy when upon careful inquiry we learn that
what they thought was pleurisy was an indefinite pain in
the chest which lasted a few seconds and recurred at very
248
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
indefinite intervals of days or weeks. If you examine the
side you will also in many cases convince yourself as to
whether or not a pleurisy existed. If the case was a severe
one, tiie intercostal spaces will be narrowed ; there will be
a limitation of motion on the unaffected side, and the lung
borders will be fixed. When the statement of the patient
is confirmed by the examination in one particular, we then
can give more credence to his statements relating to other
conditions.
In pneumonia, be careful to inquire regarding bleeding.
In pneumonia the expectoration is tinged with blood, so-
called prune juice expectoration, during the stage of red
hepatization. In caseous pneumonia or the acute caseous
forms of tuberculosis, the onset may be very similar to
pneumonia, but the bleeding, if it occurs, comes with the
breaking down of the caseous area, which is, as a rule,
after the patient has been ill some weeks, and the bleeding
is bright red and frothy. The sputum may be only streaked,
or there may be a severe hemorrhage, during which time
he will expectorate anywhere from one half a cup to a pint
or two of blood. Hemorrhages are, as a rule, multiple and
continue over a period of days, after which time the sputum
remains colored ; first red, then dark brown, as the active
bleeding subsides and the clotted blood is expectorated.
Innuire into the termination of this socalled pneumonia.
If by crisis or lysis, the termination may be continued a
week or so, but in tuberculosis the condition remains un-
changed until the caseous areas break down. Then we note
a fall of fever and an increase of expectoration. As a re-
sult of the fall of fever the patient improves ; his appetite
returns, and he may gain in weight, but he continues to
cough and expectorate, run a low fever, and the conval-
lescence is protracted. In tuberculosis with a cavity of
any considerable size the patient usually sleeps on the af-
fected side, otherwise he coughs and spits all night. If
both sides are excavated, he sleeps on his back. In the
morning he cleans out his cavities by coughing and ex-
pectorating, after which he may not raise any more during
the entire day.
Do not accept the patient's statement that he takes cold
easily, or that colds last long, without assuring yourself
of the correctness of his statement. We consider that a
man takes cold easily if, upon the slightest provocation, he
contracts a cold. If he takes cold easily, he will therefore
have frequent colds. The question whether or not his cold
lasts long also varies considerably, depending upon the
conception as to what constitutes lasting long is to the dif-
ferent individuals. As a rule, we do not consider a cold
having lasted long unless it persists for more than a
month. The average case of bronchitis lasts for three or
four weeks, and anything therefore over a month can be
considered lasting long. The question whether or not
blood was ever coughed or spat up is important. You
should convince yourself that the blood was actually
coughed and spat from the lungs. Many persons spit
streaked sputum, but it oftentimes comes from the gums
or the nasopharyngeal region. The blood spitting of tuber-
culosis is either a distinct hemorrhage, usually preceded by
the expectoration of streaked sputum for two or three
days, or a hemorrhage never occurs, but the sputum will
be tinged with bright red blood for several days or a week,
and in some cases longer.
In acute bronchitis one often coughs and expectorates
streaked sputum. This is due to the rupture of small blood
vessels in an intensely congested mucous membrane. This
rupture is due to persistent coughing. You should, there-
fore, inquire carefully as to whether or not the coughing
preceding the bleeding was severe. This information is to
be noted under remarks. In recording in the present his-
tory the period of time during which he claims to have
coughed, such information should be recorded in weeks,
months, or years. The same refers to spitting. There are
times when it is even necessary to request the patient to
show you how he raises sputum, so you can observe
whether he raises it from his lungs, or if he hawks and
spits from the throat, or draws it back through the pos-
terior nares.
Loss of weight should be accounted for. Loss of weight
in tuberculosis is due to loss of appetite, but loss of weight
often occurs in normal healthy individuals, as a result of
a change of occupation, etc., and it is to he expected that
many conscripts will have lost enormously in weight as a
result of change of occupation from a sedentary to one
associated with the expenditure of much physical energy.
At some time prior to the time the man was conscripted
he may also have lost considerably in weight, but if he is
healthy, this is nearly always dependent upon a change of
occupation from one wherein little energy is expended to
one wherein the amount expended is great.
TUBERCULOSIS EXAMINING BOARD, CAMP LEWIS.
CIRCULAR "C."
Nomenclature for Recording Lung Findings to Be Used by the
Tuberculosis Examining Board.
I. Fremitus: Common Causes.
A. Normal— Over infiltrations and consolidations due to pneu-
monia, tuberculosis, etc.
B. Increased — Above fluid, due to compression of lung tissue
and over cavities virith thick wall.
C. Decreased— (a) Pleural cavity full of fluid or air. (b)
Thickened pleura.
D. Absent — Stenosis or obstruction of large bronchus through
tumor, etc.
II. Percussion:
A. Normal.
B. Impaired — Chest deformity, scoliosis, infiltrations as pneu-
monia, tuberculosis, atelectasis, lung abscess, hemorrhagic
infarct, gangrene, tumor, cyst, etc.
C. Dull — Consolidations due to above causes of greater extent.
D. Flat — Fluid at least 400 c. c. or thickened pleura.
E. Tyrnpanitic — Cavity, emphysema, above fluid (due to dimin-
ished lung tension) pneumothorax provided tension is
not too high. Sometimes when a whole lobe is consol-
idated due to pneumonia, or tuberculosis.
III. Auscultation, Breathing :
A. Vesicular — Normal.
B. Broncho-vesicular — Infiltrations (old tuberculous process,
if no rales probably healed).
C. Broiichial — Consolidations, cavities, deviated trachea, some-
times with effusions in pleural cavity.
D. Cavernous or amphoric — Large cavities.
The following terms are used to amplify the meaning of the
above types of breathing:
E. Undeterminable — See below.
F. Weak — Thickened pleura, early tuberculosis, atelectasis.
emphysema, shallow breathing, rigid thorax, calcification
costal cartilages, lung fibrosis, etc. In tuberculosis soft-
ening when bronchi are full of secretion.
G. Absent— Thickened pleura, fluid, obstruction of bronchus.
Massive old caseation with profuse secretion plugging
the bronchi.
H. Rough — See below.
I. Sharpened — Due to swelling of bronchial m. m., heard in
bronchitis. Occasionally acute tuberculosis. With short
inspiration — pleuritic adhesions.
J. Prolonged expiration — Bronchitis, asthma, over left apex in
tuberculosis, over right apex normally.
H, I, and J are used only to amplify the meaning of breathing
vesicular.
K. Rales, (a) — Crepitant; heard along normal lung borders
and sometimes over apex in shallow breathers on first
inspiration. Occur in alveoli on inspiration in atelectasis,
disappear on coughing. Essentially the rale of acute in-
flammatory processes. Also heard in caseous pneu-
monia, lobar pneumonia, bronchopneumonia, lung
edema, hemorrhagic infarct, persist in tuberculosis.
(b) Subcrepitant (larger and louder) — Occur in infundib-
ula, heard on inspiration and expiration same as pre-
ceding, also in adherent lung. Also the rale of acute
inflammation.
(c) Crackling (still larger and louder) — Occur in finest
bronchioles, sound like burning salt on stove, heard in
edema, congestion, bronchitis, and frequently in chronic
fibrocaseous tuberculosis.
(d) Sibilant (still louder high pitched — Bronchitis (charac-
teristic) emphysema, asthma, etc.
^ (e) Sonorous (loudest low pitched) — Same as preceding.
(f) Resonating (small, medium, large), typical indetermi-
nate rales of Bushnell. The rale of subacute, acute, and
chronic inflammatory processes — -Usually found asso-
ciated with bronchovesicular or bronchial breathing and
due to the same causes. If in smooth wall cavity, may
take on metallic resonating qualities.
(g) Nonresonating, bubbling (small, medium). Atypical in-
determinate rales of Bushnell — Acute, .subacute, and
chronic lung process without infiltration or consolidation.
(h) Friction rub — Pleural, pericardial.
IV. Vocal: Resonance:
(a) Normal — i. Bronchophony, infiltration.
(b) Increased — 2. Pectoriloquy, consolidation or cavity;
egophony, large cavity.
Note. — If dyspnea is noted, state whether inspiratory (cardiac)
or expiratory (asthma).
In case of abnormal findings record results obtained by I, II, III,
IV, indicating location (with relation of lobes of lung) and charac-
ter of lesion.
Write a diagnosis in case of abdominal physical findings and give
reason man is sent for x ray examination.
Fatigue of tuberculosis usually comes on in the after-
noon. The fatigue of tuberculosis must not be confused
with the fatigue of hard work. If the man complains of
Dry. . .-J
Moist.
August 10, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
249
fatigue, although the character of his work is not changed,
it is suspicious of tuberculosis. With the same amount of
work to do, the normal, healthy individual feels refreshed
after a few moments' rest, but with tuberculosis the fatigue
will be present the next day. It is to be expected that many
conscripts will complain of fatigue, which will be due to
their drilling, but if the conscript has tuberculosis, the fa-
tigue will persist in spite of his rest. The neurasthenic
usually has his fatigue in the morning and feels better after
he gets up and stirs around. The tuberculous patient feels
good in the morning if he has not been subjected to any
physical strain the preceding day, but he gets tired when
he sits around a bit.
In reference to sweating at night : In tuberculosis the
patient goes to bed and after falling asleep awakens, find-
ing himself wet with sweat, or his clothes may be damp.
Sweating occurs, especially on the inner surface of the legs
and on the chest. These are really sleeping sweats, as they
occur only with sleep. Many conscripts will undoubtedly
claim they have had night sweats, but on careful inquiry
you will find out that their sweating occurred as soon as
they went to bed, while they were still awake, or that they
awoke the next morning and found their sleeping gar-
ments damp with perspiration. Sweats of this character
frequently occur in a person who has been under physical
or mental strain, and it is impossible to say whether or
not he had a real night sweat, if he did not awaken.
Frequent or repeated attacks of cold are oftentimes due
to obstructed nasal breathing. You can easily satisfy your-
self regarding this cause. On the other hand, they may
have a tuberculosis base, in which case they represent one
of the modes of onset of tuberculosis. Inquiry regarding
the presence or absence of pain is of questionable value.
Pain is purely subjective phenomena, and what is intense
pain in one individual passes unnoticed in another. As a
rule, all pain in tuberculosis is due to pleurisy, as there
are no sensory nerves in the lungs. The pleura is very
sensitive, and pleurisy occurs principally in two forms.
Acute pleurisy is characterized by a severe lancinating pain
in the side, more especially along the costal arch, aggra-
vated by coughing and deep breathing. Examination of
the side reveals a spasm of the costal muscles, fixation, etc.
The chronic pleurisy pain is less aching in character and
usually occurs over the site of the infection, therefore, in
the breast under the shoulder blades, in the axillary re-
gion, and at times is even referred to the shoulder. These
pains may last a few days, a week or two, after which
they disappear. Pain in the vicinity of the sternum, where-
in the examination reveals tuberculosis of the hilus glands,
may produce reflex pains in the chest, but as a rule, the
examination of this class of cases will be negative. Pain,
of course, occurs in acute bronchitis due to coughing. Pain
in the region of the sternum is also seen in phthisiophobia.
These persons, as a rule, are fearful of tuberculosis. Their
exposure has been, or is, imaginary, and they present them-
selves complaining of pain, and the pain is usually in the
region of the sternum. The real consumptive seldom, if
ever, has pain in the region of the sternum. The pain of
aneurysm, tumors, or cardiac disease is, of course, recog-
nized and requires no discussion.
The man's statement regarding the presence or absence
of fever is of no value. The neurotic complains of fever
based principally upon the fact that he feels flushed in
the afternoon. This is also seen in the man who fears
tuberculosis. Many patients with advanced tuberculosis
or severe acute tuberculosis, deny absolutely the existence
of fever, and the thermometer may record 102° or higher.
Reward Well Earned. — No one would ever
dispute the claim of Dr. Cesar Samsoen, of Haze-
brouck, Belgium, to the coveted cross of the Legion
d'honneur. It was recorded in the official journals
that at the time of mobilization he was left alone to
serve some 12,000 people and that, day and night,
he toiled among them, and when the refugees came
established a free dispensary, an amateur hospital
for those wounded by bombs, besides acting as ob-
stetrician not only for his own district, but for the
canton of Armentieres and the Belgian towns,
Ypres and Poperinghe.
MEDICAL NEWS FROM WASHINGTON.
Special Medical Training in American Universities. — Ap-
pointment Urged of Brigadier General Ireland as Sur-
geon General.
Washington, D. C, August 5, 1918.
There is, perhaps, no more popular officer among
the medical personnel of the army tlian Brigadier
General Merritte W. Ireland, Medical Corps, Na-
tional Army (colonel, Medical Corps, regular
army), and the prospect of his being appointed
Surgeon General of the Army, to succeed Major
General William C. Gorgas in October is meeting
with the hearty approval of medical officers, both
regular and temporary, and particularly those that
have been serving under him in France.
General Ireland, as chief surgeon on the staff
of General Pershing, has succeeded in bringing the
medical service of the American forces in France
to a very high state of efficiency, as evidenced by
the official reports reaching the War Department
and the statements of medical officers recently re-
turned from France.
Appointment of General Ireland as Surgeon Gen-
eral would give the service the benefit of his knowl-
edge of conditions abroad, where he has been on
duty for a considerable period, and his experience
while on duty in the Office of the Surgeon General
several years ago also would be of value to him in
the exercise of the duties of Surgeon General.
General Pershing is enthusiastically supporting
General Ireland for the place, and it is understood
that officials of the American Red Cross also have
urged his appointment.
Although the matter has been discussed, it is not
believed that there is any chance of the President's
going outside of the Medical Corps of the regular
army in appointing a successor to General Gorgas.
For one thing, it would be in violation of the present
statutes, and, therefore, special legislation would
have to be enacted before an outsider could be ap-
pointed.
^ *(• 4" "(*
The Medical Department of the Army, through
the National Research Council, shortly will issue an
appeal to American colleges and universities urging
them to alter their curriculum so that third and
fourth year students may receive special training
that will enable them to qualify as officers and for
other work in the Medical Department. Dr. Richard
M. Pearce. of the National Research Council, and
the division of laboratories of the Office of the Sur-
geon General of the Army are cooperating in the
matter.
Students taking various scientific courses are
particularly desired. The course specified by the
Medical Department should appeal to men who are
specializing in biology, zoology, plant pathology, and
in industrial and agricultural bacteriology.
The plan already has been tested in two colleges
with success. From one such institution, every man
taking the modified course was admitted directly
into the army and went to one of the training
schools, where some of them later will qualify for
commissions in the Sanitary Corps. Others have
qualified for positions with field or mobile labora-
tory units and as assistants at base and evacuation
hospitals.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Ofiice at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, AUGUST 10, 1918
SOME EARLY PAGES IN TRAUMA AND
DISEASE.
Studies of the human body a few centuries ago
were groping, imperfect of results, scarcely gain-
ing a foothold of appreciation or interest, much
less of approval, in any but the narrowest circles.
It is a far cry from such stealthy investigation to
the boldness and candor of medical activity which
seeks to support its knowledge and practice from
all that can be known from human anatomy and
from the very depths which the earth itself may
have to reveal.
Paleontology has set men thinking and investi-
gating along several new lines, and medical
pathology is roused to its share of interest in
what paleontology may have to reveal. The
pathological anatomy of ancient man presents a
stimulating field for speculation supported by in-
vestigation. Still further back in those millions
of years with which paleontology is making us at
least slightly familiar, diseases and disease agents
were operative upon animal forms, which have
also become the objects of study. Roy L. Moo-
die [Pathologicnl Lesions among Extinct Animals:
A Study of the Evidences of Disease Millions of
Years Ago] gives a summary of such study.
There is knowledge, he tells us, of the existence
of diseases upon the earth for 25,000,000 years
anyway. The evidence of traumatism in such an
extremely remote age or even in periods only a
little more recent brings a new sense of the com-
mon struggle for existence and the obstacles in
its pathway, which have varied so little even up
to the present time.
A typical simple fracture healed with callus is that
of a primitive reptile from the Permian of Texas,
probably 20,000,000 years old. The callus con-
tains such familiar features as osteosclerosis and
osteohypertrophy. There are no necrotic sinuses,
which would suggest infection, in the wound.
Such a sinus, however, is found on the posterior
end of the right ilium of a dinosaur, whose skele-
ton may be seen in the United States National
Museum at Washington. Another dinosaur skel-
eton reveals an exostosis on the visceral surface
of the scapula, sufificient to have caused consid-
erable laceration of the pleura. The lesion may
have been caused by chronic irritation or pulmo-
nary infection and resembles lesions frequently
found in human bones.
Another necrotic sinus in a mosasaur suggests
an extensive suppurative process and leads the
writer to speak of the evidences of bacterial in-
fection scattered throughout paleopathological
remains. Knowledge of bacterial forms as dis-
ease producing agents does not occur until the
coal period, millions of years later than their
known occurrence as life forms. But in the later
period can be found traces of the pathological
efifect of the organisms. The partial invasion of
the canaliculi of bone, destruction of the lacunae,
and even the complete destruction of the bone are
found. Among the many arthritides found among
fossil remains are mentioned particularly a
hemangioma and an osteoma. In one case the
osteoma has grown out from a vertebra and then
overlapped the adjacent vertebra, forming a
weak ankylosis. In another the two vertebrae
are united into a solid, true ankylosis. Such
complete ankylosis is commonly found, as well as
fractures, caries, absorptive processes similar to
pyorrhoea alveolaris, necroses, osteoperiostitis,
and other diseased conditions. These occur
among mammal remains and human bones of the
early periods show the same result of traumatic
causes. There is no basis, so far at least, for ac-
cepting tuberculosis or syphilis among the causes
August 10, 1 918.]
EDITORIAL ARTICLES.
251
of these early bone lesions, though they have
sometimes been sugg-ested. There is no real evi-
dence of syphilis earlier than 500,000 years ago.
Probably some extinct disease has been the
source of many of the lesions.
This science of paleopathology may be expect-
ed to throw light upon the nature of disease, and
particularly perhaps upon parasitism as the cause
of disease. It serves also in striking manner to
establish the close and solid continuity in living
conditions and the adjustment of life to them
throughout the w^orld's history. This is of in-
creasing importance to thought, whether con-
cerned with life in its physical manifestations or
its psychical progress.
THE ROLE OF MILK PRODUCTS IN MILK
BORNE DISEASES.
Too little emphasis is still placed upon the fact
that the danger of the spread of disease by in-
fected milk includes the milk products, butter,
cream, cheese, ice cream, etc., as well as the milk
from which they are made. Probably the dan-
ger from the latter is even greater, because so
much more attention is paid to the milk than to
its products. Most milk legislation is, if any-
thing, rather vague when it concerns the milk
products.
When once milk is infected neither it nor its
products are affected by anything but pasteur-
ization or sterilization. Low temperature or even
freezing has little el¥ect upon the contained
pathogenic organisms. This is particularly true
of the typhoid and diphtheria bacilli, which are
the highest exponents of milk borne infection.
There can be no doubt that these organisms can
cause their respective diseases when present in
milk products unless properly treated. Only safe
milk, produced by whatever method, can make
safe milk products. The freezing process that is
part of the manufacture of ice cream does not
afifect the virulence of the typhoid or diphtheria
bacillus, particularly the latter.
The investigation by the Public Health Service
of an epidemic of diphtheria in Newport, R. I.
(Public Health Reports, Reprint No. 430) dem-
onstrated that the outbreak was probably caused
by infected ice cream. Milk borne epidemics are
usually characterized: i, by their explosive char-
acter (their sudden rise and rapid decline) ; 2, by
the fact that they can usually be traced to one or
more sources of milk supply, and, 3, by the fact
that mostly women and children are affected, be-
cause they are the largest consumers of milk.
But it is often very difficult to trace an epidemic
to its source, because among the poor no one
dealer is consistently patronized.
In this epidemic in Newport, traced to ice
cream, it was found that most of the cases were
in adults rather than in children, contrary to
what would be expected. This epidemic oc-
curred during the hottest part of the summer
w'hen the consumption of ice cream was at its
height, and it was found that only six per cent,
of the ice cream sold was to children under ten
years of age. This fact amply explained the ap-
parent peculiarity of a higher incidence of infec-
tion in adults. In the same city the epidemic
among the military forces was present, but to a
much smaller extent. The fact that the disci-
pline and leave regulations caused a compara-
tively slight contact with the civilian sources of
infection explains this condition. The few mili-
tary cases are thought to have been from the
same source as those of the civilians, but because
ice cream was served but once a week to the mili-
tary forces the chances of infection were lessened.
THE DIAGNOSIS OF ACUTE PULMO-
NARY EDEMA.
The diagnosis of acute pulmonary edema is of
utmost importance from the fact that the process
is particularly serious, but may be easily over-
come by free blood letting. This treatment, to
be of any use, must be resorted to at once, so that
an early diagnosis is essential.
The importance of an exact diagnosis is quite
as great for the future as for the present of the
patient. A subject who recovers from one at-
tack remains exposed to a recurrence, and, what
is of still more import, an acute pulmonary edema
is frequently the signal of an aortitis or a nephri-
tis, which has been overlooked until the develop-
ment of the pulmonary process.
For these reasons it is well to keep in mind the
syndromes of the pulmonary manifestation in
order that a differential diagnosis may be made.
In the type of acute pulmonary edema with a
bronchoplegic onset, the pale face may lead one
to suspect a syncope, but auscultation of the
heart shows that the organ is functionally active.
The process must not be mistaken for an asth-
matic paroxysm, an error which may well be
made when the medical man is called suddenly
in the night to the bedside of a patient seized with
an attack of suffocation. Acute pulmonary
edema has the uncomfortable habit of occurring
in the night.
A mistaken diagnosis is, however, easily avoid-
ed. If the case is one of acute pulmonary edema,
252
EDITORIAL ARTICLES.
[New York
Medical Journal.
the respiration will be extremely accelerated —
sixty to one hundred per minute. The stethoscope
detects fine scattered rales over the lung, while
the expectoration is frothy and albuminous from
the onset of the attack. Occasionally it is salmon
colored. Nothing like this occurs in asthma.
Rheumatism and typhoid fever may give rise
to acute pulmonary edema, but these pathologi-
cal processes may also, by the intermediary of a
phlebitis, give rise to an embolus, which, from its
sudden onset and violent dyspnea, may more
than likely give rise to a diagnostic error. But
in embolus there are no pulmonary rales, sonority
is normal and never exaggerated, and if, later,
traces of congestion and edema are detected, the
latter are localized to a circumscribed pulmonary
area in the neighborhood of the embolized artery.
The condition must also be diagnosed from
asystolia. When the venous pulmonary circu-
lation is slowed, as in advanced cardiac cases,
there is stasis in the pulmonary capillaries and
therefore hyperemia and serosanguineous exuda-
tion. But there will be edema of the lower limbs,
hepatic congestion, sometimes ascites or pleurisy.
In infrequent cases when the edema occurs alone,
when there is only pulmonary asystolia, the
edema will be found localized, especially at the
bases, and will require considerable time to in-
vade the pulmonary territory. There is no albu-
minous expectoration, the rales are more marked,
and percussion is normal because there is no
acute emphysema.
Very frequently acute pulmonary edema is a
symptomatic expression of Bright's disease and
the diversity of the types of respiratory uremia
are well known. Therefore, an essential factor
is to be able to differentiate acute pulmonary
edema from these accidents. If the case be one
of the purely dyspneic type a mistake should be
impossible ; stethoscopic signs are absent and the
process does not undergo the same acute evolu-
tion as in acute pulmonary edema. As to angina
pectoris, the thoracic resonance remains normal,
and when the subject regains his breath a vesicu-
lar murmur is heard over the entire pulmonary
area.
A serous inundation of the alveoli means or-
thopnea, and in some cases the differential diag-
nosis will be a delicate matter. A careful post-
mortem diagnosis of acute pulmonary edema
should always be carried out. A subject is seized
in the night with violent dyspnea. A physician is
called who gives a hypodermic of morphine. The
patient dies a few minutes later. The medical
man is accused of causing the patient's death. A
medicolegal affair ensues and it at once becomes
evident what responsibility is incurred by the
medical examiner if he does not attribute the
lesions found to their true cause.
IN THE FAMILY.
'"The skeleton in the cupboard" is having rather
a bad time, first because in these days of apart-
ments and flats no cupboards can be spared, sec-
ondly, families are now less afraid of him, and,
aided by health lecturers, psychologists, and "pop-
ular science," dispensed in mild doses in the Sun-
day papers, they rather enjoy dragging him out
and discussing that particular form of crime or
disease which led to a tombless life. They even
take melancholy pride in the number of mem-
bers of the family who have followed in his foot-
steps, these not being able to avoid it, because "it
is in the family," a sentiment w^hich recalls the
old game of "My Aunt Margaret is dead. What
did she die of? Shaking her head as I do." The
player would shake and continue shaking while
telling her neighbor, who would pass on question
and answer until all the party were shaking, the
announcement being repeated with variations as
to symptoms imtil all the children were in a
pseudochoreic condition.
These "imitation" games often appear as stern
reality when, as in the case of an epileptic being
in the family, the brothers and sisters approach-
ing to or at puberty will often develop an incli-
nation to pseudo attacks of faintness and fall to
the ground, or will unconsciously fix an imitation
into a habit when there is a case of marked chorea
among them.
But, notwithstanding all the calm alleviating
light which has been thrown on heredity, it is
still an obsession with many that they themselves
or some member of the family must be heritor of
the ancestral crime or disease, and this belief, re-
cited constantly when young or delicate people
are around, has accelerated the departure from
this world of many a nervous or frail person. No
use fighting: it is "in our family."
Their fears seem justified when the doctor con-
sulted makes a "case historj'" and asks if there are
any familial diseases, or of w^hat their near rela-
tions died. "Ah, he, too, thinks I have inherited
consumption" (insanity, gout, cancer, etc.), and
they forthwith resign themselves to semiinvalid-
ism and often selfishly lose any sort of reluctance
with regard to constantly draining the sympathy
and purse of the family. We recall an Irish
family who jokingly said but firmly believed
that "all our family go to the bad (phys-
ically or morally) when they are forty," and
if, toward this age, adverse fortune or ill
August 10, 1918.]
NEWS ITEMS.
253
health came, they simply made no effort to
fight but resigned themselves to the seemingly
unavoidable, with the natural consequence that
through dissipation and recklessness, some did
surely die, and the relations were melancholy but
triumphant. This species of mind argues from
minorities, and it is, happily, forced to take some
comfort from the knowledge that thousands of
boys, coddled and screened because they were
delicate, even their doctor advising against
anything strenuous, have become fine muscular
young giants during the hardships of war. At
any rate, more wholesome views are taken today
of familial disease and frailty. To have a relation
"put away" or one operated on for cancer is no
longer spoken of in awed whispers as something
disgraceful, but as a disease to be fought against,
so it is to be hoped that in time the grisly hand
of Death will be loosened from the robe of the liv-
ing and a determined, rational, cheerful fight be
kept up against the skeleton in the cupboard.
HALF MENDED MEN.
Before convalescent homes were so common, Sir
Frederick Treves, pleading for more of them, said
that to return a weak man to his home where the
whole surgical equipment consisted of the family
sponge, a hairpin, a popular ointment and some
septic rags, was simply to undo the good gained in
the hospital. He would carry the sick even one
stage further than that attained in the usual con-
valescent home. This might be called the Bettering
House, though Benjamin Rush had used that as the
best name for hospitals. So many soldiers, owing
to lack of accommodation, have been sent home
practically well from the lay point of view, but still
needing careful supervision, and, owing to the local
hospitals with their out patient department being
also full of the wounded, do not get the aftercare
they need. The War Office, seeing the reasonable-
ness of such a presentation, has agreed tO' keep the
men longer in hospital or convalescent home so that
they may be really fit to face the scantiness of home
resources, and arrangement has been made for the
admission (if necessary) of the discharged hospital
patient into some 333 hospitals throughout the
kingdom, government bearing the expense. It
might be added, as a gentle hint to the rich in
America, that hundreds of the wealthier class in
Britain have received convalescents as guests, giv-
ing them good food, drives, quiet, and returning
them much faster to their regiments than if they
had remained in a hospital. The gratitude of the
men is enormous. One young shrapnelled officer
said to us, "Fancy the joy of stopping in bed to
breakfast and having a hot bath every day after
two years in those filthy trenches." Twice wounded,
he has gone back to France. There will be thou-
sands in America needing the aftercare so courte-
ously and rightly given to their English brothers in
arms.
THE SURGEON AS A SCULPTOR.
In view of the large proportion of wounds re-
ceived in the head, it is not surprising to learn that
many cases of facial mutilation result. The result
of such wounds is most depressing and some are
said to have committed suicide rather than live with
a face disfigured by wounds. During his recent
visit to the United States Sir Arbuthnot Lane, the
distinguished English surgeon, told of the remark-
able results which have been achieved in the restora-
tion of the contour of disfigured faces. A noted
French sculptor studies photographs of the face of a
patient as it appeared before the wound was received,
and constructs a model in plaster as near like the
original as possible. With this model before him, he
builds up the injured face transplanting bits of
cartilage and bone from the patient's ribs or legs,
holds them in place with paraffin or some plastic ma-
terial and brings over the wounded area a flap of
skin lifted from the forehead, cheek or neck and by
this means builds up a new face, not only agreeable
to look at. but with a resemblance to former appear-
ance. One hospital in London has been devoted to
these operations, and the results of the skill gained
by the dozen English surgeons employed there has
been freely offered to all American soldiers who
may stand in need of such aid, the only expense en-
tailed being the maintenance of the patient during
the rather protracted process. To this end, the
American authorities have been invited to provide
barracks near the London hospital in question, an
invitation which will, no doubt, be gratefully ac-
cepted.
NOTIFICATION OF COMMUNICABLE
DISEASES IMPORTANT.
In view of the danger of the transmission of
communicable diseases through recruits joining the
forces, it is particularly important that all physicians
and boards of health should promptly report all
cases of communicable diseases which come under
their notice. Where the patient is himself a drafted
man, the physician should make immediate report
to the local health authorities, who should in turn
notify the senior medical officer of the camp which
the selected man is about to join, by telephone or
telegraph if necessary, and a duplicate notification
should be sent to the State health authorities. In
the absence of a local board the physicians should
communicate with the State Board of Health, whose
duty it then becomes to notify the military authori-
ties. The proper observance of this precaution will
do much toward reducing the incidence of com-
municable diseases in the National Camps.
^
News Items.
Surgeon General Gorgas Praises Army Dentists.— -At
the annual meeting: of the National Dental Association,
held ir. Chicago on Tuesday, August 6th, Surgeon General
William C. Gorgas, U. S. Armv, said that the work of the
army dentists was of double value. They had helped to
keep the general health of the army up to a high standard,
as bad teeth were a prolific cause of disease, and were also
doing a wonderful work in reconstructing the faces of
soldiers who haye received shrapnel wounds.
254
NEWS ITEMS.
[New York
Medical Journal.
Cholera in Petrograd. — According to cable despatches
from Anihtcrdain, lliere are more than 20,000 cases 01
cholera in Petrograd. and uo to Saturday, August 3, 1,100
deaths had occurred. It is said tiiat the authorities are
unable to handle the situation and the disease is spreading
rapidly.
Certificates in First Aid Nursing Awarded. — The
I'olice Department has awarded certificates of graduation
in first aid nursing to thirty women and to eight members
of the police reserves who enlisted as members of the
emergency unit. Dr. Daniel Donovan, acting chief police
surgeoii, presided at the meeting.
Six New Hospitals at Vancouver Barracks. — An-
nouncement is made that six additional hospital buildings
will he erected at Vancouver Barracks, Oregon, at an es-
timated cost of $74,000. Three of these will be for con-
tagious diseases. The work of construction will be started
at once and will be carried on under the supervision of
the Construction Division of the Army.
The Health of the Navy. — Latest reports show a
death rate in the navy and marine corps from sickness of
2.4 per thousand per annum, which is less than that of
peace time. Deaths from all causes reached the rate of 3.7
per thousand per annum. Admissions to the sick list were
46.2 per thousand per annum for all causes — sickness and
injuries. There were four cases of cerebrospinal fever re-
ported, widely scattered, no two being at any one station,
three cases of scarlet fever, three of diphtheria, and seven-
teen of pneumonia. Despite the prevalence of diphtheria
in many of the Eastern cities, it has gained no foothold at
any naval training camp.
Another Hospital Ship Torpedoed. — The British am-
bulance transport Warlida was torpedoed in the English
Channel, early Saturday morning, August .3d, and 123 per-
sons are missing from the 800 who were on board. The
hospital ship was on her way to a British port bringing
nearly 600 sick and wounded soldiers from France. There
were eighty-nine women nurses on board, many of whom
were drowned. The explosion wrecked a ward room in
which were scores of wounded men, killing many. There
were seven Americans on board, one of whom is missing.
The other six are being cared for in an English hospital.
The majority of those accounted missing were killed by
the first explosion. It is said that this was the first trip
the Warlida had made without wounded German soldiers
on board.
Lectures on First Aid. — The Municipal Civil Service
Conunission has arranged a course of ten lectures on first
aid, for municipal employees and the general public. These
lectures will be given on Wednesdays at 12 :30 p. m., in the
Municipal Building, and repeated on the Fridays following
at the headquarters of the Health Department. The first
lecture in the course was given on August 7th and Qth, by
Dr. E'aniel J. Donovan, police surgeon, on First Aid From
the Police Standpoint. Other lectures in the course are :
August 14th and i6th, First Aid From the Bellevue
Standpoint, by Dr. John W. Brannan, president of Bellevue
and Allied Hospitals.
August 2ist and 23d, First Aid From the Fire Depart-
ment Standpoint, by Dr. Francis M. Banta, medical officer,
Fire Department.
August 28th and 30th, First Aid in the Home, by Dr.
Harriet W. Hale.
September 4th and 6th, First Aid in Nursing, by Miss
Elizabeth Gregg, superintendent of nurses. Department of
Health.
September iith and 13th, First Aid From the Fire Pre-
vention Engineer's Standpoint, by James O'Connell. inspec-
tor, Bureau of Fire Prevention.
September i8th and 20th, First Aid in Resuscitation, by
Charles E. Raynor, commodore, U. S. Volunteer Life Sav-
ing Service.
September 25th and 27th, First Aid for the Infant, by
Dr. Jacob Sobel, chief, Division of Baby Welfare, Depart-
ment of Health.
October 2d and 4th, First Aid for the Child, by Dr. C.
Ward Crampton, director of physical training. Department
of Education.
October Qth and nth, First Aid in Industrial Hygiene,
by Chester C. Rausch, assistant director, American Mu-
seum of Safety.
Mr. Leoiihard Felix Fuld. assistant chief examiner, will
be glad to give further information regarding these lec-
tures.
An American Navy Base Hospital Abroad. — A navy
base hospital unit, organized by Dr. Ray Smith, of Los An-
geles, and recruited principally from that city, has reached
England ready for action with the American naval forces
now operating in European waters. The unit has a personnel
and equipment for a total capacity of five hundred beds,
and is under command of Medical Director Charles M.
de Valin, United States Navy.
Revision of Dental Supply Tables. — The War De-
partment has appointed a board consisting of Colonel Ed-
win P. Wolfe, Medical Corps; Lieutenant Colonel John R.
Ames, Dental Corps ; Lieutenant Colonel John H. Schapp,
Dental Corps; Major James P. Harper, Dental Reserve
Corps, and First Lieutenant Peter C. Krupp, Dental Re-
serve Corps, to make a study of thq dental supply tables,
and submit such recommendations for their revision as may
seem necessary.
The Yale Laboratory School. — Lieutenant Colonel
Charles F. Craig, Medical Corps, U. S. Army, has been
placed in charge of the school for bacteriologists and
chemists to be conducted at Yale University for the dura-
tion of the war. About one hundred officers and two hun-
dred enlisted men are to be trained in this school to supply
the mobile laboratory in the field in France, as well as
stationary laboratories, and technicians for base hospitals
both at home and abroad. Yale has given the use of its
buildings for the work.
Disease Casualties Among American Troops. — The
Surgeon General of the Army, under date of July 19, 1918,
has issued a statement showing the disease conditions
among troops in the United States for the six months'
period ending June 28, 1918. The annual admission rate
per 1,000 (disease only) is shown to be: All troops, 1,380.3;
divisional camps, 1,261.1; cantonments, i,55;8.6; depart-
mental and other troops, 1,248.0. Average noneffective
rate per 1,000 on days of reports: All troops, 44.83; di-
visional camps, 41.62; cantonments, 53.91; departmental
and other troops, 39.37. Annual death rate per 1,000 (dis-
ease only) : All troops, 8.03 ; divisional camps, 6.27 ; can-
tonments, 9.94 ; departmental and other troops, 7.36.
Personal. — ^Colonel Henry Page, Medical Corps, U. S.
Army, has been assigned to command Base Hospital No.
.^41, at Charlotte, N. C., and Major Edward A. Coates, Jr.,
Medical Corps, U. S. Army, has been assigned to com-
mand the base hospital at Camp Wadsworth, Spartanburg,
S. C.
Dr. Timothy D. Lehane, for fifteen years a coroner's
physician, has been appointed by Police Commissioner
Enright police surgeon for the Thirteenth and Fourteenth
Districts of the Police Department.
Major Edward Wallace Lee, of New York. Medical Re-
serve Corps, U. S. Army, who is on active duty in Porto
Rico, is reported to be ill with tvpb^id fever.
Rehabilitation Hospitals Abroad for Disabled Amer-
ican Soldiers. — The American authorities have decided
to provide hospital care and treatment and training in Eng-
land. France, or Italy for every wounded American soldier
whose disabilities are of such a character that there is even
a remote likelihood of his being in reasonable time re-
stored to active service on the firing line or retrained so that
he mav take one of the innumerable positions behind the
lines, v/here many disabled men could be employed, thereby
releasing for the front line many physically fit men who are
now occupying these clerical or other positions. Only the
man who probably can give no further military service or
for whom a long course of treatment is in store will be
sent to America.
The American Board for Ophthalmic Examinations.
— At a recent meeting of this hoard, held in New London,
Conn,, it was decided that the next examinations will be
held at the New York Eye and Ear Infirmary, New York,
Friday , October 2,^th. Dr. William H. Wilder, Chicago, was
elected pecretarv of the board, which is composed of rep-
resentatives of the American Ophthalmological Society, the
Section in Ophthalmology of the American Medical As-
sociation, and the Academy of Ophthalmology and Oto-
laryn.gology. By arrangement with the American College
of Surgeons the board has become the ophthalmic creden-
lials committee of the college, and conducts the examina-
tions of the ophthalmic candidates for fellowship in the
college.
Further information mav be had upon request from
the American College of Surgeons, 2^ East Washington
Street, Chicago.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
SOME NOTES ON DRUGS AND
TREATMENT.
A Review of Recent Progress in Therapeutics.
By Mark Sadler, M. D.,
Montreux, Switzerland.
III.
THE TREATMENT OF HEMOPHILIA.
Before sera came into use many treatments were
employed to combat hemophilia, and not one hemo-
static ever gave the slightest result. Let me briefly
review those methods which have been to some ex-
tent successful before considering serotherapy,
which at present is the foundation of all treatment,
and, first, a few words on the prophylactic treat-
ment of the diathesis. In the first place, when the
physician has been forewarned of the condition, a
thing which does not usually happen, it is generally
admitted that the disease in question constitutes by
its presence a contraindication to all surgical opera-
tive work unless it be one of emergency. But the
amount and gravity of the hemorrhage in hemophilia
is in no relation to the importance of the operation,
and the most serious hemophilic accidents have
usually occurred upon the occasion of some slight
and insignificant trauma. The removal of a tooth,
the incision of an abscess, or the operation for peri-
onychia, have been the source of more severe hem-
orrhage than that resulting from a laparotomy. For
this reason de Bovis, in speaking of severe hemo-
philic metrorrhagia which resisted all treatment,
advised hysterectomy, while Fordyce, one of the first
writers on the subject, pointed out that these sub-
jects are in less danger from section of a large blood
vessel than from a superficial wound. An interest-
ing problem of prophylaxis has been raised by de
Bovis, in hemophilia in women. He believes that
in authentic cases of hemophilic families, marriage
is to be discouraged, and this in both sexes. It is
a question whether one can prevent the transmission
of the diathesis to the descendants if the mother
be treated during her pregnancy, and an essay has
been made in this direction by Mende in a woman
who had lost four babies from multiple hemor-
rhages. She was delivered at term of her fifth
child, who was healthy and was vaccinated, but died
ten weeks later. A case recorded by Brook was
more fortunate. A woman had lost two children
and was treated during the third pregnancy ; she
was delivered at term of a healthy child who sur-
vived. Kehrer advises induced abortion in all
hemophilic women, but de Bovis considers that
when this is done the uterus bleeds more and longer
than after a normal labor at term.
As to the treatments, they can be conveniently
divided under three headings. Physical means:
heat ; compression ; elevation of the limb ; gauze
packing. Means which act on the vessel walls
(vasoconstrictors) : adrenalin ; antipyrin ; ergotin ;
the acids. Substances modifying the coagulabUity
of the blood: perchloride of iron ; peroxid of hydro-
gen ; gelatin; salts of lime; extracts of organs and
tissues; artificial sera (salts and minerals) ; animal
sera.
The action of physical agents is always local.
Heat has been used by Hayem, because towards 55°
C. coagulation takes place more rapidly. It is in-
dicated, and may give a relative result in cases of
severe metrorrhagia, in the form of very hot injec-
tions. One may also obtain a partial success by
cauterization of the uterine cavity with superheated
steam, as was applied in one case by Pineus and
Stokel.
Mediate, or direct measure, is not very efficacious.
However, it has given one well known success to
Goubeyran. It must be energetic in order to be
effective, but its action ceases almost always as it
is removed. The application of circular compres-
sive bands placed at the root of a limb is of
little use.
Gauze packing of the nasal fossae has often been
useful in rebellious epistaxis of hemophilia. Dry
gauze may be used or soaked in some coagulating
solution (antipyrin, gelatin, etc.). It should be
removed not later than the second day in order to
avoid infection. When removed the bleeding will,
in all probability, recur.
Drugs acting on the vascular zvalls. — All these
have been essayed and their action is very unreli-
able. Acid solutions were in great estimation
years ago, but their efficacy is doubtful and they
have been generally given up.
Ergotine has a much more manifest constrictive
action and is unquestioned. Its effects, in this re-
spect, on the muscular fibres of the walls of the ar-
teries are well known. Whether given by mouth
or hypodermically, in hemophilia, it oflfers the great
objection that it does not influence the blood itself,
this being the pathological element, so that its use
has become very restricted.
-Antipyrin is also a good hemostatic, but it has the
same therapeutic defects in hemophilia as ergotine.
It can be used as an adjuvant in gauze packing in
the form of a five per cent, solution. Given by
mouth it is useless.
Stypticin, locally or internally, is uncertain in its
efifects.
Adrenalin possesses a very intense vasoconstric-
tive action, whether applied locally or given hypo-
dermically. This efifect is accompanied by very
marked anemia resulting from the hypertension
produced. The drug has been often used in local
applications with some success, but Sahli, of Berne,
frankly condemns it, because he is fearful that sec-
ondary hemorrhage may occur after its action
ceases. Sahli's fears are, perhaps, exaggerated, and
it must be admitted that it is a precious medicament
in local hemophilic hemorrhages of the gums, nasal
fossa;, superficial wounds, etc.
Substances acting on the coagulability of the blood.
— Their employment is more logical in hemophilia be-
2";6 MODER.W TREATMENT AND PREVENTIVE MEDICINE. [New York
Medical Journal.
cause these drugs apply better to the pathogenic
factor.
Peroxide of iron, used locally for years, has lost
much of its favor. By contact with the blood it
coagulates the albumin following a complex chem-
ical combination. It produces a rather hard, dark
crust at the point of hemorrhage, which acts Hke
a tampon. Unfortunately, its action in hemophilia
is most uncertain, and the same applies to peroxide
of hydrogen, its action being also purely local. It
can be tried in hemophilic capillary hemorrhage,
but if not successful time should not be lost in re-
sorting to some other means.
Gelatin possesses a very sure hemostatic action,
and although this has been denied by some writers,
it is a fact that, when injected intravenously, it
hastens the coagulability of the blood. It therefore
has its utility, and a certain number of successful
results have been recorded from its use.
In local applications it is used in the form of
gauze soaked in a one per cent, to two per cent, solu-
tion and applied with slight pressure over the area
of bleeding. Sahli advocates this method, and finds
that the loss of blood is often permanently stopped.
Given by mouth or rectum preferably, it has been
successful in a case of hemophilic hemorrhage of
the intestine, nose, and mouth. Per rectum, its ab-
sorption is a complex process, as it is certainly trans-
formed into a series of albuminoid compounds
whose hemostatic power is not well understood.
Subcutaneously, in the form of a one per cent, to
five per cent, gelatin serum given in doses of
from twenty to 250 c. c, its action has been much
discussed. The fear of tetanic inoculation is
groundless if care be taken to sterilize the serum
for a sufficient length of time. However, in hemo-
philia, large hypodermic injections are to be avoided,
as they might be the starting point of other hemor-
rhages.
The influences of the salts of lime, particularly
calcium chloride, is made evident from the fact
that it accelerates coagulation in vitro. The appli-
cation of this salt in a one per cent, solution on a
bleeding point controls the loss of blood, and Wright
has shown that this happy influence is likewise man-
ifest when calcium chloride is taken internally at
the dose of from four to six grams daily, and in
hemophilic hemorrhage the loss of blood has been
controlled by this drug when other means have ut-
terly failed. Many surgeons advise its use as a
prophylactic, but the results obtained have not been
at all constant.
Calcium chloride may also present an inverse
action. If its exhibition be prolonged, the coagula-
bility, in the first place increased, rapidly dimin-
ishes. More recently, Boggs, Wright, and Pararuore
have been led to conclude that calcium lactate pos-
sesses the same properties as the chloride, and that
it is better tolerated. All the statements of Wright
have been confirmed by Chantmesse, Wolfgang and
Hallemain, but recently Addis, repeating the ex-
periments of Wright, came to entirely different re-
sults. Saissi repeated the same experiments, and
his conclusions are that, while admitting the un-
questionable action of the salts of lime on coagula-
tion in vilro, it would seem premature to say that
the various salts of calcium have a sure coagulative
action when exhibited therapeutically. It is inter-
esting to place this opinion beside that of Weil,
who has found that in true hemophilia, hereditary
or familial, calcium chloride has little action.
(To be continued.)
Treatment of Recent Gunshot Wounds by
Brilliant Green. — R. Massie (Lancet, May 4,
1918) employed 1-1,000 brilliant green in normal
saline solution, 1-500 in normal saline, or 1-500 in
half per cent, chloretone, preference being given
to the latter on account of its analgetic effect. All
of the wounds were severe with extensive damage
to the tissues, but all were received for treatment
in periods of two to eight hours after their infliction.
The application of the stronger solutions cleaned up
the wounds more rapidly than that of the weaker
and there were no toxic effects observed. The ap-
plication of the brilliant green was followed by
staining of all damaged tissues to a much greater
extent than of the healthy ones and thus aided ma-
terially in determining just how much tissue should
be excised. All tissue which held the dye after the
application of the 1-500 solution was cut away, with
the exception of the skin, which was more readily
stained. The application of the drug produced ex-
uberant and very vascular granulations ; it was pain-
less ; it did not interfere with the growth of epi-
thelium ; rapidly removed edema and inflammation ;
and exerted a favorable antiseptic action. The
drug did not atone for the incomplete or faulty pri-
mary excision of damaged tissue, but its use aided
in the secondary removal of such tissue by surgical
methods.
Technic of Infected Wound Closure. — Fraser
B. Gurd (Lancet, May 25, 1918) has perfected a
technic for the treatment and closure of infected
wounds as exemplified by compound gunshot frac-
tures in home hospitals. In cases with acute supn
purative cellulitis with sloughing, the wound is ex-
cised and cleansed, the inflamed area is incised and
the Carrel-Dakin treatment instituted. The dress-
ings are changed daily, or less often as the need
indicates, and the early changes are best done under
an anesthetic to permit of incision of pockets and
removal of dead tissue. When the necrotic tissues
have separated or been removed and suppuration
has been reduced, the treatment is changed. Then
the surface of the wound and surrounding skin are
cleaned with soap and water, bathed with alcohol,
dried, and an excess of Morison's Bipp is applied
to the whole wound surface and worked into all
pockets. Gauze, wrung out of liquid petrolatum
and containing in its centre some Bipp, is placed
in contact with the tissues everywhere. This dress-
ing is changed from once in five to once in fifteen
days. When the wound is granulating well and
discharging little, and the surrounding zone of
edema and hyperemia has disappeared, approxima-
tion of the skin edges is begun. Deep mattress
sutures of heavy silk, smeared with Bipp are in-
serted and tied over rubber tubing or buttons to pro-
tect the skin. These are placed from two to four
centimetres from the edge of the wound and drawm
tightly enough to make continuous traction on the
tissues. They cross the wound over a paraffined
August 10, 191S.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
257
gauze pack, and the wound is dressed with alcohol
or Dakin's solution. This dressing is changed at
six to twelve day intervals, and each time new su-
tures are inserted to further close the wound. The
skin edges are undercut as they approach one an-
other to prevent invagination of the scar. At each
dressing also the bone ends are carefully examined
and the P3ipp pack brought into close contact with
them. Loose or white parts of the bone are re-
moved and after six weeks all ends not covered with
healthy granulations are taken away. The open-
ing in the soft parts should be kept larger than the
affected bone area until this stage is reached. When
the bone is covered with healthy, velvety granula-
tions, the scar tissue in the soft parts is cut away
and the wound is closed tightly with silk mattress
sutures after thorough application of Hipp to its
whole surface. Where sinuses alone remain after
compound fractures, these should be treated by pas-
sive hyperemia, beginning with periods of five min-
utes of gentle pressure, and increasing until two
half hour periods in one day are not followed by
fever above 99.4° F. Then, if the sinus does not
close, it should be excised en masse, including as
much of the scar tissue as possible, while still per-
mitting closure of the wound edges. The result-
ing wound is treated by Morison's technic and
closed, using mattress sutures in layers. The ap-
plication of these methods has shortened the dura-
tion of treatment in cases of this type, is economical
of dressings and the surgeons' and nurses' time,
spares the patient much pain, permits continued im-
mobilization, and gives excellent functional results.
Acriflavine and Proflavine. — Robert B. Cars-
law and William Templeton {Lancet, May 4, 1918)
draw their conclusions, with reference to the ac-
tions of both of these agents upon badly infected
wounds, from their own extensive experience at
the front. The drugs are not disinfectant and do
not render infected wounds bacteriologically sterile,
but they are antiseptic in action. Bacteriological
studies of the wounds are of little aid in judging
their progress. It is suggested that the rapid disap-
pearance of inflammation and suppuration, and their
absence from wounds properly cleansed surgically,
are due to neutralization of the toxins by the drugs.
When either of these agents is used in solutions
no stronger than 1-1,000 there is no evidence what-
ever of damage to the tissues and there is no necro-
sis of the exposed tissues. Neither of the drugs
impairs the activity of the leucocytes in the wounds.
Reparative changes are somewhat delayed by the
application of the drugs, but in the early stages
there is no reduction in epithelial proliferation and
healthy granulations are produced beneath the mem-
brane which forms. The essentials for their use
are : adequate preliminary surgical treatment ; the
continuous supply of the antiseptic to all parts of
the wound ; and the use of dilute solutions. The
dressings are usually best applied in the form of
gauze, packed into every crevice of the wound and
frequently wet with the solution. The dressings
do not have to be changed often and usually come
away easily. There is very httle sloughing and very
slight tendency to secondary hemorrhage, and dry
gauze wrung out of 1-2,000 acriflavine solution is a
good hemostatic.
Abortive Treatment of Furunculosis. — R. Bur-
uier {Pressc mcdicalc, May 2, 1918) recommends
the root of the burdock, Arctium lappa, for this
purpose. It must be collected in the spring, while
the leaves of the plant are growing; otherwise, it is
not therapeutically active. Its properties can be
preserved by subjecting it to "stabilization" by the
procedure of Perrot-Goris, which destroys the oxi-
dases and thus prevents deterioration of the dried
root. While empirical, the therapeutic action is
very evident in furunculosis, no matter how long the
condition has been present. Generally, within
twenty-four to forty-eight hours after ingestion of
the drug the pain passes off and the inflammation
is allayed, and on the third or fourth day the core
and pus surrounding it are spontaneously evacuated.
Where there are several furuncles, those farthest
advanced show this transformation ; the more recent
ones shrivel and have usually disappeared by the
time the others open. The treatment was em-
ployed with success in several cases. A typical
case was that of a man of twenty-eight years who
had beelT having for three weeks a series of furun-
cles on the neck, cheeks, and eyelids — the latter with
marked edema. After ingestion of nine pills of the
drug each day for three days, the furuncles opened
and dried up, and no more appeared. The local
treatment consists merely of applying dry gauze to
prevent friction by the clothing. The amount of the
drug administered three times each day in pills
made from a soft extract is 0.6 gram. The treat-
ment is continued until the lesions have completely
healed, i. e., for about five or six days. The author
adds that the drug is devoid of effect in folliculitis
or other superficial staphylococcic affections of the
skin ; in such cases, tin and tin salts, as recently rec-
ommended by Frouin and Gregiore, should consti-
tute the internal treatment.
Prophylactic Use of Quinine. — C. H. Tread-
gold {British Medical Journal, May 11, 1918) ex-
amined the blood of 540 men from units stationed
in Macedonia and found malarial plasmodia in over
thirty per cent., and altered leucocyte pictures sug-
gestive of malaria in over sixty per cent. Parasites
were found in the smears from over eight per cent,
of men who gave no history of fever and the sug-
gestive blood picture was present in more than
thirty per cent, of this group. Most of the men
examined had been taking quinine regularly, some
even having been taking it at the time of the exam-
ination. The question arose as to what protection
the prophylactic use of quinine really provided, and
Treadgold sought to answer it by reference to the
literature and by his own observations. He points
out that the conditions upon which the usefulness
of quinine, both as a prophylactic and a curative
agent, depends have never been thoroughly investi-
gated along scientific lines. Very little of the avail-
able literature is of any real value because it does
not represent work carried out in a scientific man-
ner with controls. From the facts which he was
able to gather, he concludes that small, prophylactic
doses of quinine, not too long continued, are of
established value to the natives of malarial districts,
both with and without the observance of effective
antimosquito measures. The drug may be given
258
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
with advantage to immigrants into malarial regions
during brief journeys when antimosquito protection
is not good; as an occasional dose after an
unusually fatiguing day ; and to nervous persons
in an occasional dose as an additional precau-
tion to efficient mosquito prevention. In general
terms, however, attempted quinine prophylaxis
of malaria for immigrants into malarial districts
gives very poor results and is little more than a
"pious fraud, which has been perpetuated from one
generation to the next" in the absence of scientific
study of the problem. Not only is it of very Httle
value, but also the continued use of quinine often
afi'ects the course of malaria unfavorably, so that
the disadvantages outweigh the advantages.
Treatment of Ureteral Calculus. — H. McC.
Johnson {Texas Medical Journal, May, 1918)
thinks that most calculi pass spontaneously. If not,
intravesical procedures will help a good many. The
mere passage of a ureter catheter to the calculus or
beyond it will sometimes so alter the position or re-
lationship that the stone may easily slip into the
bladder. Injection of liquid petrolatum through the
catheter is a well established method. When near
the ureteral mouth the opening may be incised with
scissors through the operating cystoscope and the
stone grasped and extracted. Where the stone is
large or impacted in a pocket it should be removed
from the ureter by the extraperitoneal method. If
located within the lower inch of the ureter the pre-
vesical median incision is preferable and if the cal-
culus is near the kidney pelvis the usual lumbar in-
cision for kidney operation should be made.
Abortion and Its Treatment. — Abraham J.
Rongy {Nezf York State Journal of Medicine, May,
1918) brings out with emphasis the fact that there
has been little or no advance in the methods of the
treatment of abortion in many years, due largely to
a failure to consider the fundamental physiological
facts concerned. Proper treatment should begin
with the methods of prevention of abortion, which
include the proper development of the child, the
prenatal care of the woman, and many other fac-
tors. Where abortion, complete or incomplete, has
actually taken place, the plan of treatment should be
very different from that usually advocated. In sim-
ple, uncomplicated, incomplete abortions curettage
should never be undertaken unless there be severe,
excessive bleeding. Then the retained matter can
be removed by means of a blunt curette or placental
forceps, preferably without general anesthesia. A
hot normal saline irrigation of the uterus should
follow, and the uterus should not be packed. In
the majority of cases, however, it will not be neces-
sary to curette even for marked hemorrhage, but
this can be controlled by the administration of pitu-
itary. Where the products of conception have not
yet been actually expelled from the uterus, pituitary
should be given first to contract the uterus, prevent
hemorrhage, push down the contents, and minimize
the danger of perforating the uterine wall when they
are removed. Where there are signs of inflamma-
tory reaction the uterus should not be curetted.
Half a mil of pituitrin should be given hypodermi-
cally every four hours for two or three days follow-
ing any intrauterine manipulations.
Circulation of Arsenic in the Cerebrospinal
Fluid. — John B. Rieger and Harry C. Solomon
(Journal A. M. A., July 6, 1918) determined the
presence of arsenic in the spinal fluid in 123 cases,
the fluids being collected at varying intervals from
five minutes to twenty-three hours after intravenous
injection of 0.3 to 0.6 grams of arsphenamine.
Thirty-eight of the fluids showed appreciable
amounts of arsenic, the largest amount having been
0.6 milligram of arsenous oxide per mil, and the
average, 0.18 milligram. The shortest interval
after injection at which it was found was half an
hour ; the longest, two hours. It was found that
with successive injections of arsphenamine the fluids
showed progressively smaller amounts of arsenic
in the same time interval. It was also noticed that
the patients who showed the larger amounts of ar-
senic were the ones making the more rapid improve-
ment. From these observations the suggestion was
made that repeated intravenous injections of divided
doses of arsphenamine at intervals of one or two
hours might prove more effective in keeping up a
high concentration of the drug in the blood stream
for longer periods, and thus possibly also allow the
passage of a greater amount into the perivascular
spaces of the central nervous system.
Chloramines in Surgery and Hygiene. — M.
Guillot and M. Daufresne (Pat is medical. May 4,
iqi8) assert that the chloramines possess more prac-
tically available antiseptic power than other anti-
septics. They present all the advantages of sodium
hypochlorite, which they set free, besides being
much less irritating to the skin and acting for a
longer period. They are inferior to the hypochlor-
ites only in the greater length of time required to
dissolve necrotic tissues. Chloramine-T is but
slightly toxic, rabbits tolerating one gram per kilo-
gram by subcutaneous injection. As a bactericidal
agent it is four times as powerful, in equivalent
molecular concentrations, as sodium hypochlorite.
In infected wounds a two per cent, solution may be
used by intermittent irrigation every two hours ; clean
wounds are thus rapidly sterilized, but wounds with
dead tissues, much more slowly. As a coUyrium a
two to four per cent, solution may be used ; in ure-
thritis, copious irrigations with a 0.5 per cent, solu-
tion; in mouth infections, washings and gargling
with a one per cent, solution, and for the disinfec-
tion of germ carriers, spraying of the nose with a
0.5 per cent, solution. A five per cent, chloramine
gauze, applied dry, is serviceable. The best pro-
cedure, both for convenience and continuity of ac-
tion, is the use in wounds of a paste — free of liquid
fats and chlorinophile organic matter — containing
8.5 per cent, of sodium stearate and 1.5 per cent, of
chloramine-T. Such a paste exerts a detergent ac-
tion in wounds covered with dead tissue, sterilizes
the wound surface thus cleansed, causes little or no
pain, and does not retard healing. It need be ap-
plied but once daily, after careful cleansing of the
wound with cotton ]:)ledgets dipped in tepid sterile
water. An important measure is to cleanse the skin,
surrounding the wound with pure, neutral sodium
stearate, applied with cotton moistened in tepid ster-
ile water. The surface is then carefully dried and
the chloramine paste applied throughout. War
August 10, igiS.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
259
wounds can thus be sterilized and closed as quickly
as with sodium hypochlorite. A useful sterilizing
action, after free excision of diseased tissues, was
also obtained in bone and lymphatic tuberculous
lesions. Dichloramine-T is likewise a powerful an-
tiseptic, but its advantages over chloramine-T do
not compensate for the instability of its oily solu-
tions. In sterilizing the nasopharynx or buccal
pharynx, however, it will no doubt prove of great
value Halazone, a third chloramine product, was
prepared by Dakin especially for the sterilization of
small quantities of water for drinking purposes. One
or two tablets of halazone added to a litre of water
sterilize it rapidly, no matter how badly contam-
inated it may have been. It neither corrodes metal-
lic receptacles nor imparts an unpleasant taste to
the water.
Diet in Diabetes with Dyspeptic S5miptoms. —
\igay {Journal ds medicine dc Paris, May, 1918)
notes that while the accompanying dyspeptic condi-
tions may be of various types, certain general rec-
ommendations may be made. To the original dia-
betic interdictions of diet the following should be
added : shell fish, fats and fish with greasy flesh,
goose and duck, game, rich sauces, sorrel, condi-
ments, and strong cheese. Vegetables should be
boiled, and buttered just before serving. Injunc-
tions to eat slowly and masticate well are often in
order, as many diabetics become dyspeptic through
heavy and hurried eating. Often such patients are
constipated ; bran muffins will then be helpful. The
quantity of fluid taken should be reduced, and fluids
ingested only half an hour before or three hours
after meals. For mayonnaise sauce, highly valued
for the uncomplicated diabetic, one may substitute
where there is dyspepsia a sauce made as follows :
melt slowly 100 grams of butter and then mix in the
yolk of an egg ; beat until a creamlike mass is
formed ; add a little lemon juice and salt to taste.
Senile Rheumatism. — Malford W. Thewlis
{Medical Revieiv of Reviews, June, 1918) believes
that nephritis plays the most important role in the
production of senile rheumatism. When this cause
is present, he gives, if the patient is robust, Seidlitz
mixture, magnesium citrate, or some similar saline
each morning before breakfast; if the patient is
frail, a compound cathartic pill at bedtime. The
following diet list is given : Breakfast — apples,
baked, raw, or stewed ; grapes ; berries in season ;
cantaloupe ; eggs, soft boiled, shirred, scrambled,
poached ; broiled chicken ; broiled honeycomb tripe ;
fish (mackerel, salmon, perch, eel, pickerel, white
fish, trout, haddock, halibut, shad); baked potato;
stale or toasted bread with plenty of butter ; cup of
tea, or glass of milk. Dinner — raw oysters or little
neck clams ; soups (preferably purees). pea, bean, to-
mato, potato, asparagus, celery ; chops, beefsteak not
more than once a week, roasts (beef, lamb, veal,
chicken, tongue) ; fish (broiled or baked in cream) ;
vegetables (potato, spinach, lettuce, stewed celery,
cauliflower, beets, squash, green peas, tomatoes,
asparagus, string beans) ; dessert (apple tapioca,
sago, blanc mange) ; one glass of milk or a cup of
tea or cocoa. Supper — eggs ; lamb stew with veg-
etables ; baked potato ; bread, stale or toasted, with
plenty of butter ; stewed fruit ; one glass of milk ;
stale bread or crackers and milk, with blueberries
or baked sweet apples.
\^ary the diet from day to day. Do not eat fish
and meat, meat and eggs, or fish and eggs at the
same meal. Meat or fish should not be given of-
tener than once a day. Three or four glasses of
milk should be taken daily, either with or between
meals.
In the chronic form of the diseases, if the patient
is robust, cabinet baths once or twice a week are
very beneficial, more so than Turkish baths. Sal-
icylates are harmful and irritating to the kidneys;
aspirin or acetylsalicylic acid is a depressant, causes
perspiration and constipation, and is not required in
many cases. Heroin will usually relieve the pain
in acute cases. Diathermic treatments have given
excellent results. Heat is applied to cases which
have a tendency to deformity by the application of
superheated air at 130°, 180°, or 200° C, and the
results are sometimes remarkable. Sodium suc-
cinate, ten grains every three hours, is of great
value in many cases of senile rheumatism. The re-
sults of eliminative treatment in rheumatism caused
by nephritis are often remarkable, and if the treat-
ment is instituted early enough, many old persons
are saved from great suffering. Other causes men-
tioned are tuberculosis, diabetes, plumbism, obesity,
gout, carcinoma, and focal infections of staphylo-
cocci, streptococci, and pneumococci. Senile rheu-
matism improves on exercise, while senile arthro-
sclerosis is made worse by movements. Rheumatic
fever is rare in the aged, though chronic rheu.ma-
tism may have acute exacerbations and appear like
rheumatic fever. Tuberculous arthritis is quite
common in the aged, and usually is primary. Ure-
mia may cause local symptoms and direct its whole
force upon one part.
Tyramine in Circulatory Failure. — A. W.
Hewlett and W. E. Kay {Journal A. M. A., June
15, 1918) showed in an earlier paper that the sub-
cutaneous injection of doses of sixty to eighty milli-
grams of tyramine produced a rise in the systolic
blood pressure of normal man up to levels between
150 and 200 millimetres of mercury. This rise be-
gins within five minutes, reaches its maximum in
ten minutes, and subsides to normal in fifteen to
thirty minutes. With the rise in the systolic pres-
sure there is very little change in the diastolic, so
that the volume pulse becomes larger. This action
shoiild make the drug very valuable in cases of cir-
culatory failure in the acute infections or during
or after operations accompanied with marked fall
in the blood pressure. The drug was therefore
tried in a number of cases in both groups. In the
cases suffering from circulatory failure due to in-
fections, repeated injections of tyramine caused a
relatively slight and transient rise in the blood pres-
sure and increase in the pulse volume. In no case
did permanent improvement occur. In the case of
the injections of the drug for the circulatory failure
during or after operations the efifects were also
transitory and much less marked than in the normal
person, but striking improvement in the general con-
dition occurred in some of the patients, in three the
benefits being apparently responsible for the saving
of the lives of the patients.
Miscellany from Home and Foreign Journals
Signs of Death in Military Practice. — Satre
{Prcsse medicale, May 9, IQ18) states that Icard's
fluorescein injection and the acid reaction of the
splenic pulp, the procedure of Ambard and Brisse-
morel, have both given satisfactory results in sani-
tary formations at the front and ai¥ord certain in-
formation of actual death. Other procedures, of a
physical order, have also given good results. The
first is Icard's forcipressure method, based on the
permanence or evanescence of the ischemia of the
tissues induced by compression. Another is Lo-
rain's old procedure of exposing the forearm, calf,
or thigh to a flame ; if the blister which forms is
filled with air and bursts with a cracking noise
leaving the dermis dry, the man is dead, whereas if
the blister contains fluid, death is but apparent.
Among the ocular signs, hypotonic shrinkage of the
eyeball is not characteristic. More rehable and con-
stant is the sign of Lecha Marzo ; this consists in
placing beneath the lids a strip of neutral litmus
paper, which turns red in a few minutes if the
subject is dead and blue if he is living. Other
ophthalmic reactions comprise, rube faction of the
eyeball by ether instillation, the actual cautery,
scraping the conjunctiva, application of copper
sulphate, subconjunctival saline instillations and in-
jections, and the dionin reaction.
War Edema.— F. S. Park {Journal A. M. A.,
June 15, 1918) was a prisoner of war for thii-teen
months in Germany and had the medical care of
allied prisoners in one of the large camps. There
he was able to observe the condition known as war
edema (Kriegsoedem), although he did not have
the facilities for instrumental or chemical studies
and could not collect precise statistics. He says the
condition begins with slight edema of the feet and
legs which disappears after lying down. Later the
edema becomes massive, involves the legs, thighs,
and genitalia ; tiiere is some puffiness beneath the
eyes ; at times the abdominal wall becomes edem-
atous ; and the patients often complain of general
weakness and pains in the legs. There is marked
apathy, and muscular wasting and pallor are ex-
treme. There is slight enlargement of the heart ;
the action is feeble, but regular and slow and the
blood pressure is apparently low. Hydroperi-
cardium is not common and seldom marked, but
hydrothorax is both common and extreme and
ascites is frequent. The urine is scanty at first but
later excessive. The uncomplicated cases improve
slowly with rest in bed and an increase in diet.
Digitalis and theobromine sodium salicylate are
without value. Dermatitis of the legs is common,
and cellulitis develops in some cases. Bronchitis is
a common complication and most of the deaths are
due to bronchitis and ederna of the lungs. The
commonest and most troublesome complaint is
colitis with mucus and blood, and often proved
fatal. The postmortem findings are striking and
show a total absence of fat in the positions in which
it normally persists even in the face of emaciation,
that is, about the kidneys and heart and in the
omentum and mesenter}^ In the place of the fat
the tissues are found swollen with fluid. The heart
is pale and flabby and the serous cavities contain
clear fluid. The lungs usually show bronchopneu-
monia and the kidneys and Hver are very pale. The
conclusion is reached that the condition is the result
of prolonged underfeeding, especially the absence of
tat from the dietary.
Prognosis in War Nephritis. — Rodolph G.
Abercrombie (British Medical Journal, May 4,
1918) investigated, with the aid of the Medical Re-
search Committee, the subsequent histories of 171
unselected cases of war nephritis which had been
under his care in France. The after histories were
traced for periods vaying from twenty-one to thirty-
two months. As the result of the first period of
home treatment of these cases thirty-two were in-
valided as permanently unfit as a result of nephritis,
131 were discharged to some form of duty, five died,
and two were discharged for other reasons. Of
the 131 discharged to some form of duty, twenty-two
either relapsed or developed chronic renal symptoms
and the remaining 109 showed no further evidences
of the disease. In terms of percentages the results
for the whole series were : died, 3.5 per cent. ; in-
valided for nephritis, 31.5 per cent, recovered and
returned to some duty, 63.7 per cent. Of the 109
returned to duty and remaining free from the dis-
ease, seventy-nine went back to the first line and
thirty to garrison duty or home service. Age was
foimd to have a decided influence on the prognosis,
those men under twenty-six and those over forty
years of age who developed the disease gave poorer
prognoses than those between these ages. Certain
other prognostic points of value could be made out
from the investigation ; namely, that a prolongation
of the initial stage of the disease was unfavorable ;
cases with severe uremic symptoms during the
initial stage were slightly less favorable than those
without such symptoms ; convulsions were less un-
favorable than other severe uremic symptoms ; and
definite ascites was decidedly unfavorable. There
seemed to be a definite consecutive relation between
war nephritis and tuberculosis in a number of the
cases. Finally, it was found that the longer the
cases could be kept in France during the initial
stage of the disease, the better was the ultimate
prognosis.
Prognosis in Fracture of the Thigh in Military
Service. — Couteaud (Bulletin de I'Academie de
medicine, May 7, 1918) points out that the former
view as to the extreme gravity of fracture of the
femur by firearms no longer holds good. Of 250
cases cared for at Cherbourg since the beginning of
the war, 215 were compound and led to thirty-one
fatalities. Two patients had both femurs broken.
Of the 182 who recovered, twenty per cent, showed
complete restoration of the functions of the thigh,
fifty per cent, recovered with slight shortening and
suflicient joint mobility, eleven per cent, more had
a more or less useful limb, and seventeen per cent,
were definitely mutilated and crippled. Of the
thirty-one fatal cases, twenty-seven occurred in the
first six months of the war. Some of those dip-
August .0, .91S.] MISCELLANY FROM HOME AND FOREIGN JOURNALS. 261
charged from the service with a shortening of eight
centimetres and sHght stiffness at the knee were able
to walk easily without a cane by means of an ortho-
pedic boot. The men wounded by bullets recov-
ered easily as in civil practice, with the aid of
Tillaux's simple apparatus. .Among those injured
by artillery projectiles, on the other hand, infection
and gas gangrene dominated the picture. Yet of
fifteen men brought in with putrid emphysema — a
condition favored by attempts of the wounded to
flee from danger, using their injured limb — six re-
covered. When the section of the amputated bone
is yellow, the prognosis is bad ; likewise when the
mahogany color of the tissues extends above the
groin. All forms of septicemia were observed.
Phlebitis proved a dangerous complication — less,
perhaps, that of the visible veins of the extremity
than the occult phlebitis of small vessels. Many
patients died suddenly after slight exertion. At
least four died of hemorrhage. The femoral artery
was injured in three ca.ses ; the deep femoral, in
three ; muscular arteries and the anastomotica
magna, in eight ; and the femoral vein, in two.
Tetanus occurred in five instances, hastening death
in three. The sciatic nerve was injured in nine
cases. An equine posture often counteracted the
shortening of the limb. Causalgia was noted in
four instances.
Examination of the Feces in Chronic Enteritis.
— R. Goift'on {Presse mcdicale , May 2, 1918) asserts
that coprologic analysis is indispensable as a diag-
nostic procedure in all diseases of the alimentary
canal, especially in soldiers, in whose cases there is
no time for the delay permissible in civil practice
in experimenting with various diets and other meas-
ures. In involvement of the small intestine, usually
occurring as the acute stage in diarrheic cases, the
diagnostic indications afforded by the stools are
more precise than those derived from the rather
vague clinical symptoms. Two varieties of stools
are met with in these cases, viz., one in which the
contents of the ileum are but slightly altered, though
malodorous and containing starch and vegetable
cells (cases arising chiefly through motor deficiency)
and a second, more severe and with greater irrita-
tion of the mucous membrane, in which the stools
are fluid and show many yellowish brown, mucous
flakes, teeming with bacteria, with food residue and
frequently absence of amylase. In especial involve-
ment of the cecum and ascending colon, fecal anal-
ysis is of great service in the detection of intracecal
putrefaction. Whether formed or diarrheic, the
stools in these cases show a diminution of the
amount of volatile acids and of the amylase. When
diarrheic, they are usually very dark and alkaline, of
a putrid odor, glistening, and viscid, with much
starch and cellulose. Diarrhea from excessive car-
bohydrate fermentation yields yellow, frothy, strong-
Iv acid stools, and is treated with chalk and reduc-
tion of carbohydrate intake. In the very common
mucous colitis, with pasty, piled up, yellow-brown
stools, a frequent sequel of acute diarrhea in soldiers
and of dysentery, a carbohydrate diet and a mineral
water rich in sulphates are eftectual. Irritation of
the descending colon and sigmoid is often mani-
fested in constipation interrupted occasionally by
diarrhea, the stools then exhibiting scybala mixed
with more fluid material and mucus. In some de-
ceptive instances, there occurs what the author terms
homogeneous false diarrhea; the symptoms and
stools are apparently those of mucous colitis, but the
stools show an almost complete absence of digestible
cellulose, starch, and iodophilic bacterial flora ; the
treatment is that of constipation. Many obstinate
cases of enterocolitis proved to be due to intestinal
parasites, especially arnoebie and lamblijE. Diarrhea
of gastric origin shows raw connective tissue and
yields to hydrochloric acid.
Blue Pigment in Blood Serum. — G. Patein
{Bulletin dc I' Academic dc medecine, April 23,
[918), in the course of studies on tests for bile pig-
ments in human blood serum, found a blue pigment
not yet described. It can be demonstrated by dilut-
ing 100 mils of serum to one litre with water, add-
ing acetic acid drop by drop until the fluid is slightly
but clearly acid to litmus, allowing the precipitate
formed to settle, and after a few hours separating it
by centrifugation. A bluish gray material is often
formed under these conditions which seems unevenly
distributed in the sediment and is soluble only in
0.6 per cent, sodium chloride solution. The blue
solution thus obtained is decolorized by acidification,
even with acetic acid, as well as by trichloracetic
acid and by sodium carbonate. It is partly pre-
cipitated by lead subacetate. The blue material
gives none of the reactions of indigotin and is not a
copper compound but contains traces of iron. It
can be obtained from serums containing neither in-
doxyl nor bile pigments. It is precipitated as a blue
l)ody by alcohol, and evidently consists of a blue
pigment combined with a globulin, just as hemo-
globin consists of hematin combined with globin.
Often the blue compound was present only in traces.
It was found most abundantly and frequently in
serums of cases of eclampsia.
Antigen-Antibody Balance in Lobar Pneu-
monia.— Francis G. Blake {Archives of Internal
Medicine, June, 1918) points out that natural re-
covery from pneumonia is attended by the develop-
ment of certain humoral antibodies which appear
shortly before or at the time of crisis. The rela-
tions of the antigen-antibody balance to the severity
and outcome of a given case, as well as its prog-
nostic value, were studied in detail in nineteen pa-
tients. A definite relation between the excretion of
soluble pneuniococcus antigen in the urine and the
development of precipitins in the blood was found in
these cases. Agglutinin formation in the blood bore,
however, no definite relation to antigen excretion,
and the curve of concentration of precipitins did not
parallel that of the agglutinins. Pneumococci disap-
peared from the blood prior to or coincidently with
the appearance of agglutinins. Cases developing an
excess of precipitins and agglutinins invariably re-
covered shortly after or coincidently with the ap-
pearance of these antibodies, while cases showing a
progressive increase in the excess of antigen — living
pneumococci in the blood — without the development
of demonstrable antibodies were invariably fatal.
Daily estimation of the concentration of soluble
antigen excreted in the urine and of the number of
pneumococci per mil of blood proved of great prog-
262
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
nostic value. Ihe former procedure was carried
out by the precipitin method. A sample of urine
collected shortly before the daily bleeding was
rendered clear by filtration ; 0.5 mil of a one in ten
dilution of the homologous type of antipneumo-
coccus serum was then added to 0.5 mil of increas-
ing dilutions of the urine in a series of small tubes
and incubated for one hour at 37° C, when final
readings were made. In calculating the amount of
soluble antigen in the urine, the final calculation was
made on the basis of a constant daily excretion of
1,000 mils of urine. In estimating the number of
pneumococci per mil of blood, blood was collected
by venipuncture, eight to ten mils inoculated into a
flask of plain broth, and measured amounts — from
one to five mils — poured into agar plates, the col-
onies being later counted.
Luetin Reaction in Syphilis. — Alessandro Chi-
effi {Giornale Italiano dellc Malattie Vcncrce c della
Pellc, May 26, 1918) from an extensive study of
Noguchi's luetin test concludes as follows : The reac-
tion is not constant in lues ; it is more frequently seen
in late than in recent cases ; while the Wassermann
reaction tends to become negative under mercurial
treatment the luetin reaction remains unchanged.
The nonspecific nature of the test is shown by the
fact that it may be observed in nonsyphilitic persons
who have lupus, leprosy, and other skin diseases ;
further the reaction may be produced in luetics by
other toxic bacterial substances, such as gonococcus
vaccine.
Hemiplegia Due to a Localized Focus of Tu-
berculous Meningitis. — T. Legry {Bulletin de
I'Acadcrnie de medicine, May 21, 1918) notes that
in tuberculous meningitis in adults the lesions are
apt to involve circumscribed portions of the cortex,
the symptoms correspondingly resembling those of
focal changes. He reports the case of a woman of
thirty-one years admitted to a hospital after having
for two months experienced lassitude and for a
w^eek, at intervals, tingling, beginning in the distal
portions of the left hand and foot and extending to
the entire left half of the body. Examination
showed an exaggerated knee jerk and a positive
Babinski on the left, with diminished sensation and
motor power on that side, the leg dragging during
locomotion. Movements of the left arm were also
limited. The temjjerature was normal. A diagno-
sis of specific hemiplegia was made and biniodide in-
jections instituted. In the succeeding days the
motor power diminished further, but there was no
vomiting, neck rigidity, nor Kernig sign. Ten days
after admission the temperature rose to 39° C. and
paresis of the right leg appeared. Lumbar punc-
ture revealed marked hypertension, pronounced
lymphocytosis, and tubercle bacilli. The meningitic
syndrome becanie complete only four days later, and
after a like period the patient succumbed. The
autopsy showed a few small tuberculous lesions in
the lung apices. On the upper border of the right
cerebral hemisphere was found a thick, granuloma-
tous area slightly smaller than a silver half dollar.
A few grayish patches representing incipient tuber-
culous granulations were noticed in other portions
^ . of the pia mater.
Conditions Simulating Disease which May Be
Produced by Teething. — ^James Burnet {British
Journal of Children's Diseases, January-March,
1918) records three cases and states that teething
can give rise to serious symptoms besides being a
definite exciting cause of such conditions as diar-
rhea, eczema, bronchial catarrh, convulsions,
screaming fits and strabismus. Facial palsy and
chorea may be caused by dentition. When infants
present obscure symptoms the following should be
investigated : urine, rectum, throat and mouth.
The Intravenous Use of Red Mercuric Iodide.
— L. W. Rowe {Journal of Laboratory and Clinical
Medicine, April, 1918) found red mercuric iodide
combined with an equal amount of potassium
iodide was comparatively safe to use intravenously
in guineapigs, dogs, and rabbits, if reasonable care is
exercised in the manner of injection and the size of
the dose. Its efficiency as a germicide (five times
that of bichloride) combined with the fact that it is
very little, if any, more toxic than mercuric chloride,
ought to make it of therapeutic value after it has
been tested further.
Association of True Pruritis Ani with Pyor-
rhoea Alveolaris. — E. J. demons {Medical Rec-
ord, June I, 1 91 8) declares that true pruritis ani is
caused by streptococci, and that the usual focus of
infection is a pyorrheal condition in the mouth. In
such cases there are two distinct procedures to be
carried out : first, removal of focal atria in the
mouth, and second, drainage of the rectal mucosa to
rid the tissues of the infection causing the pruritis.
The pyorrheal atria are best removed by extracting
the teeth, while the rectal mucosa is drained by re-
moving the lateral ana! cutaneous tissue under local
anesthesia, and then drawing down the adjacent
rectal mucosa and suturing it to the fascia between
the external and internal sphincters.
Traumatic Aneurysm in a Syphilitic. — F. Ra-
mond and L. Postina {Bulletins et memoires de la
Societc medicale des hopitaux de Paris. February
21, 1918) report the case of a man aged twenty-
eight, in active service at the front for three years,
who was violently thrown to the ground by a shell
explosion, landing on his chest. Dyspnea, thoracic
angor, and dilatation of the heart soon followed,
with Corrigan pulse, frequent dizziness, emd hepatic
enlargement. Compensation was lost in spite of
rest and appropriate remedies, and the patient suc-
cumbed about four months after the injury. A
strongly positive Bordet-Wassermann reaction had
been obtained. The autopsy showed three small
aneurysmal dilatations of the arch of the aorta, the
largest of the size of a large walnut. The lining of
the vessel bore a number of large, raised patches of
arteritis. The sigmoid leaflets seemed normal, but
the circumference of the aortic ring measured nine
centimetres instead of the normal six to seven. The
patches in the aorta proved syphilitic microscopi-
cally, and the giving way of the aortic ring was ac-
counted for by a di.screte arteriolitis of similar type
in the tissues at this point. The authors believe the
violent increase of pressure due to the bursting
shell, together with the effects of fright, caused a
violent peripheral vasoconstriction which overtaxed
the resisting power of the diseased aorta.
Proceedings of National and Local Societies
MEDICAL SOCIETY OF THE COUNTY OF
NEW YORK.
Stated Meeting Held Monday, February 25, 1918.
The President. Dr. How.vkd C. Taylor, in the Chair.
Reconstruction and Human Conservation. —
Major H.NRKY IC. Mock, Washington, D. C. (by
invitation), outlined the plan of the Surgeon
General's Office for the reconstruction and rehabil-
itation of the disabled soldiers of the United States
\rniy. In their scope, all the details of the plan
included that provision for coordination necessary
to make them efficient. Congress had passed a
very good war risk, or disability insurance act
which enabled the authorities to carry out a very
broad programme ; it jjrovided that in case of
permanent disabilities, the injured should follow
such course or courses of rehabilitation, reeduca-
tion and vocational training as the United States
provided ; he might be retained in military or naval
service with pay until the course was completed.
Such training was therefore obligatory and would
in consequence be valuable to a great many more
soldiers and sailors than if it were voluntary.
Physical reconstruction of the wovmded meant
the adoption of the very best medical and surgical
l)rocedures possible in order to obtain the greatest
furictional restoration. Rehabilitation included
mental 1 and phvsical training that restored the in-
dividual to a useful place in society, as well as
further supervision until a firm grip on life was
.secured, in all its economic factors. Ambition and
the desire for this training would be stimulated in
these men and the idea inculcated of grasping
every opportunity to make good by their own
efi'orts. Great assistance in this direction would
l)e given by the bill which gave more or less con-
trol over the disabletl soldier to enable the com-
]>letion of his rehabilitation.
Thus far the work in the .Surgeon (jeneral's
Office had been along the lines of studying and
preparing for this great plan, arranging for the
establishment of hospitals in every one of the
draft districts of the country and planning for
curative shops and prevocational training. The
jirogramme would fit in with programmes of ex-
isting civil organizations whose purposes were the
same. /. e., inducting war cripples into civilian life.
.\t present it was a military problem and as such
l)elonged to the Medical Department of the Army.
Closely allied to it was the same problem in the
navy and in industry. Later on it became purely
a civilian programme and entered the field of
nianv federal, state, local and private civilian
organizations whose duties it would be to complete
the rehabilitation. It was only a step from this
scheme to one more far reaching that would in-
clude proper medical and surgical supervision, re-
construction, rehabilitation, and federal, health and
accident insurance for all workers, together with
prevention of disease and accidents.
A resume of the plan indicated the scope of the
work. The disabled soldiers on their return to
this country would first lie received at a large
central hospital where a board of medical and
vocational experts would l>ass on each individual.
From here distribution would be made to general
hospitals, special hospitals, hos]Mtals with special
vocational schools, direct home, or to incurable
hospitals. The j^roblem would remain a truly
military matter until complete functional restora-
tion occurred. In connection with each hospital
]ihysical units would be established consisting of
gvmnasiums, hydrotherapy, and massage rooms,
and mechanical appliances. In addition each hos-
pital would have curative shops where the men
couU; indulge in light work ; their purpose would
be to give mechanotherapy when needed, for their
])sychological effect, for productivity and begin-
ning vocational training, and at all times a practi-
cal trend toward employment. Prevocational
training schools would be operated in connection
with each hospital with the following purposes :
for curative therapy, to teach new trades where
indicated, special schools for the blind, deaf, ortho-
pedic, and tuberculosis cases and for agricultural
pursuits. Some of this vocational training would
be given in established schools such as state uni-
versities, where short courses could be given or
regular courses adapted to special needs.
Many of these rehabilitated men would seek
federal and state governmental work, others would
be placed directly in some industry, but during
the training period they would be retained in
federal pay and supervision. Many successful
cripples would act as teachers to others. An ade-
(|uate placing system would be arranged by utiliz-
ing the National Employment Bureau aided by the
various state employment agencies. A system of
reporting would be arranged so that the central
office would know at all times what work the dis-
abled were doing, could prevent change of work to
hazardous occupations, and could prevent any
soldier from deteriorating into an idler or object
of charity by cooperation with the war risk board.
Careful study was being made of the present
and future economic conditions so that certain oc-
cupations would not be overcrowded, that suf-
ficient men be trained to fill positions in new in-
dustries which would be an outgrowth of the war,
that labor conditions would not interfere with
placing the men, that occupational hazards be
avoided and that legal obstructions to the preven-
tion of emplovment of the men in industries be
changed.
From the time he entered the army and espe-
cially from the time he was disabled, through his
period of reconstruction and rehabilitation, the
man must be thoroughly imliued with the idea that
he could again become a useful member of society.
It was as important as teaching him a new occupa-
tion to return him to society enthusiastically
ambitious to make good. His family must be
taught to cooperate and public opinion must be
moulded to ajiprove the plan. Everything that
could possiljlv be done for the disabled soldier was
264
PROCEEDIXGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
his due and his reconstruction and rehabilitation
was the greatest humanitarian movement devel-
oped in this war.
Social Aftercare for Disabled Soldiers. — Mr.
Curtis E. Lakem.vn, of the Department of Civilian
Relief. American Red Cross, Washinj^on, D. C,
regarded the ideal national programme of recon-
struction outlined by the previous speaker as pecu-
liarly appropriate to the army of a democracy. It
was fitting that the new military organization of the
American people should bear in mind its countless
relations to the social welfare of the country at
large. But civilian agencies were called upon to
participate in the work and among them the
American Red Cross had a definite part to play. Its
plans for the care of the disabled men returning
from war did not duplicate the functions of the
Government. Its field, with one exception, lay
wholly in the social supervision of these men during
their readjustment to civil life. The exception re-
ferred to was the experiment station in the voca-
tional training and employment of cripples estab-
lished at 31 1 Fourth avenue, New York under the
capable direction of Mr. Douglas C. McMurtrie who
would later on explain what was being done there.
This single instance of institutional work, which
exemplified the function of the Red Cross as an
official auxiliary of the army and navy, had been
approved by the Surgeon General and the Secretary
of War.
The Red Cross had a public purpose if any organ-
ization ever had. It represented a tremendous out-
pouring of public emotion which had been directed
into channels of effective cooperation with the
Government. This spirit of the Red Cross was
manifesting itself abroad and at home in its efifort
to supply aid and comfort to soldiers and sailors
and to sustain the morale of the fighting forces by
caring for the women and children at home. The
men returning incapacitated for further service
would be cared for as individual soldiers and sailors
in the military hosj)itals of the army and navy. But
after they were discharged from further treatment
and training in Governmerit institutions, when they
resumed their places in the community, then they
came within the appropriate field of Red Cross in-
terest and aftercare, which could properly assist
them temporarily and during their period of read-
justment to industry and normal life, in this way
continuing and completing the service previously
given to their families.
Some of the activities of the Red Cross were well
known to the public. It was not so widely known,
however, that since August, 1916, the American
Red Cross had developed a system of service to the
dependents of enlisted men which reached into
every city and town in the country. The war risk
insurance law of October 6, 1917, saw to it that the
family income did not stop, but more than money
was needed. A family in trouble needed many
services which money could not buy and which the
Government could not undertake to render efifec-
tively as could a friendly neighbor, and what
agency could more fittingly organize the patriotic
neighborly spirit of each community and direct it
through skilled workers .so that the right thing
would be done at the right time and in the right way
for the soldier's family? The Red Cross called this
work home service. It meant the preservation of
American ideals of health, education, housing, and
v/orking conditions; it meant relief in emergencies
and it meant the provision of regidar allowances to
persons who had no legal claim on the Government
because of unspecified relationship, but hitherto de-
pendent on a soldier or a sailor ; and it meant the
giving of practical, everyday information in small
matters of deep interest to friends and relatives of
soldiers and sailors. Four thousand families were
being helped in this way by the home service section
in Manhattan and the Bronx.
Another opportunity of home service was the
care of a disabled man during his return to civil life
at the point where the Government programme left
him. Every such soldier came back from France
permanently incapacitated for further military serv-
ice, recovered as far as possible from physical
disability and newly trained in a vocation enabling
him to go to work, where the Government controUetl
employment service had found a place for him. His
problems and difficulties were now the interest of
the Red Cross, and there were many of them. He
needed constant personal encouragement ; he needed
help in fincHng congenial work in congenial surround-
ings ; he needed assistance in meeting and overcom-
ing obstacles. A condition of permanent stability in
the reunited family must be maintained. Social
aftercare began with the doctor in the military and
orthopedic hospitals and it ended in the hands of
the Red Cross and other workers in the man's home
town. From beginning to end the process was con-
tinuous in the efifort to restore self confidence, self-
reliance and ambition.
When everything possible had been done to assist
the man and his family in overcoming material and
psychological handicaps, something remained to be
done with employers. They could be encouraged to
provide proper opportunities for handicapped men,
and urged to exercise forliearance in their dealings
with them. •
With crippled soldiers themselves, with employ-
ers, and finally with the public at large, the first
duty of the Red Cross and all other agencies truly
interested in the rehabilitation of disabled soldiers
was to create the most wholesome public sentiment
which should encourage every effort at selfsupport,
for the man returning disabled from the front de-
served everything that could be done for him.
Vocational Reeducation of War Cripples. —
Mr. Douglas C. McMurtrie, Director of the Red
Cross Institute for Crippled and Disabled Men,
New York, had a number of pictures thrown on the
screen showing crippled soldiers working at various
trades and industries in England, France, and
Canada. Fie commented on the fact that it had re-
mained for the present war to bring about a change
in the idea that financial compensation sufficed to
discharge all obligation for disablement while in the
performance of duty, which had previously con-
tented industrial employers. The pictures showed
many devices and practical means for enabling those
without their full complement of limbs to get along
August 10, 1 91 8.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
265
just as well as they had previously with them. In
one picture, a man with only one arm and leg was
seen easily and rapidly operating a typewriter by
changing the key shift and carriage reverse through
a strap on a pulley with his foot.
Some of these men were even better off than be-
fore their disablement. One who had been an ex-
pert stone mason after training as a mechanical
draftsman and interpreting plans of construction
put his practical knowledge to use. This had raised
him several grades in his own line of work, and this
was one of the objects of the general plan of the
Red Cross for the rehabilitation of these persons.
All possible forms of labor and their application to
local conditions had been taken into consideration ;
these differed in different countries. Abroad cob-
bling was a trade by which many of these men made
a very good living, opening little shops of their own
anywhere about the country. This trade was also
considered a very good one in Canada, as was willow
work also. Another picture was shown of a French
ex-soldier with both legs amputated at the hip, in-
dustrially and happily occupied as an expert leather
worker and saddler. A picture of a tailor shop
showed all sorts of work being done by cripples ; all
the expert processes of tailoring were accom-
plished by the aid of suitable devices. Very fre-
quently the teacher was himself a cripple and his
pupils as a rule learned more rapidly and satisfac-
torily, as was natural. In Canada it had been found
that the teacher must have been wounded overseas
himself to gain any attention from or influence over
his pupils. The reconstruction work being done in
Canada was wonderful ; in Winnipeg there was a
large training school with facilities for training 200
to 300 men where certain branches of carpentering
and cabinet work were taught.
In making provision for useful appliances, the
possibility of providing artificial arms which looked
like arms and were at the same time efficient had
so far been found impossible, so in most of these
workshops the men were provided with two sets,
working appliances for the man's trade and more
esthetic arms or legs to wear after his working hours
were over. The manufacture of artificial limbs was
one of the most suitable trades for cripples. They
could always find employment and they took a par-
ticular interest in this kind of work. The shops
were used for training cripples and for providing
hospitals with artificial limbs. The life of a limb
was not long and these men could also be trained
in expert repairing for which there would be a de-
mand. The next picture showed an electrical sub-
station with crippled attendants doing electrical
maintenance and repairing, one a trained motor me-
chanic. In the next, submarine fittings were being
expertly made for the Government. In other than
war times some of these men might have had con-
siderable difficulty in finding employment as they
were badly crippled. , Coppersmithing was a trade
in which there was a lack of skilled workers and the
graduate cripples were taken care of as fast as they
were trained. Welding was another good trade ;
ordinary operators got very high wages and ex-
perts got a good deal more. Blacksmithing was an-
other very good trade.
Well instructed men always fitted into a local
labor market, but there were other essential con-
siderations besides merely teaching the man how to
make a living. One of these led to the effort to
keep men who had been farmers on the farm and
to this end they received special vocational training
in farm specialization and the benefit of every re-
source that ingenuity could devise to enable them
to substitute skill for strength.
It had been from the first the intention of the
Federal Government to reeducate the war cripples,
but the work had not yet gotten under way. It
had seemed desirable that the Red Cross should try
out the idea and so the Red Cross Institute for
Crippled and Disabled Men had been opened, largely
through the contribution of a few individuals, among
them being Jeremiah Alilbank. This school was
located in the old College of Physicans and Sur-
geons' building at Fourth avenue and Twenty-eight
street, and work would be started at once so that
a comprehensive technic could be developed and
ready for immediate application when these brave
boys who had gone out to meet the adversities of
war came back with their work nobly done, but
leaving behind them a priceless part of themselves.
That this loss should be made up to them doubly,
trebly, that they should be to all respects as nearly
as possible bodily as they were before and in addi-
tion equipped with technical training through which
they could take and keep a place among their equals,
was the firm resolve of the founders of the school.
At present they were taking care of the cripples of
industry and were anxious to get in touch with any
case which could be helped by reeducation. In-
dustrial classes in various trades were now being
started and in a short time the institution would be
in full swing. After the war life would go on as
every one knew, but that it should be worth while
must not be overlooked ; those who had served their
country in the forefront of battle and looked aghast
at their prospects for the future, would find those
prospects miraculously glowing with promise for
lives of self respect, the power to earn a decent liv-
ing and happiness, which comes to every man who
can stand on his own feet, even if they be artificial.
ASSOCIATION OF AMERICAN
PHYSICIANS.
Thirty-third Annual Meeting, Held in Atlantic City,
N. J., May J and 8, ipi8.
The President, Dr. F. H. Vv'illiam.s, of Boston, in the
Chair.
(Couiinucd from page 1055, vol. evil.)
Immunity in Cancer. — Dr. F. C. Wood, in his
paper, said there was no branch of medical investi-
gation which had suffered so much from lack of ac-
curate thinking and correct nomenclature as the
cancer problem. These facts had caused a great
deal of work which should not have been done had
the exact conditions been appreciated. Connected with
the idea of immunity in cancer were four different
phenomena: spontaneous disappearance of primary
tumors in human beings, sometimes following no
interference, sometimes following infection, some-
times after partial removal by operation. This had
been considered due to immunity. There was, how-
I'KOCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journ.m..
e\er. no evidence that this was immunity. L")isaj>-
pearance of j)rimary tumor often coincided with
growth of metastases. The so called organ immu-
nity was not real, hecause if tumors were implanted
in the spleen they would grow there as well as
elsewhere. The fact that metastases did not take
place in the s])leen was hecause of vascular con-
ditions. Disap])earance of tumors in animals was
not disappearance of a primary tumor and was very
infre(|uent. The failure to implant a tumor in an
animal and its resistance to a second implantation
had been considered immunity, but in these cases a
second tumor might appear and grow. These errors
had arisen from transferring the nomenclature of
bacteriology to the question of tumors. Cellular ex-
tracts, filtrates, etc., had been prepared and colloidal
material and lecithins used to jiroduce immunity.
None of these preparations influenced the growth
of an already established tumor. The tumor could
not be considered separable from the host, but was
identical with the host's normal structures. The
idea of stimulation of the body against the tumor
had been held, and autoagglutinins had been pro-
duced. These were dififerent, however, from cyto-
lytic antibodies. Lymphocytosis had not been foun l
to have any influence upon the growth of tumors
and it had to be stated that the problem of im
mimizing the body against a tumor had still to be
worl'ced out.
Studies of Chronic Myocarditis. — Dr. H. A.
Christian, of Boston, gave this presentation. In
the recent studies of the heart by means of the elec-
trocardiograph, there had been a tendency to em-
l>hasize the importance of the valve lesion rather
than myocardial function. Most cases of myocardial
insufficiency were called mitral insufficiency. The
thickened valve was not differentiated from that
with the orifices enlarged. The pathologist would
term such cases myocarditis as had demonstrable
lesions at autopsy, wdiereas the physician used the
word to mean myocardial insufficiency. Cabot some
years ago had found that only twenty-two per cent,
of the diagnosis of chronic myocarditis, made during
life, were found correct at autopsy. The speaker
said his experience was different, and he thought
fewer mistakes were made in this diagnosis than
in others. The pathologist and the physician, how-
ever, were talking of different things, and the terms
did not correlate. The autopsy would not show any
sign of the interstitial type of myocarditis. Mitral
insufficiency was a rare lesion \vhen considered as
autopsy material. In analysing the cases he had
found that there was a great frequency above forty-
one years. In 407 cases 1 12 gave a history of rheu-
mati.sm ; thirty-five had a i)Ositive Wassermann ; no
were chronic users of alcohol; 178 had high blood
pressure; one half the cases had chronic nephritis.
Overeating was difficult to estimate as a cause, but
188 persons were over weight. In concltision it
could be said that the condition was a very common
one ; the change was primarily in the heart muscle.
The cause could not be determined. At autopsy a
large percentage showed no changes in the coronary
valves and no enlargement.
Dr. E. LiBMAN said he disagreed on the question
of terminology. He did not like to use the word
myocarditis interchangeably with the term myocar-
dial insufficiency. One should try to find a cause
for the myocardial insufliciency ; with a history of
rheumatism there might be a true myocardial lesion .
but with syphilis the disease would be arterial. Ane-
mia, bleeding fibromata, thyroid disease, all might
be the underlying cause of myocardial insufficiency.
In myocarditis there were definite electrographic
changes shown.
Dr. S. S. Cohen said that he wished to remark
upon the nomenclature. Da Costa used to call these
cases dilated heart. Where there was actual myo-
carditis, he called it fibroid heart. Doctor Cohen said
he preferred to speak of "myopathics" and not com-
mit himself as to whether there was definite myo-
carditis or not.
Dr. H. S. Plummek, of Rochester, Minn., said
that hyperthyroidism was a very common cause of
myocardial insufficiency. It had been recognized
that one third of the cases were due to adenomata
of the thyroid. These probably originated in fetal
rests. They were different from the condition of
Graves's disease. The adenomatous tissue developed
post natally and was erratic in development, so that
all degrees of thyroidism were obtained, without re-
gard to the thyroid demands of the tissues. These
patients ran a metabohsm thirty to fifty per cent.
alx)ve normal, and this would drop to normal w-ith
the removal of the adenoma. Blood pressure in
these cases was due to increased minute volume
flow through the right heart.
Dr. S. J. Mfxtzer asked what Doctor Christian
thought about nicotine. Did he consider that was
among the causative factors?
Dr. H. A. Christian in conclusion said that he
did not care what the condition was called as long
as the doctors defined their terms. There were as
many objections to the terms offered on the floor as
to the word myocarditis. They went from the fry-
ing pan into the fire. In the cases studied, the chief
lesion was cardiac. All were advanced cases. Most
of the patients were dead. They were not cases of
anemia, or of thyroid disease. The cases did not
occur in a goitre belt and there was no evidence of
thyroid hyperactivity. Most of them had normal
electrocardiograms. Nicotine could not have played
an essential part, as there were as many women as
men among the patients. Therapy gave only tem-
])orary eft'ect ; they all reacted well to digitalis.
.Some patients lost twenty to sixty pounds on admis-
sion and stayed fairly comfortable.
The Tension of the Gases in the Affluent and
Effluent Blood of the Lungs. — Dr. R. G. Pearce,
of Cleveland, stated that the method of determina-
tion of tension of gases was the most rational and
direct method for testing the functional capacity of
the heart and lungs. It had been used for deter-
mining amount of improvement in the lungs after
gas attacks. The amount of the work of the lungs
with that of metabolism was correlated. In passing
through the lungs the blood lost a percentage of
oxygen and by increase of metabolism there was also
increase of oxygen consumption. In this way some
blood must return to the lungs with less oxygen and
more carbon dioxide than usual. Thus the determina-
tion of the carbon dioxide tension as the blood enters
and leaves the lungs would give a very good indica-
tion of the ability of the circulation to cope with
August lo, igiS.]
PROCEEDINGS Of NATIONAL AND LOCAL SOCIETIES.
267
the needs of the l)ody's metabolism. In order to
linci this, the percentage of the carbon dioxide in the
alveolar air at a certain level of metabolism was
determined. With moderate exercise it was found
tliat there was parallelism between the oxygen meta-
bolism of the effluent and the affluent blood. With
suijerventilation or hyjjerpnea there was marked de-
crease in carbon dioxide tension.
Dr. C. F. Hoovi:k, of Saffordville, Kan., said
he had seen a man who was working at the Panama
Canal seized with a sudden attack of air hunger
when climbing a small slope. The paroxysm came
without warning. In experiments with this patient
later it was found that raising the body from the
floor by straightening the arms would at once cause
a marked attack. The radial pulse disappeared,
the other pulse remaining normal. There was a
brachial rigidity but the blood pressure on the leg
was not affected. In that man there was super-
ventilation beyond the demands of the gaseous meta-
bolism.
The Respiratory Significance of Moisture in the
Air Spaces of the Lungs. — Dr. C. F. IIgover, of
Saffordville, Kan., said that in the studv of gassed
men in France it was seen that large quantities of
foam issued from the nose and mouth, wdiile there
was cyanosis and air hunger. There was a dis-
parity between these two symptoms. In ordinary
cases cyanosis would appear before air hunger. In-
troduction of oxygen, wdiile it relieved cyanosis, did
not alleviate the air hunger. The men would not
tolerate the oxygen mask over the face. They felt
more comfortable breathing atmospheric air. The
reason of this was that the respiratory spaces were
all full of foam. In some bronchioles there was
CO2+ and in some the oxygen was minus. Thus
giving oxygen might not get rid of the COo. This
was similar to pneumonia where the consolidated
lung was contributing unrcspired blood. Unless the
CO2 was removed giving the oxygen caused no ef-
fect. When the COo pressure in the blood was re-
moved, oxygen could be given with relief of symp-
toms.
Dr. S. J. MiiLTZKR said he had read an article on
a method of giving oxygen in pneumonia ; personallv
he had used a different system. By means of a
depressor on the tongue the excessive amount of
carbondioxid was driven out mechanically through
the nose. The mask method was not a comfortable
one. It merely absorbed the quantity of carbon
dioxide which the patient spontaneously released.
Dr. C. F. HoovF.R said that when a man had con-
solidation of the right lower lobe in pneumonia and
no other sign of involvement and oxygen was given
and the cyanosis removed, it was a very difficult
problem to say why one had got rid of the cyanosis.
Cyanosis was due to unexpired blood in the aortic
stream and that would not be touched by giving of
oxygen. The problem was, whv did the cyanosis
disappear and not the air hunger, and this was only
to be explained on the basis of unexpired blood.
The Practical Value of Diphtheria Toxin Anti-
Toxin Injections in Immunization. — Dr. ^^'ILLIAM
H. Park, of New York, in a paper on this subject,
said that evidence was accumulating each year as
to how long the immunity would last after toxin
antitoxin injections, also evidence as to the harni-
lessness of the procedure, two features which con-
stituted the value of the immunization. Young in-
fants under six months of age were protected by
immunity inherited from the mothers. After this
age the inherited immunity rapidly decreased, and,
at two years children were least protected, and con-
sequently the greatest number of deaths occurred at
that age. At ten years of age the mortality was one
thirtieth less than in the second year. In regard to
the haniilessness of the injection, careful study had
shown that earlier procedures were lacking in suf-
Hcient care. The meat in which the diphtheria
l)acillus was planted was allowed to ferment.
Lately a whole broth was made, heated, and no
fermentation took place. Some 10,000 cases of ini-
niuuization had been done and no death had occur-
red. Four cases of collap.se had happened, in that
number. Within the last six months there had been
no untoward results. Twenty per cent, of children
had shown a slight rise of temperature. From one
to three units could be given with perfect safety.
In regard to the duration of immunity it would seem
as if artificial immunity in eighty per cent, of cases
would be as permanent as natural immunity. It had
not dropped off more than two per cent, in two
years. If it should be lost the child could be im-
munized again with equal effectiveness. The im-
munity at birth was found in eighty per cent, of
children. It dropped to sixty per cent, in the second
year. Nonimmune mothers had nonimmune chil-
dren. Immune mothers always had immune chil-
dren.
Dr. A. F. Hfss, of New York, said that at the
Hebrew Asylum the children given a positive
Schick test were immunized by toxin antitoxin in-
jection. There had been no cases of diphtheria in
the institution in the last two years. At first all
cases giving a positive Schick test were immunized,
but babies were found to be immune at first and
then lose their inimimity ; thus it would seem best to
immunize all individuals during the first six months
of life in order to render the institution free of
dijihthena.
Transplantation of Tuberculous Lymph Nodes.
— Dr. C. r. Ryder, of Colorado Springs, read this
pai>er, in which a new experimental method was put-
lined. It was the transplantation of infected tissue
of diseased animals into healthy tissues of normal
animals. Tuberculous lymph nodes were used.
Guineapigs were infected with small doses of viru-
lent human bacilli and when the lymph nodes be-
came markedly enlarged they were transplanted
imder the abdominal skin of healthy animals. When
these animals' inguinal nodes became enlarged they
were transplanted into a third series of animals, and
so on. The skin was found to heal in two weeks,
the gland remaining in place without inflammation,
the first week it acted as a free foreign body and if
the node sloughed out the host escaped infection.
The second week adhesions took place and blood-
vessels from the host's tissue began to penetrate the
implanted node. In three to five weeks the host's
inguinal nodes enlarged and ulceration took place
and within two to four weeks there was generalized
tuberculosis. The tuberculin reaction remained
268
BOOK REVIEWS.— BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Journal.
negative. 1 1 a second node were implanted the ulcer
would open, discharge, and heal, but the first ulcer
never healed. With other tissue, such as spleen and
liver, the results were essentially the same. The
complete experiment would of course be the trans-
plantation of the entire tuberculous organ, but as yet
the technic had not l)een mastered.
The Etiology and Pathology of Rocky Moun-
tain Spotted Fever. — Dr. S. B. Wolbach, of Bos-
ton, read a paper on this disease, saying it was
characterized by diffuse hemorrhages and necroses
of the skin, fingers, toes, and genitalia. It was
transmitted by the tick (Dermocenta anisoma), was
prevalent in Oregon, Idaho, Wyoming, California
and was spreading eastward to Montana. It was a
disease of the peripheral bloodvessels, caused by a
parasite, in the form of minute bipolar bodies. The
reaction of the body was by proliferation of large
and multinuclear phagocytic cells. The organism
was found distributed in the smooth muscle fibres.
The disease could be duplicated with great accuracy
in susceptible animals. Microscopical studies
showed that the organism was paired, lanceolate
and surrounded by a halo. In infected animals the
tissues became flooded with the germ. At present
the organism had not been successfully cultivated.
It had very little resistance to heat and drying. In
its selection of tissues it was extremely specific.
Dr. William H. Park, of New York, asked if
the doctor had been unable to get any cultivation.
Dr. S. B. Wolhacii answered that he had tried
spirochete media and protozoa media, but, compar-
ing it with other organisms,- it was found to survive
less in defibrinated blood and citrated blood than
did spirochetes or trypanosomes.
( To be continued.)
^
Book Reviews.
I We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Nauvelle methodc dc vaccination antityphoidiquc. Le
Lipovaccin TAB. Par E. Le Moignic, medecin de i
classe de la Marine, et A. Sezary, ancien chef de clinique
;\ la Faculte de Medecine de Paris. Paris : T. B. Balliere
et Fils, 1918. Pp. 76.
L.eMoignic and Sezary briefly review the several disadvan-
tages of the use of aqueous vaccines, including their poor
keeping qualities, their toxicity, and the need for the ad-
ministration of several doses in order to produce an ade-
quate degree of immunity. The authors then point out
that the suspension of the organisms in oil is largely free
from all of these disadvantages. Their work was done
with the triple vaccine for typhoid and the paratyphoids,
in which they showed that the administration of a single
dose, containing per mil 2,600 million B. typhosus and
2,275 million of each of the paratyphoid bacilli, failed to
give more than the slightest local or general reactions in
the vast majority of patients. Such a dose, given at a
single iniection, also produced a degree of immunity equal
to that from the conventional doses of the ordinary triple
vaccines. The development of the agglutinins was found
to be remarkably constant. The same contraindications
hold for the prophylactic use of the lipovaccine as for the
ordinarv preiiaration. The preparation of this vaccine is
given in detail, and while it is more difiicult than that of
the aqueous vaccine, it still is relatively simple. One of
the further advantages is held to be the fact that the or-
ganisms in the lipovaccine are not subjected to so many
influences which tend to alter their properties as is cus-
toniarj' in the case of the watery preparations. The lipo-
vaccines should not be used clinically until they are at least
a month old, during which time the organisms become
somewhat clumped, which physical change, combined with
the delay in absorption caused by the oily menstruum,
serves to reduce their rate of entrance into the body, to
prolong their action, and to reduce their toxicity. The use
of an oily menstruum is also recommended by the authors
for other vaccines. This work is not altogether new in
America, for recently we have been receiving favorable
reports upon lipovaccines. The small volume deserves con-
sideration by those interested in the subject of the prep-
aration of vaccines of low toxicity.
Oral Sepsis in Its Relationship to Systemic Disease. By
William W. Duke, M. D., Ph. B., Professor of Experi-
mental Medicine in the University of Kansas, School of
Medicine; Professor in the Department of Medicine in
Western Dental College; Visiting Physician to Chris-
tian Church Hospital, etc. With One Hundred and Sev-
enty Illustrations. St. Louis: C. V. Mosby Company,
1918. Pp. 124.
Theie is nothing new under the sun. This book opens
with a verbatim report by Dr. Benjamin Rush, over a cen-
tury ago, of a case of rheumatism which he became con-
vinced was due to apical infection of a seemingly sound
tooth. The disease was cured by the extraction of the
tooth, and Doctor Rush in the same lecture quotes other
physicians here and abroad as having published similar
observations. The present work does not deal with x ray
technic or apparatus, or with the making of dental radio-
graphs. It explains very well the bacteriology of dental
infection and the way in which this produces systemic or
remote secondary lesions and symptoms. It is illustrated
by excellent radiographs, which with their diagnostic notes
give a correct idea of the dental infections revealed by the
X ray in a great variety of diseases. An extensive bibli-
ography adds to the value of the book, which makes an
attractive volume.
®
Births, Marriages, and Deaths.
Died.
Albl. — In Hartford. ConiL, on Sunday, July 21st, Dr.
Max Albu, aged seventy-two years.
Bingham. — In New York, on Wednesday, July 3rd, Dr.
E. Bingham.
Creamer. — In Deal Beach, N. J., on Sunday, July 28th.
Dr. Joseph M. Creamer, of New York, aged forty-one
years.
FjELiiF.. — In Rolla, N. Dak., on Sunday, July 14th, Dr.
Herman O. Fjelde, aged fifty-three years.
GiLLEN. — In Brooklyn, N. Y., on Monday, July 28th,
Dr. William Aloysius Gillen. aged thirty-five years.
GooDALE. — In Arhngton, Mass., on Friday, July 26th, Dr.
Darwin C. Goodale.
Hamill. — In Phoenix, Ariz., on Thursday. July 23th,
Dr. John E. Hamill, aged fifty-five years.
Jacobs. — In Booneville, Mo., on Wednesday, July 24th,
Dr. Gus Jacobs, aged thirty-five years.
Lewis. — In Chester, Pa., on Sunday, July 28th, Dr.
Henry M. Lewis, of New York, aged sixty-nine years.
Mathews. — In Richmond, Va., on Thursday, July 25th,
Dr. William Philip Mathews, aged fifty years.
MuNsoN. — In Brooklyn, N. Y., on Saturday. July 2gth.
Dr. Forbes J. Munson, aged forty-nine years.
Person: K. — In Duluth, Minn., on Wednesday, July 17th.
Dr. Axel Personen.
Rapp. — In Ellenville. N. Y., on Tuesday, July 2.3rd, Dr.
John W. Rapp, aged thirty-three years.
RoHRER. — In Lancaster, Pa., on Tuesday, July 30th, Dr.
Thaddeus M. Rohrer, aged sixty-four years.
RuNYON. — In Danville. 111., on Saturday, July 2ath, Dr.
T. H. Runyon, aged eighty-seven years.
Todd. — In Camp Dodge, la., on Tjjursday, July 4th.
Lieutenant-Colonel Frank C. Todd, Medical Reserve
Corps, U. S. Army, of Minneapolis, Minn., aged forty-
nine years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 8 43
Vol. CVIII, No. 7.
NEW YORK, SATURDAY, AUGUST 17, 1918.
Whole No. 2072.
Original Communications
RIGHTHANDEDNESS IN ITS RELATION TO
VISUAL CONDITIONS.
Bv George T. Stevens, M. D., Ph. D., F. A. C. S.,
New York.
One of the factors of the subject chosen would
seem to have been settled long before written history
began, and, so far as I am informed, quite to the
satisfaction of all but a small minority.
Our inquiry, however, is from a standpoint rather
different from that from which the subject has been
generally viewed, and hence may possess an interest
which it would not otherwise have. We are to in-
quire whether the custom of righthandedness, or as
it is more technicaKy called, dextrality, has an in-
fluence upon vision, and if so, what is its nature.
A custom almost universal and which has prevailed
from earliest times, might be assumed to be founded
on some fundamental reason which is of a perma-
nent character.
If we inquire relative to the antiquity of the cus-
tom, we are unable at present to secure reliable data
for a period of greatest antiquity. Could we secure
testimony from the man of Piltdown, who is sup-
posed by some to have flourished perhaps 150,000
years ago, or from his predecessor, the Heidelberg
man, who in fragmentary condition is revisiting the
haunts of men after a retirement of perhaps 300,(X)0
years, we might learn more of the antiquity of the
custom of dextrality. Unfortunately, these wit-
nesses, owing to circumstances beyond their con-
trol, refuse to testify. During their long sleep they
have lost their records in this respect, and until we
can call upon some of their contemporaries who may
have preserved the evidence, we can only speculate
in regard to the table manners of three hundred
thousand years ago, whether the Heidelberger of
that day really held his fork in his left hand while
he partook of rabbit au naturcl.
It is only when we reach comparatively recent
times that we have any trustworthy information
respecting dextrality. At a period thirty thousand
years ago we get our first satisfactory information
in this respect, and it may perhaps be truly said that
nothing in historic or in prehistoric times is more
satisfactorily established than that the people who
inhabited the sheltered and sunny riversides of
southern Europe thirty thousand years ago, though
their clothing was scant and their knees were
sprung, strictly observed the etiquette of their time
and were cmj)hatically and, so far as we have
learned, alnioht unanimously righthanded. Al-
though these earlier races of pioneer Europeans dis-
appeared before the advance of stronger races, their
successors continued the custom of being right-
handed.
While, then, dextrahty can not be shown to be of
greatest antiquity, it is old enough to be regarded as
among the well established customs of the past.
So far as I recall, lefthandedness was not made
respectable until comparatively recent times, when
about four thousand years ago, a Hebrew tribe came
out to meet in battle all of the other Hebrew tribes,
and by skilful use of the left hand, and probably
of the right also, put to flight the greater array of
their opponents, taking possession of the field and
of the spoils. Perhaps it is fair to say that the men
of this tribe of Benjaminites were not, technically,
lefthanded. Men were, in those days, mentally con-
stituted much as they are today. If these tribes-
men did not cotiform to the custom of the time and
did not use the right hand almost exclusively, they
would naturally be characterized as going to the
extreme in the opposite direction. If they were not
exclusively righthanded, they must of necessity have
been entirely lefthanded. It is probably much
nearer the truth to suppose that these tribesmen
made equal use of the two hands, a fact that would
explain their unusual manual skill, if not their ex-
ceptional courage. A lefthanded person has no ad-
vantage over a righthanded one, but one who has
trained two hands to act with skill has at tiie same
time trained I'.vo sides of the brain to greater effi-
ciency than one who has trained but one hand and
one half the brain.
I have spoken of the men of thirty thousand
years ago as being generally righthanded. Why
were they righthanded, and how do we know that
they were?
As to the fir^i part of the question, it will be just
as well to confess that we do not know. Respect-
ing the second part of the question, we may reply
that we know with certainty that the races of people
who flourished in different parts of Europe from
thirty to fifty thousand years ago were right-
handed by their deformities.
Perhaps, returning to the first section of our ques-
tion, we might with some satisfaction, even if witli
no additional information, recur to it. Why were
these early settlers of Europe righthanded? No
doubt the mothers, even like mothers of more mod-
ern times, taught them. In spite of some expen-
Copyright, 1918, by A. R. Elliott Publishing Company.
270
STEFENS: RIGIITHANDEDNESS AND VISUAL CONDITIONS.
[New York
Medical Journal.
ments of distinguished scholars, I suspect that no
boy or girl falls voluntarily into the habit of using
only one half of his or her hands without the aid,
direct or indirect, of an instructor. The mother had
learned, or at least her tribe had learned, that the
left was the vulnerable side and that when the boy
became a man and got into a fight, as he was bound
to do, it would become necessary to defend the left
side with the left hand while the right hand would
be in control of the weapon. Thus, from earliest
times in the history of men, the right hand has been
the weapon hand, the left the defensive one.
I'erhaps, too, I should be a little more specific in
reply to the second part of the question: How do we
know that these pioneer people were righthanded?
I have said that we know it by their deformities.
When we turn up the cranium of one of these old
relatives of ours ( they are not necessarily our an-
cestors) we find, as a rule, that the left side of the
cranium, especially at its anterior part, is consid-
erably more capacious than the right, from which
we, of course, conclude that the left hemisphere of
the cerebrum, especially at its anterior portion, was
materially larger than the corresponding portion of
the right hemisphere, and we also conclude that this
is the result of the use of the right hand to a much
greater extent than that of the left.
The fashion Vvdiich these men of old set prevails
as universally now as it did fifty milleniums ago and
produces the same deformity. The left hemisphere
of the brain continues to outclass its fellow, and the
cranium continues as unsymmetrical as it was in the
old stone age. ,
This brings us to the point of interest in our in-
quiry. In what respect can this deformity of the
cranium be related to the function of vision ?
Let us recall that the cerebral location for the
control of the movements of the arm and hand is
near the anterior portion of the hemispheres. Re-
sulting from the more general use of the right hand
this part of the left cerebrum at its anterior part is
also correspondingly developed. A modification of
the position of the orbit naturally results from this
unequal development of the two sides of the cra-
nium. The upper arch of the orbit is pushed out-
ward and the axis of the cavity changed from a ver-
tical to an oblique direction.
The globe of the eye is thereby tilted, its vertical
meridian leaning outward toward the temple. This
leaning of the vertical meridian of the left eye is
extremely common, so common that its absence sug-
gests, although it does not prove, lefthandedness.
Why it does not prove it we may presently inquire.
This tilting outward of the vertical meridian of
the eye does not imply any disease, insufficiency, or
disability of any muscle or muscles controlling the
movements of the globe. The eye simply maintain.-
its normal relation to the orbit, while the orbit does
not maintain its normal relation to the cranium. Of
course the anomaly would occur to the right orbit
in case of excessive use of the left hand during the
period of the most rapid development of the indi-
vidual. Tt is simply a question which orbit is forced
outward by the unequal development of the cerebral
lobes.
Turning our attention to the physical relation of
the left eye to its normal environment in the case
of the average person, we are enabled by the help of
the instrument known as the clinoscope to deter-
mine the relative position of the vertical meridian of
each eye to the vertical position of the head. Ex-
aminations by this instrument, very soon after its
introduction, made it certain that the vertical me-
ridian of the left eye leans, as a rule, outward above
and this independently of whether the subject of
the examination is well or ill, fatigued or at rest.
Such results seemed so improbable at first that i;
was only after a great many examinations, made
with the utmost care to eliminate any possible error,
that t^.is anomaly became a fact established beyond
qtiestion.
On the other hand, while not by any means so
general a phenomenon as that just mentioned, it is
somewhat frequently the case that the vertical me-
ridian of the right eye has a tendency to lean toward
the medial plane, but, nearly always, in a degree less
than the other leans out.
These leanings are known as declinations ; that in
which the vertical meridian leans with its upper end
toward the temple as positive, that in which it leans
to the medial plane as negative.
Returning to the negative leaning of the right eye,
it was found, when a method for establishing a true
verticality for the nominally vertical meridian had
been adopted, that in a large proportion of cases,
the leaning of the right vertical meridian corrected
itself as soon as the normal declination of the left
was corrected. This indicated that as soon as the
involuntary tension is removed from the left e>e
the right resumes its normal position. This, of
course, is not always the case, but indicates when
it does occur that its original negative leaning was
the result of a synergic response to the unconscious
eft'ort to adjust the left eye.
I have spoken as though the positive leaning al-
ways occurs in the left eye. Of course, this is not
strictly correct. A certain proportion of cases show
distinctly and persistently a leaning outward of the
meridian of the right eye, and a certain percentage
show a leaning out of the vertical meridian of each
eye.
Just as a hemorrhage into the anterior portion of
the right lobe of the cerebrum may sometimes cause
some form of loss or disability of the faculty of
speech (although the rule is that aphasia is caused
by a lesion of the left hemisphere), so a positive
declination may occur in the right eye and for the
same reason, namely, that the right lobe of the cere-
brum is equal or exceeds in development the left
cerebral lobe.
It has been my custom for many years to inquire
of persons who show positive declination of the right
eye if they are lefthanded. In many cases the reply
is in the affirmative, but in others it is in the nega-
tive. On closer questioning I sometimes learn that
in early life the subject was lefthanded, but that
later the habit was broken. In other cases the mem-
ory of the subject of the anomaly has not been clear
regarding those formative years.
We need give but a moment to the consideration
of those cases in which there is a leaning of the ver-
tical meridian of each eye outward. Such cases
August 17, 1918.]
WRICHT: THE BLOOD AND THE SOUL.
271
are somewhat frequent and indicate an increase in
the size of the anterior portion of the cranium out
of proportion to the facial parts, possibly the result
of a change of habits in early life.
Coming to the influence of these leanings upon
vision, we can readily see that a. certain confusion
must result when the meridians are not in their nor-
mal relations. Naturally these relations must
change with every change in the direction of the
eyes. If, however, they are incorrect when the eyes
are directed exactly in the primary position, they
are incorrectly related in every other position. Un-
less these meridians are parallel in the primary po-
sition, there can not be such harmony of action of
the two eyes as to give simultaneous impressions on
exact corresponding points of the two retinte in any
position.
According to our accepted views of the physi-
ology of binocular vision, the most perfect visual
impressions are absolutely dependent upon such
impressions being received on exact corresponding
points. Of course, momentarily, we may make cer-
tain allowances in apparent violation of this prin-
ciple, but we can not continue these allowances for
a considerable time.
As a result of the absence of symmetry of action
of the motor influences upon the two eyes, binocular
vision is less perfect than it would be with the abil-
ity to form automatically all necessary movements
of binocular adjustments. True, we may, by a sort
of voluntary effort, induce an approximate adjust-
ment, but it is doubtful if, under any circum.stances,
an absolutely technical adjustment of the two eyes
can be made so as to receive simultaneously corre-
sponding images upon corresponding points of th'i
two retinae under anomalous adjustments of the
corresponding meridians.
Of course, the degree of visual confusion from in-
harmonious adjustments of the two retina; would
depend largely upon the degree of the deviation of
the meridians from the normal and also upon the
physical abilit}'- of the subject of the anomaly to
make the nearest approximate adjustments. In
case of considerable deviation of the meridians, even
the approxiniate adjustments are not continuous.
There must of necessity arise a certain want of ab-
solute fixation, even for a short time. It is not diffi-
cult to understand that such conditions of imperfect
adjustments of the eyes may work greatly to the dis-
advantage or to the dulling of vision.
It is not my purpose to discuss the many physical
disadvantages of declination. I have called atten-
tion to these repeatedly. They are many and im-
portant. It may -lOt, however, be out of place to
refer to the more immediate effects of the eft'orts at
such adjustments as have been mentioned. Ob-
jects may appear well defined for a time, perhaps for
a considerable time, but the efforts become at length
fatiguing and, if the attention is directed to such ex-
ercises as' reading or writing, the perplexity of the
continued eft'orts result, if not in weariness of the
eyes, more probably in an inability to fix in memory
the ideas com-cyed by the printed page, or in a more
or less careless method of expression in case of
writing. There results the mental condition which
Professor Baldwin calls fluid attention. We have
only touched upon the influences which rriay result
from anomalous leanings of the retinal meridians,
but when once such a principle is stated, we can
readily see thai the influence must be varied.
What conclusions should be drawn from these
facts ?
It would seem that, from the point of view of the
ophthalmologist as well as from the general point
of view, the custom of being righthancled is one to
be discouraged. To avoid the evils of righthanded-
ness it does not follow that one should be leflhand-
ed. That would involve not only all the evils of
righthandedness, but would subject the victim of the
unconventional habit to much inconvenience in
addition.
The aim of the instruction of the child should be
to induce the greatest efficiency in both hands while
preventing the exclusive use of either. The boy or
the girl should be strenuously taught to be what is
called ambidextrous, and no effort should be spared
to this end. The mother who would make the
greatest sacrifices to prevent the deformity of a ma-
terial difference in the length of the arms or of the
legs of her child will deliberately take unending
pains to make tiie two sides of the brain of her off-
spring emphatically unequal. Attention to physical
development in other respects is given with empha-
sis, but one of the most important details of the
physical development of the child is not simply neg-
lected but its laws are actually and intentionally vio-
lated in favor of an ancient custom, the necessity
for v/hich passed away many generations since.
Although outside the question we are discussing,
it is hard to resist the temptation to refer to that
which we all know relative to the connection of the
mind with the body, or, to be more specific, of the
mind with the brain. We have almost unanimous-
ly ignored the fact that an unevenly developed brain
may strongly tend toward an unevenly developed
mind.
40 East Forty-First Street.
THE BLOOD AND THE SOUL.
Ancient Belief and Their Relation to the Evolu-
tion in Medicine of Humoral and Pneumatic
Theories.
By Jonathan Wright, M. D.,
Pleasantville, N. Y.
III.
THE BELIEFS OF BABYLONIAN AND EGYPTIAN
CIVILIZATIONS.
A study of the ethnology and archaeology of the
ancient cultures on the Nile and in Western Asia
convinces the casual reader that it is impossible to
reach any conclusion as to whether Egyptian and
IMesopotamian civilizations have or have not inocu-
lated the wilder parts and even the western coasts
of Africa with theories which may have had their
origin on the Nile or the Euphrates. They reached
there an efflorescence and a fruition but their univer-
sal prevalence among the modern wild races of the
dark continent may have always existed and may be
the origin of their evolution in the higher civiHzations.
That this is true of the more definite concepts of the
soul and its immortality seems probable. Still more
apparent seems the practice of preserving the bodies
272
WRIGHT: THE BLOOD AND THE SOUL.
[New York
Medical Journal.
of the dead, at least in some of its processes. Yet
even though metempsychosis may have reached its
greater development in India and Egypt, even
though in the latter country embalming reached its
greatest perfection, we lind the concept of the soul
well developed among American tribes and at least
in its essential features known to the Australians
before the advent of the white man. Von Oefele,
while ignoring the proof we have found in primitive
medicine for the existence of the latent germs both
of a pncuma and a humoral theory, was the first
to point out that they are easily detected in the medi-
cal records and the thoughts of the ancient Egyp-
tians and Babylonians. From the exposition given
in what has preceded it does not seem probable, that
these could have originated so universally and so
essentially primitive.
Both in religion and in medicine still closely
allied with it, we find much more prominent in the
minds of men thoughts only remotely associated
with these germs of humoral and pneumatic
theories. It must be realized in thus going back into
savage life whether of African or of other conti-
nents emphasizing, selecting, and isolating certain
tendencies of thought which subsequently developed
into the importance we assign them in the history of
medicine, we are doing violence to the fabric of
reahty. In reality these were not separate or dif-
ferentiated strains of thought at all. In fact, from
the evidence, it seems nearer the truth to say, that
even when the Egyptian and Mesopotamian civiliza-
tions emerge from utter obscurity and begin to
make records which finally have been transmitted to
us and upon which we place our faulty interpreta-
tions, other concepts of the etiology and pathology
of disease were more prominent — demonology, for
instance, and the conception of the demon or spirit
— perhaps the soul as gnawing at the patient's vitals.
Black magic had thousands of thought vagaries
which at least carried fear and awe, if not entire
conviction, to the savage mind. There are few today
who have not heard of the roles played in black
magic bv certain parts of the body, especially the
excrescences of the hair, the teeth and the nails
We find traces enotigh of these among the Babylo-
nians and the Egyptians even at the height of their
civilization. While perhaps not so prominent as
among the beliefs and practices of men in a more
primitive state of culture, their importance in the
life of the old cultures, and their derivation from
the earlier stage which we can observe among mod-
ern primitive men is striking and assured. It was
supposed (49) that the pneuma pushes these organs
to the surface. This was not only a theory of
Hippocrates, but of the Egyptians. This mysterious
pneuma drawn in by thoracic dilatation and through
the distended nostrils evidently must find a lodg-
ing place within the body before it flows back. In
the Papyrus Ebers we find this provided for, but
the discoverer of the great work declares (50)
that Chabas and Le Page Renouf in translating the
Book of the Dead had early pointed out the sig-
nificance of the Egyptians' idea of anatomy, which
provided the passages of the head or arteries with
outlets which led to all the limbs and viscera of
the body. The eructations of gas and the passage
of flatus by the rectum were the tokens of internal
disturbance set up by derangements of the life
giving principle. Wreszinski, in his translation of
ihe Berlin Papyrus, in which there is a parallel
but shorter text, refers (51) to "the vascular sys-
tem of man," by which we are to understand not
our definition, but to the idea of the pores of which
our vascular system is part, which for the Egyp-
tians pierced the flesh of all parts and channeled
even the nerves and muscles. This the papyrus de-
fines as the system "in which all disease arises."
" We are familiar with the fact that until recent
centuries the arteries, as their name indicates, were
supposed to carry air. It was, therefore, the dis-
turbance of this which the writer of the ancient
treatise supposed to be at the root of all the ills
flesh is heir to. As ancient as is this belief, found
on record in a papyrus more than 3,000 years old,
we should follow von Oefele with caution when he
asserts (52) that as far back "as Chasty, the fifth
king of the first dynasty," according to the infer-
ences to that efifect he believes he finds in the
Papyrus Ebers and the Papyrus Brugsch, "the
air contents of the arteries of the corpse and the
blood contents of the veins are recognized — -the
first step in the pneumatic dogma in medicine."
We have seen reason to believe that the idea of the
"pneuma" is essentially much earlier and much
more fundamental than that among the traceable
concepts of primitive man. Von Oefele infers that
primitive man in Egypt, seeing that man becomes
a mummy through the loss of the pneuma and of
his body fluids, was convinced that the breath is
the source of life, and that the Nile giving moisture
also produces life. Indeed, this enterprising and
resourceful author pushes his positive assertions
(53) into regions which really tolerate only sur-
mises in the indications they give of the way the
early Egyptian and Assyrian looked on the prob-
lem of life. The production of sweet smelling
odors by means of incense and the application of
pierfumery had an intimate connection with the
pneuma theory, and he declares that in the Hippo-
cratic treati.^e, de medico, reference is made to the
young physician who makes use of these on his
person. He likens him to the carbolized young
physician, who in the days of bacillophobia also
carried things to an extreme. He declares religious
ideas as to the efficacy of incense and fumigation,
indubitably first invented to scare away demons,
are afflliated with the theory of the pneuma as the
life giving essence, and its derangements as the
causes of disease. The idea of primitive man was,
we 1-now, that by the production sometimes of bad
smelling fumigation, and less frequently by the pro-
duction of pleasant odors, evil spirits of disease
could be driven out. Among some of the North
American Indians, and perhaps elsewhere among
savages, the idea seemed to prevail that evil spirits
are annoyed by that which seems good to man.
Doubtless originally the pneuma and the ghost of
dead ancestors and the soul were all confounded
as the agents, by the pernicious activity of which
bodily discord arose, yet the Egyptians, at least
when they become historical, have lost this con-
fusion and have already differentiated between the
pneuma and the various souls, the Ba and the Ka.
One of von Oefele's pet ideas is that the pneuma
August 17, 1918.]
WRIGHT: THE BLOOD AND THE SOUL.
273
theory conies from Egypt and the blood or hu-
moral theory of disease from Asia Minor, but this
seems essentially unfounded.
Various accidents of religious or medical belief
may in one place or the other have brought each
into prominence, such as the blood rites of early
Asiatic creeds and the cult of the soul in Egypt,
but these underlying ideas. of the nature of life were
evidently coeval with the birth of thought itself. It
is going to extremes to force a connection as vcn
Oefele does between the superstitions and taboos
in regard to revealing or uttering the name of a
person because it is "a part of his pneuma." To
assert that such things never had any affiliation is,
of course, impossible, because it is impossible to
follow the ramifications of even the recorded
threads in the fabric of primitive thought, but one
has to be obsessed with an idea to see a reminder
of it in every flower that blooms along the path of
the progress of human thought. However, von
Oefele shows, as is so often the case in his writ-
ings, true insight into ancient psychology when he
draws attention to the preponderance of drugs in
the pharmacopeias of Egypt and Babylon many
of which have been abandoned as medical knowl-
edge moved westward, whose chief physiological
action is a carminative one. Garlic, onions, the
resinous exudates of the UmbeUifcra, and a very
formidable list of similar flatus expellers, as he
calls them, can be culled from the Egyptian and
Assyrian lists of medicinal plants in use by these
old civilizations. Von Oefele declares (54) the
pneuma is not directly mentioned in the Papyrus
Ebers until the latter part, when the remarkable
account of the anatomy of the human body is given,
but ideas depending on it are often capable of de-
tection. There is a prescription for medication by
inhalation in column XV ; there is unusual stress
laid upon the administration of purgatives, usually
made up with abundant carminatives and antacids,
and he thinks the priests were afraid to accept the
idea without convincing the people it was the word
of God hid in a book beneath the feet of a statue,^
but in a land where the hand of authority crushed
all human initiative this might have been said about
almost any unusual statement. Whether or not
it is possible to trace back the pneuma theory to
the first dynasty I cannot pretend to say, so far as
it depends on this remarkable idea of anatomy being
of stich antiquity, but there is every prolDability
that the germ of the idea existed among primitive
Egyptians as among other primitive people, and
while deprecating the practice of accepting as proof
the slight indications this gifted archaeologist ad-
vances as such, we must not lose sight of the ex-
treme probability that the concept of anatomy of
the Papyrus Ebers was due to their acceptation of
the pneuma theory rather than any support they
found for the latter in anatomical observations in
the first place. \\^e have read a report of the In-
dians of the northwest coast of America blowing
in the patient's rectum. A similar idea reads in
translation in the Papyrus Ebers (Col. cii). "When
the heart is sufifering and is beside itself, the breath
' This is declared to have been the origin of a part at least of the
papyrus, and it is stated in it (Col. ciii) that this happened during
the reign of the fifth king of the first dynasty — far .enough back for
antiquity to lend its authority of wonder and awe.
through the hollow hand ojjenings of the heb-ker-
priest has an effect on it ; it penetrates into the
large gut, in such fashion that the heart advances
and is lost in the sickness." I do not know how to
explain the meaning of this, but the mind reverts
to the queer therapy we have learned of in the
reports of the medicine of primitive man. Still
more confused is the rendering of the next sen-
tence, but the expression stands forth of the blowing
cure, which "is the breath of the openmg of the
hollow hand of the priest which the heart permits
to enter into its vessels." It is possible that in the
early Hindu medicine of the Atliarva Veda (55) a
charm against diarrhea (1.2. and H-Q.) broaches the
same idea, "tie blows upon the rectum of the
patient," for breath and life and soul were much
the same also in early India. From Hearne's
Travels Bancroft (56) gets his authority for the
assertion that among the North American Indians
of the northwest coast "for inward complaints the
doctors blow zealously into the rectum or adjacent
parts."
In this confusion, however, we see the spark of
the idea of the air which the vascular system was
supposed to contain, which conception transmitted
to the Greeks gave rise to the word artery. The
theory of the pneuma in Egypt, founded on com-
mon observation, must have preceded any knowl-
edge of anatomy in the usual sense of that term.
Indeed, it seems to me the very existence of such
a conception of anatomy is best explained by an
attempt to open a way to all flesh for this life giving
element— t!ie pneuma — through the exercise of the
imagination applied to anatomical description.
Von Oefele has an ingenious reference to the
well known passages in the Papyrus Ebers about
the breath of life going in the right ear and the
breath of death going in the left ear. Alcmaeon,
the early Greek poet philosopher, refers to goats
breathing through their ears, and this occasionally
appears even in post Renaissance time in European
medical literature. Von Oefele says (57) : "The
serviceable pneuma, as appreciated in its vital at-
tributes, we speak of chemically as the oxygenated
air ; it is breathed in through the nose, trachea, and
arteries (in the Egyptian \'iew), and is carried by
them to the organs. In reverse fashion, the useless
air, marked by its poisonous properties, containing,
as we say chemically, carbonic oxide, is carried out
of the body through the ear. In the theory here
considered the variation occurs that the ear is the
beginning or end of the trachea." The mouth and
anus thus have only one opening each, while for the
nose, as for the ears, there are two openings — one
each for the ingoing and the outgoing current being
necessary. As a matter of fact, I know no reason
to believe that this in reality was the conception of
Egyptian anatomists, but it will serve at least to
embody a possible parallel containing a germ of
physiological proof to lay alongside of the queer
conception of the right and left ears, and their
functions as related to the breath of life and death.
In a general way, Ebers himself, though disposed
to demur (58) at soiue of von Oefele's transla-
tion, is inclined to accept his view that the essentials
of the Egyptian thought later appeared in Hippo-
cratic writings.
274
WRIGHT: THE BLOOD AND THE SOUL.
[New York
Medical Journal
As for the Mesopolamians, in the very earliest of
all epics, the Babylonian poem of Gilgamesh, it is
apparent that the conception of the soul as a
"pneumatic" thing came down to them from more
primitive folk. We find (59) Nergal quickly opening
up a hole in the earth in order to let out the spirit
of Engidus, which rushed forth like a gust of wind.
It is possible that the Hebrews brought their pneu-
matic concepts from Egypt, but it is becoming daily
more evident that much of the Old Testament, espe-
cially the creation and the deluge stories, are Baby-
lonian. When "the Lord God formed man of the
dust of the ground, and breathed into his nostrils
the breath of life, and man became a living soul"
(Gen. 2:7), he became one on a Mesopotamian
model, where, with moisture added, they made
mighty things out of the dust of the ground — out
of the sun dried bricks. This conception of the
"breath of life" repeatedly recurs in the early chap-
ters of Genesis, concerned with the creation. "All
flesh, wherein is the breath of life" (Gen. 6:17) is
to be destroyed by the Flood — admittedly a Mesopo-
tamian catastrophe — in which "all in whose nos-
trils was the breath of life" (Gen. 7:22) died, while
all who "went in unto Noah, into the ark, two and
two, of all flesh wherein is the breath of life," were
saved. Preuss (60) declares that when they did
not breathe through their noses it was a sign ac-
cording to the Talmud of their forsaken idolatrous
cult. Much of evil and of good import was ex-
istent among the Hebrews in their omens as to
sneezing, which has its counterpart among all
peoples, but which is founded on the belief that
within exists a windy devil who departs or betrays
his presence in the act of sneezing.
Returning to the strikingly frequent reference in
Genesis to the "breath of life," this dwelling on a
catch phrase is significant enough of the conception
of those who in Babylon learned of the story of the
Flood and copied it closely in the Hebraic records,
but von Oefele, who ascribed an Egyptian origin to
the pneumatic theory of the Greeks, rather stretches
things when he gets, in Genesis 8:1, a ghmpse (61)
of the same idea because "God made a wind
to pass over the earth," to dry up the water. Aside
from the remarkably inefficient way chosen to as-
suage the waters, one fails, I think, to find plausi-
bility in connecting this with pneumatic theories of
life and the soul. He admits that accordmg to the
testimony to which I have alluded the Jahv/ists
must have been "conscious adherents of the pneu-
matic school," in which we have every reason to
concur except it would seem more likely to be accu-
rate if one conjectured they were unconscious ad-
herents to a belief, yet inarticulate, which subse-
quently bloomed into pneumatic doctrine. There
are references in such scanty accounts as have come
down to us from Babylonian medicine of wind act-
ing as an evil agent or spirit in the intestines. In
Kiichler's (62) translation of a Babylonian medical
treatise there are mentioned symptoms referable to
disturbances of the gastrointestinal tract, and em-
phasis is laid on the gaseous eructations. There are
other passages which might easily be given a "pneu-
jnatic" interpretation.
Carminatives are not as frequent in the pharma-
copeia of Babylon as in that of Egypt, but they are
by no means absent, and, as in Egypt, the onion
was frequently used as a drug by Semitic people
generally in gastrointestinal disturbances. Kiichler
conjectures that in one place internal fever is as-
cribed to the action of the wind. In another "a
wind moves around in his rectum," and to them
it may have been a demon or a spirit, as it was
doubtless in consonance "with this idea that pain
is referred to as "when one's insides are devouring
one," for this we know is an idea of primitive path-
ology. In the Babylonian account of the creation
occurs the story of the killing of Tiamat, the
mother of the earth and of the sea, by Bcl-Marduk.
The passage in the translation furnished by Harper
(63) reads as follows:
"To the fight they rushed, advanced to the battle.
Bel spread out his net and inclosed her.
The evil wind, following him, he let loose against her ;
And when Tiamat opened her mouth to swallow (the evil
wind),
Marduk quickly drove in the evil wind, ere she could shut
her lips.
The terrible winds inflated her stomach ;
She lost her reason ; gasping, still wider she opened her
mouth."
It would seem from this that the wind or air is
here regarded as of evil influence, and perhaps from
this passage we may infer that at the time of the
composition of the story the theory of the pneu-
matists was in full force. One wonders if the pa.s-
sage found among the fragments of verse of Em-
pedocles (64) has not a Mesopotamian origin, in
which he attributes the existence of the abdominal
cavity, and that of the intestines, to the sudden and
rapid passage of water through the body at the
moment of its formation, and the external openings
of the nose due to a current of air which was
established from the interior to the exterior.
Notwithstanding the community of belief and
practice on the continent of Africa "between the
ancient Egyptian civilization and the culture of the
wild tribes of the interior, the identification of many
of these with similar phenomena atnong primitive
men in other world divisions much invalidates,- if it
does not annihilate, the assumption that all such
things in the wild African cults are but degraded
transplants from the Nile. The hypothesis that
these things were present with the neolithic Egyp-
tians, just as they were present and are still largely
present with central or western African tribes, as
representing stages of culture, seems, in view of all
the facts, the more attractive theory. There are
certain developments of these fundamental beliefs
which obtained in ancient Egypt and in other times
and other places which do not obtain markedly
among modern African savages. The belief m the
fertilizing properties of the blood is doubtless due
to the "life" it holds, especially human blood. Much
in sacrificial ritual is due to this, even human sac-
rifice, but this is chiefly marked in people who have
reached a more or less highly developed agricul-
tural stage. This is not strongly marked in wild
Africa. Many other ramifications we have had to
avoid, even in the primitive life which we have thus
- I cannot discuss here the ardent advocacy of Elliott Smith
(Migrations of Early Culture, Manchester University Press, 1915)
for the view that in very remote times Egyptian culture spread all
over the world, even to America.
August 17, 1918.]
WRIGHT: THE BLOOD AND THE SOUL.
275
far discussed. The cusloni of blood offering to
divinities of fertility was only one of the offshoott'
of the fundamental idea of the blood as the life.
If we are to judge from the Papyrus Ebers, the
use of blood in Egyptian prescriptions was well
known. That it may have been of Asiatic origin,
it is impossible to deny, but the prevalence of the
use of blood among the African tribes and their
religious ideas in regard to it might also be argued
as evidence of an African origin for it. In the
LXIII column of the Papyrus Ebers, in the rem-
edies for eye disease occurs the transcription of
a formula which is said to have been derived from
a Semite out of Byblos, which was a city of Phoeni-
cia, tributary to Assyria at one time. In that par-
ticular prescription there is no mention of blood,
but in two which almost immediately follow, both
for trichiasis, lizards' l)lood, the blood of bats, of
a cow, an ass, a pig, a dog, and a deer are pre-
scribed. It might be claimed, of course, that these
receipts are also of Asiatic origin. Elsewhere the
use of worm's blood is recommended as a local ap-
plication to draw a splinter out of the flesh. One
or two prescriptions are recommended against the
"devouring action of the blood" within the body,
which may well be likened to the pathological ideas
entertained of demons gnawing at the vitals in the
concepts frequently noted in primitive medicine.
Another local application is a sah^e entirely com-
posed of blood drawn from a dove, a goose, a swal-
low, and an eagle. The polyvalent nature of most
of these prescriptions would indicate the blood of
each participant as the carrier of some quality with
which it was desirable to anoint the ]:)atient, so that
either the sum total or perhaps one alone, might
chance to contain the needed quality of medication -
some chance antibody like that blindly sought in our
serological therapy, the neohumoral theory of the
twentieth century. It has been asserted that the
I\gyptian authors, to hide the identity of the drugs
they used, spoke of them under the name of the
excrement and blood of dififerent animals. What-
ever the origin of the therapeutic principle, the
Papyrus Ebers alone sufficiently exemplifies the
idea of the existence of blood or of humoral theo-
ries in Egypt. Von Oefcle (65) intimates that the
Egyptians, in the proces.ses of embalming the dead
body found the arteries empty of blood. The Asi-
atics lacking this practic.> could not have ob.-;erved
it. From such a surmise perhaps little can be
oxj^cted in the way of argument, yet, notwith-
standing the appearances, in very many places, of
fvidences of the existence of a humoral pathology
among the Egyptians, general acquaintance with
such of Mesopotamia and Egyptian medicine as has
come down to us through the ages probably justifies
his remark, except in so far as it intimates a con-
scious recognition of the theories, formulated by
the Greeks, in the ancient Egyptian practitioners of
medicine. "The vVsiatic was a haematist and rec-
ognized the breathing, but gave to it a secondary
importance. The Egyptian was a pneumatist. and
recognized the importance of the blood, but in a
degree secondary to the significance of the breath-
ing." In the Ebers Papyrus all the excretions of
the human body were used in prescriptions for vari-
ous purposes. Bile is also frequently mentioned in
connection with the blood, but so is tlie mucus, fat,
and oil of animals. It is quite impossible to detect
the clean cut theories and their application in ther-
apy in the way we find them in the later writings
of the Crreeks and Romans. The writings of Plu-
tarch and Pliny, versed as their authors were in
the doctrines of Greek medicine, cannot but be mis-
leading when their remarks are applied to the earlier
eras of Egyptian science. The former (66) gives
us an insight, but a distorted one, into the thoughts
of the Egyptians, stimulated by the phenomena of
the recurring fructifying floods of the Nile and ex-
posed in their religious ideas as to Osiris.
It is difficult to understand the rise of these
humoral ideas without a consideration of homoeo-
pathic magic. It is clearly seen that in the blood and
secretions of different animals, or of different parts
of the human animal, primitive men and men of
the earliest civilizations believed there are certain
qualities which can be transmitted to others with
them. There is probably no other aspect of the
humoral pathology which so fundamentally distin-
guishes it for us from the theory of the pneuma
:it their origins. Each belonged to a different cat-
egory of thought, and they have continued to carry
different sequences of concept and practice to this
day. The pneuma itself was the life element, but
with the idea that "blood is the life" is always the
inherent implication that it carries certain attributes,
as fetich objects, for the most part, do. It is not
the stone or stick or claw itself. It is the power
which resides in it. The blood, but not the pneuma,
l)elongs to this fetich order of thought. In a way,
]jerhaps, this distinction connotes some -^^lement of
diff'erentiation in modern thought, overshadowed as
it now is by our scientifie complexity of knowledge
in biochemistry.
In Assyria, and probably in the cults derived
from it, there probably was an affiliation between
the blood and the liver and the rites of divination
as practised by the priest and augurs. Jastrow (67)
says: "The reason why the liver should have been
selected as the seat of life is no: hard to discover,
niood was naturally, and, indeed, by all peoples,
identified with life; and the liver, being a notice-
ably bloody organ, containing about one sixth of
the blood in the human body, and in the case of
some animals even more than one sixth, wa^ not
unnaturally regarded as the source of the blood,
whence it was distributed throughout the body."
Since hepatoscopy arose at a comparatively late date
in the religious divinatory rites of the Babylonians,
and since we have indubitable evidence of the preva-
lence of the conception of the blood as the life
among the most primitive people, there seems little
reason to doubt that the idea of divine purpose
manifested in the aspects of the liver as interpreted
by the priests must have arisen from the necessity
of regarding it as the "mother of the blood," the
home and the active seat of that divine principle
which is the direct gift of the gods. It therefore fur-
nishes a parallel for the rise of the remarkable con-
ception the Egyptians had of the human body as
rm organism channeled with conduits to lead the
pneuma to all its parts. This parallel I shall attempt
276
WRIGHT: THE BLOOD AND THE SOUL.
[New York
Medical Jouhnai..
to develop more in detail elsewhere. Hepatoscopy,
then, and the astonishing Egyptian idea of anatomy
arose as theoretical deductions from the misinter-
preted phenomena of the breath and the blood. Von
Oefele (68) declares that throughout antiquity it
was supposed dreams are derived from the blood,
and possibly this connection with the liver as a
blood organ may have given them the prophetic
significance which has been ascribed to them by at
least some orders of inteUigence in every age. It
is evidently from its most prolific source in Baby-
lonian civilization that the Talmud (69) draws its
behef that the liver is the origin of the blood and
the seat of anger and of envy. In view of the fact
that the word for gall, which is later associated
with the liver as the seat of envy, in the language
of the Mischna has the meaning of bitter, and since
this is also affiliated with the conception of poison,
we may imagine that primarily in the rise of the
humoral pathology the etiology of disease was as-
sociated in the same way with these ideas, espe-
cially in an etiological way with gall as a poison,
and with envy as the motive for the use of black
magic in causing disease.
There is a possible clue to the existence of a lat-
ent humoral doctrine of which little or nothing is
formulated in the Talmud, in the saying that the
blood, or rather a plethora of it, is the cause of
all disease. Dropsy was supposed by Talmudistic
writers to be due to a disturbed relationship be-
tween the blood ?<id water, the latter entering largely
into the theory of Babylonian medicine. It is pleth-
ora the Midrash describes as the cause of leprosy.
Blood and water are in equal parts in the human
body. In sickness, when water is the more abun-
dant, the patient naturally becomes dropsical, but
when he has too much blood he becomes leprous.
"According to R. Jochanan there are no lepers in
Babylon, because men eat mangold there, drink beer,
and bathe in the water of the Euphrates."
As we have seen for the pneuma in Genesis, the
belief that "the blood is the life" is strongly ex-
pressed in Leviticus 17:10 fi. Jirku (70), having
drawn attention to this belief of the Hebrews, goes
on to say that not only according to Babylonian,
but according to Arabian belief, demons nourish
themselves on the blood of their victims, and lience
he surmises that the blood sacrifice in the Hebraic
ritual was for the purpose of satiating the demons
which were seeking the life blood of the wor-
shippers. Something of this kind is probably at
the iDOttom of the conception, entertained by many
primitive people, that invisible powers are gratified
or mollified by the shedding of iDlood, which usually
at first is human blood, that of animals being later
substituted, as for the blood of Isaac that of a ram
(Genesis 22:X3). This seems a phase frequently,
if not alwavs, traversed in the evolution of re-
ligions.
Von Oefele (71) believes it probable that Egyp-
tian ideas of the pneuma and Asiatic ideas of the
blood became associated along routes of intercourse,
one of which lay through Sardis, a city of Lydia,
which later furnished its doctrines to the old Greek
schools of medicine at Cuidos and Cos and Croton.
He refers to a London papyrus. No. 137, mention-
ing a Greek physician by the name of Thrasyma-
chos, living before the time of Aristotle in Sardis,
contemporary with Hippocrates ; he is said to have
left behind him the theory of the blood as the
"cause of disease." From its metamorphoses dis-
eases arise. These changes result either from an
excess of cold or an excess of heat. The rcsult.s
of the metamorphosis is mucus, bile, pus. The
blood is a simple body, while mucus, bile, and pus
in their own complexity of structure bring forth
many varieties of disease capable of differentiation ;
black bile taking the place of pus would cause the
passage to conform to the later humoral pathologw
Deixippus, the Coan physician, is said by the papy-
rus to have taught the same, and he was a pupil
of Hippocrates. Thus von Oefele sees a connec-
tion which may have existed between Hippocratic
and Lydian medicine. Doubtless there were many
points of contact; in fact, Babylonian medical
thought, like Egyptian medical thought, often flowed
unobstructed for generations in the channels of com-
mercial and political communication between the
civilizations that were perishing and the one yet to
arise, but we are hardly justified in accepting the
view that a humoral idea and a pneuma idea arose
separately in Asia and in Africa. Frothingham
(72) has shown that the Phoenicians, at least, rep-
resented the origin of life on a tablet as due not
only to moisture, but as inherent in the breath.
Presumably vori Oefele would see in this an ocu-
lar demonstration of the blending of the two ideas.
REFERENCES.
30. H. R. SCHOOLCRAFT: Indiatt Tribes of the United
States, Lippincott, Philadelphia, 1851-57. 31. WILLIAM MAR-
INER: An Account of the Natives of the Tonga Islands in
the South Pacific Ocean, J. Martin, London, 1817. 32. WIL-
LIAM CROOKE: The Popular Religion and Folklore of Northern
India, new ed., 2 vol., A. Constable, Westminster, England,
1896. 33. R. H. NASSAU: Fetichism in West Africa, C. Scrib-
ner's Sons. New York, 1904. 34. G. F. KUNZE: The Curious Lore
of Precious Stones, J. B. Lippincott, Philadelphia, 7913. 35. W. E-
ROTH: Ethnological Studies Among the Northwest Central Queens-
land Aborigines, R. Gregory, Gov. prtr., Brisbane, 1897. 36. B.
SPENCER and F. J. GILLEN: The Northern Tribes of Centra!
Australia, Macmillan, London, 1904. 37. B. SPENCER and F. J.
GILLEN: The Native Tribes of Central Australia, Macmiran,
London, 1899. 38. T. H. PARKE: My Personal Experiences in
Equatorial Africa, Sampson Low-Marston, London, 1891. 39. A. W.
HOWITT: The Nati-rc Tribes of Southeast Australia, Macmillan,
London, 1904. 40. FRIEDRICH RATZEL: History of Mankind,
translated by A. J. Butler, Macmillan, London, 1896. 41. H. H.
BANCROFT: The Native Races of the Pacific States of North
America, D. Appleton, New York, 1875. 42. NASSAU: Op. cit.
43. CROOKE: Op. cit. 44. RICHARD NEUHAUSS: Deutsoh
Neu-Guinea, D. Reimer, Berlin, 1911,3 v. 45. W. L. HILBURGH:
Notes on Singhalese Magic, Journal of Anthropological Institute of
Great Britain and Ireland, xxxviii, 1908. 46. B. SPENCER
and F. J. GILLEN: Ti:e Northern Tribes 'nf Central .4nstraHci.
Macmillan, London, 1904. 47. J. G. FRAZER: The Magic Art,
3d ed., 2 vols., Macmillan, London, 1913. 48. J. G. FRAZER:
The Scapegoat, Macmillan & Co., Ltd., London, 1913. 49-
FEUX VON OEFELE: Allgemeine medizinische Centralblatt
zeitung, 1897, p. 81. 50. GEORG EBERS: Wie Altagyptisches
in die Europalische Volksmedizin Gelangte, Zcitschrif fiir agyjtischc
Sprachc und Altcrthumskunde, xxxiii, p. i. si. WALTER WRES-
ZINSKI: Der grosse medizinische Papyrus des Berliner Museums
(pap. Berlin, 3038) in Facsimile und Umschrift mit Uebersetzung,
Kommentar und Glossar., J. G. Hinrichs, Leipzig, 1909. 52. FELIX
VON OEFELE: Vorhippokratische Medizin Westasiens, Aegyptens
und der Mediterranean Vorarier, in Puschmann, Th., Handbuch der
Geschichte der Medizin, Gustav Fischer, Jena, 1902, p. 52. 53.
FELIX VON OEFELE: Materialien su einer Geschichte der Pha-
raonenmedizin und Pneumalehre. 54.. FELIX VON OEFELE:
Prager incdizinischc Wochrrschrift. Marz, 1905. 55. Hymns of the
Atharva Veda, translated bv M. Bloomfield. Clarendon Press. Ox-
ford, 1897 (Sacred Books of the East. xlii). 56. H. H. BAN-
CROFT: The Native Races of the Pacific States of North America,
D. Appleton, New York. 57. FELIX VON OEFELE: WHner
klinische IVochenschrift, 1896, No. 7, P- "5- 58. EBERS: Op. cit. 59.
ANTON JIRKU: Die Ddmonen und ihre Abwehr im Alten Testa-
ment, A. Deichert, Leinzig, 1912. 60. JULIUS PREUSS: Biblisch-
ta'mudische Medizin, S. Karger, Berlin, 1911. 61. FELIX VON
OEFELE: Praner mcdi-inische Wochenschrift. igoo, xxv, p. 10.
62. FRIEDRICH CARL HEINRICH KOCHLER: Beitrage xur
Kenntniv der Assyrischcn Medizin, Marburg, 1902. 63. R. F.
HARPER: Assyrian and Babylonian Literature. 1904. ^4 Fraam.
Philosoph. Grace.. Mullach, 1875, 2d ed., i, 343ff- ^5. FELIX VON
August 17, 1918.]
WALLFIELD: CONGENITAL SYPHILIS.
277
OEKKLL: Matenalicn zt. einer GLSihichtir der Pharanicnmcil!:!'!., \i,
Acgyptische Pneumalehre in Auslande. 66. Isis and Osiris, Plutarch's
Morals, translated from the Greek, corrected and revised by William
W. Goodwin, Little-Brown, Boston, 1870, 5 vol., iv, p. 65. 67.
MORRIS JASTROW: Aspects of Religious Belief and Practice tn
Babylonia and Assyria, G. P Putnam's Sons, New York and Lon-
don, 1911. 68. FELIX VON OEFELE: Op. cit. 69. PREUSS:
Op. cit. 70. JIRKU: Op. cit. 71. VON OEFELE: Loc. cit.
72. A. L. FROTHINGHAM: Babylonian Origin of Hermes, the
Snake-god, and of the Caduccus, American Journal of Archeology,
2A ser., 1916, XX, No. 2, p. 175.
- CONGENITAL SYPHILIS AND THE
DOCTOR*
By J. M. Wallfield, M. D.,
New York.
Attending Physician, Kingston Avenue Hospital; Visiting Pediatrist
to the Williamsliurgh Hospital, Brooklyn, N. Y.
When a child is bom infected with syphihs, the
condition is called congenital syphilis. The doctor
who is attending such a child is confronted with a
clinical and social problem of grave importance.
Not only is the patient to be treated, but the wel-
fare of the community at large must be taken into
consideration. The loss of an infant is in itself a
deplorable affair, but to allow an unrecognized and
consequently an untreated congenital syphilitic to
become a burden and a menace to the social body
is still worse. The cause of syphihs is the Spiro-
chaeta pallida. The infant becomes infected
through one or both parents. The positive Was-
sermann reaction confirms the diagnosis, but a neg-
ative result does not exclude the existence of syph-
ilis ; hence a clinical diagnosis is all important in
these cases. It would be a very easy matter to rec-
ognize the disease if all the symptoms were pres-
ent, but unfortunately, they are only too often
masked. According to Ernst Moro (i), in the
first two or three weeks of life coryza, pemphigus
and an enlarged spleen constitute the three cardinal
symptoms. The other symptoms are albuminuria,
osteochondritis and enlarged liver. But often,
most of these symptoms are not very well defined
or are absent altogether. It must also be borne in
mind that other diseases may produce similar ap-
pearances; e. g., coryza may be due to an influenza
infection. The spleen may be enlarged and still
not be felt below the border of the ribs. And not
all eruptions are syphilitic pemphigus. An erup-
tion on the palms and soles in the newborn is con-
sidered by Moro an indisputable indication of
syphilis.
In syphilis of a later period, Hutchinson's triad,
keratitis, deafness, and notched teeth, are positive
diagnostic points, and yet there are syphilitic chil-
dren who fail to exhibit these important symptoms.
Other symptoms are the saddle nose, claimed to be
the result of the early coryza, syphilitic dactylitis,
paronychialuetica, alopecia which is frontal in con-
tradistinction to occipital, alopecia of rickets, and a
peculiar glossy condition of the cutaneous surface
of the solar and palmar regions. Hochsinger (2)
insists that mucocutaneous scars around lips and
anus are the best proof of congenital syphilis.
Osteochondritis can be seen on the x ray plate
very clearly, but it is not always available in pri-
vate practice. According to Kassowitz (3), about
one third of congenital syphilitics die before birth,
*Read before the Brooklyn Pediatric Society, May 22, igtg.
and about another third perish during the first six
months of life. Syphilitic infants are more prone
to develop rickets and have in general a low re-
sistant power.
Very few other diseases cause such a large mor-
tality, and it is the province of the doctor to save
as many of the patients as possible. There is a
campaign on foot to save one hundred thousand
more children in the United States during the next
vear. The position of the doctor is a very delicate
one in these ca.ses of syphilis, as the laity know
that they are suspected of being diseased whenever
they are asked to submit to a blood test, and the
doctor's position may be an unpleasant one if a
negative diagnosis is returned. There is, of course,
less trouble with an intelligent than with an ignor-
ant family, but the latter class, unfortunately, pre-
dominates.
Proper care of the parents will do much to save
many children who would otherwise be born in-
fected with syphilis. I'he shorter the period which
has elapsed fom the time when the parents con-
tracted syphilis and the time when conception took
place, the greater its virulence in the children. This
explains the death of the firstborn in rotation and
the possibility of an apparently healthy child born
subsequently to untreated syphilitic parents, as in
time the virulence of the disease weakens.
During the fifteenth century there were severe
epidemics of syphihs in Europe which have never
been repeated. This is explained by the theory of
a certain degree of immunity transmitted by suc-
cessive generations to their descendants. When-
ever the syphilitic virus strikes virgin soil, as for
instance, the negro race (which has not yet acquired
immunity), it spreads more rapidly and in a more
virulent form. But the transmitted immimity can-
not last forever, and a time might come when a
community could again become susceptible. The
early settlers of the United States, by early mar-
riages and a puritanic mode of life, could be cited
as an example of freedom from syphilis. Another
instance is the orthodox Jew. As a persecuted
race the Jews must have been infected with syph-
ilis during the crusades, if Astruc (4) was correct
in his almost cynical reference to the fourteenth
centur}' : "From the Pope of Rome on this throne to
the lowest scullion in Christendom, all were infected
with syphilis." But whenever Jews were allowed
to exist without violent attacks upon them from
their charitable protectors, their leaders inaugurat-
ed a very strict morality, paying special attention
to sexual cleanliness, which in time led to an almost
complete eradication of lues in their midst. Only
recently, some Jewish doctors were convinced that
it was superfluous to look for syphilis among their
Jewish patients ; they forgot that times and morals
changed. They may have lost their immunity and
may furnish a very rich soil for specific infection.
It is certainly the doctor's province to warn the
people, whether Jew or Puritan, of the impending
danger, which increases with each successive gen-
eration.
The obstetrician enjoys the greatest opportunity
for observing the newborn, but as a rule, he is the
least interested in babies, and may overlook the
early symptoms of congenital syphilis. These neg-
U'ALLFIELD: CONGENITAL SYPHIUS.
[New York
Medical Journal.
lected cases swell the number of children who af-
terwards exhibit si^ns of latent syphilis.
Unless the physician will pay attention to the
finest details, sy])hilis can be easily mistaken for
any other disease. Without a careful history, a
diag-nosis is often inipossible. It seems a better
policy to inquire how many times the mother was
I)regnant, and then to fmd out how many living
children she has; the dil^erence, if any, may be due
to abortions, jn'emature births, or loss of babies in
their early infancy. As a rule, the firstborn are
more liable to succumb, since with them there is the
shortest interval to the time of the infection in the
]iarents. If there are any stigmata, as a saddle
nose, snufifles. pale, waxy skin, failure to ])roperly
develop, and in older infants and children, rhag-
ades and a hard and enlarged liver in connection
with a suspicious history, a positive diagnosis of
congenital syphilis is correct. The greatest dififi-
culty encountered in these cases is with a negative
history or in a case of a child from the first preg-
nancy. In hospital cases a \v'assermann test on
father, mother, and baby may be of assistance, and
as a rule, it is not always difficult to induce the par-
ents to submit to a blood test ; but in private prac-
tice it is not always practicable.
Whenever the mother appeared healthy looking
and still complained that tlie baby had not gained
in weight during the early nursing period, congen-
ital syphilis was often the underlying cause. The
mother's system, during the time she was i)regnant
with a syphilitic fetus, was undergoing a change
which afifected the milk either in quality, quantity,
or in both. As soon as these babies were put on
artificial feeding, they improved considerably.
Again it must be repeated that the social obliga-
tion of the doctor to the conimunitv forbids allow-
ing the use of a wet nurse for even a suspected
case of congenital syphilis for fear of spreading the
disease. Though it is generally agreed that there
may be fever in (onncction with congenital syph-
ilis, it is always added that the fever is never high.
It will be illustrated by actual cases, that high fever
without a definite cause may be the only symptom
of congenital syphilis. The two points just men-
tioned, I, the deficient nutritive power of the milk in
a healthy looking mother, and 2. high fever in the
infant without cause, may lead to a correct diagno-
sis and restore the child to an almost normal condi-
tion by proper treatment. The high temperature
may possibly l)e due to a disturbance of the heat
centre. Prolonged hc.idaches in older children may
well be looked U])()n with suspicion.
C.^sF.s I AND II. — Wester C, fourteen years old, and
Tony C, twelve years old, brothers, complained of pain
in the head, not relieved by attention to dlRestive organs
and corrected diet. The Wassermann test was positive.
I .alcr on the mother submitted to the same test with posi-
tive findings: the father could not be seen. The liistory
in these two ca.ses did not exactly clear up the question
whether the infection was congenital or acquired, as there
were no other tangible signs to be found.
The following two case reports will serve as an
illustration of high specific fever:
Cask III. — B. P.., white, female, born in the I 'nited
States, aged four years. The family history as given by
the mother was negative, as was the previous history.
Present status: A well nourished child taken ill during
the previous night with fever which did not diminish after
mother had administered a cathartic. Temperature 104°
F., pulse 120, respirations 28. A possible infection of
grippe was su.ggested and appropriate treatment ordered.
Tlie next day the temperature reached 105° F. On the
tliird day, a consultant assured the mother that the grippe
would turn, within a day or two, into pneumonia. He
pointed out the right upper lobe as the seat of the process.
Forty-eight hours after the consultation the patient's father
confessed to the doctor that he had been treated for syphilis
before marriage and cured. As there were no symptoms
of pneumonia, it was decided to give the child a test treat-
ment with mercury. This course met with gratifying re-
sults. The child is at present nine years old and seems
perfectly well.
Case IV. — Patient of Dr. B., who wanted a lumbar
puncture done on his patient for diagnostic purposes, as
he suspected tuberculous meningitis. The fluid was clear
and came under high pressure. In discussing the
case with the doctor, the following points were obtained :
Patient, Italian, four years old, was one of seven living
children. Family history, as far as known, was good.
The child was sick for a few days and under the physi-
cian's care for three days. The doctor found nothing
definite on repeated examination, except a fluctuating tem-
perature of 103" F. to 105^ F., and an increasing listless-
ness approaching stupor. With the permission of the at-
tending physician, the mother was closely questioned with
regard to the number of pregnancies. Finally the fact was
elicited that two pregnancies terminated in spontaneous
abortions. The suggestion to treat the child with mercury
and iodides for a few days was ventured. The spinal
fluid proved to be sterile. While patient was still under
treatment, another physician was consulted, who, accord-
ing to the mother's statement, promptly informed the fam-
ily that the child would surely die, because he was sick
with consumption in the head. On the fourth day of
treatment child looked brighter, his temperature fell, and
he sat up in bed asking for food. The last time the physi-
cian heard of him there was apparently nothing the matter
with the child.
Case V. — S. S., male, white, born in the United .States,
aged fourteen months. Family history as obtained, nega-
tive. Previous history: Firstborn from first pregnancy.
Instrumental delivery. Nursed by an apparently healthy
mother for the first five months, but did not gain. Has
had frequent attacks of cold in head, which produced
difficulty in nasal breathing. By the advice of a Manhat-
tan specialist in children's diseases, the mother placed the
child on artificial feeding, with good results. First seen
on January 12, 1915. Baby was sick with a severe cold,
and as the family physician could not restore him to health
for three consecutive days, a change in doctors was insti-
tuted. On examination, a severe coryza was visible, child
looked dull, temperature was 103.5° F., pulse was rapid,
respirations were increased in number. It was difficult
to count, as child struggled a good deal. Chest was nega-
tive, throat congested. A diagnosis of grippe was made.
January 13th, same condition held with a temperature of
104° F. ; January T4th, temperature 105° F. A nose and
throat specialist was called in, who excluded ear trouble,
and, as the diphtheria culture from the secretion of the
nose was negative, he predicted a retropharyngeal abscess
within forty-eight hours. No abscess was formed
The evident disparity in the ages of the patient's parents
(the father looked a man over forty, while the mother ap-
peared still in the early twenties), coupled with the his-
tory of deficiency in the quality of the milk during the
early nursing period, frequent attacks of coryza and high
fever, led to a tentative diagnosis of congenital syphilis.
The father was cautiously informed of the su'inicion. He
confessed that fifteen years ago he was treated for a skin
eruption which yielded to specific treatment. The child
began to improve after the third inunction with mercury,
and before a week was over was well. Since then,
whenever this child has a recrudescence of high fever,
no other remedy acts except mercury. A second child was
horn in the same family, and the mother's milk again was
of no benefit to the nursling: cow's milk was used. There
are so far no visible signs of infection in the child, which
is four months old.
.\11 these cases emphasize the importance of a
thorough acouaintance with the patient's parents.
In one case, the occupation of the father gave a cltie
August .7, .9.8.] FRIDHAM: I'REVENriVE TREATMENT OF BONE AND JOINT MALADIES.
279
to the real trouble in the infant ; the man was a
traveling salesman (the occupation, a predisposing
cause to specific infection). The difficulty in diag-
nosis in some cases may sometimes lead to very un-
pleasant consecmences, as will be seen from the last
case report.
Case VI. — Allen G., white, male, born in the United
States, aged fourteen months. Family and previous his-
tory negative. Present history: In September, 1916, dur-
ing the poliomyelitis epidemic, Allen became ill with a
high fever and dull look. The doctor in attendance, a
near relative, called in consultation a pediatrician from
Manhattan, who suggested the removal of the patient to
a general hospital where he could be kept under observa-
tion His advice was followed. At the hospital the child
was seen by a professor on nervous diseases in one of the
leading universities of Manhattan. His diagnosis after
a lumbar puncture had been made was poliomyelitis, and
the patient was removed promptly to the Kingston Avenue
Hospital. There another lumbar puncture was made,
which came back what was then considered positive. A
slight right facial paralysis could be noticed if looked for
carefully, the intercostal muscles seemed to be stationarj^
during respirations ; there were no teeth. Large, dry rales
soon developed all over the chest and the temperature was
steady at 104" F., with very insignificant remissions. The
skin of the blonde little patient was of a wa.xy pale color
and there always remained an impression that the child
was either bald headed or was endowed by nature with a
very large forehead. For almost three weeks there was
no change to be noticed, e.xcept that at times there was
profuse persniration. At last it was decided to put the
patient on m.ercury. The success of the treatment was
noticed on the fourth day, when all the symptoms began
to show an improvement. This child underwent a thor-
ough course of treatment for a few weeks and was dis-
charijed fro'ii the hospital at the end of seven weeks, in
good condition. Since then, the child has not been ill,
walks, talks, and has all his teeth, according to the infor-
mation obtained from the doctor relative of the patient.
When the doctor has made a correct diagnosis
and helped his patient to get well, he may consider
his task accomplished, but from a sense of duty he
must go deeper into the subject and take into con-
sideration the future children which may be born
to the syphilitic parents, and he must also have in
mind the welfare of the community at large. The
l)arents should be strongly urged to undergo treat-
ment and to refrani from further procreation
meanwhile, even if such advice does, to a certain
extent, come in contiict with the religious and even
civil interpretation of the law. The physician
should try to disseminate, in his social circle, as
much knowledge on the subject as possible, espe-
cially among the younger men. There are very
few degenerates who would jeopardize the future
generation for the sake of their own temporary sex-
ual gratification. Wide publicity on the subject
seems to- be the best plan. Nineteen eighteen is
intended to be the child saving year, and the pedi-
atric societies should have special committees for
the purpose of spreading information on congenital
syphiHs to the public through the general press, lec-
tures, and other usual means. Above all, one thing
is certain, the sooner the press frees itself from
false and detrimental prudery and calls things by
their own names, the better for our social struc-
ture.
REFERENCES.
1. ERNST MORO: Prof. E. Feer, Diseases of Children, p. yj^.
2. HOCHSINGER: Pfandler and Schlossman, ii, p. 559. ^ KASSO-
WITZ: Chapin and Pisek, p. 284. 4. ASTRUC: Osier's Practice of
Merlicine, iii, p. 438.
1269 FORTV-STXTTI StREKT. BROOKLYN.
THE PREVENTIVE TREATMENT Ol-
BONE AND JOINT MALADIES.
By Frederick Pkiuuam,
Baltimore, Md.
Infections of bones, bone marrow, and joints
usually go on to a slow termination, relapse, and
have a great tendency to recur time and again.
The predisposing origins of the infection are not
usually discoverable.
True, the predisposing factors may be some in-
jury or accident, exposure to cold and dampness,
excessive or poor food, excesses of effort, work,
play, or the emotions ; but be these what they
may, the fact remains that bacteria or infec-
tious microbes are the real mischief makers after
the afifection is well under way.
In order to prevent such exposures, no heavy
underwear should be worn next to the skin, and
the victim should exercise great care to avoid ex-
posure to cold and wet. He should be careful to
guard against getting chilled, especially in the
summer or autumn months. Woolen or flannel
clothing worn next to the skin is unnecessary.
Light weight clothing; should be worn in sum-
mer and in winter, the texture and weight of the
clothing, however, adapted to the individual and
the character of his occupation. In a business
confining persons in heated rooms the entire day
they are in no danger of exposure to extreme
cold or sudden changes of weather in merely
going to and from work. They do not require
as heavy flannels as does the laboring man who
is more exposed to the inclement weather. Those
who have suffered from fever are not fitted to
perform heavy manual labor. Laborers, farmers,
and servants are more susceptible than those en-
gaged in less fatiguing occupations.
Persons who have had recurring attacks should
live, if possible, in a dry, sunlit, warm, equable
climate. They should make a practice of taking
a cold sponge or tub bath every morning. There
should be plenty of daily exercise and good food,
without excess. Milk, cream, ;ind fatty sub-
stances generally may be used freely. Sweets
and pastry should be taken in small quantities
only. The diet should consist principally of veg-
etables and fruit, fresh and cooked. Experience
pistifies the recommendation to abstain from the
use of both alcohol and tobacco.
The hygienic and sanitary surroundings of
bone infected subjects should be as perfect as
possible and the home located preferably in the
country or at the outskirts of the town. The
house should be sunny and well ventilated and
have a concrete basement to prevent the entry of
dirty air.
The local point of infection in many is in the
throat, more often in the tonsils. It is well
known that bone infections are frequently pre-
ceded and accompanied by tonsillitis. It is advis-
able, therefore, that diseased tonsils be removed.
All the teeth should be attended to. and kept
clean, and the mouth and nose should be kept in
proper condition. X ray pictures of the roots of
28o
PKIDHAM: PREVENTIVE TREATMENT OF BONE AND JOINT MALADIES. [New York
Medical Journal.
the teeth are also advisable. Any stomach dis-
orders should be remedied and constipation
guarded against. The heart of a patient subject
to bone affections should be carefully examined
whether there has been previous endocarditis or
not.
Formerly, the main treatment has been to
place the body at rest so that the minimum
amount of strain would be thrown upon the
bones most likely to be affected ; to neutralize
the toxin or to kill the specific coccus circulating
in the body ; to reduce fever and relieve the pain-
ful arthritis by means of general and local reme-
dies ; to guard against cardiac inflammation, to
sustain the strength of the patient by suitable
food, to control the pyrexia ; to guard against re-
lapses, to restore the general bodily vigor, and
prevent further attacks.
At the first warning of the advent of osteo-
myelitis or gangrene the patient is put to berl
and kept there until he is well on the road to
recovery. The bedroom is well ventilated and
in the warmest and most sheltered part of the
house. The temperature of the room is kept be-
tween sixty and sixty-five degrees.
Arrangements are then made so that after the
patient is put to bed he need not be moved until
convalescence is well established, save to arrange
or change the bed clothing; this should consist of
light material, preferably woolen blankets. A
wire spring mattress and hair mattress are pref-
erable to any other kind. Ordinarily the patient
should be between blankets, but in some the
weight of the blankets is distressing to the in-
valid. The sheet may be substituted for the outer
covering, or, better yet, the upper blanket kept
off the body by means of improvised supports
made of barrel hoops or wires placed over the
body and upon which the bed clothing rests. The
sleeping suit or nightgown should be of flannel,
and on account of the profuse perspiration will
require to be frequently changed ; it should there-
fore be slit in front and behind, the sleeves slit
along their outer margins, and kept in place by
being laced with tape. A garment so arranged
can be removed easily with a minimum of dis-
turbance and discomfort.
The afl'ected joints are protected and support-
ed by pillows, air pillows, and blankets. Pres-
sure is minimized by the use of air or water pil-
lows and every precaution is taken to prevent
bedsores. The body and limbs should be sponged
daily with hot water to which a little vinegar has
been added, followed by warm alcohol. Care
should be taken to disturb the painful joints as
little as possible. To minimize the amount of
movement the patient uses the bed pan.
Attendants and friends must exercise great
care while in the sick room to disturb the invalid
as little as possible by walking across the floor,
closing doors, or doing anything which by jar-
ring the bed would give him pain. Ordinarily
the temperature is taken three times a day, and
then in the locality which would occasion the
least disturbance to the patient.
The diet from the onset and until a few days
after the subsidence of the fever consists princi-
pally of milk, although other fluids such as but-
termilk, koumis, broths, soups, fruit juices,
lemonade, limeade, and orangeade, cold carbonated
waters, rice water, and barley water may be
given. Water ices and ice cream may also be
given. After the febrile stage has passed and
with the return of the appetite a more liberal diet
is given, the quantity and kind of food depend-
ing largely upon the patient's appetite. If there
is much anemia and emaciation, a generous diet
including meats is allowed.
In my opinion, the serum and vaccine treat-
ment is yet in the experimental stage. After
having used the widely advertised vaccines quite
extensively both in private and hospital practice
I have discarded them. Another reason, however,
for discontinuing this method was the unusually
large number of stiff joints following its use. I
constantly find patients with ankylosed joints,
showing many signs of beginning arthritis de-
formans, giving a history of recent infection.
The newest and most successful treatment of
osteomyelitis, gangrene, arthritis, and the various
infections of the bones and joints is much sim-
pler and one hundred per cent, more effective
than any of these old time, troublesome, and un-
certain methods. Indeed, scores of victims of
recurrent bone diseases operated upon repeatedly
by America's most conscientious and ablest sur-
geons without a cure, and given up almost as in-
curable, have been cured by us and sent away
capable of doing a man's work in the world and
with tripled earning capacity.
This newly discovered specific applied locally
by osmosis and first chemically combined by us
has never been in medical use. Indeed, osmotic
pressure, spoken of by the late Professor Morse,
of Johns Hopkins University, as a great boon
unused by doctors, has, except in the laughed at
homemade flaxseed poultice, been ignored by
medical men and surgeons and is scoffed at by
Doctor Osier.
Certain mineral salts are necessary to physical
stability and strength. They are as much fer-
tilizers to your animal fabric as lime and phos-
phates, potash and nitre are to that agricultural
fabric, the soil. We have succeeded in making
a double boronitro salt synthetically which
seems to take this place in man. After nearly
nine years of experimental work and investiga-
tions upon seventy patients we feel safe in rec-
ommending our method and material. It is bet-
ter than any known method and has loo per cent,
cures to its credit. Many chronic and almost in-
curable invasions of bones, joints, cartilages, and
tendons have been successfully treated by this
new mineral method.
The principle of our triumph over these diseases
should be well known to chemists. It is curious
that no physician or surgeon ever combined this
double nitrooxide. Like many other great dis-
coveries, its origin is incorporated to destroy and
oxidize all diseased, decomposed, and useless flesh,
bacteria, and matter. Meanwhile, the diseased
part granulates or heals from the ground up,
August 17, igiS.J
SIMONTOX: THE THYROID GLAND IN DISEASE.
281
and all of the ill, torn, injured, and infected mar-
row, bone, muscle, and flesh are simultaneously
removed.
So extraordinary have been the results of the
application of this new physical principle to bone
diseases that victims of bone infections have
come to Baltimore to be cured from Chicago, the
centre of medical endeavor of the West. When
this mineral osmosis method has come into gen-
eral use on the battlefields and in the hospitals
and institutions all over the world, it is hoped
that such chronic bone infections as tuberculosis
and osteomyelitis will be greatly diminished, if
not entirely exterminated. We are certain that
it will eliminate most bone and joint aflfections,
and have offered our services and our method to
the Government.
2500 ExTTAw Place.
THE THYROID GLAND.
Its Role in Development and Disease.
By L. J. SiMONTON, M. D.,
Cumberland Valley, Pa.
The longer I practise medicine the more deeply
am 1 impressed with the importance of the thyroid.
That I am justified in this seems but a natural se-
quence to the slogan of our brothers of former days
and even of the present, namely : "When in doubt
give the iodides." The thyroid would seem from all
observations to be the organ riiost affected by iodine
exhibition. The diseases relieved by its administra-
tion were directly or indirectly the result of ab-
normal activity of the thyroid. In other words the
thyroid by direct effect itself or by absence of effect
upon other glands concerned in the ring of internal
secretions was productive of diseased conditions or
departures from the normal state.
Some observations of mine which may be consid-
ered interesting follow :
Hypothyroidism and hydrocephalus. — A few
years ago i read in the New York Medical Jour-
nal the report of an experimenter (unfortunately
I am unable to give the reference) who found that
upon removal of the thyroid gland in rabbits the
offspring were hydrocephalic. This did not concur,
as far as I knew, with current views on hydroce-
phalus, so 1 gave It only passing notice.
Since then I have observed two cases of hydro-
cephalus which 1 believe to be due to extreme
hypMDthyroidism.
Case I. — Two sisters, hypothyroids (diminished func-
tional activity of the thyroid), with rough, scaly skin,
very slow heart action, and scanty menstruation. Both
liad had a marked goitre, which had disappeared without
treatment. Their mother had a large goitre. The mother
and father were first cousins.
The first girl became pregnant. Her husband was a
second cousin. Toxic vomiting became so grave that she
was removed to a hospital, where for a time operation
was considered. She recovered, however, and went to
term, bearing a child who now, at nine years of age,
wears a seven and a half hat. His father (a physician)
and other physicians consider him a hydrocephalic, though
his mentality is good. This girl was not treated for hypo-
thyroidism.
The second girl became pregnant. Her husband was
unrelated. There was no vomiting, but shortly after be-
coming pregnant she had violent "heart attacks." The
heart action was very slow, almost stopping, then whipping
un to normal ; the beat was very irregular. Thyroprotein
(Beebe) was administered with immediate relief. The pa-
tient was instructed to take the thyroprotein when she felt
the onset of an attack, for fear of untoward effect on the
child. The patient was delivered at term of child with
a very large head. This child is now four years of age,
mentally bright, but wears a seven and three eighths hat.
All the physicians who saw him agreed that he was hydro-
cephalic. Shortly after birth the mother complained that
the child was not being well nourished. As her milk
seemed little else but water and because of her condition,
I arranged artificial feeding.
I believe that the procedure was injudicious, for
the following reason : The child immediately de-
veloped symptoms of (rraves's disease. The heart
beat was so rapid tint it could not be counted.
Exophthalmos, von Graefe's sign and tremor were
present. What had I done? Removed his "thy-
roidectomizcd" milk? It would seem so. I con-
clude that the little fellow, in utero, had tried to
make up in his own thyroid for what his mother
lacked ; endeavoring to supply her also with the
lacking internal secretion. When the "a-thyroid"
milk was being taken it acted for him to neutralize
his oversupply; when withdrawn, hyperthyroidism
supervened. I gave this child thyroidectin, two
grains, for a few days. I do not know that it helped,
but he is still living and shows now no signs of
hyperthyroidism, except a highly sensitive nervous
system and slight "von Graefe."
The history of these sisters simply bears out the
known relationshiji between thyroid deficiency and
consanguinity. In this instance there was in addi-
tion thyroid disease (simple goitre) in the mother.
The connection between hypothyroidism and hydro-
cephalus is, however, interesting.
Thyroid disease and sexual development in the
female. — The' average physician is graduated from
a medical school — then, with or without previous
hospital training, locates in some community where
he practises for the rest of his life. Local condi-
tions and diseases are to him normal in that he is
not in a position to know that some constitutional
difference might exist between the people among
wdioni he practises and those living in other local-
ities. He may notice, for instance, that most of
the women and many of the men have goitres. He
attributes this to the limestone water or tO' lack of
iodine in drinking water and gives it no further
thought. He does not connect the two facts, i, that
these women are sexually undeveloped ; 2, that they
have goitres. He knows that the majority of the
confinement cases he attends are very difficult. He
knows that he must use forceps in many of his cases,
that he must sew many perineal tears ; that many
mothers consult him about their daughters just com-
ing into womanhood, telling him of their suft'ering
and irregularity in menstruation. He may examine
some of them and may diagnose infantile uterus
but makes no effort to do anything for them. Why?
Because he thinks that such conditions are univer-
sal ; that women all over the world have the same
troubles. And there is nothing in the textbooks to
teach him otherwise. Undoubtedly there are iso-
lated instances of these cases in all communities,
the result of heredity, consanguinity, etc., but not in
the proportion here encountered.
282
SCHIVATT: THE HEART IN TUBERCULOSIS.
[New York
Medical Journal.
The writer has practised in several localities.
After some years' work in the hospitals of a large
city he located in a smaller city, his experience cov-
ering in all a period of about thirteen years. Six
months ago he located in the country on account of
ill health. In these six months he has had to use
forceps oftener and has had more perineal tears
than in all his former practice. He has been con-
sulted bv more women begging for relief from
menstrual pain and irregularity than ever before in
his experience — fully hfty per cent, of the female
population covered by his practice. He has never
met any sucli proportion in other localities. The
condition is due to thyroid dyscrasia ; either as a
result of limestone water, consanguinity or both.
Practically half the female and some of the male
population have goitres. Interaction between the
ductless glands (in this case ovaries and thyroid),
has not been normal with a resulting subnormal
sexual development (not true infantilism but a con-
dition not far removed).
Some of the goitres have been accom])anied by
hyperthyroid but the majority by hypothyroid symp-
toms : slow heart, irregularity of heart and menses,
rough skin, and scanty menstruation. The latter
symptom represents my departure from concurrence
with most writers. Practically all state that "hypo-
thyroidism is accompanied by profuse menstrua-
tion." In my experience fully ninety per cent, suf-
fered from scanty, irregular menstruation. These
symptoms have in every instance been brought to
normal by medication directed toward correction of
hypothyroidism.
In the cases showing heart and skin symptoms
and in those with arthritic symptoms relief has
invariably followed the administration of thyropro-
tein (Beebc). In the sexually undeveloped cases
(painful menstruation, irregularity, painful coitus,
sterility, frigidity, etc.) corpus luteum has given
wonderful results. The corpus luteum is that ob-
tained f rom the pregnant sow ; all others are worth-
less. Several of my confinement cases where
forceps were necessary and second degree perineal
laceration took place, refused to lactate. Thyropro-
tein produced an abundant milk supply but had to
be continued though in a very small dose. y\ny
attempt to discontinue the thyroprotein was fol-
lowed by drying up of the milk. This would seem
added evidence that sexual development had been
hindered by hypothyroidism.
The above observations have prompted the hope
that further knowledge of the thyroid and treat-
ment of the developing female will remove or
ameliorate that bane of modern women, child bear-
ing. Parents must be educated to consult their
physician about their developing daughters. Physi-
cians must become familiar with the proper treat-
ment of these cases. The purpose of this pp.per is
to give the author's views and to receive the views
of others on the subject.
Hyperthyroidism. — My experience with this form
is limited to five cases. AH had goitre. One had ex-
ophthalmos ; all had tachycardia, and three had
tremor.
Tincture of iodine, U. S. P., two minims, to be
taken one half hour before meals in a little milk.
was given for two days, in every instance heart
action was slower, ihe dose was increased to
three, then to hve minims tlirec times a day. No
untoward symptoms occurred in any case. In three,
the goitre disappeared. In the exophthalmic case
and one other continued nervous symptoms were
relieved by thyroidectin given in capsules three
times a day. Thyroid extracts and proteins are
certainly contraindicated in hyperthyroidism. In
spite of this fact some men persist in their use. In
no condition is the slogan "be sure you're right
then go ahead" more applicable than to diseases of
the thyroid.
THE HEART IN PULMONARY TUBER-
CULOSIS.
P.y H. SciiWATT, M. D.,
New York.
Since the cardiovascular and respiratory systems
are so intimately and vitally interdependent it is not
strange that functional disturbances and pathologi-
cal conditions of one system frequently manifest
themselves by referred symptoms and changes in
the other. This close connection led the older
writers to refer to the symptomatology of diseases
of the heart and lungs by a common term, respiratio
laesa. Abnormalities and pathological conditions of
the heart are held to have important relations to
pulmonary tuberculosis, as predisposing or antago-
nistic factors to its occurrence, and as influencing
its course and outcome. The cardiovascular symp-
toms of tuberculosis must be considered valuable
data in its diagnosis and prognosis.
The literature on the relation of the heart to
tuberculosis devotes a great deal of space to some
aspects of the subject which are of academic in-
terest, but of slight practical value to the clinician.
Among these may be first mentioned the influence
of an abnormally small heart as a predisposing fac-
tor and its presence in a majority of cases of tuber-
culosis. This view is apparently supported by re-
searches on the weight and size of the heart at
autopsy, by orthodiagraphic and x ray examina-
tions. Other investigators, however, find the heart
enlarged in just as large a number of cases coming
to autopsy. Although it is held that the preponder-
ance of evidence points to a heart subnormal in
size, it is by no means clearly established whether
this condition is a preexisting congenital hypoplasia
and a predisposing factor or whether it is the re-
sult of circulatory changes or other causes depend-
ent upon a long standing chronic tuberculous lesion.
Woods Hutchinson found that birds and mam-
mals having a small heart in proportion to body
weight exhibit a more marked degree of predisposi-
tion compared with those having a proportionally
large heart. Pottenger holds the view that the
small heart is a direct result of compensatory cir-
culatory changes brought about by interference with
inspiration over a long period of time and a con-
sequent adaptation of the size of the heart to a
"smaller intake, a smaller content, and a smaller
output." This would appear to be somewhat con-
trary to the fact that long continued chronic forms
August 17, 1 918.]
SCHW.ITT: THE HEART IN TUBERCULOSIS.
-'83
of tuberculosis cause hypertrophy, and later, dila-
tation of the heart, as a result of interference with
and contraction of the pulmonary circulation and
displacement of the heart. Cornet considers the
small heart the accompaniment and result of the
general muscular atrophy, emaciation, and fever of
chronic tuberculosis ; but according to some observ-
ers a small heart ha? been found in nearly two
thirds of well nourished and well developed tuber-
culous individuals.
In types of individuals especially predisposed to
tuberculosis, in those exhibiting the marks of con-
stitutional w^eakness and malnutrition, with long,
narrow, flat chests associated with a weak, soft,
compressible, unstable pulse, and a subnormal
blood pressure we frequently find on x ray examina-
tion a contracted area of cardiac dullness and a
heart which appears smaller than normal. But to
what extent, if at all, the constitutionally small,
weak heart itself acts as a predisposing factor to
tuberculosis and the influence of such a heart on the
course of the disease must be determined by future
researches.
Since it is practically impossible to form accurate
conclusions as to the size of the heart by the ordi-
nary methods of physical diagnosis, the question of
the small heart in tuberculosis and particularly as
an important predisposing factor, as held by Breh-
mer and others of the older writers, is of very little
if of any practical importance. Predisposition in
general presents difficult and obscure problems and
it is especially hard to understand the influence of
the heart, per se, as favoring the development of a
bacterial disease. It is highly probable that the
small heart has nothing to do with tuberculosis as
such.
Of greater clinical interest is the oft quoted view
that valvular lesions are antagonistic to the develop-
ment of tuberculosis and afford a certain degree of
protection from the disease. This idea is based on
the relative infreqtiency of valvular disease in
tuberculosis. The protection afforded by valvular
lesions is supposed to rest upon the resulting stasis
of the pulmonary circulation, yet we cannot find that
mitral disease is especially antagonistic. It is the
most frequent lesion found in association with
tuberculosis, athough it does appear to have a fav-
orable influence upon its course. Congenital steno-
sis of the pulmonary valve, on the other hand, is
well known to have a decided predisposing effect ;
it may even be stated that nearly all cases with this
lesion develop tuberculosis.
From the records of the Henry Phipps Institute
various organic murmurs are found in about five
per cent, and functional cardiac murmurs in about
three per cent, of cases of tuberculosis. In 1,000,
mostly advanced cases ( i ) , observed by the writer,
eight per cent., and n\ another series of 200 cases
(2). mostly of early disease, four per cent., ex-
hibited organic murmurs. Burns (3) found or-
ganic murmurs in 17.5 per cent, of his cases. The
most frequent murmur heard is the systolic at the
mitral valve, and next in order of frequency are
the presystolic at the mitral, systolic at the aortic,
systolic at the pulmonic and double mitral. It is
interesting to note that in the series of 200 cases five
presented unmistakable signs of mitral stenosis. In
none of these were there positive physical or
X ray findings or symptoms except a slight initial
hemoptysis. Although hemoi)tysis should always be
looked upon as a very suspicious symptom, pointing
most frequently to pulmonary tuberculosis, it should
not be forgotten that slight hemoptysis may occur
in mitral stenosis and a thorough examination of
the heart may frequently clear up a doubtful case
in which a diagnosis of pulmonary tuberculosis has
been made.
The development of tuberculous lesions of the
heart valves during the course of chronic tubercu-
losis is extremely rare. That the toxins of tuber-
culous processes elsewhere may produce sclerotic
changes in the valves is possible, but it cannot be
proved that it occurs.
A change of varying degrees in the position of
the heart in pulmonary tuberculosis is observed
frecjuently enough to be generally accepted as one
of the important complicating features of the dis-
ease. Some published statistics, however, that the
heart is found displaced in nearly all cases with
left sided disease and in about two thirds of cases
of right sided disease are probably incorrect. And
even more erroneous are the statements found in
the literature that displacement occurs in very early
disease and may therefore be accepted as a valuable
diagnostic sign. Displacement to the left is more
frequent than to the right and is explained on ana-
tomical grounds on account of which the heart is
more easily movable toward the left. In disease
of the right side the frequency of displacement in-
creases as the stage becomes more and more ad-
vanced while in left sided disease it is errone-
ously held to be as frequent in the first as in the
third stage. Pottenger finds the heart displaced as
follows : nine per cent, in first stage, nineteen per
cent, in second stage, and seventy-six per cent, in
third stage, without reference to the side involved.
Displacement, when present, may be of absolute
dullness alone or of the heart itself. A displacement
of the absolute dullness to the right may be looked
upon as a valuable sign of long standing right sided
apical contraction. In many cases the displacement
is but an apparent one due to retraction of the lung
on the diseased side and compensatory emphysema
of the border of the lung on the healthy side. In
left sided disease both the absolute and relative
dullness are equally displaced. In right sided cases
there is usually a displacement of the right relative
dullness, while the left relative and the absolute
dullness are but slightly displaced to the right, the
actual condition being rather a rotation of the heart
on its axes than a displacement.
Displacement of the heart is always a conse-
quence of contraction and retraction of lung tissue
by which the heart, or mediastinimi, or both, are
pulled over to the diseased or more diseased side.
It occurs most frequently in long standing chronic
fibroid phthisis with extensive disease of one side
and in cases with extensive pleural adhesions. In
lesions on both sides we find displacement less fre-
quently. It is practically never present in incipient,
and rarely in moderately advanced, disease. It is
present in about thirty per cent, of chronic advanced
284
SCHWATT: THE HEART IN TUBERCULOSIS.
[New York
Medical Journal.
cases (from a personal study of 2,000 cases). In
advanced cases the displacement is frequently very
marked, particularly in disease of the right side, the
entire cardiac dullness being often transposed to the
right. In this type of case the heart may be found
displaced upward, a condition more frequent in
left sided disease. Pleuritic exudates and pneumo-
thorax displace the heart toward the sound side.
The symptomatology of tuberculosis finds early
expression in various functional disturbances of the
heart. Its action may be accelerated, retarded, ir-
regular, or uneciual. Among the most frequent and
important manifestations of pulmonary tubercu-
losis is tachycardia. It is frequently present even
when no physical signs of tuberculosis are demon-
strable by the ordinary methods of examination ;
but in these cases an early lesion may be demon-
strated by stereoscopic rontgen plates. A pulse of
TOO or over is said to be present in from seventy to
seventy-five per cent, of all cases. A characteristic
feature of the accelerated pulse due to tuberculosis
is its instability. The frequency may be very easily
increased by various bodily and mental conditions
which although they have a similar efifect on the
pulse of normal individuals and particularly those
of an unstable and nervous temperament, have a
much more marked persistent effect in the tubercu-
lous subject. The patient may be unaware of the
acceleration or it may be accompanied by annoying
])alpitation and a sensation of cardiac discomfort.
The acceleration is but little influenced by even long
continued rest but may disappear after varying
periods of time. Tachycardia of such a nature
should always be looked upon with suspicion and
studied as closely as the slight rises of afternoon
temperature. It should be looked upon as an early
and even prodromal symptom of great diagnostic
importance. The more intense and constant the
tachycardia, the less influenced by rest, the more
significantly does it point to the presence of tubercu-
losis in the absence of other causes and when not
connected with any change in the respiratory rate
and not associated with fever.
The acceleration of the pulse is most generally
ascribed to the action of the toxins of the tubercle
bacillus and secondary organisms and the pulse is
referred to as the toxic pulse. It is not quite clearly
established, however, how the toxins influence the
cardioaccelerator mechanism. Tachycardia is fre-
quently absent in advanced and active tuberculosis
without fever and dyspnea, where the findings point
to a high degree of absorption of toxins. And
again, tachycardia is often a persistent and prominent
symptom in arrested and cured cases, without any
cause for it in the heart itself and without marked
involvement of lung tissue. It is held by authorities
that the tachycardia is due to compression of the
vagus by tuberculous bronchial glands and pleural
and pericardial adhesions. Although the vagus has
been occasionally found thus compressed at autopsy,
the rarity of this condition does not account for the
great frequency of tachycardia, particularly in early
disease. And furthermore, compression of the
vagus should cause a slowing of the pulse ; although
this inconsistency is explained by the fact that
gradual pressure produces the same efifect as de-
struction or section of the nerve — acceleration. Pot-
tenger holds the view that tb.e heart is stimulated
by the sympathetic system, centrally, as a result of
toxemia and, peripherally, by the sympathetic and
the vagus due to the inflammation in the lung and
deduces that the vagus tonus is overcome and the
heart shows increase in activity. In his opinion the
stimulation of the sympathetic centrally ceases when
the toxemia passes ofi'. It is then a matter of which
predominates, the sympathetic or vagus, that de-
termines whether the pulse remains normal or be-
comes accelerated or retarded. If this be the case
we have yet to learn, however, why stimulation of
the one or the other becomes predominating.
To the adherents of the "small heart" school the
tachycardia is the attempt of a constitutionally weak
heart to supply the required volume of blood by in-
creased activity. In advanced disease it may be
partly explained by the lessening of the respiratory
area due to destruction of tissue, by displacements
of the heart, chronic myocarditis and chronic peri-
carditis and endocarditis.
Irregularity of the pulse and change in rhythm is
comparatively infrequent in connection with tachy-
cardia. A full bounding pulse associated with
cardiac excitability is observed particularly in the
neurotic type of individuals, who also exhibit quite
frequently a marked degree of vasomotor instability.
A subnormal slow pulse is also encountered and is
surprisingly frequent in advanced tuberculosis.
The acceleration of the pulse is partly attributable
to lowered blood pressure. xA.ccording to some au-
thorities a fall in the blood pressure is so frequent
and constant in all stages of tuberculosis that it may
be locked upon as a symptom of diagnostic value in
early disease. Although we fairly constantly find a
subnormal pressure in advanced chronic disease,
marked deviation from the normal is not frequent
in initial and moderately advanced stages, and can-
not be looked upon as of any diagnostic significance.
It is found most frequently in the markedly
cachectic and the asthenic type. In early disease I
have found it but very rarely and then only in cases
with a high degreee of waste of nutrition. The
cause of low blood pressure is also held to be ab-
sorption of toxins and as in the tachycardia of
tuberculosis the constitutionally weak small heart is
held to be a contributing factor. Degeneration of
the heart muscle and general weakness in advanced,
as in early disease, also cause lowering of pressure.
One of the most important effects of pulmonar\'
tuberculosis on the heart is essentially a mechanical
one and is due to interference with the puhnonary
circulation. The greater demands on the right
heart in chronic phthisis produces in the course of
time hypertrophy of the right ventricle. At first
the increased action of the right ventricle manifests
itself by an accentuation of the second pulmonic,
which is the most frequent abnormal sound heard in
connection with tuberculosis, and occurs in over
fifty per cent, of all cases. Even in early disease
it is extremely frequent. In the examination of the
second pulmonic it should, however, be borne in
mind that the accentuation may be an apparent one
due to infiltration and fibrosis of the left upper lobe.
The hypertrophy is contributed to by pleural ad-
August 17, 1918.] RUBENSTONE: IMMUNIZATION THERAPY IN BRONCHIAL ASTHMA.
285
hesions in direct proportion to their extent. It mani-
fests itself more rarely by increase in the dullness
and epigastric pulsation than by accentuation of the
second pulmonic.
The course of pulmonary tuberculosis is markedly
influenced by the condition of the heart. Com-
petency of the heart muscle and valves increases the
outlook for arrest and cure of the disease and com-
pensates to a large extent for the damaging effects
of an extensive lesion. So long as the right
ventricle contracts vigorously there is no danger.
The compensatory hypertrophy of the right heart,
however, frequently fails even under moderate
stress. Under greater demands on the heart either,
by physical exertion or from increasing resistance to
the blood tlow due to extensive fibroid phthisis or
marked cavity fonnation, or as a result of toxemia,
degeneration and dilatation of the right ventricle
may result. With the development of this condition
there is found a decrease in the existing accentu-
ation indicating an easing up of the lesser circula-
tion and an exhaustion of the right ventricle. Hence
the strength of the accentuation of the second
pulmonic is a valuable prognostic sign. The dilata-
tion of the heart may or may not be associated with
tricuspid regurgitation.
The cause of death in advanced tuberculosis is
generally due to cardiac weakness. Dilatation may
occur even when -the patient is in a condition of
complete rest, when the hypertrophy of the right
ventricle can no longer overcome the contraction in
the pulmonary circulation. Weakness of the right
heart manifests itself by stasis in the systemic veins
and moderate dyspnea. When the left heart
weakens dyspnea becomes a much more pronounced
symptom while venous stasis is not so frequent.
A combination of these two symptoms points to-
ward a weakening of the whole heart.
Of unfavorable prognostic significance is a per-
sistent acceleration of the pulse, particularly if in-
dependent of fever and other discoverable causes.
Of equally grave import is a continuous fall in the
blood pressure. Preexisting valvular disease makes
the prognosis more unfavorable, although it is held
that the stasis resulting from mitral disease has a
favorable effect on the course of tuberculosis.
Marked displacements are of unfavorable import on
account of the added mechanical interference with
the proper action of an already overburdened heart.
Of the greatest importance is the condition of the
heart muscle and its weakening introduces a grave
outlook upon the outcome in otherwise favorable
cases.
In the treatment of tuberculosis the relation of
the heart to the disease is frequently not sufficiently
taken into consideration. The great importance of
complete and long continued rest in the tachycardia
of tuberculosis, irrespective of fever, cannot be
overemphasized. Accentuation of the second
pulmonic sound as evidencing a strain on the right
heart and particularly, a decrease in the accentua-
tion, should be dealt with in the same way and by
proper medical measures tending to strengthen the
heart. Even in advanced disease splendid results
are quite frequently obtained by relieving an over-
burdened heart from toxemia or from mechanical
interference with its proper action. Valvular dis-
ease associated with tuberculosis should be watched
and dealt with as carefully as such lesions not com-
plicated by tuberculosis.
In general, it should be more strongly emphasized
that the heart plays an extremely important role in
the fight of the body against disease, that a healthy,
normal heart is as great an asset as we have toward
recovery and that judicious treatment directed to
the preservation and maintenance of the heart is an
exceedingly important adjunct in the treatment of
pulmonary tuberculosis.
REFERENCES.
I. From the Jewish Consumptives Relief Society Sanatorium, Den-
ver, Colo. 2. From the Workmen's Circle Sanatorium, Liberty, N. Y.
3. BURNS: Journal A. M. A., June, 1914.
1215 Madison Avenue.
IMMUNIZATION THERAPY IN BRON-
CHIAL ASTHMA.*
By a. I. RUBENSTONE, M. D.,
Philadelphia,
{From the Bacteriological Laboratory, Mount Sinai Hospital.)
The organisms usually found in the respiratory
tract associated with bronchial asthma are those
usually present in chronic inflammation of the
nose, throat, and bronchi and constitute such a list
of microorganisms that the respiratory tract seems
an excellent culture medium and trap for all
organisms both pathogenic and nonpathogenic.
However, the frequency with which streptococci,
pneumococci, micrococci catarrhalis, staphylococci,
bacilli pseudodiphthcrici and the various hyphse
are found clearly shows that these organisms play
not a mean role in the production of a chronic exu-
dative bronchitis and either directly or indirectly
may be responsible for spasmodic bronchial attacks
of asthma.
Before proceeding to eliminate these organisms
from the respiratory tract every avenue of search
must be exhausted to locate suspicious foci and re-
flex causes that may be associated with bacteria in
the production of the asthmatic syndrome. Nose
and throat diseases, such as polypi, diseased turbin-
ates, sinusilis, deviated septum, and other abnormal
conditions must be corrected. The possibility of
associated cardiac and renal disease and metabolic
disturbances, such as acidosis, as well as nervous
diseases, must be borne in mind, and if possible,
corrected or improved. Then, and not until then,
can the offending microorganisms that flourish in
the respiratory tract because of the local nonresist-
aiice of the tissues be attacked.
In the immunizing therapy of bronchial asthma
several forms of existing methods present them-
selves for consideration, namely: i, passive im-
munization or introduction into the system of ani-
mal or human specific immune serum ; 2, the in-
jection of foreign protein to stimulate nonspecific
reaction to the disease; 3, active immunization,
which requires that a bacterial antigen be injected
to produce specific antibodies.
•Abstract of paper read before the Southeast Branch of Philadel-
phia County Medical Society, March 12, 1918.
286
RVBENSTONE: IMMUNIZATION THERAPY IN BRONCHIAL ASTHMA. INi^w York
Medical Journal.
1. The production of an animal immune serum suitable
for asthmatic cases has several drawbacks. Most sera are
antitoxic, and bacteriolytic sera are very difficult to pro-
duce, and when produced are very weak; and since asthma
is a localized infection with little toxemia, sera will pro-
duce negligible changes in this condition. A serum to be
efficacious must contain specific antibodies to neutralize
the bacterial toxins produced, and since there are innu-
merable types of every microorganism found in asthma,
each peculiarly adapted in its biological characteristics to
the tissues of its host, it is inconceivable, without proper
classification of the various strains of these organisms, to
be able to produce an immune serum suitable for a par-
ticular individual. Moreover, asthmatics frequently de-
velop marked anaphylaxis to scrum injection.
2. Nonspecific immtmization may be tried by using
phylacogens, which are fluids, the exact composition of
which is unknown, but which are supposed to contain the
toxins and filtrates of a multitude of microorganisms,
which (according to its manufacturers) are capable of
curing asthma as well as other infectious diseases. I do
them more than justice in classifying them as nonspecific
protein solutions and any beneficial results attained with
phylacogen is probably due to the liberation in the body
of nonspecific ferment which may digest the pathological
products in the lesions present, a theory advanced by Job-
ling and Petersen. However, I would urge severe cau-
tion in the use of this mystic preparation, which will do
little for your patient, if indeed it does not aggravate the
asthmatic condition.
3. The use of bacterial vaccines in asthma at least as-
sumes the cloak of rationality. Stock vaccines, both poly-
valent and mixed, are marketed with the assurance that
you will certainly find in the suspension one of the or-
ganisms that is responsible for the individual condition.
It seems inconceivable under existing conditions, since
only a few bacteria have been classified and, at that, only
partially, that a stock suspension will contain the identical
organisms present in any given respiratory tract. How-
ever, it is much more rational to use stock vaccines than
phylacogens, because besides the nonspecific protcid reac-
tion produced, specific immunization may sometimes be
attained. No such results have come to my notice out-
side of the manufacturers' claims. Stock vaccines, there-
fore, hol4 an intermediary position between phylacogens,
which are entirely nonspecific and autogenous bacterins.
Properly prepared and administered, they produce a large
percentage of immunizations and free the asthmatic of
his distressing condition.
When treatment with an atitogenous vaccine is
undertaken in the asthmatic, several conditions
must be fulfilled in order that the results of this
therapy may be favorable in the majority of cases.
The patient is instructed to collect all material
coughed up during the night and early morning in
a sterile container and send it immediately to the
laboratory. Here the sputum undergoes a general
examination including the study of the various
organisms present and cultures are made according
to the following procedtue. Four or five slants of
rich culttire media (blood or ascitic agar) are inocu-
lated with the plugs of purulent material after
washing them in three successive bouillon tubes to
remove any contamination of air or mouth sapro-
phytes. Aerobic and anaerobic cultures are made.
Two plain neutral agar slants are thickly spread
with sputum and incubated at the same time with
the foregoing cultures. The rhinologist may at the
same time give us cultures from the various local-
ities of the nose and throat, and diseased turbinates
when removed are thrown into 200 c. c. flasks of
glucose bouillon and later these cultures are trans-
ferred to solid media, if contaminations are noted
on the twenty-four hour growth, plating may have
to be resorted to, to chminate them. Since our best
results have been obtained in those patients in
whose cultures a streptococcus has predominated,
we always, if possible, attempt to isolate this
organism in cultures either from the sputum or
from the variotis respiratory surfaces, e. g.,
turbinates, tonsils, etc. If oidy a few streptococci
are found a rabbit may be inoculated with some of
the culture or material intraperitoneally. Within
twenty-four hours this animal, which is highly sus-
ceptible to streptococcus infection, will develop a
septicemia. From the animal's heart blood can be
obtained a pure culture oi streptococci, which is
then incorporated in the autogenous vaccine, to-
gether with the other organisms found in the nose
and throat and sputum. In preparing our vaccines
we incorporate in the suspension all organisms
cultured in an attempt to increase the relative num-
bers of the apparently causative organisms. To
this suspension we, furthermore, add the films of
pm-ulent sputum which were planted on the plain
dry agar slants. This material is important in pre-
paring an autogenous vaccine from an exudative
inflammation. Since it contains the broken down
specific organisms and their products, it acts as an
ideal natural aggressin in increasing the antigenic
properties of the vaccines.
The results of autogenous vaccine therapy will
depend on several factors. If the disease is of
many years' duration, with the consecpient local
and systemic pathological changes, there is not only
the localized infection to counteract, but also the
weakened resistance of the individual, due to age
and organic insufificitncy. In such cases cure is
difficult and if some amelioration of the symptoms
follow a course of vaccine treatment much has been
gained. In my experience the individuals that
respond best tn autogenous bacterin therapy are
those below forty years of age, who have been
troubled by asthmatic attacks for only a short
period (five years at most), and in whom perma-
nent changes have not yet occurred. With such
patients remarkable results have been accomplished.
In judging results in asthmatics one must be
guided by amelioration of symptoms. Oi ten
cases of pure bronchial asthma we have rid five
patients of all respiratory symptoms, and four have
been very much improved, in that the spells have
decreased in frequency, and in that any dyspnea is
of brief duration and so mild that the patients are
hardly inconvenienced. In one patient no change
in the severity of the attacks occurs. Changes in
the condition of a patient are noticed anywhere
from four to six weeks after the series of injec-
tions have been completed. This is apparent when
the seizures become milder and milder and the in-
terval between seizures lengthens until the patient
is entirely well. And lastly, the modus operandi of
vaccine administration is a very important element
in immunizing the patient. Careful clinical ob-
servation during \accine therapy is of utmost im-
portance. The number of organisms injected, the
increase of doses, and the intervals between the
number of injections given a patient, may some-
times determine whether immunity will be ]>ro-
duced. Those physicians, who use autogenous vac-
cines mechanically, i. e., inject vaccine pre])ared in
the laboratory in graded doses into the patient at
August 17, 1 918.]
LUBMAN: TUBERCULOUS LARYNGITIS.
287
regular intervals, or even intrust a nurse with the
mechanical administration of the vaccine, had bet-
ter spare their patients pain and money and seek
other forms of therapy to relieve the condition.
In my experience repeated series of autog-
enous vaccines in asthma when little results have
been obtained after the first course, sometimes
aggravate the condition. This is probably due to
protein sensitization, and 1 would urge caution in
such procedure.
1208 Spruce Street.
PREVENTION VERSUS TREATMENT IN
TUBERCULOUS LARYNGITIS.
Bv M.\x Lubm.AlN, M. D.,
New York,
Assistant (Jtologist, Mt. Sinai Dispensary.
The complication of tuberculous larj^ngitis, fol-
lowing pulmonary tuberculosis, is the saddest and
most appalling of all complications which follow
diseases or ailments to which the human flesh is
heir. Starving within the sight of food, dying of
thirst with water at hand, because of the excruciat-
ing pain in swallowing; progressive loss of weight
and strength, difficulty of speech, constant hacking
cough, painful, and increasing in severity as time
goes on, nevertheless not relieving from the tena-
cious, adhering mucus that clings to the mucous
membrane of the larynx ; the vivid realization of
the ultimate end which blasts all hope, permits no
consolation, gives no solace — is it not the most piti-
ful of existences? Is it a wonder that the patient
prays for relief, everlasting relief?
When he appears before the specialist in the
hope of obtaining relief, he is usually already be-
yond succor. Upon examination the arytenoids as
well as the cords are infiltrated, often ulcerated ;
the epiglottis is very much thickened, possibly ul-
cerated; the surrounding tissues are in a state of
tumefaction. The specialist endeavors to relieve
him with the therapeutics at his command : lactic
acid locally or by injection; tuberculin; blocking
the superior laryngeal nerve ; or by surgical means,
as cautery, epiglotectomy. laryngectomy, etc.
Knowing full well that his results will be limited,
he nevertheless endeavors to buoy up the sinking
spirit. As Getchel ( i ) reminds us, the local mani-
festations in the larynx are only part of the general
disease, and their eradication by no means controls
its progress. As to operative procedures, only in
rare instances does an operation aid. and then in
skilled hands alone.
What can be done for these unfortunates?
Brown (2) said that the average duration of life
of a patient suffering from pulmonary tuberculosis
is about eight years. The average duration of life
of a patient sufYering with laryngopulmonarv tuber-
culosis is a great deal shorter. St. Clair Thomp-
son (3) thinks that laryngopulmonary tuberculosis
renders the prognosis twice as gloomy and that in
the majority of cases the disease is incurable. By
preventing such grave complications the life of the
patient may be prolonged.
Tuberculosis in general and tuberculous laryn-
gitis in particular is comparatively easy to prevent.
Any cough that lasts longer than the usual period
ot a cold, occult blood in the sputum, are sufficient
to alarm the patient and cause him to seek the ad-
vice of his physician, for he immediately fears tu-
berculosis, and in the majority of cases he is ready
to do anything the physician will advise.
The family physician is naturally the first to sci-
the patient, he is the first to examine him, he is
the first to decide his fate, he therefore ought to
be the first to prevent com])lications. In order to
make clear wherein the physician may prevent com-
plications of the larynx in a tuberculous patient,
permit me for a moment to briefly review the etio-
logical factors, mode of invasion, and the direct
and indirect predisposing causes of tuberculous
laryngitis.
Tuberculous laryngitis is usually secondary to
pulmonary tuberculosis. Primary laryngeal tuber-
culosis is ([uite rare. Dworestsky (4) in a study
of 500 cases of tuberculosis, 128 of which
had laryngeal tuberculosis, states that in ninety-one
per cent, of the cases the sputum gave positive evi-
dence of tuberculosis. Of the remaining nine i)er
cent, a few were of doubtful natvire as to the lesion.,
while a few did not have a sufficient nvmiber of
sputum examinations made. Bullock (5) reports
100 cases of tuberculous laryngitis. Positive spu-
tum was found in every case. G. FetterolfY (6)
says. "Of 100 cases that died at Henry Phipps's
Institute and who have had autopsies performed,
eighty-three j^er cent, showed gross tuberculous
lesions, thirteen showed absence of disease and four
were doubtful." In other words, eighty-three per
cent, of these 100 cases dying from pulmonary tu-
berculosis or its complications had a definite gross
tuberculous lesion involvement of the larynx. The
probability is that the percentage of those having
actual disease is greater than eighty-three per cent.,
for unquestionably some of those which appeared
normal to the unaided eye will show tubercle forma-
tion under the microscope. This will suffice for the
etiology.
What is its mode of invasion ? Is it through the
bacilli laden sputum, the blood stream, or by the
lymphatics? Authorities differ on this point.
Coaldey and Heitiz think that the invasion is
through the lymphatics, while Ballinger and Bonney
claim the invasion to be due to the tuberculous
sputum pa.'?sing constantb,' over the complicated
structure of the larynx. The sputum theory ap-
pears to be the more logical and probable, for
should we adopt the lymphatic theory, tuberculous
laryngitis ought to be very common in children,
when tlie activity of the lymphatic system is at its
height ; while as a matter of fact tuberculous laryn-
gitis is very rare in children under the age of fifteen
years, though tuberculous adenitis is very common.
We must, therefore, with our present knowledge
accept the sputum theory, where the tubercular
■sputum is bound to adhere to the minute folds and
creases of the larynx while passing from the lungs.
This familiarizes us with the mode of invasion and
llie direct cause of tubercular laryngitis.
There is, however, another im])ortant point that
we must not lose sight of, and that is the predispos-
288
LUBMAN: TUBERCULOUS LARYNGITIS.
[New York
Medical Journal.
ing factors which by their baneful influence pave
the way for direct infection. The bacillus tubercu-
losis, per se, is not able to produce tuberculous
laryngitis, for all mucous membrane has a natural
immunity toward disease; it is only through a
lowered resistance of the part in question that it
will yield to infection. MetchnikofiE truly said, that
any organ that is performing its function in harmony
with its physiological construction cannot be dis-
eased. It has been shown experimentally that many
varieties of bacteria are found in the throats of
persons, without their showing any manifestations
of disease peculiar to the germ found. It is evident
therefore that in order to become afflicted with
tuberculous laryngitis we must have a predisposing
factor which by its pernicious effect lowers the re-
sistance of the mucous membrane of the larynx,
thereby paving the way for the ravages produced
by the direct cause.
What is the predisposing factor? There is more
than one. Excluding indirect causes as exposure,
alcohol, and smoking, it is to be found in a patho-
logical condition of the upper respiratory tract in-
cluding the nose, epipharynx, and pharynx. The
functions of the nose arc a natural protection to the
integrity of the mucous membrane of the larynx and
lungs. The larynx is centrally located between the
upper and lower respiratory tracts, and is therefore
subject to secondary infection from either end. The
injurious effects produced upon the laryngeal
mucosa from an obstructed or diseased upper re-
spiratory passage are well known, and it is not
necessary to go into details to describe how an
ethmoiditis or an atrophic rhinitis, or ozena or a de-
flected septum produces a pathological condition in
the mucous membrane of the larynx. Suffice it to
say, that almost all subacute and chronic laryngites
are secondary to pathological conditions in the nose.
It is evident therefore, that any interference with
the normal function that may cause a pathological
condition in the nose v/ill in sequence break down
the barriers to infection of the larynx.
From this we can summarize the following:
Tuberculous laryngitis is secondary to pulmonary
tuberculosis ; the mode of invasion is through the
sputum, the direct etiological factor being the
tubercle bacilli ; the predisposing cause is found in
the condition of the upper respiratory passage.
Having these data before us, our course in prevent-
ing tuberculous laryngitis is charted for us unmis-
takably.
When a patient is examined and the diagnosis is
tuberculosis, put the stethoscope aside and attire
yourself in a specialist's garb. Examine his nose
carefully, see if there is any obstruction, mechanical
or pathological. By mechanical, 1 mean a deflected
septum or a spur; by pathological, an ethmoiditis,
catarrhal or suppurative, polypoid degeneration,
hypertrophied inferior turbinates, posterior tips of
same, or sinusitis. The relation of an obstructed
nose to tuberculous laryngitis can be seen from the
cases studied by Dworetsky. Ke states that nine-
two per cent, of tuberculous laryngitis patients were
found to have nasal obstruction or disease, 36.7
per cent, having slight obstruction, eighteen per
cent, having moderate obstruction. In other words.
where the obstruction is least the number of cases
are smaller. Next, in order, examine the epi-
pharynx for adenoids, growths, etc. Then pass on
to the pharynx. The mucous membrane of the
pharynx is continuous with that of the larynx, and
there is no reason why a chronic inflammation of
the pharynx should not extend to the larynx. Fur-
ther more, a patient with a pharyngitis or naso-
pharyngitis has a constant desire to clear the throat,
either by coughing or hawking, an act tending to
cause congestion of the larynx. Examine the ton-
sils for hypertrophy or open crypts. Notice if there
is an elongated uvula, another cause of cough,
lastly examine the larynx with a laryngeal mirror,
look for an hypertrophied linguinal tonsil which irri-
tates the epiglottis, giving the sensation of a foreign
body in the throat and thereby inducing cough. In
fact any condition found in the nose, epipharynx,
pharynx, or larynx which may be the causative
factor either in interfering with normal breathing or
in acting as an irritant should be removed or reme-
died. It is the duty of the physician not only to in-
form his patient of the conditions found, but to
impress upon him the absolute necessity of remedy-
ing them as a safeguard for his future welfare and
well being. Not until such an examination has been
made and the patient has been impressed with the
absolute necessity of remedying the conditions
found does the physician perform his duty toward
his patient as well as toward himself. Statistics
show that the mortality of pulmonary tuberculosis
was reduced in the last ten or fifteen years by forty
per cent. And still many more lives could be pro-
longed and made useful by banishing this dreaded
complication of tuberculous laryngitis, which once
having laid its hand on its victim, never lets go.
REFERENCES.
I. GETCHEL: Boston Medical and Surgical Journal, July 2, 1914.
2. BROWN : Prognosis of Tuberculosis, Osier's Modern Medicine.
3. ST. CLAIR THOMPSON: Progressive Medicine, xvi. No. 3. 4.
DWORETZKY: Annals of Otology, Rhinology, and Laryngology,
December 19, 1917. s. BULLOCK: Sixth International Congress
on Tuberculosis, i. Part 2. 6. FETTEROLFF: Laryngoscope, Jan-
uary, 1917; BALLINGER: Diseases of Nose and Throat, third edi-
tion; COAKLEY: Diseases of the Nose and Throat, third edition;
BONNEY: Pulmonarv Tuberculosis and Its Complications; METCH-
NIKOFF: The Nature of Man.
616 Madison Avenue.
Case of Hematidrosis — Charles T. Scott
{British Medical Journal, May ii, 1918) saw a girl
eleven years old who had begun to have peculiar at-
tacks of sweating four months previously without
apparent cause. The attacks were usually preceded
by a distinct aura in the form of a sick feeling so
that the child knew when the sweats were coming
on and what the type was going to be. The sweat-
ing was confined to the forehead and consisted of
clear white fluid, white froth, or bright pink fluid.
The phenomenon occurred in attacks which were re-
peated at intervals of a minute or two up to ten
minutes or even an hour. The attacks were much
more frequent during the waking hours that when
she was asleep, but they also occurred at the latter
time, when they always waked her. The fluid al-
ways contained both red and white cells. There
was no discoverable cause for the sweating in the
child's family or personal history except the occur-
rence of a severe fright which she experienced a
week before their onset.
Medicine and Surgery in the Army and Navy
RECONSTRUCTIVE THERAPEUTICS.
Reinforcemetit of Body Defenses as a Basis for
Therapeutic Procedures.
By J. Max)ison Taylor, A. B., M. D.,
Philadelphia,
Professor of Applied Therapeutics. Temple University, Phila-
adelphia.
The method 1 would recommend and myself aim
to practise, is to select, combine and apply agencies
best capable of conserving inherent body and mind
defenses for the purpose of maintaining, improving
and restoring health without drugs, or only such as
are imperatively needed.
Reserve forces of the body are ample to preserve
and to restore health, when made available, set in
order, and fortified by natural means and wise guid-
ance from without. The conditions where artificial
agencies are demanded, such as drugs, medicines,
serological or bacteriological preparations, can be
reduced to a minimum by giving more scientific at-
tention to improving the efficacy of natural and
accessory remedies.
Reconstructive agencies consist of those capable
of producing regulative or invigorative effects upon
natural or inherent energies. The solution of clin-
ical problems is, first, by expert selection, applica-
tion of restitutive procedures, in short, training ; and
second, by teaching the individual to acquire and
practise conscious control, equipoise, in the expendi-
ture of energies.
Remedial procedures may be grouped as natural
and accessory or supplemental. Natural measures
are the regulation of behavior, of action and rest,
of nutrition, of respiration, of circulation, and other
master functions ; the wise selection and use of time,
place, circumstance, of body protection, of environ-
mental conditions (euthenics), and the like: includ-
ing developmental or corrective movements and
postures (biokinetic).
Accessory or supplemental measures are devices
capable of reinforcing or augmenting nature, of
adding to or of regulating one's inherent powers in
order to develop, support, or aid function in over-
strained, weakened, injured, or paralyzed parts,
whether direct or associated ; or to act as substitutes
for nature ; or to remove or remake damaged, dead
or otherwise no longer useful or now dangerous
parts ; or to so reanimate or fortify natural forces
as to enhance or reestablish circulation, respiration,
metabolism, and, in particular, to exercise guidance
by adjustment, readjustment, manipulation, mould-
ing (orthopedia), and by eliciting the defensive and
reparative actions of the reflexes.
Also supplemental remediation includes the edu-
cation, regulation and readjustment of highly spe-
cialized, interacting, associated and delicately poised
structures whose functions are evolved through elab-
orated integrations.
Contrasted with the above are artificial remedies
or agencies, such as medicines, drugs, chemical sub-
stances, most of which are wholly foreign to the
body cells and structures, yet capable of modifying
cells, glands, tissues, or functions advantageously or
of even destroying invading infectious organisms ;
also a newer and even more promising group of ser-
ological, vaccinal, and bacterial preparations made
from modifications of human or closely analogous
materials competent to reinforce body defenses and
to reestablish immunity ; also organic extracts, sub-
stances or scrapings of the ductless glands, of im-
mense efficacy, which it seems to me should be clas-
sified as foods, since they act more as a diet than as
a drug or medicament.
All clinical aims are, as a matter of course, direct-
ed toward conservation of body forces and re-
sources ; yet, in modern times, this is chiefly attempt-
ed in the form of establishing and maintaining im-
munity. Thus, while those microscopic organisms
from without, capable of acting as adversaries, re-
ceive full meed of attention, the question arises, "Is
enough attention directed toward the human organ-
ism as a whole?"
To this latter aspect of psychophysical repair,
conservation and salvation, namely the systematic
prevention, alleviation, or cure of disease efTccts by
the reinforcement of native powers, I beg to lend
some emphasis chiefly because its importance has
lacked appreciation heretofore.
Body defenses as a whole deserve more exact
study, at least from certain mechanistic aspects and
variants of availability and with appreciation of the
part played by the gross or static or neuromuscular
mechanisms. Reinforcement of massive or crude
body defenses justifies more help than it gets in
medical teaching. When set in order, systematized
and correlated, they bid fair to render service in
particular directions heretofore unrealized. Final-
ly, conditions established by the world war and the
prevailing military mental attitudes or trends of
medicine, amply warrant approaching therapeutics
from, this angle of psychophysical readjustment (or-
thopedia) as a fundamental principle of restitution.
We may thus visualize orthopedia as medical or-
thopedia, psychic orthopedia, and manipulative, de-
velopmental, or kinetic orthopedia.
All clinical problems involve integrations of the
mind as well as the body, and both require certain
degrees of straightening out, readjustment, in some
cases more, in others, less ; some by plain and simple
means ; other problems are so involved, complex
and obscure, as to tax all resources, even of the
wisest. In acute conditions of a trivial or transient
nature, the orthopedic element or need may scarcely
be noticeable. Few persons, however, when out of
health escape misconceptions of their personal atti-
tude toward their own disorders and hence are the
better for psychogenic regulation, for counsel, sug-
gestion, explanation in order to discharge their duty
in its broader economic aspects. When any disorder
becomes protracted, or runs into chroniciiy, the
need for moral, mental, or psychic as well as kinetic
orthopedia becomes urgent. Mind and body forces
need to be brought into equilibrium, into harmonious
interaction. Hence in a large group of morbid con-
ditions, all four angles of approach or repair deserve
proportionate attention : the mental, the medical, the
orthopedic, and the surgical. Also mechanistic fac-
290
MEDICINE .h\'D SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journai ,
tors exist in each condition more often than is ap-
preciated. In my experience surgical measures
need involve no cutting, yet the condition may, none
the less, urgently require mani])ulative (adaivtative;
surgery.
How shall those mechanistic or hiokinctir needs
be supj)lic(l ? What natural or accessory resources
(physicodynamic) capable of acting as equivalents
to the artificial or pharmacodynamic are available?
There are too many resources for description here.
This will be given elsewhere with the evidence.
The point for emphasis is that in solving clinical
I)rol)leins enough evidence exists to the effect that
heretofore undue prominence was given to, or con-
fidence placed in, pharmacodynamic or biochemical
remediation as contrasted with abundant resources
based on biophysics or biokinetics (physicodynam-
ics). Furthermore, it seems fair to assume from
the evidence that physicians must hereafter give pro-
portionate attention to both. Thus there shall
ensue — there is rapidly emerging — a comprehensive
and more practically efficient system of thera-
peutics.
My personal aim is to make some contribution to
this consummation. The stumbling block is not lack
of convincing evidence, but sheer inattention to, or
lack of interest in, these unfamiliar mechanistic
measures. Little or no systematic teaching of bio-
kinetics is being supplied. Even the terms used arc
as yet strange and unfamiliar. The word '"physis"
as used in physics is the opposite of physiologic.
The biggest stumbling block is that these biomcch-
anistic remedies have been seized upon and exploited
most absurdly by opportunists. Should that be
sound reason for condemning or even for ignoring
them? The whole history of medicine is one series
of incidents of entliusiasts and often fakirs forcing
upon reluctant attenlion practical points, the better
ones ultimately becoming incor]jorated into medical
practice. Extramural exploiters give oflfcnse by
their insistence ; yet even they deserve open minded
attention since logical results can only be secured by
using principles consonant with facts, causes and
effects, witli common denominatrirs ])aralleiing other
growths in experience.
Some reader may say, "But all this sketched out
is common knowledge ; what is thus recommended
is reasonable enough. The question remains, is it
as important as the writer would have us believe?
There are many experts in these procedures but
they are liable ro ovei state c!-iims."
To this the rcplv is that i have heard such state-
ments often scornfully expressed by those who mod-
estly admit themselves to be masters in medicine ;
past masters in sjjecial lines of consummate vaUie :
in "really scientific" as contrasted with plain com-
mon sense measure^ which m their eves are comj^ar-
•itively negligible.
Perhaps I. too, am fairly well informed on the
scope and resources of scientific medicine. The
above recomnumdations a^e based on precisely sim-
ilar, on somewhat divergent, directions of approach
but with equally valuable forms and manifestations.
It is no part of my purpose to '^elitlle so called scien-
tific resources, nor to exaggerate the value of ra-
tional, biokinetic. or nhvsicodynamic remediation,
but to speak from experience and re.search.
Of course I make use of all needful laborator>
findings and would beg critics to bear in mind the
possibility of achieving as high a degree of artistry
in the one as in the other chosen groups ; for art is.
after all, the doing of things as well as possible con-
sonant with personal limitations.
MEDICAL NOTES FRO.M THE FRONT.
By Charles Gkeenk Cumston, M. D.,
Geneva, Switzerland,
Privat-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London; etc.
FALLING BIRTH RATE JN GERMANY.
On May i6th a report on infant welfare in Ger-
many, prepared by the intelligence department of
the I.ocal Government Board, was issued; the fol-
lowing figures may be of interest: During the war
there has been a heavy fall in the German birth
rate. The first three years alone of the war re-
duced by over 2,000,000 the number of infants who
would have been born had peace prevailed. Some
forty per cent, fewer babies were born in 1916 than
in 191 3. I would add that the infantile death rate
has been kept well down, but is fifty per cent,
higher than in England.
The birth rate, which had risen from 36.1 per
1,000 inhabitants in the decade 1841-1850 to 39.1
per i,OfK) in the period 1871-1880, fell in the suc-
ceeding decades to 36.8, 36.1. and 31.9. The rate
for the last year of the decade 1901-1910 was under
thirty per 1,000, and the continuance of the fall
brought the rate as low as 28.3 in 1912. In 1913
there were 1,839,000 Hve births in Germany; in
1916 there were only 1,103,000 — a decrease of forty
per cent, as compared with 191 3.
TREATMENT OF CHRONIC EDEMA.
I shall now call your attention to some of the
recent Italian work, as it is of great importance, and
I will first refer to the treatment of chronic edema
frequently following contusions of the hands and
feet, and the tibiotarsal joint. Although the edenri
may occasionally be produced and maintained by
simulators, in which case the fraud must be de-
tected, it is quite frequently the result of trau-
matism. The edema always causes a prolonged
incapacity and it is important to return the men t»i
the army as soon as possible.
Considering that these edemata are the result of
stasis produced by extensive lymphatic thrombosis,
Mantelli has endeavored to obtain efficient lym-
phatic drainage by introducing silk threads in the
subcutaneous cellular tissue, extending from the
area of stasis to perfectly healthy areas. If the
intervention has been perfectly aseptic, which is
essential, the lymph is drained away rapidly along
the thread. Some very satisfactory results have
been obtained in Italy by this method.
'U'l'KAPUBIC CV.STOTOMV IN WOUNDS OF SPINE AND
CORD.
In the evolution of wounds of the spine and cord,
one of the most serious complications is, of course,
ascending infection of the urinary tract, and among
the causes of death in these unfortunate subjects, it
comes immediately after infection of the wound
itself and meningomyehtis in importance. Com-
August 17, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
291
plete retention, then incontinence from overflow,
and lastly infection, is usually the sequence of
events. To avoid infection of the urinary tract,
Colonibino suggests doing suprapubic cystotomy.
The operation may likewise be attempted in cases
where infection has already taken place."
If the retention of urine is aseptic, suprapubic
cystotomy should be resorted to as soon as possible,
but if there is at the same time considerable disten-
tion of the bladder, the organ must not be emptied
at once. If retention is complicated by infection,
the bladder should not be opened at once, otherwise
the perivesical space will become in turn infected,
a fact that is particularly serious in these patients
whose vitality is already low. In these circum-
stances Colombino performs suprapubic cystotomy
in two seances, in which, as the operation is quite
free from all danger of infection of the perivesical
space, it will not make the patient's condition any
worse, even though it may not attain the results de-
sired. At the first seance the abdominal parietes arc
incised, the peritoneum is pushed upward, and the
intact bladder sutured to the anterior aponeurosis
of the great oblique muscle. The wound is then
stuffed with gauze. One week later, the adherent
bladder is buttonholed with a knife and a small
drain inserted. Between the two operative seances,
careful catheterization must be resorted to, and if
passage of the instnmient is at all difficult a sonde
a dcmcurc should be inserted.
X'OLUNTEER MEDICAL SERVICE COR?\S.
By Franklin Martin, M. D.,
Mtmlicr of Advisory Commission and Chairman of General Meilical
Board, Council of National Defense.
rOREWORD.
The Volunteer Medical Service Corps was au-
thorized by the Council of National Defense on
January 31, 191 8. I'nder this authorization the
membership of the corps consisted of all physicians
who, because of age, i>hysical disability, dependents,
and essential home needs, were not eligible for serv-
ice in the Medical Reserve Corps of the army or
navy.
ENLARGED SCOI'E OF THE ORGANIZATION.
On August 5th the Council of National Defense
authorized a change in the sco]:ie of the organization
and an increase and amplification of its Central
Governing Board. Membership in the corps as now
authorized, makes eligible to the corps every legally
qualified physician, including women physicians,
holding the degree of doctor of medicine from a
legally chartered medical school, without reference
to age or physical disability, provided he or she is
not already commissioned in the Government serv-
ice. This organization has now the approval of the
President as indicated in the following letter.
I COPY. 1
THE WHITE HOUSE.
Washington.
12 Auc/ust, IQiS.
Mv DEAR Dr. Martin :
I have received your letter of Aiisjust =;th, laving hefore
me the matured plan for the reorganized Volunteer Medi-
cal Service Corps of which you ask my approval. This
work was undertaken by you under the authority of the
Council of National Defense; it has had great success in
enrolling members of the medical i)rofession throughout
the country into a volunteer corps available to supply the
needs of the Army, Navy, and Public Health Service. In
cooperation with the General Medical Board of the Coun-
cil of National Defense, the strong governing board of the
reorganized corjis will be able to be of increasing service,
and through it the finely trained medical profession of the
United States is not only made ready for service in con-
nection with the activities already mentioned, but the im-
portant work of the Provost Marshal (ieneral's Office and
the Red Ooss will be aided and the problems of the health
of the civilian communities of the United States assured
consideration. I am very happy to give my approval to
the plans which you have submitted, both because of the
usefulness of the Volunteer Medical Service Corps and
also because it gives me an opportunity to express to you.
and through you to the medical |)rofession, my deep appre-
ciation of the splendid service which the whole profession
has rendered to the nation with great enthusiasm from the
beginning of the present emergency. The health of the
Army and the Navy, the health of the country at large,
is due to the cooperation which the public autliorities have
had from the medical profession ; the spirit of sacrifice and
service has been everywhere present and the record of the
mobilization of the many forces of this great republic
will contain no case of readier response or better service
than that which the physicians have rendered.
Cordially and faithfully yours,
(Signed) Woodrow Wilson.
Pr. Franklin Martin,
The Advisory Coininissioii.
Council of National Defense.
EXHIBIT C.
At a meeting of the Central Governing Board, held on
Friday, August -'d, it was moved by Doctor Sawyer, sec-
onded by Doctor Martin, that the Central Governing Board
shall consist of the present Central Governing Board
(excepting Shark, Bradford, and Brophy) and others as
follows :
Surgeon General William C. Gorgas, U. S. A. ; Surgeon
(ieneral William C. Braisted, U. S. N. ; Surgeon General
Rupert Blue. U. ,S. P. H. S. ; Provost Marshal General E.
\\. Crowder; Dr. Franklin Martin, chairman of Commit-
tee on Aledicine and Sanitation, Council of National De-
fense ; Dr. Edward P. Davis, ijresident, Volunteer Medical
Service Corps ; Dr. John D. McLean, vice-president; Dr.
Charles E. Savvver, secretary; Admiral Cary T. Grayson.
U. S. K.; Dr. F. F Simpson; Dr. Frank Billings; Dr. H.
D. Arnold ; Mr. W. Frank Parsons, Red Cross ; Dr. Victor
C. Vaughan ; Dr. William H. Welch ; Dr. Robert L. Dick-
inson, chief of staff's office; Colonel R. B. Miller, U. S. A.,
chief of personnel division ; Surgeon R. C. Ransdell, U. S.
X., chief of personnel division; Colonel James S. Easby-
Smitli, Executive Officer; Dr. Joseph Schereschewsky, As-
sistant Surgeon General. U. S. P. H. S. (jjersonnel) ;
Dr. C. H. Mayo or Dr. W. J. Mayo ; Dr. William Duffield
Robinson ; Dr. George David Stewart ; Dr. Duncan Eve.
Sr. : Dr. Emma Wheat Gillmore.
GENERAL PLAN.
The Volunteer Medical Service Corps is exactly
what its name indicates. It is a gentleman's agree-
ment on the part of the civilian doctors in the United
States who have not yet been honored by commis-
sions in the army and navy, and a representative
board of governors consisting of officials of the
< iovernment associated with lay members of the
profession, in which the civilian physician agrees to
offer his services to the Government if required and
asked to do so by the (ioverning Board.
It is a method of recordiiifj all physicians who are
not yet in service and classifving them so that their
services when required will be utilized in a manner
to inflict as little hardship on the individual as pos-
sible. It is a method by which every physician not
292
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
in uniform will be entitled to wear an insignia which
will indicate his willingness to serve his Govern-
ment.
As more than sixty per cent, of the physicians of
the country will be utilized in caring for the indus-
tries at home and the health of the home people,
this large percentage of necessity will be expected
to maintain their home status and continue their
ordinary professional work.
A. Object of corps. — i. Placing on record all
medical men in the United States. 2. Aiding army,
navy, and Public Health Service in supplying war
needs. 3. Providing the best civilian serVice possi-
ble. 4. Giving recognition to all who record them-
selves either in army, navy. Public Health activities,
or civilian service.
B. This organisation provides. — i. Means for
obtaining quickly men and women for any service
required. 2. Furnishes recommendations and nec-
essary credentials to assure the best of service both
military and civil. 3. Determines beyond question
the subject's attitude toward the war. Through this
organization plan, many men will be registered for
army, navy, and Public Health Service who can be
called when needed without delay, and thereby a
medical reserve of thousands of men will be created
which will be immediately accessible for army, navy.
Public Health, and civilian service, no matter how
urgent the needs. Up to the present there have
been so many to be called that no great difficulty
has been experienced. From now on quick needs
will be m.ore difficult to fill, except as they have been
anticipated by having a direct line on all those who
are willing to serve. This necessity the Volunteer
Medical Service Corps fulfills, not alone as relates
to war needs, but also to the increasing civilian
needs.
C. Civilian service. — One great need of definite
organization is in relation to civilian service. Unless
some fixed plan is adopted home people may suffer
and medicine itself may be discredited. This plan
registers all medical men and women for all kinds
of service and places them within reach of those
who know the needs and will arrange for their
supply.
D. Recognition. — In the Volunteer Medical Serv-
ice Corps every one will have definite recognition of
his standing as related to the war and will receive
proper credit for service rendered, whether in army,
navy, public health, or civilian service.
E. Conservation of the profession. — li all medi-
cal services are conserved, we should not suffer. In-
discriminate placement and inconsiderate acceptance
of men for war service may bring suffering, while
specific organized handling of all medical forces will
afford ample medical attention for all. Such is the
purpose of the Volunteer Medical .Service Corps.
Tentative classification plan. — i. Fit to fight men
under forty ; 2, reserves under fifty-five ; 3, home
forces over fifty-five; 4, ineligibles.
Reserves will consist of those who may be called
upon for army, navy. Public Health, and civilian
service when necessity requires. The home forces
are those who are only able to do civilian service.
Definite classification. — I. Medical Reserve
Corps ; 2, Volunteer Medical Service Corps ; 3, in-
eligible.
The Medical Reserve Corps consists of such as
are needed in the present or near future army or
navy service; the Volunteer Corps of such as may
be called for special army or navy and Public Health
Service c.nd for all civilian service ; and the ineligible
class of such as have been charged with unprofes-
sional conduct, moral unfitness, or professional in-
aptitude.
RULES OF ORGANIZATION.
I. Name. The name of the organinzation shall be the
Volunteer Medical Service Corps of the United States.
II. Object. I. The object of the Corps shall be to
mobili/ce the medical profession in the present emergency
in order to provide for the health needs of the military
forces and civil population of the country. 2. Services of
members will be called for and rendered in response to
requests to the Central Governing Board from the Surgeon
General of the Army, the Surgeon General of the Navy,
the Surgeon General of the Public Health Service, or the
General Medical Board of the Council of National De-
fense.
in. The Corps. The Corps shall consist of all mem-
bers of the organization. The management of the Corps
shall be vested in a Central Governing Board.
IV. Central Governing Board. The Central Governing
Board shall be appointed by the Council of National De-
fense and approved by the President of the United States.
V. Ofncers. The Central Governing Board shall direct
the activities of the Corps and shall select from among its
own members a president, a vice-president, and a secretary.
VI. State Governing Boards. 1. The State Governing
Boards shall consist of the members of the State Commit-
tees, Medical Section, Council of National Defense. The
State Committees shall select, subject to the approval of
the Central Governing Board, from five to ten of their
members who are eligible for election in this Corps to act
as Executive Committee of the Volunteer Medical Service
Corps in the respective States. 2. The duties of the Ex-
ecutive Committee of the State Governing Board shall be
to consider applications for membership in the Corps from
the respective States and to sumbit recommendations re-
garding these applications to the Central Governing Board.
3. The State Governing Board shall aid in the work of the
Executive Committee of the State and perform such other
duties as may hereafter be deemed essential by the Central
Governing Board to accomplish the purpose for which
the Corps was created.
VII. Membership. i. Every legally qualified physician
holding the degree of doctor of medicine from a legally
chartered medical school, without reference to age or physi-
cal disability, may apply for membership in the Volunteer
Medical Service Corps, provided he is not already com-
missioned in the government service. 2. Women physicians
are eligible. 3 Application for membership in the Volun-
teer Medical Service Corps shall be made upon blanks fur-
nished for that purpose by the Central Governing Board
for proper classification according to training and special
fitness. 4 Any member of the Volunteer Medical Service
Corps who wishes to change his classification may appeal
to the Central Governing Board. 5. The Central Govern-
ing Board shall be empowered to elect from time to time
to the Volunteer Medical Service Corps members of sani-
tary engineering and hygienic professions.
VIII. Method of Election, i. The members of the Corps
shall be graduates in medicine who are licensed to practice
medicine in their respective States, who have made applica-
tion for membership, who meet the qualification requirements
that are now or shall from time to time be established by the
Central Governing Board, who are eligible as under Article
VII above, and who shall be elected to membership in the
Corps by the Central Governing Board. 2. Each person
elected to membership in the Corps shall be designated as
a member of the Volunteer Medical Service Corps. 3. It
shall be the duty of each member of the Volunteer Medi-
cal Ser\'ice Corps to notify the Central Governing Board
when he accepts a government commission.
IX. Insignia, i. Members of the Corps shall be
authorized and required to wear the insignia of the Corps.
2. The insignia and certificate shall be secured by members
of the Corps under such regulations as may be determined
upon by the Central Governing Board. 3. The insignia
August 17, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
293
shall not be loaned to any person not a member of tlie
Corps, nor shall it be worn after notification that eligibility
to the Volunteer Medical Service Corps has ceased to ex-
ist; and it shall be returned on demand of the Central
Governing Board.
X. Any member of the Corps may be expelled for con-
duct which, in the opinion of the Central Governing Board,
is derogatory to the dignity of the Corps or inconsistent
with its purposes.
XI. The Central Governing Board shall be authorized
to provide such regulations as shall from time to time
become necessary.
XII. Authorication. The organization, the insignia,
and the certificate have been authorized by the Council of
National Defense.
MEDICAL NEWS FROM WASHINGTON.
Reduction in Mortality from Pneumonia. — Lowest Death
Rate in the Navy. — Semiannual Health Report for the
Army. — Comparison of Disease and Battle Mortalities
for Mexican, Civil, Spanish, and Present Wars.
Washington, D. C, August 12, 1918.
Arrangements are being made by the Medical
Department of the Army more effectively to com-
bat disease at the camps and cantonments, in view
of the large influx of recruits that will come in as
a result of the new selective service law, and
particular attention is being given to measures to
reduce the mortality from pneumonia.
It is appreciated, of course, that this disease,
which is the most troublesome from a mortality
standpoint with which the medical authorities have
had to deal among our troops during the present
•.var, is bound to occur to some extent with the
assem-bling of large bodies of recruits, no matter
what the precautions, but every effort will be made
to reduce, by the use of improved methods, the
number of cases and the number of fatalities.
The ver\' heavy death rate, especially in some of
the camps last spring, was caused by the extremely
virulent germ streptococcus productive of the
dangerous form of pneumonia known as empyema,
which was largely responsible for the high mor-
tality. The Surgeon General of the Army was cer-
tain he would have to handle the disease in all of the
camps with the influx of later recruits in large num-
bers, and, for this reason, he early directed that
proper precautions be taken to meet the situation.
Tie placed the matter in the charge of a special com-
mission of physicians and pathologists, which in-
cltided some of the best known experts of the Medi-
cal Department. For special study and investigation,
the members of the commission went to Camp Lee,
Va., where they did most of their work. In the
meantime, also, special teams of physicians and
pathologists were put at work at every other camp
and cantonment to investigate and report to the
comnn'ssion at Camp Lee.
* -i: * * *
The lowest death rate during the period of the
war for the navy was reached last week, when the
death rate from sickness came to the remarkably
low flgiire of 1.2 per thousand per annum. This
rate is based upon the receipt of mail reports, and
it does not include the casualty hsts cabled from
France. Only twenty-one deaths were reported
from all causes. The reports for contagious dis-
eases showed two cases of cerebrospinal fever, two
of diphtheria, fourteen of pneumonia, fourteen of
measles, four of scarlet fever, and iio of mumps
from all the principal shore stations.
The division of surgery of the Surgeon General's
Office now has perfected its plans in accordance
with the system recommended by the commission,
and it is believed to be unlikely that pneumonia will
reach the death rate in the camps and cantonments
that it did in some of them in the early part of this
year.
H' * * *
Records of the division of sanitation of the
Surgeon General's Office for the first half of this
}^ear show that, despite the severe epidemics of
pneumonia, measles, and meningitis during Janu-
ary, February, and March, the Lealtii of the troops
in the United States was very good.
The annual death rate per tlionsand for disease
for this period was 8.03. On an average, forty-five
men out of every thousand were carried on sick re-
port, although a great number of them were not
confined to the hospitals. These included all cases
of venereal diseases, the greatest single cause of
disability in the army. In the majority of these
cases, the disease was contracted before the patient
entered the army.
For the months of January, February, and
March, the pneumonia season, the death rate for
disease per thousand was 10.4. For the following
three months, it v/as 4.95 per thousand. Of all
deaths during the six months' period, sixty-three
per cent, resulted from pneumonia.
The morbidity and mortality rates for the six
months for troops in this country were increased as
a result of the fact that numbered among the
soldiers in the country are all those sick and disabled
n>en left behind when the organizations of which
they were members sailed for Europe. This fact
explains in part the high admission rate for disease
in some of the camps.
if* ^
According to data prepared by the statistical
branch of the executive division of the general staff,
more than seven American soldiers died of disease
to every soldier killed in battle during the Mexican
war. Eleven in every hundred fell victims to faulty
sanitation.
In the armies of the North during the civil war,
the battle mortality increased more than 100 per
cent, over the Mexican average, while mortality
from disease was reduced nearly eighty-five per
cent. ; but the disease mortality was still double the
battle mortality.
The Spanish- American war witnessed a reversal
of the downward curve, with more than five deaths
from disease to each death in battle.
During the first ten months of the American
participation in the present war, the records of the
American expeditionary forces show an exact parity
between battle mortality and disease mortality, with
a combined mortality, which, if projected through-
out a year, would be only a little more than half of
the battle m.ortality and less than a third of the dis-
ease niortality of the civil v/ar.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, S.'\TURDAY, AUGUST 17, 191S
LS THE AlODERX TREATMENT OF
SYPHILIS A SUCCESS?
Most physicians who have been in practice
twenty years or more can lecall cases of syphilis
treated with mercury and iodine via the alimen-
tary canal for the then recognized period of two
to three years, and today c^n place the patients,
having^ had them under observation for that
length of time, or being aware of their presence
in the communit}', and can say that they have
evidenced no outward or inward signs or symp-
toms of the disease. They can even recall spor-
adic cases where the disease has appeared twice
in the same patient, thus evidencing a cure for
the first outbreak. I-'urthermore, they can bring
to mind cases wliicli have been quite thoroughly
treated, but which, ten or more years later, have
presented manifestations which point all too
clearly to tlic activating syphilitic poison.
Whether cases were completely cured or not, it
is certain that the disease remained quiescent and
did not give the patient any further trouble, often
llirougli a long life.
Today the former treatment has given way to
intravenous injections of one of the arsenical
compounds, supplemented l)y the former treat-
ment, or at least by hypodermic injections of
some mercurial compound. Can the results
achieved by this form of treatment be termed
successful? Are we any Ix.tter ofT with it than
with the older treatment? And which is the
remedy, tlie arsenical compound, or tlie mercury?
If the results achieved at the Toronto General
Hospital can be taken as a criterion and on a par
with those achieved in other similar institutions,
the majority of physicians can hold to no other
ojjinion than that the treatipent is neither satis-
factory nor encouraging, e\-en though the writer
we shall presently quote states: "Considering the
class of cases that have Ivjen dealt with at our
clinic, the results of treatment are not at all dis-
couraging." This is an o])inion of very doubtful
value.
In the July issue of the Canadian Medical Asso-
ciation Journal, Dr. W. T. Williams outlines the
•lu-tliod of treatment and the results obtained in
fi\ c Inmdred cases. Of these five hundred cases.
145. or twenty-nine per cent., were at an early
stage of the disease : 355. or .^ eventy-one per cent.,
were at later stages. On an average of seven
and a half doses of 0.5 gram plus four and a half
mtramuscular injections of mercury, negative
Wassermanns were secured in only seventv
cases, approximately fifteen per cent. Of these
seventy cases, twenty-three were in early
stages of syphilis, and forty-seven in the
later stages. "Practically all of the late
cases were given in addition mixed treat-
ment of mercury and potassium iodide."
\'ery important, too. is this sentence: "Twenty-
Tour cases had a return to positive Was-
sermann, thirty-five stiH. remain negative,
wliile eleven of them passed from our control"
— a not uncommon sequence to tlie treatment of
such cases. That is to say. of the series of five
hundred cases treated, thirty-five cases, seven
])er cent., may be said to be cured, that is, so far
as a Wassermann negation indicates a cure.
Tlie number is very, very small, and instead of
being prol)]ematically "not discouraging," is, to
say the least, entirely so.
How can tlie conscientious physician face the
l)atient who seeks a cure f(^r this elusive enemv
in his blood or his tissues, and tell him that at
the 'I'oronto General Hospital seven per cent, of
the cases are supposedly cm-ed ? .Surelv these
August 17, 191S.]
results are humiliating rather than "not at all
discouraging."
Nor can many be found to agree with a fur-
ther statement that "about eighty per cent, of
all cases experienced relief or freedom from all
symptoms, which at any rate is encouraging."
Kas it not been the common experience that a nia-
j(4rity of all cases of syphilis experience relief or
freedom from all symptoms either with or with-
out the former treatment after the so called sec-
ondary stage has ])een passed?
There is, however, another vital point in this
modern treatment of a patient with syphilitic in-
fection, the question of expense. Are physicians
justified in placing this added financial burden
upon patients, when they can probably secure
satisfactory "cures" in seven per cent, of the pa-
tients so treated ?
The time now ^cems opportune for the na-
tional medical bodies of Canada and the L'nited
States (the Canadian Medical Association, and
the American Medical Association) to consider
the entire question of the modern treatment of
syphilis by the intravenous method of arsenical
preparations, to appoint commissions or commit-
tees, and to have the statistics of hospitals and
those of private practitioners with sufficient ex-
perience along these lines collected and collated,
so that the profession of medicine and the pa-
tients may become assured of any real value
which this modern method of treatment pos-
sesses.
TESTS FOR COLOR BLINDNESS.
Color blindftess is a factor which under present
exceptional conditions must be submitted, like
many others, to more accurate and discriminative
tests than heretofore. Our nation in particular is
learning today a lesson of appreciation of the
finer distinction and gradations of efficiency and
usefulness in men or means, which our very
abundance of resources had led us extravagantly
to pass over. Just as we have learned that a
slight admixture of the less perfect rye fiour in
our wheat bread was no real loss in dietary econ-
omy but an adaptability of need to material of
varying standards, .so we are learning conserva-
tion in other matters, physiological, psychical,
economic, whatever it may be. It is a most im-
portant and needed lesson, which nature has often
tried in vain to enforce against a blind pride in
superiority ; the finding of some place and some
iise even for imperfections and inadequacies,
where each fits into some modest groove where
it can work, and where- often the imperfection
is remedied by the opportunity thus given.
This principle is the one upon which recon-
structive work and the future employment of
our crippled soldiers must be carefully based. It
is one which has already changed the tactics of
])reliminary inspection of enlisted and drafted
troops, so that now, even there, weaknesses are
many times accepted and training is adapted to
the abilities. 1'hese weaknesses are thus re-
moved by the right training, or some service is
found where they will not prove a hindrance.
This method is now supplanting the wholesale
exclusion and rejection that formerly have been
allowed to prevail in so many spheres.
Color blindness is being submitted to the same
treatment. No remedial procedure is claimed
for it, but a series of discriminatory tests have
been applied by Surgeon Collins of the United
States Public Health Service. [Color Blindness:
Its Relation to Other Ocular Conditions, and the
I bearing on Public Health of Tests for Color
Sense Acuity; Public Health Bulletin. No. 92.]
Color blindness is prevalent among ordinary
healthy individuals in America, Surgeon Collins
asserts, to the extent of about 8.6 per cent, of
men and 2.2 per cent, of women. This is exclu-
sive of those known as the pentachromic color
blind, as this class is for practical purposes unim-
portant. The defect here manifests itself only
in inability to see the orange of the spectrum and
to make the sharp distinctions between the modi-
fied color units which the average person makes.
Among those who are included are many
whose defect makes of their position a menace,
]:)articularly on the sea, on the railroad, and in
aviation. Those who have acquired color blind-
ness are aware in general of their defect, and
llierefore on their guard ; but to the congenitally
defective there is the added menace of a false
assurance of accuracy and ignorance of color dis-
tinctions. Yet there are so many grades of color
blindness, which are carefully described and dis-
tinguished in this report, that many of these indi-
viduals can be fitted into some other branch of
service or in the case of civilians are perfectly
fitted for many positions, where the same exact-
ness of distinction is not required.
In order therefore to discover such difTerences
in color blindness and to create a standard by
which fitness for service in this respect can be
properly gauged and apportioned, careful tests
have been made with special testing apparatus.
The examiners find that the apparatus which
gives the most accurate, reliable, and discriminat-
ing test is the Edridge-Green lantern, which con-
tains slides of specially colored glasses and oth-
EDITURf.lL ARTICLES.
296
EDITORIAL ARTICLES.
[New York
Medical Journal.
crs which modify the colors as they are modified
in natural conditions, such as mist, fog, rain, and
other factors, which cause the reaction to colors
to vary under varying conditions. This device
for testing also makes use of certain combina-
tions which are particularly valuable in detecting
dangerous color blindness. It has not only these
advantages over the older worsted tests, but ob-
viates the inaccuracy resulting from inevitable
change of color in the worsteds, from a false dis-
tinction often made through the luminosity of
Ihe materials and from the fact that the wools as
a rule are so large as to subtend too great an
angle at the nodal point of the eye, thus allowing
peripheral color visions to aid in determining
the color.
The lantern test, however, necessitates a some-
what complicated apparatus, and there are many
cases in which an adequate test can be made
more quickly and easily with the Jennings appa-
ratus, which is a self recording worsted test.
This does not permit the accuracy and fine dis-
tinction of the lantern tests. It has its use, but
not in testing for sea or train service, or wherever
danger might result from inaccuracy of test.
This bulletin covers the v/ide range of results
found in these various tests and also presents a
consideration of the relation of color blindness
to various pathological ocular conditions and the
amount of importance to be attached to these in
considering the results of the tests.
WHO WILL SUCCEED' GENERAL
GORGAS?
In October, General William C. Gorgas, Sur-
geon General of the United States Army, will
reach the age for retirement, and the question of
who shall succeed him is being discussed quietly
but generally in medical circles. A movement
was begun to ask the Secretary of War to reap-
point General Gorgas after his retirement, but it
is said that such a step would be illegal. His
services could be retained, however, by appoint-
ing some one else as surgeon general, detaching
him from the office for special duty, and appoint-
ing General Gorgas as acting surgeon general.
There is a rumor to the efifect that this may be
done and that General Pershing would like to
have General Merritte W. Ireland, Chief Surgeon
of the American Expeditionary Forces, appoint-
ed surgeon general and detailed for duty in
France, leaving General Gorgas as acting sur-
geon general to carry on the work of the depart-
ment in Washington. Brigadier General Charles
Richard, now on duty in the Surgeon General's
Ofifice in Washington, is the senior officer in the
Medical Corps. He would have to retire for age
about one month later than General Gorgas, and
it is possible that he may be made surgeon gen-
eral for this month, so that he may retire with
the rank of major general. Under the Senate
amendments to the army appropriation bill, pro-
vision is made for two assistant surgeon generals
in the regular army with the rank of major gen-
eral, one of whom is to serve abroad. Under
this amendment. General Ireland and General
Richard might both be given the rank of major
general, even though neither was made surgeon
general. Brigadier General Robert M. Noble, of
the Medical Corps of the regular army, has also
been named as a possible choice to succeed Gen-
eral Gorgas. General Noble has been very active
in the afi'airs of the Surgeon General's Office, first
as chief of the personnel division and for several
months past as chief of the division of hospitals,
and has made an excellent record for efficiency.
There is also a possibility of going outside the
medical corps of the regular army for a surgeon
general, in which case Colonel Franklin Martin
might be chosen. He certainly deserves special
recognition for the invaluable services which he
has rendered in the organization of the medical
profession for war, in which work he took the
initiative long before the United States entered
the war.
CANCER OF THE LARYNX.
The hopelessness of the cancer situation in ad-
vanced and deep seated cases in other parts of
the body is fully shared by the larynx, and this
notwithstanding the newer methods of treat-
ment, which are at best only palliatives. In dis-
cussing the cancer problem, especially in its ref-
erence to the larynx, Dr. J. B. Beck {Laryngo-
scope March, IQ18) sounds a note of warning
against undue overconfidence evinced by some
writers, who often overstep the boundaries be-
tween accuracy and enthusiasm, with the result
that promises are frequently put forth which can
not be fulfilled, to the disappointment of the pub-
lic and the consequent chagrin of the profession.
The fact cannot be reiterated often enough that
we have no specific for cancer, and that the only
cure, if any, lies in early surgical intervention.
This means an early diagnosis, for one of the
chief causes of surgical nonsuccess is the failure
to make a sufficiently early diagnosis (assuming,
of course, that the case presents itself in time).
Another cause is failure to operate extensively
August 17, 1918.]
OBITUARY.
297
enough to take in the contributory glands. Im-
plantation recurrence along the operative field is
still another cause for failure of the operation.
The early diagnosis of laryngeal carcinoma is,
comparatively speaking, not a difficult problem,
and the careful physician will have his suspicions
aroused by hoarseness in an elderly person, espe-
cially a man, that persists in spite of treatment
of several weeks' duration. At a certain age care
should be taken to rule out cancer, first of all, as
a cause of persistent hoarseness. The situation
of the cancerous growth is usually at the anterior
portion of the cord, and as the lymphatic distri-
bution from this region is rather limited, the
glands are not involved extensively or early
enough to assist in the diagnosis. The follow-
ing methods of treatment, both adjuvant and rad-
ical, are mentioned : TJie Percy coagulation
method, a slow destruction of the tumor in situ
by heating the tissues, with subsequent slough-
ing and discharge. There is liable to remain con-
siderable cicatricial formation, and the necrotic
mass may be very tenacious. In the diathermia
coagulation method a high frequency current is
passed from one pole to another through a por-
tion of the tissue to be penetrated by the current.
The heat developed varies between no and 130
degrees and the treatment is usually applied
daily. Deep x ray penetration seems to be of
value in sarcoma of the larynx, and in cases of
maxillary, postnasal, and pharyngeal sarcoma,
but not in carcinoma ; however, the author's ex-
perience is so limited that no positive results can
be given. The same may be said of massive doses
of radium, although the author observed in the
only case employed a marked reduction of the
growth.
Owing to the high mortality attending it laryn-
gectomy has practically been abandoned by him :
in the cases that survived the operation, loss of
the voice followed. Hopes are given for a modi-
fication of the technic of the operation so as to
enable the operator to place an artificial larynx
from the trachea to the mouth, and thus render
some help to the unfortunate sufferer.
DOCTORS STILL WANTED AS OFFICERS
IN THE ARMY.
The Secretary of War and the Secretary of the
Navy have issued the following statement : "Or-
ders issued by the war and navy departments
on August 8th suspending further volunteering
and the receipt of candidates for officers' training
camps from civil life do not apply to the enroll-
ment of physicians in the Medical Reserve Corps
of the Army and the Reserve Force of the Navy.
It is the desire of both departments that the en-
rollment of physicians should continue as active-
ly as before so that the needs of both services
may be efifectively met." We direct special at-
tention to this statement, as it is highly impor-
tant that the enrollment of physicians in the
Medical Reserve Corps of the Army and the Re-
serve Force of the Navy which has been going
on so satisfactorily shall not be interrupted. The
order issued on August 8th, in which the receipt of
candidates for officers' training camps from civil
life was suspended, has been misunderstood by
some physicians as forbidding the further enroll-
ment of officers in the Medical Reserve Corps.
We are glad to direct attention to this official
assurance that enrollment in the Medical Re-
serve Corps will go on as heretofore and that ap-
plications for such enrollments will be welcome.
A PRISONER OF DUTY.
The Turkish Government is shortly to effect an
exchange of 1,000 British prisoners, but there will
be still many left over there, and, naturally, they
will need doctors. Under the Berne agreement of
December last it is arranged that one British doctor
and five of the medical personnel of the ranks
should be detained for every 1,000 prisoners. No
inspection of prison camps under the Berne agree-
ment has yet been made, but it is very probable
that conditions there may necessitate more doctors
being detained. There are some things in warfare
which are harder than actual fighting, and to stay
behind in a prison camp tending wounded and
nostalgic men when others joyfully set sail for home
or active service requires all the unselfish devotion
to duty with v;hich doctors are justly credited by
the laity.
Obituary
MAIOR DAVID EVERETT WHEELER.
M. R. C, U. S. A.,
of Buffalo, N. Y.
Major David Everett Wheeler, of Buffalo, N. Y.,
was killed recently while attending the wounded
under fire during the iUlied counter offensive. Major
Wheeler went to Europe in the first winter of the
war in connection with the Red Cross work. He
enlisted as a soldier in the French Foreign Legion
on February 7, 19T5, ^ind was wounded during the
Champagne campaign on September 28th, of that
year. Though wounded himself he attended the
other wounded men around him and was awarded
the P>ench Croix de Guerre. He joined the Cana-
dian Army with the rank of Captain and when the
United States declared war he joined the Medical
Department of the United States Army, was given
a commission as major and has served with the
American troops as regimental surgeon in Lorraine
and at Cantigny and at Chateau-Thierry. Doctor
Wheeler was born in 1872 and graduated from the
College of Phvsicians and Surgeons of New York
in 1898.
298
NEWS ITEMS.
[New York
Medical Journal.
News Items.
Lucius P. Brown Reinstated. — The }3oard of Healtli
of the Cily of New York lias reinstated l^ucius P. Brown
as director of the Bureau of Food and Drugs of the De-
partment of >Iealth. He was suspended on May 28th, on
accusation by James E. ^[cBride, civil service commis-
sioner.
American Association of Obstetricians and Gyne-
cologists.— The thirty-lirst annual meeting of this asso-
ciation will be held at the Hotel Statler, Detroit, Septem-
ber i6th, 17th, and i8th, under the presidency of Dr. Albert
Goldspohn, of Chicago. Dr. James E. Davis, of Detroit,
is chairman of the committee of arrangements.
Civil Service Examinations for Laboratory Assistant
and Nurse. — The Municipal Civil Service Commissipji
announces two examinations for which applications . will
be received until August 20th, one for a nurse, female, for
temporary work in the health department, and the other
for an assistant in a chemical laboratory. For further
particulars address the Municipal Civil Service Comrnis-
sion, Municipal Building, New York.
Nutrition Officers for All the Large Camps. — The
Surgeon General of the United States Armv announces
that nutrition ofillcers will he stationed at all camps having
TO.ooo or more soldiers in training. These officers, who
are specialists in their particular field, have made a survey
of the nutrition in the various camps and recommended
many changes which have been adopted with advantage
to the service. Sixty new officers are to be commissioned
in this particular service.
Red Cross Contributions to Armenian and Syrian
Relief. — The war council of the American Red Cross
Society has made an appropriation of $900,000 as an addi-
tional contribution to the American Committee for Ar-
meniin and Syrian Relief, making a total of $3,000,000
contributed to this relief work during the past year.
This money is used by the committee for relief work in
•Armenia, Syria, the Caucasus, Mesopotamia, Palestine,
and otl'icr countries in the Near East.
Sioux Valley Medical Association. — The following
officers were elected at the annual meeting of this asso-
ciation, held in Sioux Falls, S. D., Wednesday, July 24th:
Dr. Joseph G. Parsons, of Sioux Falls, S. D., president;
Dr. Alfred E. Spalding, of Luverne, Minn., first vice-presi-
dent ; Dr. Daniel T. Quigley, of Omaha, Neb., second vice-
president; Dr. George S. Browning, of Sioux City,- la.,
secretary; Dr. H. G. J. Koobs, of Scotland, S. D., treas-
urer. The next meeting will be held at Sitnix City, la.,
in January, 191Q.
Special Course in Bacteriology for Laboratory As-
sistants.— The Surgeon General's Office has issued a
call for laboratory assistants in bacteriological work for
immediate service in camps and hospitals and for those
desiring to qualify a special three months' course at the
University and Bellevue Hospital Medical College has been
arranged by Dr. William H. Park, director of laboratories
of the Department of Health of the city of New York,
and Dr. Anna W. Williarns. assistant director. It will
open September 4th, with daily sessions from nine to five,
except on Saturdays. The fee is $75 and a few scholar-
ships may be available. Application should be made to
Doctor Park at the laboratories of the health department,
foot of East Sixteenth .'Street, New York.
The Medical Society of the Missouri Valley. — The
thirty-first animal iiuet n.u of this society will be held in
Omaha, Neb., Thursday and Friday, September igth and
20th, under the presidency of Dr. A. I. McKinnon, of
Lincoln, Neb. Arrangements are in the hands of a com-
mittee appointed by the Omaha-Douglas County Medical
Society, under whose auspices the meeting will be held,
with Dr. John E. Summers, of Omaha, chairman. Other
members of the committee are Dr. B. W. Christie, Dr. L.
B. Bushman, and Dr. I. S. Cutter. The reception com-
mittee is composed of Dr. A. F. Jonas, Dr. R. W. Bliss,
and Dr. Roy A. Dodge. Complete programs will be issued
early next month. Dr. Charles Wood Fassett, of Kansas
City, ITo., is secretarv of the society. Dr. O. C. Gebhart,
of St. Joseph, Mo., is treasurer, and Dr. Paul Gardner,
of New Hampton, la., and Dr. T. M. Paul, of St. Joseph,
Mo., are vice-presidents.
Typhoid Fever in an Internment Camp. — Eleven
deaths from typhcid fever have occurred among the Ger-
man civilians &nd sailors interned at Hot Springs, N. C.
.About 150 cases of the disease have developed. Shallow
wells ire blamed for the infection.
No Danger of Spanish Influenza Epidemic in New
York. — Dr. Leland E. Cofer, health officer of the port of
Ntvj York, reported that there were several cases of in-
fluenza among the passengers on board a Norwegian
steamer which arrived in Quarantine Tuesday, August
13th. Since there is no ciuarantine at this port against
any kind of influenza, the patients were removed to
the Norwegian Hospital in Brooklyn, and now all have
pneumonia. , .The ship, surgeon reported that three deaths
from pneum.onia had occurred on l)oard, and at least one
Ijatient has died since landing. It is Doctor Gofer's belief
that there is not the slightest danger of an epidemic of
.Spanish influenza in this country. The subject was dis-
cussed at a meeting of the Board of Health of New York
cijty, Thursday, August iSth.
Personal. — First Lieutenant Charles W. Myers, M. R.
C, has been awarded the Distinguished Service Cross, ac-
cording to General Pershing's report of August 7th. .■^t
Vaux, on July ist. Doctor Myers established under heavy
shell " fire an advance dressing station for the treatment
and evaCjUation of men wounded in the first waves of the
assaults.
Dr. J. Torrance Rugh has been appointed professor of
orthopedic surgery at the Jefferson Medical College, Phil-
adelphia.
Passed Assistant Surgeon Paul Tonnel Dessez, U. S.
Navy, has been awarded the Distinguished Service Cross
for bravery
Death Percentages from Wounds. — In connection •
with the casualties amoi.g the A. E. F. in the Marne-
Aisne offensive, accord ng to a statement authorized by
the chief o.f stafif, it should be stated upon the basis of the
officially attested experience of our associates durin.g four
years of this war that of wounded soldiers sent to hos-
pitals for treatment fewer than one in twenty die. Of
all the soldiers sent to the hospitals only forty-five in
every 1,000 die, says the Aryny and Navy Journal for
August 10, IQ18. These include those who die of diseases
as well as those who die of wounds. Of all soldiers
wounded in action more than four fifths return to service,
many of them in less than two months. It is necessary
to discharge for physical disability only 14. .S per cent.
These figures are based on an average of both British and
French official figures, including both officers and men.
The two are averaged together since American troops are
fighting with both the French and the British under condi-
tions which vary. They show : returned to service, eighty-
one per cent., or 810 per 1,000; discharged from service
because of physical disability or other causes, 14.5 per
cent., or 145 per 1,000; died from wounds, 4.5 per cent., or
45 per 1,000.
Health of Troops in the United States Camps. — The
semiannual report of the chief of the Division of Sanita-
tion to the Surgeon General of the Army shows that de-
spite the severe epidemics of pneumonia, measles, and
meningitis during January, February, and March, the
health of the troops in the United States has been very
good. The annual death rate per 1,000 for disease for this
period was 8.03. On an average 45 men out of every
1,000 were carried on sick report, although a great many
of these were not confined to the hospitals. These in-
cluded all cases of venereal diseases, the greatest single
cause of disability in the army. In the majority of these
cases the disease was contracted before the patient en-
tered the army. For the months of January, Febniary,
and \farch, the "pneumonia season," the death rate for
disease per 1,000 was 10.4. For the following three
months it v;as 4.93 per 1,000. Of all deaths during the six
month period sixty-three per cent, resulted from pneu-
monia. The morbidity and mortality rates for the six
months for troops in this country are increased as a result
of the fact that numbered among the soldiers in the coun-
try are all those sick and disabled men who were left
behind when -the organizations of which they were mem-
bers sailed for Europe. This fact in part explains the
high admission rate for disease in some of the camps.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Ad apted
SOME NOTES ON DRUGS AND
TREATMENT.
A Review of Recent Progress in Therapeutics.
By Mark Sadler, M. D.,
Montreux, Switzerland.
III.
THE TREATMENT OF HEMOPHILIA. ,
{Concluded from page 2^6.)
The organic extracts have naturally been em-
ployed in hemophilia. Treatment with thyroid ex-
tract has given some good results. Labbe says that
under its influence the spontaneous multiple hemor-
rhages, which nothing could stop, were controlled,
health was restored, and a permanent cure resulted.
The ovarian extract was used successfully in one
case by Tavardier, and it seems that hepatic ex-
tracts have likewise given good results. However.
Gilbert and Carnot have shown that when given in-
travenously fatal thrombosis has occurred, a fact
which did not prevent these writers from noting that
in vitro the addition of hepatic extract hastened
coagulation. The coagulating action is not peculiar
to hepatic extract, and the majority of organic ex-
tracts possess a hemostatic action, while the same
may be said of tissue juices. In this respect I
would refer to a curious experiment of Morawit^
and Lessen, who collected hemophilic blood in four
different tubes. The first was empty, and coagu-
lation took place in two hours. The second tube
contained a one per cent, solution of calcium chlo-
ride, and no change was observed. The third tube
contained fifteen centigrams of renal juice, and co-
agulation was complete at the end of a minute. Fin-
ally, in the fourth tube there were twenty-five cen-
tigrams of a 4:1,000 solution of hirudin. The blood
remained uncoagulated.
Therefore, it is evident that of all the therapeutic
agents I have considered in the order of gradu-
ally increasing coagulating action, it is certain that
some have given appreciable therapeutic results in
the disease in question, but the benefit derived
is much more evident when serotherapy has been
resorted to.
Three sorts of sera have been utilized, namely,
artificial serum, Fleig's serum of complex mineral-
ization and the animal sera. The first of these sera,
representing a 7:1,000 sodium chloride solution, has
been utilized not only for its tonic, reconstructive
and hematopoietic effects, but also on account of
its hemostatic action. Tuffier, Hayem, and Four-
meau speak favorably of its use in hemophilia.
On the other hand, Fleig has demonstrated this
hemostatic action of ordinary physiological salt so-
lution in dogs. He made a clean section of a muscle
and obtained a capillary hemorrhage which ceased
when the salt solution was injected. In two rabbits
he cut the gluteus muscle, which was followed by
capillary hemorrhage. One animal was left to him-
self, and the bleeding continued for eighteen min-
utes. In the other it ceased at the end of ninety
seconds after an injection of twenty c. c. phys-
iological salt solution, and three minutes and a half
aftei: section 6f the muscle. Continuing his experi-
ments, Fleig came to this most curious result,
namely, that massive doses of the serum prevented
its hemostatic action.
Besides normal salt solution, Fleig studied the
action of compound mineral sera containing all the
minerals of the blood, and in proportion as near
as possible. He compared, from the viewpoint of
hemostasis, the effects of normal salt solution and
his complex serum, the following being the for-
mula :
Sodii chlorid., 6 to 8 grams;
Potass, chlorid., 0.20 to 0.60 gram ;
Calcii chlorid., 0.50 to 3.0 grams;
Magnesii sulphat., 0.20 to o.so gram;
Sodii bicarb. 0.50 to 1.50 gram;
Sodii phosphoglycerat., 0.70 to 2.00 grams;
Glucose i.oo to 5.00 grams;
Aq. dest q. s. ad 1,000 c.c.
By means of this serum, Fleig came to the fol-
lowing conclusions : that this com])lex liquid has a
greater hemostatic effect than normal salt solution ;
that the addition of this serum in certain amounts
to normal salt solution still more increases the
power of coagulation ; that the mechanism of the
hemostatic action is due both to the increase of coag-
ulability of the blood and vasomotor changes, and
that these sera may be used in practice, either as a
curative or prophylactic measure.
There are also the animal sera, whose use has
now become general in hemophiha. The rules apn
plicable to animal serotherapy have been well laid
down by Weil. He advises the use of fresh serum
(from man or horse) in hypodermic injections, and
points out that intravenotis injections offer certai^n
dangers, although it may be utilized in cases where
a rapid effect is necessary. Antidiphtheritic and
antitetanic sera may be employed, but Weil prefers
the fresh horse serum. This is readily obtained
from the jugular vein of the animal by puncturing
the vein with a large needle. Fifty c.c. of blood
are sufficient. This is left to coagulate, after
which the serum is removed. An injection of
from ten to twelve c.c. is quite enough. Weil
says that the fresh serum manifests its effect
in from twelve to twenty-four hours after in-
jection, and its effect lasts for twenty-five days,
although it gradually decreases. A second injection
will produce the same effect as the first one. Schles-
inger proves the good results obtained from anti-
diphtheritic serum, but advises not to renew the in-
jection until two or three days have elapsed. An-
imal serum can also be utilized in local applications.
As to treatment, it is either prophylactic or cura-
tive. Weil has published two cases in which the
prophylactic, in hemophilic subjects, permitted sur-
gical operations to be performed without any ul-
terior complications arising. On the other hand,
Mauclaire had a contrary experience after a prophy-
300
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
lactic injection of twenty c. c. of antidiphtheritic
serum, the patient dying from a surface oozing fol-
lowing the incision for a suppurating parotiditis.
Baum had unsuccessful results in three cases in the
same family, where prophylactic serotherapy had
been employed, the blood of each subject coagulated
in vitro in contact with fresh serum.
These failures prove that the preventive method
is not always without danger, and for this reason
the practitioner will do well not to count too much
upon it, but curative treatment by this therapeutic
measure has been much more successful, and many
published cases, including two of my own, reveal a
particularly distinct and trustworthy efifect.
Antidiphtheritic serum has been most generally
employed. Be careful to distinguish between acci-
dental and familial hemophilia. In the former, Weil
has not yet had occasion to test the efifect of fresh
serum, but there is no doubt that its action is con-
siderable, when we take into consideration its
proven efficacy in other hemorrhagiparous states
and all the various dyscrasic hemorrhages. In
familial hemophilia its efficacious eftects are very
marked, while the local action of fresh serum has
been verified by Weil in a man who sustained a
severe hemorrhage from the arm. It is always ad-
vantageous to utilize it when possible in local applica-
tions alone, or combined with hypodermic injections.
The hemostatic effect is very powerful. Although
the effects do not appear until twelve, fifteen, or
twenty-four hours after its use, it would be most
•exceptional that the hemophilic state would be such
that this delay would be serious.
Mode of Action of Lactic Bacillus Therapy. —
P. Carnot and H. Bondouy {Paris medical, May 4,
1918) note ihat the partisans of lactic ferment
treatment maintain an ability on the part of the fer-
ment to liberate acids by its action on sugars, espe-
cially lactose, in the alimentary tract and thereby
to modify the intestinal flora and impede the pullu-
lation of proteolytic putrefactive organisms. Re-
cent observers, however, have failed to note an acid-
ification of the feces, even after ingestion of large
quantities of lactic cultures or of yoghoort. In a
case treated radically for cancer of the transverse
colon and having a cecal artificial anus as well as a
partial passage of fecal material to the anus, the
authors were able to investigate the subject. In
control experiments neither yoghoort alone nor yog-
hoort with an extra quantity of milk of fifty
grams of lactose, led to acidification of the feces.
The same condition prevailed in the patient with the
artificial anus. Simultaneous examination for a
week, however, of the cecal and anal stools in this
patient supplied the key to the problem. With
yoghoort alone — even 750 mils — the cecal stools re-
mained neutral, like the anal stools, but upon addi-
tion of fifty grams of lactose, the cecal stools became
very decidedly acid, while the anal stools were still
neutral. This persisted even when the yoghoort
was reduced to 250 mils ; but the acidity disappeared
upon discontinuance of the lactose. Tests for lac-
tic acid and lactose were positive in the cecal stools
but negative in the anal stools. These findings
show that to induce acidification at all, lactose must
he given along with the yoghoort. Lactose actu-
ally reaches the cecum, in which the acidifying ac-
tion occurs. Farther on in the colon, however, the
lactose and lactic acid are absorbed and the stools
return to their neutral reaction. Lactose is the
only sugar which yoghoort will ferment. With any
of the lactic ferments one should combine lactose,
fifty grams a day, to be taken in solution in several
doses between meals. Saccharose and proteoses
were also found in the cecum ; passage of food from
pylorus to cecum took but a few minutes, but from
cecum to rectum, over twenty-four hours. Failure
of acidification of the anal stools after ingestion of
lactic ferment does not prove that reduction of pro-
teolytic organisms is not taking place in the small
intestine and cecum. As for the question whether
the antiproteolytic action exerted is actually power-
ful enough to induce an autopurification of the in-
testine by modifying the flora, this remains to be
definitely settled.
Early Vaccination of the Newborn. — W^urtz
{Bulletin cie I'Academie de medicine, May 21, 1918)
states that the French laws recommend waiting
three months before vaccinating a child at the breast.
Pinard, however, has long been a partisan of imme-
diate vaccination, deeming it better to take the risk
of nonsuccess than to delay the procedure. Re-
cently an unvaccinated child two months old suc-
cumbed to smallpox in Paris. Tissier in 1904 pub-
lished a paper based on statistical data from which
he concluded that the chances of nonsuccess at birth
are greater than two or three weeks later ; inherited
immunity rapidly becomes attenuated at the expira-
tion of this period. Yet Tissier, in common with
other accoucheurs of the Paris hospitals, himself
practises and advocates early vaccination of the
new born. Exception is made in cases of congenital
debility, skin affections, etc. Bonnaire, having wit-
nessed a case of death from hemorrhage after vac-
cination of a newborn child, waits until the eighth
or tenth day. Wurtz advises that the official recom-
mendation as to time of vaccination be altered to
read "all children over ten days and less than three
months old."
Ionization in Incipient Cancer and Other
Nodules in the Breast. — G. Betton Massey
{American Journal of Electrotherapeutics and Radi-
ology, March, 1918) refers to the value of the far-
adic current in clearing the diagnosis in suspected
incipient breast cancer ; it will cause resolution of
painful areas of chronic mastitis. A "sticking"
pain is an even graver indication of cancer, while
absence of both pain and tenderness in a lump is
probably the worst subjective sign. The faradic
current is advised when expert palpation yields only
signs of apparent chronic lobular congestion. Any
nodule which resists two to six weeks' daily appli-
cations of the faradic current, should be promptly
destroyed by massive polar ionization. It is either
a cystoma, carcinoma, or fibroma. Local destruc-
tion in situ without preliminary microscopic exam-
ination is urged as the safest procedure for the pa-
tient, careful attention being also advised as regards
enlarged glands in the axilla, which are to be de-
stroyed in the same way. Patients will consent to
this treatment earlier than to removal of the breast,
and the physician himself will reach the decision
earlier than he will that of advising removal. The
August 17, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
301
ionization causes both chemical and thermic de-
struction of all the tissues between the electric
needles in a few seconds. The destructive applica-
tion must usually be carried out under a brief gen-
eral anesthesia. The author has destroyed in this
manner small breast tumors in fifteen cases. In
several the diagnosis of probable cancer had been
greatly strengthened by the presence of enlarged
glands in the axilla. AH but one patient remained
under observation or were repeatedly communicated
with, and in none of these did any manifestations
of the disease recur.
Cerebral Edema. — L. Bathe Rawling (British
Medical Journal, May 4, 1918) has seen a consid-
erable number of cases presenting evidences of cere-
bral edema as the result of heat stroke, cerebral ma-
laria, shell shock, etc., and has come to the belief
that the condition is due. in part to a damage to
the veins of the brain and its membranes which
reduces their capacity for absorbing the excess of
exuded fluid. Lumbar puncture sometimes tempor-
arily reduces the symptoms of the increased intra-
cranial pressure, but at other times it proves of no
value, or even yields no excess of fluid, probably
due to the blocking of the communication between
the brain and cord. The most satisfactory form of
treatment has been the performance of a subtem-
[)oral decompression with incision crucially through
the dura and followed by replacement of the tem-
poral muscle. This permits the escape of the fluid
into tissues whence it can readily be absorbed and
after some time the normal functions of the cere-
bral sinuses and veins are restored. In practically
all of the cases in which this operation has been
performed by the author the results have been very
good and quite permanent. The operation is not
dangerous and is recommended for all severe cases
in which improvement has not taken place after
three months of medical treatment.
Intravenous Calomel Injections in Syphilis. —
P. Chevalher {Prcsse mcdicale, May 9, 1918) had
previously shown that intravenous injections of in-
soluble powders is entirely feasible. In the case of
calomel, however, such a procedure had seemed im-
practicable owing to its high molecular weight, which
prevented its remaining in suspension in water.
With the assistance of Georget and Chazal, the
author has secured a stable suspension of calomel
and used it with success both experimentally and
clinically. In man he injects o.oi to 0.02 gram, ac-
cording to the age and strength of the patient, every
five to eight days. The dose is gradually increased
ro 0.05 gram, and the injections administered in
series of ten. Over 150 cases have already been
treated, with notably favorable results. Selective
susceptibility to the injections does not occur. A
Herxheimer reaction may, however, be induced. The
measure gives incomparable results in healing hard
chancres. Skin lesions may reappear very soon if
the patient dispenses with treatment when all his
symptoms have cleared up imder the injections.
Erosive mucous patches are often rebellious to cal-
omel, and in such instances novarsenobenzol is to be
preferred. Simultaneous injections of novarseno-
benzol and of calomel are well borne and active, and
sometimes constitute the method of choice.
Medical Treatment of Gastric and Duodenal
Ulcer. — Alexander G.Brown, Jr. {Charlotte Med-
ical Journal, June, 1918) considers the first step
the search and removal of the primary focus. The
mouth accessory sinuses, teeth, alveoli, salivary
glands may be the primary focus. A careful study
of the blood should be made: Wassermann, the
search for malarial parasites, coagulation time, etc.
A study of the feces should also be made and a care-
ful urinalysis is of great importance. It is a good
plan to begin treatment by fasting one or two
days. This should, of course, be done in a hos-
pital. Following the period of fasting, milk and
eggs are administered ; later, sugar, fats, and
proteids are added. An alkali should be ad-
ministered to reduce the hyperacidity. Sodium
bicarbonate should always be administered with an-
other alkali, as when administered alone it may in-
crease the sodium chloride from which the hydro-
chloric acid is increased, rather than diminished.
Bismuth subnitrate is of great value. Two drams
of bismuth in eight ounces of distilled water — of
which a tablespoonful is given three times daily — is
of value. Nitrate of silver, with extract of hyos-
cyamus and extract of belladonna should be given
before meals to stimulate healing and allay spasm.
If pylorospasm is present, hypodermic of atropine
sulphate, grain 1/120 to 1/60, is administered once
or twice in twenty-four hours. The Einhorn method
of duodenal feeding should be used whenever pos-
sible.
Radical Treatment in Oblique Inguinal Hernia.
— J. W. Henson {Virginia Medical Monthly, June,
191S) emphasizes the necessity of observance of the
following principles : absolute observance of asepsis ;
high ligation of the sac; restoration of the integrity
of the transversalis fascia ; the proper plastic work
for making a satisfactory muscular and aponeur-
otic buttress over the inguinal canal ; proper suture
material ; thorough hemostasis before suturing. Se-
rious accidents may and do occur when one is not
thoroughly familiar with the surgical anatomy of
the inguinal canal. The bladder or vas deferens
may be cut, the external iliac artery or vein punc-
tured with a needle, or the deep epigastric artery
injured. The omission most frequently made by
the trained operator is in not restoring the integrity
of the transversalis fascia. The hernial sac and
its contents extending down the inguinal canal pro-
duce an expansion of the tubular process of the
transversalis fascia surrounding the structures of
the cord. Recurrence seldom ensues if the sac is
ligated sufficiently high and the muscular and apo-
neurotic buttress well made. Some recurrences are
due, however, to failure to correct the expansion
of the tube of transversalis fascia, particularly
above. At least one stitch of chromic catgut should
be placed in the upper end of this tube, thus nar-
rowing the internal abdominal ring. If the trans-
versalis fascia forming the posterior wall of the
inguinal canal feels loose, one should take a few-
reefs in it with chromic gut and make it tense. An-
other oversight occurring occasionally with good
operators is the failure to remove large pads of, fat
sometimes found among the structures in the in-
guinal canal.
302
MODERN TREATMENT AND I'RliVENTlVE M EDICI X li.
[New York
Medical Journal.
Gallstones. — A. Althabe and E. Nicholson (La
Scmuna Medico, April it, 1918) review 240 cases
of gallstones with the following conclusions : The
condition is more common in women, the usual age
of occurrence is between twenty-five and thirty, and
surgical measures are indicated in every case where
medical treatment has been unsuccessful. The oper-
ation of election is cholecystectomy with gauze
drainage of the cystic duct : the drainage of the he-
patic duct is not only practicable, but should be car-
ried out in every case of lithiasis of the duct or duct
infection.
Heliotherapy. — Artant {Presse medicale, March
14, 1918) asserts that sunlight treatment can be
satisfactorily applied anywhere provided lenses be
used to augment the curative energy of the solar
rays. Despite the prevailing opinion to the con-
trary, the rays of the warm portion of the spectrum
are those which exert a therapeutic action. The
author obtained constantly good results from helio-
therapy in lymph node inflammations — ^even with
suppuration and sinus formation — and was often
successful in cases of tuberculous osteitis and or-
chitis. In Pott's disease heUotherapy is especially
effectual in allaying pain. It will even influence
considerably the pains of mammary or uterine can-
cer. It yields good results in certain forms of
eczema, and markedly allays itching in this disease.
Spinal Puncture in Sciatica. — I. A. Allen and
R. E. Parrish {Therapeutic Gn.zctte. June, 1918)
report immediate relief from sciatic pain after lum-
bar puncture m three cases. A history of exi)osure
to cold and dampness had been obtained in each of
these cases. In the first patient the spinal punc-
ture was performed for diagnostic purposes. Thirty
mils of spinal fluid, apparently under increased pres-
sure, were removed. At once the pain disap-
peared. The patient was, however, kept in bed for
some days longer. In the subsequent two months
no recurrence took place. In the second case thirty
mils were similarly withdrawn, and in the third
twenty-five. In each the pain was immediately re-
lieved. One patient got up from bed and walked
the same day and the other the following day.
Pressure of cerebrospinal fluid might have had
something to do with the results noted, since it was
found definitely increased in two instances.
Sterilization of Skin and Other Surfaces. —
Victor Bonney and C. H. Browning {British Med-
ical Journal, May 18, 1918) point out that all of
the commonly used antiseptics are more or less
powerfully irritant, so that their prolonged applica-
tion for the purpose of destroying the organisms
lying deep beneath the epithelium, in the sweat and
sebaceous glands and hair follicles, is not possible.
They are, further, all made inactive upon contact
with blood and other albuminous material, so that
their action ceases promptly upon incision of the
skin. As a result of bacteriological experimentation
and clinical tests in actual use for two and a half
years, the authors find that a mixture of methyl
violet and pure brilliant green is nonirritant, pene-
trates deeply, destroys all the organisms even in the
depths of the skin and its glands, and makes the
sl:in treated actively antiseptic. The solution con-
tains one per cent, of a mixture of equal parts of
the two dyes, dissolved in equal parts of alcohol
and water. The dyes are first dissolved in the al-
cohol and the water then added. The skin of the
operation area is painted with this solution six hours
before operation and a compress soaked in the solu-
tion is applied and covered with waterproof batiste.
No further preparation is done, the dressing being
removed on the operating table. The same solution
can be used for sterilization of the vagina and rec-
tum by packing these cavities with gauze saturated
with it. The perineum can also be sterilized by
the application of compresses wet with the solution.
In all cases the application should be continued for
six hours prior to operation. Cultures of the skin
from various regions after such preparation have
proved wholly sterile in all but exceptional instances,
when a single colony, or perhaps two or three col-
onies, has grown.
Triple Typhoid Vaccination. — Eric A. Fennel
(Journal A. M. A., June 22, 1918) draws his con-
clusions from a careful investigation of the effects
upon the agglutinins produced in healthy men from
vaccination with repeated doses of single vaccines
and doses of the triple vaccine as practised in the
army. He finds that agglutinins are developed for
all three organisms equally well after the use of
triple vaccine as after alternating doses of single
vaccines. The use of the triple vaccine is time
saving. Previous vaccination represses the devel-
opment of agglutinins for the specific organism fol-
lowing subsequent vaccination. After vaccination
fluctuations in the agglutinin content of the serum
occur in normal persons, and such fluctuations are
therefore of little diagnostic value in cases of fever.
No relation exists between the systemic and the
local reaction after vaccination, and the units of
agglutinins produced.
The Treatment of Hay Fever, — A. Sophian
[Medical Fortnightly, July i, 1918) divides the
treatment into two parts: i, preventive, and 2,
curative. In the preventive treatment, much has
been done by the enforcement of municipal laws re-
garding the destruction of weeds near homes. .A.
similar result is obtained by sending the patient
away. Active prophylaxis consists in preventive
vaccination with the causative pollen. The plan is
to test the patient with different pollens by scarify-
ing the skin and applying pollen ; by injecting pollen
intradernially, and by instilling pollen into the eye.
The pollen is prepared in the form of a solution or
alcoholic extract. One half the pollen extract
which gives the characteristic ophthalmic reaction is
used as the initial dose. Injections are given at
three to ten day intervals, rapidly increasing the
dose up to a final maximum of 1-100,000 dilution of
pollen extract. Ophthalmic tests are made every
two or three weeks to determine increased ophthal-
mic resistance. Serum treatment has been used
with favorable results. Dunbar's untitoxin serum
consists of an immune serum i)rcpared by immun-
izing horses against different pollens. The serum
is used locally. Graminol, another serum, consists
of a normal serum of cattle obtained during the
period of flowering of grasses. Results with this
were equally as good as with the antitoxin serum.
August 17, 1918.]
MODERN TREATMENT AND I'RE^ENTIVE MEDICIXE.
Solar Erythema. — Nicolas V. Greco (La Se-
mana Medico, May J, 1918) reports a case of this
interesting condition, which is sometimes wrongly
called solar eczema. It frequently goes on to the
formation of blebs and pus with the establishment
of a true deep dermatitis. Usually the condition
yields to applications of oil and dusting with a bland
powder. Meanwhile, of course, the patient must
lie protected from the sun's rays.
Chloralose as Anesthetic in Wound Cases. —
j. Gautrelet {Prcssc mcdicalc, May 2, 1918) sug-
gests the use of chloralose as anesthetic in cases of
severe traumatic injury and shock, in which the
blood pressure is greatly lowered. Chloralose not
only tones up the heart, even when atropinized, but
assists in maintaining the blood pressure at its nor-
mal level. Furthermore, while exerting a moder-
ate strychninelike effect, it diminishes or allays
convulsions and arrests vomiting, whether of cen-
tral or peripheral origin.
Serum of the Normal Pregnant Woman in the
Treatment of Pernicious Vomiting. — ^Romulo
Melgar (La Cronica Mcdica, of Lima, Peru, ^vlarch,
1918) reports the successful subcutaneous injection
of the serum of a multipara near term as a curative
measure in three cases of apparently hopeless vom-
iting of pregnancy. An injection of ten c. c. is
followed every two days by doses of ten, fifteen and
twenty c. c. The very first injection usually shows
startling improvement, and in some cases no further
administration is required. Melgar recommends
this method of treatment enthusiastically in this
usually unsatisfactory and frequently dangerous
complication of pregnancy.
Polyarthritis during Arsenobenzol Treatment.
— Chabanier and Bleton {Prcsse medicalc, May 2,
1 91 8) state that during the treatment of syphilitics
with the arsenobenzols, especially the neo variety,
there appears rather frequently a general polyar-
thralgia, localized mainly around the joints, and oc-
curring under the same circumstances as icterus and
neurorecurrences. The pains last three or four
weeks, and are apparently not influenced by the
treatment, which can be resumed as soon as the\'
have disappeared. Since such pains are sometimes
noticed in nonsyphilitic individuals subjected to ar-
senobenzol therapy, they are probably to be ascribed
rather to a direct action of the drug than to a local-
ization of the syphilitic infection about the joints
under the influence of the treatment.
Intraspinous Medication in the Treatment of
Cerebrospinal Syphilis. — P. Lewis Witchley
{Cluirlottc Medical JoiiniaK June, 1918) con-
cludes that curative agents administered orallv or
intravenously do not appear in the spinal fluid and
hence exert no spirochetacidal action upon the spiro-
chetes lying within the meninges and outer part of
the brain. There is i)robably a separate strain of
the Spirochcctcc pallida which attacks the central
nervous system, and in order to effect a cure intra-
spinous medication must be employed. Intraspin-
ous treatment should be carefully controlled by ex-
amination of the spinal fluid, including the Wasser-
mann reaction, cell count, globulin test, and colloidal
gold reaction. Salvarsanized serum is the safest
curative agent to administer intraspinously.
Weak Feet in Children. — Jacob Grossman
(Medical Record, June 8, 1918) writes that the feet
of children up to three or four years of age are ap-
parently flat. Prophylactic measures are important
and when they are unsuccessful some support should
be used, and of these the Whitman brace is the best.
Exercises are of great service such as tiptoe exer-
cise, walking in the bare feet, walking on the fore
part of the foot, grasping movements with the toes,
exercises with foot weights, and bicycling.
Charcoal in Mucous Colitis. — T. B. Broadway
{Lancet, May 4, 1918) reports two cases of ob-
stinate mucous colitis, which had resisted all known
forms of treatment, but which responded promptly
and permanently to the administration by mouth of
charcoal. The charcoal was given four times daily,
after meals, in doses of 8.0 grams (two drams) sus-
jiended in water flavored with sherry, or enclosed
in cachets. The mechanism of its beneficial action
in these cases is suggested as being in part anti-
septic and in part astringent.
Carbon Dioxide Snow in the Removal of Be-
nign and Malignant Growths of the Skin. — G. H.
.Sadelson {Chariot le Medical Journal, June, 1918)
advises this method of treatment and believes
it a useful adjunct in the removal of extrane-
ous growths for the following reasons: i, it is in-
expensive ; 2, it is practically painless in its ac-
tion ; 3, it requires no anesthetic, either local or
general; 4, the patient is not kept from his occu-
pation ; 5, it is selective in action ; 6, the cosmetic
results are better.
The Injection Treatment of Hernia, Hemor-
rhoids, and Hydrocele.— G. N. Murphy {Char-
lotte Medical Journal, June, 1918) uses a forty
per cent, solution of carbolic acid in water and gly-
cerin. Twenty minims of this solution should be
injected into the hernial canal near the internal
opening. Six or eight of these treatments, given
once a week, suffice. For hydrocele, the water is
first drawn oft' the tunica vaginalis and then twenty
to forty minims of jmre cari3olic acid are injected
into the sac. In cases of hemorrhoids, twenty per
cent, solution of carbolic acid is used and each
tumor is injected once a week. From one to three
treatments are usually required to bring about a cure.
The advantages of the injection treatment are that
chloroform and ether are avoided, the patient can
go about his work, and the treatment is safe.
Action of Miotics on the Incomplete Sphincter
Iridis. — R. J. Curdy {Journal A. M. A., June 29,
T918) calls attention to the very contradictory na-
ture of the opinions expressed in the literature a'^
to the effects of miotics in cases with radial tears
of the iris. The contradictions are concerned with
whether the miotics increase or decrease the tears.
The eiYects noticed by the author on three eyes
which had been subjected to iridectomy are shown
in drawings, there being a narrowing of the pupil
in all with no increase in the tear. He concludes
that plivsostigmine can produce contraction of the
pupil, narrowing of the coloboma, and reduction of
the tension in iridectomized eyes with relaxing effect
on the radial fibers. It also seems probable that
miotics and mydriatics neither increase nor diminish
the extent of radial tears of the iris.
Miscellany from Home and Foreign Journals
Tachycardia in the Enteric and Other Fevers.
— H. Fairley Marris {Lancet, May ii, 1918) from
an extensive observation of the cardiac condition in
the enteric and other fevers and during conva-
lescence from such fevers, classifies the tachycardias
encountered mto those due to cardiac lesions ; those
of postural or atonic origin ; and those arising from
general instability of the vasomotor nervous sys-
tem. In 650 cases of the enteric infections there
were seventy-five cases of tachycardia, of which
five were due to cardiac afifection, forty to vaso-
motor instability, and ten to postural causes. The
others showed features of both of the latter groups.
Tachycardias observed in other febrile conditions
fell into the same groups, in most of the fatal cases
being of cardiac origin, while the majority of the
nonfatal cases were of vasomotor origin. The dis-
eases in the fatal cases were chiefly diphtheria,
meningitis, miliary tuberculosis, and scarlet fever.
In the nonfatal cases the diseases were chiefly
diphtheria, scarlet fever, influenza, trench fever, and
obscure pyrexias. In the tachycardia of cardiac
disease the rapid pulse was present in sleep as well
as during waking, and the ability to hold the breath
was much impaired. In the vasomotor tachycardia
the increased rate occurred only when the patient
was awake and was not influenced by postural
changes, and the ability to hold the breath was nor-
mal. In that due to atony the increased rate oc-
curred only with the patient in the upright position
and was relieved by the application of a snug ab-
dominal binder. The cardiac tachycardias were
treated as heart cases ; those of vasomotor origin
occasionally responded to the use of strophanthin,
but usually failed to do so, while they were bene-
fited by graduated exercise, massage, and the ad-
ministration of bromides. The atonic variety were
helped by the use of tight abdominal binders, mas-
sage, and the administration of tonics.
Removal of Brain Tumor. — W. W. Keen and
Aller G. Ellis (Journal A. M. A., June 22, 1918)
first saw the patient, then a man twenty-six years old,
more than thirty years ago. He then gave a history
of having fallen out of a window upon his head, as a
child, which caused an indentation of his skull on
the left side. After a prolonged period of uncon-
sciousness he recovered and from the age of five
developed a discharge from his right ear which re-
curred frequently. For many years before being
seen he had suffered /rom frontal headache and
for two years had had recurrent epileptic attacks.
His right arm, leg, and face became paralyzed and
he lost most of the vision of both eyes. The paraly-
.sis largely cleared up. His skull was then trephined
over the site of the old scar in the left temporo-
frontal region, an opening 2^^ by three inches being
made. A tumor, growing from the dura, and meas-
uring 2^ by 2 by l-)4 inches, was easily shelled
out. The tumor was a pure fibroma which had ap-
parently developed from the irritation of a frag-
ment of the inner table of the bone. After a fairly
satisfactory course of recovery a large hernia cere-
bri developed following the reopening of the wound.
This subsided after discharging clear fluid for five
weeks and left a large depression which filled and
bulged with every muscular or respiratory effort.
The patient's symptoms were much benefited by the
operation, though he finally underwent a slow de-
terioration and died over thirty years after the
operation. The autopsy then showed that the open-
ing into the skull was covered by a newly formed
fibrous membrane beneath the skin and that the
cavity left by the tumor had its floor formed by the
lateral ventricle for a length of five centimetres and
the foramen of Monro was clearly visible two centi-
metres from the posterior end. Various cerebral
structures, including the corpus striatum and part
of the thalamus, formed the walls of the cavity.
The case presented many points of unusual interest,
among which were the great increase in the ventricu-
lar area of the brain, the very long period of sur-
vival after the removal of the brain tumor, and the
fact that this was one of the first instances of the
surgical removal of a brain tumor. All of these
points are discussed in the paper, which covers the
various details of history and progress of the case.
Stages of Urea Retention in Bright's Disease.
— F. VVidal, A. Weill, and P. Vallery-Radot (Presse
medicale, May 23, 1918) state that while the mani-
festations of chloride retention in nephritis are
curable and can be prevented by a salt free diet, dis-
turbances due to urea retention are always danger-
ous. Blood urea estimations permit of prognosti-
cating with a degree of precision rare in clinical
medicine the subsequent duration of the disease.
Patients whose serum shows persistently at least
one gram of urea per litre almost always succumb
within two years. Where, however, the urea vacil-
lates between 0.5 and one gram, the indications are
less definite. Sometimes, after remaining at this
level for a time, the blood urea returns to within
normal limits ; or, it may remain at the same level
for years, without aggravation of the patient's gen-
eral condition ; or, again, it soon rises further, ex-
ceeding one gram. As a rule this period of initial or
warning azotemia is of long duration. The original
renal disturbance, however, dates farther back and
can be detected before any urea retention has super-
vened, by means of the Ambard constant. Among
seventy-two nephritics with blood urea below 0.5
gram, only seventeen had a normal Ambard con-
stant. The heightened constant appears even in
cases of simple albuminuria, of pure hypertension,
or of albuminuria with chloride retention but with
or without hypertension. In many Bright's cases
elevation of the constant appears as a temporary dis-
turbance ; a persistently high constant may, however,
occur in the absence of urea retention. This first
stage of the disease, before urea retention begins,
sometimes lasts a number of years. In the third
stage, the urea exceeding one gram, Ambard's con-
stant is of no further clinical value; the urea esti-
mations should, however, be repeated several times
to make sure that a high reading was not due to a
temporary acute exacerbation. Above two grams
of urea per litre, death is near.
August 17, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
305
Psychoneurotic Factor in Irritable Heart. — B.
S. Oppenneimer and Ai. A. Rothschild {Journal
A. M. A., June 22, 1918) made a careful analysis of
100 unselected cases ui a large English military hos-
pital and compared their lindmgs with a similar
analysis of normal soldiers made by Wolfsohn to
determine the predisposing factors of war psycho-
neuroses. The authors reached the following con-
clusions : In the first place the fundamental pathol-
ogy of the condition known as irritable heart is un-
known. The cases can be divided into two large
groups, irrespective of whether studied from the
side of neuropsychic factors in the family and pre-
vious histories, or from that of preenlistment and
constitutional symptoms. In Group I there is a
positive family and previous history predisposing
to psychoneuroses and a history of constitutional
asthenia. This group is one of irritable weakness
of the whole nervous system including that govern-
ing the circulatory system. This group includes
about half of the cases. The second group (of
about half of the cases) gives past personal and
family histories which indicated no predisposition
and showed normal resistance. The irritable heart
condition in this group develops after prolonged
strain or some infection which exhausts the re-
serve. Such patients show symptoms of exhaustion,
which are not found among the first group. These
patients give good military services in difficult posi-
tions for an average of a year and a half vvhile
those of the first group usually break down within
a year and seldom serve in arduous capacities.^ The
burden to the army would be much lightened if the
cases of Group I could be discovered promptly and
refused admission.
Sympathetic Disturbances and Dyspeptic
States.— F. Ramond, A. Carrie, and A. Petit
( Bulletins et memoires dc la Socicte msdicale des
hopitaux de Paris, January 24, 1918) have already
described a sympathetic syndrome characterized by
vasoconstriction in the extremities, causing more or
less cyanosis and coldness of the hands and feet ;
facial vasodilatation with flushes and redness of the
skin; often tinnitus, flashes of light, dizziness, and
a sensation of intracranial throbbing; exaggerated
sweating, especially in the extremities ; attacks of
tachycardia and instabiHty of the pulse; dyspneic
sensations withotit increased respiratory rate but
with deep inspirations followed by prolonged sighs ;
fibrillary tremor of the fingers, occasionally with
tingling or numbness, and a high degree of suscep-
tibility to emotional reactions. Sympathetic dyspep-
tic symptoms may either be superadded to the typ-
ical sympathetic syndrome or occur secondarily in
true dyspeptics. The characteristic sympathetic
dyspeptic symptom is a painful sensation of fullness
and gastric distention, closely following a meal or
beginning even during the meal, and lasting fifteen
to thirty minutes or at most an hour. Generally no
actual distention can be detected by inspection, pal-
pation, or measurement. Usually there is marked
temporary sensitiveness of the epigastrium, and fre-
quently a general lassitude persisting throughout the
period of gastric digestion. In the secondary cases
the underlying gastric disorder may be of almost any
type : hvpcr or hypo conditions, atony with ptosis.
different forms of gastric ulcer, etc. The typical
immediate postprandial discomfort, together with
some of the other sympathetic manifestations, are
likewise witnessed in these cases. Between the two
groups referred to occur a number of intermediate
cases, in some of which chemical examinations and
radioscopy are alike negative in spite of pronounced
Ijuniing or crainplike, inconstant, and nonperiodic
pain. I'his condition may be likened to a causalgia.
rhe site of the irritation inducing sympathetic symp-
toms may reside either in the stomach itself ; in a
local disturbance in any other organ in the sympa-
thetic distribution ; or, the cause of the irritation may
be general — an infection or intoxication, or a dis-
turbance of the ductless glands, in particular the
thyroid, genital glands, and adrenals.
Chronic Myocarditis. — Henry A. Christian
{Journal A. M. A., June 22, 1918; presents a clini-
cal study of that form of cardiac disease which is
characterized by the signs and symptoms of a
failure of the heart to function efificiently and by the
absence of valvular lesions. The symptoms are
those of cardiac incompetency of greater or less
severity. To this condition the name chronic myo-
carditis is given for want of a better. In a series
of cardiac cases seen during a period of three years
in general hospital wards there were 367 without
organic valve lesion — that is, chronic myocarditis —
359 with organic valve lesion. In a series of
107 consecutive autopsies on patients wath cardiac
disease who were over fifty years of age, mitral
endocarditis was found in only two, confirming the
rarity of organic mitral lesions in persons past
middle life. Chronic myocarditis was found more
frequently in males than in females, in the propor-
tion of 240 males to 167 females and it was most
frequent in the decade between fifty-one and sixty
and relatively uncommon below the age of forty.
In respect of the etiology of the disease analysis
showed that relatively few of the patients had suf-
fered from rheumatic fever ; the Wassermann re-
action was positive in only thirty-five out of a total
of 369 patients tested. Chronic alcoholism was pres-
ent sufficiently often to suggest its having played
some role, but analysis of the cases did not seem to
point to its having been a factor of much etiological
importance. Hypertension seemed to play a part in
less than half of the patients and neither it nor
nephritis seemed to haive very great etiological sig-
nificance, especially since these conditions might
have been due to the same factor which caused the
cardiac condition, or might have been purely sec-
ondary to the cardiac disease. Coronary sclerosis
was a factor of importance in only about half of
the cases. The commonest cardiac lesion was in-
creased in the interstitial connective tissue, but this
was absent from many of the cases which had pre-
sented typical clinical pictures. Clinically, besides
the usual symptoms of cardiac weakness or loss of
compensation, the heart was usually found to be en-
larged, a systolic apical murmur was usually pres-
ent, and about half of the cases showed auricular
fibrillation or flutter, or some disturbance in the
conduction system as shown in the electrocardio-
gram. Digitalis was of great value in the earlier
breaks in compensation, but of little help in the later.
3o6
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Bacterial Toxin Causing Retinal Hemorrhage.
— F. Park Lewis {Journal A. M. A., June 15, 1918)
reports two cases of recurrent retinal hemorrhages
in each of which infection of tlie teeth at their
apices was discovered. In both the infection was
caused by the Streptococcus hemolyticus. The re-
moval of the infected tooth in one case was followed
by cessation of the hemorrhages, while in the other
the administration of an autogenous vaccine, made
from the Streptococcus hemolyticus, checked the re-
currence of hemorrhages. In one of the cases the
blood pressure was normal, in the other quite high.
Lewis discusses the etiology of recurrent retinal
hemorrhage in the light of these two cases and
points out that the factor of high blood pressure,
by some considered the cause of the hemorrhages,
is of no essential causative import. He contends
that the hemorrhages are due to the action of some
protein toxin, probably derived from the strepto-
coccus in these cases, which dissolves or softens the
intracellular cement of the retinal, and probably of
other, capillaries and thus permits the escape of
blood. The recognition of the existence of such a
factor as the cause leads to the ability to search out
the cause in other cases and to adopt a rational i)lan
of treatment. Other forms of hemorrhage, such as
cerebral hemorrhage, etc., may also be due to the
similar action of some protein poison and their
prevention should be undertaken along the lines of
locating the origin of the poison and removing it.
or of destroying or neutralizing the poison.
Epidemic Lethargic Encephalitis. — A. Netter
{Bulletin dc 1' Academic dc medccinc, May 7, iyi8)
is cognizant of seventy-one recent cases of this
aft'ection comprising tlnrty-seven in England and
thirty-four in France, with fifteen personal cases.
The victim is seized with fever, headache, and at
times vomiting. Almost immediately there is
marked lassitude and somnolence. At first the
patient can be momentarily roused from his slum-
bers, but later the condition passes into an actual
coma, occasionally interrupted by delirium and
restlessness. Very characteristic are the ocular dis-
turbances, usually bilateral, consisting of jstosis,
strabismus, immobility of the eyeball, or nystag-
mus. The intrinsic ocular mu.scles are less fre-
quently involved, but jjaralysis of accommodation
and a sluggish light reflex have been observed. The
muscles innervated by the facial and those of the
tongue, larynx, and extremities may participate in
the paralysis. Tremor is not exceittional. The
characteristic signs of meningitis, Kernig, rioidity.
and pulse irregularity are lacking or but slightly
marked. The meningitic line is, on the other hand,
constant. Lumbar puncture yields a clear fluid,
iinder normal pressure, without excess of albumin,
and with a normal or but slightly augmented cell
content. Of fifteen patients, seven died. Death
or recovery may occur within a few days, but gen-
erally the disease persists through weeks or months.
Lassitude and the eye disturbances continue for
some time during convalescence. Postmortem ex-
amination shows but little macroscopically ; micro-
scopically there are chiefly perivascular infiltrations,
most marked about the nuclei of the motor nerves
of the eye, in the pons, medulla, and gray substance
of the ventricular walls. 'Ilie spinal cord is b'.it
little involved. While manifestly similar to epi-
demic poliomyelitis, lethargic encephalitis arises
from a different cause. The symptoms cannot be
held due to alimentary intoxication, e. g., botulism.
The cases always occur singly, whereas in botulism
several members of a family become victims. An
identical epidemic occurred last year in Vienna.
W^iesner thinks he has succeeded in transmitting the
disease to the monkey by subdural inoculation and
in isolating the causative germ as a Gram positive
coccus. Ihe disease must, like poliomyelitis, be
propagated by germ carriers in good health or af-
fected only with a slight catarrhal form. Probably
injections of serum from convalescents, admin-
i.^tered early, will here also prove of therapeutic
service.
Predisposition of Streptococcus Carriers to the
Complications of Measles.— Robert L. Levy and
II. L. Alexander {Journal A. M. A., June 15, 1918)
made a careful .study of this problem, and of that
of the origin and prevention of the carrier state
among the troops at Camp Zachary Taylor. They
found that of 388 measles j)atients admitted to the
hospital, seventy-seven per cent, were carriers with
])ositive throat cultures of the Streptococcus hemo-
lyticus. '! he institution of a temporary receiving
ward for the measles cases, in which each man was
isolated in a cubicle until the results of his throat
cultures could be determined, the subsequent segre-
gation of those free from the streptococcus and
those who were carriers of it into two wards,
cubicle isolation of all patients in each of these
wards, and the employment of nurses in the clean
ward who were proved not to be carriers of the
streptococcus, was successful in keeping the clean
cases free from contamination. Complications oc-
curred almost entirely among the streptococcus
carriers, the incidence being almost thirty-nine per
cent, among them as compared with 6.4 per cent,
among the noncarriers. Ffitorts were made to free
the carriers of their organisms, but no method was
found which proved in the least successful, the
organisms apparently being harbored in the depths
of the tonsillar crypts and being therefore inacces-
>^ible to agents for their destruction. In a repre-
sentative company of men in the camp, throat
cultures showed that eighty-nine per cent, were car-
riers of the streptococcus, while cultures taken
from 489 new recruits as they came in showed only
T4.S ])er cent, to be carriers. It was evident that the
!))njority of the carriers had become such from con-
i.ict with others in the camp.
Phagocytic Response to Bacteria in Clean
Wounds.— W. James Wilson {British Medical
Journal. May 11, 1918) conducted a number of ex-
periments upon the phagocytic response of clean
wounds in man to the application of cultures of colon
bacilli or killed cultures of staphylococci or Bacillus
welchii. In every case the application was followed
by the prompt outpouring of active phagocytes
which completely removed the organisms within
twenty-four hours. This response began as soon
as five minutes after the application, but the simul-
taneous application of a i :i,ooo solution of brilliant
green arrested the phagocytosis for some time, al-
♦hnugh it began later and proceeded normally.
Proceedings of National and Local Societies
THE AMERICAN GYNECOLOGICAL
SOCIETY.
Forty-third Annual Meeting, Held in Philadelphia,
May i6, ly, and i8, ipiS.
The President, Dr. John G. Clark, Philadelphia, in the
Chair.
President's Address: Medical Teaching and
Research after the War.— Dr. John G. Clark, of
Philadelphia, selected this topic for his address and
presented the following conclusions concerning the
scholastic maintenance of gynecology and obstetrics :
I. An adequate endowment or an aimual budget of
not less than from $25,000 to $30,000 a year for sal-
aries would render it feasible to combine the de-
partments of obstetrics and gynecology. Some of
the advantages of this plan were stated as followed:
I. There would be less duplication of teaching in
embryology and in the anatomy and physiology of
the female reproductive organs. 2. The pathologi-
cal aspects of the two subjects could be correlated,
making only one laboratory necessary. 3. As many
of the diseases were referable to the childbearing
process, they might well be grouped under one
head. 4. The opportunity was afforded of studying"
in the obstetrical department the results of various
operations and the remedial measures employed for
the relief of gynecological diseases. II. When an
endowment was not sufficiently large to equip fully
and maintain a combined department in the most
comprehensive way, or when special endowments
for the maintenance of an obstetrical and gyneco-
logical departinent could be secured but were not
large enough to allow the chief assistants and di-
rector to retire from private practice, such depart-
ments might be conducted more successfully as
separate units, for the following reasons: i. In a
university medical school special departments were
likely to turn out a more refined product and to
ofifer better instruction if the field to be covered was
not too extensive. 2. When properly endowed, the
department of gynecology might very logically ex-
pand and enter the domain of general surgery. The
chief function of the head of such a department
was that of instructor in diseases of women, and in
a minor role of clinical teacher of abdominal
surgery. 3. With separate chairs, more time could
be given in the obstetrical department to the teach-
ing of the very important subject of diseases of
nursing infants, a subject that was now receiving
inadequate attention for the reason that the ob-
stetrician had no time to devote to this branch.
Dr. Thomas S. Cullen, of Baltimore, reported
the following cases :
I. A New Sign in Ruptured Extrauterine Preg-
nancy.— The patient, a woman, thirty-eight years
of age, suddenly developed abdominal pain and
distention. Doctor Cullen saw her three weeks
later. The umbilical region was bluish black,
although she gave no history of injury. Vaginal
examination yielded nothing on account of the
abdominal distention. Under ether, however, a
mass eight by six c. m. was clearly felt to the right
of the uterus. Doctor Cullen at once diagnosed
extrauterine pregnancy, although the patient had
missed no period and there was no uterine bleeding.
On opening the abdomen he found a rightsided
extrauterine pregnancy, and about one and a half
quarts of free blood in the abdomen. He referred
to a case reported by Ransohofif where a man,
fifty-three years of age, had obscure abdominal
symptoms. Jautidice of the umbilical region was
soon noted and at operation rupture of the common
duct was found, and there was much free bile in
the abdomen. Judging from analogy the speaker
naturally concluded that the bluish black appearance
of the umbilicus was due to intraabdominal hemor-
rhage, and the presence of the nodule to the side of
the uterus clinched the diagnosis of extrauterine
pregnancy.
2. Sloughing Amniotic Hernia of the Umbili-
cus.— The child when seen by the writer was
nine days old. At the navel was a sloughing mass
about four cm. in diameter. This projected 3.5
cm. from the umbiHcus. The walls of the sac con-
sisted of thin amnion. The sac contained small and
large bowel. This was obstructed. Although the
cliild had a general peritonitis, nothing remained
but to resect about eight inches of small bowel and
a portion of the ascending colon. The anastomosis
leaked in a few days but soon healed satisfactorily.
All the fecal matter passed per rectum. The child,
however, died on the eighteenth day from a contin-
uation of the peritonitis which existed at the time
of the operation.
3. An Umbilical Polyp Associated with a
Meckel's Diverticulum. — The child was a year
old. At the umbilicus was a bright red mass 1.5
cm. in diameter. It had been present from the
time the umbilical cord came away. It was covered
with mucosa and from the surface a little mucus
escaped. At operation the polyp was found to be
continuous with a Meckel's diverticulum which ex-
tended to and was firmly adherent to the umbilicus.
The umbilicus together with the Meckel's diverticu-
lum was removed. The stump of Meckel's
diverticulum which had been turned into the bowel
swelled up after operation and partially blocked the
lumen of the bowel. The child died of pneumonia.
The speaker would in the future leave no diverticu-
lar stump, but would cut it off flush with the bowel
and close the linear incision with two slender rows
of black silk. The umbilical polyp was covered
over l)y intestinal mucosa.
4. Removal of a Carcinomatous Cervix Sixteen
Months after Supravaginal Hysterectomy for
Carcinoma of the Body of the Uterus. — The pa-
tient entered the Johns Hopkins Hospital sixteen
months after a supravaginal operation elsewhere
for carcinoma of the body. On vaginal examination
the cervical lips looked normal, but the external os
was fully two cm. in diameter and completely
filling it was a friable new growth. Doctor Cullen
opened the abdomen, dissected the ureters free.
3o8
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
turned back the bladder peritoneum and was ap-
parently able to remove the entire cervical g^rowth
intact.
5. Adenomyoma of the Rectovaginal Septum.
— Doctor Cullen said that during the last five
months he had seen three cases in his own practice
and one case occurring in the practice of Dr.
Howard A. .Kelly. He reported two cases in detail.
The iirst case had the typical thickening in the
vaginal vault just posterior to the cervix and di-
rectly behind the cervix a bluish black cyst about
four millimetres in diameter, shone through the
vaginal mucosa.
The second case was most unusual. Posterior to
the cervix was a slightly raised polypoid area two
by two cm. At operation, in addition to recto-
vaginal growth, there was a second one. This was
situated near the pelvic brim, markedly constricted
the bowel, and at operation closely resembled a
carcinoma. Histological examination, however,
showed that it was a typical adenomyoma. There
did not appear to be a similar case on record.
The Fetal Anatomy of the Female Pelvis. — Dr.
FcLD L. Adair, of Minneapolis. Minn., based his
report on two studies: a, the ossification centres of
the fetal pelvis and, b, a wax reconstruction of the
fetal pelvis of a female fetus of fourteen weeks'
gestation. I'he first part of the work was based on
observations of fourteen x ray plates of fetuses,
twenty-one transparent embryos and twenty-five
sets of serial sections. From these two investiga-
tions the following conclusions were drawn: i. The
first ossification centre of the pelvis appears in the
iHmii about the sixtieth to sixty-fifth day of fetal
growth in embryos with a C. R. length of from
thirty millimetres to thirty-five millimetres. 2. The
median centre of the first sacral vertebra is the next
to appear about the seventy-fourth to seventy-sixth
day in embryos having a C. R. length of fifty-one
or fifty-two millimetres. 3. The lateral sacral
centres appear when two or three median centres
are present, in embryos eighty to eighty-two days
old having a C. R. length of sixty-five millimetres.
.-.].. The ischial centre appears about the ninety-
fourth to ninety-eighth day in embryos whose C. R.
measurement is from eighty-eight millimetres to
100 millimetres. 5. The pubic centre is present on
the 129th day in an embryo with a C. R. length of
150 millimetres. At this time all other centres
which appear, until just prior or subsequent to
birth, are usually apparent. 6. Practically all an-
tenatal pelvic ossification centres are evident by the
end of the nineteenth week of fetal life. 7. The
skeletal pelvis resembles closely that of the adult in
its form and markings. Most of the structures of
the adult are indicated in the fetal pelvis. 8. The
most striking ditterences between the adult and fetal
pelvic skeleton are : a, the second sacral vertebra
occupies, in early fetal life, about the position of the
last lumbar in adult life; b, the short distance be-
tween the ischii, which lie almost parallel in the
fetus; c, the very acute pubic ("fifteen degrees).
9. The absence of sacral concavities in the fetus.
10. Sex differentiation is well marked in this speci-
men on the vulva, most of the different structures
in the external genitalia being easily recognizable.
i). The vagina is well formed. The cervix is rela-
tively large; the corpus occupies about its adult
relations, flexures, and position. It is flattened
anteroposteriorly. 12. l"he two tubes show marked
differences in length, source, and height as well as
in their relations to the ovaries. 13. The ovaries
are large, being much bigger than the uterus. The
two difier in their relative positions. They both lie
above the pelvic brim. 14. The bladder is well
differentiated from the rest of the urinary tract.
It is distinctly an abdominal organ. 15. The ureters
and arteries simulate the adult relations. 16. The
development of the rectum and anal region is well
advanced and corresponds approximately to the
adult type. The colon enters the pelvis in the mid-
line and appears not to have been filled with me-
conium.
The Escape of Foreign Material from the Uter-
ine Cavity Into the Uterine Veins. — Dr. John A.
Sampson, of Albany, N. Y., stated that radiographs
of the uterus, tubes, and ovaries in which the uterine
cavity had been injected with bismuth (introduced
through the cervix) showed the form of this cavity
under various conditions ; a«d also by what chan-
nels and under what circumstances the bismuth
might escape from the uterus.
If the tubes were patent the bismuth escaped into
them ; the ease with which this occurred varied with
the degree of patency of the tubes. These experi-
ments suggested that intrauterine irrigations were
attended with the danger of some of the irrigating
fluid, at times, escaping through the tubes into the
peritoneal cavity ; and also that fluid in the uterine
cavity, under favorable circumstances (patent
tubes, relaxation of uterus and obstruction in the
cervix), might be forced into the tubes and peri-
toneal cavity. This was one way that salpingitis
and peritonitis might arise.
If the endometrium was intact the bismuth would
not escape into- the venous uterine sinuses even
though great force was used. If the patient was
flowing when the uterus was removed the bismuth
might gain access to them. If the endometrium
was removed by curettage, the injection mass would
usually escape into these sinuses. The ease with
which this occurred varied with the size of the
sinuses in the individual specimen and the degree
of relaxation of the uterine wall. Under favorable
circumstances of venous hyperemia and uterine re-
laxation, the bismuth easily escaped into the venous
sinuses and into the venous circulation outside of
the uterus.
A study of uteri in which the venous system had
been injected with bismuth through the uterine and
ovarian veins showed a rich venous plexus in the
endometrium and also one in the myometrium ; the
latter might be subdivided into a peripheral and
radial plexus, situated in the peripheral and radial
zones. Arcuate veins between the two zones con-
veyed the venous blood to the uterine plexus be-
tween the layers of the broad ligament.
Relatively large sinuses (receiving) radiated
from the base of the endometrium into the myome-
trium and conveyed the blood from the endometrial
plexus into the deeper portion of the radial. If
these receiving sinuses were exposed by removing
August 17, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
309
the overlying endometrium and the uterus was re-
laxed, thus holding the lumina of the receiving
sinuses open, fluid and small solid material could
easily esca^^e from the uterine cavity into them and
thence into the venous circulation outside the uterus.
Clinical experience had taught us that solid ma-
terial from the uterine cavity gained access to the
venous circulation — puerperal infection and the
presence of placental cells (^benign and malignant")
in the lungs of puerperal women. Exi^erimentally
solid material (bismuth in suspension) could be
forced from the uterine cavity into the venous cir-
culation under very little pressure if these sinuses
were exposed and the uterus relaxed.
Anatomical and physiological studies demon-
strated how this might occur — exposure of the
lumina of the receiving sinuses, uterine relaxation,
and pressure in the uterine cavity greater than that
in the sinuses. Doctor Sampson believed that
uterine contraction following relaxation, when there
was obstruction in the cervical canal and intrauter-
ine irrigation might bring about this increased
pressure and force fluid, sterile or containing in
suspension bacteria or placental cells, into the
venous circulation ; one way, and probably a fre-
quent one, by whicli puerperal infection arose and
placental cells reached the lungs.
Discussion. — Dr. George W. Kosmak, of New
York City, stated that the work of Doctor Sampson
was a striking demonstration of the warning that
we ought to stay out of the uterus as much as
possible because the invasion of this organ, particu-
larly in the puerperal state and at other times, was
attended with a great deal of danger. Observa-
tions which he made some years ago with reference
to the extrusion of irrigating fluid through the
Fallopian tubes demonstrated this to him in such a
dramatic manner that he should never forget the
subject, and Doctor Sampson had shown most con-
vincingly the possibility of the invasion of the gen-
eral venous system by mechanical methods as dem-
onstrated by his injection specimens.
Dr. John O. I'olak, of Brooklyn, N. Y., said the
demonstration of the protection of the endometrium
against invasion from curetting the titerus was
particularly impressive. Years ago we were taught
not to operate during the menstrual period, yet in
the hurry of hospital work we had violated the rule.
Doctor Sampson had given a clear idea of why
there was mfection in some cases.
Dr. Thomas J. Watktns. of Chicago, stated that
the paper was of great value in bringing positive
evidence against curettage of the puerperal uterus,
and the society should put itself on record against
any such procedure. Whenever the question of
puerperal infection came up before a body of-
gynecologists and obstetricians, he was surprised
and shocked at the number of men who continued
to curette and wash out the puerperal uterus.
Doctor Sampson had presented an excellent argu-
ment against it. Doctor Watkins related briefly
a series of investigations which he had made bearing
on the subject. The uteri in 200 cases, which were
removed by hysterectomy, were examined bacterio-
logically by Doctor Curtis, and an interesting point
was this : In nearly all these cases the endometrium
was sterile, whether it was a chronic case or not,
except in those in which a preliminary curettage
had been made. If the curettage had been done
two or three days or two weeks before the hys-
terectomy, and done under aseptic precautions,
in variably the uterus was found to contain bacteria
following such a curettage; and the work of Doctor
Sampson emphasized the danger of increasing in-
fection by curettage, and especially increasing the
dangers of doing hysterectomy a few days after the
preliminary curettage.
Dr. J. Wesley Bovek, of Washington, D. C, said
that the work of Doctor Sampson confirmed what
he had been doing in the last few years, namely,
discarding the frequent curettage that was so com-
mon, and he feared too common now. Doctor
Bovee still clinging to the necessity of having to
invade the uterine cavity, injected iodine into it. In
two specimens in which he injected iodine previous
to removing the body of the uterus within ten days
for Neisserian infection, he found iodine in the
blood channels in the uterine body, which caused
him to discard injections of iodine. Then came
the paper of Doctor Curtis which showed the in-
terior of the uterus was nearly always a harmless
structure above the internal os, and now Doctor
Sampson's paper confirmed that position.
Elusive Ulcer of the Bladder. — Dr. Guy L.
HuNNER, of Baltimore, stated that this type of
ulcer was first described by him in 1914. The
lesion consisted of a chronic inflammatory infiltra-
tion of all coats of the bladder wall. The areas of
active vdceration discovered by cystoscopy were
always superficial and usually minute, and an area
of congestion seen on one examination might be
absent at the next, but would be found later if re-
peated examinations were made ; hence the name
elusive ulcer.
The symptoms were usually of the most extreme
type characterizing bladder ulcer in general.
The errors in diagnosis in the past had been due
to the elusive and minute character of the mucosa
lesion, to the examination of the urine, or to the
failure to place proper emphasis on the finding of a
few leucocytes or erythrocytes in the urine, and to
the misleading character of some of the referred
extravesical pains.
Systematic treatment with strong silver nitrate
solutions, or stick silver, or actual cautery, would
give comparative relief to many of these patients,
but the only cure thus far discovered was the com-
plete excision of the involved area.
Discussion. — Dr. John G. Clark, of Philadel-
phia, said that one of his patients, who had gone the
rounds and had been treated by several doctors
without permanent relief, finallv went to Doctor
Hunner. He was present at the operation per-
formed by Doctor Hunner, the ulcer was demon-
strated to him, and its excision was followed by a
remarkable cure. Since that time he had seen three
cases of ulcer of the bladder, in all of which the
diagiTOsis was easily made with the cystoscope, and
excision of the ulcer bearing area was followed by
splendid results.
Dr Philander A. Harris, of Paterson, N. J.,
recalled the case of a girl, thirteen or fourteen years
310
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
of age, who had not begun to menstruate. Her
hymen wa.s untorn, and she showed no signs of any
infection. Examination of the bladder was dif-
ficult by the direct method because she was unable
to retain more than three ounces of urine. Night
or day the bladder had to be emptied. She had a
great deal of pain, and not being satisfied with the
nature of the pathology, he resorted to distentions
of the bladder with normal salt solution, as advised
by Doctor Kelly in years past. After about twelve
applications he lost sight of the patient, but subse-
quentlv learned that she was able to pass urine in
eight or twelve ounce quantities for about two
years. She was now twenty- four years of age and
married. He did everything he could to cure her,
but she was far from cured as she was only able to
retain two or three ounces of urine at a time.
He asked Doctor Hvmner whether he had had
experience with distention of the bladder according
to the practice of Doctor Kelly.
Dr. Charles A. L. Reed, of Cincinnati, asked
Doctor Hunner to discuss the question of etiology,
in closing, which was especially important in view
of his failure to find bacteria in the urine following
operation. He also asked Doctor Hvmner whether
or not there had been any recurrences following
excision of the ulcer.
Dr. Lewis S. McMurtry, of Louisville, asked
Doctor Hunner if he had tried other and more con-
servative methods of treatment than excision. Ex-
cision seemed a severe operation for a benign ulcer.
Dr. Edv/ard H. Richardson, of Baltimore,
stated that a striking thing in one case of ulcer of
the bladder he saw, and this obtained in other cases,
was that the clinical picture and the bladder pathol-
ogy were out of all proportion to what one saw on
cystoscopic examination. In this particular in-
stance, when he looked into the bladder, although he
searched the bladder many times with the utmost
care, he failed to discover any lesion. The patient
was not such as to suggest a neurotic individual. He
finallv called Doctor Hunner in consultation, and
operation was decided on. When the bladder was
opened, it was found that fully two thirds of the
bladder wall was involved in the pathological
change. Not only was the mucous membrane
edematous, but the musculature of the bladder was
thickened to the extent of fully three times that of
normal. The woman made a splendid recovery and
now voided urine normally.
Dr. Edward P. Davis, of Philadelphia, said it
was his fortune to have under his care during preg-
nancy and labor one of Doctor Hunner 's most suc-
cessful cases. The history was that the patient
became infected by catheterization after a previous
operation. He attempted nothing whatever con-
cerning the bladder. Lie did not examine it, but
watched the case with very great interest. Ordinary
microscopic examination of the urine showed but a
few red and a few white cells, but this was so com-
monly seen among pregnant women that it gave
rise to no suspicion. The patient passed through a
more or less miserable pregnancy, went into labor,
the normal course of dilatation took place, she was
delivered by forceps, passed through a condition of
comparative neurasthenia and shock for which no
adequate cause could be found. Her disability was
out of all pro])ortion to any vesical symptoms con-
nected with the parturition. Her cure by Doctor
Hunner of the bladder ulcer was certainly one of
the most satisfactory he had ever known. It might
interest the members of the society in this connec-
tion to know that so far as this one observation of
pregnancy and parturition went, there was neither
an increased severity of the lesion, nor did it in the
slightest degree tend to make it better.
Dr. Catherine MacFarlane, of Philadelphia,
stated that her experience with ulcer of the bladder
was limited to three cases which occurred during
the past year. The lack of proportion between the
severity of the patient's symptoms and the insignifi-
cant bladder lesion and trifling urinary findings had
been emphasized. A diagnosis was much better
made by the clinical history than by the laboratory
findings or physical examination. Complete relief
followed the operation of excision in these cases.
Dr. W. F. Shallenberger, of Atlanta, Ga.,
stated that about two months ago he saw his first
Hunner ulcer. Pie saw the patient some years
before, and at that time the urinary findings were
negative. Cultures were also negative. He over-
looked idcer of the bladder at that examination.
The patient then gave a history of bladder distress
of some ten years duration. She had been treated
by a dozen different men from time to time, and
had been operated on by one of them for a pelvic
condition without any marked relief. Occasionally
treatment would afford temporary relief. In this
particular case there were three ulcers of the blad-
der, one two millimetres in diameter, and two smaller
ones near by, situated about three centimetres above
the internal urethral orifice back of the symphvsis.
Wide excision of the ulcer bearing area had given
the patient complete relief from her symptoms.
Doctor Hunner, in closing, said he had tried con-
servative methods of treatment in these cases. He
had used the high frequency current in a few of
them, but it caused them so much afterpain that
they absolutely refused to have it continued.
Strange to say, the actual cauter^^ wire gave fairly
good temporary results. He depended mostly upon
silver nitrate in one form or another in treating
these bladder ulcers, and they could be kept reason-
ably comfortable by one or the other method. Ex-
cision of the ulcer bearing area was the onlv thing
that afforded permanent relief, but this excision
must be complete. In the case of a girl there was a
recurrence shortly after she returned to her home.
Most of the patients he had had were unmarried
women and showed no evidence of gonorrhea. The
etiological factors were still unknown.
The Bladder of Women after Operation. — Dr.
Artiiuk H. Curtis, of Chicago, reviewed briefly
the work reported two years ago, which he believed
demonstrated that postoperative catheter cystitis
was really urinary tract infection caused by residual
vesical urine. An essential feature in the treatment
of postoperative cases had been the prevention of
urine stagnation in the bladder. Four hundred and
sixty-five consecutively operated patients had been
managed as follows : All who complained of vesical
distress were catheterized. Also, even when the
August 17, igiS.]
LETTERS TO THE EDITORS.
power to void urine was present, catheterization was
performed if residual urine was suspected. Fur-
thermore, those patients who had required repeated
catheterization were thereafter catheterized once
daily immediately after ttrination, as long as residual
urine was obtained. At the time of catheterization
fifteen c. c. of one eighth per cent, silver nitrate was
instilled before the catheter was withdrawn. Medi-
cation consisted of hexamethylenamine in amounts
sufricient to maintain a positive formalin test. In
the presence of alkaline urine, acid sodium phos-
phate was added. Those who showed idiosyncrasy
to hexamethylenamine, or whose urine yielded no
formalin, were treated with alkalies. In the pres-
ence of urinary tract infection, meats were per-
mitted but twice weekly. Seasonings of all sorts
were forbidden, salt excepted. Sugar, sweets, and
pastry were limited.
Before this method of treatment was instituted
many operated patients retu.rned with urinary tract
distress and infection. Under the present plan post-
operative bladder troubles had disappeared.
He had found that many pregnant women failed
to thoroughly empty the b-ladder. He believed that
retention of vesical urine was a factor of the utmost
importance in the etiology of pregnancy pyelitis. It
V.MS therefore urged that obstetrical patients be
tested for residual urine whenever carefully col-
lected specimens revealed pus and bacteria. Through
judicious catheterization, immediately after tirina-
tion, it was believed that these patients could often
be saved from the danger of pyelitis.
The plan of catheterization for residual urine had
likewise been extended to tabetic cases. A patient
with well advanced disease, afflicted with intense
vesical disturbances, had apparently been perma-
nently relieved. It was thought that the failing
bladder of tabes might be reeducated through the
use of the catheter combined with intensive anti-
syphilitic therapy, provided treatment was under-
taken at a time when moderate function still re-
mained.
Discussion. — Dr. John A. Sampson, of Albany,
stated that he found after a radical operation for
carcinoma of the cervix that severe cystitis was a
common complication, and he attributed the bladder
disturbance to interference with the blood supply
and with its function. Some of these patients in
whom there was incidentally a vesicovaginal fistula,
were not troubled with cystitis, and he even went
so far as to suggest that possibly in these severe
cases the formation of a vesicovaginal fistula tem-
porarily would obviate the cystitis. One of the most
important ways of treatmg a severe cystitis was that
carried out by Doctor Kelly in his clinic, namely,
establishing free dramage and rest.
Dr. Guy L. Hunner, of Baltimore, agreed with
the essayist that retention of urine was perhaps the
chief factor, and this was most often due to post-
operative overdistention of the bladder. It seemed
to him that interference with the circulation and
traumatism to the bladder itself, did not have an
important bearing on the question of postoperative
cy.stitis ; but if these patients were allowed to go on
after operation with overdistention of the bladder,
we might get a partial paresis which might last for
several days or weeks, creating a most favorable
condition for infection to take place.
Dr. J. Riddle Goffe, of New York City, asked
Doctor Watkins about the treatment after washing
out the bladder.
Doctor Watkins, in closing for Doctor Curtis,
stated in reply to Doctor Goffe that a catheter was
always passed as soon as the patient had any dis-
tress. He never allowed a patient to have distress
in the bladder on account of the presence of urine.
After a patient had been catheterized every two or
three days, he also catheterized once a day after that
until he was sure the patient was not carrying an
excess of residtial urine. Daily catheterization was
stopped as soon as he was convinced that the patient
was not carrying a large amount of stagnant urine.
Dr. Leroy Broun, of New York City, asked to
what extent residual urine was found and in what
quantity ?
Doctor Watkins replied that almost invariably a
crippled bladder was found in women who had to be
catheterized every two or three days. The case
that required catheterization very seldom carried
stagnant urine.
(To be continued.)
^
Letters to the Editors.
STIMULATION OF THE SYMPATHETIC AS A
RESULT OF TOXEMIA.
New York, August 8, 1918.
To the Editors:
I have greatly enjoyed a number of articles in your
pages about the vegetative nervous system, and they have
been the means of enlightening obscure points for me. As
a result of my interest being stimulated in this field, allow
me to offer you the following clinical observation, in the
liopes that if the point mentioned has not hitherto received
much attention, that a little publicity will serve to stimu-
late widespread observation.
In giving ether to a number of patients undergoing lapa-
rotomy, I noted that the "clean" or non pus cases took the
anesthetic much better than the pus cases, the pupil con-
tracting down promptly and being maintained easily in
that desirable condition. On the contrary, the pupil in the
pus cases could with difficulty be brought into a well con-
tracted condition, and was very hard to maintain that way.
I thought that this meant that the sympathetic division of
the vegetative system was unduly stimulated as the result
of the toxemia, with the tendency noted.
Hoping, if the above has not already been worked out
by some one, that this will stimulate a little research, I am,
Yours respectfully,
"Splanchnic," M. D.
COMMISSIONS FOR DRAFT BOARD DOCTORS.
New York, August 12, 19 18.
To the Editors:
The efficient and expeditious manner in which the con-
scription law has been admini.^tered is the subject of much
favorable comment, and it should not be out of place to
call attention to the part which the doctors attached to the
various draft boards throughout the country have played
in achieving a result so fraught with importance in its
bearing on the national welfare at the present time. Spe-
cialists have worked side by side with the general practi-
tioners, and all have given freely of their abilities and
time to safeguard the best interests of the nation.
The difiiculties which the draft board doctors have to
contend with are by no means few ; and I believe from per-
sonal experience that the major portion of these may be
charged to the fact that the draft board doctors have been
312
BOOK REVIEIVS.— BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
si\en !ic uniforms or other distinctive symbol of rank,
whicii is readily conve>ed to those with whom they come
in contact. This creates misunderstanding and confusion,
which militates against the most efficacious performance
of |)rofessional duties. In some cases the doctors have
even had difficulty in securing admittance to the draft
board to which they had been assigned because they were
in civilian clothes and not readily recognized. In order
to avoid these conditions and in consideration of the im-
portant service which the draft board doctors have been
and are rendering in the nation's cause, would it not ap-
pear desirable that the government should recognize such
service by granting them honorary commissions in which-
ever branch of the service they might like to be enrolled,
thus entitling them to wear a uniform and to be accorded
due respect in the performance of such professional service
during the period of the war?
It occurs to the writer that this subject of worthy of
consideration and discussion, inasmuch as it is one that
directly affects the war service of many members of the
medical profession. John Coghlan, M. D.
^
Book. Reviews.
[We publish full lists of books received, hut we acknozvl-
edge no obligation to reviezv them all. Nevertheless, so
far as space permits, we review those in zvhich we think
our readers are likely to br interested.]
An Introduction to the History of Science. By Walter
LiBBY, M. A., Ph. D., Professor of the History of Sci-
ence, Carnegie Institute of Technology. Boston, New
York, and Chicago: Houghton, Mifflin Company, 1918.
Pp. x-288. (Price, $r. 50.)
The cost of vi'arfare — of the destruction of men — mounts
into billions of dollars, but eventually it is paid. The
debt to those who war against prejudice, ignorance, dis-
ease, has been mounting for some thousands of years, but
authorities have a method of settling claims by burning
the author or his book, imprisoning him, spying on him,
calling up opponents, imputing sordid motives, and by re-
fusing to test his theories, use his inventions, or allow him
to live in peace.
Professor Libby has taken down the ledger, blown the
centuries of dust from its cover, and shown how great the
debt we owe to scientists; and, what is just as important,
that which is owed by every learned man to his predeces-
sor, who, in laying the pievious stepping stone, showed
the utter inapplicability of the term "suddenly discovered
," for ancient Egypt thought and wrought while Eu-
rope still slumbered and Arabia numbered her scores of
learned men while infant races had not mastered the
alphabet. All this our author shows in attractive word-
ing and concise phrasing without being abrupt, and in
graceful gratitude to his learned predecessors, gives the
student a bibliography to guide him to the sources he him-
self has found useful in treating of science and practical
needs ; its continuity ; in the struggle for liberty ; its inter-
actions ; its connection with religion ; its hypotheses and
its place in prediction, travel, war, invention, and culture.
The best endorsements of this companionable volume
are the official reports we see weekly from Government
offices and consulates, even those from large sociologic
centres. Though striving only to entertain by music and
movies, and magazines, these are dependent on many re-
searches, for music means fine wood and metal ; the movies
embody the results of patient scientific work for centuries
past ; the magazines take us to the forest, the cotton and
flax fields and the chemist as he grapples with the present
momentous question of shortage of paper. In war councils
of today the engineer, the physicist, the geologist, the
chemist, the physiologist, all are asked to bring their wis-
dom to solve ryiestions of transport, of suitable sites for
our mammoth guns, of deadlier gases, more scorching
fires, of human nutriment, of skilful healing, of ever faster
message from continent to continent, from mariner and
airman. They keep the keys to all supplies, but never lock
the doors ; they give freely and ask no thanks. This is
perhaps as well, for often a belated ornate monument or
a name in dispute as to priority in discovery, is all that
the public know of a benefactor until sometim.es gently
enticed to read of the history of science in a well written
volume like the one we have just laid down.
L'Evolution de la Plate de Guerre. Mecanismes biologiques
fondamentaux. Par A. Polic.'Vrd, Professeur agrege a la
Faculte de Medecine de Lyon. Avec figures et planches
hors texte. Paris: Masson et Cie., 1918.
As its subtitle states, this book is a study of fundamental
biological mechanisms, a careful, well classified study of
war wounds from the point of view of the pathologist and
bacteriologist. Althongh seeming a somewhat academic
treatment of the subject .Tt the present time, it was the re-
sult of a thirty months' period of research in the labora-
tory of an active surgical hospital, and the studies pre-
sented of treating wounds, and the pathogenic organisms
causing infections are direct contributions from the daily
work of the surgeons themselves. The book is well illus-
trated by drawings and photomicrographs.
Les Plaics de Guerre et Icurs Complications Immcdiates.
Leqons faites a L'Hotel-dieu. Par Henri Hartmann,
Professeur de Clinique Chirurgicale. Paris : Masson et
Cie., 1918. Pp. 203.
The book consists of eighteen lectures given at the Hotel-
Dieu by Professor Hartmann, reviewing present day war
surgery. He presents varied points of view which have
arisen in society discussions, especially those of the So-
ciety of Surgery of Paris. War wounds, their treatment,
hemorrhage, tetanus, gas gangrene, traumatic shock, the use
of apparatus, the study of bone and joint lesions, amputa-
tions, wounds of the head, face, chest, and abdomen, and
frost bite are made the subjects of various lectures. Eye
wounds are made the subject of a chapter by Morax.
®
Births, Marriages, and Deaths.
Died.
Anderson. — In Seaside Park, N. J., on Monday, Au-
gust 5th, Dr. Samuel Frederick Anderson, aged fifty-two
years.
BiGELow. — In Boston, Mi^ss., on Thursday, August ist.
Dr. A. M. Bigelow, aged fifty-six years.
Cocke. — In France, in July, Dr. Paul Lee Cocke, of Bir-
mingham, Ala., Captain, M. R. C, U. S. Army, aged forty-
three years.
Crossman. — In Ro.Kbury, Mass., on Monday, August sth,
Dr. Frank A. Crossman, aged sixty years.
Edic. — In Leavenworth, Kans., on Wednesday, July 31st,
Dr. John J. Edic, aged eighty-one years.
Ferris. — In Cincinnati, Ohio, on Saturday, July 27th,
Dr. Chase L. Ferris, aged thirty-nine years.
Gavlord. — In New Haven, Conn., on Monday, August
5th, Dr. Charles Woodward Gaylord, of Branford, aged
seventy-three years.
Greene. — In Wenonah, N. J., on Friday, August 9th,
Dr. William Houston Greene, of Philadelphia, aged seventy
years.
Hamill. — In Phoenix, N. Y., on Thursday, July 25th,
Dr. John E. Hamill, aged seventy-nine years.
Hills. — In New York, on Saturday, August 3rd, Dr.
Frederick L Hills, aged forty-eight years.
Lee. — In Sheridan, Mich., on Saturday, July 20th, Dr.
Walter A. Lee, aged sixty-four j'ears.
Mann. — In Bridgeport, Pa., on Sunday, August 4th, Dr.
Charles H. Mann, aged sixty-six years.
O'Kf.efe. — In Boston, Mass., on Tuesday, July i6th. Dr.
Michael W. O'Keefe, aged seventy-four years.
Orton. — In Northampton, N. Y., on Friday, August 2d,
Dr. Darius S. Orton, aged seventy-seven years.
RoniNSON. — In West Newton, Mass., on Saturday, Au-
gust loth. Dr. Franklin E. Robinson, aged seventy-two
years.
Trahue. — In Elkton, Ky., on Saturday, August 3d, Dr.
Lee P. Tribue, aged sixty-one years.
Williams. — In Roxbury, Mass., on Monday, August 5th,
Dr. Edward Tufts Williams, aged seventy-three years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII, No. 8. NEW YORK, SATURDAY, AUGUST 24, 1918. Whole No. 2073.
Original Communications
SOME CLINICAL TYPES OF NEPHRITIS.*
A Study of Sixty-eight Cases.
By Tasker Howard, M. D.,
Brooklyn, N. Y.
I wish to emphasize some distinctions in the clin-
ical varieties of nephropathies which have come to
hght in recent studies of nephritis, and which I be-
Heve are thoroughly substantiated on pathological
grounds.
The pathologist has classified and reclassified the
nephritide:> and has put forward so many subvarie-
tics that are indistinguishable clinically that the
whole subject has attained considerable confusion
from a clinical standpoint — not that the pathologists
are altogether clear about it. The more recent work
of the physiological chemist has forced a clearer
distinction of some of the types which is of great
clinical importance. There have been clinical ad-
vances too, and the large groups which have been
separated can readily be distinguished pathologi-
cally, forming three entirely distinct diseases, which
(lifTer in their symptomatology, course, treatment,
and termination. I refer to glomerulonephritis, the
pure nephrosis of Afueller, and the arteriosclerotic
kidney, any two of which may be, and not infre-
quently are, combined in the same patient.
Tlie clinical and pathological aspects of this sub-
ject have been combined in so convincing a manner
by Volhard and Fahr that I have found at least the
principles of their classification a very valuable and
practical aid in studying any given case. Volhard
and Fahr, as you may remember, divide the nephro-
pathies into the following groups: i, nephrosis,
under a subhead of which they include necrosis, or
injury to the kidney by such poisons as mercury ;
2, glomerulonephritis, including focal or embolic
nephritis (without hypertension) and diffuse glom-
erulonephritis (with hypertension) ; 3, mixed forms
in which both nephrosis and glomerulonephritis are
present ; 4, benign or essential hypertonia (the
arteriosclerotic kidney) ; and 5, the combination
form, which is a glomerulonephritis engrafted on an
arteriosclerotic kidney.
Some of these forms I shall describe briefly and
illustrate.
I. True nephrosis is a comparatively rare disease.
Of the sixty-eight kidney cases included in tonight's
study, but five come under this category. Its main
* Rpnd before the Medical Association of the Greater City of
Xp^•• York, April 15, 1918.
clinical characteristic is renal edema and its chief
histological change, degeneration of the tubules. It
is esseniially a degeneration and not an inflamma-
tion. With the edema there is a marked retention
of chlorides and water. The urine in the stage of
edema is of high specific gravity and loaded with
albumin. Certain negative findings are of impor-
tance. There is no hypertension nor cardiac
hypvertrophy, no characteristic retinal change, nc
marked nitrogen retention, and hence no uremia,
The phthalein output is good except as it is influ-
enced by the edema. There may develop a con-
tracted kidney with j>o]yuria and hyposthenuria but
other signs of hypertensive nephritis remain in
abeyance. I^pstein has shown that these patients
present characteristic change in the blood proteins,
showing a decrease in the serum albumin with a
relative increase in the globulins. They do not die
of uremia, although they may have eclamptic attacks
which are probably due to cerebral edema. One of
my series presented this picture. They are particu-
larly susceptible to infections, the four fatal cases
in Volhard and Fahr's series dying of pneumococcus
peritonitis. In a case on my service, not included in
this series, the patient died of a fulminating hema-
togenous streptococcus peritonitis. Another died
from exhaustion due to an uncontrollable diarrhea.
Complete recovery is the rule in mild cases if
properly treated, and I believe Epstein's teaching as
to the value of higher protein feeding and trans-
fusion has assisted us in the severer cases. Not a
few pass into the stage of chronic polyuria and
slight or moderate albuminuria and live for many
years. Such a patient has been under my observa-
tion for six years. He has a constant polyuria,
hyposthenuria, and albuminuria and absolutely no
other signs or symptoms.
Mrs. C. is a typical example of a severe grade of
nephrosis. She is a married woman of thirty-one, who
had measles in childhood and has borne two children,
twe'.ve and eleven years ago. After the second birth her
ankles were swollen for a week. About a year ago her
face and legs began to swell. She was treated by many
doctors and gradually improved ))ut had had a relapse when
she entered the Long Island College Hospital, and was
complaining of general dropsy, scanty urine, weakness,
nausea, and occasional attacks of diarrhea. Examination
showed a pale woman with marked general edema. She
had many crowned teeth and cryptic tonsils. Her heart
was not enlarged, the blood pressure being 1 12-58. Her hemo-
globin was sixty-eight to sixty-two per cent., the red cells
2,600,000, the white cells 5,200, and the Wassermann was
negative. Her urine varied from sixteen to forty ounces,
was 1012 to 1026 in specific gravity, and contained from
Copyright, 1918, by A. R. Elliott Publishing Company.
314
HOWARD: CLINICAL TYPES OF NEPHRITIS.
[New York
Medical Journal.
four to twelve grams of albumin per litre. The blood urea
nitrogen was 9.4 mg. per 100 c. c, cholesterol 500
mg. Her two hour i)luhalein was forty per cent. She
has had three transfu.sions, wliich have markedly benefited
her, but she is by no means well yet.
2. Diffuse glomerulonephritis, according to Vol-
hard and Fahr, is always due to infection, and I
believe that evidence is steadily accumulating to sup-
port that contention. Barker states that the strep-
tococctis is usually responsible. Histologically we
will content ourselves with saying that the most
characteristic lesions are the inflammatory changes
going on to complete destruction of the glomeruli
scattered here and there throughout the entire
organ. Clinically the most constant feature is hy-
pertension with cardiac hypertrophy. The urine is
apt to show more or less blood from time to time,
in contrast to the urine of nephrosis or arterio-
sclerosis. The kidneys eliminate water well, salt
with some difficulty, and nitrogenous crystaloids
with more and more difficulty. We therefore sec
no edema i;ntil the heart has given out, but an ac-
cimiulation of nitrogenous waste products in the
blood. First the uric acid is retained, then the urea,
fmally the creatinine, and with the severer grades of
retention, perhaps because of them, we get the
symptoms of uremia anorexia, weakness, twitching,
drpwsiness, coma, and death. The phthalein output
varies inversely with the nitrogen retention.
To go back to the kidney's difficulty in excreting
these nitrogenous waste products, there develops
pari pasH a compensatory polyuria, so that as the
disease progresses we find, up to a certain point,
more urine but of a lower specific gravity — the so
called hyposthenuria. With this decreasing specific
gravity, we find a tendency for the kidney to work
nights in order to finish the uncompleted day's work,
so that there is a nycturia as well as a polyuria.
Mosenthal has shown that the functional capacity
of the kidney can be gaged by watching these fac-
tors about as reliably as by the more complicated
methods. A normal individual on a normal diet will
excrete about twice as much urine in the twelve
hours of the day as in the twelve hours of the night,
the night urine will have a higher specific gravity,
and the variations in the specific gravity of the urine
collected in two hour periods during the day will
amount to eight to ten points. Constant variations
from this normal are extremely significant.
Albuminuric retinitis is found exclusively in
glomerulonephritis.
It is said that some grade of anemia is more apt
to occur in nephritis than in the benign form of
hypertension. I have not found it so.
Mr. G. represents a typical case of chronic diffuse
glomerulonephritis. He was forty-eight years of ag;e,
a Hungarian, a tailor, and married. He had had typhoid
at nine and frequent attacks of tonsillitis. Six months
before admission he began to complain of weakness,
anorexia, nycturia, and dyspnea. One week before ad-
mission he developed dependent edema. He was pale,
showed a marked dependent edema, a large heart with a
blood pressure of 226-224, the urine varying from twelve to
twenty-three ounces, having a specific gravity of 1005-1010
and containing considerable albumin. The phthalein output
was o. The hemoglobin was seventy-six per cent, the reds
4,200,000, the whites 12,000. The blood urea nitrogen
eleven days before his death was 32.2, the creatinine 3.3,
and the alkaline reserve 7.6 (Marriett). The eye grounds
sliowed albuminuric retinitis, hemorrliages, arteriosclerosis,
and hazy nerves (Doctor Rogers). He became delirious,
went into coma, and died. Autopsy showed a large heart.
The two kidneys weighed 172 gm. The left kidney was about
one third less than normal size, with a finely granular
and pale surface. The capsule stripped with difficulty.
Two small cortical cysts were present. On section the
cortex was seen to be thinner than normal and the mark-
ings were indistinct. Microscopically many tubules were
filled with desquamated and necrotic epithelium. There
were areas of compensatory hypertrophy of tubules, with
edema and flattened epithelium, and many areas of small
round cell infiltration. The connective tissue was in-
creased with atrophy and obliteration of many tubules.
Well marked vascular sclerosis was present and very
marked glomerular changes, including atrophy with hyaline
degeneration, proliferation of cells lining Bowman's cap-
sule, disuse atrophy, edema of tufts and fluid in capsular
space, with occasionally some red cells in the capsular
space (Doctor Murray).
3. The mixed form combines the findings of the
two types just described. The early acute stage of
a glomerulonephritis frequently presents this pic-
ture.
4. Benign or essential hypertonia is, as you know,
not a kidney disease at all, but is classed here be-
cause it usually presents some kidney pathology,
and because it is so often confused with nephritis.
The kidney in such cases is apt to show patches of
degeneration due to narrowing or obliteration, of
the vessels supplying these patches. The glomeruli
involved are as a rule entirely destroyed and these
destroyed glomeruli are bunched and not scattered
diflrusely through the organ. Evidences of inflam-
mation, such as adhesions between the layers of the
capsules and proliferation of the tufts and capsules,
are lacking. I have heard Dr. L. A. Conner etn-
phasize the fact that there may be no kidney changes
whatever.
Clinically the essential feature of this disease is
arterial hypertension with cardiac hypertrophy.
There may be no. other finding. The urine may con-
tain a little albumin and a few casts, and there may
be enough damage to kidney function to cause* a
slight polyuria and fixation of the specific gravity.
Nitrogen retention is moderate, never ainounting to
enotigh to cause ureinia, unless as sometimes hap-
pens, there has been superadded an actual nephritis
— the combination form of Volhard and Fahr.
From a practical standpoint it should be remem-
bered that about ten or fifteen per cent, of patients
with apparently benign hypertonia ultimately de-
velop symptoms of actual nephritis.
In simple hypertensive cases the phthalein output
remains good until the heart fails, the retinal
changes are those of arteriosclerosis only, and ure-
mia is absent. The dangers are apoplexy and heart
failure.
A typical example of benign hypertension is found in Mrs.
T^., whose case may be summarized as follows : A w^oman
se\-enty-five years old had been complaining of dyspnea
and swelling of the legs. Clinically she exhibited a large
heart, a blood pressure of 240 over 120, and a dependent
edemia. The urine was 1018 in specific gravity and con-
tained a trace of albumin but no casts. The Wassermann
was negative, the red cells 4,000,000. A blood analysis
showed 45.9 mg. of urea nitrogen, 6.4 mg. uric acid,
and 0.8 mg. of creatinine. The phthalein output was o.
The patient died of a failing heart. Autopsy showed the
following: The heart weighed 475 gm. ; the valves were
normal, but there were marked fibrous changes in the
myocardium. There was general passive congestion with
August 24, 1918.]
IIOWARD: CLINICAL TYPES OF NEPHRITIS.
edema of the lung and some fluid in each pleural cavity.
The kidneys were lobulated, the right and left weighing
135 and 150 gm. respectively. The surface was not granu-
lar, the width of the cortex varied, being indented at the
margins of the lobulations. Microscopically these in-
dentations were found to correspond to wedge shaped
areas of degeneration, the tubules being atrophied and
crowded together, the glomeruli having undergone com-
plete hyaline transformation. Elsewhere the kidney pic-
ture was normal.
5. The combination form of Volhard and Fahr,
as has been stated, consists in the addition of the
inflammatory changes of glomerulonephritis to the
degenerative changes of a wide spread arteriolar
sclerosis. Opluds. from a careftil study of a num-
ber of such cases followed to autopsy, has come to
the conclusion that the pathological changes are in-
flammatory from the beginning and that they are
always due to infection. At all events they are so
similar to the diffuse glomerulonephritis just de-
scribed that at present the writer sees no practical
advantage gained in trying to separate them and
has not done so in this study. The important point
lies in remembering that what seems to be a simple
arteriosclerosis may turn out to be a malignant
glomerulonephritis.
TABLE OF SIXTY-EIGHT CASES STUDIED.
Average Phenol-
Average phthalein No.
No. of Average Range in Maximum output — of
D iagnosif. cases. age. age. B. P. 2 hrs. Deaths.
Chronic Glomer-
ulonephritis .. J3 47 17-64 202-119 11.5% 15
Xeph^o?;<i 5 30 22-43 120-80 43.0% I
Mixed Form ... 11 38 17-45 187-116 24.0% o
Benign Hyperten-
sion 18 59 42-86 201-113 25.0% 5
Passive Conges-
tion I . .... .... ... I
Comparative youth is a diagnostic factor point-
ing to nephritis rather than arteriosclerosis, but
simple hypertension is sometimes seen as early as
the twenties, so that age is not an absolute guide.
The average maximum blood pressure recorded
w^as as follows: nephritis, 202-119; arteriosclerosis,
201-113; combination form, 187-116; nephrosis,
1 20-80.
Of course many of the patients studied are in an
early stage of the disease, which has tended to
lower the blood pressure averages. A high diastolic
pressure has been considered as pointing to nephritis
rather than to arteriosclerosis, but in this series
patients were encountered with apparently simple
hypertonia who registered diastolic pressures of
130, 140, and 150.
The phenolphthalein output for two hours may
be seen in the table. Aside from the kidney func-
tion, the one factor which most influences the
phthalein outpttt is the presence of edema. When
the drug is injected into edematous tissue, it is ab-
sorbed slowly and therefore excreted slowly. This
has to be taken into account in the consideration of
any reading. Many of the arteriosclerotics and all
of the patients with nephrosis, were edematotis at
the time the readings were made, or their figures
would have been higher, as was shown by a study
of their nitrogen retention, or rather the demonstra-
tion of their lack of it. A kidney that can eliminate
nitrogen well can eliminate phthalein well.
Polyuria and hyposthenuria. — It is impossible to
give the figures in such a report but it should be
remarked that a study of the amount and specific
gravity of two or four hour specimens taken
through the day and of the night urine as a whole
I)roved of great assistance in differentiating glomer-
ulonephritis from simple hypertension. One of
the two mistaken diagnoses out of nine cases
studied histologically tnight have been avoided had
stifficient attention been given to this point.
A man of sixty had suffered from dyspnea and depen-
dent edema for two months. He had a large heart, a
1)lood pressure of 260-150. His urea nitrogen was 20.7
mg. per 100 c. c. The day urine varied from loio to 1018
in specific gravity, the total amount being 800 c. c, while
the night urine amounted to but 100 c. c. and had a specific
gravity of loio. He died of a lironchopneumonia before
other observations could be carried out, and the autopsy
showed chronic glomerulonephritis with considerable ar-
teriosclerosis, the combination form of Volhard and Fahr.
The lov/ specific gravity of the night urine should have put
us on our guard against supposing, as we did, that he had a
simple arteriosclerosis.
The other mistake, on the contrary, was due to a mis-
interpretation of these findings. It occurred in the case
of a man with cardiac dropsy, who, under diuresis, was
passing large quantities of low specific gravity urine day
and night. He also had hypertension and retinal hemor-
rhage, and we supposed that a chronic glomerulonephritis
complicated his passive congestion, in spite of a blood urea
nitrogen of 8.9 mg. The uric acid was 5 mg. Autopsy
liowever. showed no nephritis.
The test then, to be of value, should be carried
out tmder conditions approximating the normal ;
that is, on a general mixed diet, and in the absence
of artificial diuresis.
Blood chemistry opens a wide field for discussion.
It was used as a routine in these sttidies, as an aid
to diagnosis, prognosis, and treatment. Some degree
of nitrogen retention was invariably fotind in
nephritis cases, affecting first the uric acid. Of the
twelve nephritics in whom this was investigated the
uric acid varied from three to 8.2 milligrams. The
same was true of arteriosclerosis. One case show-
ing a retention of 6.4 milligrams of uric acid caine
to autopsy and the kidneys merely showed patchy
areas of arteriosclerotic degeneration. One of the
pure nephrosis cases also showed a uric acid reten-
tion of five milligrams. Urea is a very variable
factor and at times may be much influenced by
treatment. A high urea nitrogen content is danger-
ous but what appears to be a comparatively low
reading does not always indicate freedom from
danger. Widal's old dictum that uremia could not
occur with a reading below 100 was revised by him-
self. Of the seven patients in our service dying of
itremia and in whom the firea nitrogen was esti-
mated within eleven days of death, the urea nitrogen
read as follows: 239. 174-9, 156.8, 97.4, 82, 54.6,
32.2. The last figure mentioned (32.2) was ob-
tained eleven days before death, at which time the
creatinine read 3.3. The case with the tirea
nitrogen of 54.6 had a creatinine reading of eight.
The ]:)atients with nephrosis averaged 12.8 milli-
grams of urea nitrogen.
Creatinine was not determined as regularly as the
tirea. The five tiremia cases in which it was studied
shortly before death gave reading as follows : 8, 5,
3.3, 2.5, I.I. The last two mentioned gave high
urea figures. One patient with a reading of 3.2
two months ago is now up and about, having left
the hospital much improved. Of the eight arterio-
sclerotics on whom a creatinine determination was
3i6
BLUMGARTEN: TREAT MENT OF NEPHRITIS.
[New York
Medical Journal.
made but one exceeded two milligrams and that by
but O.I niilligram.
Albuminuric retinitis was found in fifteen of the
nephritics examined, including the mixed form, and
in no other condition. Twelve nephritics exhibited
retinal hemorrhages and ten edema pupillse. The
only changes seen in nineteen simple hypertension
cases examined were those of arteriosclerosis. The
nephrosis cases were all negative.
The hemoglobin in twenty-six nephritis cases
including the mixed fomi was seventy-one per cent.
In eight arteriosclerotics it was seventy-four. In
five nephrosis patients it was sixty-five.
Convulsions occurred in seven of the nephritics
including one who died of uremia with a urea
nitrogen of 174.9, in one arteriosclerotic, and in one
patient with nephrosis and edema.
Twenty-two of the series died. Of these fif-
teen had nephritis, five arteriosclerosis, one ne-
phrosis and one passive congestion. Eleven au-
topsies were performed. Unfortunately two of the
eleven were not examined histologically. Of the
nine who were studied histologically six showed
glom.erulonqihritis, including the combination
forms. Two were arteriosclerotic, and one was a
kidney of passive congestion.
CONCLUSIONS.
From a practical standpoint there are three com-
mon nephropathies which difi^er widely in signs and
symptoms, course, treatment , and prognosis. These
are : i. Pure nephrosis, characterized by renal edema
without hypertension or nitrogen retention. It is
usually curable by rest and a dry diet relatively
rich in protein. Transfusion is of great benefit in
some cases. 2. Simple hypertonia characterized by
hypertension and its dangers. 3. True nephritis in
which to the dangers of hypertension are added the
dangers of nitrogen retention and uremia. Combi-
nations of these types frequently occur, the ne-
phritic element as a rule being the malignant com-
ponent, and justifying us in considering them as
actual, if modified, examples of true nephritis.
Negative Laboratory Findings in Syphilis. —
Albert E. Sterne (Journal A. M. A., July 13, 1918)
discusses the difficulties which often arise in diag-
nosis when the results of laboratory tests do not
agree with the clinical picture, or when their re-
.sults are negative in cases of . syphilis. He con-
cludes that a Wassermann reaction, properly done
by a conscientious and competent man, if positive on
either the blood or specially the spinal fluid, means
syphilis invariably. A negative blood reaction, or
even spinal fluid reaction, does not necessarily ex-
clude syphilis. This and other laboratory diagnos-
tic tests should be regarded solely as clinical signs
which may be present or absent. In every case of
suspected syphilis the spinal fluid should be sub-
jected to the Wassermann, the colloidal gold, and
other tests. The best results in the diagnosis of
doubtful cases are only to be obtained when the
laboratorian and clinician are more closely related
scientifically than is usually the case. The labora-
tory and clinical findings should harmonize to the
extent that the former agree with the latter.
THE RATIONAL TREATMENT OF
CHRONIC NEPHRITIS.
By a. S. Blumgarten, M. D.,
New York,
Assistant Visiting Physician to the Lenox Hill Hospital; First
Lieutenant, M. R. C, etc.
It is not the purpose of this article to present any
startling new discovery in the treatment of chronic
nephritis. I wish merely to advocate therapeutics
based upon the functional pathology of the kidney.
I wish to divert our therapeutic attention in chronic
nephritis from the fatalistic acceptance of the dis-
ease as a chronic incurable condition in which we
must sit quietly at the bedside, adapting the patient
to his progressive lesion. I think the sooner we
learn to employ our eflForts in attempting to at-
tack the lesion itself, the more will our therapeutic
results parallel the brilliant achievements of modern
chemistry in elucidating the functional pathology
of the disease.
For therapeutic purposes the usual classification
of chronic nephritis along pathological lines into
chronic interstitial and chronic parenchymatous ne-
phritis is not practical. Nor are the attempts to
localize the excretion of various waste products of
any definite clinical value. In the first place, in
many instances there seems to be no relation be-
tween the clinical phenomena and the post mortem
patholog}' of the kidney. Moreover, a pathological
classification does not give us any aid in the treat-
ment of the disease. For clinical work the follow-
ing classification, based upon the blood chemistry,
seems to me to be most helpful in the treatment of
chronic nephritis, irrespective of the underlying
pathology of the kidney.
Since the kidney is the main excretory organ for
protein waste products, and since the retention of
protein waste products in the blood is the most vital
element of the nephritic syndrome, chronic nephritis
may be classified into the following three groups :
I, chronic nephritis without retention of protein
waste products ; 2, chronic nephritis with retention
of protein waste products ; 3, chronic nephrosis, or
better still, metabolic nephrosis. In the latter group
are included many of the cases of the so called
chronic parenchymatous nephritis, but not all.
METHOD OF HANDLING INDIVIDUAL CASES.
When a suspected case of nephritis comes under
our observation, it is essential: i, to establish the
presence of a nephritis: 2, to obtain the basic data
for a therapeutic classification ; 3, to place the case
in one of the groups outlined above.
DIAGNOSIS OF CHRONIC NEPHRITIS.
When a case of chronic nephritis comes under
our care, the existence of a chronic nephritis will
be established by the following data: i. Repeated
examinations of the urine will show the presence of
albumin and casts, associated with or without high
blood pressure. 2. In doubtful cases, however, one
of the most important and perhaps one of the
earliest signs is an increase in the uric acid content
of the blood, and the presence of a nocturnal
polyuria of more than 400 c. c. from 6 p. m. to
6 a. m.
August 24, 1918.]
BLUMGARTEN: TREATMENT OF NEPHRITIS.
BASIC DATA FOR THERAPEUTIC CLASSIFICATION.
When the existence of a nephritis has been estab-
Hshed, an attempt should be made to place the case
in one of the groups I have outlined. To do so it
will be necessary to obtain the following data:
1. A record should be kept of the total intake of
fluids during every twenty-four hours.
2. A daily record of the patient's weight should
be kept. This enables us to note the quantity of
fluid lost by the skin and the bowels, as well as the
status of his nutrition.
3. A record should be kept of the total output
of urine for twenty-four hours, as well as the output
from 6 p. m. to 6 a. m.
4. The degree of albuminuria, preferably by quan-
titative method, should be determined, as well as
the presence or absence of casts.
5. The phenolsulphonephthalein test should be
done weekly. It is the most reliable test for func-
tional capacity of the kidney.
6. The blood pressure should be recorded every
week.
7. The blood should be examined chemically every
week, to determine the quantities of nonprotein ni-
trogen, urea, uric acid, creatinine, and cholesterol
present.
8. The carbon dioxide combining power of the
blood should be estimated in all cases to determine
the presence of acidosis, and especially in cases
showing uremic symptoms.
g. In selected cases it may be helpful to determine
the nitrogen partition of the urine, and to determine
its ability to eliminate added chlorides, nitrogen, and
urea.
10. In cases that have been proven to be merely
nephroses, it may be wise to determine the protein
content of the blood and the ratios of serum albumin
to serum globulin, which Epstein has shown to be
changed in such cases.
CLASSIFYING THE CASE.
When the essential data have been established,
the case should be placed in one of the groups I
have outlined.
The cases showing practically normal percentages
of nonprotein nitrogen, urea, uric acid, and crea-
tinine in the blood, although the patients may show
evidence of the existence of a nephritis, such as the
increased percentage of uric acid in the blood,
should be placed in the first group. These are the
cases which usually come under our observation in
office practice, sufiFering from few symptoms other
than the nocturnal polyuria, increased blood press-
ure, and the presence of albumin and casts in the
urine. The ca.ses showing increased percentages of
protein waste products in the blood are the most
common cases seen in hospital practice during an
acute exacerbation of a chronic nephritis. The
majority of these cases suffer principally from
oliguria, more or less marked albuminuria, in-
creased blood pressure, and edema, with or without
uremic symptoms.
Chronic nephrosis, or better still, metabolic ne-
phrosis, is a type of chronic kidney lesion to which
most of the cases of so called chronic parenchyma-
tous nephritis belong. These cases can be more
definitely isolated by means of chemical examina-
tions of the blood and by functional tests of the
kidney.
In this type of case the lesion is probably a de-
generation of the cells of the tubules and glomeruli,
or a disturbance in their function, so that they be-
come more permeable to the serum albumin of the
blood, which then filters through into the urine.
The condition may be secondary to a metabolic dis-
turbance, possibly to a disturbance in the metabol-
ism of proteins. Perhaps the evident faulty utili-
zation of proteins is the result of a disturbance in
the activities of those fascinating regulators of
metabolism, the endocrine glands.
The cases that may be placed in this group are
nephritics with marked edema, who pass urine con-
taining large quantities of albumin. They usually
eliminate more fluid than they ingest, and are con-
stantly losing in weight. The phenolsulphone-
phthalein output is fairly normal. Repeated blood
examinations of these cases usually show no reten-
tion of protein waste products, except as a terminal
phenomenon. According to Epstein, the blood of
these patients shows a diminution of the protein
content with a relative increase in the globulins. In
other words, we are dealing with a functionally
nornial kidney whose cells are permeable to al-
bumin.
When we have placed the case in the category to
which it belongs, it is important to attempt to de-
termine the prognosis, so that we may tell the
patient or his familv what his prospects are for an
ultimate cure or improvement. While we cannot
in each individual case oflFer an ironclad prognosis,
we can, however, determine by means of repeated
chemical blood examinations and by careful ob-
servation of the daily urinary output, those cases
in which a fatality is imminent, or those whose
lease on life is very short.
Cases with uremic symptoms shov;ing persistent
low figures of carbon dioxide combining power of
the blood are usually fatal within a few days.
The presence of uremia may be shown by high
figures tor total nonprotein nitrogen, urea, and
creatinine in the blood. The figures may be high
even before actual uremic symptoms occur. High
percentages of these substances in the blood merely
indicate the degree of uremia, although these sub-
stances are not the cause of the condition. I can-
not emphasize too strongly the value of the high
percentages of protein waste products in the blood
as an indication of uremia. It is often surprising to
find very high figures of these waste products in
cases which are not frankly ureinic but which soon
pass into a fatal uremic condition.
A bad prognosis should not be made on one blood
examination alone : but when repeated examinations
of the blood show a total nonprotein nitrogen of
more than too, urea nitrogen of fiftv or more, and
creatinine of five per cent, or more, the prognosis is
usually bad. 1 he higher the figures the sooner does
death ensue. Figures of 200 or more for total non-
protein nitrogen frequently occur before death.
High percenragcs of protein waste products arc
usually associated with a hypocholesterinemia.
1
3i8
BLUMGARTEN: TREATMENT OF NEPHRITIS.
[New York
Medical Journal.
THERAPEUTIC ATTEMPTS ON THE LESION.
Before considerins? the treatment of chronic
nephritis, let us consider the pathology of the dis-
ease in the light of function. The kidney is not an
inanimate filter ; its function is carried on by means
of the living cells which form the glomeruli and
tubules. Whatever the type of pathological change
in the kidney in chronic nephritis, whether the
lesion is a glomerulitis, a diffuse fibrosis, or a
vascular involvement, from the standpoint of func-
tion the essential disturbance in the kidney is the
atrophy of the cells of the glomeruli and degenera-
tion of the tub\iles. Functionally, it is generally
agreed that the water of the urine is eliminated by
the glomeruli, and the salts by the tubules. The
ideal treatment of chronic nephritis would con-
sist of a method to stimulate the regeneration of
the cells of the glomeruli and tubules. At the
present time, however, there is no such direct
method. Yet I am keenly conscious of the hope
held out to us bv the ante bellum studies of Carrel
and others on the growth of cells in vitro. It is
quite probable that such studies of the factors
which govern the growth and regeneration of cells
may ultimately develop a method for the stimula-
tion of atrophic cells and for the formation of new
ones.
In the present state of our knowledge, however,
the only known practical factor that stimulates cell
regeneration, even to a small degree, is an improved
circulation. The only method which produces this
effect on the kidney is the operation for decapsula-
tion of the kidney. Because this method actually
attempts to attack the pathology of chronic nephritis,
I shall depart from the usual custom of discussing
it last, just as the method itself is usually consid-
ered a last resort.
The evidence of Edebohls and numerous subse-
quent observers has shown that decapsulation of
both kidneys in chronic nephritis results in a cure
or marked improvement in about thirty per cent, of
the cases, and a lesser degree of improvement in a
great many others. As a rule the milder cases were
those that showed the most improvement.
In the absence of other more direct methods. I
believe this operation should occupy a prominent
place in our therapeutic armamentarium, in those
cases of chronic nephritis with retention of protein
waste products that have had one or several acute
exacerbations w'hich have been rather resistant to
treatment. We have absolutely no guide to the de-
gree of destruction of kidney tissue in the lesion of
ch'.onic nephritis. 1 am quite conscious of the fact
that Edebohls's operation will not regenerate a dis-
eased kidney : but no harm is done by the operation
apart from the small surgical risk. And a patient
who has had repeated acute exacerbations should
certainly have the benefit of such treatment. A re-
cent report of Morse, of Boston, showing the cure
of a iiuniber of acute cases of nephritis, some of
them almost moribund from uremia, further eni-
phasir.es the value of the method.
My own observation of cases in which the method
was tried has convinced me of the following facts:
I, the efficacy of the method in improving some
late cases of '.-hronic nephritis, which were the only
ones in which I had the opportunity to see the
method used ; 2, the small risk of the operation
even in bad cases of nephritis with uremia. In the
cases thus operated upon the mortality was due to
the progress of the original nephritis, and rarely
was ii the result of surgical interference. Whatever
the theory as to the cause of the improvement,
whether it is the formation of a collateral cir-
culation as promulgated by Edebohls, or the
removal of tension as Harrison explains it, or a
change in the nerve supply as the work of I. Levin
seems to show, the fact remains that there is evi-
dence of improvement, as shown by the records of
the competent observers who have had the courage
to try the operation. Perhaps the improvement is
due to the stimulation of the regenerative kidney
cells as a result of the collateral circulation and
change in nerve supply. I am quite conscious, how-
ever, of our innate reluctance to advise surgical
treatment of what is ordinarily regarded as a
medical disease. Yet as evidence of the favorable
results of the operation accumulates, I believe that
the method will be tried more frequently.
.'vnotlier method for treating chronic nephritis
that has been used on a definitive basis is the treat-
ment of Martin Fisher, of Cincinnati. Fisher be-
lieves that chronic nephritis is caused by toxins
which cause an accumulation of acid products in the
cells of the kidney, with a consequent disturbance
of the kidney function. He believes that many of
the symptoms of nephritis, such as the edema, are
due to a similar condition in all the tissues rather
than the result of the nephritis itself. He, there-
fore, attempts to neutralize the acid condition
throughout the body. Fisher's treatment consists in
allow^ing tl.e patient to drink large quantities of
water, about a glass every hour, preferably an alka-
line water. If an alkaline water is not obtainable,
sodium carbonate or sodium bicarbonate in doses of
0.5 to one gram may be added to each glass.
Sodium tartrate or sodium acetate may also be
given ; or we may use calcium hydroxide by adding
lime water to milk. The diet consists mainly of
vegetables, preferably cooked. Such a diet is rich
in alkalies. Plenty of salt should be given in the
form of salt fish and salt meats.
In severe cases suffering from an acute exacerba-
tion of an old lesion, more vigorous treatment is in-
stituted. In such cases Fisher gives the following
solution, by rectoclysis :
Sodium carbonate, gm. lo.o;
Sodium chloride gm. 14.0;
Distilled water, c. c. looo.o.
This solution makes the blood hypertonic, conse-
quently fluid is withdrawn from the tissues into the
blood, which then becomes hydremic. The exces-
sive fluid is then eliminated by the kidneys and the
elimination of urine is increased. The sodium car-
bonate solution makes the blood more alkaline, so
that the acid condition of the cells of the kidneys
and tissues is neutralized and the kidney function is
improved.
My own experience with this method of treatment
has been quite satisfactory. The best results are
obtained in those cases in which the total urinary
August 24, 1918 ]
BLUMGARTEN: TREATMENT OF NEPHRITIS.
319
output is fairly normal ; in other words, in cases in
which the dominating lesion is a tubular one.
THE TREATMENT OF CHRONIC NEPHRITIS WITHOUT
RETENTION OF PROTEIN WASTE PRODUCTS
IN THE BLOOD.
The cases which may be classified in this group
are those which usually present themselves for
treatment in office practice. A great deal can be
accomplished in these cases in a prophylactic way.
A knowledge of the etiological factors of chronic
nephritis will enable us to eliminate at once those
factors which clinical experience has proven to be
important in the cause of the disease. On this basis,
the elimination of the continued use of alcohol and
other irritants and condiments from the diet should
be advised.
In the treatment of those infectious diseases which
are particularly apt to be followed by chronic ne-
phritis as a complication, the conservation of the
kidneys should be instituted before a kidney lesion
is manifest. This may be accomplished by eliminat-
ing the proteins from the diet, and thorough stimula-
tion of the other excretory channels, such as the
bowels and the skin, throughout the illness. If a
syphilitic basis is found, then the treatment of the
syphilis may improve the nephritis. Although it
is questionable whether overactive antiluetic treat-
ment may not really aggravate the nephritis.
The limitation of meat in the diet, or better still,
the substitution of vegetable for meat food, and the
diminution of the total daily quantity of food in-
gested, will do much to conserve the kidneys of a
man who is entering the terminal years of an active
Hfe.
When the disease is already manifest, the treat-
ment should begin by the determination of the func-
tional capacity of the kidneys, and the presence or
absence of protein waste products in the blood.
Since the kidneys are the main excretory organs
of the body, the most important essential in treat-
ment should consist in putting as little strain upon
those organs as possible. This may be carried out
by limiting the total daily quantity of food ingested,
especially the solids, and by a moderate reduction
of the proteins.
In the cases belonging to this group, repeated
blood examinations show no retention of protein
waste products. The limitation of proteins in the
diet is carried out with the idea of lessening the
formation of protein waste products in the blood,
but as there is no retention of these substances in
this type of case, a rigid limitation of protein in
the diet is unnecessary, and the patient should be
allowed considerable latitude in the choice of his
food, so long as his nutrition is maintained and he
feels well. The presence of albuminuria alone is
no reason for limiting his proteins.
Great care should be taken, however, not to elim-
inate all the proteins from the diet, nor to regulate
the patient's diet to the extent that the patient suf-
fers from starvation or feels uncomfortable. The diet
in these cases should be rather liberal, without at-
tempting to curtail proteins entirely. Meats should
be limited and vegetable proteins should be sub-
stituted. But more attention should be paid to
limiting the quantity of food and maintaining the
nutrition than attempting to limit accurately the
proteins ingested.
Many a patient is treated for chronic nephritis
by gradual reduction of the proteins in the diet, until
he is actually suft'ering from malnutrition, when
excellent results are obtained by suddenly putting
the patient on a full diet. Needless to say, dietetic
treatment does not afifect the underlying pathological
lesion. The diet simply adapts the food to the de-
gree of retention of waste products and to the
eliminative capacity of the kidney. But as the
lesion is a progressive one, the patient should be
observed frequently and repeated examination made
for the evidence of a change in both the degree of
retention and functional capacity of the kidneys.
Changes in the diet should then be made according-
ly, without, however, sacrificing the patient's caloric
needs.
As far as drugs are concerned, I believe they are
of little value. For the oliguria, the administration
of potassium iodide in excessive doses does help
the elimination of urine, and the administration of
diuretics is useful in some cases. The saline diu-
retics, often combined with such rather old fashioned
but useful substances as the infusion of juniper, are
often very valuable. In cases, however, where the
urinary output is persistently low, the glomerular
lesion is probably too extensive to hope for much
favorable reaction to treatment.
A great deal can also be done by attention to the
blood pressure, when the patient suffers from symp-
toms due to excessively high blood pressure. For
the reduction of blood pressure, much better results
can be obtained from the use of saline cathartics
and the limitation of fluid intake than from the use
of vasodilators ; although the nitrites in larger doses
than those usually given are not to be disregarded
entirely.
When the patient's financial condition permits, a
sojourn for the winter in a warm southern climate
may be extremely beneficial.
In cases suffering from secondary myocardial
insufticiency, rest in bed and a course of digitalis are
very valuable. The tincture of digitalis should be
given in large doses up to about 120 minims a day
until the heart is thoroughly digitalized.
THE TREATMENT OF CASES WITH RETENTION OF
PROTEIN WASTE PRODUCTS IN THE BLOOD.
These cases usually come under observation dur-
ing an acute exacerbation suffering from edema,
slight uremic symptoms, or in actual uremia, After
our basic data have been established, the degree of
retention, the severity of the uremia, the urinary
output, its relation to intake, the functional capacity
of the kidney, etc., our first aim should be to attack
the most important symptoms.
The most vital condition in chronic nephritis that
requires treatment is uremia. This is so regularly
associated with marked retention of protein waste
products, although these are not the cause of the
condition, that the retention becomes the most im-
portant symptom to treat. Our first aim should be
to attack this. We can lessen the formation of
protein waste products in the blood by eliminating
from the diet as much of the protein foods as is
commensurate with maintaining caloric needs. We
320
BLUMGARTEN: TREATMENT OF NEPHRITIS.
[New York
Medical Journal.
must, however, be very careful to avoid starvation,
which is perilous in actual uremic cases. Instead of
determining the quantities of protein necessary to
eliminate the waste product retention, by gradual
reduction of the normal diet, it is perhaps better,
when there are no imminent uremic symptoms, to
put a patient on starvation treatment for a few
days. Such a patient should receive nothing but
small quantities of sweetened cofifee or lemonade,
or perhaps a little alcohol to maintain his energy
requirements, until the protein waste products have
been appreciably reduced ; and at the same time
sufficient alkalies must be added to the diet. We
then gradually add carbohydrates and small quanti-
ties of proteins in the form of milk and vegetable
substances.
While the use of accurate diets based upon the
absolute functional capacity of the kidneys, or based
upon the ability to eliminate the various solid con-
stituents of the urine are very valuable, such diets
can only be carried out in exceptionally well regu-
lated institutions. In ordinary practice, however,
such methods are impracticable. Besides, the mar-
gin of safety m the use of diets in chronic nephritis
is so elastic that I do not think it wise to force the
patient to adhere strictly to an accurate diet, which,
for practical reasons, cannot be kept up for a very
long time.
THE TREIATMENT OF EDEMA.
The presence or absence of edema is not as vital
as the degree of retention of protein waste products,
yet the two conditions are often associated with each
other. I believe that most edemas that we see in
chronic nephritis are due to myocardial insufficiency,
rather than to the nephritis, because most of them
occur principally in the lower extremities. The
usual nephritic edema is a general edema ; occurring
over the entire body, the face, chest, abdomen and
the extremities, and is associated with a very
marked pallor. It seems from the general distribu-
tion and the extent of the edema that its cause is not
due to the kidney alone, but is rather a disturbance
in the tissues themselves, giving rise to an accumu-
lation of fluid in them. Experimentally, we can re-
move a large part of both kidneys without produc-
ing edema.
The removal of the edema may be effected by
dietetic and medicinal treatment. The diets gener-
ally used are the Karell and the saltfree diet. The
Karell diet, which consists of four glasses of milk
in twenty-four hours, represents i,ooo c. c. of fluid,
about thirty-two grams of protein instead of the
necessary seventy-five grams for the normal indi-
vidual. Its caloric value is very low, but it com-
bines a low salt content with a low water intake.
Because of its low caloric value, this diet cannot
be maintained very long.
In selected cases this diet works very well, but
we must remember that the result of any method
of treatment will depend upon the amount of func-
tionating kidney tissue that is left, and this may ac-
count for the rather discouraging results in some
cases. Of course, when the urinary output is per-
sistently low, when we may assume that the dom-
inating lesion is in the glomeruli, little is to be ex-
pected from ;my method, because the elimination of
the fluid depends upon the efficiency of the circula-
tion and upon the functional efficiency of the
glomeruli.
The saltfree diet, which was originated by Widal,
is based upon the fact that the edema is due to the
retention of chlorides in the blood and tissues, con-
sequently the fluid remains in the tissues, so as to
keep the salt content of the blood and tissues iso-
tonic. The difficulties in the use of the saltfree diet
are its unpalatability, and the difficulty of obtaining
and preparing foods that are absolutely saltfree.
Personally I have obtained the best results in
the removal of edema by utilizing the physiological
salt and sugar constants of the blood in a thera-
peutic way. These constants in the blood are main-
tained by absorbing fluid from the tissues or by
drinking, when the percentages are higher, and by
eliminating fluid when the percentages are lower,
or when the blood is hydremic. Consequently, I
have used the following modification of Fisher's
solution given by rectoclysis, or in severe cases in-
travenously, with the fluid intake limited at the same
time, although in many cases Hmiting the fluid in-
take alone is sufficient.
Sodium carbonate (crystallized) gm. lo.o;
Sodium chloride gm. 14.0;
Glucose gm. 30.0;
Water, up to 1000.0 c. c.
The theory upon which the use of this method
is based, is that by making the blood hypertonic to
salt and sugar the fluid is absorbed from the tissues,
resulting in a hydremic condition of the blood that
increases the flow of urine, and thus releases the
edema. However, in cases that have a persistently
low urinary output, when we may assume that the
dominating lesion is glomerular, little is to be hoped
from this method; or indeed from any method.
At first sight the use of such a solution seems to
be contrary to the principle involved in the use of
a saltfree diet, but it must be remembered that the
saltfree and Karell diets both limit the quantity of
fluid, which, with the elimination of fluid by the
lungs and bowels, makes the blood and tissues hy-
pertonic, thus acting in a similar way. Further-
more, Fisher believes that the edema is due to the
retention of acid products in the tissues throughout
the body. He has also shown that sodium chloride
neutralizes the acidity, and that the retention of
sodium chlorifle in the tissues (a well established
phenomenon) is perhaps compensatory to the acid
retention in the tissues.
Intravenous injections of glucose in five per cent,
solutions may also be used for the relief of edema,
and are often very valuable. In the few severe
cases in which I have used such solutions, the re-
sults \vere very astounding. The action is probably
due to the production of a hyperglycemia, causing
an absorption of fluid from the tissues, and subse-
(juent diuresis. A similar diuresis may be observed
in the polyuria of diabetes.
The relief of edema by drugs should only be tried
when the usual dietetic and physiological methods
fail. As a diuretic, perhaps digitalis is the best
drug, because it acts indirectly through the heart
and thus serves to relieve the functionating kidney
tissue. Theobromine sodium salicylate, agurin, and
saline diuretics may also be tried, but in cases where
Augufit 24, 191S.]
BLUMGARTEN: TREATMENT OF NEPHRITIS.
3-1
the kidney tissue is inactive, either as the result of
atrophy, toxic degeneration or vascular disturbance,
little is to be expected from these substances.
Coincident with stimulating the secretion of urine,
our efforts should be utilized toward increasing the
elimination of fluids through other channels, such
as the skin, by means of electric baths, by hot packs,
by pilocarpine, and through the bowels, by the ad-
ministration of saline purgatives in sufficient doses
to produce ten or fifteen fluid stools a day. When
a marked result is brought about by these methods,
the retention of protein waste products is also con-
siderably lessened. These methods should be used
vigorously when the urinary output is persistently
low and the protein waste product retention is high.
THE TRE^VTMENT OF UREMI.V.
Uremia, the onset of which is dreaded in any case
of nephritis, is a group of symptoms largely cerebral,
due to the presence in the blood of as yet unknown
toxins. The degree of uremia may be determined
by the degree of total nonprotein nitrogen and urea
in the blood, though these substances are not the
cause of it. In observing a large number of ne-
phritics with uremia, I am struck by the remark-
able infrequency of convulsions, which seems to be
the one expected but rarely met symptom of nephri-
tis, except in the nephritis of eclampsia. This leads
me to believe that perhaps the convulsions are due
to a specific toxin, or to an associated edema of the
brain. I believe edema of the brain is more fre-
quent in nephritis than we suppose. The regularity
of the association of high blood figures with uremia
seems to indicate that the presence of uremic symp-
toms with negative blood figures is probably due to
an edema of the brain rather than to uremia. In
such cases lumbar punctures are often very helpful.
The object in the treatment of uremia should be
to ehminate as much of the toxins as we can, to
stimulate all the other excretory channels as actively
as is possible and to prepare ourselves against acido-
sis by vigorous alkaline treatment.
Frequent venesections with the removal of large
quantities of blood, followed by intravenous injec-
tions of alkaHes, have given brilliant results. After
observing the effects of transfusion in other con-
ditions, I believe repeated venesections followed by
transfusion of the blood from normal individuals
would be an ideal treatment in cases of uremia. I
have tried it in one case with excellent results. At
the same time, free purgation by means of saline
purgatives should be carried out, and colon irriga-
tion given twice a day. It is sometimes surprising,
after a series of disheartening failures, what bril-
liant results may be obtained by active unrelenting
treatment.
ACIDOSIS.
.Acidosis is the condition that ends many a case
of nephritis. It is best to anticipate it in severe
cases of nephritis by vigorous alkaline treatment.
If the condition does occur, intravenous injections
of sodium bicarbonate preceded by venesections
often give surprising results, but usually when the
carbon dioxide combirwng power of the blood is very
low, the case is quite hopeless. In the diet of such
TV.tients one should avoid starvation by limiting the
diet in any way. In fact, dietetic treatment must be
abandoned temporarily and the patient put ui)on a
full diet, as the danger from the proteins is usually
less than that from the acidosis.
THE TREATMENT OF METABOLIC NEPHROSIS.
This condition comprises a group of cases which
are lost in the inaze of chronic nephritis, without
a careful attempt to differentiate them. Clin-
ically, these cases are perhaps types of what is or-
dinarily called chronic parenchymatous nephritis.
It is merely an excretory phenomenon, however, of
either disturbed permeability of the kidney cells,
or possibly a diminished protein destruction as a
result of deficient protein metabolism, or perhaps
a very early stage of chronic nephritis. These cases
frequently follow in the course of diabetes.. If we
substitute protein for sugar and kidney for pancreas
in our conception of diabetes, the picture becomes
a similar syndrome of disturbed protein metabolism.
The characteristic phenomenon is the presence of
a nephritis with a marked edema, with excessive
amounts of albumin in the urine, with usually a
normal output of urine, very often even a greater
output than intai<:e of fluid, normal blood figures and
a normal phenolsulphonephthalein elimination, with
a severe anemia, loss of weight, and other evidences
of malnutrition. Epstein has shown that in these
cases there is a diminished protein content of the
blood and a relative increase in the globulins.
In these cases there is no need to lessen the pro-
tein intake, since there is no retention of protein
waste products. Such patients may be given white
of egg, lean meats, poultry, and other proteins. Per-
sonally I have had good results by the addition of
])lenty of salt and sugar to the diet, especially in
those cases that are eliminating more fluid than they
ingest, since the addition of salt and sugar helps to
retain the fluid in the tissues, while at the same time
it retains the protein and diminishes the albuminu-
ria. After such treatment the edema usually sub-
sides, the patient gains in weight, a more normal
relation between intake and output of fluids is estab-
lished, the albuminuria is diminished and improve-
ment follows.
Medicinally, the use of thyroid extract in large
doses gives good results in some cases, but the exact
underlying disturbance of internal secretion, if in-
deed it be that, is as yet unknown. The occurrence
of the edema in these cases may be explained by the
fact that the protein content of the blood is lessened.
Consequently, a higher percentage of protein in the
blood is established by passing some of the fluid
into the tissues. It is interesting to note that the
edematous fluid in these cases contains a small
amount of protein. The edema may be relieved
by the addition of salt and sugar to the diet, which
increases the percentage of these ingredients in the
blood, thereby withdrawing the fluid from the tis-
sues and reestablishing an isotonic condition of the
blood.
In a recent typical case of chronic nephrosis, with
the presence of albumin and casts in the urine, with
normal blood figures and normal phenolsulphone-
phthalein output, with an output of fluid of 2,000
to 2,800 c. c, and an intake of 1,000 to 1,500 c. c,
with a progressive loss of weight and anemia, the
improvement resulting from a regular diet with the
322
GRAHAM: TWO CASES OF MEASLES.
[New York
Medical Journal.
addition of sail and sugar was quite startling. The
patient gained in weight, the output and intake ratio
were normal, the edema subsided, and the patient
gradually improved.
CONCLUSIONS.
I. I have endeavored to discuss the treatment of
chronic nephritis from the standpoint of functional
patholog}'. Function, however, is always dependent
on structure. There is no way in which we can
determine the amount of functioning tissue of the
kidney, but we can determine in each case the func-
tional capacity of the kidney, its ability to excrete
the various constituents of the urine and whether
the dominant lesion is glomerular or tubular.
In those cases with a persistently low water out-
put, in which the dominant lesion is evidently a glo-
merular one, there is but little to be hoped for from
treatment, for no matter how actively the tubules
may excrete waste products there is no f^uid being
secreted for their solution and retention of waste
products and uremia will result.
, 2. Besides determining the dominant lesion, we
can also dififerentiate the cases without retention
of waste products, and with retention of waste
products, and from these two groups we may ex-
clude the chronic nephroses.
3. I have attempted to show that we should aim
to attack the lesion itself more actively rather than
to adapt the treatment to the inevitable outcome of
the disease.
4. The operation for decapsulation, while it is
by no means a panacea for chronic nephritis, never-
theless is rational and should be tried more often in
earlier cases, and especially in those with repeated
acute exacerbations.
5. In cases without retention of waste products,
more attention should be paid to regulating the gen-
eral regimen of the patient's life than to limiting
the diet or treating him with drugs. The aim of
the diet should be to limit the total quantity of food
ingested, with a very moderate limitation of pro-
teins, if any. It is more important to maintain the
patient's nutrition than to attain a scientific balance
of elimination.
6. In cases with retention of protein waste pro-
ducts it is essential to eliminate this retention as
much as possible. This may be done by dietetic
means, by lessening the protein intake without sacri-
ficing caloric needs. When uremia is absent or not
imminent, the protein tolerance may be attained,
without producing retention of waste products in
the blood, by beginning with starvation and increas-
ing the proteins until tolerance is established.
7. Edema may be best relieved by taking advan-
tage of the physiological constants of the blood by
the use of hypertonic salt and glucose solutions,
though the Karell and salt free diets often give ex-
cellent results. Medicinal methods are of very lim-
ited value, with the exception of digitalis.
8. Uremia should be anticipated by treating the
retention of protein waste products. When it does
occur, venesection and intravenous or rectal use of
alkalies gives best results. Venesection followed
by transfusion should be tried more frequently.
9. Acidosis should be anticipated by the use of
alkalies. When it does occur, more vigorous intra-
venous use of alkalies should be resorted to.
10. Cases of nephrosis should be treated icono-
clastically, by not limiting the proteins and by add-
ing extra amounts of salt and sugar to the diet.
1114 Madison Avenue.
TWO INTERESTING CASES OF
MEASLES.
Bv John Randolph Graham, M. D.,
New York.
Lecturer on Dermatology in Polyclinic Medical School and Hospital;
Diagnostician, Department of Health of the City of New York.
It has imdoubtedly been noted by those inter-
ested in the diagnosis of eruptive diseases that
the percentage of atypical rashes has been un-
usually high this spring. Particularly has this
been true of measles, although scarlet fever has
also presented a large number of very puzzling
cases, as is characteristic of that disease. I be-
lieve, too, from personal observation, that pro-
dromal rashes in measles have been more fre-
quent in proportion to the number of cases seen
than in other years. It makes one suspicious
that measles is preparing to follow in the foot-
steps of scarlet fever, so far as furnishing con-
stant pitfalls for the unwary diagnostician is con-
cerned. I have recently seen two cases which
have deviated so far from the textbook variety
that I feel justified in reporting them:
Case I. — On April i8th, I was called in to see a boy
of four years, whose brother 1 had treated for measles
shortly before. The mother stated that he had not felt
well for two days, but he was bright and showed no evi-
dence of illness so far as his appearance went; no involve-
ment of the eyes, and no coryza or cough. The rectal
temperature, however, was 102° F. and examination of the
buccal mucous membrane revealed numerous Koplik's
spots.
I next saw him on the morning of April 21st, the rash
having first appeared the evening before. At this time,
the little fellow was quite ill, temperature 105° F. (R),well
tnarked bronchitis with a troublesome cough, very much
congested eyes, and he showed no interest whatever in
his surroundings. The throat was hardly as sore as that
usually seen in a severe case. The postcervical glands
were enlarged and the mucous membrane lining the cheeks
was shot with Koplik's spots. The rash was very striking
— the most unusual it has ever been my privilege to see,
in measles. The skin on the face, that behind the ears,
on the trunk and extremities, was literally covered with small
macules ; these were slightly smaller than a split pea, not
noticeably elevated, perfectly round and light pink in color,
resembling very much the shade of pink seen in rubella.
These lesions were clean cut, clearly defined, and closely
set. but white skin showed plainly between the spots. The
writer does not recall having seen such an evenly formed
rash or such clear cut lesions in any skin aifection, and it
certainly developed with remarkable rapidity.
On the morning of April 22nd. the temperature had
risen to 106° F. (R) and all symptoins were intensified, the
patient bemg about as ill as it is possible to be in an un-
complicated case. The exanthem had changed completely
in character. It had become a generalized, confluent ery-
thema, dark red in color, not unlike the skin manifesta-
tion in a well marked case of scarlet fever, and this like-
ness was emphasized by the fact that, in some areas,
darker punctate spots appeared in the place of the small
macules of the day before. In addition to this, the face,
in a poor light, seemed clear, though with better illumi-
iiation the rash w;is easily noted. On the side of the hips
and on the buttocks, little groups of the typical blotchy
maculopapules of measles could be found, but only in
these localities was there to be seen anything bearing re-
August 2^, igis.] GLVCKMAN: ADVANTAGES OF HOME TREATMENT IN TUBERCULOSIS.
3^3
semblance to the classical rash of measles. The patient
remained very ill until the morning of April 25th, when
the temperature fell to normal and recovery followed.
The unusual features in this case are: i, the
rapid development of the rash, which spread
practically over the entire body in about twelve
liours ; 2, the remarkably small, clear cut lesions,
somewhat resembling rubella, and the even for-
mation and distribution of the initial rash ; 3, its
rapid amalgamation into a scarlatiniform type of
eruption. I would like to add that, without ques-
tion, this sort of rash is very often mistaken for
scarlet fever, especially if the case is not seen
during the prodromal period, and if the catarrhal
symptoms and the signs in the mouth are ig-
nored. Such cases get into scarlet fever wards
occasionally and cause trouble. My own feeling
is that mixed infections of scarlet fever and mea-
sles are extremely rare. The fact that desquama-
tion frequently follows in these attacks has been
brought forward to back up the opinion that
scarlet fever had existed alone or with the mea-
sles. It is easy to see, however, that with such
an intense congestion of the skin as the type of
case just described presents, more or less profuse
desquamation can readily ensue ; and measles, at
times, can certainly desquamate most freely.
Cask 11. — The second patient, a boy three years of age,
was seen in one of the hospitals where he had been ad-
mitted April loth for a minor operation. There was no
history of exposure to contagion before admission. The
history stated that the child had developed a rash on
April rSth, which had persisted for two days. When I
saw it on April 20th, it consisted of very red punctate
spots a little larger than those normally seen in scarlet
fever. There was a lighter red erythema involving the
skin between these puncta-. The eruption was confined
to the trunk and extremities and was accentuated in the
groins and flexures. The face had been, and still re-
mained, absolutely clear. The inguinal glands were some-
what enlarged, but nothing unusual was noted about the
glands of the neck. The eyes were clear ; there was no
cough or coryza. On the other hand, while there was no
history of vomiting, and the temperature was irregular,
the throat was congested and showed a uniform redness.
The tongue was also clearing off with the papillae show-
ing. Bearing in mind the possibility of a prodromal rash,
I examined the mouth thoroughly for Koplik spots and
can say positively that there were none there at the time.
Here then was a rash, out for the third day, with the
proper distribution for scarlet fever, and possessing many
of the characteristic points of the scarlet fever eruption.
Besides, there was marked angina and a tongue showing
a disposition to clear. There were no catarrhal symptoms
present, and I felt certain that this was a straight case of
scarlet fever. The diagnosis was concurred in by two
experienced physicians, though it is fair to state that a
third, just as competent, disagreed with us. Less than
forty-eight hours later, this rash had faded out and a
typical eruption of measles had developed, with all the
usual accompanying symptoms and signs, including Kop-
lik's spots.
In this case the following points seem of in-
terest: I, The prolonged existence of a prodro-
mal rash with no facial involvement ; 2, the com-
plete absence of any pathognomonic symptoms
or signs of measles thirty-six hours before the ap-
pearance of a distinctive measles eruption ; 3, the
prodromal rash was scarlatiniform in character.
This I believe to be the type of eruption most
commonly preceding an attack of measles.
202 West Eigiitv-sixth Street.
.VDVANTAGES OF HOME TREATA'lENT IN
TUBERCULOSIS.*
Bv I. Edward Gluckman, M. D.,
New York,
Foniu"!- Suiicrintt'ndcnt. Newark San;itoriuni ; Consulling Physician;
I'-s-^cx C'liunty Tuliiiciilii>i'^ Sanatorium; Consulting Phy-
sician, Antitiibcrciilnsis Association.
I wish to relate in short and condensed form the
experiences I have gained during the last ten years
in the home treatment of tuberculosis. The number
of cases of tuberculosis which fall into my hands
is so large that it will be of interest to the general
practitioner to intjuire into the results obtained in
cases of tuberculosis occurring among the poorer
laboring classes who, for financial reasons, cannot
afford the comforts and luxuries of sanatoria. For
a long time a diagnosis of tuberculosis of the lung
meant nothing less than a trip to California, Colo-
rado, or the Adirondacks, but we have learned dur-
ing the last decade that tuberculosis can be treated
at home and that a victim of the disease need not
be turned away from his family circle, nor segre-
gated as a carrier of the white plague ; that the
victim of tuberculosis can be restored to health and
usefulness ; that he can again become a wage earner
and a welcome member of the family circle under
conditions which are within the reach even of those
who are not endowed with riches.
I consider tuberculosis a curable disease. It is
our first duty to convey to the patient the encourage-
ment which a favorable prognosis can give, but we
can be successful only if the diagnosis of tubercu-
losis of the lungs is made early. In the incipient
stage the disease can be arrested and the patient
restored to health. Patients frequently apply to us
when the disease has advanced considerably, and
the process of destruction has extended to such a
degree that there is hardly any chance for restora-
tion of the tissues. In a large number of cases the
symptoms of incipient tuberculosis are indefinite,
and it is iri these cases that we physicians err. It
is the sin of omission, not commission, that is re-
sponsible for the large number of advanced cases
of tuberculosis. Those of us who study larger
bodies of men where the examinations are compul-
sory, where members of organizations have the op-
portunity to apply for medical examination and ad-
vice without any individual tax, are convinced that
incipient cases of tuberculosis readily escape obser-
vation, and that if we are not on the constant look-
out, if we are not continually trying to disprove the
existence of tuberculosis, many a positive case will
escape attention.
It is not my intention to convey the impression
that the diagnosis of early tuberculosis is to be rele-
gated to the specialist. I am quite sure that every
physician is fully able to arrive at an early diagnosis
if he spends sufficient time and gives sufficient at-
tention to his patients. The physical signs are lack-
ing in the early stages, but the short hacking cough
with or without sputum, slight rise in temperature
in the afternoon, the rapid increase of pulse on
slight exertion, the slight loss of weight, and the
easy fatigue — these are all very suggestive symp-
*Read before the Williamsburtrh Medical Society, January 14, igi8.
324
CLUCKMAX: ADVANTAGES OF HOME TREATMENT IN TUBERCULOSIS. t^-^w York
Medical Journal.
toms. Do not wait for a positive sputum ; it is then
obvious that a detinite breaking down of the lung
tissue lias taken place, and such cases can hardly
be considered incipient, in this group the early
incipient stage has been overlooked. Our conclu-
sion as to the causative factor of the change in the
condition of the patient, if the physical examination
is definite, can be fortified by x ray examinations
and serological tests. X ray examination by plater,
or fluoroscope has been of the greatest help and
should not be omitted in any case where the physical
examination is not conclusive. In experienced
hands the x ray examination afliords undeniable
findings.
During the last two years, the examination of the
blood of tuberculosis patients was of decided diag-
no.^tic help. According to the results obtained by
Zinsser and Miller and corroborated by many re-
liable investigators, the complement fixation will
soon occupy the same position with respect to tuber-
culosis as the Wasserman test does to syphilis. The
test is found positive in cases of active tuberculosis,
in other words, specific antibodies are found in the
sera of patients who are actively diseased, and as
it is these cases of active tuberculosis that chiefly
concern us, such supporting evidence from the lab-
oratory is unquestionably of great value. Brawfen-
brenner has recently published a series of cases of
much interest. Doctor Lowy and myself are now
working along the same lines, and we hope shortly
to publish the results.
I have dwelt on the diagnosis of tuberculosis
because successful treatment depends on early
diagnosis.
In my trade union antituberculosis work, I have
collected the data concerning 284 patients, all of
whom had tubercle bacilli in their sputum. Of
these, 208 were treated at home, and 76 at the
sanatorium. Of those treated at home 149 are alive
and well, or 71.4 per cent.; of those treated at the
sanatorium, 51.3 per cent, are well and working.
It is my opinion that home treatment of tuber-
culosis is not dangerous to the family or to the com-
munity when it is conducted under intelligent medi-
cal supervision. I believe that ninety-nine per cent,
of all infections occur before the physician gets con-
trol over the cases, and that when the diagnosis is
made and the patient cautioned, there are few who
will not use ordinary precautions to safeguard those
living with them.
In considering home treatment of tuberculosis. I
do not include the acute miliary type, the symptoms
of which are very acute, the sputum containing
numerous tubercule bacilli. This type is of course
a potent source of infection and is often mistaken
for an ordinary pneumonia. The subacute type of
the disease may be ushered in with acute symp-
toms, but these gradually lessen and continue as in
a chronic, or chronic ulcerative type ; these are the
tyjjes met in every dav practice, and .for months
they infect those in contact with them until they
come under the supervision of a physician.
In my work in the Trade Union Antituberculosis
Association, I have made it a practice to examine
all children in the family where a case of tubercu-
losis occurs. I apply the Von Pirquet test imme-
diately. Those children who gave a negative reac-
tion, continued to be negative for three or four
months after the patient carried out the home treat-
ment (118 children— sixty-seven positive, fifty-one
negative).
In order to bring out clearly the advantages and
the disadvantages of home treatment versus sana-
torium treatment, we shall have to go somewhat
into detail, as to what constitutes good home treat-
ment. The term home treatment means, not only
medication, but also proper supervision of the en-
tire liousehold. On visiting a patient there are
many things to be taken into consideration : the
surroundings, financial status, character of food,
sleeping facilities, and the general home conditions.
The first things to be considered in the home treat-
ment of tuberculosis are sleeping facilities and
willingness to ol)ey orders. 1 have made it a prac-
tice to i>ick out the largest, airiest and sunniest
room that is available. This is at once stripped
of everything except a small table, a chair, and the
bed, which is placed facing the window, not along
'^ide of it. The next step to be taken up in detail
with the housekeeper, mother, wife, or person who
will care for the patient, is the character, quantity
and caloric value of the food.
I aways endeavor to have the ])atient sleep in an
enclosed porch ; I have also made use of protected
roofs with excellent results. Linens should be
rhanged frequently and boiled ; if they are soiled
l)v excretions, thev should be changed daily. All
excreta are burned and containers boiled for at
least twenty minutes. Sputum cups of paper are
the only ones to be used. The room should be
dusted with a damp rag daily, windows should be
open at least eighteen hours out of twenty-four,
and sunlight admitted.
Medical treatment is a secondary consideration.
Children should not be allowed to see patients,
more than once or twice a day, and then only for a
few minutes ; embraces and kisses on the mouth
shoTild not be permitted.
Patients having a temperature above 100°,
with sweats, rapid pulse, and profuse expectoration
will respond only to one method of treatment,
absolute rest in bed. Bleeding cases belong to the
same group. Such patients must be strictly con-
fined to bed, must not get out of bed under any
pretext ; a bedpan should be used, and all exertion
by the patient avoided.
I have made it a practice to put all patients to
bed at the beginning of the treatment until I have
determined to which type they belong, and two
weeks is the shorte.st period I have kept them in
bed. Fever cases are kept in bed just as long as
the temperature goes above 90° F., even for months
if necessary. As the fever decreases the cough,
expectoration, sweats, dyspnea, and rapidity of the
pulse will diminish. When these symptoms are
gradually reduced, and the range of temperature
becomes normal, T permit them to get up, beginning
with half an hour the first day, and then increasing
every three or four days, by half hours, meanwhile
watching the temperature and pulse very closely
and gauging the amount of exertion the patient
may be able to stand without causing the return of
August 24, 1918.] GLUCKMAN: ADVANTAGES OF HOME TREATMENT IN TUBERCULOSIS.
325
acute symptoms. If ho has reached tlie stage where
he may be up practically all day without causing
any appreciable rise of temperature and pulse, then
he is allowed to walk gradually ; first around the
house, afterwards in the open, for increasing
periods of time. After I find the patient is able to
walk two or three hours without causing any un-
due symptoms, he is made to walk up hill very
slowly.
Now, we have him in such condition that we
may take up the consideration of some kind of
work for him. I do not approve of taking patients
away from their usual occupations, and putting
them at other work which would involve the use of
new muscles and new training, unless easy outdoor
work can be found. I think that the patient will
spend less energy and do better at the work to
v/hich he is accustomed, if he is careful to Hmit
the amount of work undertaken. It does not seem
fair or just to prevent a man from supporting his
family as soon as a diagnosis of tuberculosis is
made. If tiiis man is careful he is not a source of
danger and should be allowed to work with other
men. My experience has been that the men with
whom he is working will very soon report the case
if he is careless or unsanitary in his habits.
The foregoing, constitutes my opinion of what
home treatment must consist to be ef¥ective.
I am not a believer in the tuberculin treatment in
pulmonary tuberculosis. Statistics have proved
that tuberculosis cannot be cured in less than four
to eight years. It is impossible for patients among
the poorer classes to give so much of their time to
the search for health, and except for the well to do,
sanatorium treatment is out of the question. Many
of the free and semiprivate sanatoriums of today
limit their terms of residence to six months or one
year. It is well known that most cases of tubercu-
losis cannot be cured in that perio^. The result is
that the patient goes back to the same conditions he
left, believing the disease is completely arrested,
and consequently, puts aside all precautions.
Therefore, after he has been home six or eight
months the lung condition becomes active again,
and the patient is as badly ofi as he was in the
beginning. I am not condemning sanatoriums, as
T am aware they do much good, especially from the
educational point of view ; but I am absolutely
opposed to the theory that all patients must go to
a sanatorium.
Home and living conditions differ with each pa-
tient, and it should be the duty of every medical
man to inform his patients as to the proper mode of
living, and the care he should take in preparing him-
self for the trying conditions of life which the
modern struggle for existence renders necessary.
Formerly, we considered climate the prime requisite
for treatment of tuberculosis of the lung; we now
know that climate is not a specific for the disease.
We have lost sight of the fact that ninety per cent,
of our tuberculous patients are financially barred
from going to a sanatorium, and of this ninety per
cent, only about eight to ten per cent, can go to the
so called free sanatoriums established by municipali-
ties and charity organizations. Even if these in-
stitutions were all that advocates claim for them.
we should still have the vast majority of cases on
our hands, and these would require some intelligent
supervision at home.
It is the opinion of many that some antitubercu-
losis association should take up the establishment
of tuberculosis pay clinics in large centres, to be
operated for the benefit of the middle class suffer-
ers from this disease who present the most difficult
cases for the antituberculosis worker. Such a clinic
has already been established in Boston, at the Bos-
ton Dispensary, and also in other cities.
When wage earners whose salaries range from
S18 to $25 per week become afflicted with tuber-
culosis they are reluctant to go to charitable institu-
tions for free treatment, while, on the other hand,
they are unable to pay for maintenance in a private
sanatorium. There are a number of institutions
charging $7, $10, and $15 per week, such as the
Adirondack Cottage Sanatorium, the Loomis Sana-
torium, the Agnes Memorial Sanatorium, and the
Stonywood Sanatorium for Women. These semi-
private, semicharitable institutions are, however,
compelled to solicit funds in order to make up the
difference between the small amount paid by the pa-
tient and the cost of maintenance.
Poor patients having no resources at all are not
loathe to go to a dispensary and receive free treat-
ment, but the patient who is earning a moderate
salary, and who, in some cases, especially in the
beginning, can afford to pay a small fee to the
physician, is under the impression he is lowering his
selfrespect if he applies to a charitable institution
for free treatment. But he would not hesitate to
go to a pay dispensary, charging a fee within the
limit of his means. There is no doubt that a tuber-
culosis pay clinic for middle class patients, where
ambulant cases could be examined at regular inter-
vals, and salaried nurses provided to pay frequent
visits to the homes, would be most desirable. In
such an institution much good work for the tuber-
culous patient and his friends could be accomplished
through educational propaganda against the disease,
by giving courses of lectures, the aims being pre-
ventive, curative, and consulting work. Such an
institution could be made a general information bu-
reau on tuberculosis, open to all citizens.
I am sure that if such service were rightly or-
ganized, it would provoke little or no opposition
from medical men, and if such institutions were
established by public spirited men and physicians,
they would most undoubtedly have far reaching re-
sults.
In Newark, N. J., there are about 8,000 cases of
tuberculosis with sanatorium facilities for only 120.
Is it not ridiculous to consider sanatorium treatment
for the 7,880? At present I am very glad to say
that through the efforts of my association and my-
self, the county will build a hospital of 1,000 beds
for these patients.
Comparison made by Pratt of the results obtained
in sanatorium and in home treatment in his tubercu-
losis work in Boston with results obtained by two
English sanatoriums and the Massachusetts State
Sanatorium, shows the following: Fifty-two per
cent, of the patients discharged from the English
sanatoria were alive and well, four to eight years
326
yjN ALSTVNE: PROTEIN TREATMENT OF PSORIASL^;.
[New York
Medical Journal.
afterward. The report shows twenty-four per cent,
of the former patients of the Massachusetts State
Sanatorium were leading normal lives four to seven
years after discharge. Pratt in his report on home
treatment shows that sixty per cent, of patients who
had home treatment are alive and working after
four to eight years. By no means do I oppose sana-
torium treatment ; but I am considering the best in-
terests of the average patient and the community.
\\'hen one compares the great number of cases of
tuberculosis and the exceedingly limited sanatorium
facilities, it is apparent that the problem to solve is
the treatment applicable to all cases and the protec-
tion of the healthy.
I cannot too strongly emphasize that in the case
of this disease the most important consideration
should be given to the prevention of infection in
children.
Phthisiophobia or the hysterical fear of tubercu-
losis is very often fostered by the Board of Health
nurses with the result that the entire family are in
fear of contagion and the patient is shunned as
though he were a pest. The duty of the nurse or
doctor should be to enlighten the family and patient
as to the chances of infection, thereby relieving their
minds of a great amount of worry.
I have dwelt on the importance of early diagnosis,
giving the results of my experience. I have en-
deavored to point out that home treatment is the
only means of adequately and intelligently dealing
with the vast majority of cases of tuberculosis ; that
this treatment is not a menace to the community
since the preventive measures necessary can be car-
ried out in most homes, and that it is as fully effec-
tive as sanatorium treatment in bringing about a
cure. Here I would reiterate that I do not wish to
be taken as opposed to sanatorium treatment ; but I
have tried to demonstrate the fact that sanatoria
can only take care of a very limited number of
cases.
My experience forced on me the opinion that the
prime requisites for intelligent treatment of tuber-
culosis consist of the trinity, fresh air, rest (mental
and physical), and proper food with a minimum of
medication.
6i6 Madison Avenue.
THE PROTEIN TREATMENT OF
PSORIASIS.*
By Eleanor Van Ness Van Alstyne,
Ph. D., M. D.,
New York.
A preliminary paper has already been published
about this method, but the results have continued
to be so favorable that it may be of interest to
summarize the conclusions which it has been pos-
sible to make during the last few months. The
treatment of psoriasis has always been an interest-
ing and baffling problem to the dermatologist. The
comparative ease with which early lesions can, at
times, be controlled temporarily, together with the
almost invariable redevelopment of the lesions at a
* Read Ijefore the Women's Medical Society at the New Y'ork
Academy of Medicine, March, 1918.
Inter date, stimulate feelings of alternate hope and
despair in both the physician and the patient.
Psoriasis has sometimes been classed by dermatol-
ogists as a disease of the healthy, and "once a
psoriatic always a psoriatic" has become almost a
proverb in this department of medicine. It indi-
cates in a striking fashion the limitations of the
therapeutic methods now in use. For the most part
psoriasis has been treated by empirical methods
which are based on clinical experience, but it has
been impossible to outline a method of treatment
both logical and effective because of the limitations
of our knowledge of the pathogenesis of the disease.
There has been considerable dispute as to whether
psoriasis is to be considered an expression in the
skin of a constitutional condition or whether the
lesions are caused by a local infecting organism.
The most careful search has failed to demonstrate
any organism having a causal relation to the disease,
but on the other hand in recent years studies in
metabolism have demonstrated a quite remarkable
and fundamental metabolic fault in the organism.
The deranged metabolism is a constant and most
important factor in the disease, and the writer's
method of treatment has a direct relationship to this
disturbance.
The investigations of Shamberg, Raizias ( i), and
associates have demonstrated that during the period
of the attack there is a marked retention of nitrogen
even on a low protein diet. In the severe cases they
found the nitrogen in the irrine elimination de-
pressed to the lowest level on record in normal or
pathological conditions. Of course during the
period of active scaling much more nitrogen is lost
through the skin than is ordinarily the case, but
even if all losses of nitrogen through scaling, urine,
and feces are taken into consideration, there is still
a retention even on a low protein intake that is be-
yond anything observed in other conditions. The
reinarkable facility with which the body can nor-
mally adjust itself to different nitrogen levels in-
dicates that this is a metabolic fault of no small
significance. These investigators further found that
m both eczema and psoriasis there is no increase in
the nonprotein nitrogen in the blood ; so that there
rnust ht' a true tissue retention in which it is quite
possible that the skin takes part. The skin shows
itself particularly sensitive to the presence of
foreign proteins and it not infrequently happens
that the introduction of a considerable dose of
foreign protein parenterally, such for instance as a
large dose of tetanus antitoxin, mav cause a marked
inflammatory reaction in the skin, followed by scal-
ing. Such reactions have been observed frequently
following the introduction of other proteins than
serum proteins. In so called serum sickness, there
are at times remarkable skin manifestations varying
from hyperemias and erythemas to efiflorescences
resembling measles or scarlatina. Of course not all
patients subjected to protein administration show
ihese reactions. Many of thcin do, however, and
it may not be illogical to suppo.-e that if through a
metabolic fault in the organism, imperfectly assimi-
lated nitrogen is retained in considerable quantities,
as has been shown to be the case during an attack
of p.soriasis, this protein may give rise to the
I
August 24, 1918.]
FAN ALSTYNE: PROTEIN TREATMENT OF PSORI.ISIS.
chronic inflammation and scaling noted in the dis-
ease, and we have then a chronic protein poisoning
rather than the acute protein poisoning noted in
serum sickness.
If an excess of imperfectly metabolized protein is
an important factor in the etiological production of
the symptoms of the disease, it is logical to suppose
that a low protein diet should be of some service in
relieving the condition, in that it would require the
organism to deal with a much smaller amount of the
food element than it was incapable of properly
handling. As a matter of fact, such observations
have been made for many years, and Bulkeley (2)
long ago pointed out the value of such a diet in thii
condition, basing his conclusion entirely upon clini-
cal observation. Without having exact analytical
evidence that there was a protein retention, Bul-
keley nevertheless concluded that psoriasis was, at
least in part, due to protein poisoning and put his
cases upon a strictly vegetarian diet. He found
that as a result of observing more than 200 cases
for more than twenty years on a vegetarian diet, he
was able to state that in effectiveness it far exceeded
anything which had been previously secured by the
be.st treatment at the hands often of the best men
in the profession. These conclusions have not been
'.miversally confirmed but it is quite possible that
some of the failures haAe been due to an imperfect
regulation of the diet and to its continuance over
too short a period of time.
Shamberg and his coworkers cite one case of
eczema as showing a marked nitrogen retention
somewhat similar to psoriasis, and it was in this
case that the low protein diet exerted a beneficial
effect which, as they state, was gradual and pro-
gressive.
It would appear logical, therefore, to attack this
problem not only l)y reducing the quantity of food
nrotein which is difficult for the organism to prop-
erly handle, but also by trying to educate the cells to
deal effectively with the amounts which must be
handled. Walker has found that the administration
of thyroid extract produces favorable effects in
vhese patients and it is quite possible that this is due
to the well known stimulation to nitrogen meta-
bolism which this gland extract produces. It is
indeed quite possible that the nitrogen retention
which the psoriasis patient exhibits has its origin
primarily in a deranged activity of the endocrine
[:lands.
The method of treatment in which the writer has
been interested is based upon attempts to correct the
metabolic fault by stimulating the organism to deal
with protein by the repeated hypodermic injection
of small doses of a foreign protein. While a single
injection of a foreign protein in a large dose, as has
been stated above, often produces a severe cutane-
ous reaction, the repeated injection of graded doses
over short intervals of time gradually trains it to
deal with larger doses without producing any severe
disturbance. The parenteral introduction of a
foreign protein stimulates the production of
enzymes capable of splitting the particular antigen
in much the same way as the digestive enzymes,
pepsin and trypsin, do. Not only does the organism
respond to a fullv formed native protein but the '
work of Abderhalden has shown how effective this
resi)onse is toward even the protein fragments,
peptones, and polypeptids. Formerly all the em-
phasis on this question has l)orne on the specific
(|uality of this res])onse and there is no question
that reactions may be devised which show in vitro a
high degree of specificity but in the living organism
nonspecific reactions are quite as important. The
specificity in all biological reactions has quite domi-
nated the field until up to the last three years.
There is now, however, a growing understanding
of the fact that when a foreign protein is injected
into the body, a variety of responses is elicited
other than those which we have been accustomed to
measure in the test tube. To such a degree has this
development proceeded that Davis in his paper on
Vaccine Therapy, published a year ago (3), states
that "the nonspecific effect of vaccines is just now
I)robablv the most important problem that concerns
the vaccinationist" and "at the present moment the
facts woulfl seem to indicate that the nonspecific
substances referred to are able to do almost every-
thing that specific vaccines have done in the cure
of disease. In other words, the curative effects of
vaccines reported heretofore may be explained by
the action of nonspecific substances in the vaccine
leather than by its specific factors."
Briefly what t!ie writer has attempted to do is to
whip up or stimulate the metabolic process dealing
with retained nitrogen by using a foreign protein
as a vaccine. The success obtained in the treat-
ment of the disease bv this method affords some
confirmation of the theory at its foundation.
Proteins have been injected before as therapeutic
agents in the treatment of psoriasis. Based upon
this premise a number of workers have used auto-
serum injections in this disease. The results were
sufficiently encouraging to cause favorable reports.
As a moans, however, of stimulating the organism
an autoserum is not to be classed as an alien protein.
More in line with the writer's work is Perry's use
of horse serum (4) as a therapeutic agent. These
workers were using serums in the belief that the
serum itself possessed some curative property aside
from its protein content.
About a year ago Ijiginan and McGarry (5) re-
ported some success in psoriasis with typhoid vac-
cine given intravenously, and Scully has continued
that inethod in conjunction with applications of
chrysorobin ointment to the lesions. The use of
typhoid vaccine intravenously in this condition has
been used to produce a severe reaction, accompanied
by fever, in the belief that the reaction and hy-
perpyrexia are the essential elements in the bene-
ficial effects. These men give a small jiumber of in-
jections only and expect immediate results following
the severe reactions. There is no gradual, long con-
tinued process of educating the tissues to deal with
foreign protein and the permanency of the results
by that method is thus far open to serious doubt,
l^ngman and McGarry note that in their most
favorable cases relapse occurred in a week to ten
days. There is no question that typhoid vaccine
given intravenously is a foreign protein. It has,
however, extremely toxic properties for the human
organism and is not a suitable protein to be used
over a continued period of reeducation. Its injec-
tion is followed by severe general reaction, accom-
328
K/iiV ALSTYNE: PROTEIN TREATMENT OF PSORIASIS.
[New Vobk
Medical Journal.
panieH by chill, fever, headache, vomiting, and occa-
sionally a collapse, so that it is not a method which
can be used outside of the hospital nor for any con-
siderable period of time. Scully (6) observes that
it was not considered advisable to use typhoid vac-
FiG. I. — Case i. Psoriasis of eighteen years' standing.
cine on a patient who did not remain under ob-
servation for the peri(;d foUowmg its administration.
When one considers the severity of the reaction
there can be no question as to the wisdom of that
conclusion.
Unless it can be demonstrated that this severe re-
action is essential, which Scully, Engman. and
McGarry report, and which is similar in all respects
to that observed by Miller in his treatment of
arthritis by the same method, there can scarcely be
any justification for producing it. The protein se-
lected by the writer for this pur])ose has none of the
di.sadvantages inherent in animal serums or bacterial
vaccines. It causes no disturbing general ef¥ect nor
local reaction. It is not necessary for the patient to
be in the hospital during the period of treatment nor
to have his usual activities in any way interfered
with, and since the therapeutic results are better
than any that have been described following the in-
jection of the ty])hoid vaccine, it does not seem to be
in any way necessary to produce such an unpleasant
disturbance in order to benefit the patient.
The protein selected for this purpose is prepared
from millet and alfalfa seed according to the method
outlined by Beeljc. This protein has already been
administered to many patients so that its reactions
and doses are well known. Tlic method of prepa-
ration was described in detail in the first paper pub-
lished on this matter (7), but it is essentially an acid
hvdrolysis of the protein to a point where the solu-
tion niDy be sterilized by heat without causing
coagulation. It has all the advantages of being
&tal)le, sterile, and readily standardized and agrees
in every respect with the conditions described by
Davis for such a therapeutic agent. Davis states
that "in case it is shown conclusively that for thera-
peutic purposes any foreign protein may serve, the
logical preparation for use would seem to be a
sterile chemical preparation of some proteose which
can be carefully standardized." The method of
preparing these proteins was devised before Davis's
paper was published but the preparation agrees in
every respect with his outlined conclusions.
In the treatment of psoriasis with this protein,
the remedy is given by hypodermic injection, sub-
cutaneously in the arm, in gradually increasing
doses, beginning with a dose of six to eight minims
of a two per cent, solution and increasing gradually
up to twenty or thirty minims. The injections are at
first given three times weekly. As previously stated,
they in no way cause any disturbance to the patient
nor do they interfere in any way with his ordinary
activities. Improvement is a slow and gradual one
and the treatment must be continued over a consid-
erable period of time. In from ten days to six
weeks, that is, after five to fifteen injections, there
will, in most cases, be observed a diminution of the
ervthema about the scaly patches, followed by fall-
ing of the scales. This beneficial change continues
J'JG. 2. — Case i. Showitig condition after six months' treatment
gradually and slowly, tmtil finally the scaly patches
are entirely cleared up and there is left a ])igmented
area which itself gradually fades and leaves a clean,
healthy, pink skin.
The changes which take place during the inijirove-
August 24, 1918.]
VAN ALSTYNE: PROTEIN TREATMENT OF PSORIASIS.
329
ment in the case of psoriasis under this treatment
arc slow and gradual and this point must be remem-
bered. There is no dramatic cessation of the whole
difficulty within a few days. During the last few
months this method has been applied to some cases
Fig. 3. — Case 2. Psoriasis of two years' standing.
of psoriasis that have resisted all forms of treat-
ment heretofore employed. There are cases in
which the whole body has been covered with the
lesions and the condition has been a chronic one, in
that the process was always active without the re-
missions which are observed in the less serious
degrees of the disturbance. In these cases the im-
provement has been decided and definite not only as
regards the skin lesion itself but with respect to the
general health of the patient; but the improvem.ent
has been slower to manifest itself than in patients
who have had a smaller area of the skin involved
and in whom in all respects the disease had a much
milder form. The mild early cases respond
promptly, the long standing severe cases more
slowly, but in each case the first sign of improve-
ment is a diminution in the inflammatory reaction
of the skin and a diminution in the formation of
scales.
The treatment has thus far been employed on
fifteen cases for a sufficiently long time to make it
possible to say that very satisfactory effects are ob-
tained by means of it, but obviously no final con-
ohi.sions as to the permanent curative value can as
yet be made. The two cases pictured in the first
report were of a severe form and in one patient the
disease had lasted for a period of eighteen years.
These cases wore under treatment altogether for a
period of about six months and they have now
been without treatment for the sime length of time
without any recurrence of the disease.* This is of
interest in contrast to the findings of Engman and
McGarry who found that the intravenous injections
of typhoid vaccine produced temporary relief but
that even in the best cases there was a relapse after
a period of a week to ten days. In contrast to the
typhoid vaccine the protein used by the writer is of
such a character that the injections may be carried
on throughout this long period without any disturb-
ance to the patient and the continuous stimulus to
the formation of proteolytic enzymes which is thus
afforded is apparently a much more favorable factor
in the relief of the disorder.
It is of interest to note in this connection that
none of the cases of psoriasis seen by the writer can
b\' any means be classed as being in good health and
the generally accepted dictum that psoriasis causes
no impairment to the general health is difficult to
understand. It is furthermore of interest to observe
that progressive improvement with final complete
relief has been obtained in some cases that have con-
FiG. 4.— Case 2. Showing condition after five months' treatment.
tinned throughout the period of treatment on a high
protein diet. The organism has apparently been
educated to deal effectively even with the larger
' The two cases pictured were the first cases treated. The older
patient ha? shown a few scaly recurrences since this paper was
read. She has lived in most unhygienic conditions during the
unusually severe winter. The recurrences are yielding rapidly to
renewed injections.
330
CORNWALL: Sr.lMSfl LXFLUEXZA.— KXOPF : TFUDEAU MFA10RL4L. CNe^' Vork
Medical Journal.
quantities of jjrotcin which the patients have been
taking. In none of the cases has there been a re-
striction to a low protein vegetarian diet. In the
course of five or six years it will be possible to de-
termine how permanent the results are as obtained
by this method and its place in the treatment of the
disea.se may have a final decision. Nevertheless, the
favorable effects obtained thus far seem to indicate
that it is possible to aiYord great relief to these
patients I)y this method and these clinical observa-
tions taken in conjunction with the known errors in
metaljolism wliich such patients show make it seem
probable that a reeducation in the metabolism of
nitrogen has been elTected.
17 East Tiitrty-eigiith Street.
references.
I. SrH\.MBERr, and Razias: Journal of Cutaneous Diseases, vol.
XXXV, No. i. 191- ; iliid.. Journal of Cutaneous Diseases, Xoveniber.
1013; ibiii., Journal A. M. A., vol. Ixiii, p. 729, 1914. 2. Bulke-
ley: Diet nnd Hygiene in Diseases of the Skin, 1913, Paul B.
Hoeber, N. Y.; ibid., Journal A. M. A., August 26, 191 1. 3.
Davis: Journal A. H. A., vol. Ixviii, p. i5i, 1917. 4. Perry: Boston
Medical and Surgical Journal, 1916, 174, p. 274. 5. Engeman and
McGasry: Jo'irnal A. M. A., 1916, p. 1741. 6. Scully: Journal
A. M. A., vol. Ixix, p. i6?4. November 17, 1917. 7. Quoted in first
paper, New York Medical Record, September 29, 191 7.
„ - SPANISH INFLUENZA.
Cases of Jnftuciisa and Pneumonia Taken Off SS.
"Bergensfjord," Arrived in Nezv York, August
12, 1918, from Nori<.'ay.
By Edward E. Cornwall, D.,
Brooklyn, N. Y.
From the Norwegian liner, Bergensfjord, which
arrived in New York with a story of having had
more than two hundred cases of sickness resembling
influenza or pneumonia during the voyage, with
four deaths, eleven sick passengers were trans-
-f«4ed immediately, or very soon after arrival, to
the Norwegian Hospital, in Brooklyn. Four of
these patients entered the hospital with histories,
symptoms, and physical signs which suggested in-
fluenza, and seven of them with histories, symptoms,
and physical signs which suggested pneumonia com-
plicating influenza. One of the patients, who en-
tered the hospital with a temperature of nearly io6°
F., and signs of pulmonary edema, died two hours
after admission. Another, who had signs of con-
solidation involving nearly the entire right lung,
.showed increasing dyspnea and progressive weak-
ening of the heart, and died on the third day after
admission. A third, with consolidation involving
the right upper and left lower lobes, died on the
third day after admission. At the present time,
August 19, 1 91 8, all the remaining cases are either
frankly convalescent or are progressing favorably.
One of the patients who entered the hospital with
a diagnosis of influenza, gave the following history :
Five days- before admission he had a moderate chill,
and felt chilly for two days after. He also felt very
weak, had a poor appetite, and sulYered from a
frontal headache. He did not go to bed until one
day before admission, when he felt too weak to
keep up. Shortly after going to bed he had another
moderate chill. This patient states that ten years
ago, when in the United States, he had an attack
of sickness with symptoms almost exactly the same
as those of the present attack, except that the head-
ache was not so much frontal as lateral.
In all these patients a leucocytosis was found and
an increase in the percentage of ix)lymorphonu-
clears. The leucocytosis in the four cases which
were diagnosed as uncomplicated influenza was re-
.^ijectively, 14,500, 11,600, 10,050, and 14,500; and in
six patients with pneumonia, it was respectively,
16.400. 10,200, 35,600 (died), 21,200, 27,500, and
10.600 (died). The percentage of polymorphonu-
clears ranged between eighty-two and eighty-five
in most cases, but in one patient who died it was
ninety-one.
Cultures were taken from the throats of all. ex-
cept from the patient who died two hours after
admission, and also cultures of the blood; and the
sputum was examined in one case. The report of
the examination of the cultures and sputum, by Dr.
Esmonde B. Smith, is as follows : Throat cultures
made on Loeffler's blood serum show chiefly staphy-
lococci. Two of the cultures show many minute
colonies of a biscuit shaped diplococcus. Blood
cultures from the two most severe cases showed no
growth after thirty-six hours. Sputum : But one
specimen could be obtained, as there was little ex-
pectoration in spite of considerable cough. This
specimen [which was from a patient with signs of
jmeumonia and a clinical history stiggesting a previ-
ous influenza] showed white, frothy mucus, slightly
tinged with blood. It contained streptococci, diplo-
cocci resembling those obtained from the throat cul-
tures, and clumps of organisms morphologically
like Bacillus influenzje.
The prevalence of influenza in Europe at the
present time, "Spanish" influenza, is the excuse
for reporting these few apparently ordinary cases.
1218 Pacific Street.
THE STATUE OF EDWARD LIVINGSTONE
TRUDEAU.
B\' S. Adolphus Knopf, M. D.,
New York,
A distinguished company of physicians, friends,
and former patients of Dr. Edward L. Trudeau
gathered in the grounds of the Trudeau Sanatorium,
Saranac Lake, N. Y., on .\ugust loth, to witness the
unveiling of a memorial statue of the noted physi-
cian. In this life size bronze the sculptor, Gutzon
Borgluni, has succeeded in reproducing in a marvel-
ous manner the spiritual expression so characteristic
of the great teacher.
The statue is the gift of 1,200 of Doctor
Trudeau's former patients, and the formal presenta-
tion to the institution was made by one of these
•(■alients, Miss Louise £. Bonney, now a high school
teacher in New York.
Dr. Walter B. James, of New York, president
of the board of trustees of the Trudeau Sanatorium,
opened the ceremonies with a feeling tribute to
the founder of the great institution as the pioneer
of the sanatorium movement in the United States,
as a scientist and a great humanitarian who, like
Saint Theresa, started out to build hospitals with
nothing but faith in God and man. He stated that
no less than a hundred former patients of the sana-
torium are now in the military service of the L^nited
August 24, 1918.]
KNOPF: TRl'DEAV MEMORIAL.
3.V
States lighting for democracy and liberty for all
nations. There could hardly be a better proof than
this of the curability of tuberculosis.
Re\ . Philemon 1* . Sturges, rector of (]racc
Church. Providence, R. I., a former patient and life
long friend of Doctor Trudeau, delivered the ora-
tion. Doctor James said there was so much of the
spiritual and religious in Doctor Trudeau's life that
the ISoard of Trustees felt that a teacher of relig-
ion rather than a medical man should have this
honor. Reverend Mr. Sturges in an eloquent and
touching address traced Doctor Trudeau's career
fro'ii his arrival in the .\dirondacks as a seemingly
hopeless invalid to his death after forty years of con-
tinned and most successful Inbor among tuberculous
invalids. 1 !e described the gradual growth of the in-
stitution from a little cottage accommodating two pa-
tients to the great sanitorium of the present day with
its infirmary, library, laboratories, and post graduate
school. The statue was then unveiled by Francis B.
Ttudeau, now a captain in the Medical Reserve
Coips and the only surviving son of Doctor Trudeau.
The exercises concluded with the ]>lacing of
wreaths on the monument by a group of nurses in
uniform and a benediction by Rev. \V. B. Lusk, rec-
tor of St. Stephen's Church, Ridgefield, Coim.
The following lines express the thoughts sug-
gested by the contemplation of the spiritual but
somewhat saddened face of the great Trudeau so
accurately reproduced :
Statue of I'Muard l.ivingstouf i ruiU-au lt\ Ciutzon Burgluin at Saraiiac.
EDWARD LIVIXGSTONE TRUDEAU.
A youth he came into the wilderness
Where few before him cared to seek a home.
Weak, in broken health, he found this place
And called sweet nature here to be his nurse.
And she was kind tho ofttimes stern indeed.
Health, strength, and courage came again to him.
The mountain air, the sun, the balsam's balm,
All helped him to be strong; a man again.
What did he with this glorious gift of health?
Did he enjoy it merely for himself?
His first thought was to share what he had found
With those afflicted just as he had been.
Who had abandoned hope of being well.
Who needed courage to renew the strife.
A modest cottage his first mountain home ;
But soon another at its side was built.
Good men and women saw the glorious work.
They caine to help him who was helping them.
Thus cottage after cottage rose where once
Was naught but wilderness of hill and wood.
And thousands came to find new health and life.
To this great love for men unfortunate
He added wisdom, science, common sense ;
His fame as teacher spread o'er all the world
And millions blessed through his disciples' deeds.
He bore his sorrows as few mortals could.
Serene and hopeful to the last sad end.
His faith in God and man showed through each thought
And blessed were those who could be near to hitn.
I well remember when I saw him last.
This noble man, beloved teacher, friend.
Though ill once more and then not free from pain.
Still no complaint escaped from those Tirave lips.
He spoke of science and the common good.
Discussed the modern ways of cure, and his
Last words to me expressed a hopeful prayer
That care may be bestowed upon more poor
Than he had yet found means to shelter here.
Rest thou in peace, brave soul, thy poor want not.
Like this fair place that bears thy natne, they are
Provided for in days that are to come.
Thou art not gone, thy deeds and spirit live.
This monuinent may crumble into dust,
But what thou didst and what taught to the world
That must endure. Such men as thou die not.
Med icine and Surgery in the Army and Navy
THE HOSPITAL SHIP "MERCY."*
A brief description with remarks on the application
of the Hague Conventions to hospital
ships in general.
By Medical Director Norman J. Blackwood,
U. S. Navy, Commanding.
In 1868 an attempt was made to apply the prin-
ciples of the Geneva Convention of 1864 to naval
warfare. The Hague Peace Conference of 1906
agreed upon a new Geneva Convention for land
warfare, and the Conference of 1907 found it neces-
sary to revise the Convention of 1899 in order to
apply its principles to naval warfare. The German
delegation presented a draft which was taken as the
basis of the deliberation of the Conference. The
first three articles of convention X of the 1907 Con-
ference are exactly like those articles of convention
III of the 1899 Conference. Article I applies to mili-
tary hospital ships, and reads as follows : "Military
hospital ships, that is to say, ships constructed or
adapted by states specially and solely with the view
of aiding the wounded sick and shipwrecked, the
names of which have been communicated to the
belligerent powers at the commencement or dur-
ing the course of hostilities, and in any case before
they are employed, shall be respected, and cannot
be captured while hostilities last. These ships,
moreover, are not on the same footing as warships
as regards their stay in a neutral port."
x\rticle 4 is the same in both conventions and
reads as follows :
The ships mentioned in articles, i, 2, and 3 shall afford
relief and assistance to the wounded, sick, and shipwrecked
of the belligerents without distinction of nationality. The
governments undertake not to use these ships for any
military purpose.
Such vessels must in nowise hamper the movements of
the combatants.
During and after an engagement they will act at their
own risk and peril.
The belligerents shall have the right to control and
search them ; they may decline their assistance, order them
ofY, make them take a certain course, and put a commis-
sioner on board ; they may even detain them, if the gravity
of the circumstances require it.
As far as possible the belligerents shall enter in the log
book of the hospital ships the orders which they give them.
Article 5. Military hospital ships shall be distinguished
by being painted white outside with a horizontal band of
green about a metre and a half in breadth. The boats of
the ships above mentioned, as also small craft which may
be used for hospital work, shall be distinguished by similar
painting.
All hospital ships shall make themselves known by hoist-
ing, with their national flag, the white flag with a red cross
provided by the Geneva Convention, and, further, if they
belong to a neutral State, by flying at the mainmast the
national flag of the belligerent under whose control they
are placed.
Hospital ships which under the terms of Article 4 are
detained by the enemy must haul down the national flag
of the belligerent to whom they belong.
The ships and boats above mentioned which wish to in-
sure by night the freedom from interference to which
they are entitled must, subject to the assent of the bellig-
erent they are accompanying, take the necessary measures
to render their special painting sufficiently plain.
•Published by authority of the Secretary of the Navy.
-Article 6. The distinguishing signs referred to in Arti-
cle 5 can only be used, whether in time of peace or war,
for protecting or indicating the ships therein mentioned.
********
Article 8. The protection to which hospital ships and
sick bays of vessels are entitled ceases if they are made use
of to commit acts harmful to the enemy. The fact of the
staft of the said ships and sick bays being armed for main-
taining order and for defending the wounded and sick,
and the presence of wireless telegraphy apparatus on board,
are not sufficient for withdrawing protection.
********
Article 18. The provisions of the present Convention do
not apply except between Contracting Powers, and only if
all the belligerents are parties to the Convention.
Austria-PIungary, Great Britain, Italy, France,
Turkey and twenty-one other nations have all rati-
fied the 1899 Convention, but Germany, Great
Britain, Turkey and the United States, signed with
reservation of Article 10. It was subsequently
agreed, on an understanding reached by the Gov-
ernment of the Netherlands, with the Signatory
Powers, to exclude Article 10 from all ratifications
of the Convention.
The Convention of 1907 was ratified by Austria-
Hungary, France, Germany, United States and
twenty-two others, whereas Great Britian and Italy
have signed the Convention but have not yet (1915)
ratified.
The above quoted articles are the only ones
which refer directly to hospital ships and their
method of treatment and distinguishing marks. It
will therefore be seen that the character of the
officers and crews has not been a matter of ques-
tion, each government simply guaranteeing that the
ships shall be used only for their designated pur-
pose, the good faith of the nation standing as
guarantee for the honesty of the ship, the Geneva
flag flown at the main assuring protection to all
aboard. But if any belligerent doubts the good
faith of his enemy, he has a perfect right to stop
and search any hospital ship, and so ascertain that
all is as it should be.
The simplicity of the articles, the lack of elabor-
ate details in specifications, is a perfect indication
that the nations entering into this Convention felt
assured that all that would be necessary would be
to indicate definitely that a certain vessel was a
hospital ship, to have her granted complete im-
munity from attack, and that no nation would
knowingly jeopardize its wounded and sick, by using
hospital ships for any but their legitimate purposes.
The United States navy has now three hospital
ships in full commission : the Solace, the Mercy and
the Comfort. The first of these was placed in
commission in 1909, fully fitted as a hospital ship,
and since that date she has been doing continuous
duty with the North .A.tlantic Fleet. She. like the
other two, was originally built as a merchant ship
and had to be converted throughout in order to
make her serviceable as a hospital ship.
To make a thoroughly satisfactory hospital ship,
she must be built from the keel up, and such a
liospital ship is now in process of construction, but
August 24, 1918.]
MEDICINE AND SURGERY JN THE ARMY AND NAVY.
333
her ultimate completion has been delayed by the
onset ot war which necessitated the stoppage of
work on her in order to build more essential fight-
ing craft for the immediate requirements of the
wai. Taking into consideration the fact that these
ships are converted merchant ships, they accomplish
their purpose remarkably well, and will serve for
many years to take care of the sick of the navy
afloat and to be the foundation upon which plans
for future hospital ships will be built up.
The Mercy and Comfort were respectively the
Saratoga and Havana of the Ward Line. They
are ships of about 10,000 tons displacement, and,
therefore, about twice the size of the Solace.
commanding officer of the Mercy in his work of
fitting out these two new ships, and every sugges-
tion that could be gained from other sources was
carefully weighed, and when practicable and ad-
visable, was adopted. Inasmuch as the Mercy and
Comfort are sister ships, and as similar equipment
was placed on each ship, a description of one will
serve for both, their dififerences being only in mirror
details.
This ship is capable of carrying over 300 patients
in all departments without expansion, and if neces-
sity arose, space could be utilized to carry for a
brief period, such as the transatlantic trip, from one
to tw^o hundred additional patients. There are 312
The U. S. S. Mercy, our first completely equipped hospital ship, which is now in active service. Her sister ship the Comfort is
about to be placed in commission. The Mercy is under the command of Dr. Norman J. Blackwood. Both ships will serve our Navy
and are among the most completely equipped vessels of their kind in the world.
While the arrangement and equipment of the Solace
were as near perfect as could be made at the time
she was converted, and new. and more modern
equipment has been added from time to time, yet
these two new ships, being converted nine years
later and being so much more capacious have
turned out far more serviceable hospital ships and
are equipped in many respects in greater detail and
with greater facilities for the handhng of the sick
and wounded.
The knowledge and experience gained while in
command of the Solace were utilized by the present
bunks for the sick, and provision is made for ex-
pansions, by the placing of cots and Gosso beds in
the unoccupied spaces. The ship is divided into two
main departments, that having to do with the ship
itself and that having to do with the hospital proper ;
the latter is the one of most interest to the medical
profession and is, therefore, the one which will be
dwelt on in this article.
Every department found in a well equipped hos-
pital ashore is represented in the ship and the wards
are divided into surgical, medical, genitourinary,
eye, ear, nose, and throat, contagious, and convales-
MliDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
cent. Each department is presided over by a
speciaHst with an assistant, all of whom arc officers
of the regular or reserve force of the navy. P>e-
sides these medical officers, there are a rontgenolo-
gist, a laboratorian, a dentist, three pharmacists,
The operating room of the Mercy corresponds in size to the
solarium. It is forward of the ship and on the upper deck. ItfS
equipment, complete to tlie minutest detail, was donated by the Colo-
nial Dames of America.
eight chief pharmacist's mates, and ii i trained male
nurses.
The operating suite is a model in all respects and
has within it the main operating room with two
tables — one of the orthopedic type — instrument
cabinets, sterile dressings drums, a pantostat, solu-
tion bowls and every appliance necessary to a per-
fect operating room. There is a large sterilizing
room with all of the equipment found in the most
modern hospitals ashore, a scrub-up room, an anes-
thetic room, an instrument room, and a smaller pus
operating room. This suite is all done in white
enamel and white tiles and the furniture is the
latest equipment for operating suites. It is con-
nected with the surgical ward of fifty-four beds,
which is situated on the deck below, by an elevator
with capacity for at least two wheeeled stretchers.
The medical ward for acute medical cases con-
tains thirty-six bunks and is likewise fitted with all
appliances for the care of medical cases.
The genitourinary and convalescent ward com-
bined contains 134 bunks and has a s])ecial operating
room with tabic and all appliances for cystoscopic
work.
The contagious suite consists of five wards and a
disinfecting room and contains forty-four bunks,
with the possibility of expansion on the open decks
under canvas. These wards are chiefly on the upper
decks where there is free circulation of lieht and
air and are in every wav attractive and serviceable
for the care of the sick and iniured. Where wards
are situated below decks, and have not the ndv-in-
tagc of natural ventilation, artificial ventilation is
provided. Tn addition to these wards, on the after
end of the promenade deck is built a large, light and
airy solarium in which fifty to too patients mav ob-
tain relaxation and the benefits of air and sunlight
--^t all times, nrotected from the weather, or where,
t nder the circumstance of large numbers of con-
tagious cases being suddenly thrown on the ship,
these cases could be segregated and taken care of.
Under normal conditions this solarium is used for
the care of tubercular cases. This is an addition,
the necessity for which was learned from experience
on the Solace, where the overflow of contagious
cases had to be taken care of under canvas on the
open decks and where there was otherwise no place
for the convalescents to enjoy the open air and
sunlight. This solarium, being protected from the
weather, is available at all times.
The eye, ear, nose, and throat ward, situated
below decks and in a quiet part of the ship, contains
twenty-eight bunks and is in close proximity to the
operating and examining room of that department
and easily takes care of the cases which come under
the ophthalmologist.
Each ward is provided with a pantry where all
diets are served and mess gear cared for, and the
surgical ward has in addition a surgical dressing
room where dressings are changed and minor
operations may be performed.
.\ large central diet kitchen provided with all
modern electric appliances for preparation of special
diets is situated near the centre of the ship and
within easy access to the pantries of the wards.
The x ray room, presided over by a specialist in
rontgenology, is equipped with all of the latest im-
]jrovements in that specialty, including modern table
and tubes, stereoscopic view holders, high fre-
(juency machine, and everything for the most min-
ute x ray examination and development of plates.
There is a good sized laboratory, presided over
Ijy a special laboratorian, where all of the laboratory
))roceedings can be carried out in relation to micro-
scopical examinations, serum and culture tests,
blood and stomach contents examinations, and at-
tached to the laboratory is a modern animal house
The whole section of the upper deck aft is enclosed and cffi-
cially termed the snlariutii. Here the slightly wounded and con-
valescent spend their leisure hours.
containing rabbits, guineapigs, fowl, and sheep for
the various uses required of them in laboratory
technic.
There is a dental office, presided over by an of-
ficer of the Dental Corps of the Navy, thoroughly
e(|ui])pcd with all appliances, not only for the ordi-
-August J4, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
335
nary but for the special work connected with that
profession, and also with the means of performing
operations in modern oral surgery.
In addition to the equipment for the purely medi-
cal and surgical care of ])atients, the ship is amply
A section of the large surgical wards. The photograph shows
particularly well the clever utilization of bunk space in the ward.
provided with refrigerating and ice making ma-
chines and a cold storage plant capable of carrying
foods for a period of six months for at least 600
people.
One of the most important and latest inventions
to aid in the feeding of the sick has been installed,
a machine which is popularly known as the me-
chanical cow. This machine is probably one of the
most valuable additions to any hospital ship afloat,
for by it, with the aid of milk powder and unsalted
l)Utter, can be produced in the course of about an
Transfer of a wounded man from a tug to the upper deck of the
Mercy by means of the form fitting Stokes stretcher.
hour, fifteen gallons of the most delicious, pasteur-
ized milk containing any degree of butter fat that
may be desired. The problem of furnishing milk
to the sick when away from communities having
dairies, and milk of known purity and proper nu-
tritive value, has been completely solved by the in-
troduction of this machine, and inasmuch as the
ship's cold storage ])lant is capable of carrying, in
addition to other food stuffs, a six months' supply
of the ingredients with which to make this milk,
there is no visible danger of the patients ever being
deprived of this most necessary article of diet.
Besides the things already mentioned, there is
a large sterilizing plant for disinfecting bedding and
clothing: there are sterilizers in all of the pantries
for sterilizing mess gear ; there is an autopsy roam
complete in its equi]Mnent. and a morgue with a ca-
pacity of eighteen caskets, the temperature of which
may be kept as low as desired to preserve bodies
which have already been embalmed and prepared
for shipment. The ship also has a complete modern
electric laundry, which can care for all the linen.
For the benefit of the medical stafif, a large medical
library is provided, containing most of the standard
and many of the newest works in medical litera-
ture, and the weekly and monthly periodicals.
The method of handling patients aboard a hos-
Medical Director N. .1. Blackwood, U. S. Navy.
pital ship, while similar in many respects to that
in a hospital ashore, has some features of special
interest. The so called Stokes stretcher is now in
general u.se in the United States Navy, and con-
sists of a long wire mesh basket reinforced with
iron rods and shaped something like the casing of
a mummy. Patients are strapped into this stretcher
aboard the ship from which they come and they
can then be handled in any w^v desired, without
danger, either by hand or by means of block and
tackle. \\'hen leaving their ship they can either
be lowered over the side or carried down the gang-
way and placed in a bo.'it. The hospital ship is
]n-ovided with two large commodious ambulance
l)oats of the gasoline motor type, capable of holding
about sixteen stretchers, which make trips about
the fleet and gather up the patients. They are then
brought alongside the hospital ship and if the
weather is smooth they are carried up the broad
gangways and distributed to the different wards,
f the weather is rough, the boat Hes off, clear of
336
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Mkdical Journal.
the ship's side, and the stretcher is picked up by
a tackle lowered from a special davit, and hooked
into a bridle attached to the stretcher, and so
hoisted to the l)oat deck.
The happiness and amusement of the patients is
also looked after in every way that that could pos-
sibly be suggested. A large circulating library of
several hundred volumes of fiction, history, and
travel is provided ; most of the current literature is
subscribed to in numbers sufficient to accommodate
everybody ; the daily papers, through the kindness
of some of the large New York and Providence
journals, are supplied and there is a nightly exhibi-
tion of moving ])ictuies, the films bemg generously
REEDUCATION OF DISABLED SOLDIERS
AT l.iOMBAY.
By Douglas C. McMukirie,
New York,
Director, Red Cross Institute for Crippled and Disabled Men;
President, Federation o: Associations for Cripples.
Since the outbreak of the war, it has come to be
regarded as sound national policy to train disabled
soldiers for special trades which they can follow in
spite of their handicap rather than leave them to a
future of idleness, dependent for support upon pen-
sion alone. The enlightened provision by the state
of such "reeducation," as it is called, was earlv
CripjiitJ iiidian soldiers intent upon their work at the Harrison knitting machine making socks and stockings, neckties, vests, caps
mufflers, etc., at Queen Mary's School, Bombay, India.
provided by the Y. M. C. A. A pianola and a
number of victrolas aie placed in dififerent parts of
the ship and quartets and choral societies are organ-
ized together with a volunteer band which will fur-
nish music on demand. Comfort kits have been
provided by the Red Cross and sewing kits by in-
dividual donations, while the Ainerican Chocolate
Fund has supplied the ship with chocolate.
Nothing that could be thought of to while away
the hours of tedious convalescence has been omitted,
and the mothers and fathers, sisters, brothers, and
wives of those who are fighting in this war can
be well assured that their loved ones, when stricken
down by wounds or disease, will have every care
and every comfort that medical science and friendly
hands can administer.
made by the European belligerents. The British
colonies have, one by one, followed suit, and all of
them now offer training for the crippled soldiers of
their own forces.
.A.t Bombay, India, is one of the most picturesque
schools in the world. It is known as Queen Mary's
Technical School for Disabled Indian Soldiers, and
was founded about a year ago through the efforts of
Lady Willingdon. wife of the Governor of Bombay.
Soldiers of the Indian Army, of all ranks and
classes, who have been disabled in action or pen-
sioned for any reason as unfit for military service,
are offered a course of instruction six months or
longer in duration.
The building itself, formerly Braganza Hail, is at.
Byculla, and was generously placed at the disposal.
August 24, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
337
of the commivtee, rent gratis, by the executors of the
late Sir Jacob Sassoon, Bart. It is splendidly ap-
pointed with sitting rooms, dormitories, and work-
shops accommodating 200 men, and is snrtounded
by beautiful giiruens where the pupils take their ex-
ercise or spend pleasint hours conversing or read-
ing. Spacious verandas aflord them ample space
for gaiTies and amusements. In the well ventilated
dormitories, each man has beside his bed, his own
"lock up," in which he keeps his personal belongings.
Everything that the disabled man needs is supplied
at Queen Mary s School. He is provided with
clothes, bedding, and food during his entire training
period ; he is given a return railway ticket and trav-
ehng expenses if he comes from a distance, and
very often, after he has
completed his course, he
is supplied free with a
set of tools for his trade.
Each man is permitted
the choice of the trade
that he wishes to pursue.
On a large poultry
farm disabled soldiers
are taught by an expert
instructor all. branches of
modern poultry raising.
The poultry houses are
stocked with prize fowls,
among them Minorca,
White Leghorns, and
other species. Breeding
by means of incubators
is one of the branches
taught. The school's
spacious grounds offer
ready opportunities for
teaching the elements of
agriculture. Lectures
and personal instruction
in the most modern scien-
tific principles of the cul-
tivation of grain, fruits,
vegetables, etc., are given
by experienced men.
Besides poultry farming and agriculture, classes
have been started in tailori;ig, motor car driving and
motor mechanics, knitting, carpentering, cinema op-
erating, oil engine driving, fitting and turning, and
elementary engineering. A machine shop is being
constructed with the following machinery for in-
structional purposes : metal lathes, wood lathes,
drills, nut making and bolt making machines, brass
foundry, tin box making plant, copying lathes for
making handles of every description, dovetailing
machine for making ammunition boxes, electric mo-
tors, etc.
The committee in charge of the training uses the
following general plan for the placement of trained
men : in Bombay and other industrial centres, in
workshops and factories ; as tailors in regiments,
and in the army clothing department ; as chauffeurs
in the mechanical tiansport service; as turners, fit-
ters, machlnenien, engine drivers, and ammunition
boxmakers in the government dockyard, ordnance
factories, and arsenals.
There are at the present lime about 200 men in
the school. A nuniL/er have received diplomas for
oil engnie drivmg, motor car driving, and other
trades, and employment has been secured for them
at salaries rangmg from twenty to 100 rupees a
month ($6.40 to $32). The value of such a sum of
money must be estim.ated on the basis that the aver-
age man in the school can live easily on twenty ru-
pees or $640 a month. Upon completion of his
coarse, he is likely to receive a small sum from the
sale of some piece of work that he has made during
his training period. The disabled man's pension
continues, of course, regardless of his salary.
Artificial limbs are provided for cripples at one
of the hospitals in Bombay, while in hospitals at
Dehra, Dun, and Musso-
orie, electrical and mas-
sage treatments are
given for disabled men.
In addition to the em-
ployment department of
the Queen Mary's Tech-
nical School, there have
been formed at the vari-
ous centres in India
bureaus that take care
of the problem of plac-
ing disabled men in suit-
able employment.
The school is under
the patronage of the
King and Queen of Eng-
land, and is maintained
by a monthly subscrip-
tion from the Women's
Branch of the Bombay
Presidency War and Re-
lief Fund, by substantial
donations from the
Western India Turf
Club, and the Bombay
Presidency Branch of
the Imperial Indian Re-
lief Fund.
Science finds a way. This Indian soldier uses a prosthetic
appliance instead of a left arm, and goes about his work as deftly
as an ablehodied mechanic. [Queen Mary's School, Bombay, India.]
Reconstruction Work in the Army. — The Di-
vision of Reconstruction of the Medical Department
of the United States Army has recently issued a re-
port covering 537 cases sent to five general army
hospitals from overseas and from base hospitals in
this country. Of these patients, 151 are now able
to return to full duty and 212 to partial duty. One
hundred and twenty-two will be able to return to
their former occupations despite their injuries.
Only thirty-nine will be unable to resume their for-
mer occupations. Many of these patients were
suffering from more than one injury or disease
which accounts for apparent discrepancies in the
following statistics : 530 patients suffered from
medical diseases, seven had been gassed, and 292
suffered from some surgical disease. While the
total number of patients was 537, the number
of disabilities was 1,034. Fourteen general mil-
itary hospitals have been designated by the
Surgeon General for the work of physical recon-
s1 ruction.
33S
MEDICINE AND SURGERY IN IHE ARMY AND NAVY.
[New York
Medical Journal.
MEDICAL NEWS FROM W ASHINGTON.
Coming At>pomtments in the Medical Corps. — Health Con-
ditions in the Nai'al Service. — Organizatioti of the Vol-
unteer Medical Service. — Health Conditions in th^ Army.
Washington, D. C, August 19, 191S.
Notwithstanding the fact that it is about nine
weeks before Major General WiUiani C. Gorgas,
Surgeon General of the Army, reaches the retiring
age of sixty-four years and goes on the retired list,
speculation as to the identity of his successor con-
tinues. Additional advices from France, where
Brigadier General Merritte W. Ireland, Nation-
al Army (colonel, medical corps, regular army),
is serving as chief surgeon on the staff of
General Pershing, indicate the practically unani-
mous desire of the medical people of the service
there to have him appointed to the place. More-
over, it develops now that medical officers in this
country, particularly those belonging to the regular
corps, are almost to a man in accord with this wish.
In the meantime, there has not been much specu-
lation as to who will be appointed to fill the other
medical places of high rank authorized by the last
army appropriation bill — namely, one assistant sur-
geon general with the rank of major general and
two with the rank of brigadier general, to be ap-
pointed from the regular medical corps, and two
major generals and four brigadier generals, to be
appointed from among the members of the medical
reserve corps.
*****
Plans for the organization of the volunteer med-
ical service, as prepared by the medical section of
the Council of National Defense, have been ap-
proved by the President, who has expressed his
deep appreciation of the services rendered by the
medical profession during the present emergency,
and who states that the mobilization of many forces
of the country will contain no case of readier re-
sponse or better service than that which the physi-
cians have rendered.
The volunteer force will have among its members
physicians that have not been commissioned in the
army or navy. They will aid the government in sup-
plying the war needs of the several localities where
they reside. It is proposed that they shall be given
proper credit for the services rendered, whether in
the army, navy, public health service, or civilian
service.
.\ campaign is being launched by the Council of
National Defense for enrolling doctors in the Vol-
unteer Medical Sei-vice Corps, as many members of
tlie medical profession not already in the service are
anxious to be enrolled as volunteers before the regis-
tration under the new draft law, taking men up to
j.nd including the ngc of forty-five years goes into
e^Tect.
*!}:***
The ])resent health condition in the army, both
at home and overseas, has never been surpassed, so
far as known. For the week ending July 26th, the
combined reports of the expeditionary forces in
France, and of troops stationed in the United States,
show an annual death rate from disease of 1.9 per
T.ooo, less than two men per t.ooo per year. The
annual death rate from disease of men of military
age in civil life is 6.7 per 1,000.
This new rate is based on an approximate strength
of 2,500,000 men, and it includes men living under
abnormal conditions. The overseas record was
made while American soldiers were participating
in the heavy fighting in the Marne salient, when
they frequently were comf>elled to sleep and eat
under most primitive conditions.
That this record is truly representative of the
general health of the troops is shown by the com-
bined reports that indicate the figure of 2.8 per
1,000 as the average death rate for disease during
the past two months.
An idea of the progress made in military sanita-
tion is gained by a comparison with the following:
During the Mexican War, the annual death rate
from disease was 100 per 1,000. During the Civil
War, the rate in 1862 was forty per 1,000, while in
1863 it jumped to sixty per 1,000. The disease
death rate for the Spanish-American War was
twenty-five per 1,000. As far as available records
show, the lowest figure heretofore recorded was
twenty per i ,000 during the Russo-Japanese War.
*****
According to the latest reports received by the
Surgeon General of the Navy, the health conditions
of the naval service continue to be most satisfactory.
The death rate for all causes at the latest compilation
was 2.7 per 1,000 per annum; for disease 1.7. Ad-
missions for all causes were 432 p>er 1,000 per an-
num, as against a normal peace time rate of 650.
Reports of contagious diseases include eight cases of
cerebrospinal fever, five of diphtheria, twenty-one
of measles, twelve of pneumonia, three of scarlet
fever, fourteen of malaria, and one of typhoid, the
patient, a recruit who was taken ill within eight days
after his enlistment.
While this is a very favorable season of the year
in so far as the respiratory diseases are concerned,
it is the time when the menace from intestinal and
insect borne diseases is the greatest. Intestinal dis-
eases are practically absent from the navy, and the
reports for malaria, forty-seven cases in the entire
service, are very gratifying, considering the large
number of the personnel in the West Indies and
other localities where there is likelihood of expo-
sure. The low sickness rate for all causes is con-
sidered remarkable, in view of the wide distribution
of the forces and the trying conditions under which
tliey are serving.
There were four cases of cerebrospinal fever re-
ported, widely scattered, no two being at any one
station, three cases of scarlet fever, three of
(li])htliern. and seventeen of pneumonia. Despite
the prevplence of diphtheria in many of the Eastern
cities, it has gained no foothold at any naval train-
ing camp. As a result of investigations, courses of
treatment arc being adopted by which, during the
])resent favorable weather, the mortality attendant
u{)on ])neumonia has been cut to such a proportion
that makes it insignificant. The first idea of the
commission is to nrevent inception and spread of the
disease, a result it accomplishes bv means of quar-
antine and isolation in part and for the rest by
means of prophylaxis. If in spite oi these efforts
empyema aT)pen.rs. the surgeons treat it by operation
for drainage of the lung abscesses that form.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. dh M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
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Cable Address, Medjour, New York.
NEW YORK, SATURDAY, AUGUST 24, 1918
THE "SPANISH" INFLUENZA.
The epidemic, which has been given the name of
Spanish influenza and which seems to have spread
over a considerable portion of the European con-
tinent, has made its appearance among the pas-
sengers on transatlantic steamers arriving in New
"York. These patients began to arrive some six
weeks or two months ago and the Health Officer
of the Port has kept in close touch with the situa-
tion. Some of the cases which attracted the most
attention occurred on the Norwegian liner Bcrgens-
ijord, which arrived in New York after having had
more than 200 cases of sickness and four deaths
dtiring the voyage. Eleven sick passengers were
transferred immediately to the Norwegian hospital,
in Brooklyn, and we print, in another column, the
clinical history of these cases as observed by Dr.
Edward E. Cornwall in whose service they were
placed.
The history of these cases, including as it does
the blood count and bacteriological studies, indicates
that these particular cases, at least, did not differ
materially from the classical influenza already well
known in this country. We also publish a letter
from Dr. F"ernandez Ybarra, who has recently re-
turned from a nine months' stay in Spain where he
had an opportttnity to observe the epidemic in
Madrid. Doctor Ybarra agrees that the disease
does not differ materially from the grippe or epi-
demic bronchitis and is of the opinion that its spread
in Spain was due to the unhygienic conditions found
in that country where little attention seems to be
paid to the ordinarv rtiles of hygiene.
LEGAL INTEREST AWAKENED TOWARD
THE FEEBLEMINDED.
It is most gratifying to catch the same strong
note from the legal world, which has been sound-
ing for a good while among psychiatrists. In
Mental Defectives and the Lazv} Francis D. Gal-
latin, a member of the New York Bar, presents
a concise and vigorously stated report of a study
made in preparation of a larger rejx)rt to the
Committee of Criminal Courts and Procedure of
the New York Cottnty Lawyers' Association.
The atithor of this pamphlet attributes to the
persistence of psychiatrical interest, aided by
certain devoted psychologists and teachers, the
final overcoming of prejudice against this sub-
ject, which until recently prevailed rather exten-
sively among members of the legal profession.
He bases his conclusions and confirms his own
convictions upon psychiatric experience and
study, largely that made public in Doctor Glueck's
article noted in our editorial pages, June 22, 1918.
It is the feebleminded to which Mr. Gallatin
devotes his discussion. They constitute a pecu-
liar class under the law, and as stich have had
no adequate provision made for their treatment
as criminals and their relation to society in re-
gard to crime and misdemeanor. Partictilarly
are those of a higher grade of intelligence the
ones who need such attention. These have suf-
ficient intelligence to permit them a certain inde-
pendent freedom and also responsibility, as well
as greater choice of opportunity for asocial be-
havior than the more pronounced feebleminded,
who obviously come under greater restraint and
sufifer greater individual limitation. For a mem-
ber of the former class, however, in spite of spe-
cial classes in schools and in spite of certain char-
itable aids established for him, the state has
sadly fallen short in providing permanently and
' Distributed by New York Committee on Feeblemindedness and
the Committee on Mental Hygiene of the State Charities Aid Asso-
ciation.
340
EDITORIAL ARTICLES.
[New York
Medical Journal.
tluis keeping him from being a menace to himself
and still more to society.
In these cases it is not a question of criminal
responsibility. Technically and actually these
individuals are as a rule to be accounted respon-
sible for the commission of their criminal acts.
And such being the case, the law under present
conditions must commit them to penal institu-
tions regardless of the ultimate social and indi-
vidual eflFtct. The result has been made very
apparent through the psychiatric reports to
which reference is made. It is seen in the large
proportion of defectives among recidivists, which
is as startling and significant as the large propor-
tion of feebleminded among all criminals.
The feebleminded are different from the psy-
chopathic or the insane, and therefore their prob-
lem for legal consideration is one by itself. They
are children in mind whatever they may be in
body, and should be accorded the same consider-
ation which the law gives to children, dealing
with them from the reformative and educational
rather than the penal side. In this sense of re-
tarded development, while tliey may have legally
complete knowledge of their criminal acts, they
are still irresponsible for their general asocial at-
titude and inability to make good socially and
refrain from repetition of crime. They drift too
easily into vagrancy, into ill conditions of life,
into vicious environment and influences.
Extracts from the laws enacted in other states
and in England give some idea of the trend of
thought and action toward a remedy of the con-
dition of the feebleminded through legal chan-
nels. This would provide for the alteration of
the sentence otherwise imposed and substitution
for it of committal, for life if necessary, to an in-
dustrial and reformatory institution which will
provide proper care and restraint and at
the same time develop latent constructive
puv/ers. These powers may be limited, but under
proper control they will make of the unfortunate in-
dividual a productive member of society
rather than one actively disorderly and de-
structive if at large, or a disturbing element
within the prison. There he is being prepared
for repetition of crime, if submitted to a limited
term of imprisonment, for the feebleminded can
least easily submit to prison life without moral
deterioration.
There is a brief presentation of legislation in
various states legalizing sterilization, but this is
shown to be a very inadequate and unfair method
of handling the subject of feeblemindedness.
There is as yet no thoroughly established prece-
dent for such laws, and they are as a rule not
put into effect. It is strongly advocated, how-
ever, that there should be established "psycho-
pathic clinics in connection with the criminal
courts and penal institutions, and legislation
should be enacted for the segregation and deten-
tion or proper supervision of delinquents discov-
ered to be defective."
THE FUNCTIONAL UTILIZATION OF
STUMP MUSCLES.
There is no medical topic connected with the
war which is claiming greater attention at the
present time than that of the restoration of dis-
abled men, and justly so, for the ability to restore
our hosts of disabled men to full or partial ca-
pacity presents one of the major economic prob-
lems of the present and the future. We have
had long experience with the education of the
blind and the deaf for useful pursuits, but in the
realm of the maimed we are treading upon al-
most virgin soil. Even there, however, much
progress has already been made in the fitting of
artificial limbs and the vocational training of re-
turned soldiers, but we are yet only at the begin-
ning of the work. Suggestions of new methods,
and especially of new broad principles, are there-
fore more than welcome and merit comment de-
signed to draw attention to them that they may
be put to the test upon a large scale and judged
upon the basis of practical utility. Some highly
promising new principles are those of cinemati-
zation of amputation stumps and the preparation
and utilization of "plastic motors," as first lal^
down by the Italian physician Giuliano Van-
ghetti in 1896, but not seriously considered until
the occasion of the present war's product of crip-
pled men. These principles are described briefly,
but clearly, by V. Putti, of the Italian Royal
Army Medical Corps, in both the British Medical
Journal and the Lancet for June 8, 1918.
The term cinematic plastics or cineplastics is
used to include any form of operative or blood-
less plastics designed to economize, restore, or
substitute those muscular masses in an amputa-
tion stump which can be used to impart direct,
voluntary motion to an artificial limb. The term
plastic motor is applied to the effective moving
entity obtained by cineplastics. These plastic
motors are of various forms, the commonest and
simplest being the clava, or peg; the ansa, or
loop, and those obtained by canalization or tun-
neling of muscular masses. It would take us too
far afield to enter into details regarding the prep-
aration and uses of these several motors, but they
may be described briefly. The clava motor is
August 24, 191 8.]
EDITORIAL ARTICLES.
well represented by the production of one or two
peglike projections from the distal end of a
forearm stump, connected with and moved by
the normal extensors and flexors, and capable of
producing those movements in the artificial hand
to be attached. The ansa type is illustrated by
the gathering together of the flexor and extensor
tendons of the forearm into a ring or loop, after
shortening of the bones, covering this loop with
skin, and forming a moving mass at the end of
the stump. The canalized motor is well typified
by the tunneling of the quadriceps of the thigh,
lining the tunnel with healthy skin, and the in-
sertion into the tunnel of a vulcanized rubber
rod, which, through proper attachments, is capa-
ble of imparting voluntary extension to an arti-
ficial, jointed leg. The various essential condi-
tions for the success of these methods are dis-
cussed by Putti, and some of the remarkable
functional results so far obtained are described
and illustrated.
It is, of course, still too soon to wax over en-
thusiastic about the methods, but we feel that
we may be pardoned the expression of a measure
of enthusiasm sufficient to direct our readers' at-
tention to these radical principles of plastic or-
thopedics that some, at least, may be prompted
to take part in the efforts which are certain to be
made in their development, should they prove
only partially successful. The principles cer-
tainly seem more than promising, and it is patent
that, should their value be confirmed and estab-
lished, the extent of their application is limited
only by human ingenuity and the ef¥orts expend-
ed in their study.
ON SURGICAL SHOCK AT THE FRONT.
In a recent editorial in the May number of the
Journal of Laboratory and CUmcal Medicine, on
Investigations on Surgical Shock at the Front,
Dr. J. J. R. MacLeod presents a critical review
of some of the recent work on this important and
bafifling question. At this time the subject of
shock needs no external stimulus to engage the
attention of either the men at the front or those
who are working in the laboratories on the prob-
lem, but Doctor MacLeod's editorial has supplied
something that is of value, the cool and discrimi-
nating judgment of a bystander, one who, though
not actually in the game, is looking on with a
friendly and critical eye. In the present review
he considers the work of W. B. Cannon and his
collaborators, which has been published during
1918 in the Journal of the American Medical As-
sociation. In this article Caimon discusses and
dismisses the acapnia hypothesis, as well as the
possibility of suprarenal exhaustion, and nerve
cell exhaustion, and the possibility that the low
blood pressure in shock is due to cardiac failure.
After considering the factors responsible for the
blood pressure he arrives at the conclusion that
the blood stagnation must occur at a part of the
vascular system that is beyond the sphere of
vasomotor control, that is, in the capillary area.
MacLeod does not find Cannon's explanation of
the causal relationship between low blood pres-
sure and capillary stagnation quite clear. To the
former the cause of both conditions must be loss
of fluid because of leakage through the capillary
walls into the tissues — a leakage which is suffi-
cient to impede the free movement of blood in the
capillaries because of increasing viscosity. Such
a condition will become progressively more pro-
nounced, resulting in the establishment of a so
called vicious circle. The question of acidosis
and the effects it may bring about are next con-
sidered. Cannon found "in general, the lower
the blood pressure, the lower the alkaline re-
serve," and he emphasizes the importance of
keeping a threatened person warm and of using
measures to prevent the development of acidosis.
MacLeod criticises the use of the suggested term
"exemia" as a suitable one to designate the shock
due to a holding back of blood from normal cur-
rency, on the ground that the fundamental cause
of the condition is not sufficiently established to
justify the coining of such a term, which, he
points out, may only, after all, refer to one of the
accompanying symptoms. This is a single in-
stance of the careful way in which MacLeod has
examined the evidence presented, and the above
is but a brief outline of his excellent review.
THE CLINICAL LABORATORY IN THE
ARMY.
The Surgeon General of the United States
Army has adopted a very ambitious program for
the clinical laboratories in the service. Every
division of troops has or will have a mobile clin-
ical laboratory provided with a bacteriological
outfit, where diagnostic examinations can be
made. Every base hospital, every general hos-
pital, and every special hospital will also have its
clinical laboratory as soon as the personnel and
equipment can be provided. In order to unify
the methods of examination and the forms of re-
ports, the Division of Infectious Diseases and
Laboratories of the Surgeon General's Office has
compiled a Manual of iMboratory Methods which
will undoubtedly prove of great value. This
book, which is No. 6 in the Medical War Manu-
34-
OIUTUAKY.
[New York
Medical Journal.
.".Is issued i)y l^c;i (S.- I'cbigcr, covers the collec-
lioii and shipment of specimens and materials
and gives a description of and standards for solu-
tions and stains to be used in the clinical labora-
tory, and a summary of the pathological work, of
the quantitative analytical methods, and of the
bacteriological methods to be followed. There
is also a chapter devoted to the sanitary exami-
nation of milk and another on the sanitary ex-
amination of water and sewage. The work is in
no sense a textbook. It assumes a previous
knowledge of bacteriology, but furnishes the for-
mulas and technical methods to be followed, giv-
ing data which even the most experienced bac-
teriologist is hardly expected to remember. It
will be of great value in securing uniformity in
the practices of the army laboratories, though it
is not intended to curtail the inventiveness or
originality of the laboratory worker.
As is pointed out in the manual the chief func-
tion of the army laboratory is to safeguard the
health of the troops by making rapid and ac-
curate diagnoses of mfectious and other diseases
for the guidance of the division surgeon and his
staff, both in prophylaxis and treatment.
The high degree of development to which the
clinical laboratory is being brought by the Sur-
geon General and the extent to which the mem-
bers of the Medical Reserve Corps will come to
rely upon laboratory findings in the service, will
undoubtedly have a very marked effect upon the
practice of medicine in civil life, when the sur-
geons now in the service return to civilian prac-
tice. The clinical laboratory has, it is true, already
reached a high stage of development in the larger
cities and particularly in connection with hospi-
tals, though the number of private laboratories
is increasing. But the practitioner in the smaller
towns and even many of those in the cities have
not made a general use of laboratory findings.
In the army these men will be trained to resort
systematically to the clinical laboratory for aid
in routine diagnosis, and the advantages of this
practice will undoubtedly be so thoroughly
proved that, on return to civil life, the surgeons
now in the service will demand the assistance of
the clinical laboratory in private practice just as
they now have it in the army. The laboratory
workers who are now being trained by the Sur-
geon General will therefore find a profitable field
open when they return to civil life, in the estab-
lishment of private clniical laboratories. Many phar-
macists have entered this service and are receiving
laboratorv training which will be invaluable when
the war is over.
ARMY HOSPITAL PLANS.
Three fully equipped, debarkation hospitals are
now ready in New York for the reception of sick
;uid wounded soldiers from overseas, with a ca-
l)acity of 5,651 patients. Three more debarkation
hospitals will be provided in New York and a
fourth in Long Beach within a few weeks, doubling
ihe present capacity. Two completely equipped
hospital trains are now ready to distribute patients,
as soon as received. Attached to these hospitals
and trains there are 529 officers of the Medical De-
l)artment, 2,649 trained hospital attendants, ambu-
lance drivers, and enlisted men of the department,
342 graduate army nurses, and sixty-five civilian
helpers. All these hospitals are constituent portions
of the great medical receiving and clearing station
of this port which is under the command of Colonel
James K. Kennedy, Medical Corps, U. S. Army,
with headquarters at 68 and 70 Hudson street,
Hoboken. The big embarkation hospitals at
Moboken, at Secaucus, and at Hoffman's Island
are also under the jurisdiction of Colonel Kennedy
and six hospital steamers are attached to the service.
Patients arriving from overseas will first be re-
ceived in the debarkation hospitals, where they will
be detained only a very short time. They will then
go to the receiving hospitals in or near New York
where they will be sorted out according to the char-
acter of the injury or disease and then sent to the
general hospitals, the reconstruction hospitals, or
the special hospitals, as the case may require. In-
cluding the army hospitals of all kinds in the United
States, there is now. or under construction, hos-
))ital accommodation for 90,095 patients under nor-
mal conditions or a maximum capacity of 99,343.
In addition to these hospitals, a number of private
residences have been tendered to the Government
and these will be fitted up for the receipt of patients
when occasion arises. These statistics are ex-
tremely interesting and show that the Surgeon
General and his staff' have made ample provision
for any contingency which might normally be ex-
pected and are now prepared to give adequate care
to all the sick and wounded returned from Europe.
^
Obituary
LUTHER HALSEY GULICK, M. D..
of New York.
Doctor Gulick died at his camp at South
C^asco, Me., on August 13th. He was born in
Plonolulu in 1865 and graduated from Oberlin Col-
lege, Harvard University, and the University and
Bellevue Hospital Medical College, of New York.
13octor Gulick was well known as a lecturer and
writer on physical training and v/as at one time di-
rector of phvsical training for the public schools
of New York City. He occupied many prominent
positions in this work but latterly has devoted all
his time to the Campfire Girls, an organization
founded by his wife. Doctor (lulick exercised a far-
reaching and salutary influence on the public health
by his teachings and his work.
August 24, iQiS.]
NEWS ITEMS.
343
News Items.
Flight Surgeons. -Plans have been elaborated for
assigning a corps of surgeons and physical trainers for
each aviation field and camp who will supervise the period
of rest, recreation, and duty of aviators and candidates
so as to get the best results. The surgeon so assigned will
be known as Higiit surgeon.
New York Headquarters for Nurses.— The New York
County Cliapter of the l\ed Cross announced that on Sep-
tember 1st a headquarters for army nurses who are in New
York temporarily will be opened at 120 East Nineteenth
Street. At lirst. there will be dormitory accommodations
for only ten or twelve nurses, but it is expected to enlarge
the establishment later.
Grade of Army Nurses. — The Secretary of War has
issued an order amending paragraph 9 in the army regula-
tions by inserting a new grade of nurse next below the
grade of cadet and above that of sergeant major. This
places the nurses in authority above all the enlisted men in
the army but does not meet the views of the nurses who
have asked for commissioned rank.
Colonel Hoff Resigns.— Colonel J. Van R. Hoff, M. C,
U. S. Army, retired, who has been acting editor of The
Military Surgeon for many years, has resigned and has
been succeeded by Colonel Louis A. La Garde, M. C, who
16 also on the retired list. Colonel Hoff has conducted The
Military Surgeon in a brilliant manner during his occu-
pancy of the editorial chair, and his resignation will be re-
gretted by the readers of that journal.
An American Military Hospital Near Southampton,
England. — Cable despatches from London announce
that a large American military hospital is to be established
at Sarisbury Court, a large country estate near Southamp-
ton. The central building of the hospital will be the manor
house, and the surrounding grounds comprise 186 acres.
This will be the largest American military hospital in
Great Britain, and when completed will accommodate
nearly three thousand wounded soldiers from the western
front
Sanitarians to Meet in Chicago. — A convention of the
sanitarians of the United States and Canada will be held
in Chicago from October 14th to 17th, under the auspices
of the American Public Health Association. Among the
speakers who are expected to address the meetings are
Surgeon General Gorgas, Colonel Victor C. Vaughan, and
Major William H. Welch, of the Medical Department, U.
S. Army ; George H. Vincent, president of the Rockefeller
Foundation; Dr. Charles J. Hastings, president of the
American Public Health Association, and Dr. Allan J.
McLaughlin, assistant surgeon general of the United States
Public Health Service. Among the subjects to be dis-
cussed will be the laboratories and laboratory methods,
industrial hygiene, vital statistics, sanitary engineering,
etc. The mayors of the larger cities and the governors
of the States have been requested to send their health
officers to the conference as a war measure. Full informa-
tion regarding the meeting will be furnished bv the secre-
tary of the American Public Health Association, A. W.
Hedrich, 1041 Boylston Street, Boston, Mass.
Rockefeller Foundation Disbursements. — The Rocke-
feller Foundation spent $5,944,969 in war work last year
and a total of $11,457,086 in educational and relief work.
The disbursements of the foundation during the year were
as follows :
War work $5,944,969
International Health Board 557,839
China Medical Board 501,421
Rockefeller Institute 3,127,914
Fonder's designations 943,151
Miscellaneous :
After care of infantile paralysis cases, mental hygiene.
School of Hygiene, and public health miscellaneous. . . . 277.035
Administration 105.666
Total $11,457,086
Demonstrations such as those which are being made at
home and abroad in the field of public health, well organ-
ized cooperative undertakings, like the camp and com-
munity plan for the welfare of American soldiers, a com-
prehensive program of inquiry of the sort which the
National Committee for Mental Hygiene is carrying out,
represent characteristic Foundation policies.
Animal Tuberculosis Work. — It is reported by the
Department of Agriculture that sixty-four federal em-
ployees and fifty-four State employees are engaged
this year in fighting animal tuberculosis, that widely
distributed disease which causes an annual loss es-
timated at $25,000,000. The Bureau of Animal Industry
has recently extended operations for the control of this
disease to thirty-one States. Headquarters have been es-
tablished in twelve important centres from which the work
will be supervised and directed.
Red Cross Convalescent Hospital. -A hospital for
convalescent officers of the Army and Navy of the United
States and our Allies, and the .'\tnerican Red Cross So-
ciety, has been established on Cuttyhunk Island, at the
month of Buzzard's Bay, Massachusetts. The medical and
surgical equipment is complete and all forms of recreation
are provided on the hospital grounds. Application for
admission to the hospital should be made to Dr. Norman
E. Ditman, medical director of the hospital, Cuttyhunk,
Mass. The hospital will remain open until October ist.
Women Physicians Organize Hospital Unit for
Gassed Soldiers. — .\ three hundred bed hospital unit
for gassed soldiers has been organized by the Women's
Overseas Hospitals of the National American Woman
Suffrage Association and is now on the way to France.
This is the first hospital unit for gas cases exclusively, and
it iias a personnel of only American women. Dr. Marie
Louise Lefort, of New York, is in charge of the unit, and
the staff includes four general practitioners, an ophthal-
mologist, and a laryngologist. Among the members of the
staff are Dr. Ada McMahon, of Lafayette, Ind. ; Dr. Irene
Morse, of Clinton, Mass. ; Dr. Elizabeth Pruyn, of Brook-
lyn, and Dr. Alice M. Flood, of New York.
Personal. — Dr. Frank S. Monaghan, secretary of the
Department of Health of the City of New York, has been
appointed acting Deputy Health Commissioner, succeed-
ing Dr. B. Frank Knause, who has resigned after serving
the department for twenty years. Doctor Knause, who is
an expert epidemiologist, has received a commission as
major in the medical department of the U. S. Army.
Private Kenneth H. Meeker, son of Dr. Herman E.
Meeker, of 72 West Fiftieth Street, New York, has been
awarded the Distinguished Service medal for bravery in
patrol work at the Battle of the Marne. As a member of
Company B, Thirty-eighth Infantry, he was in the thick
of the fight and was slightly wounded.
To Expedite Enrollment of Physicians. — Dr. Frank-
lin Martin, chairman of the General Medical Board of the
Council of National Defense, has arranged for a series of
meetings to be lield throughout the country as part of the
campaign for expediting the enrollment of physicians in
the reorganized Volunteer Medical Service Corps. These
meetings will be held August 22d and August 29th, at the
most central and accessible place in each State. Their pur-
pose is to arrange for enlargement of State executive com-
mittees to handle the active campaign for the corps, to
arrange for the appointment of a representative in each
county, and to acquaint the State and county representa-
tives with the details as to the reorganized Volunteer
Medical .Service Corps.
Tuberculosis Conferences. — .\nnouncement is made
by the National Tuberculosis Association that plans are
under way for five conferences to be held this fall in
various parts of the United States to discuss tuberculosis
as a war problem. Means of providing adequate care for
the thousands of soldiers and sailors already discharged
from the army and navy on account of tuberculosis and the
still greater number rejected in the draft for the same rea-
son will be one of the main questions discussed. The
closely related (luestion of educating the civilian popula-
tion more fully regarding tuberculosis during the war and
thus combating its further spread in the community at
large will also be considered. The programmes for
each section will be announced at an early date. The meet-
ing places and dates are as follows : Spokane, Wash., Sep-
tember 27th and 28th : Denver, Colo., October 4th and 5th ;
Birmingham, A\a., October nth and 12th; Pittsburgh, Pa.,
October 17th and i8th ; Providence, R. I., October 25th
and 26th. New York State workers in the antituberculosis
movements will attend the North Atlantic conference to
be lield in Pittsburgh.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
VlLiOUS CIRCLES IN RESPIRATORY DIS-
ORDERS AND THEIR TREATMENT.
By Louis 'J\ de M. Sajous, B. S., M. D.,
Philadelphia.
The extensive scope and practical significance of
vicious circles in disease have not been given suf-
ficient recognition. (Granting the truth of the propo-
sition that each function in the body de])ends for its
most perfect expression upon adequacy of every
other function with which it is in any way related,
the multiplicity' of possible interacting disturbances
in any given disease is obvious.
In the true vicious circle two or more disturb-
ances so react one upon the other that the patient's
condition grows progressively worse, and an affec-
tion which would otherwise soon be mastered or
wear itself out may continue indefinitely whether
its original cause has or has not been removed.
From the standpoint of diagnosis, pathogenesis, and
prognosis vicious circles are of considerable im-
portance, for through their study light may be
thrown upon many otherwise obscure manifesta-
tions and processes of disease and our ability to
account for steadily progressing morbid conditions
augmented. Death is not infrequently the result of
the operation of a vicious circle.
In treatment the vicious circle is likewise highly
significant. Its serious influence in accelerating the
course and in many instances even the fatal termi-
nation of disease is reversed and passes into an
equally beneficent influence when the circle is arti-
ficially interrupted, improvement being all the more
rapid and striking the more menacing the preexist-
ing unfavorable trend. Often the breakiiig of a
vicious circle appears to be the most essential aim
in treatment next to actual removal of the cause, and
where the cause has already been overcome without
eliminating the symptoms, breaking up a vicious
circle may remain the most effectual therapeutic
measure available.
Interruption of a vicious circle, intentionally or
unwittingly, appears sometimes to account for per-
sistent benefit from purely symptomatic treatment
whicli could not otherwise be readily explained.
Thus, cough, whatever be its cause, tends to pro-
duce congestion of the lower respiratory passages.
This congestion, in turn, promotes local irritability
and tends to increase the frequency of the cough
paroxysms. These, again, augment the congestion,
and a vicious circle thereby results which tends to
aggravate and perpetuate the disturbance, even
though the original cause — usually some fonn of
local irritation — has spontaneously or artificially
been eliminated. Administration of a drug, such as
codeine, to depress the cough centres in cases of
this type, would at first sight appear to constitute
merely symptomatic treatment, the beneficial effects
of which will disappear when the drug is discon-
tinued, the irritative cause of the cough persisting.
As a matter of fact, however, the codeine in addi-
tion breaks into the vicious circle just referred to,
preventing the increase of cough due to local con-
gestion, likewise the mcrease of local irritability
due to this cough, and consequently the aggravation
and perpetuation of the latter, which would other-
wise have occurred through the operation of the
vicious circle. If at the same time one has suc-
ceeded in removing the irritative cause of the cough,
complete recovery will be hastened by the artifi.cial
interruption of the vicious circle; even if one has
not, the benefit from the remedy will be far more
Lasting on this account than if the vicious circle had
not been present and a purely symptomatic eflfect
alone had been ^jroduced. By repeated administra-
tion of short courses of codeine treatment the evil
effects of the vicious circle can be continuously ob-
viated and, through the consequent removal of an
important factor of aggravation, a great reduction
of the severity and duration of the disturbance is
secured.
According to Jamieson B. Hurry, 191 1, with
whom rests the great credit of writing the first book
upon the subject of vicious circles, these conditions
are very frequently dependent upon a failure of the
autoprotective mechanisms by which the body is
ordinarily enabled to resist disease and repair in-
jury. Thus, cough, a recognized protective act
having for its ]jurpose the removal from the re-
spiratory tract of noxious material, is manifestly ef-
fectua\ where the disturbing agent is not too viru-
lent or persistent, but in the opposite event it intro-
duces prejudicial secondary effects — increased con-
gestion and irritability, etc. — which would not be
encountered were the protective mechanism wholly
removed. Herein lies the physician's opportunity to
intervene and attempt to complete artificially Na-
ture's insufficient protective efforts or, at least, to
prevent her abortive procedures from becoming
maleficent instead of beneficial.
In truth, the occasions presented for artificially
breaking up vicious circles are surprisingly fre-
quent. Hurry practically eliminates the treatment
of vicious circles from consideration in his ijook
as being "too large a subject for discussion." The
subject is nevertheless one of great importance to
the practitioner.
HEMOPTYSIS.
In the commonest variety of hemoptysis, that
arising in pulmonary tuberculosis, several vicious
circles are simultaneously operative, and markedly
favor continuation of the bleeding. The blood ex-
travasated, by inducing irritation of the tissues,
causes cough ; this, in turn, by temporarily increas-
ing intrathoracic pressure, as well as by mechani-
callv promoting detachment of clots, tends to in-
crease the hemorrhage and prevents its arrest by
clot formation ; the additional blood causes further
cough, and so a vicious circle is created. Again, the
excitement and anxietv of the patient result in
quickening of the circulation, which increases the
August 24, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
345
hemorrhage, and thereby causes further anxiety.
The excitement is also Hkely to inci-ease voluntary
movements, again accelerating the circulation, aug-
menting hemorrhage, and thereby adding to the ex-
citement. Possibly also the excitement may en-
hance the cough reflex. Whatever increases the
hemorrhage also increases the cough. Hence the
several vicious circles present become intercon-
nected and reinforce one another, the condition as a
whole growing worst until Nature's belated and
somewhat risky means of hemostasis — partial ex-
sanguination — comes into play.
Direct treatment would consist in closing down
the bleeding vessel. Emetine has been thought by
Flandin, IQ13, and others to exert some such action,
but of late we have heard little of it in this con-
nection. Less direct measures comprise bandaging
off the extremities, cupping over the chest { An-
ders), venesection (Foxwell), etc. While often
serviceable, these procedures are hardly as valuable
as those which break up the vicious circles. From
this standpoint morphine is the first remedy, re-
moving both excessive cough, mental excitement,
and motor restlessness ; it thus interrupts at least
three vicious circles. Verbally allaying the patient's
anxiety and enjoining quiet and avoidance of un-
necessary coughing act similarly, but as a rule less
powerfully. Greer, 1916, and others have reported
good results from artificial pneumothorax in hemo-
ptysis. This may be held to act both directly and by
interrupting all vicious circles in which undue agi-
tation of lung tissue tends to prevent firm clot de-
position.
{To be continued.)
Surgery of the Gallbladder and Biliary Ducts.
— K. S. Judd (Journal A. M. A., July 13, 1918) dis-
cusses the clinical pictures of the several more
common types of gallbladder and gall duct affec-
tions and lays special stress upon the methods of
surgical treatment which should be employed. In
the cases of more or less chronic cholecystitis the
simple operation of drainage generally relieves the
majority for a time, but in a large proportion there
is a recurrence of symptoms. The operation which
is indicated in this group is the removal of the gall-
bladder, after which the patient is truly cured. In
cases with typical gallstone colic the removal of the
gallbladder is the operation of choice, since it both
prevents recurrences and removes a chronically in-
flamed organ which might later become the source
of trouble. The third group includes cases with
typical cholangeitis with stones in the common duct
and here the gallbladder should be saved if there is
any question about the patency of the common duct.
Otherwise recovery is more complete after its re-
moval. The last group includes those cases with
atypical cholangeitis and painless, or nearly pain-
less, jaundice. A definite diagnosis is difficult be-
fore operative exploration and such should gener-
ally be undertaken, especially when there is varia-
tion in the jaundice or fever and chills. In such
cases the operative difficulties are many and spe-
cially arise in connection with the fact that the
patient is seldom a good surgical risk, and with the
liability to oozing and frank hemorrhages from the
mucous membranes within the first eight to ten days
after operation. If the coagulation time of the blood
is longer than about twelve minutes the patient may
generally be regarded as an extremely poor risk for
operation, and even when the time is within normal
limits the danger from bleeding is considerable.
Jaundice is always a source of added risk. Calcium
salts, given either before or after operation, have
not proved of distinct value and the one means of
real value lies in transfusion. This must be done
before any oozing has begtm. If, in spite of proper
transfusion, oozing does occur, the most satisfactory
method of attack is either aspiration of the liver
through a large trocar and cannula or liberal in-
cision into the liver, both being done to relieve the
hepatic congestion. In all cases of this class the
drainage tube should be left in the common duct
for a long time and the duct should be frequently
irrigated with physiological salt solution. The op-
eration for removal of the gallbladder is not one of
great danger or technical difficulty, but special
caution should be exercised to make a complete
separation of the cystic duct down to its junction
v/ith the common before even applying a clamp.
This is necessar}' to avoid the risk of damaging the
latter.
Gunshot Wounds of the Chest. — J. F. Dobson
{British Medical Journal, June 15, 1918) speaks of
some of the features in the surgical treatment of
these wounds and emphasizes that the chief cause
of failure is sepsis. The best preventive of sepsis
is complete closure of the chest after very early and
thorough surgical treatment for the purpose of
mechanical cleansing. In spite of the adoption of
this method some cases will yet become septic and
the problem is then to deal with the infection. This
must be undertaken at once and one must alwavs be
on the lookout to discover its occurrence as early as
possible. When sepsis is discovered drainage of the
chest cavity must be provided, which can be done
either by resection of a short length of rib, or by
resection of from four to five inches followed by
opening of the chest for inspection and the removal
of clots, foreign bodies, bone fragments, etc., and
for the repair of damage to the lung or diaphragm.
The latter is the better plan. But even such drain-
age is not sufficient in the majority of cases since
the sepsis may not be overcome, or it may become
chronic with the formation of dense masses of
fibrin on the lung and parietal pleura and the
patient will be left with a chronic empyema and a
poorly expanded lung. The drainage should be
supplemented by sterilization of the pleural cavity
with some antiseptic, which is best accomplished by
the insertion of a bent silver cannula through an
mterspace at the upper level of the cavity, where it
is fixed to the skin by sutures. The original large
incision is then tightly closed and sutured about a
drainage tube placed in the dependent portion of the
chest. This tube should be long enough to have its
outer end dip below the surface of an antiseptic in
a bottle. The chest cavity is then irrigated every
two hours with eusol or other antiseptic solution.
This method gives striking results in the control of
the infection and the lung promptly expands leav-
ing the patient with a sound organ.
MODERN TREATMENT AND I'REVENTIVE MEDICINE.
[New York
Medical Journal.
Intravenous Injection in Wound Shock. — W.
M. Bayliss {British Medical Journal, May i8, 1918)
deals only with the condition of secondary shock
and points out that the most general and obvious
manifestations of the condition are associated with
the low blood pressure. The exemia hypothesis,
i. e., the accumulation and stasis of blood in capil-
lary areas, seems best to explain the condition, the
resulting symptoms being due to an insufficient
blood supply as a result of low pressure and de-
creased blood volume. The chief means of thera-
peutic attack must include the elevation of the blood
pressure and restoration of adequate blood volume.
Simple elevation of pressure in the face of contin-
ued reduced blood volume has proved of little avail.
The most logical method to suggest itself is the
transfusion of blood, but this has many disadvan-
tages, especially near the firing line, the chief one
being the difticully of obtaining sufficient suitable
donors. The use of whole blood is also not fol-
lowed by better results than is that of other solu-
tions. Various sahne solutions have been suggest-
ed and tried, but none of these meets the conditions
because they all are too transitory in their effects
due to too low viscosity or the absence of a colloid
with an osmotic pressure. The one solution which
has the proper theoretical characteristics and which
gives the desired results clinically is a six per cent,
solution of gum acacia in nine tenths per cent, so-
dium chloride solution. The acacia contains suffi-
cient calcium and potassium salts to render their
addition unnecessary. The acacia has the advan-
tages of being colloidal, of having a sufficient os-
motic pressure to prevent the solution's prompt pas-
sage from the vessels into the tissues, of providing
the requisite viscosity, of being nonprotein, of being
cheap and easily secured, and of being readily ster-
ilized by boiling. Though acidosis may be present
in secondary wound shock, it is not a factor of seri-
ous importance, and alkaline injections are not nec-
essary.
Method of Dealing with Divided Ureters. —
W. Blair Bell (Lancet, June 15. 1Q18) describes a
method which deals with the implantation of the
ureters when thev cannot be inserted into the
bladder for one or another reason. The operation
is performed in two or three stages. .\t the fi.rst
stage the abdomen is opened through a central
subumbilical incision. A loop of lower ileum about
eighteen inches long is isolated with its mesentery
intact, an anastomosis being performed to unite the
remaining intestinal tract. The apex of the isolated
loop is lightly attached to the fundus of the bladder
and the two ends are brought to the surface through
stab wounds in the iliac regions, one on either side.
The abdomen is then closed. When the attach-
ments of the two ends are firm the lumen of the
loop is washed out twice daily with a one thirtieth
solution of Milton fluid and within about ten days
it will have become practically sterile, when the sec-
ond stage is undertaken. A selfretaining catheter
is placed in the bladder, the abdomen reopened and
the intestinal loop detached from the bladder
fundus. The ureters, cut at the pelvic brim, are
next transplanted into the intestinal loop by Stiles's
method. That portion of the bladder which is to be
removed is next excised and the opening closed
with two layers of sutures. The apex of the in-
testinal loop is then anastomosed with the fundus
of the bladder and the abdomen closed. The cath-
eter is left in place for a week. The open ends of
the intestinal loop are closed at the time of the
second stage, or they may be left open for the pur-
pose of lavage and closed later. This operation is
especially suitable for cases of cancer of the cervix,
which can then be treated by complete cleaning out
of the whole pelvis during the second stage of the
operation, for ectopia, and other conditions. Its
great advantage lies in the safety secured by im-
planting the ureters into a sterilized, isolated in-
testinal loop, thus obviating the dangers of infec-
tion.
Temporary Cecostomy in Resection of the
Distal Portion of the Colon. — Gordon Taylor
[Bniish Medical journal, June 15, 1918), strongly
recommends the performance of a temporary cecos-
tomy in cases in which part of the distal portion of
the colon is to be resected for some nonobstructive
condition. The procedure is simple and is a meas-
ure of decided safety in the operation of resection.
Among the classes of cases in which it proves spe-
cially valuable are those of resection for carcinoma,
for the closure of a proximal inguinal colostomy
and for excision for gunshot wound of the large
intestine. The cecostomy is made through a grid-
iron incision and the drainage tube is inserted in a
way similar to that followed in Senn's gastrostomy.
The cecum is usually not opened until the chief
operation has been completed. The application of
a collodion or mastisol dressing prevents material
danger of infection of the laparotomy wound from
the cecostomy.
Organic Basis and Surgical Care of Neuras-
thenia.— H. \\\ Riggs {Northwest Medicine, May,
1918) contends that many cases of so called neuras-
thenia are found to be due to ptosis of one or more
of the abdominal or pelvic viscera. The traction
of the ptosed organs upon the nerves of the mesen-
tery or the nerves accompanying their vascular sup-
ply produces reflex eflfects through the sympathetic
plexuses with resulting symptoms of delayed peris-
talis, gastric and intestinal digestive disturbances,
headache, and other neurasthenic svmptoms. Care-
ful examination will show among the commonest
conditions some degree of increased motility of the
kidney or kidneys, the fiver, the small and large
intestines, the stomach, and often some displace-
ment of the uterus. Most of such patients will be
found to have very lax abdominal walls with loss of
fat tissue and poor musculature. Medical treatment
by rest in bed, the prescription of a fattening diet,
etc., to restore tone to the muscles and increase the
deposition of abdominal fat often relieves the symp-
toms, but the relief lasts only so long as the fat
deposit can be maintained. More permanent relief
can be secured in all cases by proper surgical inter-
vention, which consists in replacement of the ptosed
organs. The kidney is fastened, the liver supported
by means of its round ligament, the uterus replaced
by a suitable operation, and the ptosed parts of the
intestines elevated and retained by one of the meth-
ods which has proved satisfactory.
August 24, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
347
Treatment of Colds. — D. C. Dennett (Boston
Medical and Surgical Journal, July 11, 1918) makes
a plea for the early, careful treatment of colds. He
begins by treating the conjunctival sac, as he thinks
some colds start there and work down, placing a
fifty per cent, solution of argyrol on the everted
lids. The argyrol will pass through the lacrymal
duct and trickle down the posterior pharyngeal wall.
He also syringes out tlie pharynx with the solution.
The patient is given a twenty-five per cent, solution
for use in the eyes and nose. Medicated cotton and
sprays should not be used. Aspirin is not given
except for pain, and quinine and whiskey are not
used. Sulphate of atropine and aconite are given
in the first stage of "head colds," steam and oil in-
halations for "loss of voice colds," Dover's powder
early for "cold on the chest."
Cautery Excision of Gastric Ulcer. — D. C. Bal-
four (Annals of Surgery. June, 1918) points out
that the apparent advantages of the above method
may be thus summarized: i. The cautery efficiently
destroys the focus of infection in gastric ulcer
without the sacrifice of Nature's protective indura-
tion surrounding the ulcer centre. 2. It may be
applied in a large percentage of gastric ulcers. 3.
It entails a minimum of operative risk. 4. Clinical
and rontgenologic evidence shows better mobility
and function than follow knife excision and gastro-
enterostomy. 5. It has a particular efficiency in ob-
viating early and late postoperative hemorrhage.
6. The late results are better than those obtained
with any other method. 7. It can be used in cases
in v.-hich no other means of direct attack on the
ulcer is justifiable. 8. It is probable that gastric
ulcer cautery, like knife excision, should always be
combined with gastroenterostomy.
Idiopathic Epilepsy a Sympathicopathy. — Ed-
ward A. Tracy (Boston Medical and Surgical
Journal, June 6, 13, 20, and 27, 1918) had establish-
ed the fact, by previous research work, that the
normal reaction of the skin to a gentle stroke with a
wooden tongue depressor is a brief vasodilatation
followed by a vasoconstriction in the stroked area
lasting a couple of minutes. One day, on testing a
patient with idiopathic epilepsy, he was struck by
the intensity in color and the very long duration of
the vasoconstriction reaction. Later he found the
variation at different times in the intensity and dur-
ation of the vasoconstriction very striking, as well
as the irregularity in time of its appearance, in this
patient, sometimes appearing within six seconds, at
other times not until after thirty. This case was
studied carefully during a period of two and a half
years, together with ninety other cases of idiopathic
epilepsy. The chronic vasoconstriction spots dis-
covered, with their intensifying and fading while
under observation — even while the patient slept —
seem to demonstrate a diseased condition of the
sympathetic neurones. The many abnormalities of
the reaction at times likewise seem to show a dis-
eased condition of the sympathetic neurones. Cer-
tain spots appear to be related to an outburst of
convulsions, and the increased irritability frequently
demonstrated in sympathetic neurones, preceding
convulsions, reveals a relation between the diseased
svmpathetic neurones and the seizures.
The Action of "Female Remedies" on Intact
Uteri of Animals. — J. D. Pilcher (Surgery, Gyne-
cology, and Obstetrics, July, 1918) states that ex-
periments demonstrate conclusively that the entire
list of female remedies is (|uite void of action on the
uterus in situ, thus confirming the interpretation of
the results of the work on the excised uterus and
intestine. They cannot therefore influence the tone
or contractions of the uterus through any central
innervation or through the blood stream, no matter
whether the uterus is in a state of normal, in-
creased or decreased tone.
The Multiple Myelomata and Their Ability to
Metastasize. — Douglas Symmers {Annals of Sur-
gery, June, 1918) concludes as to the multiple mye-
lomata and their ability to metastasize as follows :
I . The so called multiple myelomata represent
neoplasmic growths which spring from myelo-
blasts. 2. Since the term multiple myelomata is
broadly inclusive, the designation of the neoplasmic
disease under consideration, Symmers thinks, might
be appropriately changed to that of multiple myelo-
blastomata. 3. The multiple myeloblastomata are
capable of originating growths in the extra
medullary hemopoietic viscera by hyperplasia of
preexisting myeloblastic foci, and in certain other
tissues by the process of metastasis by cell trans-
plantation.
Cranial Surgery. — Robert T. Morris (American
Journal of Surgery, June, 1918) asks how, in cases
of brain injury in which drainage of the cranial
fluid is to be continual, is a good protection of the
brain area to be obtained? If there are several
layers of gauze immediately protecting the area and
dressings are changed frequently outside of a first
layer of iodoform gauze, the entrance of sepsis will
be avoided. One or two layers of iodoform gauze
should be employed. The first layer need not be *
changed ; it may remain for two, or three, or four
days at a time, while the outer dressing of gauze
may be changed very frequently, and in this way
the menace of the traveling of infection through
the dressings to the brain area is avoided fairly
well.
Fluctuations in the Growth of Malignant Tu-
mors.— G. L. Rohdenburg (Journal of Cancer Re-
search, April, 1918) has collected from the litera-
ture 302 cases (including three of his own) in
which either temporary or permanent recession of
a malignant tumor has occurred. The fact that
spontaneous recession undoubtedly does occur
should make one very wary of hailing a new cancer
"cure," for the beneficial effect may be entirely due
to processes of nature concerning the workings of
Avhich man is profoundly ignorant at the present
time. Rohdenburg states that the causes of reces-
sion most frequently found in this series are heat
and an incomplete operation. The heat mav either
be artificially supplied, or may be the result of an
acute febrile infection, such as erysipelas, tubercu-
losis, or pneumonia. Nutritional factors, and in a
few cases, fibrosis, are described as the cause of the
absorption. The knowledge that spontaneous re-
gression does occur ofifers some hope that the cancer
research worker may find some method of inducing
it in time.
Miscellany from Home and Foreign Journals
Heat Stroke and Malignant Malaria. — C. E. H.
Milner {British Medical Journal, June 8, 1918)
says that it is admitted that a close relation exists
between heat stroke and malignant malaria, but that
he is convinced that heat stroke does not exist as a
clinical entity, being only a symptom, on a hot day,
of malignant tertian malaria. He supports this
opinion, which he admits to be radical, by the re-
sults of his observations during the recent hot
periods in Mesopotamia. From a routine examina-
tion of the blood of the cases admitted as heat
stroke during the second hot spell it was found that
a very large proportion of the cases showed the
presence of malignant tertian malaria. The routine
administration of a dose of eight or nine grains of
the bihydrochloride of quinine intramuscularly even
before the results of the blood examination had
been reported reduced the mortality from over
twenty-hve per cent, to less than twelve per cent.
It is suggested that infection with the malignant
tertian malaria parasite produces an intoxication of
the heat regulatory centre, upsetting its functions
so that the temperature of the body tends to ap-
proach that of the surrounding atmosphere, hence
the occurrence of so called heat stroke in these in-
fected patients.
Dilatation of the Duodenum. — V. Pauchet
(Paris medical, May 18, 1918) notes that the sur-
geon operating in the upper abdomen frequently
finds both the duodenum and the last loop of the
ileum greatly dilated. Below the ileal dilatation and
a few centimetres from the cecum a kink is found.
A bismuth meal and the use of the x ray soon reveal
the duodenal enlargement, while the ileal disturb-
ance is shown by markedly delayed evacuation of
the bismuth from the terminal portion of this sec-
tion of the bowel. As Lane has pointed out. the
sequence of events in such cases is visceroptosis,
formation of defensive ligaments, and finally an
ileal kink. The mesentery attempting to hold up
the ileum reacts upon the duodenum above and nar-
rows it at one point by traction on the mesenteric
artery ; or, the duodenum may be blocked through
accentuation of the duodenojejunal angle. Patients
with chronic duodenal occlusion sufifer from habit-
ual indigestion with nausea and vomiting, the latter
often bilious. The stomach artificially emptied at
night is found again filled with bile the next morn-
ing. There is frequently vague pain in the right
side, sometimes relieved by ingestion of food as in
duodenal ulcer. Constipation is the rule. The
stools are light in color. Persistent headache and
general lassitude of toxic origin are complained of.
The abdominal wall is flaccid, the x rays show sag-
ging of the stomach and colon, and examination of
the blood and urine often reveals acidosis due to
progressive inanition. The medical treatment con-
sists in recumbency after meals, a supporting belt
liefore rising, abdominal gymnastic exercises, and
measures to promote fat deposition. Such treat-
ment failing, ileosigmoidostomy, with or without
right colectomy, is indicated. Acute gastroduode-
nal dilatation is a condition occurring after opera-
tions and manifested in vomiting of black material
caustic to the oral mucosa; marked abdominal dis-
tention from gastric and duodenal dilatation, with
thready pulse and collapse. These patients have
been suffering preoperatively from chronic duodenal
occlusion, with beginning acidosis ; swallowing of
saliva to neutralize the gastric contents resulted in
aerophagia, followed by acute gaseous distention
and mechanical obstruction of the duodenum. The
treatment comprises gastric lavage, or better, per-
manent gastric siphonage ; the ventral, or better,
the genupectoral position ; and continuous procto-
clysis with sugar and alkaline solution to supply pab-
ulum and overcome the acidosis.
Effect of Convection Currents on Agglutina-
tion.— W. VV. C. Topley and S. G. Platts {Lancet,
June 8, 1918) present the results of a number of
experiments which show that the occurrence of ac-
tive convection currents in the tubes increases the
rapidity of agglutination materially, especially in
the case of bacterial suspensions which agglutinate
rather poorly. The presence of the convection cur-
rents does not seem to alter the maximum titre of
the serum to be tested. The quality of the aggluti-
nation is also altered favorably, the flocculi being
large and very readily seen with the naked
eye. Often the titre obtained after two
hours of incubation with convection currents
is not equalled in twenty-four hours with the
same serum and suspension in the absence of such
currents. The production of convection currents is
best secured by immersion of the agglutination tubes
in ti-ie waterbath at 55° C. to such a point that the
water rises to only 1/6 to 34 the height of the
column of fluid to be tested. The adoption of such
a technic gives uniform results and materially
shortens the required time of incubation.
Throat Smears in Measles, Rubella, and Scarlet
Fever, — Ruth Tunnicliff {Journal A. M. A., July
13, 1918) previously described grampositive diplo-
cocci which she isolated in anaerobic cultures from
the blood of measles and rubella patients. The
diplococcus of measles is small and round, while
that of rubella is larger, has pointed ends, and is
elongated and encapsulated. From a study of
smears taken from the throats of patients having
measles, rubella or scarlet fever and from normal
persons the features of the smears were found to
be of decided diagnostic value. The smears were
taken from the most highly inflamed portions of the
throat. In measles there were generally some poly-
nuclear and epithelial cells and many of the small,
round diplococci. Rubella throat smears showed
few polynuclears, many epithelial cells, and many
of the typical, elongated cocci, often showing cap-
sules about the pairs and frequently appearing with-
in the epithelial cells. Smears from scarlet fever
throats showed many polynuclears and a variable
number of cocci in pairs or short chains and having
a wide capsule. None of the diplococci found in
the throats in these three diseases were found in
smears from normal throats, except in four persons
recently in close association with rubella cases.
August 24, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
349
Trench Fever, — W. Byam, J. H. Carroll, and
associates {Journal A. M. A., July 20, 1918), in the
third instalment of their report of investigations
into the subject of trench fever, present the results
of research upon the mode of transmission of the
disease. They summarize the evidence which they
have been able to secure. Intravenous injection of
the whole blood, drawn up to the fifty-first day of
the disease, can reproduce the disease. In such
transmissions the incubation period varies from five
to twenty days. The addition of large amounts of
distilled water to the whole blood seems to destroy
the virus. Lice are capable of transmitting the dis-
ease, but the bites alone of infected lice do not
transmit it. On the other hand, the excreta of in-
fected bee readily produce the disease when applied
to an abraded surface, the incubation period then
being very constant with an average of eight days.
These excreta do not become infective until at least
a week after the lice have fed upon infected per-
sons, suggesting a developmental cycle or the multi-
plication of the organisms in this host. Having be-
come infective, lice remain so for at least twenty-
three days from the time of their infection. The
virus of the disease contained in louse excreta
resists drying at room temperature, exposure to
sunhght, and heating to 56° C. for twenty min-
utes, but it is destroyed in ten minutes by a
temperature of 80° C., showing that it is not
spore bearing. Certainly infective blood from
trench fever cases equivalent to the content of
eleven lice is not infective through the broken skin.
The mouth and respiratory tract are probably not
channels of infection. Normal lice do not harbor
the virus of trench fever and when infected they do
not transmit it to their young. Immunity resulting
from an attack of the disease is not permanent and
may last only so long as the person shows evidence
of the disease. Lice may be infected from the blood
of a patient as late as the seventy-ninth day of the
disease if there is a febrile attack. Finally, the
different clinical varieties of trench fever depend
upon differences in the persons infected rather than
ni)on the source of the infection.
Notes on Pulmonary Tuberculosis. — Prosper
Merklen (Pressc medicale, May 23, 1918) divides
soldiers examined for tuberculosis into four groups.
In the first, the typical general and functional dis-
turbances and physical sigTis coexist, and a positive
diagnosis is made after due pains have been taken
to exclude nontuberculous pulmonary lesions and
nonbacillary general disturbances in patients whose
physical signs suggest an arrested tuberculosis. In
the second group the general signs of tuberculosis
exist in the absence of or with but slight objective
indications of the disease. If these indications are
wholly absent, and radioscopy is negative, tubercu-
losis is eliminated ; if there are slight indications, de-
cision is deferred until after repeated examinations.
In the third group, definite local manifestations
occur in the complete or almost complete absence of
general symptoms. Here an actual, but healed,
fibrous, or calcified tuberculous process is suggested,
but rather prolonged confirmatory observation is
necessary. In the last two groups are placed the
numerous cases, emphasized by Bezangon, of tuber-
culosis running its course in repeated small exacer-
bations : the latter may awaken toxemic symptoms
without much local change or, on the contrary, pul-
monary manifestations with but slight general dis-
turbance. In the fourth group are placed atypical
cases characterized by repeated attacks of bron-
chitis, persistent pulmonary congestion, chronic
bronchitis with emphysema, or periods of fever. In
some of these cases a very probable diagnosis of tu-
berculous infection can be made at the first exam-
ination, but confirmation is generally required. Ab-
sence of bacilli should not prevent a positive diag-
nosis supported by other signs. A type of case now
frequently met with is that of a fatigued, thin, lan-
guid soldier, with little or no cough or expectora-
tion, but complaining of diffuse pains in the trunk
and extremities, breathlcssness on exertion, and an-
orexia. Pulse and temperature are normal or
slightly variable. The apices show slight impair-
ment of resonance, obscure respiratory sounds, and
an almost or quite normal radioscopic appearance.
Pest greatly improves the condition, which recurs,
however, upon exertion or fatigue. These are prob-
ably very torpid tuberculous cases, indistinguishable
in civil life ; or, old. healed processes may have been
restored to activity by military conditions. Fatigue
states, exhaustion, asthenia due to adrenal insuffi-
ciency, or psvchic depression occurring in subjects
with slight or healed tuberculosis are also to be
thought of.
Blood Pressure Studies in Five Hundred Men,
— Bertnard Smith (Journal A. M. A., July 20, IQ18)
records his observations made upon 500 applicants
for the aviation service. The readings were made
with the men in the recumbent position, in the
standing position, and standing after having done an
average of 1,600 foot pounds of work in five
seconds. The pressures were taken by the ausculta-
tory method and the diastolic was read at the point
of change from the third to the fourth phase. The
tin.e required for the blood pressure to return to
normal after the exercise test was also recorded in
200 of the men and called the recovery time. Four
hundred of the men stood all of the tests as good
normals. The average age of this series was 24.2
years and the average readings in the recumbent
position were : pulse rate, 85.4; systolic pressure,
127.7 diastolic, 84.1; pulse pressure, 42.2; and the
lengths of the several phases averaged: first, twelve :
second, 24.5; third, 6.2, and fourth, 5.1 mm. of
mercury. Several of the suggested formulas
were applied to the readings ; thus the Tigerstedt
, , PP X PR ' , ^, .
formula of c.;p ^ pp^ gave an average of thirty-
three per cent, as compared with the estimated
normal value of tliirtv to thirty-five per cent.
PP
Stone's formula of gave an average of 50.2
per cent, as compared to the normal of fifty per
cent. Goodman and Howell gave a cardiac strength
figure of 55.4 and the present series showed an
average of 55.8. In none of this series was any
tonal arrhythmia observed. In this same series of
patients after measured exercise the averages
showed characteristic and normal responses. The
pulse rate averaged it 2, the systolic pressure 145.4,
diastolic 90.6, pulse pressure 54-1, the first phase
350
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
thirteen, the second 33.5. the third eleven, the
fourth, seven milHmetres of mercury, and the aver-
age recovery time was 4.4 minutes with a maximum
range of 3.1 to 7.6 minutes. The area of cardiac
dulhiess was never found to have been increased by
the exercise, while sixty-nine per cent, of the men
showed an apparent decrease in the area. One
hundred of the men showed some variation from
the normal. Five had a cardiac murmur and all of
these showed an increase in cardiac dullness after
exercise, labored breathing, and three showed some
tonal arrhythmia. The ratio of the second phase to
the pulse pressure was low after exercise and the
cardiac strength values were somewhat reduced.
These tests gave some indication of myocardial
weakness, but this was better shown by the change
in the cardiac area after exercise, the dyspnea and
the prolongation of recovery time to from ten to
fifteen minutes. Similar findings were noted in five
cases with palpable radial arteries. A number of
men with abnormal findings were encountered, these
findings being due to fatigue or to the beginning of
some acute infection and in all the findings returned
to normal after rest or recovery. Tonal arrhythmia
persisted throughout all of the phases in seven men
and all seven responded poorly to the exercise test.
The conclusions reached were that the various blood
pressure findings alone were of relatively little im-
portance in determining physical fitness, but that the
added information given by some form of measured
exercise was of definite value. The increase in the
pulse rate after exercise was not found to be of any
value.
Indurative or Rheumatic Headache. — Hugh
T. Patrick {Journal A. M. A., July 13, 1918) says
that our knowledge of this form of headache re-
mains at much the same point as thirty years ago,
when it was first described very inadequately, and
that much nonsense has been perpetrated and per-
petuated concerning it. Since there is very little of
value on the subject in the literature, Patrick draws
largely upon his own careful observations. The
headache may be acute, though most cases are sub-
acute or chronic and last for weeks, months, or
years. The condition is slightly more common in
women than men and it occurs very rarely below
the age of twenty, not uncommonly below thirty,
but most commonly above forty years of age. The
pain is real and may be constant, or fairly steady
with remissions, intermissions, and exacerbations.
It does not occur in instantaneous shoots or brief
excruciating paroxysms, nor does it come in definite
attacks. Nausea and vomiting are not present with
it. The course of the pain closely resembles that of
chronic arthritis, with bad days, better days, and
good days, but with more or less pain or soreness
always present. The pain is apt to be worse in the
latter part of the day or the evening. The pain is
never frontal or vertical alone and rarely temporal.
It is characteristically occipital or suboccipital and
may radiate from these areas to the other parts of
the head, down the neck and to the shoulders or
back. It is usually bilateral. The painful region
is tender to deep pressure but not to surface pres-
sure. The presence of the so called indurative
nodules may be ignored for they are seldom to be
found. This form of headache is really a rheuma-
tic afifection and various other evidences of past or
present rheumatic involvement elsewhere are al-
most always to be found. Specially noticeable is
I)ain upon movement of the neck. The condition is
also prone to be worse after exposure to cold and
dampness and cold applications aggravate the pain.
In the majority of the acute and many of the sub-
acute cases there is sHght fever up to 100° F. and
a mild leucocytosis and these manifestations of the
infectious nature of the condition can often be
elicited even in the chronic cases when the pain is
very severe. The exact pathology of the condition
is obscure, as is its etiology, but the evidence is very
strong in favor of the idea that the headache is a
manifestation of an infection with either actual mi-
crobic invasion of the tissues of the affected region,
or the selective action upon them of toxins pro-
duced by the organisms elsewhere. In a very large
proportion of the cases foci of chronic infection
can be found in the cranial sinuses or about the
mouth or nose and their cure often removes the
headache. Symptomatic treatment consists in the
prolonged, repeated application of heat and the em-
ployment of persistent massage of the afYected
region.
Bacteriological Examination for Meningococ-
cus Carriers. — L. D. Bushnell {Journal of Medical
Research, March, 1918) brings out some very well
known, but often neglected, points of interest to the
general practitioner which may make the, difference
between success and failure in identifying meningo-
coccus carriers. As soon as the swab is taken it
should be planted on the media on which it is to be
cultivated, and not carried around for any longer
time than is absolutely necessary before being taken
to the laboratory. The use of the West swab was
discontinued, as the swab itself was considered un-
satisfactory. The streaking method is particularly
helpful in the isolation of the microorganism. The
media used was a two per cent, meat infusion agar
to which had been added one per cent, peptone, 0.5
per cent, glucose, and five per cent, defibrinated
sheep's blood. Full directions are given for its
preparation, and for that of the stains used. The
plates may be examined in about twenty hours, and
l^etter results are obtained when they are warmed
before use. The type of colony, the method of
staining, and the agglutination reactions are de-
scribed in detail. The organization of an ordinary
laboratory staft so that 500 examinations are made
in a day is something of a problem, which was
solved by the following assignment of work : two
helpers washed and sterilized glassware and made
and sterilized swabs ; one person made media,
poured plates and made stains of colonies ; one ex-
amined plates, studied microscopic preparations and
made the agglutination tests ; one took swabs and
smeared them on the plates ; another streaked the
plates with the needle, and still another took the
names and numbered the plates with the corres-
ponding number. The carriers were isolated and
treated with a spray of an oil solution of dichlora-
mine-T. Of the persons examined, 2.52 per cent,
of the normal population were found to be carriers.
Proceedings of National and Local Societies
THE AMERICAN GYNECOLOGICAL
SOCIETY.
Forty-third Annual Meeting, Held in Philadelphia,
May i6, ly, and i8, 1918.
The President, Dr. John G. Clark, Philadelphia, in the
Chair.
{Continued from page Ui.)
Tubal and Ovarian Hemorrhage. — Dr. J. Wes-
ley BovEE, of Washington, D. C. said that trauma
played a part in producing these hemorrhages, as in
cases reported by Freeman, Primrose, and many
others. Hemorrhage from the Fallopian tube might
occur from general conditions that similarly afifected
other tissues. Venous stasis from circulatory dis-
turbances or pressure from tumors might be rea-
sonably included in a list of its causes. Ovarian
hemorrhage might be confined within the ovary,
forming heniatomata, or it might take place into the
peritoneal cavity producing, if abundant, an hema-
tocele.
No other organ of the body was so frequently the
seat of hemorrhage as was the ovary, and a large
amount of literature had been written on the pa-
thology of the ovary in ovarian hemorrhage.
Stromal hemorrhage was commonly preceded by
infection of the ovary.
In but few cases had correct diagnoses been made
before operation or autopsy.
As to treatment, in the milder forms of the con-
dition rest and anodynes might meet all indications.
In the severer forms the same rules applied as were
employed in the treatment of ectopic gestation.
The Results of the Conserved Ovary. — Dr.
John O. Polak, of Brooklyn, N. Y., from a study
of seventy-three reoperations on patients in whom
one or both ovaries were conserved, drew the fol-
lowing conclusions : i . Routine conservation without
due consideration of the ovarian and contiguous
pathology as it exists in the individual case, is not
good practice. 2. Regeneration of the conserved
ovary, depends largely on the type and duration of
the existing infection and the condition of the
tunica of the individual ovary. 3. Even where the
most detailed technic is observed, the ovarian cir-
culation is impaired. 4. The retained ovary, with-
out the uterus, is always a focus for possible trou-
ble. 5. The life history of the retained ovary is of
short duration and the trophic influence of the dis-
eased ovary has been overestimated. Finally, a
cured patient has few nervous symptoms.
The Effect of Hysterectomy upon Ovarian
Function. — Dr. Edward H. Richardson, of Balti-
more, Md., drew the following conclusions: i. The
ovary is a glandular organ of complex function, our
knowledge of which is at present far from complete.
2. The uterus is not essential to a continuation of
ovarian function, except as regards menstruation
and reproduction. 3. The advocates of total abla-
tion have not furnished convincing evidence of the
correctness of their contention. 4. The disturbances
of ovarian function attributed to hysterectomy are
partly those associated with normal menstruation
and partly those arising from damage to the ovary
through operati\ e trauma or disease. 5. The weight
of evidence furnished by anatomical, experimental
and clinical investigations is overwhelmingly in
favor of retention of sound ovaries both before and
after the menopause age.
Discussion. — Dr. Howard A. Kelly, of Balti-
more, believed in practice it was best to conserve
the ovaries or as much of healthy structures as
might be retained in women who were under forty,
and in women of forty or forty-two it was best not
to be so conservative. In the past we had decidedly
overdone conservatism. If we could conserve either
ovary and a portion of the uterus and keep up
menstruation, if only for a year or two, it was a
great advantage.
Dr. Walter W. Chiphan. of Montreal, Canada,
said that every effort should be made to care for the
circulation of the ovary that was left behind.
Within the past he had not been sufficiently careful
in this respect. He certainly was conservative in
the matter of the ovary. If a woman could be told
after an operation that the sexual organs were
preserved, it was a great psychological comfort to
her. It went without saying that where the ovaries
were diseased they should be removed. He had
given up the resection of diseased ovaries.
Dr. Henry T. Byford, of Chicago, stated that
so much attention should not be given to the s\-mp-
toms of the menopause. It was well not to enumer-
ate these symptoms to patients, but give them
ovarian substance or extract, and when they knew
they were getting it, the psychological condition
would be kept up, which was so necessary in these
cases, and there would be less oj^erating. With a
little treatment and advice along the line of mental
suggestion, we wotikl not have to do quite so much
surgery.
Prolapsus Uteri. — Dr. Walter W. Chipman,
Montreal, Can., gave a short description of the
true pelvic floor, in order to identify the essential
supports of the uterus and to get a correct under-
standing of the treatment of its prolapse.
In the treatment of prolapsus uteri, he stated that
in selected cases, especially during the cliild bearing
period, vaginal pessaries, j'troperly fitted and cared
for, had a distinct use. It was, however, of the
surgical treatment of this condition that lie desired
to speak. In all essentials, cystocele, prolapsus
uteri, and rectocele were hernias. The diaphragm
of the true pelvic floor had yielded. Its two halves
had been pushed aside or torn asunder, and between
them the bladder, the uterus, and anterior rectal
wall were dislocated and descended. These organs
slid downward, and in their descent gradually in-
verted the vagina. This surgical treatment, as in all
hernias, aimed at a radical cure. Here the dis-
carding of the terms anterior and posterior colpor-
rhaphy was urged, since these names no longer
accurately expressed the stirgical measures that
were undertaken. A much more adequate and ex-
pressive term was a radical cure of the cystocele or
rectocele.
352
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal
A Vaginal Hysterectomy Technic. — Dr. Dou-
GAL BissELL, of Ncw York City, stated that the
usual curved incisions were made about the cervix
at the vaginal mucosa junction and the mucosa
freed. Anteriorly the bladder was completely freed
from the vaginal wall and the cervix, the peritoneal
cavity was opened, the corpus delivered anteriorly
and the uterus removed from above down.
Throughout the operation the posterior tissues
formed a barrier, and prevented the intestines from
jjrotruding into the vagina and the blood from en-
tering the peritoneal cavity. They were cut last.
The two anterior vaginal wall flaps were trimmed
longitudinally to the e.xtent required and that to the
left of the operator was completely denuded of its
mucous membrane. The free cut margin of the de-
nuded flap was now anchored under the undenuded
flap by four mattress sutures to the stable portion
of the vagina on the opposite side. The undenuded
flap was anchored by three or more interrupted and
continuous sutures to the stable portion of the
vagina along the opposite sulcus.
A chromic gut suture, number two, penetrated and
was tied about each cut cardinal ligament, leaving
two free strands. One strand of each suture was
utilized as a running stitch along the cut surface of
the posterior vaginal wall, and the other was tied
to approximate the cut ends of the cardinal liga-
ments. The latter .sutures were again made to
penetrate the lower margin of the newly constructed
anterior vaginal wall and tied to the sutures pene-
trating the posterior vaginal wall.
When in cases of procidentia uteri it was found
advisable to retain the uterine body and amputate
the cervix, the mitial technic was identical to the
above, as was the lapping of the fascia. The
sutures anchoring the mucosa over the cervical
stump were placed so as to make the mucous edges
approach each other in a vertical direction instead
of a horizontal direction according to Emmet.
To correct a rectocele, a transverse incision was
made through the rectovaginal fascia into the
cellular area between the rectum and the vagina.
The tissues were freed laterally and longitudinally
and as the freeing was continued longitudinally a
median incision was made through the fascia and
mucosa, extending to within a short distance of the
cervix. The vaginal flaps were prepared for
lappiiig and were anchored in practically the same
way as described above in lapping the flaps of the
anterior vaginal wall.
One of the great advantages of the fascial
lapping technic here described, whether dealing with
a cystocele or rectocele, was that the finding and
following of only one line of fascial cleavage was
necessary. When this line of cleavage only was
followed, a minimum amount of bleeding resulted,
but when both lines of fascial cleavage were fol-
lowed a maximum amount of bleeding occurred,
which under certain conditions might terminate
seriously. Another important advantage in thus
utilizing the fascia without disturbing its continuity
was that a minimum amount of disturbance in its
circulation was occasioned and when the flaps were
anchored the circulation in them remained practi-
cally unimpaired.
Too much emphasis could not be laid on the de-
sirability of trimming the vaginal flaps to appar-
ently an excessive degree. Failure would occur if
the effect produced after the completion of the
operation was not that of overcorrection.
Cystocele. — Dr. Regin.\ld M. Rawls, of New
York City, said that from the time of the Egyptians
(1550 B. C.) to the Arabian School, the ancients
possessed a considerable knowledge of the mechani-
cal and local medicinal treatment of prolapsus uteri.
However, Hippocrates and Soranus referred to suc-
cessful vaginal hysterectomies when the uterus
could not be replaced or had become gangrenous.
The treatment in early modern gynecology, up to
the first quarter of the last century, was also prin-
cipally medicinal and orthopedic until 1828 when
Diffenbach performed anterior colporrhaphy for
prolapsus. He was followed in 1833 by Fricke and
in 1849 by Hugier.
In 1 8 S3 Baker Brown utilized in addition for his
denudation the vulva and perineum. In 1856 Sims
devised an improved method of anterior colporrha-
phy by his oval, V, and trowel denudations. Em-
met in 1862 made the V into a triangle and in 1869
devised his prolapse operations by utilizing the
fascia to support the uterus and bladder.
Jn 1874 Simon and Hegar simultaneously devised
an operation on the posterior wall, claiming this
would not only support the uterus but also the an-
terior wall and bladder. They were followed by
other operators some of whom also utilized both
anterior and posterior wall and LeFort made a
longitudinal septum in the vagina.
In 1887 ITadra made a decided advance when he
used flap splitting and elevation of the bladder.
.Saenger in 1888 used a similar method and was fol-
lowed in 1892 by Mackenrodt and Ouhrssen who de-
vised vaginal fixation. In 1895 Freund first deliv-
ered the uterus into the vagina, and was followed in
1890 bv Watkins. Wertheim, and Schauta who re-
ported the operation of transposition of uterus and
bladder. Various other vaginal operations had been
devised by Doleris, Reynolds, Hirst, AlexandrofT,
Tweedy, Dudley, Jelett, and others ; and among ab-
dominal operations for cystocele might be mentioned
those of By ford, Stone, Lawson, Dickinson, Polk,
and DuBose. In 1002 Gofife devised a vaginal opera-
tion for mobilizing the bladder and elevating and
supporting the bladder by suturing it to the uterus
and broad ligaments.
In the early part of the present century various
operations had been reported based on anatomical
studies. Operators who attempted to restore tlje
fascial sling of the anterior wall were Kreutzmann,
.SiDpel, Petersom, Violet, Martin, and Frank.
Martin demonstrated by his recent anatomical
investigation that cystocele was due to a lack of
fascia and connective tissue at the base of the blad-
der and showed that by dissection of the anterior
wall the fascia could be demonstrated, and by sutur-
ing the edges in the midline the cystocele would be
obliterated.
In the American Journal of Obstetrics, March,
]Qi8, Doctor Rawls reported a technic devised inde-
pendently by him of overlapping the fascia and re-
attaching it to the uterus bv transverse mattress
August 24, 191S.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
353
sutures, which were so applied as to carry the un-
(lerlapped fascia smoothly under the overlapped
fascia. His tirst operation was performed June 5,
1917, and it was therefore too early to make a final
report. However, in nineteen operations done by
this method he had always been able to demonstrate
a strong^ fascia that could be overlapped and the
primary results had been most satisfactory.
Prevention of Venereal Diseases. — Dr. J.
Montgomery Baluv, of Philadelphia, stated that
legislation in the line of prohibition had proven a
failure. All methods, single and combined, used in
the past had driven victims of the diseases to drug
store clerks and quacks. Education of the type so
far carried out had proven a failure. The holier
than thou attitude of the community had been most
disastrous. I'he method of control which gave any
promise whatever of success was the open treatment
of the whole subject on the basis of sanitation, deal-
ing with these venereal diseases as with any other
class of diseases.
The community must be taught that their old
attitude in regard to these matters was erroneous.
Hospitals must be forced to the position of repeal-
ing any rules that they might have prohibiting the
admission of these cases freely to their wards.
Sv'perintendents assuming the attitude of fear of
these diseases must be taught to change their at-
titude in these matters, or be driven out of the
business. Hospital staffs must have full liberty of
admission of such patients as in their judgment
needed hospital treatment. Hospitals running dis-
pensaries rnust open special dispensaries for the
treatment of these diseases. All advertisements in
public places of a quack nature must be abolished
and in their places proper types of notices of legiti-
mate clinics at which such sufferers might apply
must be substituted. This class of patients must be
taught that their confidences would be kept just as
secretly as would their confidence in any other class
of disease, and thev Vv'ere perfectly safe in anplying
to hospitals for treatment. Hospitals must gradu-
ally provide free treatment for those suffering with
these diseases who were unable to pay for treatment.
The question of registration by physicians of pa-
tients at public boards of health, excepting in an
extremely limited way, the name of the patient
being not involved, was most indiscreet if results
were to be obtained.
The Perineum in Primiparae. — Dr. Ralph H.
PoMEROv, of Brooklyn, N. Y., said that rending an
orifice to enlarge its calibre was strictly unsurgical.
He had condemned such a procedure in conditions
calling for prompt and large approach to the uterine
cavity through the cervix ; he cut in the median line
and reconstructed. The typical perineal laceration
associated with spontaneous first time expulsion of
a fully rotated occiput anterior position was median
in principle, crudely attained in fact. A median
perineotomy, preceded by thorough stretching of
the sphincter ani and executed with definite technic,
shortened the second stage more fortunately than
pituitrin or forceps. Even though the median in-
cision by intent or error extended through the re-
laxed sphincter, symmetrical repair was so simple
that failure of reconstruction was not to be ex-
pected. Repair of median perineotomy might be
easily done with buried and subcuticular catgut
stitching so effectively as to reproduce conditions
suggesting a nullipara. Such conditions, while
cosmetically commendable, did not presage the con-
version of the patient into a competent multipara,
potentially capable of spontaneous rapid delivery
without fresh wounds. He described a tentative
technic for an expanding perineorrhaphy.
The Conservation of Infant Life. — Dr. Collin
FouLKROD, of Philadelphia, stated that the investi-
gations of the Children's Bureau of the Department
of Labor of Wisconsin, of Massachusetts, of New
York and of Newark, had been productive of no
definite programme to make this question a national
one, to propose laws fitted to our country and the
needs. Such investigations had so far stopped short
of basic causes. We must pay, as a nation, our
families for producing effectives, and guarantee
them the right to develop by a system of govern-
ment which would be truly democratic. We must
insure our mothers. We must awaken women to
their responsibility. Advanced prenatal work would
in time eliminate preventable diseases, and would
bring the application of modern methods to non-
preventable diseases. In France the pregnant
woman was becoming a state care and ward. In
time we should have enough hospitals in each dis-
trict to scientifically care for all children born.
Why the Midvvife? — Dr. J. Clifton Edgar, of
New York, said that hospital records bore out
the fact that foreign born women, after their first
confinement under the care of the midwife, subse-
quently turned to the maternity hospital or a physi-
cian for obstetric aid. After a short residence in
this country, the foreign born woman did not usually
persist in the employment of a midwife. Her am-
bition was eventually to be in a financial position
enabling her to employ the services of a regular
practitioner.
During the existence of the Midwife Bellevue
School, 235 midwives had been graduated; 5,125
confinements had been conducted by- the pupils,
1,755 in the school, and 3,370 in the patients' homes,
with a maternal mortality of 0.7 per cent. Only
three cases died in the school itself, a mortality of
0.05 oer cent. Six others died after being trans-
ferred to Bellevue for operation. The 5,125 cases
cared for by the midwives at the Midwife School
and the patients' homes were practically all normal
labor cases, as fetal and maternal dystocia, and
bleeding cases, severe toxemia, and other abnor-
malities were sent to the Bellevue Obstetric Serv-
ice for treatment. As far as the handling of strictly
normal labor cases by the midwives went, the result
had been excellent. The records indicated that little
septic infection had resulted.
A plan for better and safer obstetrics in the out-
lying rural districts must recognize two main prob-
lems: I, the best practical care of normal cases, and
2. the detection of abnormal cases and their care.
By education and supervision the midwife might
be rendered reasonably safe for strictly normal
labor, safe even for a minimum of sepsis, or for the
prevention of ophthalmia neonatorum. But no
amount of education could fit the material, which
354
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
the physicians had been brought in contact with, for
the early care of prenatal complications, and
maternal and fetal dystocia, which caused most of
the infant and maternal mortahty. Who should de-
termine what was a strictly normal labor? The
midwife? She was incompetent to do so; only the
trained obstetrician could accomplish this. The
midwife could never stand upon her own responsi-
bility. For safe obstetrics the obstetrician must
ever perform the prenatal examination and care.
He must ever be at hand for the maternal and fetal
dvstocia of labor and tlie complications of the post-
natal period.
Pernicious Anemia Complicating Pregnancy.
— Dr. PAL^rER FiNDLEV, of Omaha, Neb., said that
while pernicious anemia was not a disease peculiar
to pregnancy, it was nevertheless true that the dis-
ease occurred with unusual frequency in the course
of pregnancy and the puerperium. Fichhorst in a
series of fifty cases of pernicious anemia in women
found twenty-nine were associated with pregnancy
and labor. Clibio, Caruso, and Bertino found 0.15
per cent, pernicious anemia in all pregnancies, while
I.ebert and Myerrugg estimated the frequency at
0.22 per cent. We were told that pernicious anemia
was more common in women than in men, but ex-
cluding all cases arising in the period of gestation
the percentage of frequency was higher in men.
Just what the predisposing factors were in preg-
nancy was not known. Prolonged lactation, fre-
quent child bearing, the toxemias of pregnancy, and
unfavorable hygienic surroimdings were factors to
be reckoned, but were not conclusive. Neither post-
partum hemorrhages nor puerperal infection tended
to develop pernicious anemia if we were to judge
from case records. With few exceptions, pernicious
anemia rarely developed in a primipara, and was
more frequently observed in a pregnancy which
had been preceded by the birth of several children
in rapid succession.
The blood findmgs in the mother were charac-
teristic. The red cells were decreased in number,
even to 250,000. The blood did not show a propor-
tionate decrease in its hemoglobin content, but there
was a marked alteration in the shape, size, and
staining of the individual cells. Macrocytes and
microcytes abounded and megaloblasts were occa-
sionally present. Nticleated red cells did not as a
rule appear until the disease was well advanced ;
they tended to appear in showers, and in some cases
had failed to appear or at least had not been found
even in the last stages of the disease. Poikilocyto-
sis was a marked feature ; fibrin and blood platelets
were diminished and the leucocytes were lessened
in number.
In every frank case of pernicious anemia compli-
cating pregnancy the maternal mortality was prac-
tically TOO per cent., although in exceptional cases
death might be deferred for a period of weeks,
months, and even a year or more following child-
])irth. 1'hcre might be periods in which improve-
ment might^ l)e great, but the end result was always
the same. The earlier in pregnancy the disease ap-
peared, the more rapid its course and the graver
the prognosis.
The management of these cases might be said to
be in the interest of the mother in the early stages
of the disease and of the child in the late stages of
the disease. Where the disease was well advanced,
the fetus developmg and approaching the period of
viability, pregnancy should be allowed to proceed to
term, if possible, in the hope of delivering a healthy
child. The case of the mother was hopeless and no
good could come from sacrificing the child by the
interruption of pregnancy.
Two cases of pernicious anemia complicating
[iresrnancy were reported, with one death.
The Treatment of Puerperal Blood Stream In-
fection by Means of Arsenobenzol. — Dr. H. A.
Miller and Dr. S. A. Chalfant, of Pittsburgh,
stated that no form of intravenous medication up to
the present time had been entirely satisfactory,
although many had been tried. Puerperal bacteri-
emia had always been a very serious condition with
a liigh mortality.
The treatment as used in these cases was followed
up by experimental work by Allison. He found that
arsenobenzol, together with similar preparations,
could be given frequently in large doses without
injury to animals, that the mortality was less in
treated than in vmtreated animals, and that the in-
jection of arsenobenzol would usually rid the blood
stream of streptococci in twenty-four hours.
He also showed that there was a fall in the leu-
cocyte count before the blood culture again became
positive.
The authors had treated eleven cases of puerperal
infection by means of arsenobenzol given intra-
venously usually in six gram doses as frequently as
three or four day interv^als, giving from one to four
doses. There were no toxic effects other than a
mild albuminuria.
Seven patients had a streptococcus in the blood
stream with two deaths ; two a Gram negative
bacillus, with no deaths : and two had a negative
blood culture but were both clinically bacteriemic
and both died.
Two patients had intrauterine irrigations at two
hour intervals with Dakin's solution, of whom one
recovered and one died. In the fatal case autopsy
showed the uterus free from infection. Death was
due Lo multiple abscesses of both kidneys.
Conclusions: i. With the use of intravenous in-
jections of arsenobenzol, we have been able in every
instance to rid the blood stream of its invading
organism. 2. All varieties of organisms so far en-
countered seem to be equally influenced. 3. Cul-
tures from localized abscesses are usually identical
with cultures from the blood stream. Cultures from
the uterus, although this organism predominates,
are rarely pure cultures. 4. Reinfections from focal
infections may and do occur, but are as readily in-
fluenced by arsenobenzol as the original infections. 5.
The leucocyte count is usually low in comparison
with the temperature and pulse. After arsenobenzol
has been given there is a marked increase in the count.
If, after this time, there is a decided decrease in the
leucocytes with a corresponding improvement in the
patient, including the pidse and temperature, it is
very possible that the patient has reinfected herself,
and arsenobenzol should be given without waiting
for confirmation of this culture report. 6. The
August 24, 191 8.]
PROCEEDINGS OF NATIONAL
AND LOCAL SOCIETIES.
355
blood stream is usuall}' found to sterile in
twenty-four hours, always in forty-eight hours, ex-
cept in one case where but four grams of arseno-
bcnzol was given. 7. Rabbit experiments made by
Dr. C. S. Allison would indicate that a dose of six
milligrams is necessary to secure prompt results.
8. In suspected blood stream infections arsenobenzol
may be given immediately after a culture has been
taken in order to avoid tlie delay incident to waiting
for a laboratory report.
Pathological Conditions Associated with Myo-
mata Uteri. — Dr. Le Roy r>ROUN, of New York
said that he had reviewed all of the myomata
operated on at the Woman's Hospital during the
past eight years, ending with September, 1917.
There were 1,500 such cases. All of these had
some form of hysterectomy or myomectomy. As a
result of the operations, twenty-eight patients died.
Of these, seven died from embolus, chiefly between
the eighth and twentieth day. Seven died from
peritonitis, and the remamder from various causes.
The percentage rate of 1.86 could be taken as a fair
estimate of the mortality of operations for this con-
dition, since it represented the results of the com-
bined operative work of a large attending and
junior attending staff, together with that of a large
corps of surgeons, who were given the privilege of
sending their patients to the private rooms of the
hospital. This compared favorably with 1.73 per
cent, reported by Deaver in 759 cases covering a
period of eleven years .and with 1.75 per cent, re-
ported by Frank in 400 cases operated on by Bret-
tauer and himself. Associated with the total num-
ber of cases (1,500) sixty-six malignant conditions
were found, twenty-nine of which could be unques-
tionably determined before operation. It was
doubtful whether all of the seven cases of sarcoma
could have been determined, and it was certain that
the nature of the remaining twenty-one cases of
malignancy, ovarian carcinoma, four, and papillo-
matous cyst, seventeen, could not have been previ-
ously diagnosed before opening the abdomen.
Of the ovarian pathology associated, fifty-eight
cases occurred. The previous recognition of any of
these conditions before operation, excluding the
four instances of abscess of the ovary, would de-
pend entirely on the size and character of the
myoma present, also on the size of the pathological
ovarian conditions associated. There were 265
cases of associated tubal disease, the majority of
which would have required at some time surgical
interference. To what extent the circulatory dis-
turbance as a result of the presence of the tumor
was the cause of the predominating presence of
salpingitis, could not be stated. No tube was, how-
ever, reported as the seat of inflammatory changes,
unless positive pathological examination and evi-
dence showed such a condition. A large number of
uterine appendages were removed in connection
with hysterectomies in patients about the meno-
pause, in whom only minor pathological changes
were found. None of these were included among
the 150 cases of salpingitis cited. One hundred and
sixty-seven chronic or subacute appendices were
found. There were nine instances of associated
extrauterine pregnancy and fifty-one of normal
pregnancy. Three hundred and fifty-five cases,
23.7 per cent, of the 1,500 consecutive myomatas
operated on, contraindicated the use of radium and
the x ray. He was convinced from a review of
these cases that the symptoms, on account of which
the majority of patients entered the hospital, were
due in the greatest measure to conditions outside of
the uterus and not to the presence of the tumor
itself, unless it was from hemorrhage.
Two Hundred and Ten Fibroid Tumors Treat-
ed by Radium. — Dr. Howard Kelly, of Balti-
more, INld., said that the only effective method of
treating fibroid tumors of the uterus up to the
present time had been the surgical, developed with
such care through two generations that the opera-
tion had become in skilled hands one of the safest
of our major procedures.
The author had operated in this way upon 2,000
women but felt now that the radium treatment,
which was without danger and which was found
effective in ninety-three per cent, of the cases,
should be preferred to the operation, which was,
after all, a major operation of mutilating character
ofi'ering considerable risk to life and health.
He stated his thesis with regard to the ac-
compHshments of radium in this class of cases as
follows: I. Control of hemorrhage and checking of
menstruation. 2. The shrinkage of the tumors. 3.
In many instances the disappearance of the tumors.
4. In some cases, even after two years, the return of
menstruation either normal or scanty. There had
been no mortality associated with the treatment of
210 consecutive cases.
Between the dates of March 23, 1913, and Janu-
ary 8, 1918, 2TO cases of uterine fibroids were
treated with radium by the author and by Dr. Curtis
F. Burnam, and forty-five cases were operated on
either because there was some contraindication to
treatment or because operation was preferred.
In twenty-eight of these 210 cases, the data was
insufficient ; six did not complete treatment, al-
though four of these were markedly benefited ;
seven had been lost sight of ; two died of causes
unconnected with the treatment ; thirteen were too
early for results to be reported with certainty.
There were, therefore, 182 cases in which the re-
sults were known. In 171, or all but eleven cases,
radium alone was sufficient to relieve the patient.
In these 171 cases (93 per cent.) the tumor was
either gone or markedly diminished, or the patient
was symptomatically well. In five of the eleven
cases, some complicating condition w^as present
(ovarian cyst, gallstones, calcified uterus) ; in two
cases operation was preferred to further treatment ;
in three cases operation was found not to have been
necessary as the tumor had decreased under treat-
ment ; one case proved resistant to prolonged treat-
ment. Nine of the eleven cases were operated on.
The fact should be emphasized that if radium
failed, the operation has simply been postponed
without detriment to the patient.
The technic of the treatment included a prelim-
inary curettage both to rule out malignancy and to
remove any small polypi which might be found to
exist. The average inside application was for three
hours with 500 mc. of emanation. A small glass
356
LETTERS TO THE EDITORS.— BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
bulb was placed in the end of a metal tube, suf-
ficiently thick to screen off all but the gamma rays.
This tube was screwed on to a uterine sound and
wds then covered by a rubbei* cot. The cervix was
dilated and the sound introduced to the top of the
uterine cavity. The applicator was gradually with-
drawn, not being allowed to remain longer than one
half hour on each spot. In the external treatments
to shorten the time, four to five grams of radium
were being used and the entire treatment could be
given in from five to six hours. In any one case the
treatment, internal and external, could be given in-
diviilually or combined in any desired method. At
least seven weeks should be allowed to elapse before
a second treatment was given and it should not be
given if an amenorrhea was already obtained.
Usually the second should be an external one.
Some tumors reduced rapidly ; others slowly over a
year or more.
Menopausal symptoms were usually not severe.
In fifty per cent, of the cases, no menopausal symp-
toms were complained of ; in slightly more than
twenty-five per cent, they were moderate and in
slightlv less than twenty-five per cent, they were
marked.
( To be concluded.)
Letters to the Editors.
SPANISH INFLUENZA.
New York, August i8. igi8.
To the Editors:
I have recently arrived in this city from Spain, where I
travelled extensively during the last nine months. When
I was at Madrid, in April, the so called Spanish influenza
broke out in that city, the very first place in Spain that
suffered from it. I took the trouble to investigate the
cause of the epidemic, its symptoms and complications, and
afterwards studied its spread to Barcelona, Valencia ancf
other cities, which I also visited.
On July 19, 1918, I published a letter in The New York
Herald contradicting the opinion of a nonprofessional per-
son, also just arrived from Spain, who had informed that
journal "that Spanish influenza was caused by the infected
air blown into Spain from the western front of the present
war." And I personally gave to the editor of a medical
journal my opinion of the cause and nature of that epi-
demic disease, its symptoms and complications, because he
had published that very week an editorial note about it ;
but he has not thought it worth while to say anything in
his journal concerning my personal opinion and observa-
tions in Spain of that epidemic.
Having read in today's Herald that five sailors of a large
Dutch steamer arrived last Friday at this port of New
York from Rotterdam died on board of pneumonia as a
sequela of Spanish influenza ; that a large number of the
cabin passengers were down with the mysterious disease
during the voyage, and that several third class passengers
had been removed to Saint Vincent's Hospital for treat-
ment ; also that the health officials of New York City were
taking vigorous steps to safeguard it from the spread of
Spanish influenza, I address this letter to you with the de-
sire to help solve the problem.
The nonprofessional opinion of the person informing
The Herald that the infected air blown into Spain from
the western front of the war in France was the cause of
the epidemic disease in Spain, is of course pure nonsense,
simply because Madrid is situated almost in the centre of
that country, and Madrid was the very first place where the
outbreak occurred. My own conviction is that the disease
in question is neither new nor extraordinary, but solely and
alone grippe or epidemic bronchitis, which is at present
attacking the inhabitants of Havana, Cuba, and is well
known there with the Spanish name of trancazo. that is
to say, a blow with a heavy stick. Some of its symptoms
resemble those of dengue fever.
In Spain the epidemic was caused and was easily spread
by the unhygienic conditions of the cities, particularly of
Madrid, the capital. Before the outbreak of the epidemic
1 attended in Madrid several meetings of the Spanish So-
ciety of Hygiene, read in one of them a paper of mine, and
became convinced from what I heard there of the need of
precautionary measures of public health. And the unmis-
takable practical proof of that necessity was the presence
of an extraordinary abundance of flies all over the country.
I was present, by special invitation of the operating sur-
geon. Professor Enrique Lopez, at the ovariotomy per-
formed by him in the Hospital Provincial, in Valencia, and
the flies in the operating room were so numerous that they
posed on the naked arm of the surgeon while he was doing
the operation, and on the faces, heads and necks of all the
physicians who were in that room, including myself.
I am preparing a paper to be read before some one of
the medical societies of this city, which I shall entitle "Hy-
gienic Misconceptions in Spain."
A. M. Fernandez- Ybarra, A. B.. M. D.,
Corresponding Member of the Spanish Society of Hy-
giene of Madrid in the United States.
%
Births, Marriages, and Deaths.
M arried.
Freunl/Lich-Groner. — In New York, on Monday, August
I2th, Dr. M. L. Frcundlich and Miss Ruth Groner.
Died.
Butcher — In Heislerville, N.* J., on Saturday, August
3d, Dr. Joseph Butcher, aged fifty-nine years.
Calder. — In Claysville, Pa., on Monday, July 22d, Dr.
George Calder, aged eighty-three years.
Callaghan. — In New Haven, Conn., on Thursday,
August 8th, Dr. Patrick J. Callaghan, aged fifty-four years.
Cole. — In Fort Sam Houston, Texas, on Thursday,
August 8th, Lieutenant Colonel Qarence Le R. Cole, Medi-
cal Corps, LI. S. Army, aged forty-one years.
Fat.ge. — In Manitowoc, Wis., on Sunday, August 4th,
Dr. Louis Falge, aged fifty-seven years.
GiLLAPD. — In Sandusky, Ohio, on Sunday, August
nth. Dr. Edwin E. Gillard, aged seventy-three years.
GuLiCK.— In South Casco, Me., on Tuesday, August loth,
Dr. Luther H. Gulick, of New York, aged fifty-three years.
Hklm. — In Columbus ,Ohio, on Wednesday, August 7th,
Dr. William M. Helm, aged seventy-one years.
Howell. — In Camden, N. J., on Friday, August gth. Dr.
Mary Anna Howell, aged seventy-one years.
Leonard. — In Detroit, Mich., on Sunday, August nth.
Dr. James A. Leonard, aged sixty-four years.
Mann. — In Bridgeport, Pa., on Saturday, August 3d,
Dr. Charles H. Mann, aged sixty-five years.
Morrow. — In Kalispell, Mont, on Thursday, August 1st,
Dr. Arthur Morrow, aged fifty-four years.
Nf^fif. — In Jersey City, N. J., on Wednesday, August
7th, Dr. Harry Neafie, of Freehold.
Osborne. — In Lawrenceville, Va., on Friday, August gth,
Dr. Andrew J. Osborne, aged forty-nine years.
Robinson. — In West Newton, Mass., on Saturday, Au-
gust loth, Dr. Francis E. Robinson, aged seventy-three
years.
Ross. — In Brooklyn, New York, on Monday, August
i2th, Dr. Frank Harper Ross, aged sixty-two years.
Stowe. — In Salina, Kan., on Friday, July 19th, Dr.
Charles \V, Stowc.
Whitley. — In Webster City, la., on Sunday, July 21st,
Dr. Frank E. Whitley, aged sixty-one years.
Van Deusfn. — In Philadelphia, Pa., on Friday, August
gth. Dr. Isaac Van Deusen, aged eighty-nine years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal r£ Medical News
A Weekly Review of Medicine, Established 1 8 43
Vol. CVIII, No. 9.
NEW YORK, SATURDAY, AUGUST 31, 1918.
Whole No. 2074.
Original Communications
PASTEUR'S RELATION TO MEDICINE AND
SURGERY.*
By W. C. Borden, M. D., F. A. C. S.,
Washington, D. C,
Lieutenant Colonel, M. C; Professor of Surgery, George Washington
University; Chief of the Surgical Service at the
Walter Reed General Hospital.
On Friday, December 27, 1822, in the small town
of Dole, in western France, was born of humble
parents, Louis Pasteur, one of the greatest original
investigators of all time. This eminent scientist was
to disprove beyond question the doctrine of spon-
taneous generation, was to establish the basic facts
of the causative relation of microorganisms to fer-
mentation, decomposition, and disease ; by the prac-
tical application of his findings he was to rescue
from bankruptcy several of the most importan^
agricultural activities of France, and t&y the fou
datioh for our modern concept of the transmission
of communicable diseases and the treatment of in-
fections by vaccines and serums.
To understand the conditions which surrounded
Pasteur at the time he did his work it will be well
to briefly review the status of medicine and surgery
in the first half of rtie nineteenth century when he
began his researches.
The teachings of Galenic medicine had persisted
up to the first half of the sixteenth century, when,
coincident with the religious reformation begun by
Luther, a medical new birth took place under the
initiative of Vesalius in anatomy, Pare in surgery,
and Paracelsus in medicine. Dogmas and intro-
spective thinking along all lines gradually gave way
to original investigations into the facts of nature
and deductions therefrom. The scalpel explored
the mysteries of normal human anatomy and Beni-
vieni and Fernel laid the foundation of pathology
by pointing out the value of the examination of the
dead body for discovering the causes of disease.
In the seventeenth century this new spirit of re-
search spread throughout all the centres of learning
in Europe, especially in England, the Netherlands,
and France. The progress of science in* Germany
and Central Europe was delayed by the Thirty,^
Years' War with its resulting devastation, loss of X
life, and pestilence, but in all directions other than
the war smitten areas, there was a breaking away
from old beaten paths with the result that progress
in knowledge was decided and material.
*Read before the Medical History Club of Washington, D. C.
In the favored countries medicine brought for-
ward the names of Harvey, Van Helmont, Sylvius,
Borelli, and Sydenham ; Descartes, Bacon, Hobbes,
and Locke produced their works on philosophy ;
Galileo confirmed the truth of the revolution of the
earth about the sun, enunciated in the previous cen-
tury by Copernicus ; Newton made his wonderful
discovery of the law of gravitation ; Romer calcu-
lated the velocity of light, and Huygens discovered
the polarization of light, a physical phenomenon
which Pasteur later used in making his first con-
tribution to science — namely, the discovery of the
isomeric forms of tartaric acid.
The greatest physiological discovery of this cen-
tury was that of the circulation of the blood by
Harvey, published by him in 1628. Forty years
later Malphigi completed the demonstration by
showing the capillary circulation and Leuwenhoek
described the blood corpuscles and their movements
in the small vessels of the larva of the frog.
In the next century (eighteenth), that preceding
the birth of Pasteur, Haller proved the existence of
the irritability of the muscles and extended the
knowledge of the intimate structure of the heart, the
brain, and the lymphatic system. Morgagni, by his
wonderful work, t)e Sedibus et Causis Morborum,
founded pathological anatomy as a science. Aven-
brugger discovered percussion and Laennec was the
first to teach and practice auscultation. The father
of English surgery, John Hunter, made many
researches and so memorable was his work in hu-
man and comparative anatomy and in surgery that
to commemorate him a Hunterian oration is still
given annually at the Royal College of Surgeons in
London, and his operation for aneurysm is used in
appropriate cases.
The one piece of work in the eighteenth century
which was of greatest benefit to mankind and which
was most closely related to that afterward done by
Pasteur, was the establishment of vaccination for
smallpox by Jenner, who in_ consequence is known
as the father of vaccination.
Parenthetically we may say that of the men who
by their discoveries have done the most for preven-
tive medicine, Jenner was the first ; Pasteur the
second : and Ross and Walter Reed, by establishing
the causative factors of malaria and yellow fever,
the third and fourth. Also, it is safe to say that the
work of these four men has been of more economic
value and has more influenced the commerce and
Copyright, 1918, by A. R. Elliott Publishing Company.
358
BORDEN: PASTEUR'S RELATION TO MEDICINE AND SURGERY.
[New York
Medical Journal.
welfare of mankind, than have the findings of any
other investigators up to the present time.
When Pasteur was born, researches had already
been made which were closely related to the work
he was to inaugurate and carry to successful accom-
plishment.
Two centuries before Pasteur's time, Harvey
published his treatise on generation, notable in that
it entered a field almost untrodden from the days of
Aristotle, but which was overshadowed by the
greater importance of his work on the circulation
of the blood. In it, Harvey brought forward the
original dictum that almost all animal ova are pro-
duced from eggs usually quoted Omnc vivum ex ova
and which was to be followed more than 200 years
later by \'irchow's celebrated dictum. Omnis ccUula
e cellule. Thus Harvey's treatise declared against
spontaneous generation, a doctrine whose death
blow was to be dealt by Pasteur. This theory which
included such absurd ideas as that frogs were gene-
rated from the mud of the Nile and that maggots
were formed from decaying cheese, lost ground
following the publication of tlarvey's work, but be-
lief in it was renewed at the end of the seventeenth
century, when the improvement of the microscope
by Leuwenhoek brought to view the minute forms
(bacteria) found in all dead vegetable and animal
matter, whose existence was explained only by the
supposition that they were spontaneously generated
therein.
Ehrenberg published an imperfect grouping of
bacteri^a in 1830 which covered practically all that
was known of these minute forms of life up to and
during Pasteur's researches, but not until Cohn
published his work between 1853 and 1872 was
there any accurate knowledge of them.
In the early part of the nineteenth century our
modern concept of the minute structure of the
human body was just being formed. In 1838
Schleiden enunciated the cellular theory of the
construction of the tissues of plants, and
Schwann, in thefollowing year, extended the same
idea to animals. The original work of Schleiden
and Schwann ideated the cell, as the word cell
implies, as an inclosure the wall of which was a
vital part. They supposed new cells to arise by
a sort of crystallization from a mother liquid or
cytoblastema. In 1861 Max Schultze presented
the fact that the cell is "a small mass of proto-
plasm endowed with the attributes of life." A^ir-
chow's cellular pathology was published in 1858,
then establishing for the first time the great truth
that all cells, whether animal or vegetable, origi-
nate from preexisting cells.
When Pasteur began his researches in fermen-
tation and decomposition the greatest authority
in chemistry was Liebig, .who held that these pro-
cesses were the result of chemical activities and
long opposed Pasteur's discovery that they were
in reality due to the action of microorganisms.
In the sixteenth century the alchemists of the
fifteenth century had been succeeded by the
iatrochemists, who held that chemistry is the art
of preparing medicine. This school, in turn, had
succumbed to^ the arguments of Boyle, who
taught that chemistry is the science of the com-
position of substances. Later, Lavoisier formu-
lated the law of the conservation of mass, Dalton
and Berzelius, the law of chemical combination,
the notation of atoms, and equivalents, and thes^
discoveries were followed by the brilliant re-
searches of Avogadro, Ampere, and others, and
by Frankland's conception of valency and the
periodic law.
The belief that the formation of organic com-
pounds was conditioned by a vital force and the
supposed impossibility of synthesizing organic
compounds had been shaken by Wohler's synthe-
sis of urea in 1828; and Demas and Liebig about
1837, by defining organic chemistry as the chem-
istry of carbon radicals, laid the foundation of
modern organic chemistry.
Pasteur was educated as a chemist, but most
of his research work was done with the micro-
scope ; even his detection of the two forms of tar-
taric acid was made b}' the aid of that instru-
ment. The first real improvement in the micro-
scope objective dates from T830. only eight years
after Pasteur's birth, when V. and C. Chevalier
produced objectives, consisting of several achro-
matic systems arranged one above the other. It
is an interesting coincidence that Joseph Jackson
Lister did important work in improving the mi-
croscope— the instrument which in the hands of
Pasteur was to assist in laying the foundation
upon which Lister's distinguished son Joseph,
afterward Lord Lister, was to place his super-
structure of antiseptic and aseptic surgery.
From the foregoing it wdl be seen that when Pas-
teur began his invasion into the realm of scieijce
l^racticaily nothing was really known of the vast
world of microorganisms; the cell theory of or-
ganic structure had just been enunciated, the the-
ory of spontaneous generation had been revived,
and the foundation of chemistry had but recently
been laid.
Following this very general vitw of the condi-
tion of medicine and its allied sciences at the time
of the beginning' of Pasteur's researches, it will
be well to particularize the surgical conditions
which then obtained.
In surgery there was no accepted concept of
the idea that the conditions which we now know
as septic were communicable. Semmelweiss, in
advance of his time, w^as teaching in Vienna
those facts relative to the transmission of puer-
peral fever which have given him an eminent
place in the history of medicine, but his opinions
met with such bitter opposition by Klein and
other reactionary teachers that his work was
buried, forgotten, and not resurrected until after
the antiseptic researches of Lister.
In 1846 Alorton introduced the use of ether as
a general anesthetic and the first operation under
general anesthesia was done in the IMassachu-
setts General Hospital. The following year Sir
James Simpson introduced the use of chloroform
in England.
Apparently through anesthesia a new era w^as
opened in surgery. The doing away with the
dreadful pain which had prevented the perform-
ance of large surgical operations, except in direst
August 31, 1918 ]
BORDEN: PASTEUR'S RELATION TO MEDICINE AND SURGERY.
359
necessity, allowed operations to be undertaken in
great number. But the use of anesthetics, by
permitting- more operations to be done, instead
of being a blessing, proved to be the reverse of
beneficial. The great number of operations per-
formed under the septic conditions which then
obtained caused septicemia, pyemia, and gangrene
to sweep through the wards of hospitals with re-
doubled fury, and the greater number of opera-
tions meant a greater number of deaths. In con-
sequence anesthesia, wdiile it ameliorated pain,
was indirectly the cause of increased mortality
in both hospital and general surgery, and did not
reach its complete efficiency until it was com-
bined with asepsis and antisepsis.
The surgeon of that day had neither felt the
need of nor practised cleanliness. To wash his
hands before an operation was, in his opinion,
unnecessary, as they would soon be soiled by the
blood of the patient. When the formal frock
coat of the time was too old for ordinary use, the
surgeon kept it in the operating room to wear in-
stead of his better coat when he operated, and
that his ligatures might be ready, they hung in
the buttonlioles and his needles were thrust into
the lapel. His only prepaiation was to don his
old coat and roll up his sleeves ; and during an
operation he often found his lips a convenient
place to hold his instruments. The same pro-
fessional hand, often unwashed, dealt with
wouiids, abscesses, obstetrical cases, and not in-
frequently with post mortems. In the hospital
wards, a single basin and a single sponge were
carried from patient to patient and used indis-
criminately upon all.
With our present knowledge it is easy to account
for the dreadful results in surgery under such con-
ditions. In the hospitals of Edinburgh. Glasgow,
and London, two in every five amputations, includ-
ing those of the smallest members, ended in death.
The high death rate was not the only disaster.
No statistics can give the unspeakable suffering of
patients aft'ected with hospital gangrene, pyemia,
virulent septicemia and other pathological conditions
incident to these afflictions.
In some hospitals the pathogenic microorganisms
were so disseminated and had been raised to such a
degree of virulence that practically every patient
whose skin was broken either by accident or by the
smallest surgical operation died, for fatal wound
diseases and complications were never absent.
Sir Hector Cameron, who worked under Lister
when the latter made his first attempts in the di-
rection of antisepsis, draws a vivid picture of the
surgical horrors then existing :
■'Every wound discharged pus freely and putre-
factive changes occurred in the discharges of all,
producing in the atmosphere of every ward no mat-
ter how well ventilated, a fetid, sickening odor
which tried the student on his first introduction to
surgical work just as much as the unaccustomed
sights of the operating theatre."
Writing of hospital gangrene in i8or, John Bell
says : "When it rages in a great hospital, it is like
a plague ; few who are seized with it can escape.
There is no hospital, however small, airy, or well
regulated where this epidemic ulcer is not to be
found at times ; and then no operation dare be per-
formed. Every cure stands still — every wound be-
comes a sore, and every sore is apt to run into
gangrene, but in great hospitals especially it
prevails at all times and is a real gangrene.
It has been named the hospital gangrene, and
such were its ravages in the Hotel Dieu of
Paris (that great storehouse of corru^ion and dis-
ease) that the surgeons did not dare to call it by its
true name ; they called it the rottenness, foulness,
sloughing of the sore. The word, hospital gangrene,
they durst not dare pronounce, for it sounds like
a death bell ; at the hearing of that ominous word,
the patients give themselves up for lost. In the
Hotel Dieu this grangrene raged without intermis-
sion for two hundred years, till of late under the
new government of France, the hospital has been
reformed."
"A young surgeon" says a French author of that
time, "who is bred in the Hotel Dieu, may learn the
various forms of incisions, operations too, and the
nianner of dressing wounds, but the way of curing
wounds he cannot learn. Every patient he takes in
hand, do what he will, must die of gangrene."
In Volkniann's clinic at Halle, the mortality in
complicated fractures as late as 1872 was forty per
cent. Lindpainter from Nussbaum's clinics in Mu-
nich wrote "eighty per cent, of all wounds were at-
tacked with hospital gangrene. Erysipelas was so
frequent with us that we might have regarded it as
almost an expected occurrence. Out of seventeen
cases of amputation m one year eleven died of py-
emia alone."
Those were the times in which wound fever, in-
flammation, and suppuration were regarded as in-
separable and were thought to be the natural reac-
tion of an injured organism, hence the expression
"laudable pus" which was then so ujiiversally used.
Even with those patients who were fortunate
enough to recover, convalescence was always ex-
tremely protracted. Nussbaum in 1875, complained
of the hospital regulations which limited the treat-
ment of persons of the lower class to nine weeks,
stating that for many this period was insufficient ;
for. by reason of mflammation, even in trivial
wounds, the healing process was not completed until
after a much longer time. Union, after amputation
of the breast, then required from one fourth to one
half a year and healing of amputations often oc-
cupied months. So late as 1872, aside from
Cjesarean section, the only intraabdominal operation
described in textbooks was that of ovariotomy, first
performed by McDowell, of Kentucky, in 1809; and
considered by most authorities as an unwarrantable
operation on account of the high mortality. Out-
side the gates of Paris stood a small residence
known as the house of death for the reason that six-
teen patients had been taken there for ovariotomy
and all had been brought av/ay in their coffins.
It was then that Pirogoff, one of the greatest sur-
geons of his day, wrote his dissertation upon
"Fortune in Surgery" wherein, after enumerating
and discussing all the then known etiological factors
of post operative and post traumatic conditions,
such as age, sex, environment, and diathesis, and
36o
BORDEN: PASTEUR'S RELATION TO MEDICINE AND SURGERY.
[New York
Medical Journal.
realizing that all causative conditions then known
could not and did not explain the untoward effect of
trauma, gave expression to the overwhelming feel-
ing of powerlessness then present in surgerj^ by say-
ing: "The influence of the physician, the therapeutic
resources and mechanical dexterity are of no im-
portance ; the results of an operation are dependent
entirely iipon chance."
Sir James Simpson, in an address delivered in
Edinburgh in 1853 said: "I believe that, at the
present moment, any individual in the profession
who in surgery or in midwifery could point out
some means of curing — or some prophylactic means
of averting by antecedent treatment — the liability to
these analogous or identical diseases, would, I say,
make, in relation to surgery and midwifery, a
greater and more important discovery than could
possibly be attained by any other subject of investi-
gation. Nor does such a result seem hopelessly un-
attainable." Little did Simpson think that at that
very time in France those studies were beginning
which would lead within his own generation to a
realization of the hope which he expressed.
The dawn of light in the darkness of medicine
and surgery was to be ushered in by the work of
Pasteur.
Pasteur's father, Jean Joseph Pasteur, after
serving in Napoleon's armies, where he rose to the
grade of sergeant and was decorated with the cross
of the Legion of Honor, upon the dissolution of
the Empire, took up his family trade of tanner,
married Elmennette Roquie, the daughter of pros-
perous peasants, and in their humble home Louis
was born.
Pasteur first attended the ccole primaire at-
tached to the college of Arbois, to which town his
parents had moved from Dole. He received the
degree of bachelier des lettres from the college of
Benascon. In 1842 he passed his examination
(baccalaureat des: sciences) before the Dijon Fac-
ulty being put down in chemistry, the science he
was later to adorn, as mediocre.
After occupying several teaching positions, during
which time he published his findings regarding tar-
taric and other acids, Pasteur, in 1854, when thirty-
two years of age, was made dean of the Faculte des
Sciences at Lille.
In his inaugural address. Dean Pasteur said :
"In the fields of observation chance only favors the
mind that is prepared." He was shortly to ex-
emplify the truth of his own statement by the
matter which almost by chance was to be brought to
his hand.
M. Bigo, whose son was one of Pasteur's pupils,
had trouble with the production of beetroot alcohol
in the manufacture of which he was engaged. His
son advised him to come to Pasteur for advice and
thereupon Pasteur began a series of investigations
in regard to fermentation, putrefaction, and spon-
taneous generation which, together with succeeding
researches, was to have the most profound influence
upon surgery and medicine.
In 1836, Lateur had published experiments by
which he claimed to prove that minute specks which
he saw in yeast were alive. Schwann, the author of
the cell theory, also came to the conclusion that
these minute particles were alive and that as a result
of their growth, sugar was changed into alcohol in
the process known as fermentation.
Both Lateur and Schwann held also that putre-
faction of vegetable and animal substance, like fer-
mentation, was due to the action of microorganisms.
The great chemist, Liebig, resisted this doctrine in
the most strenuous manner. He would have noth-
ing to do with microorganisms as a cause of fermen-
tation or putrefaction. He wrote, "As to the opinion
which explains the putrefaction of animal sub-
stances by the presence of microscopic animalculae,
it may be compared to that of a child, who would
explain the rapidity of the Rhine current by at-
tributing it to the violent movement of the mill-
wheels at Mainz."
When Pasteur began his researches, the work of
Lateur and Schwann had been practically forgotten
and Liebig's view everywhere prevailed that fer-
ment was an alterajDle organic substance acting by
a catalytic force.
The young dean, with the purpose of doing a
kindness to the father of one of his students, visited
Bigo's factory frequently and in his laboratory,
where he had only a student's microscope, examined
the globules in the fermented juice. In continua-
tion, he took up a general study of fermentation,
including that of sour milk.
In sour milk he found globules, much smaller
than those of yeast, which heretofore had escaped
the observation of chemists and natura^ts. He
isolated these, scattered them in a liquia and the
characteristic lactic fermentation appeared.
Following this observation on lactic fermentation,
he studied another known as butyric ^ermentation.
He determined that this fermentation, also, was due
to an infusory and that this infusory lives without
free oxygen. This led to his important discovery
of the influence of the presence or absence of
oxygen upon bacterial growth, and the consequent
differentiation of bacteria into aerobes and anaerobes,
so elucidating for the first time these basic condi-
tions of bacterial life, later to be extended into the
discovery of the facultative aerobes and anaerobes.
Now came the problem, whence come these fer-
ments, these microorganisms, these agents which,
while weak in appearance, are in realitv so power-
ful.
The time for Pasteur's attack upon the doctrine
of spontaneous generation was at hand.
He placed putrescible liquid in flasks, boiled the
flasks and sealed their mouths while the liquid was
boiling. He set the flasks aside for observation and
although the material was present which originally
putrefied, no putrefaction took place. When ex-
amined microscopically no microorganisms could be
found.
He thereupon concluded that fermentation and
putrefaction were due to microorganisms introduced
into the putrescible matter from without, probably
from the air. He plugged a glass tube with cotton
wool, drew air through it and placed a part of the
dust blackened cotton in one of the flasks. Very
promptly putrefaction resulted.
Now came the battle between Pasteur and the
advocates of spontaneous generation which was to
August 31, 1 91 8.]
BORDEN: PASTEUR'S RELATION TO MEDICINE AND SURGERY.
result in the complete overthrow of the theory of
spontaneous generation and the establishment of
conclusive proof that the microorganisms present
in putrefaction, fermentation, and disease are not
caused by but are the cause of these processes.
In 1862 Pasteur had been elected a member of
the Academic des Sciences and before this body was
laid from time to time his experiments and argu-
ments and those of his adversaries — the believers in
spontaneous generation. Pasteur's lectures before
the Academic and the discussions thereon were pub-
lished in the Comptes Rendus Hehdomadaircs for
i860, '61 and '63, and it was through the readings
of these papers in the early part of 1865 that
Lister was led to the conclusion that the septic pro-
cesses in man may be due to microorganisms in the
same way that fermentation and putrefaction are
caused by them.
Thus the direct connection was made between
Pasteur's work and the antiseptic researches insti-
tuted by Lister.
Pasteur, in relating his experiments to the Aca-
demic, wrote : "It seems to me that it can be af-
firmed that the dusts suspended in atmospheric air
are the exclusive origin, the necessary condition of
life in infusion" ; and, also, clearly pointed out a
hope that he had in view by saying, "What would
be most desirable would be to push these studies far
enough to prepare the road for serious research into
the origin of various diseases."
In this latter sentence is seen the practical side to
which Pasteur's mind turned in all his investiga-
tions and which, so far as surgical infections are
concerned, was brought into use by Lister ; and by
Pasteur himself was applied to the prevention and
cure of the abnormal conditions in beer and wine
manufacture, of silkworm disease, chicken cholera,
anthrax, and hydrophobia. In regard to beer and
wine, he not only discovered the minute parasitic
vegetations which are the causes of the abnormal
conditions, but he demonstrated how they could be
ehminated and by the application of his researches
to the various grades of beer and wine, showed how
these could be maintained in purity ; a finding of the
greatest value in the making of these beverages.
While in the midst of these investigations he was
called upon to attempt to save the nearly destroyed
silkworm industry of France. This had reached a
value of nearly 100,000,000 francs annually, when
suddenly a mysterious disease appeared in the
cocoons of the silkworm. So fast did the infection
travel that it rapidly invaded Europe and Asia, and
it was only in Japan that healthy cocoons could be
found.
When tA French Government chose Pasteur to
investigate this cocoon disease the silkworm cult-
ivators almost unanimously expressed regret that a
mere chemist was chosen for the work, instead of
some zoologist or silkworm cultivator, but Pasteur's
reply to these criticisms was : "Have patience." It
is not possible, in the limits of this paper, to go into
the details of his silkworm researches. It is only
necessary to say that he not only discovered the
cause of the disease, but pointed out exactly the
method by which the industry could be restored.
This practical research work was of such impor-
tance in monetary value to the industries of France
as to be beyond calculation. It was the first of
Pasteur's victories in the application of his experi-
mental methods as a chemist to biological problems
and it placed his name among the most illustrious
benefactors of the practical industries.
rhis work was to be immediately followed by
other brilliant triumphs of the same sort.
Two diseases, chicken cholera and anthrax, were
ravaging the agricultural industries of France ; ten
per cent, of the fowls and cattle were being killed by
these scourges. Pasteur undertook the task of find-
ing the causes of these diseases and methods to
prevent them. Step by step, with remarkable
acumen he overcame all difficulties and finally de-
termined beyond question their causative factors
and established methods of prevention.
During the course of these investigations, his
work met with strong criticism and opposition and
the means by which he proved the truth of his
findings were often dramatic in the extreme, as for
instance, when on one occasion, in order to demon-
strate the efficiency of anthrax vaccination, he in-
oculated a large number of animals in the presence
of agricultural observers, then gave one half of
these animals his anthrax vaccine, predicting not
only the death but the exact hour when the symp-
toms of the disease would begin to appear in the
unvaccinated animals. In the presence of the ob-
servers he showed the vaccinated animals entirely
healthy and all unvaccinated animals stricken as
predicted and later dead from anthrax (as proven
by post mortem).
The acuity of his observation and the practical
character of his findings are shown in .the way by
which he determined how anthrax is transmitted
from animals buried beneath the surface to those
grazing above. It was known that when an animal
died of anthrax, even when deeply buried, another
animal eating grass above the buried place would
contract the disease. The deep burial was used by
Pasteur's critics as an argument against transmis-
sion by microorganisms. Pasteur, in studying this
problem, noted little cylinders of earth in an in-
fected pasture and his active mind at once jumped
to the thought that they came from the intestines of
earthworms and that these hitherto unconsidered
worms, by bringing the anthrax from the dead
bodies below to the surface, were the intermediaries
of the transmission of the disease. He thereupon
examined the bodies of earthworms, in infected
localities and found their intestines teeming with
anthrax. He at once recommended that infected
animals be buried in quicklime so that the micro-
organisms would be destroyed and thus by one of
his characteristic practical applications of his find-
ings, closed another gate against anthrax transmis-
sion.
In the course of his investigations of chicken
cholera and anthrax he made the discovers, now
recognized as being of major importance in the
etiology and progress of infections, that the viru-
lence of microorganisms can be diminished or in-
creased and that weakened cultures of many of the
disease producing bacteria* can confer immunity
upon susceptible animals.
362
BORDEN: PASTEUR'S RELATION TO MEDICINE AND SURGERY.
[New York
Medical Journal.
On these brilliant findings rest all later investiga-
tions in regard to variation in virulence of bacteria
and all our present knowledge of serum therapy and
vaccination.
Pasteur's discoveries on chicken cholera and
anthrax were made shortly after the Franco-
Prussian war, and Huxley, speaking of them, gave
it as his opinion that their value was more than
sufficient to cover the cost of the war indemnities
paid by France to Germany. This estimate we now
know was far too low. for the saving of life in fowl
and cattle and the value of the estimation of vaccine
therapy is entirely beyond any possible calculation
or comparison.
His conclusions in regard to transmission of dis-
ease, the control of the virulence of bacteria and
vaccination by attenuated cultures were so original
that, far from being welcome, they met with much
opposition and criticism.
At this time Doctor Koch, in Germany, had risen
to prominence in bacteriology and he and his pupils
started a vigorous campaign against Pasteur, claim-
ing that though he had discovered the septic
bacteria, he could not recognize them or cultivate
them in a state of purity. They argued that many
of his experiments regarding the variability in viru-
lence of microorganisms signified nothing and that
his claim that earthworms were carriers of anthrax
was laughable.
This attitude of Pasteur's opponents is presented
only to illustrate the opposition and criticism to
W'hich he was subjected, a condition common to all
original investigators.
While his researches on anthrax and chicken
cholera were in progress, Pasteur began and carried
forward his attempts to determine the cause and
prevention of hydrophobia. Although he did not
discover the cause, nor for that matter has the
specific cause of this disease been ascertained up to
the present time, he did succeed in accurately de-
termining the location of the virus in animals
afiected, the means of attenuating the virus and a
method of preventive inoculation — a method since
unimproved and still a recognized practice. .
Pasteur first used his antirabic vaccine upon ani-
mals. He found that the virus was in its most
concentrated form in the medulla and that he could
raise its virulence by passing it through the brains
of rabbits and decrease its virulence by gradually
drying the medulla of animals containing it, until
at the end of fourteen days the virulence was abso-
lutely extinguished ; and further, that the resistance
of animals to the virus could be increased by inocu-
lating them with the dried medulla, beginning with
a medulla of low virulence and gradually increasing
to a higher.
The first patient treated by his method was a
little Alsatian boy who had been bitten in fourteen
phices by a rabid dog. Pasteur undertook this, his
first human inoculation, with great perturbation of
mind. He kept the child under his own care and
with the greatest anxiety watched the result of the
treatment. Regarding this, Madame Pasteur wrote
to their children : "Your father has had another bad
night ; he is dreadirtg the last inoculation of the
child." The result was happy and the patient at no
time presented any untoward symptoms. Following
this success, a great number of persons bitten by
rabid animals were brought to Pasteur for treat-,
ment and this in connection with the great impor-
tance of his other researches led to the establish-
ment of the Pasteur Institute, the work of which
has since become so famous.
Pasteur's attachment to this institute was very
great and he visited it daily until his last illness.
On Saturday, September 28, 1895, passed
away, "full of years and honors."
The interrelation of the dififerent branches of
science is illustrated by Pasteur's work and his con-
nection widi the scientific societies in France.
Although educated as a chemist, much of his work
was done along lines pertaining to medicine.
He was first elected as a mineralogist to the Aca-
demy of Science, next as a free associate of the
Academie of Medicine, and finally a member of the
Academic Francaise.
His strongest supporters, as well as his greatest
critics, w^ere medical men.
It was his controversy with Doctor Bastian in the
Academie of Medicine which led to his important
discovery of the great resistance of the spores of
bacteria. Bastian claimed that urine treated by
Pasteur's sterilization method would still decompose,
but Pasteur showed that this was due to a fault in
Bastian's technic by which the spores of bacillus
subtilis, on account of their great resistance, gained
access to the urine.
The custom of raising liquids to a temperature of
65° C. (pasteurization) dates from this conflict with
Bastian.
Pasteur's mind constantly turned toward the re-
lation which microorganisms bear to disease. By
virtue of his research he was, in 1873, elected to the
Academie of ^Medicine and before that body of men,
eminent in medicine and surgery, he often presented
and defended his new and startling findings which
so absolutely controverted the theories of transmis-
sion and causation of disease then held by the medi-
cal world. As a member of the Academie, when ad-
dressing that body, he often expressed regret that he
had not been graduated in medicine ; and, as has
been stated by a biographer, when Pasteur first took
his seat in the Academie of Medicine, no one among
his colleagues suspected that this quiet and unassum-
ing new member would become the greatest revolu-
tionist ever known in medicine. The year of his
election to this Academie he wrote : "How I wish I
had enough health and sufficient knowledge to throw
myself, body and soul, into the experimental study
of one of our infectious diseases."
Of the healing of wounds, wdier^lddressing the
Academie in 1874, he said: "In order to demon-
strate the evil influence of ferments and protoor-
ganisms in the suppuration of wounds, I would
make two identical wounds on the two symmetrical
limbs of an animal under chloroform ; on one of
these wounds, I would apply a cotton wool dressing
with every possible precaution ; on the other, on the
contrary, I would cultivate, so to speak, microor-
ganisms abstracted from a strange sore and offering
more or less a septic character. Finally, I should
like to cut open a wound on an animal under chloro-
August 31, >9i8.] McGRATll AND BYRNE: FRACTURE DEPRESSION OF LAMINA..
form, in a very carefully selected part of the body,
for the experiment would be a delicate one, and in
absolutely pure air, that is, air absolutely devoid of
any kind of germs, afterward maintaining a pure
atmosphere around the wound and having recourse
to no dressing whatever. I am inclined to think that
perfect healing would ensue under such conditions,
for there would be nothing to hinder the work of
repair and reorganization which must be accom-
plished on the surface of a wound, if it is to heal."
Had Pasteur been a surgeon, how he would have
proceeded with experiments which, no doubt, would
have founded antiseptic and aseptic surgery, is
shown in an address before the Academic of Science
when he said : "The water, the sponge, the charpie
with which you wash or dress a wound, lay on its
surface germs which, as you see, have an extreme
facility of propagating within the tissues, and which
would infallibly bring about the death of the patient
within a very short time, if life in their limbs did
not oppose the multiplication of germs. But how
often, alas, is that vital resistance powerless, how
often do the patient's constitution, his weakness, his
moral condition, the unhealthy dressings, oppose but
an insufficient barrier to the invasion of the infini-
tesimally small with which you have covered the in-
jured part. If I had the honor of being a surgeon,
convinced as I am of the dangers caused by the
germs of microbes scattered on the surface of every
object, particularly in the hospitals, not only would
I use absolutely clean instruments, but, after cleans-
ing my hands with the greatest care and putting
them quickly through a flame (an easy thing to do
with a little practice), I would make use of charpie,
band'ages, and sponges which had previously been
raised to a heat of 130° C. to 150° C. ; I would only
employ water which had been heated to a tempera-
ture of 110° C. to 120° C. All this is easy in prac-
tice, and in that way I should still have to fear the
germs suspended in the atmosphere surrounding the
bed of the patient. But observation shows us every
day that the number of those germs is almost insig-
nificant compared to that of those which lie scattered
on the surface of objects, or in the cleanest ordinary
water."
The debt which medicine and surgery owes to
Pasteur was voiced in the great medical and surgi-
cal congresses which he attended in the later years
of his life, where he was received with enthusiasm
and accorded the highest honors.
Lister, as early as 1874, wrote him : "Allow me
to take this opportunity to render you my most
cordial thanks for having, by your brilliant re-
searches, demonstrated to me the truth of the germ
theory of putrefaction and thus furnished me with
the principle upon which alone the antiseptic system
can be carried out."
Pasteur's closing words in his oration at the in-
auguration of the Pasteur Institute are of particular
significance at this time, when France, the country
which he so much loved and for which he did so
much, is engaged in a mighty war and when we, our-
selves, are facing the conditions of this international
struggle :
"Two opposing laws seem to me now in contest.
The one, a law of blood and death, opening out each
3^>3
day new modes of destruction, forces nations to be
always ready for battle. The other, a law of peace,
work and health, whose only aim is to deliver man
from the calamities which beset him. The one seeks
violent conquests, the other the relief of mankind.
The one places a single life above all victories, the
other sacrifices hundreds of thousands of lives to the
ambition of a single individual. The law of which
we are the instruments, strives even through the
carnage to cure the wounds due to the law of war.
Treatment by our antiseptic methods may preserve
the lives of thousands of soldiers. Which of these
two laws will prevail, God only knows. But of this
we may be sure, that science, in obeying the law of
humanity, will always labor to enlarge the frontiers
of hfe."
In closing this brief summary of the obligations of
medicine and surgery to this master mind, we may
appropriately repeat the eulogy of Renan, president
of the Academic Francaise, when in welcoming Pas-
teur to that body, he said : "That common basis
which inspires science, literature, and art — we have
found it in you, sir, it is genius. No one has walked
so surely through the circles of elemental nature ;
your scientific life is like unto a luminous tract in the
great night of the infinitesimally small, in that last
abyss where life is born."
2306 Tracy Place.
FRACTURE DEPRESSION OF Lx\MIN^ OF
FIFTH AND SIXTH CERVICAL
VERTEBRA.*
With Serious Involvement of the Spinal Cord:
Operation: Recovery.
By John J. McGrath, M. D., F. A. C. S.,
AND Joseph Byrne, M. D., M. R. C. S.,
New York.
{From the Second Surgical Dhnsion of Fordham Hospital.)
The following" is an interesting case of depression
of the laminae of the fifth and sixth cervical verte-
brae, causing contusion of the cord, especially in the
left posterior column, and the right spinothalamic
tract, and contusion of the eighth cervical and first
thoracic nerve roots on the left side. The case was
characterized by the flexor flexion movements, indi-
cative of incomplete transverse lesions of the spinal
cord below the bulb.
Case. — J. T., eighteen years old, while playing football
attempted to tackle the runner by diving for the latter's
ankles. Failing to stop his man the patient's head was
carried forward, the runner's weight ultimately coming
down upon the neck in a state of dorsal hyperextension
and left lateral hyperflexion.
Before operation examination showed : Motor. Volun-
tary motion lost in lower limbs and trunk and impaired
in arms, especially in the left; retention of urine and
feces; flexor flexion movements in the legs; priapism.
Sensory. i. Spontaneous phenomena: no_ pain unless
body moved ; sense of absence of body weight. 2. Elic-
ited phenomena : loss for touch, pain, and temperature of
all grades up to the third thoracic segment (inclusive) on
the right and to the second thoracic segment on the left.
Reflexes. Knee jerks equally exaggerated ; plantar gave
extensor response on both sides accompanied by marked
*Case shown at the combined meeting of the New York Neurolog-
ical Society and the Neurological Section of the Academy of Medi-
cine, January 8, 1918.
364
McGRATH AND BYRNE: FRACTURE DEPRESSION UF LAMINA.
[New York
Medical Journal.
fle.xor flexion movements. Pupils, R. 6.5, L. 5.0 mm. ;
otherwise normal.
The picture was one of almost complete func-
tional tran.<5verse lesion. An operation was carried
out by Doctor AlcGrath twenty-two hours after
injury. Tlie laniinje of the fifth and sixth cervical
vertebr;e were found depressed and were removed.
The dura was not opened. After operation flexor
flexion movements of the legs as well as voluntary
motion in both arms and hands were completely
suspended. Power returned in the right arm in two
or three days, followed two weeks later by the re-
turn of power in the left arm. After operation, con-
trol appeared in the abdominal muscles and bladder
in two weeks ; in the right leg in five weeks ; in the
left leg in six weeks ; marked involuntary flexor
flexion movements reappeared in both legs in four
weeks and occurred from time to time with dimin-
ishing force and frequency for some months. Eight
weeks after operation these movements were pre-
ceded bv a spontaneous pricking sensation over the
Sensory examination on June 11, 1916, seven months after opera-
tion. Sensibility lost for:
Prick, algesimeter at two to four grams pressure up to heavily
dotted line; heat, at 55° C. up to interrupted line; cold (ice), up to
line of dots and dashes.
Shaded areas represent impairment for prick and gross heat and
cold.
The doUed circles in the hypochondria represent areas in which
sensibility was preserved for 38° C.
inner aspect of the thighs four inches above the
upper border of the patella. Six weeks after opera-
tion, sensibility for gross affective stimuli (prick,
pressure pain, 55° C. and ice) returned in the right
leg and foot, and a short time later in the left leg
and foot. Sensibility for these stimuli was never
more than temporarily disturbed in the hands and
arms. For a few weeks after operation priapism
was a feature ; occasional seminal ejaculations with-
out psychic equivalent.
On June 11, 10^6, seven months after operation,
examination showed the following :
Motor. Station, normal ; gait, in walking there is a
slight catch in the left leg consisting of involuntary ex-
tension of the knee and foot (extensor thrust), slight
spasticity of both legs; left forearm and hand atrophied
with movements correspondingly impaired; left calf larger
than right, partly due to edema.
Sensory, i, Spontaneous phenomena: None. 2, Elicited
phenomena: Toiicli — no loss or appreciable diminution for
cotton (parts unshavcd) ; for the finer von Frey hairs
impairment on feet, legs and thighs, especially on left
side: no impairment on trunk; pressure touch (unweighted
esthesiometer), slight impairment on left foot, leg, and
thigh compared with the right; localization — impaired.
Pain. For prick, algesimeter at four grams pressure,
sensibility impaired on right up to fourth thoracic seg-
ment inclusive, and on left up to second thoracic. Pres-
sure pain, average threshold on ball of great toe, right and
left, at four kilos; right calf, four kilos; left calf, 3.5
kilos.
Temperature. Heat — for 55° C, sensibility absent from
level of fourth lumbar, right and left, up to the fourth
thoracic segment on right and to the second thoracic (in-
clusive) on left. On the remainder of the limbs (L V to
to S V, inclusive) and on the ulnar half of the left arm,
forearm and hand, sensibility was impaired ; over the
hypochondria on both sides sensibility was preserved for
38" C. in a few small scattered patches.
Cold. For ice, sensibility absent and impaired over ex-
actly the same areas as in the case of heat but the level
of loss upon the trunk reached only as far up as the
seventh thoracic segment on both sides.
Compass tests, points simultaneously applied, showed
impairment over ulnar aspect of left hand.
Reflexes. Epigastric, abdominal and cremasteric dim-
inished on left; knee and ankle jerks equally exaggerated
on both sides ; trace of ankle clonus on both sides ; plan-
tar showed extensor response in all toes on left, while on
the right the hallux was stationary, as the small toes
fanned ; flexor-flexion movements generally accompanied
the extensor response of the toes.
Myotatic irritability absent in first interosseous muscle
of left hand.
On July 20, 1916, examination showed the fol-
lowing :
Motor. Left leg, forearm and hand had improved but
there was still much awkwardness and weakness ; atrophy
of forearm and hand still marked.
Sensory, i. Spontaneous: heaviness and awkwardness
of left leg; 2, Elicited: the most striking defect was.: for
vibration in the left leg; no appreciable defect in left hand
or arm except for the compass points simultaneously ap-
plied.
Reflexes. As on June nth; the plantar showed frank
extensor response on both sides and was accompanied by
marked flexor flexion movements, the leg and thigh being
lifted high off the table.
On August 5, 1917, examination showed:
Motor. As on July 20th.
Sensory. As on July nth and in addition:
Pain. Prick, at two grams pressure, impaired, es-
pecially on left leg and foot with marked overreaction on
anterior aspects of the thighs, especially on the left,
threshold for pressure pain lowered on inner aspect of left
thigh, the average of the algometer readings being, right
thigh, seven kilos; left thigh, five kilos; overreaction, sub-
jective (pain) and objective (flexor flexion movements),
especially on the left side when the threshold was reached.
Heat. Marked impairment for 38° C. on dorsum of
left foot and on outer aspect of left leg to knee; felt 55°
C. as "cold-hurt-sting" on left side up to level of fourth
thoracic segment, sensation for this stimulus being normal
on the left over the gluteal region, and over the posterior
aspect of the thigh, knee, and upper calf (sacral seg-
ments) .
Cold. Impairment for ice and for 23° to 27° C. on
dorsum and sole of left foot; threshold (subjective) on
these parts found at 27° C, objective threshold (reflex
movenlents) for all stimuli even for 27° C. on left sole
carefully applied.
Tests for vibration and for weights (limb supported
and unsupported) showed no appreciable relative defect.
Tests for posture and passive movement showed some im-
pairment on the left at the hip. knee, and toe joints.
Compass tests, points simultaneously applied, showed
some defect on the dorsum of each foot ; more marked on
the right. Thus with the points lYi inches apart in ten
trials the answers were: for "ones" ten right on right and
left, and for "twos" ten right on right and eight right on
August 31, 1918.]
McGRATH AND BYRNE: FRACTURE DEPRESSION Of LAMINAi.
365
left. Witli the points one inch apart for "ones" ten right
on right and left foot and for "twos" seven riujiit on left
foot ynd none right on right. Too nuicli reliance must not be
placed on the findings in these tests as the iiatient was
slightly fatigued when they were made. On the ulnar
aspect of the left hand there was marked inability to ap-
preciate two points simultaneously applied. Thus at half
an inch apart the answers were : for "ones" ciglit right
on right and ten on left hand and for "twos" nine right
on right and none right on left hand. No relative defect
was found on left hand for compass points consecutively
applied. In the hand no appreciable relative defect was
found for size, shape, and form. On the soles marked de-
fect was encountered on both feet.
Reflexes. As on July 20th.
On January 5, 1918, examination showed:
Motor. As on July 20, 1917, but the muscles were not
so easily fatigued; there was still some atrophy of left
forearm and marked atrophy of left hand.
Sensory, i, Spontaneous; none.
2, Elicited ; touch, relative impairment for finer von
Frey hairs and for the unweighted esthesiometer (pres-
sure-touch) over left leg, back and front, to level of the
middle of the buttock; localization also impaired.
Pain. For prick (algesimeter at two to twelve grams
pressure), impairment for single and rapidly repeated
stimuli over an area roughly corresponding to the area of
impairment for light touch. No subjective overreaction
although the flexor flexion movements were readily in-
duced. On the calves the average threshold for pressure
pain w-as found with the algometer to be : right, six kilos ;
left, four kilos; for this stimulus there was. on the left
leg, marked objective (flexor flexion) and subjective over-
reaction with radiation and sudden entry into conscious-
ness. For hair pulling and superficial pinching of skin,
over the left leg from foot to knee, there was, as in the
case of prick, impairment without subjective overreaction
or spreading although the flexor flexion reflex was readily
elicited.
Temperature. Impairment for 38° C, 55° C, 26° C,
and ice on left leg from foot to knee; sensibility well pre-
served elsewhere; for 55° C. impairment; at times a trace
of subjective overreaction on left calf for 55° C. For
massive applications of heat at 55° C. and cold (ice), sen-
sibility was found impaired on left calf without subjective
or objective overreaction for 55° C, whereas in the case
of ice, fl.exor flexion movements were readily elicited from
each calf, the subjective overreaction being overshadowed
by tl^ limb movements.
Posture and Passive Movement. Tests showed slight
impairment on the left side at the knee and marked im-
pairment in the ankle and toes.
Vibration. Impaired on left foot and leg up to crest
of ilium (inclusive), the late of vibration of the tuning
fork appearing to be faster on the right than on the left
leg.
Compasses. Marked relative impairment on dorsum of
left foot for two points simultaneously and consecutively
applied. Thus in ten trials with the points five eighths of
an inch apart and simultaneously applied the answers
were: for "ones" ten right on right, and six right on left;
for "twos" ten right on right, and five right on left. For
the points consecutively applied at five eighths of an inch
apart there were in r^eated trials often as many as ten
errors in ten trials.
Reflexes. Epigastric and abdominal relatively impaired
on left; cremasteric response brisker on left than right
with slight subjective overreaction on left; knee jerks
exaggerated and equal; ankle jerks, slightly exaggerated
and equal, with a trace of ankle clonus in both feet, but
no true sustained clonus with the foot at right angles to
the tibia. Plantar response : on right at first hallux showed
no movemrnt. while the small toes fanned ; later all toes
showed extensor response ; on left all toes showed ex-
tensor response for the first stimulus, the outer two fan-
ning slightly.
In attempting to map out the limits of the receptive
field for the flexor flexion reflex of which the Bab-
inski phenomenon is, according to some observers,
the minimal residue (though Babinski himself main-
tains that the phenomenon is an independent reflex),
it was found that potentially noxious stimuli enter-
ing the cord above the third sacral and below the
twelfth thoracic segment (in some instances below
the eighth), elicited the flexor flexion response. In
making these tests it was found that when the
stimulus was carefully applied, as the upper bound-
ary of the receptive field was approached or en-
tered, areas were found, e. g., at levels ranging from
the eighth thoracic to second liunbar segments and
especially a small area one inch above and slightly
posterior to the great trochanter of the femur, in
which homolateral plantar flexion of the distal
phalanx of the great toe was readily elicited. When
the stimulus was applied forcibly or in frequent se-
quence the regular flexor flexion reflex was elicited.
Summary of examination of January 5, 1918: i.
Atrophy and weakness of left forearm and of the
interosseid, thenar, and hypothenar mtiscles of
hand ; slight motor impairment, stiffness and awk-
wardness in left leg and foot which are made worse
by cold weather. 2. Sensibility impaired in the left
foot and leg for superficial critical stimulation
(light touch, compass points simultaneously applied,
etc.), as well as for deep critical stimulation (pos-
ture passive movement, compass points consecu-
tively applied) ; and for superficial and deep afifec-
tive stimulation (prick, hair pulling, pinching, heat,
cold, vibration, etc.), with one exception, viz., deep
pressure pain for which the threshold was lowered
on the left calf with an occasional trace of subjec-
tive overreaction. 3. Absence of subjective overre-
action for affective stimuli excepting on the left
calf.
Diagnosis. — i. Crushing in of laminse of fifth and
sixth cervical vertebrae ; 2, contusion of the cord, the
brunt of the permanent lesion being borne by the pos-
terior column on the left (defect in left leg for com-
passes and for posture and passive movement) and
by the spinothalamic tract and adjacent regions on the
right (defect in left leg for affective stimuli, super-
ficial and deep, without subjective overreaction) ; 3,
contusion or stretching of the eighth cervical and
first thoracic nerve roots on the left side.
Dorsal hyperextension accompanied by lateral hy-
perflexion accounts for the crushing in of the
laminae and for the direct contusion of the posterior
colunm on the left with contre coup of the antero-
lateral column on the right. The nerve roots on
both sides were contused or stretched directly by
bony displacements, these latter being apparently
more extensive on the left side.
The presence of flexor flexion movements (flexion
of thigh on abdomen, leg on thigh, foot on leg, and
toes on foot, dorsal flexion) before and after opera-
tion, showed serious interference with cord function,
which in large part must have been anatomical since
these movements even now. twenty-six months after
injury, can be readily elicited. Flexor flexion luove-
ments are the characteristic accompaniments of
lesions of the cord below the bulb that are almost, but
not quite, complete transverse lesions. Such lesions
give the clinical picture of paraplegia in flexion, first
described by Babinski {t), whereas bilateral lesions,
that merely involve the pyramidal tracts in the brain,
brainstem, or cord give the clinical picture of para-
366
HANCE: RHYTHMICAL BREATHING.
IKew York
Medical Journal.
picgia ill extension. Compare the spastic extension
of the lower Hmb in ordinary cases of hemiplegia.
Uilateral lesions involving only the pyramidal tracts
give a picture closely resembling the decerebrate
rigidity seen in animals after section of the brain-
stem just posterior to the optic thalami. Sherring-
ton (2) has shown that this extensor rigidity is a
postural tonic reflex with its centre located in the
bulb. This prespinal centre is served by afferent
paths from the cerebellum, otic labyrinths, and other
sources hicluding the musculature, via the posterior
spinal roots. The site of the efferent pathway is
not known, but it is extra pyramidal. In gradually
increasing compressive lesions of the cord before
the stage of complete interruption with its abolition
of reflexes is reached, there may be observed a
reversion to the simpler type of phasic reflex, viz.,
the flexor flexion. In the present case it is evident
that the efferent paths from the bulbospinal centre
were injured, presumably in the vicinity of the
median fisstire on both sides.
The flexor movement of the hallux, elicited on
stimulation above the great trochanter, represents
presiunably the minimal residue of the extensor
thrust, another reflex that is simpler and more prim-
itive in type than the postural extensor tonic reflex
of decerebrate rigidity.
The sensory findings in the left leg indicate sever-
ance of, or marked interference with the spinothala-
mic pathway on the right side of the cord. The
absence of subjective overreaction for superficial af-
fective stimuli (prick, hair pulling, superficial pinch-
ing, heat, cold, etc.), clearly indicates such inter-
ference, whereas the lowered threshold and the sub-
jective overreaction for pressure pain stimuli show
that some of the pain paths escaped. The paths
mediating these forms of stimulation are the last
to yield to lesions, gradually abolishing function, as
the author has recently pointed out. The fact that
impairment for touch (superficial and deep) is more
complete and extensive than for pain, emphasizes
the mechanism and site of the lesion, viz., injury
of the posterior column on the left, and of the antero-
lateral column on the right. It is only such a lesion,
when small and situated at any distance below the
sensory decussation in the medulla, that can give
complete loss for touch in any area at the periphery.
In the present instance the path for touch has been
partially interrupted before and after crossing in
the cord. Such an interference with the paths for
touch would undoubtedly be accompanied by sub-
jective overreaction for affective stimulation were it
not for the fact that the affective paths (spinothala-
mic) were themselves interrupted.
Opening the dura in spinal operations is regarded
by neurological surgeons as not only a harmless
procedure, but in most instances a necessary one.
In fact it is done practically at every operation as
a routine procedure. It is claimed that in this way
decompression of the cord is effected. From what
we have seen of cord operations performed soon
(two to forty-eight hours) after injury we have
come to the conclusion that opening the dura in
early operations, where the cord is seriously injured,
is extremely hazardous to life. Almost without ex-
ception the patients die in two or three days. The
cause of death in these cases must not be laid to
infection, but rather to some change probably of an
anaphylactic nature taking place in the cord, as the
result of the accession of air or of other foreign
substance to the damaged cord tissue. It seems that
the experiments of Allen (3) have misled the sur-
geons. Allen, after measured traumatization of the
cord, found that if the dura were immediately
opened and the posterior median septum incised the
animals recovered, whereas control animals, in
which the dura had not been opened, invariably died.
CONCLUSIONS :
1. In spinal injuries with serious cord involve-
ment, other than that accompanied by rapidly pro-
gressing symptoms (intradural hemorrhage), early
operation may be indicated provided the dura is not
opened.
2. In later operations, e. g., one or two weeks
after injury, the dura may be opened with safety
and even benefit.
3. Opening the dura may help certain cord
lesions, but it does not seem to do so by the relief
of edema of the cord.
4. Death occurring a sho^t time (twenty-four to
seventy-two hours) after early operation in which
the dura has been opened is not the result of in-
fection.
REFERENCES.
I. BABINSKI: Rev. Nenrologique, igii, No. 2, p. 132. 2. SHER-
RINGTON: Brain, 1910, xxxiii, i. 3. A. R. ALLEN: Journal oj
Nerz'ous and Mental Diseatses, 1914, xli. 141.
RHYTHMICAL BREATHING.
Irwin H. Hance, M. D.,
Lakewood, N. J.
In a recent paper on breathing I called attention to
the great value of deep breathing and to the fact that
the adult or child be taught the voluntary control of
the diaphragm and the internal muscles of respira-
tion ; that the volumes or currents of air may be di-
rected through the nares over its floor or into the at-
tic, and that at will the currents of air can expand
the lower or the upper portions of the thorax. The
use of the term deep breathing suggests the attain-
ment of one end, a full expansion of the chest, which
result may be attained by various forms of breath-
ing exercises. This is undoubtedly true, but unless
the proper relation in the timing of the respiratory
act is also taught and mastered much energy is
wasted and lack of coordination of the breathing
with muscular motion may be observed : hence fa-
tigue of not only the muscles but of the nerves
results as expressed by rapid heart action and
breathing, the end being the derangement of the
functioning power of other organs. The dynamo
of life is breathing. Powerful as is the dynamo
when constructed perfectly, how useless it would
be if the timing of the interruptions of the electrical
current were made in a haphazard manner ; it must
work rhythmically always to attain its greatest
efficiency. Bv analog")' the greatest human efficiency
can be secured by rhythmical breathing, the depth
of the breathing being guaged by the demands made
upon the bodv : it must alv/ays be rhythmical, how-
ever. If walking is done slowly, no discord in the
August 31, 1918.]
HANCE: RHYTHMICAL BREATHING.
367*
rhythm is apparent, but in running, unless trained
to move ra])idly, irregular rhythm gives way to
shortness of breath and inability to continue such
rapid motions. The shortness of breath is nature's
metliod of restoring proper rhytlim and prevents
resulting injury to the lungs and heart. In other
words breathing should be timed, like the dynamo,
to respond rhythmically to the demands made upon
it ; this can only be learned by practice and training.
The usual way is to train the various groups of
muscles by setting up exercises and to let breathing
take care of itself. Were we to begin the in-
struction with rhythmical breathing and develop the
breathing first, all setting up exercise would not only
increase muscular power more rapidly, but also the
general efficiency of the whole man, brain, nerves,
and internal organs. Efficiency in man represents
the proper functioning ol all the organs and glands
of the body; this is dep>endent upon the proper dis-
tribution of the oxygen content of the blood and
the elimination of the carbon dioxide through the
lungs, which is best secured by proper breathing.
This is generally ignored, the few are taught to
breatlie properly, the many are left uninstructed.
W'hereas nearly all seek, of themselves, to develop
all other groups of muscles.
To breathe rhythmically one must secure absolute
control of the diaphragm and the internal muscles
of respiration ; to learn this the cycle of the respira-
tory act. inspiration — pause — expiration, must be
kept clearly in view concentrating upon the whole
action. The length of the cycle must be short, at
first, to avoid using or straining other external
muscles. The advance from one type of breath-
ing to the next must be gradual. For convenience
the writer distinguishes three types of breathing:
abdominal, diaphragmatic, and thoracic. These terms
are arbitrarily used, founded partly on the physio-
logical definitions of breathing and partly on the
assumption that the power of directing at will cur-
rents of air into different sections of the lung is
demonstrable. Abdominal breathing must be
learned first ; it gives control of the diaphragm and
makes for more rapid progress in learning dia-
phragmatic and thoracic breathing.
Abdominal breathing, as its name indicates, is
evidenced by the expansion of the abdominal walls ;
the air fills the lungs from below upward and
there is a greater distention of the lower half of
the thorax than the upper.
Diaphragmatic breathing begins as in abdominal,
then by a stepping up process the air is directed
from, the lower into the middle, finally into the
np])er portions of the thorax, an even symmetrical
expansion of the chest resulting; in this type one
is prone to strain by bringing into action some of
the so called external muscles of respiration.
Thoracic breathing is evidenced by the expansion,
first, of the upper chest and, lastly by the filling of
the lower half, the abdominal wall protruding but
slightly at its termination. Spirometer tests show
that the lung capacity is greater in this than in
abdominal or diaphragmatic breathing.
Sitting in a chair or standing adjust the body to
the erect posture, spine straight, shoulders elerated
without any tension on back or pectoral muscles.
head so fixed that no strain of any of the neck
muscles is felt, chin very slightly depressed, teeth
a little apart ; all body muscles are thereby in a state
of relaxation : only thus can one give undivided
attention to the group of muscles which alone are
to be trained and brought into action. The relaxed
recumbent posture in bed enables one morning and
night to test the progress made, since some }M;r*sons
thus grasp the idea better and appreciate more
clearly the simple movement of the diaphragm.
Each respiratory act must be timed, inspiration
and expiration being of same length, the pause or
interval of rest at times somewhat shorter. It may
be represented as follows : Inspiration, three ;
pause, two; expiration, three. Count silently 3 —
2 — 3 in about eight seconds. The timed cycle will
range in all breathing from 2 — 2 — 2 to 8 — 8 — 8.
In learning abdominal breathing pay no at-
tention to the amount of visible expansion
of chest. The lower portion of the thorax
alone rises and falls during these earlier efiforts when
the excursion of the diaphragm is so short. To
begin, the cycle is 3 — 2 — 3, expiration being purely
passive. By concentrating the mind upon each
act of respiration and avoiding all upper chest
breathing one will appreciate after a few days'
practice what the motion of the diaphragm, when
called upon to act voluntarily, implies ; all efforts
to exceed this small movement of the diaphragm in
its downward and upward excursion will produce
tension and strain of other muscles resulting in a
visible expansion of the upper chest, which must be
avoided. In drawing the air into the nose one will
learn by practice how to roll the currents of air
over the floor of the nose, producing thereby a
nasal resonance. This sound is a proof that the
nasal and throat muscles are in a state of complete
relaxation. Nasal resonance of abdominal breath-
ing differs from the resonance produced by thoracic
breathing. Three minutes devoted to these earlier
efforts four or five times daily suffice ; later, more
time is required when breathing exercises are added ;
too prolonged efifort produces fatigue and diminished
concentration and tends to discouragement. The
next step shortens the cycle to 2 — 2 — 2. By this
quicker and shorter breathing one more fully ap-
preciates that the diaphragm possesses the power
like all other muscles of voluntary responding to
.'•■eparate stimulus. By successive steps the cycle
is lengthened to 3—3 — 3, 4 — 3 — 4, 4 — 4 — 4, and so
on up to 8 — 8 — 8. When one reaches 6 — 6 — 6 it is
proper to begin to learn diaphragmatic breathing.
Pumping with the diaphragm is practised in ab-
ilominal breathing and carried out by the quick
forcible contraction of this muscle during inspi-
ration.
The rhythm of diaphragmatic breathing differs
from that of abdominal breathing. To secure this
rhythm begin as in abdominal, counting two, then by
a stepping up process expand the middle and upper
chest, counting two at each step, pause counting
three — expiration of sam.e length counting six ; pas-
sive throughout without using abdominal muscles.
When fully carried out the result gives the best ex-
ample of full deep chest breathing. The currents of
air are directed into the lower, then the middle, and
368
RETAN: MEDICAL INSPECTION OF SCHOOLS.
[New York
Medical Journal.
lastly the upper portions of the lung, until the chest
is wholly expanded ; in other words diaphragmatic
breathing in a sense combines both abdominal and
thoracic at the beginning and ending of the respira-
tory cycle. r,reat care must be taken not to use
the external chest muscles in the middle and upper
chest expansion. Rhythm of second cycle corre-
sponds to a count of two as in abdominal breathing,
three for middle, three for upper chest expansion
— pause and expiration of same duration, namely,
six. In all subsequent cycles count two as in ab-
dominal and progress to 4 — 4, then to 5 — 5. The
currents of air pass chiefly over the floor of nares
as in abdominal breathing.
With the full understanding and mastery of dia-
phragmatic breathing one should be able, after com-
plete full expansion of the lungs, to perform short
nbdominal breathing while keeping the upper chest
fullv expanded.
Rhythmical thoracic breathing can now be easily
understood and carried out since it is the natural
effort of every one, when asked to take a full deep
breath, invariably to use this type of breathing. In
performing it one first notices the difference in
which the air passes into and up through the attic
of the nose ; the louder na.sal resonance produced
by the other types of breathing is changed to one
of a lower softer tone, i. e., one cannot produce the
same volumes of nasal sound with this method as
with the others.
Many teachers begin their instruction in deep
breathing with the thoracic type of breathing. Bet-
ter results can be attained by following the method
above described ; pupils make .slower progress in
their earlier instruction, yet when fully compre-
hended, the pov/er, the uses and control of the
diaphragm are more readily applied
The cycle can begin with 4 — 4 — 4 and be very
quickly lengthened until 8 — 8 — 8 is counted and it is
only at the very close of a full deep thoracic breath
that a slight abdominal effort is made causing a
slight protrusion of the epigastrium. For rapid quick
filling of the lungs thoracic breathing is best. Spi-
rometer readings show that a larger volume of air is
always expired after a deep thoracic breath than
after the other types. Abdominal 1.>reathing records
the smallest — diaphragmatic somewhat less than
thoracic.
Breathing exercises should be begun when one
has attained an abdominal breath cycle of 4 — 4 — 4 :
these must always be rhythmical, all the movements
r)f the extremities or trunk being timed to corres-
pond to the breath cycle. Each exercise begins with
the inspiratory act, durmg the pause the muscles
remain in their extended position, resuming the
original position at the end of expiration. The
pause may be shortened, if desired, to one half of the
duration of inspiration.
Until proper rhythm is secured all exercises must
be timed slowly. Later when they are done rapidly
the value of this method is shown by the ability of
the pupil to exercise harder and longer with less
fatigue and by the effect upon the heart, which
often shows a lower pulse rate. When one is in
perfect physical condition one can perform the
same motion almost indefinitely without fatigue.
Many years ago the writer read a statement that
in climbing a hill or going upstairs dyspnea could
be avoided or lessened by breathing in on advancing
the right foot and breathing out when the left foot
is advanced. He tried it and it worked not only
with himself but "especially with delicate patients.
This is simply rapid rhythm of breathing. For a
longer rhythm breathe in when advancing the right
foot for the third step.
Besides the beneficial influence of rhythmical
breathing upon the musculature and the cardiovas-
cular system, all patients have noted that their men-
tal powers of concentration were increased ; the
effect upon the neurasthenic has been to increase
his powers of self control and several have stated
that in using a certain type of relaxing breath sleep^
could be induced in a short period of time. All
these ^tients had previously relied upon veronal.
The effect upon these patients and upon the asth-
matic has enabled the writer to dispense with the
use of those drugs which physicians oft times dread
to administer because of their habit forming ten-
dency. Two asthmatic patients, of whom each used
daily six to eight hypodermics of adrenalin, stopped
using any, one in a few weeks' time and one in a
few months. Other patients have been enabled to
ward off the spasm of asthma by the muscular use
of the diaphragm.
From personal use and the application of the
above described method and his observation upon
the results secured by others during the past four
years the writer has concluded that physicians can
do much for the betterment of the health and also
the efficiency of individuals by directing their atten-
tion to the great need of physical training* of the
respiratory muscles at all ages. For the neuras-
thenic when inspired by your personality to faith-
fully learn and carry out the method, not only has
his general well being improved but also regains his
self control by doing light and easv daily tasks. To
the asthmatic you give the DOwer of voluntarily over-
coming the tetanic spasm of the diaphragm, which
x ray pictures reveal is nearly motionless. This
power also enables him to abort the spasm. Having
v.'itne.ssed these results I have thought it v/orth
while to place before you in detail a full description
of the method of rhvthniical breathing.
421 Second Street.
SOME PHASES OF MEDICAL INSPECTION
IN PUBLIC SCHOOLS.
By George M. Retan, M. D.,
Syracuse, N. Y.
Medical Inspector in Solvay Schools.
At no time in the history of civilization has the
development of the growing generation assumed the
importance that it has today. The wholesale slaugh-
ter on European battle grounds makes it imperative
that we train a body of healthy and vigorous chil-
dren to take their places. The need of expert su-
pervision of the physical health and development of
children was recognized before the war; in fact, a
law was enacted and has been in force for four
years making this supervision compulsory. A good
RETAN: MEDICAL INSPECTION OF SCHOOLS. 369
August 31, 1 9 18.]
law, but the reaction to and practice of the law by
our profession are deplorable.
We face with alarm the percentage of rejections
among army and navy recruits. The figures run
all the way from forty to seventy-seven per cent.,
and the majority of these men are between the ages
of twenty-one and thirty-one, the height of physical
vigor. The causes of rejection show that between
sixty and seventy per cent, are from preventable dis-
eases. We have all read that the percentage of
rejections was higher from the country districts.
Prior to obtaining this data, much had been
learned by the writer from personal inquiry and
discussion with teachers and physicians from dif-
ferent [Xirts of the state, but, in order to determine
as nearly as possible the present status quo of med-
ical school inspection throughout the state of New
York, a questionnaire was sent to all the school
superintendents of New York State by our super-
intendent, Mr. Roy B. Kelley, of Solvay. The ques-
tions asked and results obtained are included in
this report:
Does the school doctor make the chest examinations of
the children with the clothing removed from their chests
and backs?
Answers: Yes 15 Remarks: In many
No - 47 cases, "Clothing is re-
in part 5 movei only after par-
In suspected cases.. 11 ents' consent."
Is the weight of each child recorded?
Answers : Yes 59 Remarks : "Is it of
No 13 value to record
In part (estimated). 6 weight?"
Is the height of each pupil recorded?
Answers : Yes 63
No 12
In part (estimated). 3
Is the community convinced that the results obtained
are worth while?
Answers : Yes 39
No 14
In part 25
Is the work of the doctor followed up by the nurses?
Answers : Yes 55 Practically all an-
No 22 swers in the negative
In part i are followed by the
comment, "No school
nurses are employed
and the follow-up
work is done by the
doctor, with the as-
sistance of the fac-
ulty."
Is this follow up work securing satisfactory results?
Answers : Yes 48 Remarks : Where
No 17 answer is "No," the
In part 13 reason given is either
"No nurses are em-
ployed" or "Insuffi-
cient force of nurses."
Do the school nurses visit the homes in doing follow up
work?
Answers : Yes 56
No 17
In part 5
General Remarks.
"Need of more nurses to make follow up work effective."
"Follow up work is the most important branch of med-
ical inspection."
"Much medical inspection is largely formal."
"Much medical inspection work is done only to cover
requirements of the law."
No data were obtained from New York city for
the reason that the writer enjoyed the privilege of
a visit to the schools in that city and watched the
examinations. Mention will be made of their meth-
ods later. The seventy-eight answers received do
not come from that number of schools, but from
seventy-eight school systems under the supervision
of these superintendents, and includes the majority
of the schools of the state. It is therefore compre-
hensive and, I believe, of value.
The first question asked ; Does the doctor make
the chest examinations of the children with the
clothing removed from their chests and backs?
The answers show unwarranted neglect. Of course,
there is no object in making an examination of a
child's lungs and heart with the child partly un-
dressed. All manner of confusing sounds are elic-
ited by the rubbing of the stethoscope on the cloth-
ing, and again by the rubbing of the clothing on
the chest wall. Therefore, the five cases may be
classed with the forty-seven making a total of fifty-
two school systems (not fifty-two schools) where
no examinations of the lungs and heart are made.
The eleven cases where examination is made in
suspected cases is a little better, but still far from
satisfactory. One examiner who is a full time man
and does only school work, makes the claim that he
can pick out the cases in a schoolroom that re-
quire chest examination. This is absurd. He can
pick out cases of malnutrition by inspecting a school-
room, but tuberculosis does not produce emaciation
in children in the early stages of the disease. True,
the malnourished child is more liable to any infec-
tion, but the incipient tuberculous child is often not
malnourished.
The hectic flush cannot be used to pick these
cases, and will only give the child a more complete
picture of perfect health. I have repeatedly been
surprised both in school, dispensary, and private
practice to find active tuberculous cases well nour-
ished and of healthy appearance. This will apply
equally in cases of heart disease. Of course, the
cases with broken compensation will complain of
fatigue, vertigo, etc., and will frequently lean over
their seats in the schoolroom. These cases may
therefore be found, but is it not just as important to
find these cases of valvular disease before the com-
pensation is broken ; acquaint the parents with the
true condition and have the family doctor teach the
parents how the child should live to avoid using up
the heart reserve. 1, therefore, feel justified in
placing the eleven with the fifty-two school systems,
making a total of sixty-three school systems or
sixty-six per cent, of the schools in the State in
which the children are allowed to attend school
from year to year without an examination of lungs
and heart.
There are three excuses oftered : None of these
will stand the test of experience. Iliat it is against
the law ; that there is not sufficient time ; that the
time required for a competent chest examination is
too great to make the procedure practicable.
A quotation from the school law will clear up the
first objection, "A health certificate shall be fur-
nished by each pupil in the public schools upon his
entrance in such a school, and thereafter at the
opening of such schools at the beginning of each
370
RETAN: MEDICAL INSPECTION OF SCHOOLS.
[New York
Medical Journal.
school year. luich certificate shall be signed by a
duly licensed physician who is authorized to practise
medicine in this State, and shall describe the condi-
tion of the pupil when the examination is made
which shall not be more than thirty days, etc.
. . . If the pupil does not present a health cer-
tificate as herein required, the principal or teacher in
charge of the school shall cause a notice to be sent
to the parents of such pupil that if the required
health certificate is not furnished within thirty days
from the dale of such notice, an examination will
be made of such pupd as provided herein."
A prescribed form of certificate is contained in
the law requiring a recorded examination of the
following: age, sex, height, weight, lungs, heart,
glands, hernia, digestion, nose, throat and teeth. This
makes the duty of the examining physician and the
scope of the law quite plain. It also shows that it
is lawful to make an examination of the lungs and
heart. Of course it follows that no examination
of the lungs and heart of a child can be made with-
out the clothing removed.
The excuse that the parents'will object is largely
hypothetical and presents no serious trouble in
practice. A hypersensitive parent will occasionally
be encountered, but these have recourse to their
family doctor or they may be present at the school
while the examination is made. This occurred in
several instances during the first year that I made
the examinations. When the parents see the man-
ner in which the examination is made and the object
is explained to them, they will be pleased and will
go away to boost for the work. The next year no
trouble will be encountered from them, and they
will have their children examined at the school.
Systematic routine is the answer to the next ob-
jection. In our work we regularly examine chil-
dren in time ranging from a minute and a half to
three minutes. More time than three minutes is
rarely taken. This includes an examination of all
the organs mentioned above, with the exception of
the eyes. The eyes are examined separately, to save
time. Now I hear critics saying that an examina-
tion cannot be made in that time, and that it re-
quires half an hour at least for a competent exam-
ination of the lungs alone. That is partially true.
An internist will spend more than an hour in many
cases in making a chest examination. But I believe
that the man who makes the above objection has the
wrong conception of the duties of the medical in-
spector and a wrong version of the object of the
law. We are not working in the school building
as internists, nor as expert diagnosticians. If we
did, we would overstep the boundaries of our re-
quirements and we would do an injustice to the
medical profession as a whole and to the family
doctor in particular.
The internist will spend time on chest examina-
tion, in inspection palpation, percussion, ausculta-
tion, sputum tests, von Pirquet, x ray, family his-
tory, etc. These tests may be necessary in order
to reach a correct conclusion. To expect the school
doctor to make these examinations is absurd. All
he has to say is that this child has some trouble with
his lungs and the parents are advised to consult the
family physician. We are in the school for just one
purpose, and that to separate normal children from
abnormal and to see that the family is acquainted
with defects found. The rest of the work lies be-
tween the parents and the family doctor. We do
not examine a chest to determine whether the lungs
are affected with chronic bronchopneumonia or
tuberculosis, nor are we to differentiate asthma from
bronchitis. That is none of our affair unless the
disease is of a contagious nature.
There is much difference of opinion in the matter
of weight. This is difficult to understand, since the
weight of the child and its variance from year to
year is a valuable means of determining the con-
dition of his health and his rate of development. In
sending out our notice to the parents, weight of the
child is always considered. If a child is normal in
other respects as far as could be determined by the
examination, but the child's weight has remained
stationary, or has decreased from the previous
year, we know that he is not normal, and the family
is notified. «
This is very valuable in keeping the children well,
and acts as a check on our examination work. It
is illuminating to see the reaction of the family to
this notice. They will often take the child to a
doctor for a careful physical examination, and in
case nothing is found will begin feeding and tonic
treatment, with the result that the child will soon
show improvement. In the light of these results
obtained by so small an effort on the part of the
examiner, it is difficult to understand the attitude
of the physician who says that weight records are
of no value, that they consume valuable time, or that
scales are too expensive.
Out of the seventy-eight school systems, in fifty-
nine the weights were taken, in thirteen they were
not taken and in six taken in selected cases. In these
cases, I believe that it is possible to select the chil-
dren that require weighing for malnutrition, but, if
routine weighing is not carried out, the objection
that there is no data for comparison from year to
year is too serious to neglect a procedure demanding
so little effort.
In some cases, notably in New York City, the
nutrition of the children is recorded by the Dun-
fermline scale w^hich places all children in the fol-
lowing classes as regards nutrition : The normally
or excellently nourished ; the passably nourished ;
those needing careful supervision ; those needing
actual medical attention. This system of grading
children is good but has several objectionable fea-
tures. There is no exact record of weight and it is
impossible to tell whether a child has made a normal
gain from the preceding year. Moreover, the indi-
vidual variance of opinion of different examiners is
too great. Furthermore, any examiner will find
that his judgment will vary from day to day de-
pending on whether he is feeling buoyant or
whether he is "down in the mouth." I have checked
my dailv opinions from day to day by weighing, and
found this to be true. I believe that the nutritional
data are as valuable as data concerning the condition
of the tonsils and adenoids. The tonsil data are
never neglected, especially if the examining physi-
cian is skillful in removing them. I am an advocate
of tonsil removal in selected cases but I feel that too
August 31, igi8.]
RETAN: MEDICAL INSPECTION OF SCHOOLS.
371
much energy is expended in these cases in propor-
tion to the consideration of the child's nutrition and
his physical growth and development. The height
being a measure of development should be taken for
the same reasons as the weight.
In fifty-five school systems, the work of the
doctor is followed by the nurse. This means in
fifty-two per cent, of the schools. It should be done
in 100 per cent. There is little accomplished in
school inspections if the cases are not followed to
the homes. Of course, no doctor can give the time
this work requires and the faculty is, not qualified to
do it.
The answer to the next question depended on
whether a suf^icient corps of nurses is employed
to care for local conditions.
In order to develop a competent and effectual
school inspection system, it is necessary to have a
sufficient force to handle the local problems. It has
been estimated that one physician should be em-
ployed to every 3,000 pupils. No physician should
be asked to examine more than 2,000. Too much
work encourages and makes necessary slipshod
methods. He should be compelled to do his work
well ; he should also have supervision over the work
of the nurses, dentists, and other working forces
employed and should be responsible to the school
superintendent. It will be found that a physician
who confines his efforts to pediatrics or, at any rate,
to medicine, would be the man best qualified for this
work. I believe that surgeons are liable to over-
estimate the importance of surgical conditions to
the neglect of medical diseases.
I have allowed five minutes as the estimated time
for examination, since there is much difference in
the rapidity of movement of different men, and
some might fail to systematize their work suffi-
ciently to save time. However, I repeat that five
minutes is more time than is necessary if the work
is properly systematized. One nurse would be kept
very busy taking care of the follow up work and
class room inspections for this number of pupils,
and two should be employed. However, one would
be able to procure excellent results. A dentist
should be employed, with his office in the building.
Working a limited number of hours at the building
each day, wonderful results will be secured.
Our medical inspection work is conducted in the
schools of Solvay, N. Y. There are registered
1.450 children ranging from the kindergarten
through the high school. We have an unusually
complete equipment and a strong working force.
This has been made possible because the system is
financed in a large part by the Solvay Process Com-
pany. We have one physician working five days
each week; two dentists working respectively fif-
teen and eighteen hours each week ; a dentist
assistant working thirty-three hours each week ;
one ophthalmologist who takes care of all refrac-
tion work in the school ; two nurses doing school
work, and one nurse who has charge of the baby
welfare work done through the schools. These
nurses give full time. We are therefore able to
take the best care of our children.
We use the following routine in making examina-
tions. Each pupil is received with the chest un-
dressed down to the waistline. The age and grade
are taken, the child then passes before a measuring
stick placed on the wall. The child is weighed.
The mouth is inspected, examining the pharynx
first and then the teeth. A wooden tongue de-
pressor is used to depress the tongue. The hands
are now passed along the sternomastoid muscle to
determine the condition of these glands and along
the back of the neck for the same purpose. The
hearing is tested by the whispering method. The
watch was discarded for this purpose because of
the habit of all children to answer questions in the
affirmative. Any number or word may be used, and
the pupil will answer promptly, providing his hear-
ing is acute.
The examination of the lungs consists of at least
six auscultations in the front. These are made in
the supraclavicular spaces at the region of the third
ribs and in the axillae. As the auscultation is made,
the examiner will take a long breath which will
immediately be imitated by the pupil. One of the
proclivities of childhood is imitation, and it is rarely
necessary to tell the child to follow the example.
Percussion was used as an aid in examining the
lungs. After making 2,000 examinations, it^was
abandoned, since auscultation was found more
valuable and the results of percussion were too
doubtful to be relied upon. Each valvular area of
the heart is then auscultated and the child is re-
versed. Auscultation of the lungs is repeated in the
back in the same manner. The same mfmber and
relative examinations are made as in front.
As stated above the time required for this ex-
amination varies between a minute and a half to
three minutes. Much time may be saved by fol-
lowing a given routine of examination as outlined
above and by having your subjects ready with the
chests bare, thereby saving any waiting between the
examinations.
At the close of each day's work, cards are sent
home to the parents acquainting them with the con-
dition of the pupil. In cases where the examination
reveals no abnormality, this fact is stated. I be-
lieve this is of equal importance, for parental pride
will react toward the correction of defects where
comparison is made w-ith a normal sister, a brother,
or a neighbor's child.
If nothing is done by the parents toward the cor-
rection of these troubles within two weeks, the
school nurse visits the home to discuss the case.
The result of the conference is recorded on the card
under its date for future reference. The parent is
always advised to consult the family doctor, and, if
he cooperate, little difficulty is experienced in cor-
recting the defect. *
Much time may be saved the doctor if the de-
tails of this examination work are done by some
assistant. In our system, the nurse acts as the
assistant. She organizes the order of examination,
aids the children in undressing, marks the record
cards and sends the reports to the family. A
teacher or one of the older pupils could be used
for this work or the physician could do this himself.
However, the physician's time can be used to better
advantage than in detail work. Of course, it is
necessary that some woman be present while the
3/2
RET AN: MEDICAL INSPECTION OF SCHOOLS.
[New York
Medical Journal.
girls above the age of adolesence are examined. If
possible, it is much better that the nurse be em-
ployed, for tlie physician can give her valuable in-
structions in selected cases which will greatly aid
her in following the case to the home.
Special cases have been treated in the following
manner. In refractive errors in vision, notice has
been sent the family and advice to" consult an eye
specialist. In the vast majority of cases this has
not been done, generally for financial reasons. In
case the family could not afford to have this done,
the eyes have been refracted at the school building.
Dr. Roy Moore has been employed for this work
by the Solvay Process Company. In the majority
of cases the parents furnish the glasses. In this
manner, we have been able to place io8 pairs of
glasses in 112 cases in need of refractive correction.
This is ninety-six per cent, efficiency.
Of equal interest is the care and treatment of
teeth. When the dental clinic was first installed,
only those were treated which were discovered by
the examining physician to be serious. With the
addition of a second dentist, it was possible to take
care of these cases and also devote more attention
to th» prevention of dental trouble.
To this end, a careful examination by the dentists
of all the children in Boyd School from the 2-2 to
7-1 grades inclusive was recently made. The con-
ditions found were astonishing ; particularly so,
since there is no reason to suppose that children
in this school differ from children everywhere.
The results shown by the examination were :
Number examined 476
Number needing dental attent-'on 460 — 97%
Number with serious molar defects 120 — 25%
Number with other serious defects 75 — 15%
Total with serious defects in one elementary
school 40%
Certainly, the need of careful dental examination
and treatment of school children is imperative.
The cases of enlarged tonsils presented our most
difficult problem. There were 274 cases in 1,378
examinations which is about one case out of every
five children ; ninety-two have been operated, a per-
centage of thirty-three.
In making daily examinations of the chest, num-
erous children have been found presenting areas of
bronchial breathing and rales of varying character.
In order to save time and to prevent unjustified
alarm, we have instructed the nurses to take the
temperature of each of these cases every afternoon
and record them. The chest is then reexamined
in a week's time and if these signs persist or if the
temperature is found to be above normal, the child
is sent home with instruction to consult the family
doctor. In this manner, we have been able to find
fourteen cases of pulmonary disease, the majority
of which I believed to be tuberculous. Three of
this number were proven to be tuberculous by
sputum examination. In none was there any sus-
picion of the child's condition in the minds of the
parents. The importance of this phase of the
work cannot be overestimated not only in the
future of an afflicted child, but also in guarding
other children from infection. The result of the
close association of normal children with tubercu-
lous ones having a positive sputum is obvious.
It is surprising to learn the number of children
who have had valvular heart disease and still more
of a surprise to find the number of parents who
are unaware of it. Of course, it is important in
these cases not to mistake functional murmurs with
those of an organic nature, but, having decided that
a given murmur is organic, surely the parents
should be notified. In these cases, we have not sent
the notices to the home, but have sent the nurse to
personally notify the parents. We have done this
in order not to cause undue alarm. We have told
them that there is no active heart disease and have
asked them to consult their doctor for advice in
protecting the child's heart reserve. We have also
advised these children concerning their choice of
occupation, a matter of great importance.
Malnutrition in the absence of an evident cause
is considered a defect. The parents are advised
that their child is undernourished. They are also
advised to procure a more extensive examination
than that given in the school and to give the child
a nourishing diet, excluding cofifee and other stimu-
lants. In case that he should not respond to the
parents' efforts, the case is placed in the nutrition
class of the school. Each child in this class is given
a bowl of oat meal and milk at 10:00 a m. and a
glass of milk at 3 :oo p. m. We take weekly weigh-
ings of these cases and chart them. These children
belong to the group called the pretuberculous group.
They are badly nourished, with lowered resistance
to disease, and the work done is very valuable in
lowering mortality figures. After reaching normal
weight, they are taken from the class and the week-
ly weighings continued. Many will continue to gain
after they have been taken from the class.
The school work in New York City is very good.
The examination work is nearly the same as de-
scribed above with the exception that the height
and weight records are not kept. I believe that the
examination work would be better systematized,
and that the height and weight could then be taken
without the expenditure of more time than is now
used. The nutrition is judged by means of the
Dimfermline scale. However, the work there is •luch
better than in any other place in the States of which
I have personal knowledge.
The following conclusion may be drawn : First,
the medical school work as practised in the State of
New York at present, in the majority of schools, is
of little benefit: second, that positive harm may be
done by a slipshod method of examination, since
parents will rest assured that their child is in normal
health, having been examined by the physician and
no defects reported ; third, that no child should be
allowed to attend school without an examination of
heart and lungs with the chest undressed ; fourth,
that there should be a uniform method of examina-
tion adopted throughout the State following ex-
plicit directions; fifth, that a dental clinic should
be attached to every school ; sixth, that school
nurses should be employed and, seventh, that the
«anie record cards should be used througliout_the
.State in order that the data may be vised for statis-
tical ])urpo.ses.
131 South Avenue.
August 31, 1918.]
TAYLOR: CAN FLAT FOOT BE CURED?
373
CAN FLAT FOOT BE CURED?
By J. Madison Taylor, A. B., M. D.,
Philadelphia,
Professor of Applied Therapeutics, Temple University, Phila-
delphia.
Personal experience would lead me to say yes :
certainly I have seen patients with impaired arches
restored to normal. Perhaps certain lamed individ-
uals may not have become as sound and enduring in
their feet as some others. If taken early enough
and adequately trained, all weak arches could be
made strong arches. Young men with dropped
arches can certainly be vastly improved. Weak
arches in older sufferers may be much ameliorated.
The whole subject seems to focus itself on the
biological fact that the foot was and can become
again a prehensile organ, and defective arches be
made to disappear in proportion as the foot can be
restored to its prehensile capabilities. Hence cura-
tive measures should be chiefly means of reacquiring
the primal power of prehension and flexion.
The use of some support may be desirable, even
necessary for a tim.e, but only until the foot becomes
strong enough to need no artificial pediment and to
perform its own natural function, i. e., to hold the
full impending weight of the body. Do surgeons
put a Splint on a sprained wrist or ankle and keep
it there indefinitely ? Certainly not ; nor do ortho-
pedists use braces except to enable the weakened
parts to do normal work and by constant exercise
regain tone, power, and neuromuscular competence.
Most arch supports ordinarily employed simply
render the plantar structures weak, even useless ;
soon or late they become atrophied. The last state
then becomes worse than the first. Note those old
men who tinker with diverse foot props. They
hobble along as if they had ingrowing heels, with
toes turned up, treading on a solid peg foot ; the
normal action lost. In addition, they turn their toes
widely apart. It may be funny while the foot can
still do fair work, but it is anything but funny when
it no longer can carry a man wherever he desires to
go.^ •
The only form of artificial adjustment I have
ever found safe and really capable of aiding repair
is that "elevation" described by me in the New
York Medical Journal, November 10, 1917. I
<\m inclined to believe this hollow heel with a slight
elevation just anterior to the calcaneum is a desir-
able addition to anv shoe. It permits the os calcis
to rest comfortably in its normal position, leaving
the whole foot free to function normally, and hold-
ing it back from the compressing action of the front
part of the shoe on the toes.
The following are some recommendations derived
from thirty j'ears' experience in repairing arch
"anomalies : On examining the loot one of the first
points often observed is that the metatarsophalan-
geal joints are abnormally rigid. This rigidity must
be overcome by persistent and skillful manipulation,
bending the toes down till gradually the normal
flexor action car be performed. At the same time
the toes should be forcefully widened, i. e., sep-
arated and stretched apart, until with the foot rest-
ing on step or raised surface the toes can be bent
at an angle of ninety degrees, i. e., from the hori-
zontal to the vertical. C3n standing on a step the
'.oes should be made to touch the upright (vertical)
surface below them. This facility, passive though it
be, is only acquired after months of careful mold-
ing and mobilizing.
At the same time the patient should make volun-
tary efforts to perform flexion acts, i. e., to bend
down or flex the toes as nearly as possible to an
angle of ninetv degrees. This movement is a nor-
mal but long lost flexor function. \Vhen flexion
can be readily performed daily, the arch has become
practically normal. Power will be increased by per-
formance. There are in addition many other ac-
cessory movements of equal importance. Among
these are placing the bare foot on the floor about
twentv inches in advance and then pressing down
with the toes, drawing the foot toward one at the
same time rotating it inward, describing the quad-
rant of a circle. Of course this involves work, hard
v.'ork, but the price of emancipation from any pro-
tracted motor disability is vigilant and persistent
correction of faulty action.
In reading the voluminous literature on flat
foot there will be found, along with trivial, confus-
ing, and misleading suggestions, many valuable
hints. The weakness of the presentation lies chiefly
in the general failure to appreciate the obvious
biological fact already emphasized and which is the
basis of remediation.
The foot is by original conformation closely an-
alogous to the hand. Through ages of disuse civ-
ilized man has lost pedal flexor function which
under any circumstances is very much worth re-
gaining; as I have demonstrated to my own satis-
-f action. Manv Indians (especially the Stoneys of
AlbertaV have excited my admiration by their pre-
hensile action in climbing mountains. They quietly
rmd lazily lounge ahead of the sturdiest and cockiest
white guide, while the degenerate city sportsman is
left far behind or is patiently waited for.
The modern shoe splints, immobilize and weak-
en this basis of locomotion until the foot is wholly
out of function. To regain this primal function is
worth effort. The road to success is persistency
and consistency in treatment, with an earnest and
cordi.il cooperation between adviser and patient.
1504 Pine Street.
Fractures of the Elbow. — Jacob Grossman
(Interstate Medical Journal, June, 1918) advises an
anesthetic where possible for reduction of fractures
of the elbow. The reduction is accomplished by
flexing the elbow at a right angle and making ex-
tension with one hand while the fragments are
manipulated into position with the other. Acute
flexion is the only position likely to maintain the
fragments in good position. The forearm should
be fully supinated and the elbow flexed as far as
it will go. This flexed position is maintained by
adhesive strips and flannel bandages, then the arm
is placed so that the hand rests on the opposite
shoulder, and the elbow is carried forward on the
chest. Passive movements are begun on the tenth
to the twelfth day.
9
374 HODGSON: X RAY PLATES.— COST^
THE SYSTEMATIC DEVELOPMENT OF
X RAY PLATES AND FILMS.
Bv MxLLARu B. HoD(;soN.
Rochester, N. Y.
If the delicate nature and extreme sensitive-
ness of photographic materials were better un-
derstood, there would probably be fewer poor
negatives in all branches of photography. In
average amateur photography of the better class
the operator is usually an enthusiast who has
gone to considerable trouble to inform himself
of the nature and possibilities of the materials
with which he is working. With him it is a rec-
reation. In the case of professional work, the
photographer is usually one who has spent years
in photographic practice.
With the average radiographer, however, pho-
tographic processes are but a means to an end
and are very seldom considered as they should
be. He fully understands the technic of taking the
picture and he is able to interpret radiographs cor-
rectly, but too often he loses the efficiency that this
knowledge should give him by faulty photographic
work.
Few average radiographers have proper dark-
rooms. Any small cupboard or room may be
made into a proper darkroom by observing a few
simple rules. First, all cracks and holes for the
entrance of outside light should be carefully
plugged up. This done, the room should be
illuminated by light of photographically safe
quality. For a safelight of very moderate cost
the Brownie safelight lamp is ideal for a small
darkroom. For larger rooms, the Kodak safe-
light lamp or the Wratten safelight lamp may be
used. Any of these lamps will provide illumina-
tion of safe quality. A convenient bench should be
at hand for the manipulation of trays or tanks con-
taining developer, wash water and fixing bath, and,
if possible running water should be accessible.
Development is rarely considered as the chem-
ical reaction that it is. The reduction of the
ohotographic image to a silver deposit giving the
finished image is a process of extreme delicacy.
There is the utmost need of cleanliness, as with
any other delicate chemical reaction. There
should be a constant condition of temperature,
purity of chemicals, and precision of timing. To
eliminate difficulties in development so that the
operator does not have to be a trained chemist to
obtain good results the Eastman Kodak Company
has prepared certain kinds of developing powders
which are of the pro{>er purity and have been pre-
cisely weighed. These may be mixed properly bv
any one if a simple direction sheet is followed.
After the completion of the development of the
image, which is one chemical process, another
chemical process must take place before the neg-
ative is complete, that is, the plate must be fixed,
to remove unused and undesired materials. Be-
fore using an apparatus in any chemical opera-
tion, it is good practice to wash it thor-
oughly. The same rule holds good in the case
of the photographic plate, which should be
washed after the first chemical process (develop-
er .• TIUWMROSIS AND EMBOLISM. „ [New York
Medical Journal.
ing) and before the second chemical process
(fixing) is performed. Now the finished inijige
consists of a metallic silver deposit, the image,
in gelatin. These materials in a dry state are
relatively permanent. It is to render them so
that all the chemicals which would afifect this
condition of permanency should be removed by
thoroughly washing after fixing. The negative
should then be dried in a place where there is no
dust.
If these rules are adhered to, that is, i, devel-
opment under standard conditions for a fixed
time, 2, proper rinsing between development and
fixing, 3, thorough washing, 4, careful drying, all
negatives that are reasonably exposed should be
good negatives. A comparison of the work of
individuals using this system, with others using
haphazard methods, will be sufficient to prove
the point.
THROMBOSIS AND EMBOLISM.*
By H. R. CosTON, M. D.,
Birmingham, Ala.
Thrombosis is the coagulation of blood, usu-
ally in a vein or artery. Embolism is the ob-
struction of, or presence in, a bloodvessel of a
foreign body, a clot, a vegetation from a valve of
the heart, or any floating or adventitious material
in the blood stream. Thus a thrombus becomes
an embolus after its detachment.
The following three ca.ses illustrate the formatioa
of thrombi. In Case I a patient with throm-
bosis of the ovarian vein was operated upon and re-
section was performed, but the patient died of septic
pneumonia one month after delivery. Case II
illustrates a thrombosis of the mesenteric vein. The
])atient died in twelve hours. Case III shows a
venous embolus occurring in a patient after labor.
Case I. — Mrs. H. G. H., aged twenty-eight years, has
liad premature laliors at six and eight months. This, the
third pregnancy, went to full term. The labor was short
and easy; only a few minutes after I entered the foom
the child was born, in the left occipitoanterior position.
The woman gave a history of severe pain in the right iliac
region for the past five months. Four hours after delivery
I visited her again and found her suffering severely with
what she supposed were after pains. But she had a tem-
perature of 102° F. The temperature continued to fluc-
tuate; sometimes it was as high as 106° F., sometimes nor-
mal. The uterus was movable. I made a diagnosis of
appendicitis which was concurred in by Doctor Prince
with the suggestion that possibly we would find a thrombus
of the vein. This suggestion was found to be correct
upon operation and the tiiboovarian vein was removed
up to the vena cava. The abdominal walls were ver}-
thick : the woman weighed over 200 pounds. She was
profoundly septic.
I began the use of sodium cacodylate in large doses —
as much as fifteen grains daily. The patient died of septic
pneumonia one month after delivery.
Case II. — J. E. A., male, aged sixty-two years, had been
an active man all his life, with no illness until six weeks
ago, when his heart began acting badly. Under strychnia
and digitalis he had been much better recently. On the
afternoon of the 24th he took calomel and followed this
with sal hepatica. The following morning he had several
\ery loose movements of the bowels but had no pain or
'Paper read before the Jefferson County Medical Society, May
10. 1 918.
•
August 31, 1918.1
PALMER AND ECKLES: MILK AS A GALACTACOGUE.
375
vomiting. At 5 p. m. he had a "tarry" stool with ex-
ceedingly great pain in the ahdomen and was almost in a
state of collapse. Doctor Love, who saw him at this
time, said he looked like a dead man. He had at that time
one fiftieth grain of atropine, and between that time and
8 p. m. of the 26th, one and one half grain of morphine.
I saw him with Doctor Love at 8 p. m. on the 26th. He
was rolling from side to side in agony but there had been
no movement of the bowels since the tarry stool the pre-
ceding evening. The abdomen was tender all over and but
slightly distended. Vomiting had occurred during the past
twenty-four hours, at first of a bilious character, but now
with a distinctly fecal odor. Rectal temperature 101.5° F-
Pulse 130. Pain was Intense. There was occasional vorn-
iting. A large quantity of urine was voided but the speci-
men looked to the unaided eye as if it contained blood.
Pain was worse around the umbilicus and in the lower
abdomen. The man was manifestly in a very serious con-
dition. Dr. Cunningham Wilson was called in consul-
tation. All agreed that there was intestinal obstruction of
some kind. I expressed the opinion that it was thrombosis
of the mesenteric veins. At the operation by Doctor Wil-
son, this was found to be the case. He removed some five
feet or more of collapsed, black, small intestine. The pa-
tient died twelve hours later.
My diagnosis of thrombosis was based on the
following data: Intense pain, all over the abdo-
men, a single tarry stool, and collapse. The his-
tory of perfect health, and particularly no history
of indigestion, and vomitns free from blood, elim-
inated gastric and duodenal ulcer. The history
of the case, with no previous infection, the char-
acter of the pain, and the tarry stool excluded
gallstone. Bands and adhesions were ruled out
because there had been no illness to produce
them. Appendicitis should have given an en-
tirely diflferent history and no hemorrhage. As
regards Meckel's diverticulum, there had been no
previous attacks of colic. Concealed hernia would
scarcely have produced such violent pain so
abruptly ; would not have had so serious a hem-
orrhage, with no further movement of the bow-
els ; and there probably would have been a tumor,
detectable somewhere in the abdomen.
Case HL — Patient, Mrs. W. H. B., aged thirty-six
years. She had had five children. Sextipara. Unusually
large and tortuous varicose veins of each leg. The child
was born after a very easy and quick labor at 6:15 p. m.,
September 20th. On September 21st, 8 a. m., the patient
was sitting up in bed, and was warned to lie down and
remain still. On the morning of September 22d the pa-
tient was found sitting on a chair and was again warned
of the danger of being up and particularly that the legs
were liable to give her trouble as the veins would not
return to their natural size with her in the upright position.
On September 26th she walked to the door, warned in the
presence of her husband that she was liable to have an
embolus with death as a result. She said that she never
felt better in her life and that it was a punishment to
make her remain in bed. Hard nodules could now be
easily felt in the veins of the legs.
September 28th, 8 a. m., the patient had no fever and
begged to be allowed to get up. Permission was refused.
At 2 p. m. of the same day I was called hurriedly and
reached her in a very few minutes (certainly not over ten
minutes) and found her in articulo mortis. Death resulted
in five minutes.
There were no symptoms indicating that the em-
bolus had passed through the chambers of the heart
to the lungs, the heart was simply wearing itself out
on an obstruction. This obstruction came either
from a uterine sinus or from the varicose veins of
the leg. There had been no indication of distur-
bance in the uterus ; but hard nodules had been de-
tected in the varicose veins two days previously.
MILK AS A GALACTAGOGUE.
By Leroy S. Palmer, Ph. D.
AND C. H. ECKLES, D. Sc,
Columbia, Mo.
(From the Department of Dairy Husbandry, University of
Missouri.)
Some months ago our attention was called to an
article in this journal entitled. A New and Powerful
( "lalactagogue (i), in which a certain amount of in-
direct evidence was presented to show that milk from
a newly parturient person or animal when injected
into itself acted as a powerful galactagogtie. We
were interested especially in that portion of the
article which recommended that stich a treatment,
"be brought to the attention of the cattle raisers,
stockmen, farmers, dairymen, etc.," and also that,
"])ractically every cow be thus treated to insure her
doing her duty toward supplying milk." To this
end it was suggested, "to inject each cow with a half
ounce or more of her own milk on the third, fifth,
and tenth day after delivery." The statements were
also made that, "We never know whether a cow is
supplying her full quota of milk until after the
treatment is given," ;md that, "If she is not, this
treatment will speed up quickly the supply of milk
until it reaches the m.aximum capacity."
If milk is indeed such a powerful galactagogue
as these statements indicate it is patent that a dis-
covery has been made, the practical value of which
can hardly be estimated. Many investigators have
sought for such a substance. It is apparent, how-
ever, to any one who has had occasion to follow
closely the normal milk production records of dairy
cows that the method suggested in the article for
judging the galactopoietic powers of milk is open to
serious criticism. Not only is it impossible to pre-
dict with certainty in advance of parturition what
the maximum milk producing capacity of an indi-
vidual cow is going to be, but it is well known that
even under normal conditions this maximum is
never reached until a number of days, frequently
several weeks after parturition. When these well
known facts are taken into account it is readily seen
that any data, taken with the view of ascertaining
whether milk itself exerts any galactopoietic action
on the mammary gland when injected into a cow
immediately following parturition, would be very
diflicult to interpret.
In the many investigations which have been car-
ried out to determine the inflttence of numerous sub-
stances, body fluids, and extracts of body tissues
upon the secretion of milk, which extensive liter-
ature it is not our purpose to review at this time,
we are not aware of any previous attempts to study
milk itself as a galactagogtie. Doctor Duncan's
article has led us to carry out several experiments
on this question. Our method of attacking the
problem, however, apf>ears to us a much more ra-
tional one than that suggested by Doctor Duncan.
It seemed to us, that if milk is as powerful a
galactagogue as has been suggested, a more logical
way to determine this would be to inject the milk of
a fresh, heavy milking cow into the body of another
cow of the same breed, whose milk production had
also been rather heavy when she was fresh but
which had decreased greatly due to a more advanced
PALMER AND ECKLES: MILK AS A GALACTAGOGUE.
[New York
Medical Journal.
Stage in her lactation period. This method was sug-
gested by the experiments of Gaines (2), who
sought for a galactagogue in the blood stream by the
transfusion of blood from a fresh, heavy milking
goat into a low milking one.
Two experiments were performed to determine
the efifect of injecting the milk of the fresh cow
upon the daily milk flow of the cow more advanced
in lactation. One experiment was also carried out
to determine whether milk has an immediate action
upon the mammary secretion when injected from a
heavy milking cow which had recently freshened into
one which had lost some of the natural stimulus
due to advanced lactation. A description of the
three experiments is set forth below.
Experiment i. — Twenty c. c. of the milk of Jer-
sey cow 96, fresh June 22, 1917, and giving about
forty pounds of milk per day, was injected sub-
cutaneously into each shoulder of Jersey cow 64,
fresh August 25, 1916. Cow 64 gave thirty-five
pounds of milk per day as her maximum after
freshening. Injections were made at 7.30 o'clock on
the mornings of June 30, July 2, and July 4, 1917.
The daily milk flow per day of cow 64 prior to and
following the injections is given in Table I.
Experiment i, Cow 64. Experiment 2, Cow 102.
Milk flow
Milk flow
Date
per day.
Vote
per day.
1917.
Pounds.
/or/.
Pounds.
June
27
10.4
July
4
12. 1
28
10. 0
5
I3-I
29
(injection)
10.8
6
(injection)
14-4
30
9.0
7
12.4
July
I
10.6
8
10.8
2
(injection)
10. 0
9
(injection)
15-3
3
(injection)
9-4
I 0
(injection)
14.7
4
9.9
1 1
14-4
.■;
9-3
12
14.3
6
8
10.3
9.6
13
15
14-4
II. 4
1 0
II. 0
17
13.3
15
8.9
20
12. 1
20
9-7
25
1 1 .0
25
8.7
30
1 1 .2
30
8.7
Table I. — Milk flow of cows 64 and 102 orior to and following
subcutaneous injection? of milk from cow 96.
Experiment 2. — Twenty c. c. of the milk of Jer-
sey cow 96, described above, was injected subcu-
taneously into each shoulder of Jersey cow 102,
fresh May 17, 1916. Cow 102 gave twenty-seven
pounds of milk per day as her maximum production
when fresh. Injections were made at 7 130 o'clock
on the mornings of July 7 and July 9, and at four
o'clock on the afternoon of July 11, 1917. The
daily milk flow of cow T02 prior to and following
the injections is given in Table i.
Experiment 3. — On the afternoon of July loth,
cow 102 was milked out completely by the herds-
man at four o'clock, and at five o'clock the cow was
milked again for a period of five minutes. Two
hundred grams of milk were obtained.
On the following day, the experiment was re-
peated under as nearly identical conditions as pos-
sible, except that immediately after the first milking
twenty c. c. of the milk of cow 96 was injected sub-
cutaneously into each shoulder of cow 102. At the
end of the hour when the five minutes' milking was
carried out all the injected milk apparently had been
absorbed, since the slight swelling caused by the in-
jection had completely disappeared. The milk
secured amounted to only eighty-five grams. As
far as any immediate stimulating ef¥ect of the in-
jected milk was concerned the results were entirely
negative as compared with the test carried out
without the injection of milk. The results actually
suggest an inhibitory efifect on the milk flow, but the
difterences noted may have been entirely normal.
CONCLUSIONS.
The conclusion which the authors are forced to
draw from these experiments is obvious. Even
granting that our method of attacking this interest-
ing question may have shortcomings, it seems ex-
tremely doubtful whether cow's milk could under
any circumstances be made to exert the function of
a galactagogue toward the milk secretory system of
the cow. Unfortunately it appears that no "new
and powerful galactagogue" is found in cow's milk
which would be an Aladdin's lamp in the hands of
the dairvmen and farmers of this country. The
authors cannot help being reminded of an old adage
which has to do with pulling oneself up by his own
bootstraps as closely paralleling the injection of a
cow's milk into itself to insure maximum milk pro-
duction.
The authors do not desire to question the authen-
ticity of the numerous cases quoted by Doctor
Duncan, in which the injection of mother's milk
into herself is stated to have been followed by a
stimulation of the milk flow. In view of the fact,
however, that this treatment appears to have been
most efifective in cases in which there was a sudden
cessation of the milk flow, it is not unlikely that the
milk which vvas injected had to do with the removal
of the inhibitory factor, rather than that it exerted
the efifect of a galactagogue. If milk itself contains
an active galactagogue, the question might well be
raised why the chances are not equally as good for
the resorption of the galactagogue into the blood
stream while the milk is still in the mammary gland
as after the milk is withdrawn and injected into
another part of the body. It hardly seems probable
that milk would develop its powers as a galacta-
gogue only after it had been withdrawn from the
body.
REFERENCES.
I. CHARLES H. DUNCAN: A New and Powerful Galactagogue,
Nc-ji York Medical Journal, cv. i, pp. 22-23. '9i7. 2- W. L. GAINES:
A Contrihution to the Physiology of Milk Secretion, American Jour-
nal iif Physiology, xxxviii. 2, p. 2S5, 1915.
Treatment of High Blood Pressure. — Wilbur
Blackman (Charlotte Medical Journal, July, 1918)
points out that in the treatment of high blood pres-
sure regularity is of the greatest importance. This
applies to eating, drinking, sleeping and even think-
ing. In heart lesions with dyspnea rest in bed is
imperative. In kidney lesions elimination is of
prime importance. In autotoxemia a nonproteid
diet, preferably an antitoxic buttermilk ration, col-
onic irrigations and skin elimination are indicated :
in the case of the overworked man, rest, away from
his usual surroundings. Hydrotherapy and the elec-
tric light bath are of value. At the sanatorium for
heart cases the Nauheim baths are used ; for kidney
conditions, the sweating packs ; in autotoxemia, ab-
dominal fomentations and colonic irrigations ; for
high nervous tension, the prolonged neutral bath or
the wet sheet pack is efficacious ; for a laboring
heart, intermittent ice applications to the precordium
are used.
Medicine and Surgery in the Army and Navy
MEDICAL NOTES FROM THE FRON T.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
GENERAL ANTISEPSIS WITH UROTROPIN AND
URASEPTINE.
Quite recently Dupuy de Frenelle has undertaken
some interesting work on general antisepsis. The
idea of this surgeon was to transform the body into
a medium unfavorable for the development of bac-
teria and at the same time not to interfere with the
natural means of organic defense. When urotropin
is given per as, the analysis of the urine shows the
presence of formol, and de Frenelle has endeavored
to -discover if the same reaction could be traced in
the pus on dressings from subjects having been
given this drug.
The result has been that after a certain daily
dose has been attained, the reaction on the dressings
has been found positive ; therefore it seems proved
that urotropin given per os transforms the organ-
ism into a formolated medium, and that the totality
of the tissues infected by the wound undergo the
influence of the formol or of its derivatives, result-
ing from decomposition of urotropin in the organ-
ism.
In his researches de Frenelle used Schifif's reagent
(bisulphated fuchsin), which is employed for de-
tecting formol in milk in a dilution of i : 100,000.
At the daily dose of two grams, urotropin gives
a positive, although weak, reaction 011 the dressings,
in the form of light violet spots which appear on
the gauze soaked in the reagent. At the dose of
three grams in twenty-four hours the reaction is
much more distinct, while four grams daily gives a
very characteristic positive reaction.
Uraseptine gives a weak reaction at the dose of
three cofteespoonfuls a day, a distinct reaction at
four coflFeespoonfuls, and when five are given a very
intense reaction on the gauze in the form of
large violet spots. The normal dose for obtaining
a constant reaction would seem to be from two to
three grams of urotropin or from to three to six
cofTeespoonfuls of uraseptine in twenty-four hours.
Urotropin at the above daily doses is not con-
sidered toxic by de Frenelle, even when given for
one month. In some wounded Germans, with ex-
tensive infected bone lesions, de Frenelle was able
to reach, the dose of fourteen grams in twenty-four
hours, and yet these patients offered no evidence of
poisoning. On the contrary, they greatly benefited
from the urotropin treatment and in no case could
albumin be detected in the urine.
BLOOD TRANSFUSION.
Blood transfusion which became very popular fol-
lowing the first excellent results obtained and was
then severely condemned by many surgeons, has
now regained the favor that it deserves. The danger
of blood transfusion lies especially in faulty tech-
nic and the incompatibility of the blood of the donor
with that of the receptor, but with modern technic
the risks accruing from this operation are small
and need hardly be taken into consideration.
Transfusion is to be resorted to either for re-
plenishing blood lost, for obtaining hemostasis in
cases of hemorrhage, or for provoking a hemato-
poietic reaction. In the case of acute anemia, blood
transfusion is unquestionably superior to physio-
logical serum, while as a hemostatic agent it is one
of the most powerful we possess and as a hemato-
poietic agent it has certainly given very brilliant
results.
Monod has published some twenty cases in his
recent thesis (Paris, 1917), which confirm the above
statements, particularly instances of anemia gravis
produced and maintained by repeated hemorrhage.
However, it must be said that other than in cases
of hemorrhage the procedure does not appear to
give particularly good results. As to instrumenta-
tion, Monod advises the use of Elsberg's cannula.
INDIC/\TIONS FOR AMPUTATION PROCEDURES.
Metivet, with an experience of 100 cases, has
.studied the indications for amputation in war
surgery and points out that all procedures have their
indications. The circular or flap operations, which
are excellent when infection is absent, are danger-
ous in infected tissues. The two step procedure
gives the maximum of drainage and also results in a
supple, painless stump. In selecting the procedure
in each particular case, the surgeon should take into
consideration the level at which the incision of the
integuments is to be made, likewise the level at
which the bone lesions are seated, as well as their
site on either the distal or proximal portion of the
limb involved, and last but not least, the presence
or absence of infection. According to circumstances
primary or secondary amputation will be done.
INDURATION OF CORPUS CAVERNOSUM.
A very interesting and curious case of indura-
tion of the left corpus cavernosum following crush-
ing of the parts has recently been shown by Le Fur
at the Paris Society of Svirgeons. There was per-
manent priapism, and I will briefly give the prin-
cipal data concerning the case.
A soldier received a contusion on the anterior
aspect of the left side of the pelvis. This was fol-
lowed by symptoms of rupture of the urethra and
a month later by those of traumatic stricture. At
the same time a permanent priapism took place,
which v/as most uncomfortable for the patient.
Exploration revealed a massive induration of the
left corpus spongiosum at its posterior aspect, at
the level of the root of the scrotum, due evidently to
rupture of the corpus, followed by interstitial hemor-
rhage. This condition resulted in a permanent,
painful erection which lasted three months and was
accompanied by genital impotency, because the pa-
tient desired but could not accomplish the act of
coitus, and never during the three months of priap-
ism did ejaculation occur.
At the same level as the induration of the left
MEDICINE AND SURGERY
corpus cavernosmi!, a very indurated nucleus of
limited extent was detected in the lower urethral
wall, which explained the traumatic stricture.
After internal urethrotomy and numerous dilata-
tions a distinct decrease in the size of both the
indurated nodes in the corpus and urethral wall was
noted while at the same time there was an evident
improvement in the traumatic stricture. The per-
manent, painful erection also decreased and the
genital impotency disappeared.
i:)l;crease in sympathetic ophthalmia cases.
Doctor Weekers, the Belgian oculist, has not met
with a single instance of sympathetic ophthalmia
out of a total of over 800 ocular injuries, and de
Lapersonne, of Paris, has had the same experience
in a total of 1,000 eye lesions of war.
This decrease in the frequency of sympathetic
opthalmia appears to result from the rigorous appli-
cation of the principles of antisepsis and asepsis at
the first dressing and subsequently during treatment
and operative work. Enucleation of the wounded
eye was formerly the rule in order to prevent
sympathetic involvement of the normal fellow
organ, but today this is no longer the case. In every
case where the injury ofifers any hope whatsoever
of preserving the globe in a presentable shape, con-
servative treatment is to be adopted. If, after the
lapse of one month to six weeks, the injured eye is
still painful and irritated, enucleation must be done
and when this is necessary exenteration is to be
preferred as it offers quite as much guaranty
againt sympathetic ophthalmia as enucleation and
gives far better prothetic results.
DRY WOUNDS OF THE LARGE BLOODVESSELS.
Neuberger has published in his thesis (Paris,
T916) twenty-five cases of dry wounds of the large
vessels, five of them being personal. From the
viewpoint of localization, there was complete divi-
sion of the humeral artery in nine, a lateral wound
of the axillary artery in two, total division of the
femoral artery in one, one case of lateral wound of
both the femoral artery and vein, one case each of
lateral wound of the femoral vein and artery, com-
plete division of both popliteal artery and vein in
one case, the popliteal vein alone in another, and
finally complete division of the primary carotid
once, and once a lateral wound of the external
carotid.
In five instances there was neither hemorrhage
nor clot (typical dry vascular wounds) ; six cases
offered some clot in the wound without a true
hematoma and two cases offered an interstitial
hemorrhage.
The evolution was always favorable except in
the case of complete division of the primary carotid,
the patient developing a hemiplegia followed by
death, and in two cases of serious lesions to the
popliteal vessels where gangrene supervened.
As soon as a patient, brought to a first line am-
bulance, is suspected of having a dry vascular
wound, this being based on the assumption that
anatomically, given the direction, the track of the
wound probably involves a large vascular trunk, the
wound should be opened up as in any wound of
warfare but with the addition of careful explora-
tion of the large vessels. Search should be made
IN THE ARMY AND NAVY. [New York
Medical JournaL|-
for' rupture of the vessels or the branches of a ves-'
sel if it is ruptured, and all are isolated. The
hgatures should be placed at some distance from
the divided ends in order to avoid applying them in
the midst of the zone of thrombosis.
LACTIC llACTERIOTIIERAPY AND WOUNDS.
The use of lactic ferments has, as is well known,
given excellent results in intestinal affections and
Ferrata has shown that it is always possible to
transform the intestinal flora by substituting the
lactic bacilli for the preexisting natural bacteria of
the gut. He has also shown that in acute types of
intestinal disturbances lactic bacteriotherapy is the
most powerful of all treatments. The temperature
rapidly falls and a cure is wrought in exact ratio of
the transformation of the intestinal flora.
Starting from this point of view, Patellani and
Colombino have applied lactic bacteriotherapy to
wounds of warfare. They commenced by under-
taking some experimental work which showed that
not only did the lactic ferm.ents completely prevent
tissue putrefaction, but that they caused the pu-
trified tissues to rid themselves of their bacterial
content, such for exam])le as the staphylococcus,
and all other bacteria of putrefaction.
After settling the above question, they next re-
sorted to the use of lactic ferments in the treatment
of a very large number of injuries of warfare.
They say that it is possible to sterilize a wound in
a few days when the lactic ferment is placed in
direct contact with the entire infected wound sur-
face and that repair is hastened, this being prob-
ably due to the sterilization of the wound.
These favorable results are readily explained, be-
cause the fluid used being very bactericidal on ac-
count of the lactic ferments, is, from its chemical
composition, a real physiological serum and in addi-
tion it possesses the great advantage of remaining
sterile. The good results obtained by the use of
lactic bacteriotherapy should be essayed by surgeons
in order to study the action of the lactic ferment in
various types of infection and to improve the technic
of the method in wounds of warfare.
BACTERIOLOGY OF TRENCH FEVER.
At a recent meeting of the Society of Tropical
Medicine, England, Major W. Byam, R. A. M. C,
related a bit of work produced under the direction
of Sir David Bruce, which, for the time being, at
least, would seem to be destined to enter into the
ranks of the most important scientific research work
being carried out in both England and France.
The affection designated as "trench fever" has
been a scourge among armies almost since the com-
mencement of the present war. The number of its
victims has been fearful and it has been largely
responsible for a high rate of illness, although it
must be admitted, it is not dangerous as far as
mortality is concerned. Many have been the efforts
to conquer this disease, but until recently they have
not been attended with success. The medical de-
partment of the War Office was nevertheless deter-
mined to deal adequately with the question and
spared no pains to organize research work. Sir
David Bruce was asked to form a committee and
gathered about him a number of eminent scientists.
The actual work on patients was carried out by
August 31, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
379
Major Byam, who, with a staff of experts, went to
work at the New End Hospital at Hampstead.
For the purposes of this work it was necessary
that volunteers willing to be infected with the dis-
ease should be obtained and no difficulty was met
with in this direction because as soon as the need
was made known many offered their services.
Many of these were ex-service men whose desire
to fight in the army or navy had not been gratified
and they declared that at least they would now be
given an opportunity of doing something for their
country. How much they were able to do was
made clear by the paper read on May 21st by Major
Byam, in which he depicted the brilliant researches
completed under his direction.
In the first place it was suspected that lice were
the carriers of the disease, but it soon became mani-
fest that the carrying powers of the insect were
more complex than had been suspected, since a
subject might be bitten by many lice which had been
previously fed on trench fever patients and still
not contract the disease. This fact led to the idea
that possibly it was the excreta of the lice and not
their bites, which conveyed the infection, the means
of entry of the virus being provided by the scratch-
ing of the patiefit. This theory was tested and
proved positive ; for in every case in which lice
excreta was scratched into the dermis by the sub-
jects the disease developed in a few days.
The importance of these findings is evident when
it is recalled that lice abound in the trenches and
their excreta is scattered about as a fine dust. The
findings aft'orded an explanation of the origin of
trench fever occurring among persons handling sol-
diers' clothing and likewise suggested the possibility
of an infection of the civil population some distance
from the firing line. Even if no lice were present
the excreta remained virulent if brought into con-
tact with a cutaneous solution of continuity.
Again, it was found that for a week after feeding
on a trench fever case a louse was not infective,
or rather its excreta were not infective. After a
week, however, it became so, even if it had fed
only once on the patient. Probably, therefore, the
germ of the disease passes through a part of its life
cycle in the body of the louse, as malaria does in
the mosquito, and until that period is completed the
disease is not spread. The importance of this from
the viewpoint of prophylaxis is self evident. In-
deed, it was proved that the amount of heat suf-
ficient to kill Hce is by no means sufificient to rob
the excreta of its infective properties. In other
words, louse free clothing may still be highly in-
fective owing to the excreta they contain.
Among the complications sometimes arising from
trench fever under field conditions are "soldier's
heart" and neurasthenia, and Major Byam was able
to announce that some very important observations
on this aspect of the question had been made and
methods of treatment devised.
FAMINE IN AUSTRIA AND STYRIA.
That there is famine now in Austria and Styria
is unquestionable. The scarcity of breadstuffs so
increased during June, July, and August that as a
result during these three months these countries
were the field of epidemics of rather severe type.
BOMBING OF BRITISH HOSPITALS IN FRANCE.
As I conclude this letter, more detailed news of
the bombing of the military hospitals behind the
front in France has come to hand. Such is Hun
savagery at its worst.
"Man Icrnt nie aus" — one has never done learning
— say the Cicrmans. Consequently they seem bent
on teaching the world that Mr. Kipling's classifica-
tion of mankind into human beings and Germans
was scientifically exact. Their latest exploit in
deliberately bombing a well known group of British
hospitals in France, and in sweeping the cots of the
wounded men and the devoted nursing sisters and
attendants with machine gtm fire, is on a par with
all the devilish, nay hellish, abominations that have
caused the German name to stink in the nostrils of
humanity since the very outset of the war, and
that will cause it to stink while memory endures.
To outrages of this kind there is but a single
reply ; fierce and relentless war upon the Huns and
their kind till they be utterly vanquished, and then
ostracism from the society of civilized nations and
of all decent minded men.
Upon scientific felons who know neither truth
nor chivalry let there be among the allied nations
a ban outlasting in duration and intensity even
the remembrance of the chastisement which the
allied nations are more than ever bound to inflict
upon them. And in this particular circumstance
let the medical profession of the United States be
ever mindful of the recent slaughter of their pro-
fessional brethren of Britain and the innocent
wounded to whom they were tendering their skill at
the moment of the foul Hun murder.
PSYCHOLOGY IN THE ARMY.
At a meeting of the College of Physicians of
Philadelphia, on Wednesday, June 5, 1918, with
Dr. Thomas R. Neilson in the chair, the advisa-
bility of the use of psychological tests in the army
was discussed. Neuropsychiatric examinations were
described with emphasis on their bearing in preven-
tive work and in the reconstruction of soldiers. The
opinion was given that on the medical side of the
war, the neurologist was the man who had the best
chance to be of use.
PSYCHOLOGICAL EXAMINING IN THE ARMY.
Major Robert M. Yerkes, Sanitary Corps, Na-
tional Army, said that the principal purposes in ex-
amining drafted men and company officers were to
assist the psychiatrist and neurologist in eliminating
the mentally unfit ; to assist the personnel officer in
classifying soldiers, and to aid all officers in the
selection of men who were fit for special responsi-
biHty or for training in officers' training camps.
Methods for this work had been devised during the
summer of iQi/ and had since been greatly devel-
oped. Approximately 300,000 men had been
examined. Of these, 10,000 were officers and ap-
proximately 25.000 were students in officers' train-
ing camps. At least 50,000 psychological examina-
tions were being made a week. The work had more
important significance for the personal bureau of
the army than for the Medical Department. The
38o
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
procedure of examining was roughly as follows : A
group of from loo to 300 drafted men, reporting
in examining room, was divided into two sections,
one consisting of those who can read and write
English fairly well, and the other those who because
of foreign birth or lack of education had less
knowledge of English. The literate group was then
given one form of examination; the illiterate group
an entirely different sort of examination, which did
not require either reading or writing. A man fail-
ing in either or both examinations was given indi-
vidual examination. Several varieties of individual
examination were used and were applied in accord-
ance with the characteristics of the individual to be
examined. ( Slides were exhibited at this point to in-
dicate materials used for examinations, show exam-
ining procetkire in one of the National Army can-
tonments and to present important results of
examining in the army.) The personnel for this
work was of very high quality. More than seventy
officers had been trained for work in military psy-
chology at the School in Military Psychology, Medi-
cal C^fficers' Training Camp, Fort Oglethorpe, Ga.
These men were now conducting psychological ex-
aminations in the various army training camps. At
the same school about 250 enlisted men had been
given training in militarj' psychology.
NEUROPSVCHIATRY IN THE ARMY.
Colonel Pearce Bailey, Medical Corps, National
Army, described the examinations to determine
whether or not men were to be allowed to go over-
seas. One method employed consisted of a rapid
survey of the whole organization, of all the troops,
ofificers included. All passed under the eye of one
or more neuropsychiatrists. They were given a test
of about a minute and a half, long enough to test
the knee jerk, tremors of hand and tongue, and the
reaction to the immediate situation. This test de-
termined the indication for a more extended exam-
ination. The other method, used much in the first
draft and before the neuropsychiatry department
was organized, was a method of referred cases, in
which only those referred by other officers, line or
medical, were examined. We had in this more co-
operation from the laymen than from the medical
ofificers. At present we had very close cooperation
from every one. The psychiatrist did not recom-
mend a discharge without such recommendation
going through the disability boards and thus being
endorsed by at least three nonspecialists. We be-
lieved that by the means employed in our work
neuropsychiatry would reach a point in preventive
medicine of high significance. In the reconstruction
of soldiers we believed that neuropsychiatry would
also have an important function. We had exam-
iners at the camps, depots, and ports of embarka-
tion. A certain percentage of the men were found
to be nervously unfit. Not many neurological cases
have yet been returned from the other side. We
had just secured a hospital at Plattsburg to which
patients were transferred from the cantonments as
fast as possible. How these cases differed from the
war neuroses of the other side we did not know,
but we were confident that there were no neurotic
symptoms produced on the front not to be found
here. Wc had found a much smaller number of
insane requiring hospital treatment than we had
anticipated. A contributing factor to this smaller
percentage was the fact of the examinations made
at the point of entrance to the army. The States,
with but few exceptions, had cooperated in caring
for their insane when insanity developed immedi-
ately after entrance in the army. While only 300
have gone back it was shown that army life renders
a neurotic the subject of custodial care. We had
had less than 500 cases of drug addicts. If the
number proved to be very much above this, a special
camp would be established for the treatment of such
patients, after which they would be drilled for
military service. We now had in the neuropsy-
chiatric department about 359 officers, about one
third of whom were on the other side. They had
come chiefly from the State hospitals. We were
asked to send men with neurological training and last
montli we were obliged to decline 100 applications
for positions to be filled. Men who spoke Italian
and Spanish were especially wanted.
Discussion. — Dr. F. X. Dercum said that we
could group the symptoms of the psychoneuroses met
with in the army under the familiar clinical pictures
seen in civil life. Curiously enough, they occurred
largely among the draftees just as in the outpatient
departments and hospital wards; they were less
frequent among officers, just as they were less fre-
quent among the better classes in civil life. It was
most important that these be excluded at the source.
Tliese tests were not a measure of a man's physical
strength, of his endurance, of his ability to shoot, of
his personal courage. Many a man had sprung
from the ranks who did not have the qualities of
mind enabling him to pass through such a series of
complicated tests, and yet had made an efficient
officer.
Dr. Thomas McCrae remarked that if any one
who had been abroad working on the medical side
in the war v/ere ask'ed who had the best chance of
being of use, he would answer the neurologist.
Doctor McCrae did not believe that this was suf-
ficiently recognized. He had urged upon every man
connected with the formation of a military hospital
unit the necessity of having a well qualified neurol-
ogist on the staff. As head of the medical side of
a hospital without a neurologist he had had to meet
the neurological problems arising among 2,000 pa-
tients. Many cases of nerve injury were extremely
complicated and the decision as to treatment was
often a difficult matter. The need in this war for
the neurologist must be emphasized.
Athletic Equipment for Men in Training
Camps. — Athletic material sufficient to supply
1,750 companies, or 125 complete regiments, has
been purchased by the War Department Commis-
sion on Training Camp Activities, an appropriation
of $250,000 having been obtained for this purpose.
The supplies, for which the War Department
through the commission invited bids, included the
folloviing items: 17.500 sets of boxing gloves, 7.000
baseball bats, 21,100 baseballs, 3,500 playground
baseball bats. 10,500 playground balls, 3,000 Rugby
footballs, 7,000 soccer footballs, 3.500 volley balls,
and 1,750 medicine balls. Allotment of the material
to the various training camps is being made.
August 31, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
381
MEDICAL NEWS FROM WASHINGTON.
Appointment of Brigadier General Merritte W. Ireland to
Be' Assistant Surgeon General. — Mobilization of Hos-
pitals Under One Head.— More Rigid Physical Tests for
Aviators. ^ ^ , ^ o
Washington, D. C, August 26, igrs.
The appointment during the past week of Brig-
adier General Merritte W. Ireland, chief surgeon
on the staf¥ of General Pershing in France, "to be
assistant surgeon general, with the rank of major
general, during the existence of the present emer-
gency, for service abroad, under the provisions of
the act of Congress approved July 9, 1918, with
rank from August 8, 1918," has revived the interest
that has been prevalent in the appointment of an
ofiicer to succeed Major General George W. Gorgas
as surgeon general upon his retirement for age in
October.
No indication has been given by the authorities
as to what bearing General Ireland's new appoint-
ment has upon his chances for appointment later to
the position of surgeon general of the army, but his
friends, both at home and in France, who have been
advocating his appointment, do not believe that it
will affect his chances adversely.
In the meantime, a number of other prominent
physicians and surgeons connected with the army
have been mentioned in connection with the place,
and it is known that some of them, or their friends,
have been working actively in their behalf. *
The suggestion has been made that a step in the
direction of efficient medical service for the period
of the war would be a mobilization and coordina-
tion of the hospitals of the country under one con-
trolling authority to the extent that full use might
be made of their capacity, and the matter has been
given much consideration at the hands of the
government medical authorities.
Under present conditions, most of the hospitals
are filled with patients, many of whom could be
treated at their hom.es. This would give increased
bed capacity, and, in conjunction with the activities
of the Volunteer Medical Service Corps, would
provide for many additional patients.
Those that are interested in the subject believe
that boards of directors of local hospitals should be
encouraged to increase their present hospital facili-
ties, but one difficulty at present lies in the almost
prohibitive cost of building construction and the
curtailment by the war industries board of non-
essential activities.
The government hospitals at Washington are
particularly crowded to an extent that is not con-
ducive to good health, and the same conditions pre-
vail to a greater or less e.Ktent in other cities where
industries relating to the war have brought in many
new residents. For this reason, it is believed that
the hospital facilities of every community where
there are military men and war workers should be
carefully surveyed and such additions made as are
justified to insure adequate medical protection in
case of epidemic. Mobilization of the hospitals
tmder one central authority would further a more
adequate conception of these increased needs due
to present conditions.
More rigid physical tests lately have been pre-
scribed for aviators of this country. All men that
have won their wings in the air service now are
required to pass a new heart, lung, ear, and eye
test to establish their physical and mental fitness
when high in the air, and particularly to indicate
at what heights they are in a condition to fly. Ca-
dets receive a test before they finish their schooling;
fliers are given the tests periodically to eliminate
any whose physical or mental efficiency has become
impaired in any way.
The prescribed tests are the results of study and
investigation by the medical research laboratory at
Hazelhurst Field, Mineola, N. Y., whose staff has
devised apparatus and determined upon a standard
examination for classifying pilots.
To stay in the rarefied air at an elevation of
20,000 feet for any length of time has been found
to be a strain even upon the most physically per-
fect. It also has been discovered that many of the
most seasoned lliers cannot undergo the sudden
quick changes in altitude occasioned by diving and
climbing, without physical deterioration. It was
recognized as too great a risk to subject these men
to actual flying tests. Therefore, the research
laboratory at Hazelhurst Field undertook to devise
some way of getting the same results by means of a
ground test.
In the early tests the pilot was placed in a sealed
airtight cylinder from which the air was gradually
exhausted and then replaced to simulate a flight
into the rarefied air of high altitudes and back to
earth, but today the pilot sits comfortably in the
same room with his examiners. His nose is clamped
so that he cannot breathe through it. Over his
mouth is placed the breathing apparatus, which is
connected by tubes with a tank of measured air and
with the instruments that record every breath he
takes. The air is analyzed at various stages of the
run. As fast as he exhales, the air is taken into a
reservoir, where it is cleared of carbon dioxide and
then returned to the tank. Gradually he uses up the
oxygen, and thus air conditions of high altitudes are
duplicated. The higher one goes up, the rarer the
air becomes ; just so with the man under test, for
after a certain time he has consumed an amount of
oxygen that leaves the remaining supply just equal
to the oxygen available at a certain altitude. Time
takes the place of height in the test. "All the way
up," so to speak, several speciaHsts watch him ; one
his heart, pulse, and blood pressure, one his eyes,
and the others his responses to signals and observa-
tions. Records of his pulse and blood pressure are
made every oftier minute ; the eyes are tested every
three minutes.
The man under test is kept fairly busy, just as he
would be piloting an airplane. Before him on a
table is a bank of small electric lights, one or an-
other of which flashes every five seconds. These
he must extinguish as fast as he observes them and
before they go out. He has but a few seconds.
Below the lamps is a corresponding set of buttons,
which, when touched with a pointer held in the
right hand, extinguishes the respective lights. Two
observers watch him constantly and check his errors
or delayed actions.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A IVcrkly Review of Medicine
EDITORS
CHARLES E. dh M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY-,
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Cable Address, Medjour, New York.
NEW YORK, SATURDAY, AUGUST 31, 1918
THE MENTAL HYGIENE MOVEMENT
IN CANADA.
There was recently formed at Ottawa a Cana-
dian National Committee for Mental Hygiene,
with Dr. Charles K. Clarke, dean of the Medical
Faculty of the LTniversity of Toronto and med-
ical superintendent of the Toronto General Hos-
pital, as medical director of the organization.
Doctor Clarke has since resigned the superin-
tendency of the hospital and will henceforth
devote his time and energies to the new organ-
ization. For many years he has been one of Can-
ada's leading alienists, having held the position
of superintendent of the Rockwood Hospital for
the Insane, at Kingston, and latterly the super-
intendency of the Hospital for the Insane, at To-
ronto. Associated with him in the prosecution
of the work will be Dr. Charles M. Hincks, of
Toronto, as secretary and assistant medical
director.
For quite a number of years it has been held
in medical circles that intelligent and organized
effort should be put forth to prevent, if possible,
the annual increment in ihe admissions to the
hospitals for the insane throughout Canada.
Year by year these hospital reports for every part
of the Dominion showed that insanity was on the
increase; and while Ihe figures presented were of
the official insane, it was recognized that those
not domiciled within institutions could be count-
ed in considerable numbers. Additions were
constantly being required to existing institutions,
new buildings were being erected, new institu-
tions were being established, but the require-
ments could not keep pace with the demand. At
times jails had to be pressed into service, until it
became a public scandal that persons requiring
hospital treatment of the most enlightened and
modern aspect very often had to be housed in
criminal institutions and herded with offenders
against the law.
Gradually public sentiment revolted against
this condition as it had revolted against the plac-
ing of politico-doctors as superintendents of hos-
pitals 'for the insane over the heads of trained
vnd competent assistants; and not for some years
now, in Ontario at least, has there been any evi-
dence that the hospitals for the insane are used
as sops to the physicians who had engaged in po-
litical and party warfare. Still, Canada was a
little slow in following the example of the United
States and establishing a National Committee for
"Mental Hygiene. Now, however, a beginning
has been made, and as in other departments of
medicine for the public, the government is awak-
ening to its responsibility for the personal health
and welfare of the people, recognizing that it is
the common agent of all, charged with the in-
terests of all.
Possibly the aims of the Canadian National
Committee of Mental Hygiene can best be set
forth by the following quotation from the con-
stitution of the organization : "To work for the
conservation of mental health and for improve-
ment in the care and treatment of those suffer-
ing from nervous or mental diseases or mental
deficiency and for the prevention of those disor-
ders ; to conduct or to supervise surveys for the
care of those suffering from mental diseases or
mental deficiency ; to cooperate with other agen-
cies which deal with any phases of these prob-
lems ; to enlist the aid of the Dominion and pro-
vincial governments and to help organize and aid
affiliated provincial and local societies or com-
mittees of mental hygiene."
That there is a wide field in Canada for this
EDITORIAL ARTICLES.
383
work can be understood by a consideration of
?onie statistics presented by Dr. C. A. Porteous,
assistant superintendent of tlie Protestant Hos-
pital for the Insane, Verdun, Quebec. Of 4,780
admissions to that institution in twenty-seven
years, 1,884, nearly forty per cent., showed defi-
nite hereditary taint. There were 1,134 patients
in whom no facts as to heredity were ascertain-
able. Of the 1,762 remaining-, or thirty-six per
cent., hereditary tendency was absolutely denied.
Twenty-seven per cent, of all the cases, 1,300,
occurred at or about pubei ty, or the climacteric,
or in the presenile period of life. Five per cent,
of the total admissions, 230, were defectives, all
of severe grades.
The figures bearing on war conditions are quite
as interesting. In Canada, up to within a recent
date, 15,000 men had been rejected because of
some nervous or mental disability. Since the
war began Verdun has admitted forty-eight sol-
diers, thirty returned from active service. Five
had been patients previously in civilian life. Six-
teen patients of these have recovered — thirty-
three per cent, of the whole number of soldiers
admitted.
The National Committee of Mental Hygiene in
Canada proposes to establish centres, or affiliated
societies, in various parts of the Dominion, so
that the work may be adapted to the more partic-
ular needs of each community. There is gener-
ally little trouble in securing public spirited citi-
zens to act on such committees, but physicians
are, as a rule, if they may be judged from the
committees in the tuberculosis campaign, more
or less indififerent. If the committee, or the di-
rectors, can overcome this indifiference and secure
the hearty cooperation of the profession, the
work will be advanced rapidly. * Having secured
that cooperation, there yet remain to be ap-
proached the national, pro\'incial, and municipal
governments.
An alternative plan would be the wholetime
medical officer for provincial districts.
INFECTION OF THE SALIVARY GLANDS
IN INFANTS.
The anatomical development of the salivary
apparatus of the newly born is probably too well
known to require mention, likewise the infec-
tious agents to which this apparatus is exposed ;
but the resistance offered to this infection, its
mechanism, and the pathogenesis of the infection
when it does occur, are matters of considerable
interest. If the general etiology of salivary in-
fections is considered, it becomes manifest that
in infants no obstruction from calculi, new
growths, etc., exists and that specific infections,
such as mumps, play no part. What does occur
in infants are serious acute deuteropathic infec-
tions of the salivary glands, followed by cachexia.
The infection travels to the glands by the ca-
naliculi and not by the lymphatics, so that any
condition favoring buccal infection will, of neces-
sity, favor secondary salivary infection. Thrush
is particularly prone to infect the salivary glands,
especially when the infant is puny.
Much has been said about the antisepsis of
the saliva in the prevention of these infections,
but in reality this is most problematical. It is
far more probable that the bacteria in infants'
mouths are of low virulence and that the white
corpuscles in the saliva exert a phagocytic action.
But, on the other hand, during the first three
months of life the production of saliva is small
and the hematopoietic organs are only in a rudi-
mentary state, therefore there must be a relative-
ly weak phagocytosis, so that if any microbicidal
action of the saliva exists in reality, it must of
necessity be slight.
The bactericidal properties of the mucus of the
glandules of the excretory ducts are likewise hypo-
thetical, and any action that it may possess is
rather more due to the renewing and shedding
of? of tl">e epithelium, two phenomena related to
the general activity of the salivary secretion, and,
consequently, reduced in infants as is the func-
tion itself.
The only real defensive barrier to infection is
the length of Stenson's duct and the peculiar po-
sition of the orifice of Wharton's duct ; and this
is why infection of the parotid and submaxillary
glands is not as common in infants as it other-
wise might be.
The bacteria found in the pus when these
glands become infected are usually the staphylo-
coccus and streptococcus, singly or combined,
and occasionally the saccharomyces albicans.
The prognosis of salivary infections in infants
is particularly serious, and of course varies with
the individual resistance of the child.
The symptomatology differs in the case of
parotiditis and submaxillitis. The parotid gland
being divided up by a series of very resistant
fibrous septa, the lobules are thus imprisoned
separately and the gland is rendered both hard
and compact. From this two consequences re-
sult: I, The pus does not collect in a single
focus ; 2, when inflammation and suppuration oc-
cur in the gland a true strangulation and gan-
grenous melting of the organ takes place. For
this reason no definite fluctuation can be detect-
384
EDITORIAL ARTICLES.
[New York
Medical Journal.
ed, only a doughiness of the parts with regional
edema is felt.
In the case of the submaxillary gland there is
an appreciable tumefaction of the organ, with
pain on pressure. The overlying integuments
soon become red and adherent and distinct fluc-
tuation soon becomes manifest. The floor of the
mouth projects and pushes the tongue backward
so that deglutition is interfered with, requiring
the use of a catheter for feeding. But there is
no compression of the larynx nor respiratory dis-
turbance.
Finally, general symptoms of septicemia ap-
pear, even of a hyperacute type in some cases,
and death occurs. Recovery is infrequent. It
is to be noted that the affection is in most in-
stances unilateral and that but a single gland is
usually involved.
A PLEA FOR GREATER DEFINITENESS
IN REGARD TO OVARIAN AND
PLACENTAL EXTRACTS.
Clearness and definiteness of procedure is cer-
tainly essential in the preparation and use of in-
ternal glandular substances. So much is expect-
ed from this newer branch of therapy, and so
much is claimed, that hopeless confusion and un-
certainty and distrust will be the result, unless
the steps are carefully taken and adequately ex-
plained. A plea for greater carefulness is issued
by W. H. Morley, M. D.,^ who reviews the re-
searches which have been published in regard to
the preparation and employment of ovarian and
placental extracts, with a notice of results ob-
tained. Some of this is the result of careful and
accurate work and is cautiously reported ; other
results are claimed without clear explanation of
method or results.
The results would be much more uniform and
clearer, the author states, were the active princi-
ple of the ovary and placenta isolated. The fact
that this is still imknown makes it so much more
necessary to proceed by some uniform method of
preparation and necessitates the standardization
of ovarian and placental extracts.
It is only within ten years that search has been
made for this active principle, although before
this there had been a use of dessicated ovary or
corpus luteum for symptoms which manifested a
disturbance of the inner secretory activity of the
ovary. Iscovesco, investigating the "lipoids"
obtained from red blood corpuscles, the hypo-
physis, the kidney, the suprarenal capsules, the
^ The Preparation and .Standardization of Ovarian and Placental
Extract, Transactions nf the American Gynecological Society, 1917,
pp. 22S-239.
ovaries, the testicles, and the corpora lutea, dis-
covered that they had a special influence upon the
female genitalia. He found that there were two
classes of these lipoids and among them two
lipoids of special importance to be obtained
from the ovary. He was followed by Her-
mann, Seitz, and others, all of whom em-
ployed a similar method of extraction of a defi-
nite character, which aimed to discover and iso-
late the active principle of these substances.
Their products could be submitted to experi-
mental and clinical tests which tended toward
definite physiological and anatomical results.
In the reports of other researches the terminol-
ogy has been too vague and nondescriptive to
assist in a standardization of the resulting prod-
ucts. The same lack of precision prevails too
often in determining clinical results only through
the testimony of the patient and in reporting re-
sults.
The presence of a pressor principle in these ex-
tracts has been especially tested by Rosenheim
in order to confirm previous observations of
Dixon and Taylor. He did not find such a
principle in normal human placenta. Similar
experiments were carried on by the writer, who
proved, with Rosenheim, that normal placenta
does not contain a pressor or a marked oxytocic
principle. There was some contraction of the
uterus of a guineapig in the author's experiments
and slight change in blood pressure, but neither
were marked. These effects in two of the sam-
ples at least were due in part to the fact that de-
composition of the substance had begun. Rosen-
heim identified the pressor principle as belonging
to the amines and as probably derived from the
cleavage product of proteins. Other experiment-
ers found that tht pressor principle is present in
putrid meat. Moreover, all meat extracts, the
author states, will contract the isolated uterus if
they are used in sufficient concentration, and this
action is increased by decomposition.
PSYCHIC EFFECTS IN SURGERY.
Much has been heard about needless surgery ;
and when a body of eminent surgeons deem it
necessary for the protection of the reputation of
their own branch of practice to sign an agree-
ment not to perform unnecessary operations, the
accusation from without would seem to receive
full confirmation.
But there is little doubt that, as in the giving
of drugs, the use of the knife often produces good
eft'ects from a purely psychic influence. The
effect of an operation, especially of the prepara-
August 31, 19 1 8.]
EDITORIAL ARTICLES.
385
tions for an operation, upon the patient is pro-
found, and were there not hope and expectation
of improvement back of it all, the bodily results
of mental states would often prove disastrous.
Improvement is expected, and improvement usu-
ally takes place, therefore, no matter what emo-
tional disturbance is undergone.
Operations are of such common occurrence
and so much discussed that by a certain class of
persons, women especially, they come to be de-
sired as a curative means, and even when not
needed for mechanical abnormalities or for the
removal of foci of disease, their performance pro-
duces good results. The patient, with a few ex-
ceptions, is satisfied with the experience, and
above all feels (even if the symptoms are not re-
moved) that everything possible has been done.
It must be a hard hearted surgeon who would re-
fuse to operate in such a case, especially if the
fee were at all adequate ; and since the risk is
slight, he is certainly not more culpable than the
physician who doses his patient, to the injury of
the digestive apparatus, with drugs whose efifects
are likewise psychic. How to twist the mentality
into healthy channels without the use either of
the drug or the knife, especially if a friend of the
victim has recovered through such treatment, is
not an easy proposition — certainly far less simple
than the use of material means as an aid to the
cure.
The experiment of giving bread pills to pa-
tients in one medical ward of a hospital, and reg-
ulation drugs to those in another, has been tried
and the results are familiar to the reader. A
comparison of the efifects of a scratch through the
skin and a few superficial stitches and some
more complicated procedures in selected cases
(for which experiment there would be many
cases to select from) might prove equally in-
structive.
CALLING IN A SPECIALIST.
While many patients, especially women, take
pleasure in telling how many specialists they have
seen, concluding from this their case was particu-
larly bad or interesting, there are many who are
annoyed and bewildered by being sent from one
doctor to another. They see the inevitability or
necessity for many men to make only one part of
their autos or their shoes, but still think the doc-
tor should understand the interdependence of
every pa-rt of their bodies and be able, by him-
self, to give medical or surgical aid comprehend-
ing all. Admitting that the "family doctor" does
well to call the pathologist, rontgenologist, bac-
teriologist, stomatologist, alienist, ophthalmolo-
gist, and what is known as a "nose and throat
man" to assist in diagnosis, there are many small
towns where this plan is abused For instance,
many doctors often have their offices in one
building, and the desire to do a good turn to a
colleague in return for referring a patient catiscs
them to send cases from one office to another,
though knowing that only an opinion will be
gained rather than an elucidation, for the "spe-
cialists" do not deserve the title, being only "good
on eye work" or "first rate on stomachs" ; that is,
they have had a little more experience than the
referring doctor, but certainly not enough to
merit an extra ten dollars being added to the ac-
count for their services. While some patients
are gratified by these additional opinions, in the
long run this practice will lead to distrust of that
old friend the "general practitioner," and he will
have to take a new name — "omnispecialist,"
which will help to sustain his reputation, the
therapeutic value of a long or little understood
word being universally acknowledged.
THE MEDICOTELESCOPIST.
The greatest of scientific discoveries are at first
given a brief notice in some "Proceedings," or get
permission to lodge in a short paragraph in a sci-
entific journal, until a subeditor, seeking copy for
his daily, hashes it up with his own incorrect
knowledge and the general public read, com-
ment, and forget, until, long after, they wonder-
ingly link it up with the "new discovery" con-
cerning which all the world is talking. So it was
with the idea of seeing over the telephone or
transmitting a picture over the wires, yet that
television and telephotoic plan has now come to
stay and monthly improves. The question for
us is. How will it af¥ect the doctors? It is true
that a great many now charge for advice so sent,
but what will be their fee for a telecHnico visita-
tion? The plan is, to elucidate matters by using
a diagram of the human body and to trace on it
the source of pain in the same way as in trans-
mitting maps by telephone. Doubtless a photog-
rapher will be in the sick room to make quick
proofs to speed over the line, and, when he sends
the vmmistakable facies Hippocratica, the doctor
will say, "All U. P. : ring ofif."
But there will be gross abuses. Picture the neu-
rotics who wake the doctor at 4 a. m. to ask if they
shall take some more of the medicine, or telesmil-
ingly tell him, as they drag him away from his
dinner, that they knew they would be sure to find
him, as it was his dinner time. How if they can
exhibit their physical diagram and "touch the spot"
to elucidate their verbose muddling symptomatolo-
gic statements. Clearly the only way will be for
every doctor to term such call a "consultation" and
to charge the higher fee usually asked.
386
NEl^/S ITEMS.
[New York
Medical Journal.
News Items.
Epidemics in Northern Russia. — According to cable
despatches from Amsterdam, dated August 24th, the north-
ern provinces of Russia are being swept by epidemics of
cholera and typhus, the starving population dying in great
numbers.
Yale Buys a New Haven Hospital. — The Elm City
Hospital, a private institution, has been purchased by Yale
University. Possession will be given September ist, and
the property will be available for Government work in
connection with the Yale army laboratory school and the
medical side of the chemical warfare service.
Reconstruction. — This is the title of a periodical de-
voted to the reconstruction of disabled soldiers and sailors,
which is published monthly at Ottawa, Canada, by the De-
partment of Soldiers' Civil Reestablishment. It is similar
in scope to Carry On, a monthly periodical issued from
the Office of the Surgeon General, Washington, D. C.
A Case of Leprosy in Connecticut. — On June 6, 1918,
there was reported to the United States Public Health
Service a case of leprosy in Bridgeport, Conn., in the per-
son of T. H., a native of Greece, aged forty-one years, who
had lived in Bridgeport six months and previously in Stam-
ford and in New York. The patient has been in the United
States four years. The Bridgeport department of health
has supervision of the patient, who is in an isolation hos-
pital.
Four Chairs Endowed at Toronto University. — A re-
cent endowment to the University of Toronto, which may
amount to about three million dollars, provides for the
establishment of four special chairs in medicine, as fol-
lows : One in obstetrics, one in gynecology, one in pedi-
atrics, and the fourth m some special branch of medicine
which has not yet been decided upon. These chairs will
be held by specially qualified men who will be able to de-
vote all their time to the work.
Airplane Ambulances. — All flying fields in the United
States are to be equipped with airplane ambulances to
carry injured aviators quickly from the scene of an
accident to a field hospital. A standard training plane
is to be used for the ambulance, the rear cockpit being
cleared and enlarged sufficiently to permit a combination
stretcher seat to be placed in it. The injured person is
placed with his head toward the pilot and rests easily.
The first airplane ambulance is being operated successfully
at Gerstner Field, Lake Charles, La.
Chiropodists in the Army. — The War Department
announces that as far as is consistent with the military
demands, chiropodists taken into the army will be trans-
ferred directly to the medical department and either as-
signed directly to the various camps for duty under the
camp surgeon or first sent to Camp Greenleaf for further
training under the regular orthopedic instructors. On the
demonstration of proper skill and attainments they may be
advanced to the grade of sergeant. A canvass of the camps
is now being made to determine the need of this service.
Flight Surgeon Killed. — Major William R. Ream, of
San Diego, California, flight surgeon of the British-
American "flying circus" which started on August 24th
from Indianapolis for St. Louis, was killed near Effing-
ham, 111., when the airplane in which he was riding fell
about one hundred feet to the ground. The pilot was
seriously injured. This is the second death which has
occurred since the mission started on a tour of the Middle
West. Major Ream was forty-one years of age. He had
served on the Mexican border, and until his assignment
on this flying tour was stationed at a flying field near his
home in San Diego.
Enlarging the Scope of Azalea War Hospital. —
United States General Hospital No. 16, situated at Azalea
in the mountains of North Carolina, near Asheville, was
designed primarily for the care and treatment of tubercu-
lous soldiers and sailors, but climatic conditions proving
to be advantageous in gas cases, it has been decided to
enlarge the scope of the institution to admit gassed sol-
diers. The hospital was opened on August 20th, with
accommodations for one thousand patients, and orders
have been given to add twenty-two buildings, which will
provide for an additional five hundred patients. The cost
to date is about $1,500,000.
The Journal of General Physiology.— This is the
name of a new publication which will be issued bimonthly
by the Rockefeller Institute for Medical Research. Ac-
cording to the announcement, this journal is intended "to
serve as an organ of publication for papers devoted to the
investigation of life processes from a physicochemical view-
point." The editors of the new journal are Dr. Jacques Loeb.
of the 'Rockefeller Institute of Medical Research, and Pro-
fessor W. J. V. Osterhout, of Harvard University. The
lirst number will be issued on September 20, 1918.
Special Hospital for Aviators at Cooperstovm, N, Y.
—The War Department has accepted the offer of Edward
S. Qark, of Cooperstown, N. Y., to use the Mary Imo-
gene Bassett Hospital and Pathological Laboratory at
Cooperstown for the period of the war and one year
after. It \y\\\ become a general hospital, where special
attention will be given to nervous conditions among avi-
ators. The hospital, which is being erected at the present
time, will be ready for use early in 1919. It is a stone
building of fireproof construction, consisting of one main
building and wards with accommodations for 185 patients.
One hundred beds and full equipment necessary for car-
ing for that number of patients will be provided by Mr.
Clark. The balance of the equipment is to be furnished by
the government.
A School for Nurses Opened at Camp Dix.— The first
class of the Army School of Nursing which was opened
on Wednesday, August 21st, at Camp Dix, Wrightstown,
N. J., is composed of thirty-five young women from New
England and Atlantic States. Miss Caroline Milne, for
twenty-three years head nurse at the Presbyterian Hospi-
tal, Philadelphia, is in charge of the school. The candi-
date nurses were required to enlist for the period of the
war, or a three years' course which includes two years in
an army hospital and one year in a civilian hospital as
necessary to win a diploma. Following their preliminary
training they will be assigned to assist graduate nurses in
the hospital. Later their advancement will make it pos-
sible to release many graduate nurses for overseas work.
The hospital has accommodation for two thousand patients.
American Red Cross Work in France. — The monthly
report of the American Red Cross Society, issued on
August 25th, shows that the society has supplied 1,100,000
surgical dressings to the American wounded during the
last month ; twelve hospitals are being operated, four new
hospitals are being built, and convalescent homes have
been established at Biarritz and other places. The report
also shows that the canteen service has supplied 100,000
meals and a million hot drinks to the wounded, to whom
4,000,000 cigarettes also have been distributed. The Amer-
ican Red Cross is now operating farms for the conva-
lescent, aggregating 249 acres. The report dealing with
supplies shows that each division of the army receives
2,500 daily papers and 500 weekly magazines. Loans to 362
newly commissioned army officers have been made to assist
them in buying equipment.
Hospitals' Plea for Exemption, — In response to a let-
ter from the Office of the Surgeon General suggesting the
calling out of the hospital interns and that certain hospitals
transfer to the Army School of Nursing considerable num-
bers of senior and intermediate pupil nurses, the Hos-
pital Conference of New York voted, at a meeting on
Aiigtist 27th, to send a committee to confer with the Sur-
geon General for the purpose of forming a definite plan to
furnish the greatest amount of medical and nursing aid to
the army without entirely disorganizing civil hospitals.
The directors of several hospitals here have urged the use
of nurses' aids in hospitals in France, but this was not en-
couraged until recently by the Surgeon General's Office,
whose original plans called for hospital nursing by only
trained nurses. The members of the Hospital Conference
consider that the deprivation of the civilian hospitals of
jimior and intermediate nurses will not fulfill the present
and future needs of the army; will seriously cripple the
activities of the civilian hospitals ; and will present a seri-
ous obstacle to the training of pupil nurses in tJie future,
since all the senior nurses will be taken away. They sug-
gest a special six months' course of intensive training for
special nurses' aids who will serve in France to be given
bv the hospitals in association with the Army School of
Nursing.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
VICIOUS CIRCLES IN DISORDERS OF THE
RESPIRATORY SYSTEM.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Continued from page 344.)
In lobar pneumonia an - important vicious circle
involving the functional relationship of the heart
;md lungs is not infrequently encountered. The
blood vessels of the consolidated lung tissue, though
still in some degree pervious, are compressed by the
edematous and leucocytic infiltration in the walls
of the air cells and by the exudate lying within these
cells. Even in certain portions of lung tissue not
actually consolidated edema bordering on a state of
gelatinous transformation may prevail. Obstruct-
ing circulation through the pulmonary vessels, these
conditions place abnormal stress upon the right
heart, itself already exposed to the debilitating ac-
tion of pneumococcic toxemia and at times, also, to
that of hyperpyrexia. In response to the increased
functional demand thus thrown upon it, the right
Acntricle undergoes up to a certain point, as does
the left ventricle under analogous conditions of in-
creased arterial resistance, a process of physiological
dilatation, whereby in virtue of the elongation and
increased tension of the muscle fibres, the latter are
able to develop more energy and yield the required
output of blood in spite of the unusual resistance
in the pulmonary circuit. If the severity of the
disturbance increases further, however, or if the
heart has already been impaired before the advent
of pneumonia, the protective dilatation becomes
inadequate and gives way to a more pronounced,
pathological dilatation, in the presence of which the
necessary output of blood from the right ventricle
is no longer maintained.
At this point a vicious circle becomes established
which in many ways resembles that encountered in
primary cardiac disease with failure of compensa-
tion. The stasis in the pulmonary circulation result-
ing from insufficiency of output of the right ven-
tricle necessarily implies a subnormal inflow into
the left ventricle. I'hus, all organs supplied by the
general circulation receive less blood than under
normal conditions and their various influences in
imparting nutritive material to and removing toxic
material from the blood are impaired through defi-
cient oxygenation and otherwise. The quality of
the blood supplied to the heart muscle being thereby
impoverished, defective nutrition is added to the
difficulties under which the right ventricle is already
laboring and its weakness accentuated, with conse-
quent completion of the vicious circle. Again, since
there is stasis in the pulmonary circulation, deficient
aeration of the blood supplied to the ventricular
walls is likely to be an additional evil factor which
may react directly upon the activity of the right ven-
tricle and constitute another phase of the vicious
circle.
The danger attending this vicious circle is illus-
trated in the unfavorable prognostic portent of its
clinical manifestation. Combinations of two or
more of these manifestations, which include an in-
crease in the heart rate above 125 ; impaired volume
and rhythm of the pulse ; cyanosis and distended
jugular veins; cold extremities; a high rate of res-
piration; a blood pressure relatively low in com-
parison with the pulse rate, and disappearance of
the accentuation of the second pulmonic sound, are
of considerable significance as indications of a
lethal trend.
The ease with which the vicious circle attending
decompensation in primary cardiac disease can fre-
quently be broken up bv appropriate remedial meas-
ures suggests a priori that the somewhat similar
circle encountered in pneumonia may likewise be
susceptible to artificial interruption, with analogous
clinical benefit. As a matter of fact, the vicious
circle in pneumonia may be therapeutically attacked
from several different angles.
The dilatation of the right ventricle itself can be
treated by drugs of the digitalis group, by other
directly or indirectly cardiostimulant remedies, and
by venesection. According to some, the efficiency
of digitalis in febrile states is slight; during fever
the vagi are in abeyance, and the action of the drug
in slowing the heart rate is thus interfered with.
That part of the cardiac enfeeblement which is due
directly to toxemia is, j>erhaps, less easily influenced
by ihe drug than that resulting from impaired nutri-
tion or oxygenation of the myocardium. Yet among
careful clinical observers the utility of digitalis in
pneumonia is by no means despised. The assertion
of Vaquez, 19x8, that strophanthin is far more
effectual than digitalis preparations in restoring
myocardial tone, coupled with the experimental
observation of Jamieson, 1915, that the action of
strophanthin in normal animals is identical with that
in pneumonia infected animals, would seem to ren-
der advisable a special clinical study of the utility
of strophanthin in the pneumonia cases under con-
sideration. Stimulants such as aromatic spirit of
ammonia, caffeine, strychnine, and adrenalin may
also exert a certain beneficial influence, the details
of which need not here by described. In failure of
the right ventricle, blood being no longer pumped
with sufficient rapidity through the lungs owing to
the circulatory obstruction therein, the systemic
veins and right ventricle itself become overfilled ;
hence the efficacy, at times striking, of blood letting
— eight to twenty-four ounces — or in less degree, of
dry cupping two or three times a day.
Any of the measures which enhance the propul-
sive power of the dilated right ventricle ipso facto
improve the general circulation by causing more
blood to enter the left ventricle from the lungs in
a given period of time. All nutritive and elimina-
tory functions may thus be improved, the quality
of blood supplied to the myocardium likewise, and
the tendency of the vicious circle further to impair
388
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
cardiac nutrition and power abolished. To promote
elimination by means of simple diuretics, saline
solution, and laxatives is, of course, a useful auxil-
iary procedure. Again, certain drugs are credited
with the power to dilate the coronary vessels, pre-
sumably thus increasing the blood supply to the
heart muscle.
Imperfect blood oxygenation as a factor in the
vicious circle is in part counteracted by all measures
which increase the output of the right ventricle.
An additional special agency in this connection,
however, is oxygen. Although Norris, 191 3, asserts
that he has never seen any benefit follow the use
of oxygen in pneumonia, it is the definite view of
pharmacologists that wherever, as in this disease, tlie
blood becomes distinctly venous, oxygen inhalation
will promote saturation of the hemoglobin with this
gas. Some indirect beneficial action of oxygen may
also be implied in Stewart's observation, 191 1, of
a marked increase in the blood flow of the hands in
a cyanotic patient to whom oxygen was adminis-
tered. Theoretically, oxygen will spare a fatigued
respiratory centre. At times, however, stimulation
of this centre with strychnine seems of very distinct
service.
Fresh air may break into the vicious circle at sev-
eral dif?erent points. It probably improves oxy-
genation by supplying additional oxygen ; spares
myocardial activity by reducing the demand on the
mechanical process of respiration, quieting restless-
ness and promoting sleep, and favors proper nutri-
tion of the heart by enhancing the digestive
functions.
Sudden phvsical exertion is to be remembered as
a factor which may rapidly and dangerously accen-
tuate the vicious circle, and which therefore must be
carefully guarded against.
(To be contiKued.)
Fracture of Patella. — C. D. Schaeflfer (Penn-
sylvania Medical Journal, June, 1918) considers the
end results of nonoperative measures markedly in-
ferior to those obtained by operations. Nonopera-
tive measures can not meet the following pathologi-
cal conditions: i. The tilting of the fragments;
2. hemorrhage into the joint ; 3. the inversion over
the fragments of the periosteum and prepatellar
tissues, preventing the accurate apposition of the
fractured surfaces and consequently interfering with
the bringing together in close contact of the osteo-
genetic elements of the fragments ; 4. the lateral
laceration of the apvoneurosis which is much larger
in a refracture than in the original injury. Refrac-
lure of the bone is common following nonoperative
procedure. Operation at a late date is not attended
with good results. Operative interference is con-
traindicated in fracture of the patella in diabetic
patients, advanced tubercular, cardiac, renal and
hepatic diseases ; in longitudinal fracture without
displacement and in fracture without laceration or
tearing of the prepatellar tissue. The best time
for operation is from six to ten days following the
injury, in order to give the synovial membrane an
opportunity to react to the irritation of the trauma
i.nd the irritation of the blood clot in the joint.
Immediately after the fracture an injection of ten
c. c. of formalin and glycerin solution is made into
the joint. This produces a chemical irritation caus-
ing an increase in the number of jX)lymorphonu-
clear leucocytes and is a prophylactic measure. At
the operation a U shaped incision with the convexity
above is made and the flap dissected up from the
prepatellar tissue. The fragments are inspected
and the intervening clots removed with a forceps
and irrigated with normal saline. Absorbable
sutures should be used. The prepatellar and capsular
tissues are carefully sutured with chromic catgut,
after which the circumferential suture which had
previously been introduced is tied. This brings the
bony parts together. The joint should be closed
without drainage. After ten days passive exercise
may be allowed. On the 14th day the limb is flexed
from five to ten degrees. The fixation of the joint
is continued for three weeks, when the splint is
removed and the patient allowed to bend the joint.
During the course of the treatment the leg should
be slightly flexed on the abdomen in order to relax
the quadriceps femoris muscle.
Bacterial Examination of Wounds. — C. Leva-
diti {Presse medicate, June 10, 1918) states there
is no longer any doubt as to the importance of
bacteriologic examination of war wounds as a guide
to the indications and results of primary, primo-
secondary, and secondary suturing. In the case of
a primarily sutured wound the inoculations are made
from a wick of silkworm gut strands placecl in the
centre of the wound before suture. In wounds that
are to be left open, the cultures are taken fifteen to
twenty hours after the surgical cleansing procedures
by means of a tampon on a metallic rod, placed in
a sterile test tube. From this tampon are inoculated
in succession an agar slant; a tube of glucose agar
( Veillon), and a tube containing two mils of bouillon
and 0.2 mil of horse serum. With a fine pif>ette a
second passage is made, beginning with the agar
slant and glucose agar. Finally, a smear should
always be made from a second tampon previously
passed into all the wound recesses. This should be
stained with Gram fuchsin. The results are re-
corded after twenty hours' jncubation on a special
chart with separate columns for the bacterial species
detected and the results of quantitative microscopic
study of the smear, the number of bacteria per field
being noted. This quantitative examination, carried
out every two or three days until suture is deemed
opportune, supplies data for a bacterial curve and
shows the precise moment of critical depuration of
the wound. In a separate column the indications
for suture are noted by the bacteriologist for the
surgeon's information. Wounds with streptococci,
primarily sutured, must be watched and the sutures
cut in the event of marked general and local re-
action ; if not yet sutured, they should be submitted
to adequate treatment, preferably the Carrel pro-
cedure, and left open until the cocci disappear or
are sufficiently attenuated to permit of healing by
first intention or almost complete closure. In
wounds showing other germs, suture is in order
unless the infection is very abundant, in which event
they should remain open until the bacterial curve
indicates the moment of critical depuration.
August 31, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
389
Ichthyol and Glycerin in Gunshot Wounds. —
C. W. Duggan {Therapeutic Gazette, June, 1918)
asserts that while the much lauded watery anti-
septics soon check suppuration, they leave the gran-
ulations water logged — which necessitates astring-
ents or a change of antiseptic — and delay healing.
Glycerin places wound surfaces in a much better
condition for healing, while ichthyol markedly re-
lieves the congestion of the surrounding skin pres-
ent in the great majority of gunshot wounds.
Duggan uses ichthyol and glycerin in equal parts
as long as there is suppuration, i. e., for three days,
where foreign bodies have been removed, abscess
cavities completely opened, and counteroj^enings
made if sinuses exist. The concentration of ich-
thyol is then reduced to twenty per cent. The com-
bination is painted over the wound and surrounding
skin with a camel's hair brush and then covered
with antiseptic gauze, absorbent cotton, and a band-
age. No impermeable dressing is used, as it delays
healing. At the redressing on the next day, the
surface is simply dried with a sterilized swab, and
occasionally, pure alcohol is used. No drainage tubes
are used. Cavities and sinuses are syringed out
with pure alcohol and painted with ichthyol and
glycerin. Where the alcohol irritates, methylene
blue, four grains to the ounce, is added with good
results. The method is asserted to avoid all risk of
extension of sepsis and secondary hemorrhage ;
septic absorption is checked ; the dressing does not
adhere ; it does not irritate the wound ; frequent
redressing is unnecessary, and the time in the hos-
pital is greatly curtailed. Mud should be removed
from the wounds with vaseline applied on sterile
swabs Ichthyol, alone or with glycerin is also
recommended by Duggan in burns, whitlow, boils,
carbuncles, vaccination conjunctivitis, gonorrhea,
abscesses in general, external carcinoma and opera-
tive wounds in tropical abscess of the liver and sup-
purative appendicitis.
Pyorrhoea Alveolaris. — B. Kritchevsky and P.
Seguin (Presse medicale, May 13, 191 8) report
good results in sixty cases from Barton L. Wright's
method of mercury succinimide injections. They
noticed in the pyorrheal secretions numbers of large
SDirochetes. which generally disappeared almost
completely as a result of the injections. This led
them to suspect that the spirochetes might be of
etiological importance, and even better therapeutic
results secured by means of the organic arsenicals.
Studies in 244 cases showed that the spirochetes
are present in large number in three fourths of all
cases of pyorrhea, in fact, in twenty-two out of
twenty-four cases not previously treated. In healthy
mouths, on the other hand, the spirochetes were
absent or few in three fourths of all instances. Six
to ten injections of o.l to 0.6 gram of neosalvarsan,
among forty-two patients all showing numerous
spirochetes, caused disappearance of the latter in
twenty-nine cases, in the absence of all local
treatment. X few patients were treated with local
instillations of neosalvarsan solution or by applica-
tion of the powdered drug in the pyorrheal pockets.
Excellent results were obtained both as regards
clinical improvement and rapid disappearance of
the spirochetes. The treatment the authors recom-
mend for pyorrhea is as follows : intravenous injec-
tions of o. r to 0.3 gram of neosalvarsan; if contra-
inclications or special technical difficulties exist, in-
tramuscular injections of mercury succinimide
should be substituted. Local treatment is equally
necessary. If the tooth is entirely loosened and the
alveolar process destroyed, the tooth had best be
removed. If the alveolar process is but partly in-
volved the roots should be scraped and even care-
fullv polished Fluorine salts will assist in break-
ing un and loosening the tartar. Neosalvarsan
should also be introduced into the pyorrheal pockets
in solution or powder form. Recurrence is obviated
only by persistent, careful cleansing of the teeth by
the patient or a dental specialist.
Cysts and Pseudocysts of the Pancreas. — A. A.
Kerr {Surgery^ Gynecology, and Obstetrics, July,
1918) summarized on the above conditions as fol-
lows : Pancreatic and pseudopancreatic cysts, while
not rare, are of sufficient importance to be recorded.
The x ray is an important aid in diagnosis in show-
ing the position of the cyst in relation to the
stomach and other organs. The treatment is surgi-
cal, usually incision and drainage. Sometimes it is
practical to remove the entire cyst in favorable
cases. Diabetes is an occasional complication of
pancreatic cysts, and when present renders the
operation more dangerous, although one should
hesitate when less than four per cent, of sugar is
present (C. H. Mayo), after giving a diabetic diet
and a course of alkaline treatment to minimize the
acidosis, to give even the benefits of the operation.
An antidiabetic diet is advisable following opera-
tions on the pancreas ; especially where the dis-
charge is irritating. Paraffin ointments are serv-
iceable to allay the irritation.
Quinine Hydrochloride and Cacodylate of Soda
in Chronic Malaria. — John C. Clark (Therapeutic
Gazette, July, 15, 1918) uses a preparation of dihy-
drochloride of quinine of such a strength that one
c. c. represents one half grain of the salt. It is given
intravenously. When used in connection with
cacodylate of soda the following dose has been
adopted : one grain of quinine for every ten pounds
of body weight and one grain of cacodylate of soda
for every fifty pounds of body weight. This amount
is to be given daily for five days. Subsequently on
each fifth day, for a period of thirty five days, the
same amount of quinine is given with one grain of
cacodylate of soda for every twenty-five pounds of
body weight. In addition a certain amount of quinine
hydrochloride is given by mouth daily, an average
of five grains, together with Blaud's mass, laxatives,
etc., depending on the general condition of the
patient, and, when necessary, alkaline diuretics in
sufficient quantity to insure a relatively low acidity
of the urine. The injection is given at the rate of
about one c. c. per minute. The after care con-
sists in the oral administration of from one to tw^o
drams of alcohol containing five minims of chloro-
form to the dram. Following this the patients re-
main in a reclining position for a variable length
of time before leaving the office. Fresh distilled
water should always be u.sed in order to avoid the
chill which sometimes occurs.
390
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Malaria. — S. Grehant (Bulletin de I' Academic de
medecinc, May 14, 1918) reports constant success
in nine years of practice in the French colonies
from the following plan of treatment : Any malarial
patient whose temperature rises to 39° C. is given,
in the absence of albuminuria, intramuscular injec-
tions, for three successive days and at twenty-four
hour intervals, of from 0.75 to one gram of quinine
sulphate, according to his size. Where, after a
time, a fresh paroxysm occurs, another like series
of injections is made. Were this plan generally and
systematically followed, most malarial cases would
be rapidly and permanently cured. Among illustra-
tive cases the author cites that of his own person.
In 191 1, on the Niger, he had several attacks of
fever and finally a grave bilious remittent condition.
Injections of saline solution and of quinine, admin-
istered by his wife, saved his life. Subsequently
he had no more attacks of fever and led an ex-
tremely active and fatiguing life.
Ulnar Nerve Paralysis. — N. I. Spriggs and
Astley V. Clarke (Lancet, June 8, 1918) points out
that the condition of main-en-griff e, so common in
ulnar paralysis, can be produced in the cadaver by
simultaneous traction on the extensor and flexor
tendons of the forearm, or in the^iving person by
simultaneous electrical stimulation of these two
groups of muscles. Under these conditions the
forearm muscles are acting while the small muscles
of the hand are not. If, under the conditions
named, the tendon of one interosseus also be pulled
upon the deformity does not result in that finger.
If the interosseus tendon on each side of the finger
be joined to that of the flexor sublimis just distally
to where the latter splits, the fingers are given a
useful prehensile power when the flexor tendon is
pulled upon and the main-en-griff e deformity is
prevented. On the cadaver this operation is com-
paratively easy and it is suggested that it be applied
to correction of the deformity in cases of ulnar
paralysis presenting the main-en-griff c.
Intravenous Arsenobenzol Treatment Com-
bined with Lumbar Puncture. — A. Tzanck and
A. Bernard {Paris medical, May 11, 1918) deem all
intraspinal injections of arsenobenzol unsafe, how-
ever small the dose, in late syphilitic meningo-
myelitis. Sicard having shown that such injections
alter meningeal permeability, the reaction locally
being such as to permit drugs introduced intraven-
ously to pass through the pial carrier, the authors
have been seeking to obtain the same meningeal
perturbation and pial permeability by simple spinal
aspiration by lumbar puncture, intravenous admin-
istration of the arsenical being thus alone required.
They give successive injections of 0.15, 0.3, 0.45,
0.6, 0.75, 0.9, 0.9, and 0.9 gram of neoarsenobenzol,
each followed within five minutes by lumbar punct-
ure. The amount of spinal fluid removed must
always exceed ten mils, and the fluid obtained is
used for cell numeration, albumin estimation, and
the Wassermann reaction. The lumbar puncture
regularly proved less disturbing to the patient than
in cases with normal spinal fluid ; the patients wel-
comed the punctures because they relieved their
headaches. In some cases the combination of in-
travenous injections and lumbar puncture alone re-
lieved the headache, either measure practised inde-
pendently failing to do so. Eleven cases were treated,
including one of tabes, one of paresis, two of men-
mgomyehtis with arteritis and paralysis, one of
Erb's syndrome, and seven of chronic syphilitic
meningitis of various types. Pronounced improve-
ment was noted in over two thirds of these cases,
both serologically and symptomatically. Objective
signs persisted, but the course of the disease was
arrested. While less efficacious than intraspinal
arsenical injections in meningitis cases of the sec-
ondary stage, this treatment is the only safe pro-
cedure where late organic involvement of the
neuraxis is considered a possibility.
Senile Chorea.— Malford W. Thewlis (Medical
Review of Reviezvs, July, 1918) says that true
senile chorea should be treated with arsenic. He
prefers to give a tablet containing i/ioo grain of
arsenic trioxide before each meal and at bedtime.
Fowler's solution may be used in five minim doses
three times a day, but it is essential to watch for
the secondary effects of arsenic in the aged, as
elimination is very slow and the drug is apt to have
a cumulative action. To prevent this the bowels
should be kept open by free catharsis. When symp-
toms of poisoning appear, such as a puffiness of the
lids and coryza, the arsenic should be discontinued
for a few days. Ordinarily he discontinues the
arsenic at the end of three weeks, replaces it with
elixir of iron, quinine, and strychnine phosphates, a
dram before each meal, and resumes the arsenic
at the end of two weeks. If nephritis is the cause
of the condition it should be treated by dietary
methods and free elimination through the emunc-
tories. If the patient is robust a saline laxative may
be prescribed each morning before breakfast, and
electric cabinet baths are beneficial. If he is physi-
cally frail a pill should be used.
Results of Blood Transfusion. — J. Rieux
[ Paris medical. May 4, 1918) reviews the subject
of blood transfusion, as illuminated through general
discussion at the recent Fourth Interallied Surgical
Conference. He takes up first the rules for choos-
ing donors, then the indications for transfusion,
and later the various methods employed. The
artery to vein method may now be considered ob-
solete. Transfusion of pure blood from a re-
ceptacle coated with paraffin, of citrated blood, or
of preserved blood, constitutes the prevailing pro-
cedure, the preserved blood method being simplest
of all, though not as yet definitely established.
Transfusions in rather large series of cases yielded
7T.8 per cent, of recoveries in cases of hemorrhage
or of hemorrhage with shock ; twenty-seven per
cent, in cases of pure shock, and 44.4 per cent, in
cases of infection. Results from the three methods
referred to — pure blood, citrated blood, and pre-
served blood — have seemed practically the same,
about three fourths of all cases of grave hemor-
rhage being saved. The percentage of recoveries
in the entire number of cases of different types
under discussion, covering 150 transfusions, was
sixty. This result is so gratifying that Tuffier has
characterized the lack of attention paid until lately
to blood transfusion as one of the gravest thera-
peutic omissions since the beginning of the war.
August 31, 1 9 18.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
Obstetrical Physiology and Delivery— F. M.
Horsley {Virginia Medical Monthly, May, 1918)
believes the average confinement case is better de-
livered in the dorsal than in the lateral posture. It
is important to allow enough for the tissues to
stretch ; if need be, the presenting part should be
held back until gradual dilatation has made it safe
for the child to be delivered. The head, when pro-
truding should be strongly pressed upward toward
the symphysis to save the perineum. This may be
done by placing the thumb on the one side of the
perineum and the fingers on the other, covering the
head as it begins to open the vulva about 2/2 inches.
The prone position permits of better use of the ex-
pulsive muscles and intraabdominal forces. Since
the perineum is more quickly dilated in this posi-
tion, the head can be kept by pressure from flexing
too soon- at expulsion and thereby preventing a
larger diameter at the vaginal outlet than would
otherwise be presented. The author does not hesi-
tate to make vaginal examinations when they seem
needed. There often arises some obstruction to the
passage of the fetus that can be relieved by manipu-
lation and which might otherwise waste the
strength of the mother and cause contusion at cer-
tain points of the parturient canal, with consequent
greater liability to infection. Failure of engage-
ment in spite of thorough dilatation of the os is
often remedied by rupture of the bag of waters.
Again, a slightly excessive extension of the head
causing delay may be helped through counter
pressure upon the brow. Similarly, any variation
in the size or shape of the head or in the form of
the pelvis may cause the head to bind at certain
points and this difficulty may easily be overcome by
manipulation.
Simple Treatment of Scabies. — G. Milian
, {Paris medical, May 18, 1918) lays stress on the
importance of scabies in war practice. He thinks
two army corps may yield as many as 500 cases
every month, thus removing a large force from
active service and entailing great expense for treat-
ment. The official course of treatment, he finds,, is
too complicated and is frequently misapplied by the
attendants. The chief source of difficulty is that
sulphur being insoluble, does not penetrate the skin,
yet must be brought in direct contact with the
parasites if successful results are to be obtained.
Milian's simplified treatment is based on the use of
a soluble sulphur preparation, and this does away
with the necessity not only of the preliminary rub-
bing with soft soap and the hot bath, but also of the
rubbing in of the sulphur itself, and even of the
disinfection of the clothes — if the patient can con-
tinue to wear the latter during the treatment. The
ointment employed is made by mixing 250 grams
each of petrolatum and wool fat, incorporating
with them a solution of fifty grams of potassium
polysulphide in 250 grams of water, and adding
five grams of zinc oxide and 200 grams of liquid
petrolatum. The odor of this ointment persists only
half an hour. The patient first rubs himself with
soap in a shower bath or takes an ordinary cleans-
ing bath. The entire surface of the body, with the
exception of the head, is then covered with the
ointment and the patient dons the same clothes he
had on before. For greater certainty, a second in-
uncticm may be carried out the next day. On the
third day the body is well washed with soap to
remove the ointment. The underwear is then
changed and, if possible, also the sheets. The
ointment is less irritating than those hitherto used
and can be used even where furunculosis or ex-
tensive impetigo coexists. In the first three or four
days the lesions of scabies become larger, due to
edema, but the parasites upon examination are
found to be dead. In about one case in fifty, viz.
in susceptible subjects and those insufficiently
cleansed with soap on the third day. a harmless
eruption of small papules on the trunk, lasting five
to six days, may be noted. In cases with impetigo
or furunculosis already present, a paste of equal
parts of zinc oxide, petrolatum, and wool fat should
be applied locally.
Therapeutics of Oily Solutions of Sulphur. —
L. Bory (Bulletins et memoires de la Societe med-
icate des hopitaux de Paris, March, 7, 1918) uses a
one per cent, solution of sulphur in oil of sesame.
Flis earlier favorable results from injections of the
solution in psoriasis have been confirmed by further
experience. He now administers large amounts
from the outset, giving five mils of the one per cent,
solution at a dose. In cases of syphilis in which a
particularly active mercurial treatment is required,
an injection of one to five mils of sulphur solution
every five to eight days greatly facilitates the treat-
ment. Bory was thus enabled, in cases previously
intolerant of mercury, to administer as much as
1. 1 5 to 1.3 grams of mercury, divided into eighteen
to twenty injections, in the course of twenty-five to
thirty days. In joint afifections the remedy has
seemed particularly useful. In a case of gonococcic
arthritis of the knee, three injections of one to two
mils of the solution were followed, by rapid disap-
pearance of pain and functional recovery. In a case
of multiple chronic arthritis following severe
tetragenous septicemia, of over two years' standing
and but slightly benefited by colloidal sulphur, three
injections of five mils of a 0.2 per cent, oily sulphur
solution at weekly intervals were followed by
marked and lasting improvement. In Achard's ex-
perience, sulphur injections proved of value in fa-
cilitating mobilization of stiffened joints in seven
war fracture cases; in three other instances curative
■nti^amuscular injections were given, with rapid sub-
sidence of joint effusions and febrile temperature.
Liquid Tight Closure of Wounds. — Walter
Herbert Taylor and Norman Burke Taylor
{Lancet, May 11, 1918) hold that the method of
liquid tight closure in the treatment of infected
wounds has the following advantages : It provides
thorough mechanical cleansing by insuring the pene-
tration of the fluid to all recesses and insuring its
tidal removal from such recesses. It secures an out-
ward flow of lymph and bacteria under negative
pressure. Large and mutilating incisions are
avoided. The concentration of the solution used
for treatment remains constant and the solution can
be renewed as often as necessary. The beneficial
effects of heat can be secured readily. The bed
and dressings are kept dry and time, effort, and
dressings are economized.
Miscellany from Home and Foreign Journals
Absorption of Air from the Pleural Cavity. —
P. E. Weil and Loiseleur {Prcssc medicale, June 6,
1918) state that where, after removal of intrapleural
fluid by puncture, air is injected, its reabsorption
occupies a very variable period of time. A careful
study of the cause of this variability showed, in the
first place, that reabsorption becomes increasingly
slower as the pathological damage to the pleura in-
creases. Air was still found after three months in
thick walled purulent pockets in cases of suppura-
tive tuberculous pleurisy. In ordinary serous pleur-
isy, six weeks is an average period, while in the
hydrothorax of Bright's disease all traces of in-
jected air have disappeared in a week. Methylene
blue, injected into the pleura in serous tuberculous
pleurisy, continued to pass out in the urine for
three and even five days. In suppurative cases the
stain cannot pass into the urine at all, and can be
recovered in the intrapleural fluid five or ten days
after the injection. Production of a pneumothorax
often hastened elimination of the methylene blue, as
though the air injected lessened the disease of the
.serous membrane or increased its permeability. In
cases in which the pleural fluid showed rapid and
massive coagulation in vitro after puncture, the air
and fluid were quickly reabsorbed and complete re-
covery without adhesions took place. Variations in
the functional activity of the diaphragm were also
found to influence the rapidity of absorption of in-
trapleural fluid.
War Dyspepsia. — G. Mouriquand and L. Bou-
chut {Prcssc mrdicale, June 6, igi8) comment on
the increasing number of dyspeptics in military hos-
pitals. They present an analysis of 200 cases based
on complete clinical and laboratory examinations.
Organic diseases of the stomach are excluded from
consideration. The cases are divided into three
groups, according as the chief symptom is flatulence,
pain, or vomiting. The first group is the largest ;
associated symptoms are eructations, heat flushes,
somnolence, and frequently dizziness, headache,
precordial anxiety, anorexia, coated tongue and con-
stipation. In the painful group of cases, there is
burning or epigastric tightness coming on immed-
iately or one half to one hour after ingestion of
food. The epigastrium is tender, but under radio-
scopy the gastric area proper is painless. In the
group of cases with vomiting, this symptom ranges
from simple regurgitations one half to one hour
after meals to copious vomiting immediately after
each meal. Radioscopy revealed a normal form,
position, mobility, contractility, and mode and dura-
tion of evacuation of the stomach in three fourths
of the 200 cases. Five cases, however, seemed to
show gastric hypertonia and forty-five, atonia. Of
the latter, twenty-three were in the painful group.
Gastric acidity was nearly always normal. The
general condition was little influenced in the cases
dating back only two or three months, but later there
were loss of weight, anemia, tachycardia, dizziness,
etc. A prominent etiological feature was that nearly
all the cases were in robust men, for the most part
peasants, previously entirely free from gastric dis-
lurl:)ances ; among city dwellers the tendency seemed
rather toward relief from preexisting dyspepsia.
The gastric neurosis sometimes had become estab-
lished after a violent shock, as the bursting of a
shell nearby ; after a wound, sometimes slight ; after
typhoid or paratyphoid fever or febrile gastroen-
teritis; as a result of bad teeth, or after gas in-
toxication. Placing these cases by treatment in a
condition fit for return to the front proved a difficult
matter. The only possible way of restoring a con-
siderable number to service appears to be to prepare
for each man a careful protocol of the results of
the various clinical examinations undergone, to be
presented to the various medical officers in whose
hands he passes, including those at the front ; the
tendency toward un Jue leniency and unnecessary
prolongation of hospital treatment could thus be
eliminated.
Alcoholism in China. — W. H. Park (China
Medical Journal, May, 1918) says that alcoholic
drinks are made and sold in immense quantities in
China. Distilleries and breweries are found all over
the country, and, in addition, the farmers make for
themselves more alcoholic liquors than are probably
made by farmers in any other country in the world.
Drinking seems to be a universal habit, from the
coolies upward. Farm laborers stipulate that they
shall have so much liquor daily in addition to their
wages. Business and professional men, merchants,
doctors, priests, and officials, drink more than the
coolies and laborers. Worst of all are the idle rich.
The possibility of alcoholism has to be kept in mind
in every important case needing treatment in China,
regardless of age, sex, or condition in life. It may
not be apparent at first sight, owing to the Chinese
way of drinking and to the fact that many stop
drinking before consulting a doctor, but it is present
just the same. In taking histories we have to be on
the alert else alcohol may never be mentioned.
Otherwise many cases will not be tmderstood and
the diagnoses may be as unreliable as the histories
given by the patients.
The editor of the China Medical Journal com-
menting on this article says that the assumption
that the Chinese are, and always have been, a very
sober people, is not correct. In the second century
a law existed which prohibited more than three
persons from drinkmg together without special
cause and license. Quotations from Chinese liter-
ature show the same sentiments and songs shared bv
topers all over the world. Hard drinking seems to
be common in some parts of China, especiallv in the
smaller places, but a drunken person is rarely seen
on the streets of a Chinese city. In Shanghai, dur-
ing 1917. there were only sixty-four arrests for
drunkenness among a Chinese population of
644,580. According to Rodney Gilbert the Chinese
drink as much as they can, but the fear of "losing
face" acts as a deterrent to open drunkenness. It is
no impropriety to succumb to a great quantity of
alcohol, in fact it is rather heroic, but one loses
prestige by succumbing to a little, and as the Chinese
resi)ond quickly to stimulants there are very few
August 31, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
393
successful topers among them. It is suggested thai
in the keen struggle for existence families with
a propensity to drunkenness have been weeded out,
so that as a nation the Chinese may be more tem-
perate than formerly. At any rate Western
nations cannot be accused of having led the Chinese
astray from the patlis of sobriety. There is a gen-
eral impression that the suppression of the opium
traffic is leading to an increased consumption of
alcohol.
Antibody Production after Partial Adrenalec-
tomy m Guineapigs. — Frederick L. Gates
( Journal of Experimental Medieine, June, 1918)
does not believe the adrenals play an important
part in antibody production or in the known im-
munity reactions of defense against bacterial in-
vasion. He arrived at this conclusion after observ-
ing the effect of partial adrenalectomy on guinea-
pigs immunized either before or after operation
with typhoid vaccine or with washed red blood
corpuscles of the hen. The typhoid agglutinins or
hemolysins and hemagglutinins were titered at in-
tervals during the course of antibody production.
It was found that partial adrenalectomy with re-
moval of a single gland or of one gland and as much
of the other as could be safely taken had no in-
fluence on the formation of typhoid agglutinins in
guineapigs.
Mesenteric Vascular Occlusion. — Arthur A.
Ciisenberg and Henry A. Schlink (Surgery, Gyne-
cology, and Obstetrics, July, 1918) conclude with re-
gard to the form of occlusion as follows: i. Mesen-
teric vascular occlusion is not an extremely rare
condition, there now having been collected about
four hundred cases. 2. The occlusion is most fre-
quently in the arteries. 3. By far the most common
lesion produced is hemorrhagic infarction of the
intestine. 4. The most common cause of the occlu-
sion is embolism resulting from infection and in-
jury. 5. There is no difference clinically between
the arterial and the venous occlusion, regardless as
to whether it is due to embolism or thrombosis, in
the superior or inferior vessels. 6. The clinical
diagnosis should be made on sudden onset, acute
coliclike abdominal pain, distention and tenderness,
signs of shock, and collapse. Often there may be
vomiting and constipation. If diarrhea is present it
is almost always accompanied by melena.
Tachycardia with Hypertension in Soldiers. —
C. Aubertin (Bulletins ct memoires dc la Societe
mcdicale des hopitaux de Paris, January 24, 1918)
states that, of the cases of tachycardia met with at
the front, some present a valvular murmtir, others
a systolic murmur of doubtful significance, while
others still exhibit no murmur. In the latter variety,
high blood pressure often coexists, thirty-four out of
forty-three cases, and rest usually reduces the rate
twenty-three out of twenty-eight cases. The patients
are usually young infantrymen. The heart rate is
generally 120 to 140 in the standing position and
100 to 100 in the recumbent position. After"rest in
bed for one day the rate shows a tendency to fall
during the course of the day and at night, rising
again in the morning. Compression of the eyeballs
generally fails to slow the heart, as do also rest in
bed and digitalis ; potassium bromide and a milk
diet, however, sometimes influence the rate. The
accompanying hypertension is usually manifest in
a systolic pressure of 160 to 170 mm. of mercury.
The diastolic pressure is either normal, eighty to
ninety, or slightly raised, 100 to no. Exertion gen-
erally causes considerable dyspnea and the rate rises
to 150 or 170. Of thirty cases, sixteen showed re-
duction of both rate and blood pressure after one
to three weeks' rest and a meatless, wineless diet.
Seven cases showed reduction of tachycardia but
not of blood pressure. In two the tachycardia had
already passed off on admission. In five, rest in
bed, milk diet, and drugs failed to reduce either
pulse rate or blood pressure. Possibly these were
hyperthyroid cases. The cases recovering under
treatment may be sent back to the front, but must
be spared heavy exertion. In the diagnosis, cer-
tain conditions must be carefully excluded, viz.,
valvular disease with temporary marked tachycar-
dia, in which rest, digitalis, and at times ocular
compression will slow the heart and cause the mur-
mur to reappear ; secondly, tachycardia due to tu-
berculosis. Overlooking the tachycardia because
the pulse is normal in recumbency must also be
avoided ; blood pressure estimations and exercise
tests are necessary for this purpose.
Bradycardia, Low Blood Pressure, and Acro-
cyanosis.— H. Vincent (Paris medical, May 25,
191 8) has observed rather frequently among child-
ren, adolescents, or young adults of both sexes a
syndrome comprising these features. The subjects
are frequently of an apathetic disposition, growth
of hair is somewhat delayed, and among females
menstruation may be insufficient or irregular. Of
twenty-nine cases nine had a personal or family
history of rheumatism. Degenerative stigmata are
not uncommon. Some have ichthyosis of the knees,
elbows, or ears. The acrocyanosis consists in a cold,
bluish condition of the extremities, favored by ex-
posure but occurring even in the summer time, and
commonly complicated in winter in children and
young girls by edema of the hands and chilblains.
The pulse is small and the blood pressure decidedly
low. The change of pulse rate from the standing to
the recumbent position is fifteen to thirty pulsations
per minute instead of the normal eight or nine, and
in recumbency the rate falls to fifty-eight or even
lower, down to forty. Upon rising, the blood pres-
sure, already low, descends twenty or thirty m.m.
further. The sphvgmogram shows exaggerated and
delayed dicrotism. Ihe syndrome becomes atten-
uated or disappears in the adult or aged, frequently
at the time of active genital functioning, e. g., in
young women after marriage and especially after
pregnancy, which brings into action the uteroovarian
and mammary functions and excites thyroid activity.
Upon examination of the thyroid gland before this
period one finds reduction of its lobes or at times
almost complete absence of one lobe ; or, the gland
mav be rather large, but is soft and devoid of
tonicity. Regular use of thyroid substance with
potassium iodide or iodine causes marked improve-
ment. Chilblains, if present, quickly disappear.
Adenoid tissue, if noted, should be removed and in
a few of the cases in young girls, ovarian substance
should be given in addition to the thyroid.
394
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Emotion in the Etiology of Tabes Dorsalis. —
E. Fernandez Sainz {Rcvista dc Mcdicina y C'irugia
Practicas, May /, is strongly of the opinion
that emotional disturbances as well as traumatism
and exposure may sharply aggravate the course
of a latent tabes, or provoke the appearance of the
first appreciable symptoms of the disease in a patient
predisposed by a previous syphilis.
Salt Metabolism in Diabetes Mellitus. — A. H.
Beard {Archives of Internal Medicine, June, 1918)
has been attempting to determine the cause and con-
ditions leading to rapid loss or gain in weight in dia-
betics. The large amounts of sodium chloride that
diabetic patients will ingest proved of interest in this
connection. Increase of weight in patients with un-
restricted intake of chlorides was invariably associ-
ated with chloride retention. Ilie edema usually
passed off after the disappearance of glycosuria.
Two cases showed a variation of carbohydrate toler-
ance directly in proportion to change in weight.
The Psychoneurotic Syndrome of Hyperthy-
roidism.— ^Malcolm S. Woodbury { Journal of Nerv-
ous and Mental Disease, June, 1918) says that the
contention of certain alienists that the thyrotoxic
psychosis does not deserve a separate classification
is very likely correct, though there is in the non-
insane cases of thyrotoxicosis a very definite men-
tal and nervous picture differing in degree, and
somewhat in type according to the acuteness and
type of dysthyroidism. Depression of moderate
duration is more common in thyrotoxic nonexoph-
thalmic cases than in the exophthalmic, and when
it occurs in the latter it is usually much more transi-
tory ; in neither is it usually associated with self ac-
cusatorv delusions. The presence of nervous symp-
toms with other classic symptoms of dysthyroidism
should arouse suspicion, regardless of the size of
the thyroid. In all such cases it is best to studv
basal metabolism if possible, but the adrenalin chlor-
'de tests as described by Goetsch, should certainly
be applied.
Researches on the Cancerous Diseases in Nor-
way.— F. G. Gade {Journal of Cancer Research,
April, 1918) presents an investigation of cancer in
Norway. The statistics are based on the Mortality
Statistics from 1902-1911, and the material col-
lected by the Norwegian Committee for Cancer Re-
search from 1902 to 1912. It covers a vast number
of figures which are marshalled together in an or-
derly and impressive fashion. One of the most
striking facts is the high occurrence of gastric car-
cinoma, which is reported as 61.2 per cent, of all
carcinomas. An analysis of the social position and
occupation of 2,554 cases showed that carcinoma
was most frequent in farmers and least often found
in officials, officers, artists, and university gradu-
ates. Attention is called to the frequent occurrence
of cancer on the lower lip, particularly in those
regions where the use of the clay pipe is in vogue,
although all the deduction drawn from the figures
and from such facts are made with every reserva-
tion. It is concluded that married life with a can-
cerous ]>erson does not involve any greater risk of
the development of cancer than does the factor of
heredity, as some of the cases reported may perhaps
point to a family predisposition to the disease.
Nocturnal Enuresis and Adenoids. — A. M. Cal-
deran [Kevista de Medicina y Cirugia Practicas,
April 14, 1918) in reporting a case of nocturnal
enuresis in a child of eleven years which resisted all
medical treatment and was readily cured by removal
of adenoids, draws attention to the common connec-
tion between adenoids and incontinence of urine and
the frequency with which this condition of the naso-
pharynx is either overlooked or passed over as of
no consequence.
Alexin Deficit in Overwork. — H. Vincent
{ F'rcssc medicate, May 2, 1918J, in experiments on
guineapigs, found that acute and prolonged ex-
ertion causes a lowering, often marked, of the
alexic power — complement — of the blood serum.
This may account for the fact that the resisting
powers toward certain bacterial infections are
greatly weakened during periods of exaggerated
and prolonged fatigue, when the serum has lost a
large portion of its protective constituent.
Early Leucocytic Modifications in Wound
Cases. — Brodin and Sairit-Girons (Presse medi-
cale, May 2, 1918) state that in all cases of exten-
sive wounds a marked leucocytosis rapidly arises.
The differential count, moreover, is of prognostic
significance. Predominance of the large mononu-
clears over the lymphocytes and intermediate mono-
nuclears taken together signifies a grave condition ;
the converse constitutes a favorable indication,
which is all the more favorable as the lymphocytes
and intermediate mononuclears predominate over
the large mononuclears.
Focal Necrosis of the Adrenal: with Remarks
upon Acute Adrenal Insufficiency. — E. Mosch-
cc\\'itz, (Proceedings of New York Pathological
Society, October-December, 1917) describes two
cases, the first occurring in a man forty-one
years old. The most prominent symptoms were a
subnormal temperature and slow respiration and
pulse. Death followed three days after a nephrec-
toniv for a pyonephrosis. Post mortem examina-
tion showed a number of sharply defined focal
necroses scattered throughout the cortical zone of
the right adrenal, with degeneration of cells, poly-
nuclear infiltration, and moderate hemorrhage of
the gland. Many of the capsular vessels were
thrombosed, so that this thrombosis of the vessels
may be a possible cause of the adrenal lesions. The
second case was that of a child who had been sick
for a long time with an abdominal ascites and chylu-
ria. Autopsy examination showed bacterial emboli
in the spleen, pancreas, and kidney, and beneath the
capsules of both adrenals, at places surrounded by a
polvnuclear infiltration. The patient had died from
a streptococcemia of three days' duration. A re-
view of the literature showed that acute inflammatory
lesions in the adrenal were most common in some
of the infectious diseases, as diphtheria, variola,
typhoid, tetanus, pneumococcus infections, dysen-
tery, and streptococcus infections. It may be ob-
tained experimentally by injections of some of the
pathogenic bacteria. Moschcowitz calls attention to
the various and conflicting symptoms that have been
described under the clinical aspects of acute adrenal
insufficiency, and states that they do not correspond
to what is known of the physiology of the gland.
Proceedings of National and Local Societies
THE AMERICAN GYNECOLOGICAL
SOCIETY.
I'orty-thb'd Annual Meeting, Held in Philadelphia,
May i6, 17, and 18, 19 18.
The President, Dr. John G. Clark, Philadelphia, in the
Chair.
{Concluded from page 356.)
Final Results of X Ray Treatment of Fibroids.
— Dr. Joseph Brfttauer, of New York city, in
conclusion, formulated very briefly his views on the
X ray treatment of fibroids, i. At an age below
forty-five the x ray treatment for fibroids should
not be the choice, but should be employed only when
operative measures are not advisable or are refused.
2. Between the ages of forty-five and fifty-five, x
ray treatment should be the method of choice and
no patient should be deprived of the right to un-
dergo it. With an open cervix and a distinct
diagnosis of the submucous development of a fib-
roid, operative measures promise better results.
Patients with relaxation and laceration of the gen-
ital tract should be expected. These cause no
symptoms while the uterus is large and above the
pelvis, but when as a result of the treatment the
uterus becomes smaller and sinks down into the
pelvis, serious inconvenience is caused and operative
interference becomes necessary for its belief. 3.
Uterine hemorrhages due to fibroids in women be-
yond the age of fifty-five should raise suspicion of
sarcomatous degeneration and operative measures
are preferable to any other form of treatment.
The Use of Radium by the Gynecologist. — Dr.
Curtis F. Burn.\m, of Baltimore, Md., stated that
the basic principle underlying all radium treatment
was that pathological tissues were in general more
sensitive to radiation than normal tissues, and that
consequently it was possible with appropriate dose
to destroy the former and leave the latter intact.
The gamma rays of radium, which alone could be
usecTfor therapeutic purposes, could not be focused
and consequently were dispersed in the form of a
sphere. This led to their rapid dilution inversely
with the square of the distance. In addition there
was an absorption of about eight per cent, per cm.
in tissue. The absorption in tissue could not be
helped. It was, however, possible to minimize the
dispersion factor by placing the source of radiation
away from the surface and consequently increasing
the radium as well as the time of exposure. If the
radium was placed two millimetres from the sur-
face, at one cm. below the surface only 2.5 per
cent, of the surface application was still present and
at five cm. only 0.107 P^i" cent, remained. But if
the radium was placed twelve cm. above the sur-
face, at one cm. below the surface seventy-eight
per cent, of the surface radiation was still intact ;
at five cm. 35.8 per cent., and at nine cm. a little
less than twenty per cent.
Radiosensibility of tissue was extremely difficult
to determine. Individuals varied immensely so far
as normal tissues were concerned. Variations of
tumors of the same type were even more marked.
The same tumor varied at different stages of its
development. The single dose method was very
valuable in giving us standards to work by, but the
broken dose method at week intervals permitted of
giving nearly twice the dose within six weeks, the
time necessary to elapse between massive treat-
ments.
At a distance of 2.5 cm. from the skin a gram
of radium on an ap])licator 2.5 cm. square filtered
through two millimetres of lead would lead to an
erythema in two hours and would cause a marked
retrogression or cure of an epithelioma. One one
thousandth of this dose might be effectual in de-
stroying large masses of lymphosarcoma or of
splenomyelogenous spleen tissue. Three or four
times the dose, however, had to be given to destroy
normal skin. Ovarian tissue was roughly ten times
as easily injured as normal skin ; the vaginal wall
would tolerate four or five times the skin dose; the
rectal mucosa as much as the skin ; the mucous
membrane of the bladder certainly twice as much.
The vaginal and cervical cancers were fully as sus-
ceptible to treatment as skin cancers, perhaps more
so. The adenocarcinomas of the rectum as well as
of the body of the uterus were decidedly more sus-
ceptible than epithelioma. Uterine fibroid tissue
was tremendously more susceptible than normal
skin.
The doses given were for massive radiation
with at least six weeks' interval between treatments.
They could not, as a rule, be repeated then without
leading to more or less destructive effects on sur-
rounding normal tissue. Effectual treatment could
only be secured by careful preliminary determina-
tion of the distances of ail parts of the growth from
the portals. Cross fire radiation should be em-
ployed and normal tissues protected by pushing the
parts aside wherever possible and by metal screens.
For radiation within the cervix, uterine cavity,
and rectum, the radium emanation was enclosed in
glass tubes, these in metal tubes, and these in rub-
ber tubes, securing a pure gamma radiation. The
small growths of the bladder were best treated by
direct application through a cystoscope. Extensive
infiltrating bladder growths and some rectal cancers
were best treated from without the body.
A number of illustrative cases of cervical and
vaginal cancers were discussed in detail. Appro-
priate treatments for each were suggested. The
injuries likely to result from overradiation, such as
fistulas and rectal ulcers, were described as were
also the most effectual methods of guarding against
them.
Clinical Data on Chorioepithelioma. — Dr.
Hiram N. Vineberg, of New York City, said that
chorioepithelioma occurred in two types, benign and
malignant, but as yet there were no recognizable
histological differences between the two varieties.
An endeavor should be made to make a diagnosis
on clinical data, inasmuch as a curettage was at-
tended with the risk of causing rapid and extensive
metastases. Furthermore, a microscopic examina-
396
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[NiEw York
Medical Journal.
tion of the curetted material was not always de-
cisive, and might even be misleacHng. For the
present, net knowing the cause, we could have no
means of prevention. But, as a possible safeguard,
placental residue, when present, should be promptly
removed, and in every case of hydatid molar preg-
nancy, an anterior hysterotomy should be done for
the double purpose of removing all the vesicles and
exploring the entire inner wall of the uterus for any
suspicious nodules or extra thinning of the wall at
any one point. Once the diagnosis had been made,
panhysterectomy was mdicated, as we had no means
of differentiating betv\'een the so called benign and
the highly malignant cases.
Cancer of the Cervix Complicating Triplet
Pregnancy. — Dr. Benjamin 1'. Watson, of
Toronto, Can., reported the following case: Pa-
tient, aged thirty years, quintipara, pregnant. On ex-
amination a^ large cauliHower carcinoma was found
growing from the anterior lip of the vaginal portion
of the cervix. The abdomen was opened, the uterus
incised, and three five months' fetuses removed, and
then three separate placentas connected by mem-
brane. A Wertheim operation was then proceeded
with. The patient made a good recovery. He re-
viewed the histories of other cases of cancer of the
cervix complicating pregnancy.
The Graduate Degree in Obstetrics and Gjme-
cology. — Dr. Jennings C. Litzenberg, of Minne-
apolis, Minn., stated that the Minnesota plan for
graduate work in the medical specialties was new,
but new only in its application to medicine. The
plan simply applied the principles governing univer-
sity graduate work in any other branch of advanced
learning to the medical branches and placed them
not only under the same principles, but actually in
the graduate school of the university.
The«requirements for entry were a college degree,
a medical degree, and a thorough reading knowl-
edge of French and German, and an internship of
at least one year. The course extended over three
years of work with a major and a minor, the same
as candidates for other advanced degrees, and ex-
aminations were by graduate faculty. A thesis,
which must be an original contributon to science,
was required and must be defended. This led to the
degree of Doctor of Philosophy in Obstetrics and
Gynecology. A two years' course might lead to
Master of Science. Withal it was a plan to raise
to a high level the training of specialists.
The Use of Dakin's Solution in Suppurative
Conditions Within the Peritoneal Cavity. — Dr.
Rai.f.igu R. Huggin.s, of Pittsburgh, drew the fol-
lowing conclusions: i. When Dakin's solution is
brought in proper contact with an infected surface, it
will destroy pus; if this does not happen, it is be-
cause there is some focus not reached by the solution
or because of imperfect technic. 2. As a result of
its use, there is rapid return of strength, and the
postoperative course is more comfortable, and with
less danger of secondary complications. 3. Any
oflFensively smelling discharge is destroved almost
immediately. 4. It is contraindicated in the presence
of an intestinal fistula. 5. That it may delay the
final healing by interfering with the normal gran-
ulating process in some instances, may be true. Fur-
ther observation is necessary to determine this
question.
Dystrophia adiposogenitalis in Women. — Dr.
EuwAKD A. Schumann, of Philadelphia, drew
the following conclusions : The syndrome resulting
from the effects of deficient pituitary secretion upon
the female sexual system may properly be divided
into three clinical groups, according to the sex epoch
aft'ected. The terms amenorrhea of obesity and lac-
tation atrophy or superinvolution of the uterus are
no longer correct, since it seems reasonably well
proven that both these conditions are but phases of
a primary hypopituitarism. Definite regression of
the reproductive tract may follow deficient pituitary
secretion in parous women of mature age, and may
and frequently does give rise to erroneous diagnosis
of pregnancy. Treatment for all groups consists in
general measures and the empirical use of glandu-
lar extracts, the systolic blood pressure being a fair
index of the particular gland substances to be em-
ployed ; low pressure indicating pituitrin ; high pres-
sure, thyroid. The prognosis is guarded in all
cases, as to recovery, but is favorable in direct ratio
with the age of the patient.
Description of Goffe's Gastrocolonopexy Op-
eration.— Dr. J. Riddle Goffe, of New York city,
stated that from his experience he had gradually
evolved the method which he now employed as fol-
lows ; This description embraced the complete
operation in which both stomach and colon were
involved in extreme ptosis and adhesions.
.A. longitudinal or transverse incision was made
below the umbilicus. Through this adhesions were
severed, the organs were set free, the appendix was
removed, the caput, if overdistended, plicated, the
uterus, which was frequently found displaced, re-
stored to normal position and supported there, and
if necessary the appendages were dealt with as indi-
cated. The incision was closed.
A longitudinal incision was then made above the
umbilicus through which the upper abdominal
cavity was thoroughly explored with the hand,
noting the condition of the liver, its ligaments, the
gallbladder, and ducts especially. Any pathological
conditions \v;ere dealt with according to indications,
new incisions having been made or the original one
enlarged, if necessary.
The stomach was then delivered through the
wound, inspected and palpated for ulcers and
pyloric irregularities. If dilated, the anterior wall
was depressed with a sound along the middle hne
and over this the stomach wall was plicated in a
double row of linen sutures. In a line just above
or below this, and midway between the extremities
of the stomach, two, three or more linen sutures
were threaded along in the stomach wall, including
the peritoneal and muscular coats, each one being
buried for one half to three fourths of an inch, the
two ends left long and protruding from the wound.
They were wrapped in sterile gauze. The trans-
verse colon was then delivered through the wound,
the omentum ligated along the border of the gut
and cut away. The long sutures were threaded
singly in a Peasley needle and passed successively
through the abdominal wall into the interior of the
abdomf-n and brought out in the bottom of the skin
August 31, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
397
incisions previously described. First, the stomach
sutures were passed, emerging in the middle in-
cision, tfie stomach restored to normal position, the
sutures drawn taut, tied, and cut short. The three
pairs of sutures in the colon were successively
passed in the same way, each pair in the three desig-
nated loci of the colon, being directed to the incision
in its corresponding location. All the sutures were
drawn taut to straighten out the intestine and make
intimate contact between it and the parietal peri-
toneum, and were then tied external to the deep
fascia in the bottom of the incision and cut short.
The three incisions were then closed with a sub-
cuticular catgut suture and sealed with sterile col-
lodion.
It will be observed that the fixation sutures of
the stomach and transverse colon were brought out
through the same incision. When both organs were
to be attached the fascia in the bottom of the wound
was laid bare for half an inch above and below the
midline of the incision and the respective sutures
passed at the extreme limits of the denuded spaces,
the stomach sutured above and the colon sutured
below. The sutures composing the pairs were
threaded along in the same line and about one quar-
ter of an inch apart. He had deemed it advisable
in some cases to link the sutures together, thus con-
verting them into a figure of eight or chain suture.
This distributed and equalized the tension over a
broader area and diminished the tendency to con-
tract. The abdominal wound was closed in the
usual three layer method. Adhesive plaster and
abdominal binder were applied rather tightly, and
the foot of the bed kept elevated from six to eighteen
inches according to the tolerance of the patient.
ASSOCIATION OF AMERICAl^I
PHYSICIANS.
Third-tkkd Annual Meeting, Held in Atlantic City,
N. J., May 7 and 8, IQ18.
The President, Dr. F. H. Williams, of Boston, in the
Chair. »
(Continued from page 268.)
A Study of the Empyemas at Camp Upton. —
This paper was presented by Major H. Brooks,
M. R. C, and Major R. L. Cecil, M. R. C. Major
Brooks said that his coworker had undertaken a
very extensive study of the laboratory side of the
problem. They had had a very virulent type of
empyema. I'he cases were all associated with pneu-
monia. The disease had also been associated with
measles but not with mumps. The causative germ
had been the streptococcus in fifty per cent., in the
other fifty per cent, the pneumococcus. Cases of
pneumococcus empyema had recovered after opera-
tive treatment. There were forty-nine cases of
streptococcus empyema with a mortality of sixty-
one per cent. Of four streptococcus viridans cases,
three died ; four mixed infections with streptococcus
and pneumococcus, no deaths ; of thirty-five hemo-
lytic streptococcus cases, twenty-two died. The
empyema seemed in each case to be a concomitant
infection of the pleural sac. With the entrance into
camp of a large contingent of colored troops the
percentage of hemolytic streptococcus infections in-
creased. The question arose as to whether this dis-
ease was transmitted directly from soldier to
soldier, but with very careful isolation of cases there
was found to be no diminution of occurrence. Still,
the isolation was being carefully maintained. In
the bronchial type there was very little cough, very
little sputum raised, and little pleuritic pain, the
chief symptom throughout being prostration. The
diagnosis was made by aspiration and confirmed by
the x ray findings, also the changes in percussion
were important signs. The exudate in these cases
liad the appearance of alkaline urine and generally
contained streptococci. Pericarditis usually devel-
oped early, and was progressive, but there was lack
of metastases elsewhere. Of twenty-seven cases
that came to autopsy, twenty-three were strepto-
coccus cases. The pulmonary lesion showed inter-
stitial bronchopneumonia, of the type described by
Cole. Pneumothorax was also present. As regards
treatment, it had been found that it was essential
to wait till the pus became cellular in character,
when operation cotild be safely performed.
Dr. H. A. Christian remarked that, in civil •
practice they had had practically the same experi-
ence as had been reported in army cases, and ex-
perience showed that fatalities occurred from too
early operative interference.
Dr. E. LiBMAN said that Fraenkel had drawn
attention to the fact that during epidemics of
grippe the pneumonias and empyemas followed a
devious course. During such epidemics it was
found that primary empyemas occurred. This form
of the disease had been named pleuritis acutissima.
The apex had to be watched for accumulation of
fluid. His experience had been that the x ray
would help in detection of empyema, but that it
failed when the empyema was localized between
the lobes and under the axillae.
Major W. H. Welch said investigations made
by Zinsser and Dochez brought out clearly that the
streptococcus was the most important cause in these
infections. At one camp the cases seemed to be
due to the streptococcus viridans, and it was a ques-
tion as to what had played a part in enhancing the-
virulence of this streptococcus. It was necessary
that groups of experts should give undivided atten-
tion to the better control and management of the
disease. Men all over the country should unite irt
comparing their investigations so that medical oflfi.-
cers should have the necessary knowledge for con-
trolling disease among the troops. MacCallum had
thrown much light the problem of the lesion in
the lung as seen at autopsy. The pulmonary lesion-
was frequently so mild as not to be recognized. In
the infection through the respiratory tract the
streptococci made wav rapidly to the pleural pass-
ages, but no doubt they left small foci of disease
which could be detected on careful examination.
Major R. L. Cecil, M. R. C, spoke about the
bacteriological aspect of these cases. In regard to
the pneumococcus, cases were found with Type 11
in the sputum and Type IV in the pleural fluid. Of
the streptococcus group four cases had shown non-
hemolyzing streptococci. These were recognized as
398
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
viridans. He was loathe to make a diagnosis of
viridans. as this could be said to be a constant in-
habitant of the normal mouth, but upon using blood
broth medium the sputum cultures showed absolutely
pure growth of this organism. The colonies were
typical, small, green, with a very slight zone of
hemolysis which did not appear in blood broth cul-
tures. In the types of cases with mixed infection
there was a mortality of sixty per cent. Often there
was streptococcus in the pleural fluid and pneu-
mococcus in the sputum. In regard to sterile em-
pyema, there was some confusion as to what was
empyema and what simply pleural fluid. Empyema
cases had pus cells in the fluid.
Major E. P. Jocelin, M. R. C, said that of fifty-
five patients operated upon, seven died. Opera-
tions were by simple drainage and no ostectomies
were done. Twenty patients died without opera-
tion. In many cases several cavities were involved.
Dr. RuFi:s Cole remarked that from the epi-
demiological view, rather than the viewpoint of com-
plications of pneumonia, the streptococcus empyema
was very different from the pneumococcus infection.
It was necessary to be very accurate about inter-
preting favorable results of any procedure until con-
siderable conclusive evidence had been obtained and
until one could tell whether one was dealing with
a frank streptococcus pneumonia or an empyema
developing upon deep lobar pneumonia. Another
important point was the necessity of cooperation
between the surgeon and physician following opera-
tion. The internist had not completed his whole
duty when he had made a diagnosis of empyema
and had turned over the case to the surgeon.
Experimental Hemochromatosis. — Dr. Peyton
Rous made this presentation. The pigment seen in
cirrhosis of the liver was stated to be derived from
the blood. If the activity of the spleen and the
liver could be overborne, the pigmentation could be
controlled. It was sought to do this by experiments
on rabbits, which were known to be able to put away
a very large quantity of alien blood. Rabbits were
transfused and in three months there was found to
be a considerable siderosis of the spleen and bone
marrow, caused by the pigment hemosiderin. This
was analogous to the deposits of hemosiderin in
human hemochromatosis. In the human subject the
hemosiderin pigmentation might be secondary to the
cirrhosis. The injury to the pancreas in the cases
caused death. The pectoral distribution of lesions
in hemochromatosis indicated the influence of actinic
rays u])on the pigment.
Hemosiderin Granules in Cells of the Urine : An
Aid to the Diagnosis of Pernicious Anemia and
Hemochromatosis. — The same speaker gave this
paper, saying it was thought that hemosiderin might
be found in the urine. In a soldier of forty-six
year.'^, with lesions of hemochromatosis, the diag-
nosis between this disease and syphilis was doubtful.
There was enlargement of the liver and spleen and
a peculiar gray pigmentation of the skin. The urine
was found to contain considerable hemosiderin gran-
ules. The patient died within three months with
characteristic signs of hemochromatosis. It was
also stated that in eight tenths of the cases of per-
nicious anemia hemosiderin granules were found in
the urine. Fresh urine should be used for the test.
Dr. E. L. Opie, of St. ^^ouis, Mo., said that the
experiment did not explain the etiology of hemochro-
matosis, but it did account for the pathology. In
every essential it seemed clear that the disease had
been reproduced by the experimental method. The
disease was perhaps due to interstitial inflammation
of the pancreas. The cirrhosis of the liver was
probably secondary to accumulation of iron pigment
in the cells.
Dr. W. TiLESTON, of New Haven, said that in a
patient of sixty-seven years, with chronic jaundice
he had found in the spleen and liver a hemosider-
osis comparable with that shown by Doctor Rous.
In this case, there was no cirrhosis of the liver.
Dr. P. Rous said that the animals had not been
pushed far enough to get breaking down of the
cells. They were now trying to keep the animals
longer. The body was found to tolerate hemosider-
osis to a remarkable degree, but in the human
organism, in cirrhosis, the cells were not flooded
with pigment as were those shown in the experi-
ment. One must assume that the liver was in some
way prevented from destroying the blood pigment
so that hemosiderin would accumulate in the cells.
Mould Infections. — Dr. C. P. Emerson, of Indi-
anapolis spoke of a patient, a man of forty-eight
years, who presented himself for treatment of tu-
berculosis. He had no toxic symptoms, no asthenia,
no secondary anemia. He stated that he had not
been able to lie down to sleep for eleven years, on
account of asthmatic attacks. The sputum culture
showed aspergillus and was negative for tubercle
bacilli. J he x ray showed massive cirrhosis of the
hylus of the lung. He was put on large doses of
potassium iodide and improved greatly, but the x ray
still showed masses of scar tissue. Two other cases
had occurred in one family at the same time. The
Sporolhrix Shankii was isolated, a parasite supposed
to be derived from buckwheat. The infections had
come on after the buckwheat crop. It was said
among the population in the buckwheat raising
country that those who worked among buckwheat
plants were subject to chronic boils. This was
clearly a mycosis infection. One woman showed
lesions*in which the pus had small black flecks,
clearly sporothrix.
Dr. W. W. Ford, of Baltimore, said he would like
to confirm Doctor Emerson's observations in regard
to buckwheat. In Northern Ohio, a buckwheat
district, boils were extremely common. This had
been interpreted as increased sensitiveness to the
buckwheat poison. The boils did not have the aj>-
nearance of ordinary infections. No bacterial
studies had been made so far as was known.
The Rat and Infantile Paralysis. A Theory. —
Dr. M. W. Richardson, of Boston, gave this, the
second communication, on the subject. The possi-
bility of transmission of human poliomyehtis by
means of the rat and the flea was considered. That
direct human transmission was not likely was shown
bv the fact that a block adjacent to an infected
block was frequently untouched. Cases occurred
in the same house, but in different • families.
Nothing but the rat and the flea could effect such
conditions. A comparative studv with bubonic
plague had been made. Great similarity was found
in the phenomena. Rats were always noticed be-
August 31, 1918.]
BOOK REVIEWS.
399
fore the appearance of the plague, but it was not
necessary to find the rats to prove the existence of
the plague. 1 he question, "Does the rat suffer from
paralysis ?" had been answered. At the time of
epidemics of infantile paralysis rats had been seen
with paralyzed legs, and hardly able to move. Chil-
dren who played with dead rats had been found to
contract poliomyelitis within a short time. Since
i8r/4, plague had become pandemic and had ex-
tended all over the world. Infantile paralysis had
spread in about the same time. Rats were lound to
follow the grain traffic and a connection between in-
fantile paralysis and grain traffic would have tO' be
proved. In a very large number of rural epidemics
the infections were found to start "at the mill." In
plague, the flea curve preceded the plague curve by
about ten days, and it was found that it also oc-
curred with the poliomyelitis curve. Water fronts,
usually infested with rats, were commonly centres
of infection. There was also a disease of rabbits
which carried off large numbers every six or seven
years, and this was found coincident with the polio-
myelitis years. Another point was that in plague
the lesion was apt to occur where the patient was
bitten, and in poliomyelitis the paralysis was most
apt to occur in the lower limbs which would be the
ones to be bitten by the flea.
Major S. Flexner said he was very much inter-
ested in the views of Doctor Richardson. The
aspect of the epidemiology had received consider-
able attention, but the other aspects had also to be
considered. The possibility of the reservoir of the
virus was very evident to the men engaged in the
study of the disease. It very soon came to light
that there were eases of animal paralysis coincident
with the outbreaks. y\nimals had been studied by
the experimental method to see if any evidence
could be secured to indicate epidemics in the lower
animals. Paralytic disease of all kinds of animals
had been studied. Material had been used for inoc-
ulation into monkeys, the only secure method for
transmission of virus. The histological lesions in
the man and the monkey were very characteristic.
It was supposed that the effects would be similar.
There was, however, no instance on record in which
histological characteristics had been sufficient to
compare the disease in animals with the disease in
human beings, or in which inoculations could be
successfully performed with the nervous tissues of
animals on monkeys. Observers began early to use
the reverse method. They tried domestic animals ;
mice, rats, rabbits, guineapigs, calves, sheep, goats,
ponies, and cattle. Thev had never succeeded in
showing characteristic poliomyelitis in those animals.
Inoculations could cause death in rabbits but there
was no histological change in the nervous system.
In 1916 a large number of rats were collected from
infected districts in Brooklyn, in order to test ou*^
Doctor Richardson's views. It seemed a promisir'
direction in which to search for evidence. The
nervous system of these animals was examiner'
Inoculations into the nervous systems of monkeys
were made with the material from rats. In no in-
stance was monkey poliomyelitis produced. The
reverse method was then used.
Active virus from monkeys was injected into rats
to find out how long the virus survived in the
nervous system. The tissue was then removed and
put into monkeys to see if the virus survived. At
the expiration of seven days the virus had appar-
ently disappeared. It would seem that if the virus
did not survive this length of time in the rat, that
the rat could not act as a reservoir. One could not
say that Doctor Richardson's theory was disproven.
The rat might be the reservoir and the flea, under
favorable circumstances, might carry the disease to
human beings.
Doctor Richardson said the diseased rats might
be done away with, and the old rats would not be
likely to have the disease. If there was anything in
the theory of rat transmission, it would appear in
rhe trenches which were known to be overrun with
rats. In one sector of the trenches eleven cases had
been reported. This was an unusual number among
adults.
(To he continued.)
®
Book Reviews.
[We publish full lists of books received, but zve acknozvl-
edge no obligation to reviczv them all. Nevertheless, so
far as space permits, we review those in which zve think
our readers are likely to be interested.]
J^essons ft am' the Encmv. How Germany Cares for Her
War Disabled. By John R. McDill, M. D., F. A. C. S.,
Maior, Medical Reserve Corps, U. S. Army. Philadel-
phia and New York: Lea & Febiger, 191 8. Pp. xiii-262.
(Price, .'^1.50.)
Our medical officers are indeed fortunate in being able
to profit by observation of service on both sides of the
battle front. Dr. John R. McDill went to Germany as
director of a hospital unit, arriving on June 17, 1916, where
he was assigned to duty at Coblenz. Later, he served in
different sections and received specific permission to in-
spect the sanitary system tollowed by the German army
and to prepare manuscripts on this system for publication
in the United States. The Germans assert that through
their system they have been able to return ninety-five per
cent, of their wounded either to military duty or to self
supporting civic or industrial usefulness. It is well for us
lo s.'udy methods which have produced such satisfactory
rest'.lts, and we are fortunate in having such an excellent,
clear, and concise exposition of these methods as is
furnished in Doctor McDill's manual, which forms No. S
in the valuable series of medical war manuals issued by
Lea & Febiger.
The Way Out of War. Notes on the Biology of the Sub-
ject. By Robert T. Morris, F. A. C. S. New York :
Doubleday, Page & Co., 1918. Pp. vi-i66.
War exists as a biological and social fact. Individual cells,
organisms, and social groups are always in a state of war-
fare with each other. All of this is not such destructive
\varfarc, however, as the modern form of it by arms,
which is particularly directed to destruction and not merely
to the elimination of what is useless and in the long run
inimical. The latter is not so directly in the service of
progress as is much of the inherent biological conflict in
organic nature. More and more in modern times the de-
structiveness of war has overbalanced any constructive
and progressive effect it may formerly have had.
Such war demands preventive treatment, and this can
only come about by understanding the biological foundation
of \v;ir. This includes also, the writer believes, the grasp-
ing 0/ the fact that a too complex social development has
not been oaralleled by an equal alteration of the germinal
inheritance of the race. War is then precipitated as a rem-
edy for the existing state of things. It is then a result of
decadence, not an essential function of the State. The
principle of the senescence of protoplasm in nations or
parts of nations is involved in this. All this in the history
400
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
of these nations or groups must be taken into account, also
the actual differences whic'.i exist among peoples, their
biolo<^ical development, and their different channels of
outlet and reaction. Only on such a fundamental basis of
inherent factors can a real and enduring peace be made.
The author's views are largely presented in mechanistic
fashion, and he regards the greater difficulties which man
has in keeping himself from this destructive warfare as
dependent upon recent physical evolutionary development.
His rising upo!i his hind legs threw him seriously out of
balance. One is forced to question the sure foundation of
such fantastic reasoning. Originality of expression and
a direct stimulating grasp of thought presents much matter
for further pondering. Conception and presentation form
a bioad and sweeping background for the practical con-
sideration of conditions which the war has so forced upon
attention. The book lacks unity of treatment in its rapid
passage from one to another of the many points of view
from which the questions of peace and war are consid-
ered. This unity is not essentially demanded in the short
essay form in which the book is written, and yet it exists
in the general background upon which the theme is worked
out.
Medical Service at the Front. By Lieutenant Colonel
John McCombe, C. A. M. C, and Captain A. F. Menzies,
C. A. M. C. Philadelphia and New York : Lea & Febiger, "
rgiS. Pp. 128. (Price, $1.25.)
Medical Serznce at the Front is the attractive title which
has been given to a medical war manual by two officers in
the Canadian Army Medical Corps, Lieutenant Colonel
John McCombe and Captain A. F. Menzies. The manual
sets forth clearly and in an easily comprehensible manner
the organization of the army in the field and the duties
of the medical officer at the front. While the observations
are made by a Canadian, the organization is the same as
that followed throughout the British army. Our own
medical officers will find this manual most informing and
helpful. It is rather unfortunate, we think, that the ter-
minology of the medical department of the British and the
.A.merican armies differ, but the reader is warned against
the differences which otherwise might lead to some con-
fusion. For instance, what in our own army is spoken of
as the "field hospital" is known in the British army as the
"ambulance," the British using the term ambulance here
v/ith the significance attached to it by the French, namely,
that of a movable hospital. Notwithstanding these and
other minor differences, the organizations of the British
and American army are so nearly alike that our own of-
ficers can study this interesting book with much profit.
Alcohol: Its Action on the Human Organism. A Review
by the Advisory Committee of the Central Control
Board (Liquor Traffic) in England. New York: Long-
mans, Green & Co. Pp. x-133.
This book is a report of the Advisory Committee of the
Central Control Board (Liquor Traffic), appointed in Eng-
land in 1916. The report embodies a brief resume of the
investigations and a succinct statement of the conclusions
which this committee reached in regard to the physiologi-
cal action of alcohol, especially the effects of its use in
beverages of varying strength and constituency upon
health and industrial efficiency. No clearer and more con-
cise report of actual results of investigation has been pre-
pared. Its aim is to present a purely physiological study,
avoiding all partisan discussion based on prejudice and
leaning as little as possible on subjective testimony.
Therefore the facts which pertain to the use of alco-
holic beverages are carefully examined and weighed in as
straightforward a manner as possible. The simple and
convincing manner of the report commends it for careful
readinf. Wherever investigation must necessarily pro-
ceed with some uncertainty and unreliability of results
this is carefully noted. The whole work bears the marks
of .1 painstaking and fainninded gathering of evidence,
which then is thrown into the balance in the concluding
summary, while the reading of the scale is left to those
who would pursue tlie subject and take practical action in
any way upon it. The report admirably fulfills its strictly
limited purpose.
Yet in spite of this there is much food for consideration
sunnned up in these pages. The facts are often those not
popularly accepted. The work throws a clearer light upon
the real nature of the alcohol effect, which is narcotic and
never really stimulant. It discusses the influence upon
the nervous system, the action upon the digestive organs,
the limited effect upon respiration and heart action, its
mental effect, and the reason for its widespread use. It
points out just to what degree it may be considered as a
food, and whether its value as such is sufficient to offset
accompanying deleterious action. ' It presents the differ-
ence ui effect of the isolated indulgence and the repeated
use of alcohol and the cumulative effect of frequently re-
peated doses or portions. The book is of great value at the
present time ; since without a well considered study of facts
no true judgment can be formed in regard to the value of
alcoholic substances.
Essentials of Dietetics for A^urses. By Maude A. Perry,
B. S., Formerly Instructor in Dietetics at Michael Reese
Hospital, Chicago ; Red Cross Dietitian for Base Hos-
pital Unit No. 14. St. Louis: C. V. Mosby Company,
1918. Pp. 154.
This book recommends itself tc both physicians and nurses,
for its manner of presentation is concise, definite, and the
subject matter has been well selected from the many things
that mi.ght be said and which have been said on the subject
of diet. Its form makes it particularly suitable as a text-
book or a guidebook for the busy nurse, but even the phy-
sician will find its pages oftentimes useful for reference.
Moreover, with the present intensified interest in food
values and the cheapest way of getting these, it contains
information useful to the public generally. It also in-
cludes specific directions and diets for various diseases.
Food is discussed under its different groupings, with
the chemical constituency of each food. Its relation to
varying needs of the individual 'is pointed out, and then
the various forms of food and their values are treated in
relation to those needs. The care, preservation, and prepa-
ration of food are all considered. Of course throughout,
and in particular in the second half of the book, emphasis
is laid upon the use of foods in disease and in the feeding
of infants. There is no attempt made to link up the prob-
lems of dietetics with other medical problems, which gives
the book a somewhat dogmatic character. This is felt par-
ticularly in the chapter on diet in skin diseases, where this
particular factor in skin diseases is given no relation to
other factors. In so simple and direct a volume for daily
practical use not too much of such matter could be looked
for. Yet we are coming to expect more and more in all
medical treatises, inclusive of this important one of diet, a
recognition of the wider interaction of factors, based upon
a broad psychical backgroun'.'. This point of view needs to
he impressed upon nurses.
<$>
Births, Marriages, and Deaths.
Died.
Berendsoiin. — In Brooklyn, New York, on Friday,
.August i6th. Dr. Rudolph Berendsohn, aged eighty-one
years.
Dryfoos. — In New York, on Thursday, August 22d, Dr.
Arthur D. Dryfoos, Captain, Medical Reserve Corps, U. S.
Army, aged forty-one years.
Hanchett. — In Siasconset, Mass., on Monday, August
19th. Dr. Henry Gronjer Hanchett, of Orlando, Fla., aged
sixty-five years.
Hill. — In Bainbridge, N. Y., on Saturday, August 24th,
Dr. PVederick W. Hill, of Brooklyn, aged forty-three years.
Holmes. — In New York, on Thursday, August 22d, Dr.
David H. Holmes, aged fifty-five years.
Keatiisg. — In Saranac Lake, N. Y., on Friday, August
i6th, Dr. John Joseph Keating, of Brooklyn, aged forty-
two years. '
Landis. — In Cincinnati, Ohio, on Saturday, August 24th,
Dr. T. H. Landis, of Chicago, aged fifty-eight years.
Martin. — In Attica, N. Y.. on Thursday, August 15th,
Dr. M. Eugene Martin, aged fifty-four years.
N-.AFiE. — In Long Branch, N. J., on Sunday, August nth.
Dr. Harry Neafie, of Freehold, N. J., aged fifty-nine years.
Stevens. — In Sayre, Pa., on Monday, August 12th, Dr.
Edv.'ard H. Stevens, aged fifty-one years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII, No. 10. NEW YORK, SATURDAY, SEPTEMBER 7, 1918. Whole No. 2075.
Original Communications
OVARY: CORPUS LUTEUM,
Oliver T. Osborne, M. A., M. D.,
New Haven, Conn.,
Professor of Therapeutics, Medical Department, Yale University.
GENERAL CONSIDERATIONS
The close correlation of many of the endocrine
glands makes it necessary to discuss briefly several
of their interrelations before we can well describe the
function and therapeutic uses of any one of them.
The close relationship of the ovary and its most
active part, the corpus luteum, makes it logical to
discuss them together.
'As this ailicle aims to ouUine tersely the present
knowledge concerning the function, pathology, and
therapeutic uses of these glands, for the sake of
brevity only a few references will be given, but
due credit should be given to Dr. C. E. de M. Sajous
for the many years of hard work on, and stimula-
tion which he has given to, the study of the glands of
internal secretion. Much of the therapeutic advice
here ottered is founded on the writer's own clinical
experience.
At \vhat embryonic age the sex glands (ovaries
and testicles) begin to furnish specific hormones
has not been determined, but external anatomical
sexual characteristics are apparently not caused by
stimuli from these glands. Various metliods for
the determination of sex have been suggested, but
none is beyond practical criticism. Forced protein
feeding of the mother has been advised to produce
a male child. Per contra, it has been thought pri-
vation of proteins in starvation and war times is
the cause of more male births in such periods.
Theoretically, anything that stimulates the mother's
adrenals, which are more male than female glands,
should develop a male fetus. Feeding of suprare-
nal to the mother has been thought to produce a
male child ( i ) .
The testicles and ovaries resemble each other
histologically, not only during embryonic life, but
even well through early childhood ; but if the animal
is castrated before sexual life develops or before
puberty, secondary sexual characteristics do not
develop. In males the penis does not grow, hair on
the face does not develop, hair on the pubis is
generally scanty, the voice remains high pitched,
there is more or less muscle weakness, more or less
obesity, and the mentality is sluggish, i. e., a eunuch
is the result. In the castrated female, the pelvis
does not grow to the female size, the breasts do not
normally develop ; more or less hair appears on the
face, the voice is low pitched, the legs are longer,
and the mentality may be sluggish. In other words,
the castrated male takes on a feminine type, and
the castrated female, a male type. Now, if in the
castrated male is transplanted an ovary, he devel-
ops female characteristics, such as enlarged mam-
mary glands, and there may even be a tendency
to the secretion of milk. If in the castrated female
a testicle is transplanted, she grows taller, and
develops male characteristics.
In males the extremities grow longer than in
females, and it has long been noted that the earlier
the menstruation in the female, the shorter the legs,
and the later the development of this function, the
longer the legs. There are many exceptions to
this rule, but ordinarily, at puberty the girl ceases
to grow tall.
In boys sexual precocity may be caused by an
hypertrophy or an abnormal growth of the testicles,
or of the suprarenal glands (the cortex especially),
or perhaps of the pineal gland, and of the pituitary
gland. Precocity in girls is perhaps always caused
by an hypertrophy of the ovaries. Hypersecretion
of the pituitary or of the suprarenal cortex, or a
disturbance of the pineal gland in girls tends toward
masculinity and not to precocity. Goetsch (2.)
believes there is a close relation between the func-
tion of the pituitary and the sex glands, and that
over function of the anterior lobe of this gland is
associated with over activity of the sex glands.
Deficiency of pituitary secretion seems to cause
underdevelopment of the sex glands in youth and
sextial inactivity in the adult.
It has long been known that a disturbed secretion
of the hypophysis, as in acromegaly, causes a woman
to become masculine in type, with amenorrhea and
loss of sexual desire, and the skin, hair, voice,
and facial contour become masculine and gross.
The efifect on female development of an early sub-
thyroid secretion is well understood ; though the
uterus and ovaries may be apparently normal, men-
struation is Hkely not to occur.
If subthyroid secretion is the condition after
puberty, the menstruation becomes scanty or is
entirely in abeyance. The symptoms and physio-
logical conditions of cretinism and myxedema need
not be here described, but ovarian secretion is al-
ways abnormal in thyroid subsecretion. Also the
ovaries are overstimulated in thyroid hypersecre-
tion. In thyroid insufficiency the skin is dry and
Ccpyri^ht. igrS, by A. R. Elliott Publishing Company.
«
402
OSBORNE: OVARY— CORPUS LUTEUM.
[New York
Medical Journal.
coarse; in pituitary inST..fficiency, if the thyroid is
not also much disturbed, the skin is moist and soft.
In both conditions, as just stated, there is likely
to be amenorrhea. Thyroid disturbance is far more
frequent, about eighty per cent, of all cases, in
women that in men, and is often due to genital dis-
turbance or to abnormalities in the female pelvic
organs. The thyroid is typically a female gland,
entering constantly into the woman's sexual life.
Menstruation cannot properly occur without the
activity of the thyroid. Too much thyroid secretion
may cause profuse or too frequent menstruation.
The thyroid hypersecretes at each menstrual epoch
and during pregnancy, and many of the disturb-
ances of the menopause are due to too much or too
little thyroid secretion.
Too long continued or too much ovarian secretion
probably causes increased sexual desire in women at
all times, but especially perhaps at the menopause,
and at that time ovarian irritability, with disturbance
of the thyroid gland, causes the vasomotor irregu-
larities of this period. On the other hand, a too
rapid loss of ovarian secretion may cause depression
and melancholic conditions.
The role of the thymus gland in female develop-
ment is not'known. This gland ceases its activities
and atrophies at about the time of puberty, when
the thyroid becomes more active and the full ovar-
ian activity, with the development of corpora lutea,
has occurred. It has been suggested that a too early
loss of thymus secretion may allow a precocious
puberty, with a diminished growth of the girl. The
thymus seems to be engaged in calcium metabolism,
perhaps most closely related to the growth of the
bones. Too early menstruation may cause a coin-
cident too early loss of calcium to the girl ; hence
perhaps the stunted growth.
X ray radiations may inhibit more or less com-
pletely the activities of the ovaries, which may also
be accomplished by destructive lesions, inflamma-
tions, and growths in the ovaries.
MENSTRUATION.
While it is probable that one of the functions
of the corpus luteum is to cause menstruation, it
cannot yet be declared just what determines the
day and hour of the flow. Although a large amount
of calcium, as well as other salts, is lost with such
blood, still this blood does not coagulate. If uterine
clots occur the bleeding is abnormal. Profuse or
too frequent menstruation causes too much loss
of calcium as well as of other salts, and the bones,
hair, teeth and nails suffer. Also much loss of
calcium causes nervousness, loss of sleep, and great
irritability. Calcium is a nerve sedative. Perhaps
by such extra loss of calcium the parathyroid
glands become affected, and for this reason alone
the calcium salts are sedative.
Too frequent pregnancies and too much ovarian
secretion may cause too great a loss of calcium and
consequent osteomalacia.
During pregnancy the calcium normally lost by
the woman goes toward the needs of the fetus, and
if she has insufficient for herself and the child, she
has signs of its loss, viz., decaying teeth, irritability,
and lack of strength. Feeding extra calcium may
help hei. After the child is born, the calcium goes
into the milk, if the mother nurses the baby. When
menstruation again begins, the milk secretion either
ceases, or the milk becomes inferior in quality.
Of course a too long lactation causes a drain on the
mother, and an inffrior milk, even if menstruation
has not occurred.
Women castrated during menstrual life generally
add weight, not only because of the cessation of
the loss of blood, but also because of the loss of
ovarian secretion and of coincident lessening of
the thyroid secretion, and perhaps of the pituitary
secretion. If the thyroid hypersecretes for a time,
there is no gain in weight. Normally, when men-
struation ceases, the woman gains weight on ac-
count of a normally diminished ovarian and thyroid
secretion, and perhaps, also because of a dimin-
ished pituitary secretion causing an increased car-
bohydrate metabolism.
AH through female life the thyroid secretion is
of constant importance, and normal ovarian and
uterine fmiction cannot occur without normal thy-
roid function. In female cretins the genital organs
may develop, but the)^ do not function.
At the time of the menopause, if the thyroid
begins to gradually diminish its secretion, with a
gradual cessation of the ovarian activity, there are
few unpleasant symptoms occurring at this period.
If, on the other 'hand, the cyclical hypersecretion
of the thyroid which occurs every twenty-eight days
continues to occur and menstruation does not
take place, the patient becomes very uncomfortable
at these periods, with hot flashes, restlessness, irrit-
ability, sweatings, and many other associated dis-
turbances due to hypersecretion of this gland. This
condition, with more or less symptoms of hysteria,
and with neurotic symptoms will continue inter-
mittently until the thyroid activity is normal for
this period of life.
If, on the other hand, at the menopause the thy-
roid, with the absence of stimulation by hormones
from other glands (such as the corpus luteum or
other parts of the ovaries) subsecretes, the woman
more or less rapidly adds weight, the skin becomes
dry, digestive disturbances may occur, and she is
sleepy and more or less mentally apathetic. If the
secretion of the thyroid is very greatly diminished,
the woman shows symptoms of myxedema. This is
tlie period of life when myxedema is most frequent,
by far the majority of all nonoperative myxedema-
tous cases occurring in women, and in the decade
of forty to tifty.
Puberty in this country occurs at about the four-
teenth year. If it occurs before the age of twelve
or not until after the age of seventeen, it is abnor-
mal. If puberty occurs earlier than twelve years
of age. such precocity may be due to heredity;; to
overfeeding ; to too much sexual talk ; and to too
nuich theatre, novels, "movies," dancing, parties,
and other social affairs. If puberty occurs late, after
seventeen, it may be due to heredity ; to a low pro-
tein diet ; to seclusion ; to too much book work ; to
lack of amusement, etc. Insufficient thyroid secre-
tion will and insufficient pituitary secretion may,
prevent or delay puberty and prevent all sexual
gland activities. Puberty is delayed by ill health,
and by hard work in bad hygienic surroundings.
September 7, 19 iS.]
OSBORNE: OVARY— CORPUS LUTEUM.
403
Sexual 'excitements hasten puberty. Excessive
thyroid secretion generally increases menstrual flow,
but occasionally it may so disturb the pelvic organs
as to cause amenorrhea. Profuse menstruation in
girls is often due to hyperthyroidism, and may be
prevented by the administration of manmiary sub-
stance, and by treatment directed toward slowing the
activity of the thyroid. Amenorrhea and chlorosis
are often well treated by thyroid extracts, with or
without iron. Pituitary feeding may also stop
uterine bleeding.
M.VMMARY GLANDS.
The gradual development of the mammary glands
in the girl just before and at puberty is one evidence
of her maturity ; but some girls have only rudimen-
tary mammary glands, and others have very large,
even at times enormous glands, and that without
much relationship to the development of menstrua-
tion, its amount, or its frequency. In fact, girls with
very large mammary glands may have long periods
of amenorrhea without pregnancy, or they may have
very irregular and scanty menstruation.
It should be noted that very large mammary glands
at any age may not denote a large amount of real
glandular secretory tissue ; in fact, the large glands
of -Stout girls and women are mostly fat.
It has not been shown that these glands have
an mternal secretion, but they certainly have a close
chemical or hormone relation to the ovaries and
uterus. Castrated male animals having ovaries im-
planted in them may develop secreting mammary
glands.
Not always, but quite generally, the mammary
glands are painful and become swollen and conges-
ted for a few days before menstruation, from one
to seven days. As soon as menstruation begins,
the mammary pains abate and soon disappear, and as
menstruation ceases the glands return to their nor-
mal quiescence, unless there is pregnancy. If men-
struation is delayed, the pain in the breasts may
continue for a longer time, but anything that has-
tens menstruation will shorten or prevent the pain
In the breasts ; hence some hormone of the ovary
cCtivates these glands, but without the stimulus of
pregnancy they return to the normal inactivity of
the menstrual interim. If there is pregnancy, the
glands normally continue to grow in size and in
activity. This has been thought to be due, at first,
to corpus luteum chemical stimulus and later to a
placental chemical stimulus. It would seem, how-
ever, more harmoniously logical to believe that the
ovary, which is apparently able to start the activity
of the mammary glands, may continue to stimulate
these glands throughout pregnancy, and until men-
struation again begins, the more important function
of the ovary, viz., ovulation, being temporarily in
abeyance. However, according to Bell, the removal
of both ovaries in pregnancy does not interfere with
subsequent lactation.
The glandular tissues of the breasts generally
diminish in size after the menopause, especially
in women who have nursed children. In stout wo-
men the fat enlargement will remain. Adenomatous
cysts may disappear after double ovariotomy,
though, on the other hand, apparently harmless
cystic enlargements or adenomatous growths of the
r. ammary glands may rapidly develop into cancer
after the menopause.
There also^ seems to be a reciprocal action of the
mammary glands on the ovaries, as is so well known
by lactating women who often prolong their lacta-
tatien to prevent menstruation and hence the danger
of another immediate pregnancy. If lactation is
soon stopped, menstruation early occurs. Also, a
profuse or too frequent menstruation, when there is
no pathological excuse, especially in young girls,
may be coirected by feeding mammary extracts.
Tile reflex stimulation of the breasts on the uterus
is well known to cause its better contraction after
parturition, thus preventing hemorrhage. There-
fore the child, after birth, is soon put to the breast.
The uterus after parturition is thought to involute
more rapidly when the woman nurses than when
she does not suckle her child.
SYMPTOMS OF OVARIAN EXTIRPATION.
The exact physiology, or pathology, of total re-
moval of the ovaries depends upon the age of the
individual at the time of the removal. It is rarely
justifiable ' to remove both entire ovaries in the
human female, and of course it is excessively rare
that such an operation should be performed on a
girl before puberty. Most knowledge of early ex-
tirpation is acquired by operating on animals. There
is no question that the early removal of the ovaries
causes the masculine type of development, with a
greater growth of the extremities. A later removal
of the ovaries causes atrophy of the uterus, and
may or may not cause abortion in a pregnant animal.
There seems to be a great disturbance of the nu-,
trition, and especially of the chemical metabolism,
after ovarian extirpation. More especially is there
a diminished calcium excretion, and probably there
is a disturbance of the chloride and phosphorus
equilibrium. Waste metabolism is less active, and
the body puts on weight largely in fat, if the ex-
tirpation is after puberty. Other endocrine glands
are also disturbed by such extirpation, notably the
thyroid. The ihyroid may have its colloid content
increased, but often it soon becomes less active, and
may even hyposecrete.
In early extirpation of the ovaries the thymus
has become enlarged and active, and the pituitary
and suprarenal glands may become more active, to
the production of a masculine appearance and mas-
culine tendencies.
If a small portion of an ovary, or if a supernum-
erary ovary is left in the animal, there may be no
signs of privation of this secretion, or, if at first
such signs are in evidence, they may soon disappear.
SYMPTOMS OF OVERSECRETION OF THE OVARIES.
Excessive ovarian secretion (probably generally
associated with increased thyroid secretion) causes
increased sexuality, even to all kinds of sexual per-
version. Simple increased secretion may make girls
coquettish and constantly seek male companions.
Even if there are no other symptoms of increased
ovarian secretion except profuse menstruation, the
body loses an excessive amount of lime and other
sails, as well as blood, essential to the general
welfare of nutrition and of the nervous system.
Often this excessive menstruation and increased
wa'-te metabolism may be due primarily to hyperthy-
404
OSBORNE: OVARY— >
CORPUS LUTEUM.
[New York
Medical Journal.
roidism. Excessive ovarian secretion in girls may
lead to masturbation or may be caused by masturba-
tion. It may cause insanity, and the relation of the
various internal gland disturbances to female in-
sanity should be carefully studied. Removal of a
diseased ovary or a diseased uterus has at times
cured serious mental disturbances.
Excessive ovarian activity, either de novo or from
too frequent pregnancies may cause osteomalacia.
Ovarian hypersecretion may also cause parathyroid
disturbance (perhaps due to calcium shortage from
a too great loss) and therefore more or less nervous
symptoms. Removal of one, or of one and a half
ovaries, and feeding calcium may cure osteomal-
acia.
CORPUS LUTEUM.
This small glandular structure was thus named by
Malpighi. Although the corpus luteum is an in-
tegral part of the ovary and should be considered
as the most active part of that organ, it is often
discussed as though it were a separate gland fur-
uishing an internal secretion. Although it seems to
be a mistake so to consider this body, still the corpus
luteum has so many proved positive activities that
these may be with profit described separately from
the whole ovarian activity.
This part of the ovary does not develop until
puberty, i. e., until the girl menstruates, or at least
until the ovule. Graafian follicle, ripens and rup-
tures. Until puberty, the important necessary se-
cretion of the ovaries seems to be elaborated by
the interstitial cells.
, Though asserted, it has not been proved and is
probably not a fact that the corpus luteum deter-
mines or produces menstruation. It does, however,
seem to furnish the hormone that sensitizes the
uterus tO' make it ready for pregnancy and for the
growth of the placenta. It is uncertain how much
this gland, new at each epoch, has to do with sexual
imoulses, sexual excitement, or sexual desire.
The corpus luteum generally continues to grow
for about two and one half weeks and then progres-
sively degenerate's, provided conception has not oc-
curred. If the female becomes pregnant, the corpus
luteum persists, at full activity apparently, for about
two months and then begins to degenerate. Just
what (^uses the degeneration of this body at this
time is not known.
It has been suggested that some hormone or
activating substance is elaborated to cause the next
ovule to develop, rupture (ovulation) and the next
corpus luteum to grow. In tlie later degenerating
corpus luteum of pregnancy it has been suggested
that this hormone was not furnished, and hence
ovulation did not occur and new corpora lutea do not
grow.
Abnormal degeneration or disease of the corpus
luteum seems to prevent the next menstruation, or
at least an abnormal function of corpora lutea seems
to cause irregular or abnormal menstruation. The
resorption or degeneration of the corpus luteum of
pregnancy, occurring about the middle or end of the
third month, has been thought to be the cause of the
cessation of the nausea of pregnancy, i. e., the ab-
sence for two months of this secretion to which the
mature woman is more or less constantly subject
is a cause of nausea. Hence it suggests itself to feed
tii's gland for such nausea. Some therapeutic suc-
cess has seemed to follow such treatment. It would,
however, seem almost paradoxical that this enlarged
gland is furnishing no secretion and only does its
work when .some hormones are released at the time
of its degeneration.
It should be noted that the surface study of an
extirpated or exposed ovary showing an absence of
corpora lutea does not preclude the possibility of
these bodies being deeply seated in the structure of
the gland. The part of these bodies that furnishes
an important secretion is probably the lutein cells ;
the so called paralutein cells may also furnish an
important secretion.
Anything that irritates the ovaries, either an in-
flammation in the ovarian tissue or an inflammation
elsewhere in the pelvis, may cause hyperactivity of
the ovaries, one or both, and excessive or too fre-
quent menstruation. Later, by disease, or by over-
tiring of the ovaries, a diminution of glandular
activity and atrophy of the ovaries may occur ; or
there may be diminished function and amenorrhea,
with ab'^ence of ovulation and hence absence of cor-
pora lutea, and consequent symptoms of the meno-
pause will occur. There are normally no active
corpora lutea in the nonmenstruating woman, at
least after a few months of amenorrhea. Why a
nursing woman so rarely ovulates or menstruates
is not known, but there is certainly an interaction of
the ovaries, of the corpus luteum, and of the mam-
mary glands. Hence some secretion from the lat-
ter may inhibit the corpus luteum growth and ac-
tivity unless lactation is too long continued and be-
comes abnormal from all standpoints. It is also
suggested that the swelling of the breasts before
menstruation and then the continued growth of the
l^reasts during pregnancy is due to corpus luteum
stimulation.
Removal of both ovaries (and hence also of all
corpora lutea activities) causes all the symptoms of
the menopause, only the symptoms are aggravated
because the transition of the woman from one con-
dition to the other is so sudden ; however, a normal
or an abnormal menopause is really a polyglandular
disturbance.
It has been thought that removal of the ovaries
has stopped the growth of mammary cancer. This
is doubtful. It has not been shown, however, why
ruammary cancer, and in fact cancer in other parts
of the body, so frequently develops after the men-
opause. Whether or not there is a germ of cancer,
as seems probable, certain it is that the polyglandu-
lar condition of the menopause predisposes to, or
stimulates, this small cell proliferation. The peri-
odical uterine activity may cause the breasts to en-
largo, and then the placenta may furnish a hormone
to stimulate the breasts for lactation. Later the
atrophy of the uterus, at the time of the menopause,
iriay furnish a hormone that irritates the breasts.
All of this is, of course, only suggestive hypothesis.
Some unexplained, and often recurrent, abortions
in:^v be caused by a too early corpus luteum degen-
eration. This suggestion should not be considered
September 7, 1918.]
GOLDFADER: MODERN TREATMENT Of SYPHILIS.
405
until other local and systemic causes are excluded,
although in syphihtics this may be the active cause
of the abortion.
Tust how long the corpus luteum (pf pregnancy
furnishes secretion after it begins to degenerate,
about the third month, is not known, but the corpus
luteum body persists until the end of pregnancy.
Also, after the menstruation, the corpus luteum,
which begins to degenerate about the third \yeek,
does not reach the stage of so called corpus albicans
or soar tissue until some time later; hence several
degenerating corpora lutea may be found in the
same ovar\\
REFERENCES.
I. BRAM: New York Medical Journal. June 6, 1014- 2.
GOETSCH: Sttrgical Gynecology and Obstetrics, 1917, xxv, p. 229.
(To be continued.)
THE MODERN TREATMENT OF
SYPHILIS.*
By Philip Goldfader, M. D.,
New York,
Clinical Assistant in Urologry and Venereal Diseases, Brooklyn Hos
pital and St. Mark's Hospital, New York.
The object of this paper is not to unfold new and
original ideas in the management of the syphilitic,
but to set forth the generally accepted principles and
methods in the modern treatment of syphiHs. In
the first draft I was fortunate to be a member of
the advisory board in venereal diseases at St.
Mark's Hospital, New York, under the direction of
Dr. V. C. Pedersen. Those men called for physical
examination, who claimed to have venereal diseases
were sent to St. Mark's Hospital. We examined
about 1,500 cases and about sixty to seventy-five per
cent, were syphilitic. In taking the histories of
these men one of the questions asked was the
amount of previous treatment they had had. I
Avas surprised to learn that the majority of the
syphilitics had had very little treatment. Some
were going to their family physicians and were car-
rying anywhere from twenty-five to fifty mercury
pills in their vest pockets. They had never received
a salvarsan injection, for their doctors told them
salvarsan was dangerous and did more harm than
good. Others, on the other hand, were getting as
much as one salvarsan treatment every six months.
It was gratifying to learn that the patients going
to well organized and up to date cHnics were re-
ceiving adequate treatment. On account of the
inadequate and inefficient treatment of the syphilitic,
by his physician, I decided to choose the treatment
of this class of oatients for the subject of my paper.
The elements of the subject of the treatment of
syphilis include the time - for beginning treatment,
treatment in the various stages, hygiene of the pa-
tient, the place of the newer substitutes of salvarsan
and neosalvarsan, the place of mercury and the
value of the Wassermann reaction.
A thorough physical examination is essential in
determining the character and intensity of the treat-
ment. The examination should include the weight of
the patient, the examination of the heart changes in
blood and bloodvessels, the taking of the blood press-
ure, the condition of the lungs, reflexes, reaction of
•Read before the Brooklyn Urological Society, March 12, 1918.
the pupils, examination of the mucous membranes
of the mouth and rectum, condition of the kidneys,
and abnormalities of the urine.
After the diagnosis has been made by a carefully
taken history and thorough physical examination,
and by finding the spirochetes in the serum from the
initial lesion by the dark field illumination or India
ink smear, or by obtaining a positive Wassermann
reaction from the blood serum or from the cerebro-
s]Mnal fluid, we are ready to begin the treatment.
The important factors are immediate diagnosis and
immediate institution of treatment.
In reference to the Wassermann reaction as a
control in syphilis, in the majority of cases a
strongly positive reaction indicates syphilis. There
^are a few diseases which we have to take into con-
sideration in making our diagnosis, for they give
positive Wassermann reactions. Those diseases
are : malaria, during the febrile stage ; yaws, a dis-
ease caused by a spirochete; cancer; scarlet fever;
relapsing fever; occasionally, some case of leprosy;
cases of autointoxication; and cases of diabetes, in
which acidosis is present. The ingestion of alcohol,
if taken within twenty-four to thirty-six hours be-
fore a test is made, often converts a strongly posi-
tive to a negative reaction. Even small amotmts
may cause this change, and where the reaction is
used as a control in the progress of the treatment,
it may mislead us as to the real serological status of
the patient. The Wasserman is also of importance
in the early diagnosis of the disease, as shown by
Major Craig, Medical Corps, United States Army,
in a series of 600 cases of primary syphilis :
Thirty-six per cent, of primary cases gave a positive
Wassermann within the first week after appearance of the
chancre; almost sixty per cent, during the second week;
almost seventy per cent, during the third week; over
seventy-seven per cent, during the fourth week; over
eighty per cent, during the fifth week after the chancre
had appeared.
The Wassermann is therefore of distinct value in
the earlj' diagnosis of syphilis, where the spiro-
chetes cannot be demonstrated. It is also of value
in determining the progress of the treatment and, at
times, it is the first clinical symptom in forewarning
a relapse, before any other clinical symptoms are
present. When beginning ' treatment the patient
should receive a pamphlet of instructions, concern-
ing the general significance of his affliction, his diet,
general hygiene, and the danger of communicating
his disease to others. In a general way the aims of
the treatment of lues should be: i. Destruction of
the spirochiEtae pallida? in the circulation ; 2, pre-
vention of the organisms from becoming surrounded
by infiltration ; 3, absorption of the infiltration
surrounding the organisms, so that they may be
acted upon by our spirocheticides.
TREATMENT OF SYPHILIS.
In the primary stage. — If a chancre is diagnosed
before, or even after, the Wassermann reaction be-
comes positive, salvarsan should be immediately
administered. If, for some reason or other, the pa-
tient cannot be induced to take salvarsan, a wet
antiseptic — mercurial dressings, such as lotio nigra,
or weak solutions of bichloride (1-5,000) — should
be used locally until the ulceration begins to granu-
late. Then the blue ointment or white precipitate
ointment should be applied until the sore becomes
4o6
GOLDFADER: MODERN TREATMENT OF SYPHILIS.
[New York
Medical Journal.
covered over with new skin. It is best to continue
the use of one of these salves until the infiltration
has been absorbed. If the salvarsan treatment is
adopted — and it is the only one to adopt — an in-
jection should be given every five to seven days
until six injections have been given. This should
be followed by a series of mercury injections or in-
unctions, until a negative reaction has been obtained
and maintained.
the secondary stage. — Give six to eight sal-
varsan injections at intervals of five to seven days,
followed by twelve to fifteen insoluble mercury
injections or by thirty to forty soluble mercury in-
jections or inunctions. At the end of that course of
treatment a blood test should be taken, and the same
course of treatment should be repeated as often as
necessary until a negative Wassermann is obtained.
Then the patient receives treatment for a period of
four to six months and, if the Wasserman is still
negative, treatment is suspended, but the patient is
kept under observation.
In the latent period. — In the course of syphilis a
latent period, or one free from symptoms, represents
merely a shorter or longer period of remission. A
positive Wassermann reaction, indicative of latent
syphilis, is an indication for careful examination,
lumbar puncture and antisyphilitic treatment similar
to that followed out in the secondary period. Suf-
ficient treatment during the latent period will pre-
vent dangerous and incurable conditions of the
tertiary period, particularly involvement of the cen-
tral nervous system.
In the tertiary stage — (Excluding cerebrospinal
cases). Treatment in these stages is similar to that
in the secondary stages. Courses of salvarsan and
mercury with iodides are given. We meet from
time to time cases which have been thoroughly
treated with salvarsan and mercury for two to three
years, and yet the positive Wassermann has not
been converted into a negative. In those cases, if
the patient is in good health and is gaining weight
and the spinal fluid examination is normal, it is
better to desist from further treatment and keep
the patient under observation.
Patients cannot be considered as cured until the
following requirements have been met : i . Absence
of all clinical svmptoms ; 2. continuation of treat-
ment for four to six months after the first negative
test, and a negative test at the end of that period
of treatment ; 3. observation for another six
months, and a negative test each month ; 4. a prov-
ocative injection of salvarsan and blood tests, show-
ing negative on the second, fifth, and seventh days
afterward ; 5. six months later a negative test ; 6,
normal cerebrospinal fluid.
THERAPY OF SYPHILIS.
Salvarsan and its substitutes — diarsenol and ar-
senobenzol— neosalvarsan and its substitutes — neo-
diarsenol and novarsenobenzol — are the most effi-
cient remedies in the modern treatment of syphilis.
Notwithstanding the fact that the high hopes we had
when salvarsan was first introduced to the profes-
sion— that one injection of salvarsan would destroy
every spirochete — hopes which were speedily shat-
tered as soon as we started to use this drug, it would
nevertheless appear that salvarsan and neosalvarsan.
or their substitutes, are the most efficient remedies
we have in the modern treatment of syphilis. By
experience we know that there is no marked differ-
ence in the therapeutic value of salvarsan and neo-
salvarsan. The majority of the profession prefer
the neosalvarsan because it is easier to administer —
a smaller quantity of water can be used and the
immediate effects are so much less trying physically
than those caused by salvarsan. Neosalvarsan must
be administered in larger doses than salvarsan, in
the general ratio of 0.9 gramme of neosalvarsan to
0.6 gramme of salvarsan. A course of four injec-
tions of salvarsan is inadequate treatment. A
course should consist of six to eight injections of
salvarsan, or one of its substitutes, followed by the
use of mercury and by iodides, if they are neces-
sary. A series of salvarsans, not followed by mer-
cury, produces few negative serum results (i).
Dose. — The dose to be employed and the fre-
quency of administration should be determined by
the stage of the disease and by the weight, age,
vigor, and constitution of the patient. In the
primary stage, when abortive treatment is desired,
large doses should be given and repeated at intervals
of five to seven days. During the secondary stage,
when a spirochetic septicemia exists, it is also de-
sirous to push the drug to its physiological limit. In
ordinary and latent cases, it is best to start with
smaller doses in order to determine the susceptibility
of the patient, and this is especially true in cerebro-
spinal cases. In myocardial and renal cases great
care .should be taken in the administration of sal-
varsan. If the changes are marked, it would con-
stitute absolute contraindications for the use of the
drug. The drug, though powerful, has the incon-
venience of being eliminated too rapidly from the
body, and its action, therefore, extends over a short
period of time. In order to get results it is abso-
lutely essential that the drug be administered at
short intervals and in as large doses as the patient
can tolerate. If given at long intervals, the salvar-
san introduced will cause the destruction of large
numbers of the spirochetes that exist in the circula-
tion ; those forming behind them will not be affected.
Preparation of the patient. — Before receiving an
injection of salvarsan. the patient should be in-
structed not to eat for five hours and to take a
cathartic the night before, in order to have a clear
gastrointestinal canal. He thus avoids the severe re-
action following the administration of the drug.
After the injection the patient should lie down for
two or three hours and then, if no symptoms de-
velop, he may have a light lunch.
Administration of salvarsan. — Salvarsan may be
administered intravenously, intramuscularly, or sub-
cutaneously. The method generally employed is the
intravenous, where the salvarsan is given by the
gravity method, using a greater or lesser dilution, or
in a concentrated form with a twenty c. c. record
syringe. In the gravity method, usually 125 to 150
c. c. dilution is made, freshly distilled water
is run into the circulation, before starting the flow
of salvarsan, to make certain that the needle is in the
lumen of the vein. The salvarsan is then run in
slowly, and, when all has entered the circulation,
more distilled water is used to wash the salvarsan
September 7. 1918.] GOLDFADER: MODERN
out of the vein to avoid a phlebitis. I have seen
two cases of phlebitis following the administration
of diarsenol, 0.6 gramme. Both patients had pre-
viously received two to three injections of salvarsan.
Distilled water had not followed the administration
of the drug.
The method which I have been using for three
years is the syringe method, employing a twenty c. c.
record syringe. Neosalvarsan, diarsenol, neodiarse-
nol, and novarsenobenzol may be injected with a
syringe. The manufacturers of arsenobenzol (Phil-
adelphia) advise that their preparation be diluted in
120 c. c. of boiling water, as they have reported un-
desirable reactions following the use of concentrated
solutions of arsenobenzol. American made salvar-
san (Metz) is also very toxic in concentrated solu-
tions. In giving salvarsan by the syringe the follow-
ing technic is employed. The drug is dissolved in
nineteen c. c. of freshly distilled water and, when
perfectly dissolved, a fifteen per cent, solution of
chemically pure sodium hydrate is added drop by
drop. At first a heavy yellowish precipitate is pro-
duced, which clears up when sufficient alkali has
been used. When neosalvarsan, or one of its sub-
stitutes, is used, no alkali is employed. The solu-
tion is drawn up into the syringe, and air
bubbles are expelled. The patient's arm is
tlien pamted with tincture of iodine, a tour-
niquet is applied, and the patient closes his
hand. By gently massaging the forearm, from the
wrist upward, the veins become more prominent at
the bend of the elbow. The left thumb fixes the
most apparent vein at the bend of the elbow, so as
to prevent its slipping away from the needle. Punc-
ture the skin and the vein at the same time ; a flow
of blood into the syringe indicates that the technic
has been successful. Push the needle along the axis
of the vein for about one c. c, but do not go through
it. If the needle has gone through the vein, the flow
ceases, and a hematoma forms. If a mistake is
made, remove the needle and try another vein. At-
tach the syringe to the needle before removing the
totirniquet. Inject the medicine slowly, taking two
to three minutes to do it. By the slow and inter-
rupted injection of the salvarsan, the blood stream
washes the medicine along and mixes with it. After
the salvarsan has run in, inject a few c. c. of dis-
tilled water through the needle to wash the salvarsan
out of the vein. I have seen several cases of in-
filtration following an injection of salvarsan, in
which the patient experienced no pain while receiv-
ing the injection ; but pain and sweUing made their
appearance from a few minutes to an hour after the
administration of the salvarsan.
Intramuscular or subcutaneous injections of sal-
varsan were formerly used, but are rarely used now
on account of the intense and persistent pain they
cause. They may be of use in obese patients where
it is impossible to give the drug intravenously. L.
W. Harrison, C. F. White, and C. H. Mills (2)
state that in a parallel series of cases treated by in-
travenous and subcutaneous methods, the subcutan-
eous or intramuscular method was distinctly more
efficient than the intravenous in both primary and
secondary stages, and that this method has the fol-
lowing advantages over the intravenous: i. Since
TREATMENT OF SYPHILIS. 407
it is simpler of excution, it is more generally ap-
plicable by the general practitioner. 2. The alarm-
ing and unfavorable side actions are almost wholly
absent. 3. Pain can be eliminated, or at least ameli-
orated, by making a solution of 0.6 gramme in seven
mils of four per cent, stovaine to which one mil of
creocamph cream is added and the whole well
shaken.
Mercury. — The former method of treating syphilis
by the internal administration of mercury leaves
much to be desired. Tabes and paresis occur almost
exclusively in this class of patients. Patients who
had taken mercury by mouth for three to four years
in the days before the Wassermann was discovered,
and were clinically cured and discharged by their
physicians, come back today with strongly positive
reactions. As Keyes, Jr., says, "visceral syphilis,
notably of the liver, heart, and aorta, is the heritage
of the present generation from the 'pill and potash'
of the preceding one." Mercury is useful, when
employed between courses of salvarsan for the pur-
pose of preventing relapse of symptoms, and can be
administered either intramuscularly or by inunc-
tion. Intramuscularly either soluble or insoluble
preparations of mercury are used. The soluble
preparations in use are the bichloride and the binio-
dide. They must be administered daily. The in-
soluble preparations in use are the salicylate, gray
oil, and calomel. They are administered every five
to seven days.
The injections are made with an ordinary hypo-
dermic syringe or a specially constructed Gottheil
syringe, using a needle two to two and a half inches
long and with a thick bore. The mercury cream or
suspension is thoroughly warmed and then shaken.
If the patient is to receive the injection in the up-
right position, let him stand on one leg, while the leg
which is to receive the injection hangs free in order
to relax the gluteal muscles. In that way the medi-
cine will not be forced into the fat and so cause a
node. The skin is sterilized with tincture of iodine.
The needle with the syringe attached is thrust into
Ihe gluteal muscles at a point either an inch above or
below the top of the gluteal fold and from one to
three inches from the median line, so as not to injure
the sciatic nerve. The syringe is removed to make
sure that a vein has not been penetrated. If blood
oozes out through the needle, the needle is removed
and another location used. Injections of mercury
into the vein may cause a pulmonary embolus.
Begin as a rule, with one grain of salicylate of mer-
cury in males and one half grain in females, and run
it up just short of salivation. Injections should be
given every five to seven days, using alternating
sides.
Treatment by inunctions of mercury is the oldest
method of treating syphilis. Each treatment should
be preceded by a hot soap and water bath and an
alcohol rub. The treatment consists in rubbing a
definite quantity of blue ointment, or a substitute
calomelol ointment, into a different part of the skin
every night for a week and, then, after two such
courses of treatment, allowing a period of rest.
The ointment is rubbed into the skin until every
part of greasiness has disappeared. This method is
efficient, but is dirty, and irritates the skin ; and
4o8
GOLDFADER: MODERN TREATMENT Gf SYPHILIS.
[New York
Medical Journal.
the dose is uncertain. When a syphilitic under
active treatment begins to lose weight, stop the
mercury and put the patient on tonics. While giv-
ing a course of mercury injections, the urine should
be tested for albumin and casts and, if they are
present, treatment should be suspended for one or
two weeks. At the end of that lime reexamine the
urine.
Iodides. — The iodides have no direct action in
destroying the spirochetes, but they are of great
help in removing infiltrations, gummata, and nodules.
Their field of usefulness is therefore reserved for
the latter part of the secondary stage, the latent
period and. particularly, the tertiary stage. Usually
a saturated solution is used, one minim of distilled
water representing one grain of the salt. Begin with
small doses and gradually increase the dose, watch-
ing the effect on the patient.
Hygiene. — The patient should be treated as well
as the disease. It is a good plan to push all medi-
cation in syphilis up to the point of tolerance ; but,
if the patient does not stand up well under the
routine, it is better to stop treatment for a week or
two and put him on tonics, fresh air, and nourishing
foods.
TREATMENT OF CONGENITAL SYPHILIS.
As soon as it is ascertained that a woman known
to be luetic is pregnant, treatment should be in-
stituted at once, combining salvarsan with mercury
and iodides. When the baby is born, it is deter-
mined as soon as possible by clinical and laboratory
data, employing the Wassermann and luetic tests,
whether or not he also is luetic. If the baby shows
no clinical evidences and the laboratory findings are
also negative, he is closely watched, and examina-
tions made from time to time. If, on the other
hand, clinical evidences and laboratory findings
corroborate the diagnosis of lues, the treatment is
begun immediately. The mother and baby should
be treated with salvarsan and mercury. Salvarsan
is given intravenously in the same manner as to an
adult. The accepted dose is .01 gram per kilogram
of body weight. A satisfactory vein should be
selected, either at the bend of the elbow or, in in-
fants, the jugular vein, the veins of the scalp, or
the longitudinal sinus through the fontanel. Mer-
cury may be given by mouth, by inunctions, or in-
tramuscularly. The drugs given by mouth are
calomel in doses of 1/20 to i/io grain, three times
daily, gray powder, one half grain, three times daily,
or bichloride of mercury, 1/200 to i/ioo grain,
biniodide of mercury in the same dose. Usually mer-
cury is given by inunctions. The blue ointment is
diluted with two to three parts of vaseline. The
dose used is ten to thirty grains increasing to the
point of tolerance. This is laid on the belly band
and renewed with it. Injections of mercury should
be employed in about one tenth of the adult dose.
This dose may be doubled at the time of second
dentition, trebled thereafter. In infantile syphilis
the division into secondary and tertiary periods is
not clearly defined, and the lesions peculiar to both
periods may exist at the same time. For this rea-
son, it may be necessary to prescribe iodides early
in the disease. The iodides mav be given in doses
of one to two grains, three times daily, to an infant
of six months to one year, and the syrup of iodide
of iron in doses of three to six drops, three times
daily, for the same ages. The duration of routine
treatment in infancy should cover the first two to
three years.
CEREliROSPINAL SYPHILIS.
There is little to be hoped from treatment in ad-
vanced cases, hence the crying need for an early
diagnosis. The best treatment is the prophylactic —
vigorous and thorough courses with salvarsan and
mercury. It has been learned that when salvarsan
alone is used, neurorecurrences are apt to follow.
According to Fordyce (3) twenty to twenty-five
per cent, of all syphilitics are candidates for nerve
syphilis. In general, the lesions due to inflamma-
tion are much improved. By our treatment those
due to degeneration are but little improved. The
results are better in the tabetic than in the paretic
patients.
Some patients show improvement, especially
those having symptoms due to exudation, by an
intensive course of treatment with salvarsan, mer-
cury, and potassium iodide. Some patients, on the
other hand, need intraspinal treatment with either
salvarsanized or mercurializerl serum. Many cases
of tabetics improve under the intravenous injections
of salvarsan and mercury alone, while others need
intraspinal treatment in addition. In well developed
cases of paresis we may improve the patient, but
the ultimate hope of recovery is slight. Treatment
to be effective in paresis must be given in its earliest
stage ; in cases of long standing it is useless. Cell
destruction cannot be replaced.
According to Evans and Thome (4) twenty-
three victims of paresis were subjected to intra-
spinal treatments with salvarsan, neosalvarsan and
albuminate of mercury. Three patients showed
mental and physical improvement ; ten died — four,
during the course of the treatment, and six, several
months after the treatments were discontinued ; ten
are living and markedly demented. I have seen
Normal Sharpe. of New York, treat early cases of
paresis by injections of solutions of salvarsan and
blood serum into the lateral ventricles of the brain
with fair results. His report of thirteen cases is as
follows : Two of the patients died of paresis, one
was unimproved by the only injection he received,
another showed no improvement. The remaining
nine showed decided improvement both serologically
and clinically. Bernard Sachs (5), on the other
hand, believes that no case of general paresis has
been cured by intraspinal injections of salvarsan.
He claims that the changes in the spinal fluid fol-
lowing intraspinal injections have also followed in-
travenous injections, repeated lumbar punctures,
and the introduction of the patient's nonsalvarsan-
ized serum. Therefore, the only hope for improve-
ment in cerebrospinal cases is in the early diagnosis
and persistent treatment of these cases. A patient's
cerebrospinal fluid should be examined before dis-
charging him. This examination should include a
cell count, a test for globulin, colloidal gold and a
Wassermann ; for in many cases of cerebrospinal
syphilis the blood Wassermann is negative.
In treating a syphilitic, do not give a short course
of intensive treatment, obtain a negative Wasser-
mann and then stop treatment. If treatment is dis-
continued at that time, the Wassermann will be-
September 7, 1918.I
KUHN AND GLASS: yiSCEROPTOSIS.
409
come positive in a few weeks or months. As in
tuberculosis, the patient and the disease must be
treated continuously until results are obtained. Our
insane asylums are overcrowded, as the result of
the former quick and early cures, and our cHnics
contain the remainder of the incapacitated victims
of this insufficient and hasty treatment. Our aim
should be to secure a negative Wassermann as early
as possible and to keep it so. Then treatment
should be continued for several months thereafter,
and the condition of the blood should be examined
by reasonably frequent blood tests to determine
whether the negative reaction has remained unal-
tered.
The duration of treatment is still a question of
opinion. Formerly, under mercury alone, the dura-
tion was set down as two and a half years, but,
today, we can be less definite in our statement. The
patient should be under treatment and observation
for at least three years. Following this limit of
three years, the patient should still be under ob-
servation for two to three years, and have Wasser-
mann tests made every three or four months. Those
cases which remain negative are the hoj>eful ones,
while a relapse may be looked for in those in which
the serum reaction returns to positive.
REFERENCES.
I. TRIMBLE: Journal of the American Medical Association. 2.
L W. HARRISON: British Medical Journal. May 5, 1917. ^. FOR-
DYCE: Journal of Cutaneous Diseases, October, igi6. 4. EVANS
and THORNE: New York Mfdical Journal, September 8, 1917.
BERNARD SACHS: Journal of the American Medical Associa-
tion, 191 7.
123 Reid Avenue, Brooklyn.
VISCEROPTOSIS: ITS DIAGNOSTIC
IMPORTANCE.
By I. Russel Kuhn, A. B., M. D.,
Fallsbnrgh, N. Y.,
AND Jacob Glass, M. D.,
New York.
One of the most prevalent of gastrointestinal
diseases is visceroptosis. Though it is essen-
tially a disorder of the alimentary tract, the
ef¥ect on the nervous system is most marked ; in
fact, often the extreme nervousness of the pa-
tient far overshadows the visceral symptoms.
The causes are many, the most common being
loss of weight and pregnancy.
The symptoms are very varied. There is no
condition of the gastrointestinal diseases which
visceroptosis cannot simulate. The most fre-
quent source of error is the diagnosis of gastric
ulcer or gallstones. Frequent complaints are
made of pains in the abdomen which may occur
at any particular time. Nausea is a common
symptom, though vomiting is unusual. Head-
ache, loss of appetite, and loss of weight are very
frequent symptoms. Eructations, which may or
may not be sour, and constipation also occur.
Of great importance is the nervous instability of
these patients. They are extremely irritable,
sleep poorly, complain frequently o£, extreme diz-
ziness, and palpitation of the heart*
This affection is most common among women.
Physical examination reveals a fairly obese per-
son. The abdominal wall is flabby, and there is
tenderness all over the abdomen, usually on deep
palpation. The cecum is frequently palpable, as
are the kidneys. Gurgling sounds are heard as a
rule. Scars, the result of appendectomies or
cholecystectomies, or what not, are of very fre-
quent occurrence.
Of greatest interest is the large number of use-
less operations performed upon this class of pa-
tients. It seems that as many types of opera-
tions have been performed as there have been
varied diagnoses made, with no improvement and
often an exaggeration of -the condition.
A few case histories, perhaps, may be illustra-
tive of the points in question :
Case I. — J. G., female, aged thirty-six years. The chief
comphiint was distress, distention and belching immedi-
ately after each meal. The past history was negative.
The appetite was poor, and bowels costive. At times the
patient had palpitation of the heart.
Present illness. — About two years ago patient first com-
plained of distress after eating, distention and heartburn.
Went from physician to physician with slight relief. In
August, 1917, patient again experienced pains and above
symptoms were renewed. Has never vomited. Bowels
have been costive. Pains start in epigastrium, radiate to
back; for these, the patient formerly took bicarbonate- of
soda, which afforded relief. Pains have no relation to
meals. Physical examination showed a fairly well nour-
ished woman. Heart and lungs negative. Blood pressure,
systolic 130, diastolic 80. Abdomen on inspection showed
numerous striae. Palpation revealed a soft abdominal
wall with tenderness in epigastric and left hypochondriac
regions. Gurgling sounds were frequent. The liver was
not enlarged, spleen was not palpable. Left kidney not
felt, right kidney palpable, slight tenderness in right costo-
vertebral angle. Extremities — Reflexes very active.
Rontgenoscopy showed ptosis and hypotonia of the
stomach. An examination of blood, urine, and stool were
all normal. The condition had been diagnosed by one
physician as chronic appendicitis, and by another as cho-
lecystitis. She was told repeatedly that only operative
measures could effect a cure. A diagnosis of visceroptosis
was rnade and we instituted treatment accordingly. She
was discharged cured.
Case H. — Mrs W., aged thirty-eight years. The chief
complaint was weakness, pain in the back and palpitation
of the heart for a number of years. She had been very
weak for the past two months. Past illness was nega-
tive as to present condition. Patient had had an opera-
tion seven years ago for prolapsed uterus. Appetite has
been poor and bowels costive. Frequent palpitations of
heart, menses scant, dysmenorrhea, slight leucorrhea.
The patient sleeps fairly well, but dreams considerably;
has frequent flushes of face.
Present illness : Patient has had pain in the back for
a number of years and weakness for past two months.
Is awakened almost nightly with acute pain across lower
abdomen ; pain does not radiate, there is no vomiting, al-
though at times a feeling of distention and of pressure
which rises upward. No urinary trouble. No headaches.
Physical examination reveals a well nourished woman,
tongue somewhat coated, seven teeth capped, heart and
lungs normal. Abdomen shows a median scar extending
from epigastrium to about two inches above pubes. The
abdominal wall is very flabby, no masses are felt, but
there is epigastric tenderness on deep palpation ; the colon
is very easily palpated as well as both kidneys. Liver is
not enlarged and spleen not palpable. Kneejerks are not
over active. Vaginal examination negative.
Mrs. W. was advised operation for nephropexy as the
only means of relief. She was suffering as a result of
visceroptosis. Treatment was begun. After four weeks
she was very much improved.
Case III. — L. W. F., aged thirty years. The patient
had had nervousness and pain in stomach for past six
months. Had lost from thirty to thirty-five pounds in
past year. Past history negative.
Present Illness. — For past six months patient has com-
plained of pain and tenderness in epigastric region. No
KUHN AND GLASS: VISCEROPTOSIS.
[New York
Medical Journal.
vomiting — fell bloated and belched considerably, which
afforded her relief. Slie sleeps well, the appetite is good
and bowels regular. Physical examination reveals a fairly
well nourished woman. Heart and lungs normal. Ab-
dominal examination shows a flabby abdominal wall, no
masses felt nor muscular rigidity, but tenderness in epi-
gastric and both lumbar regions. No costovertebral ten-
derness. Right kidney palpable, left not. Urine and stool
analyses were negative. Blood examination showed a
slight secondary anemia. An x ray examination revealed
ptosis and a moderate degree of atony of the stomach.
An examination of the stomach contents showed hyper-
acidity, free acid, sixty-five, total acid, eighty.
A diagnosis of gastric ulcer had been made. Treatment
had been instituted accordingly, with poor results. Treat-
ment outlined below for visceroptosis effected a marked
improvement.
Case IV. — F. K., female, married, aged thirty-three
years. Chief complaint, vomiting and dizziness for past
five years. Had lost sixty pounds in two and one-half
years. Past illness negative. Appendectomy two years
ago.
Present Illness. — Five years ago patient began to vomit
and felt bloated. Complained of acid eructations, was
constipated, never vomited blood, nor had acute abdominal
pains, but had epigastric distress. The pains then did not
radiate, but now at times they radiate around to the right
shoulder. Pain and vomiting have no definite relation to
meals. Appetite has always been fair. Hemoptysis five
years ago. The patient has palpitation of the heart fre-
quently. Urinary history normal, menses irregular during
past six months, but there is no dysmenorrhea or leucor-
rhea. Symptoms have steadily increased. Physical exam-
ination reveals a poorly nourished woman, extremely ir-
ritable and nervous. Conjunctiva pale, throat congested,
tongue coated. Chest — Apices depressed, poor expansion,
fremitus increased over left base, hyperresonant in left
ape.K, dull posteriorly in left base. Auscultation reveals
lironchovesicular breathing in right infraclavicular region
and in both bases. Heart normal. Blood pressure, sys-
tolic no, diastolic 65. Abdomen shows a flabby abdomi-
nal wall, with scar in right inguinal region (appendec-
tomy). No masses are felt, but there is tenderness in
epigastric region and extreme tenderness in right costo-
vertebral angle. Left kidney is palpable, also the cecum
Liver and spleen not enlarged. Knee jerks markedly over-
active. Appendix had been removed two years ago, but
no relief had been afforded. An examination of her urine
and stool was riegative. A blood examination showed a
slight secondary anemia. A Wassermann was negative.
A gastric analysis showed seventy-five, free acid, ninety,
total ; no blood.
A report of her x ray examination, given by Dr. I. W.
Held, shows an arrested tuberculosis of the right lung
with pleurodiaphragmatic adhesions and a very high de-
gree of enteroptosis. Two years ago, the patient was told
that symptoms were due entirely to an inflamed appendix.
The appendix was removed, but after a few weeks, symp-
toms were renewed in exaggerated form. Patient went
from physician to physician and was finally told that she
had a gastric ulcer. Being too weak for an operation,
she was advised to regain some of her health in a sani-
tarium in preparation for a gastroenterostomy. A diag-
nosis was made of visceroptosis. Treatment was insti-
tuted accordingly and in several months she was dis-
charged cured.
Case V. — M. W., female, aged thirty years. The chief
complaint was nervousness, vomiting, and loss of weight
for past three years. Past illness negative. Operations —
appendectomy and cholecystecomy four years ago. Appe-
tite was good and bowels regular. Palpitation of heart
was frequent. Urinary history normal ; dysmenorrhea and
severe headache during menstrual period.
Present Illness. — Four years ago had sudden pain in
right side. A physician was called and a diagnosis of
appendicitis was made — appendi.x was "frozen." Felt well
for six months when again stricken with cramplike pains
and was sent immediately to the hospital. Appendectomy
was performed. Patient was afforded very little relief.
She began to have spells of weakness, belched consider-
ably, and abdomen was much distended. Eructations at
times were sour. There was no abdominal pain, vomit-
ing, or blood in the stools. Constipation became marked
and there were frequent severe headaches. Condition
would come on with no relation to meals. The pressure
upward would cause a feeling of constriction around
chest. There was no history of jaundice. Being afforded
no relief by the removal of her appendix, she again con-
sulted a physician and was referred to a surgeon. He
advised an operation six months ago, and a cholecystec-
tomy was done Patient was relieved for two months
when symptoms again returned.
Physical examination reveals a well nourished woman,
tongue coated white, a number of teeth capped, heart and
chest normal. The abdomen shows a longitudinal scar
extending from right hypochondrium to right lumbar re-
gion. There is a flabby abdominal wall, moderate ten-
derness in epigastric and inguinal regions, no muscular
rigidity, no gurgling sounds heard, no Murphy sign or
costovertebral tenderness. Liver and spleen not enlarged,
kidney not palpable. An examination of the blood, urine,
and stool was negative. Wassermann negative. Gastric
analysis showed free acid sixty-five, total acidity eighty.
Patient was referred to an institution by Dr. G. A diag-
nosis of visceroptosis was made, and treatment was begun.
Patient is still under treatment and is doing splendidly.
The successful treatment of visceroptosis re-
quires the greatest possible cooperation of physi-
cian, nurse, and patient. This is best undertaken
in an institution. It is essentially a rest cure and
drugs have very little place in it. The patient
is put to bed and the foot of the bed is elevated ;
in fact, everything is done to raise the ptosed
organs and to increase the strength of the liga-
ments and muscles of the abdomen. Treatment
is also directed toward bringing about the nor-
mal tone of the organs. For that reason, great
importance is attached to the knee and chest ex-
ercises which all of the patients are urged to do.
The faradic current is applied to the abdomen
daily. A tight abdominal binder, so applied that
pressure is from below upward, is of the greatest
importance. Fats occupy a large place in the
dietetic treatment, and food is given in small
quantities frequently. Fluids are restricted. As
many of these patients are extreme neurasthe-
nics, hydrotherapeutic means have often been of
great assistance. Medication has been left last
as it is least important. Strychnine for increas-
ing the tonus is at times used. A daily evacuation
of the bowels is very essential. Saline cathar-
tics are contraindicated and enemas should be
ordered as little as possible. Bismuth has proved
invaluable in many cases. When anemia is pres-
ent sodium cacodylate, •>4 grain, is given intra-
muscularly every other day.
Visceroptosis is a very common disease. Many
of the vague alimentary disorders are due direct- '
ly to this condition. Unrecognized it often brings
untold sufifering to the patient. As a last resort,
operations are undergone with very little relief.
CONCLUSIONS.
1. Visceroptosis is a very prevalent gastroin-
testinal disease which is frequently overlooked.
2. It is most commonly confused with gastric
ulcer, cholelithiasis, or chronic appendicitis.
3. As a result of mistaken diagnosis, useless
operations are performed with frequently an ex-
aggeration rather than an amelioration of symp-
toms.
4. The successful treatment of visceroptosis re-
quires the greatest cooperation of physician,
nurse, and patient. This is best obtained in an
institutional environment.
September 7, 1918.]
HERTZBERG: CLINICAL CONGRESS WEEK.
411
A NEW AND HIGHLY EFFICIENT DRESS-
ING FOR WOUNDS.
Bv Alfred Kahn, M. D.,
New York.
In these military times, when so much is spoken
and written of war wounds, I desire to call the at-
tention of the profession to a new material and a
new technic in the treating^ of wounds, which I
have used from time to time.
The material I have in mind for an internal
dressing or drain and for an external absorptive
dressing, either wet or dry, is blotting paper pre-
pared in a variety of ways ; and as an external
binder to take the place of the cloth roll or band-
age, punctured paper adhesive on one side for
binding it over the dressing or wound. In passing
1 desire to state further that this adhesive roll
last mentioned can be variously medicated and
used over surfaces much as our present day ad-
hesive plaster or mustard plaster. The paper, how-
ever, IS much less expensive and can be more easily
removed, besides having other advantages which
will readily make themselves apparent to the sur-
geon.
The wound is prepared for dressing much as any
wound is prepared, the difference being that in-
stead of using gauze and cotton as a drain, I use
blotting paper, corrugated, thin, and in strips, as a
drain ; and blotting paper crumpled up in my hand
as aii external dressing. When I am using this
process, I may now either reinforce my blotting
paper with a little gauze, or I may not reinforce
it with gauze, or I may use a cloth roll bandage
over the blotting paper, or I may use as a binder
the corrugated, punctured, adhesive paper. The
paper dressing makes a light, airy, and inexpensive
dressing, it is easily removed, and is more readily
destroyed than a cloth dressing.
Oli' and on, for several years, I have been using
this most efficient dressing for surgical cases, es-
pecially in the packing of the mastoid cavity after
the acute mastoid operation, or after the radical
mastoid for a chronic suppurating ear condition.
In conjunction with syringing, I often pack the
paper, the material sometimes being used medicated
with various antiseptics and deoderants, such as
bichloride of mercury, permanganate of potash,
argyrol, iodoform, carbolic, peroxide, aluminium
acetate, etc. Of course the material and dressing
can be variously adapted to any surgical wound
other than the mastoid. I have used it in the treat-
ment of ulcers, lacerated and punctured, and infec-
tious wounds of various types ; but I mention the
mastoid specially because it is more in my province
and I have had more experience with it there than
in other portions of the body. As a wet dressing
over contused wounds and over highly inflamed,
irritated surfaces, either plain or medicated, it is
excellent. In the treatment of furunculosis of the
external auditory canal, where I have used it as a
wet dressing soaked in a solution of aluminium
acetate, I have had most excellent results. In the
treatment of furunculosis associated with diabetes,
and as a dressing for carbuncles, abscesses, and fur-
uncles of the neck, I have likewise had excellent
results. In the treatment of dee]i, lacerated wounds,
as a cigarette drain wrapped in some stiff material
such as rubber tissue, it is even superior to a gauze
drain. As an outer dressing it is equal, if not
superior, to gauze.
50 I'' AST FORTY-SECONO STREET.
CLINICAL CONGRESS WEEK.*
Bv G. R. R. Hertzberg, M. D.,
Stamford, Conn.
Surgeon, Stamford llot^pital; Lecturer in Anatomy and PhysioIoKy,
Stamford Training School.
The eighth annual session of the Clinical Con-
gress of Surgeons was held in Chicago during the
week of October 22 to 27, 1917. The headquarters
were at the Congress Hotel. The registered atten-
dance on the opening day was 2,500, which in-
creased (o over 3,000 before the close of the session.
Every state in the union was well represented,
and several of the belligerent countries allied with
us in the war sent representative delegations. Eng-
land sent Colonel T. H. Goodwin and staff. France
sent Colonel C. Dercle and staff. Our own Govern-
ment thought the occasion important enough to send
to the first evening meeting, the Hon. Josephus
Daniels, Secretary of the Navy ; Surgeon General
W'ilHam C. Gorgas, U. S. A. ; Surgeon General
William C. Rraisted, U. S. N., and Surgeon General
Rupert Blue, U. S. P. H. S.
On the staff of the British representative was one
of England's best surgeons, a man whose writings
we all know, and who is now responsible for the
hospitals in 200 square miles of the western war
zone- — Sir Berkeley Moynihan. He is the represen-
tative of the tenth successive generation of his fam-
ily to serve his country.
Among American surgeons who took a prominent
part in the session were Majors Charles H. Mayo,
William J. Mayo, A. J. Ochsner, George W. Crile,
Allen B. Kanavel, Howard Kelly, Charles M.
Frazier, L. L. McArthur, A. D. Bevan, and many
other prominent surgeons.
Chicago's hospitals are numerous and modern in
every particular. There is no slovenly work seen,
and the technic in the operating rooms is universally
good. Gloves are worn by all operators and nurses.
An improvement in operative technic noted, and
especially insisted on in bone operations, is the di-
rect (from sterilizer to patient) method of steriliz-
ing instruments. The instruments are placed in
oerforated trays with handles all one way, then put
in the sterilizer and sterilized. When ready the full
trays are removed from the sterilizer, placed on the
instrument table and covered with a sterile towel.
The instruments are taken from the tray only bv the
operator or his assistant. This eliminates dumping
the instruments into a basin of water and the sorting
out by a nurse, thus saving both handling and time.
Another noticeable thing is the much diminished
use of artei'y clamps during operations. Where it
was a common sight two or three years ago to see
from twenty to forty artery clamps sticking about
a wound, each grasping and crushing anywhere
from a shred to an ounce of tissue, now only the
* Paper read before the Fairfield County Medical Association,
Bridgeport, Conn., April g, 1918.
412
HERTZBERG: CLINICAL CONGRESS WEEK.
[New York
Medical Journal.
bleeding vessel itself is carefully caught and tied as
soon as possible. Clamps are only left on the tissue
that is to be removed, and insistence is made, that
in the past, many a recoverable case was lost by too
strenuous a use of artery clamps.
Speed that sacrificed safety and did careless and
rough work, has been replaced by slower but more
careful work, work based on anatomical knowledge.
Wherever possible, known main branches of ves-
sels are isolated and clamped before cutting them,
instead of cutting first and tying after the loss of
considerable blood. The tendency in modern surgery
is not so much to a successful or brilliant operative
procedure, often followed by a dead patient, but
rather to a more careful and searching attack on the
pathological condition, carried out with the mini-
mum of trauma to the surrounding tissue. This is
giving lower mortality rates and fewer postopera-
tive complications.
Chicago has forty-seven hospitals, and it is
obviously impossible for one man to visit them all
in one short week, but, from hearing other men's
views oi the hospitals that I could not visit, I came
to the conclusion that they all conformed to one
standard and that an exceptionally good one. Any
number of operations were performed every day
during congress week, these operations running the
gamut of all surgical procedures, old and modem.
DR. A. D. Sevan's clinic.
The first clinic that I attended was that of Dr.
A. D. Bevan, professor of surgery. Rush Medical
College. The clinic was held at the Presbyterian
Hospital.
Radical amputation of the breast. — Doctor
Bevan demonstrated a practically bloodless method
of radical amputation of the breast. The incision
follows the lower border of the pectoralis major
from the humerus across the breast in a broad
curve. Another incision starts at the first incision
about where the pectoral tendon becomes diffuse
and sweeps across the breast in curve to lower point
of first incision. Skin and fat vessels are carefully
clamped by assistants. Skin is dissected forward to
sternum and backward to serratus magnus. The
axilla which was opened by first incision is now
cleaned out from above downward, and especial at-
tention is given to fat about the axillary vein. The
whole mass of glands and fat is stripped down and
left attached to the pectoral fascia. The lower and
outer border of the pectoral major is now isolated,
two sharp tenacula are placed into this border, and
strong traction is made by the assistant pulling the
muscle, breast and all, toward the sternum. With
one sweep of the hand the space between chest wall
and pectoralis is entered and widened until sternum
is reached, then upward to the clavicle. Here the
branches of the acromiothoracic vessels are clamped
?.nd tied as they come through the costocoracoid
membrane. These are the only vessels that need be
tied in this part of the operation. The sweep of the
hand under the pectoralis is now carried to the
humerus, the hand grasps the tendon about an inch
from insertion, and the tendon is then squarely cut
across. A rapid knife cut then frees the pectoral
fascia from the clavicle by a downward stroke from
the sternum, and then the whole mass, of skin.
breast, pectoral fascia, and pectoralis major, comes
away together. The pectoralis minor may be in-
cluded in this removal by including th'is muscle in
the stripping process. The operation performed in
this way is clean, rapid, radical, and with practi-
cally no loss of blood. It can be performed in less
time than it takes to describe it. With two as-
sistants operation can be done in fifteen minutes.
Esophageal stricture. — Doctor Sippey, Doctor
Bevan's associate, presented a number of cases of
esophageal stricture. The progress of the cases was
demonstrated by x ray plates. Doctor Sippey has
devised a method of dilating these cases which he
claims (and he is supported in this by Doctor
Bevan) renders any operative procedure unneces-
sary, providing the patient can swallow water. If
water will trickle through the stricture, it can be
dilated, because where water will go, a silk thread
will go, and he had six cases to show that it would.
Most of the cases were acid burns, one a car-
cinoma, and the patients sat in the operating room
with silk threads hanging out of their mouths. And
the strange part was that the thread could not be
pulled out. In some way, as Doctor Sippey puts it,
the thread becomes anchored in the intestines.
These patients are made to swallow a small ball
of No. D twisted silk. One end of the silk is then
tied to a tooth and the patient drinks water repeat-
edly. If water will trickle through the stricture,
the silk will go through in about twenty-four hours
and be anchored securely in the intestine. Doctor
Sippey has constructed a long, flexible piano wire,
threaded on one end. To this end is screwed a
bulb just large enough for a hole through which to
pass the silk. This bulb guided by the silk thread is
then pushed through the stricture bv the wire.
When it has gone through, a series of perforated
bulbs of increasing size are strung on the wire be-
hind the first bulb, the whole held in place by a
closely twisted spiral spring which slips onto the
piano wire and is held fast by an artery clamp. In
this way any size bulb can be used that the stricture
will admit, succeeded by the gang of larger ones,
and'there is no danger of perforation, for the dilator
is guided bv the smallest bulb always pushed along
the silk string.
Doctor Sippey also showed one case of stricture
of the sigmoid which he had successfully dilated by
this method.
Doctor Bevan then operated in a case of unde-
scended testis. The operation devised by him
makes a tunica vaginalis out of the coverings of the
cord. The success of the operation in all these
cases depends on the absolute absence of tension
when the testicle is placed into the scrotum. He has
operated in 300 cases with only two per cent, of
failures.
OstcoinyeHtis nf the hip joint. — Doctor D. B.
Phemister presented a number of cases of osteo-
myelitis of the hip joint. He pointed out the fact
that the x ray does not show any changes in bone
or joint before the twelfth day. He placed great
emphasis on the fact that in these cases the joint
always becomes dislocated backward, and. the leg
should be kept in some form of extension so that
when ankylosis occurs, as it always does, the leg
September 7, 191S.]
HERTZBERG: CLINICAL CONGRESS WEEK.
would be ill full reduction and the patient able to
walk. The disease is generally found in the neck
of the femur, the head being rarely involved. The
causative organism is usually the staphylococcus
aureus albus.
He opens these joints from the front, making his
incision to the outer side of the rectus femoris. This
gives easy access to joint. All dead bone is curetted
out and necessary drainage is instituted by counter
openings, and the upper incision closed. Patients are
then put in Buck's extension until the active symp-
toms have subsided, and then put into plaster cas_t^,
This method has reduced the stay of these patients
in the hospital from months and even years to from
six to ten weeks. Attempts to get motion into
these joints by manipulation should never be coun-
tenanced. Doctor Phemister attempted to increase
the motion in a case that had been healed for
eighteen months, and there was a sharp recurrence
of the old trouble necessitating another operation
with the same siege.
DR. A. J. OCHSNEr's CLINIC.
j\cw method of myesthesia in thyroidectomy. —
The first case was a thyroidectomy for hyper-
thyroidism. The unique feature of this case
was that the patient did not receive a particle of
anesthetic after she entered the operating room.
The operation was completed in about half an hour,
and the patient did not struggle and only moaned
once toward the end. The procedure is as follows :
A half hour before the time set for operation, the pa-
tient is given morphine, one quarter grain, and atro-
pine, i/iOG grain. She is then thoroughly anesthe-
tized to point of complete, deep surgical anesthesia.
The operating table is inclined in reverse Trendel-
enburg position, head high and feet low. This
position, it is claimed by Doctor Ochsner, under the
anesthetic and morphine, induces a cerebral anemia.
The patient's face throughotit is covered with sev-
eral layers of toweling.
The advantage of this method is obvious, but of
course can be carried out only by an operator of
large experience with a thoroughly competent and
trained team, for the operation must be completed
within a narrow limit of time. The stomach of all
thyroidectomy patients is washed out after opera-
tion with water at a temperature of 105° F. This
lessens the hyperthyroid sequelae.
Doctor Percy performed the next operation for a
large rectocele. A transverse incision was made
across the perineum between the vagina and the
anus. A careful dissection between the rectum and
vagina was made until the upper limit of the recto-
cele had been passed. The margins of the levator
ani, which now showed in the depth of the wound,
were brought together in midline, and sewed with
kangaroo tendon. The wound was closed in the
axis of the vagina. This cures not only the recto-
cele, but also the lacerated perineum.
Elastic stocking for leg idcer. — Doctor Percy then
showed his method of applying a perfectly fitting
elastic stocking. Instead of keeping these leg ulcer
cases in the hospital for weeks at cost to the hospital
and loss of time to the patient, they keep them only
long enough to clean up the ulcer, then this elastic
stocking is applied and the patients are allowed to
return to work. The ulcer will heal under the
stocking. The stocking is of great value in the
varicosities antedating delivery. All that is neces-
sary are several gauze bandages and a mixture of
four parts sheet gelatin, four parts zinc oxide
powder, ten parts glycerin, ten parts water. The
gelatin is dissolved in the water and glycerin, and
the zinc oxide stirred in until a thick white paint is
obtained. The mixture must be kept warm. Now
put the gauze bandage loosely on the leg, and with
an ordinary brush, have the nurse paint the bandage
freely with the mixture as the bandage is being
applied. Six or eight layers make a perfectly fitting
and elastic stocking. When dry rub the stocking
with talcum powder, otherwise it is rather sticky.
Any discharges from the ulcer are carried
rhrough the stocking by the hygroscopic action of
the glycerin, and the ulcer is said to remain clean and
dry. They have placed and replaced hundreds of
these stockings in the last five years at a great sav-
ing to their hospital and with universal good result
to the patient.
Lane plating on fractured femur. — Doctor Percy
then did a Lane plating on a fractured femur in
which the fragments overrode an inch. His technic
was even more perfect and rigid than that of Sir
Arbuthnot Lane, whom I saw do this same opera-
tion in London. The direct from sterilizer to
operator method of instrument sterilizing was car-
ried out, and nothing but an instrument came near
the wound, not even the gloved finger. The sutures
were all tied by clamps. It was clean, rapid, ad-
mirable work. Long willows or hickory strips,
such as are used to make baskets, are used
by him in applying plaster casts. They have the
advantage over ordinary coaptation splints, in that
they are long and can be molded accurately over
the curves of the pelvis and leg.
Ochsner operation for femoral hernia. — Doctor
Ochsner now did his well known operation for
femoral hernia. He says "The more scientific you
are in the operation for femoral hernia, the worse
your results are going to be." They get no recur-
ences of their femoral hernia cases and they have
done thousands. He cuts down on the hernial sac,
opens it, ligates it as high up as possible, cuts it ofif,
drops the stump, and sews up the skin. It takes him
about fifteen minutes from start to finish. If it
works in hands not so skilled as Ochsner's, it
removes the bane of hernia operations, for I think
we all have mastered the operation for inguinal
hernia.
Percy method of blood transfusion. — Next was a
demonstration of blood transfusion by a method
devised by Doctor Percy himself. He has con-
structed a large glass tube holding 500 c. c. This
tube IS drawn out at one end to a fine point. The
other end has a connection for a bulb syringe.
Some paraffn is melted inside the tube and the
v/hole inside of tube coated with it. About an
ounce of liquid albolene is placed in the tube. The
two patients are prepared by opening a vein in
each as in an infusion, the end of the warmed tube
is pushed into the vein of the donor, and the tube
fills with blood, the liquid albolene in the tube float-
ing on top of the blood ; thus no air or glass comes
414
HRRTZBERG: CLINICAL CONGRESS WEEK.
[New ^'oRK
Medical Journal.
In contact witli the blood and no clotting occurs.
When the tube is as full as the operator desires, it
is witlKlrawn frnni vein and inserted into the vein
of recipient, and by slight pressure on bulb is
forced into blood stream. It is done (|uickly and
under ai)solute control of the operator and is a
very simple procedure.
CLINICS OF DR. J. K. B.M.LINGF.R AND DR. E. W.
kVKRSON.
Doctor Ballinger performed an operation for a
meningoencephalocele. The baby had a mass pro-
truding from the occipitocervical region as large
as an orange. The mass contained brain and it
was impossible to reduce it. This condition is anal-
ogous to spina bifida.
Doctor Ryerson's clinic was interesting and in-
structive. Several astragalectomies were done, and
knockknees anrl bow legs were straightened in a
number of children, some by open operation, others
by breaking the legs with the osteoclast.
TIlUkSD.W CLINIC OF DOCTOR M'kENNA.
At this clinic new joints are manufactured
and hopeless cripples throw away their crutches
and walk. Joints that have seen no motion for
years are restored to almost perfect func-
tion in from two to six months. It makes no dif-
ference whether it is an elbow, wrist, hip, or knee,
it can be and is made over, so as to give its owner
renewed joy in a heretofore useless member. It
would take too long to go into the detail of tliese
various operations. The first principle of treatment
is absolute and perfect asepsis : nothing but instru-
ments come in contact with the wound, not even
the gloved finger. No finger touches a suture ; these
are picked up and tied with artery clamps. The
second general principle is the interposition of
fascial and fat flaps between the ends of the bones.
These flaps are cut from the fascia near the joint,
and a pedicle is left attached for nourishment. But
this is not absolutely necessary, as a transplanted
fascial flap from the outer surface of the thigh will
live. These flaps prevent bony ankylosis and make
splendid synovial membranes for the new joints.
It is really wonderful work.
Doctor Strosser showed the x ray plates of eight
cases of chronic lumbago, of from two to twelve
years' standing. In each there was a fracture of
one of the transverse processes of a vertebra. Re-
moval of the loose fragment cured all these cases.
A history of injury was not obtainable in all the
cases.
Friday was spent at Cook County Hospital, an
enormous structure and up to date in every way.
Doctor Kanavel excised stomach ulcers, and took
out several spleens. His work is clean, neat, and
expeditious, and the most interesting part is the
lecture that accompanies the work. He advises
splenectomy in pernicious anemia, hemolytic jaun-
dice, persistent large spleen of malaria, and in
Banti's disease. He says that the condition under-
lying all these manifestations and also hyperthyroid-
ism is in all ])rol)ability a local toxemia. The en-
larged s])k'en is not the disease, but only the end
result of the malignant action of the toxic agent.
If we knew what that agent was and could combat
it, it would be wrong to remove this organ. But,
as we do not know its nature and we do know that
in these always fatal cases a removal often means
recovery, it would be wrong not to give the patients
this chance.
Doctor Kanavel has made a long series of experi-
ments with dogs, and finds that in fractures, there
is perfect microscopic restoration of bone only after
a Dcriod of from seven to nine months.
The evening meetings were the feature of the
congress, and always of an international character.
Tlie first meeting was addressed by Secretary of
the Navy Josephus Daniels. He spoke right from
the shoulder about the danger to this country from
the venereal diseases afflicting the men in the serv-
ice. He said that last year the navy lost 140,000
days in illness from this cause alone, and he laid
strong emphasis on the statement that it was up to
the medical and surgical profession to help stamp
out this evil, by reporting cases, instituting quaran-
tine, and above all, by adequate warning and educa-
tion of young people. The measures adopted for its
control in the service are as follows: If a man has
been indiscreet, it is made his duty to report this
fact within twenty-four hours after his return to
duty. He is at once given a prophylactic treat-
ment. If he fails to report his indiscretion, and
develops the disease, he is courtmartialed and given
a year in jail with a dishonorable discharge. There
has been a decided decrease in the number of cases
and the entailed loss of time since this ruling went
into efifect.
Doctor Ochsner spoke on the standardizing of
hospitals ; plans are on foot to bring a bill before
the various state legislatures forcing all hospitals to
conform to a certain standard of efficiency in their
staffs, number of nurses, and general equipment.
Surgeon General Gorgas spoke on the medical
man in the army, and how wonderfully the profes-
sion has responded to the call to colors. There are
now 14,000 medical officers in the training camps :
8,000 more are needed and will be called when there
is room for them.
Sir Berkeley Moynihan spoke at length on the
advance in knowledge this war is bringing to medi-
cine and surgery. During the South African war
of two years' duration there were 57,684 cases of
typhoid fever with 8,022 deaths in an army of less
than a million. In the present war, in an army of
over five million, there were in the first two years
only 6,022 cases with only 292 deaths.
Colonel Russell, the originator of the typhoid
vaccine, described the establishment of the labora-
tories and the tremendous demands made on this
department, and how it was being met by the or-
ganization of new units in different parts of the
country.
Tuesday evening was taken up with a symposium
on wound treatment in this war. The papers were by
Sir Berkeley Moynihan, Major George W. Crile, Dr.
Edward Martin, Doctor Dakin, Dr. Alexis Carrel,
Dr. William O'Neil Sherman, and Dr. E. W. Lee.
These papers were a spirited discussion on the
merits and demerits of the Carrel-Dakin solution.
Doctor Carrel gave his paper with slides showing
what had been accomplished by this method, and
September 7, iQiS.]
HERTZBERG: CLINICAL CONGRESS WEEK.
415
there is no doubt that, in his hands, it has in some
cases accomplished the seemingly impossible. But
there are many drawbacks. The conditions for its
best effect must be ideal, the cases must
be secured early, the treatment must go on un-
interrupted, for if discontinued for even a short
period the results are disastrous and always end in
death It never attains absolute sterility , it does
obtain clinical sterility in wounds in twelve days.
The method cannot be used in mobile hospital units,
for if interrupted it means death to the patients.
The opinion of this treatment as voiced by Sir
Berkclev IVloynihan and concurred in by Doctor
Crile, the two men who have seen it used the most,
is that "The Carrel-Dakin solution has attained its
greatest success in those cases where it need never
have been used." For its proper employment, in
common with all other forms of treatment, the
patient must be absolutely at rest, treatment must
be begim early, and the widest possible excision of
the wound must be practised. And herein lies the
secret of all successful wound treatment, absolute
physiological rest of the part and free excision of
the infected areas. The first few months of the
war were heartbreaking to the military surgeons.
It seemed as if all their previous knowledge of
wound treatment was as nothing in the wind of the
present siorm. All wounds became infected if not
already so when they came to hand. Patients died
awful deaths from trivial wounds who had been
carefully treated according to accepted standards.
It was just one riot of awful, stinking, rotten pus,
with, apparently, no way to check it.
Then came Carrel with at first, his free incision,
Dakin solution, and bihourly flushing. This in a
measure showed the way.
Then some of the surgeons began to notice that
even severely wounded men, who had survived the
iiemorrhage and the shotk, and had lain out in No
Man's Land for several days, and whose wounds had
become flyblown and were full of maggots, were in
much better shape as regarded sepsis and eventual
recovery, than those whose wounds were not in this
condition. The reason was searched for and found
to be in the fact that flies lay their eggs in putrescent
and devitalized tissue, the developing maggots feed
on this putrescent matter in the wound and remove
it, reducing absorption of toxins and lessening the
pabulum for bacterial growth. When this was suf-
ficiently understood, the next step was taken. The
wounds were excised, at first gingerly and with
many misgivings, but as case after case proved the
correctness of the theory, the confidence was gained
that herein lay the crux of all the previous trouble.
The whole wound, no matter what its condition, is
excised in one piece whenever possible, well into the
normal tissue, regardless of mutilation, for in wide
excision and only in that lies the safety of the
patient.
While this method of dealing with these horrible
infections was gradually being evolved and im-
proved, Rutherford INIorison, in charge of several
base hospitals under Sir Berkeley Moynihan had
compounded a mixture which he named Bipp,
consisting of equal parts of bismuth, iodoform, and
parafim. This he sprayed into the incised clean
wounds, and v/as so impressed with the rapid heal-
ing, that he went a step further. He took several
of these unspeakably foul wounds, excised them
according to the method that had been developed
and sprayed them with the Bipp, and sewed them up
tight.' He got union by first intention, a marked
advance over the precarious Carrel-Dakin method.
Sir Berkeley Moynihan was impressed by the re-
sults obtained by Rutherford Morison, but upon
analyzing the various steps of the procedure, he
came to the conclusion that so small a quantity of
Bipp was used by Morison, that he did not believe
it had much to do with the healing of the wounds.
So, as he expressed it, in a moment of exaltation,
he instituted at one of his hospitals the hipping of
these wounds without the Bipp. In other words,
after excision he sewed them up as any other clean
wound, and eighty per cent, of the wounds healed
by first intention.
So out of chaos has come order, and instead of
relying on antiseptic surgery in these cases, they are
brought back into the realm of aseptic surgery, and
eighty per cent, heal by first intention. Even gas
gangrene has been conquered by these measures.
The mfiexible rule now is, if possible, cut out the
wound in one piece. If this is impossible, every
part of the wound is cut out, so that not a particle of
the old wound surface remains, and as Doctor Crile
said, "It makes one's hair stand on end when first
seeing wliat has to be done." But it is the one es-
sential thing, do the work the maggots did, only do
it quicker and in a thorough manner.
i'he statement was made by all the writers, that
doctors in civil life, have absolutely no conception of
the horrible condition that these wounds get into,
in a few hours. The reason for it lies in the
Flanders mud which is everywhere. The men
sleep in it, work in it, eat in it, they become coated
with it outside, it is an ooze that pervades every-
thing, no one can escape it. It even becomes the
missile that inflicts the wound. W^hen a high ex-
plosive shell explodes, it transmits enormous energ)'
to ever\^thing that it strikes, and often through a
small opening in the skin, a large quantity of this
mud is driven with sufficient force to shatter bones.
It is this mud that carries the deadly contagion of
these horrible infections, and the reason is clear.
For centuries the fields of Flanders have been sub-
jected to hitensive cultivation, and being easy to
get, human excreta has been largely used as fer-
tilizer. This had caused the soil to be impregnated
with all the intestinal flora of the human family, as
proven by the bacteriologists, and these organisms
cause these intense and rapid pathological changes
never seen before in wounds.
It was the consensus of opinion that if the ele-
ments concerned in wound healing could be reduced
to the figure lOO, the pait played by any anti-
septic would be less than ten, tlie remaining ninety
parts would be reorcsented by the physiological re-
sistance of the patient and complete excision or free
mechanical exposure of all parts of the wound and
removal of all dead tissue with free drainage.
In those wounds where excision and closure are
impossible, recourse must be had to some antiseptic.
The ideal anti.septic for war wounds has not yet
4i6
HERTZBERG: CLINICAL CONGRESS WEEK.
[New York
Medical Journal.
been found, even the best one has some disad-
vantage. In our older disinfectants, the speed of
the disinfection depends on the concentration of the
disinfectant. This means, that if a quick and pos-
itive antiseptic action is to be obtained, a degree of
concentration must be employed which always
causes injury or death to the tissues. This fact was
demonstrated early in the war, and in the papers by
Doctor Dakin, Dr. E. K. Dunham and Doctor
Lee, the various steps that were taken to evolve an
antiseptic that would not have this drawback were
clearly portrayed.
The Dakin solution was the first one evolved. It
proved unreliable ; except in expert hands, the solu-
tion is very unstable, and if not absolutely neu-
tra.lized, the free alkali does damage to the tissue.
It is explosive in its action, not continuous as it
should be. It was the best they had for a time, but
nor good enough.
Th(^ so called flavine compounds, also hypochlor-
ite solutions, v/ere tried and found wanting. Then
Doctor Dakin produced chloramine. This proved
more effective, but was unstable, and the permissi-
ble concentration was only five per cent. Then
Doctor Dakin evolved the last, and so far the best
antiseptic, dichlcramine-T. This has only one
drawback — water must not touch it — for upon its
action with water depends its antiseptic action. It
may be used in a concentration of twenty per cent.
Its preparation for use is easily carried out by any
one. It comes in the form of a dry white powder.
The propel amount is rubbed up with enough
chloroform to make a rather thick emulsion. This
is then stirred into a eucalyptized oil. It is now
ready for use. It may be painted on to the wound
with an ordinary brush, or sprayed into every
crevice with an ordinary atomizer. The only cau-
tion necessary, and that must be absolute, is that the
receptacles and the wound must be absolutely dry.
The dichloramine-T, in the presence of water,
gives up its chlorine quickly, and this gives the anti-
septic action. When it is dissolved in oil, this action
goes on slowly, but is continuous until complete
decomposition has taken place ; the secretion in the
wound furnishes the necessary moisture to enable
the slow and continuous elaboration of chlorine
from this compound. Surgeon General Gorgas,
who had requested a report from the British Medi-
cal Board, received the answer by telegram at this
meeting. It stated that in a series of 1,200 cases,
there was an average gain of over four days in
clinical sterilization over all other antiseptics, and
only six deaths from sepsis in this series of cases.
It can be used in all cases requiring an antiseptic,
requires no complicated apparatus, and the solution
in oil is stable if the bottle is kept corked.
The diagram shows the relative speed of disin-
fection by the various chemicals employed.
Sir Berkeley Moynihan stated that is was impos-
sible to convince Tomniy Atkins that the Germans
were not using explosive bullets in their rifles. At
first, even all the medical officers believed thev were
using them, for it appeared, these rifle bullets,
especially at short range, were explosive in their
effect, especially on bones. After a great deal of
grilling of captured officers, and denial by them.
exhaustive experiments with captured German rifles
and ammunition were made. It was found that the
German service rifle shooting the full steel jacketed
Spitzer bullet has a muzzle velocity of 3,000 feet.
This bullet in its flight has three distinct motions,
forward in a straight line, then an axial rotation
imparted by the rifling of the barrel, and a third
motion not heretofore recognized, a circumduction
with the point of the bullet forming the fixed apex.
When fired at short range, upon striking any resist-
ance, the apex or point of the bullet is, for a frac-
tion of a second, arrested, the body of the bullet not
being in a straight line with the point, the bullet
turns over and the tearing effect of the dum-dum is
produced. If the bullet flies a long way, 1,000 yards
or more, the circumduction is lost and the bullet
steadies down and upon striking, does not turn over,
but merely causes a perforation.
The chest will be opened in the future for injury
of the lung and pleura as freely and as safely as the
Phenol
24 hours.
Sterilization.
TIME INDEX, LABORATORY EXPERIMENT.
Doctor Dakin and Doctor Dunham.
abdomen is now being opened. This epoch making
paper on War Surgery of the Lung and Pleura, was
by Sir Berkeley Moynihan. The mortality of chest
wotinds has been reduced to twenty per cent., where
before the new method of handling these cases, the
mortality had been forty-six per cent. Out of a
hundred men receiving chest wounds, twenty-five
die before reaching a clearing station, fifteen die
before reaching a base hospital, and five die before
veaching a general hospital. Shrapnel and shell
wounds are much more fatal than rifle wounds,
because the lung is usually torn at a distance from
the passage of the missile throtigh the chest ; an in-
September 7, igiS.]
LEVBARG: RETROPHARYNGEAL ABSCESS.
417
jury by contrc-coup, so to speak, due to the blow de-
livered on the resisting pleura at the moment of
entrance of the shell fragment. These cases are
nearly all fatal as shock and hemorrhage are ex-
cessive.
It is in the cases of small penetrating wounds of
the lung with retention of missile or missiles within
the lung, that the great progress has been made. It
must be remembered, that in most cases, the injury,
even thougii only a single bullet has passed, is an
injury by multiple missiles, for as pointed out be-
fore, the high power projectile, and especially the
rifle bullet, upon impact, converts everything in its
path into secondary projectiles. So bits of clothing,
paper, buttons, spicula of shattered bone, pieces of
tissue, even coins and pipe stems, in fact anything
that is in the way of the bullet has imparted to it a
terrific motion, and each particle in turn becomes an
added mjury inflicting projectile. The result is, that
a single perforating wound of the pleura and lung
is seldom seen, but the usual injury consists of the
entering wound, and multiple lacerations of the lung
with all kinds and numbers of particles imbedded in
the lung tissue itself. The method of treatment is
as follows : If the patient is quiet, does not cough,
or spit blood, he is left alone. If he is restless, has
short hacking cough, or spits blood, the following
procedure is undertaken :
The patient is etherized in the ordinary way,
having received a hypodermic of morphine sulphate,
one quarter grain, and atropine, i/ioo grain, half
an hour before the operation. An incision along the
fourth rib starting at the sternum is made and car-
ried to the anterior axillary line, the rib is freed
along its entire length, the costal cartilage is cut,
and the rib is fractured in the axillary line and
either bent up or removed. All bleeding is now
stopped. The ribs are retracted as widely as pos-
sible, and the pleura is dissected from the ribs as
far as possible, up and down, inside the chest cavity.
The adhesion between pleura and chest wall bleeds
freely, but it must be separated or it will be impos-
sible to close the pleura. When the bleeding has
ceased, the pleura is opened nearly the entire
length of the incision, the hand is put into the chest
cavity, swept around it, the lung is grasped and all
of it is brought up and spread out on the chest. The
lung is kept warm and moist by towels and saline.
Often adhesions are encountered between the
parietal and visceral layers of pleura. These are
easily separated. Then the search for the foreign
bodies in the lung tissue is made. Even the smallest
spicula of bone or foreign matter is easily detected
with the fingers, by pressure on the lung as it lies
on the chest wall. It gives one very much the same
sensation, as do the calcareous particles in a new
sponge when being squeezed. As each foreign
particle is detected, the lung tissue is made tense
over it, a small incision is made, and the particle
removed. The wound is then sewed up, just as you
would sew up liver, kidney, or any other tissue.
When every particle has been removed, the tear
made by the bullet is examined, dead tissue removed
freely, and the tear is repaired by suture. The
whole lung is then dried, sponged rapidly with ether,
and dropped back into the chest cavity. The pleura
IS sewed up, and the chest wound closed, without
drainage. The ether with which the lung is
sponged, vaporizes within the chest and prevents
TOO rapid an expansion of the lung and consequent
hernoirhage. If the lung does not expand in forty-
eight hours, an aspirating needle is introduced and
the ether vapor is aspirated. This is the operation
tiiat has reduced tlie mortality of gunshot wounds
of the chest from forty-six per cent, to twenty per
cent.
This paper proves that no matter what emer-
gency confronts the doctors in France there will
always be some one who will rise to meet the emer-
gency and conquer it. And as these men conquered
the Flanders' mud in their wounds, so Sir Berkeley
Moynihan has conquered that heretofore terra in-
cognita— the injured lung.
40 South Stkeet.
RETROPHARYNGEAL ABSCESS.
With a Report of Three Cases.
By John J. Levbarg, M. D.,
New York,
Assistant Laryngologist, Polyclinic Hospital; Adjunct Visiting
Otologist and Laryngologist to the Beth David Hospital.
In this condition a collection of pus is situated
either well up in the nasopharynx and behind the
soft palate, or very low down, and if not discovered
this pus may borrow further down and involve the
cervical structures. This condition is most frequent
in infants in the winter, as diseases of the nose and
throat are then most common and it occurs
mostly in the simple form, i. e., the lymphatics are
involved. In adults usually the cellular tissues are
at fault. The simple form is a suppurative in-
flammation of the lymphatic glands lying in front
of the cervical vertebrae and it usually occurs in
infants of tuberculous or syphilitic parents. It
may follow an attack of influenza, measles, or
scarlatina.
In children our attention may not be called until
pus is well formed and there are symptoms of
severe dyspnea, regurgitation of food, and choking;
in others the symptoms may begin insidiously, the
condition looking more like a chronic abscess. The
diagnosis is usually made on inspection by the
bulging or the asymmetry of the pharyngeal wall,
or by fluctuation on palpation. If left alone an
acute process will run a few days and discharge
spontaneously. This is dangerous as some of the
pus may get into the lungs and cause a pneumonia.
Case I. — Baby, A, L., Italian, four months old (breast
baby). Mother stated that the baby had been crying for
the i)ast eight days, that the cry was harsh in tone and the
resonance nasal in character, and that the child could not
nurse properly. A physician was called in and upon ex-
amination diagnosed it as teething, with slight bronchitis,
but still the baby failed to improve. The child's parents
consulted three other physicians, who made the same diag-
nosis The mother, seeing no improvement, brought the
child over to the children's department of the Beth David
Hospital, and Dr. F. Shapiro referred her to me for ex-
amination of the child's ears. Examination of the ears was
negative, but on inspection of the throat I found a bright
red asymmetry of the pharyngeal structures and upon pal-
pation felt distinct fluctuation. I advised operation, and
I'OHLY: NASOPHARYNGEAL POLYPI. INew Vork
Medical Journal.
418
upon a free incision obtained a profuse, greenish, fetid
pus. The next day I found child greatly improved and
mother informed me that child slept quietly and nursed
more freely. Child fully recovered.
Case II. — Girl, F. C, two years old, examined by me at
her home. Upon examination found baby croupy. and it
seemed to me that it was a simple case of diphtheritic
croup. I injected 10,000 units of antitoxin. Next day
showed no improvement. Advised hospital, and child was
admitted to the New York Throat Hospital, and I asked
the doctor in charge to watch for retropharangeal abscess.
The next day I was advised by the doctor that child had
developed an abscess and would be operated that day.
After incision, child showed very little improvement; the
condition was becoming worse instead of better. It was
then advised that the child should be intubated, and with
the permission of the New York Throat Hospital I took
the child immediately to the Willard Parker. Instead of
intubating, Dodor Dixon found an abscess deep and low
down, and with a good incision evacuated pus. Child
recovered.
Case III. — Girl, three years old, Italian. Upon inspection
a bulging tumor was found on the pharyngeal wall. This
had been increasing in size slowly for the past six months.
Child had a slight temperature at night, perspired a good
deal, and was verj- anemic in appearance. A sister, nine-
teen years old, died of tuberculosis. Father and mother
were alive and healthy. Examination of blood was nega-
tive. Case was referred for tubercular abscess to Hospital
for the Crippled and Ruptured.
1425 Madison Avenue.
NASOPHARYNGEAL POLYPI.
By Albert E. Pohly, M. D.,
New York.
While nasal polypi are of comparatively common
occurrence, nasopharyngeal polypi are rare. They
originate most often in the maxillary sinus but may
occasionally originate in the sphenoidal sinus or pos-
terior ethmoidal cell. The polypus is pear shaped
and histologically does not diflfer from the ordinary
nasal polypus. Authorities differ on the tendency
of the polypi to recur after removal and in case of
recurrence the maxillary sinus should be opened.
1 have had the good fortune to see two cases of
nasopharyngeal |X)lypi. Both cases occurred in
young girls.
Case I. — M. S., twelve years old, born in New York,
came with a school nurse to St. Mark's Hospital Dis-
pensary some seven years ago, complaining of difficulty in
breathing, especially at night when lying down; the nurse
told me that the patient was stupid and absent minded in
school. On examination I found a large nasopharyngeal
polypus extending just beyond the soft palate and uvula.
I took her into the hospital and under general anesthesia
removed the polypus with a Jarvis snare through the nose.
A few months later I saw the nurse again and she told
me that M. was now the brightest girl in her class.
Case II. — C. M., a young girl of eighteen, born in Hun-
gary, was referred to me by Dr. A. Gumbar in April,
IQ18. About a year ago she noticed an irritation in her
throat causing her to cough. She also had great difficulty
in breathing, especially at night ; and suffered from head-
aches and pain in the back. On examination I found a
very large nasopharyngeal polypus hanging down behind
the soft palate touching the tongue. I took her into the
St. Mark's Hospital and under a general anesthetic tried
to remove the growth, but did not succeed, as the polypus
disappeared behind the soft palate while she was lying
down. The next morning she came to my office and under
criraine I removed the growth through the left nostril with
a Jarvis snare. The polypus was 3J/2 inches long and
inch wide. All her symptoms disappeared after its removal.
640 Madison Avenue.
The Protein Nature of Antitoxins. — \V. N.
Berg, biochemist, and R. A. Kelser, veterinary in-
spector, of the United States Department of Agri-
culture, have just completed a series of experiments
with tetanus antitoxin whose ultimate object was to
determined the chemical nature of antitoxins in gen-
eral, and the possibility of their preparation in the
pure state.
No antioxins have as yet been separated from
their associated proteins. The well known tetanus
and diohtheria antitoxins contain nearly all the im-
munity units present in the original serums, but only
a I art of the proteins. The failure of all attempts
to obtain a protein free antitoxin has led some to
the conclusion that the antibody or group of anti-
bodies which constitutes the antitoxin is one of the
serum proteins, and hence cannot be completely sep-
arated from protein. On the other hand, the con-
centration of antitoxin that can be obtained by
concentrating the antitoxic serum without a corre-
sponding concentration of protein is regarded as
an indication that the antitoxin may be a body of
nonprotein nature.
If tetanus antitoxin is of nonprotein nature the
experimenters thought that it should be possible to
prepare artificial digestion mixtures containing the
antitoxic serum or derived globulin in such a manner
that the protein would undergo digestion without
loss of antitoxin. If, on the other hand, the anti-
toxm is a protein, and its power to neutralize the
corresponding toxin is a function of the intact pro-
tein molecule, then the antitoxin would be destroyed
in every case where the proteins had undergone
cleavage, whether the cleavage was caused by pro-
teolytic enzyme or other chemical agent. The toxin
might possibly be destroyed by the chemical agents
used. Proteolysis was determined by chemical
measurements, and inoculation experiments on
guinea pigs indicated any loss of antitoxic units.
The results indicate that tetanus antitoxin is a
sul)stance of nonprotein nature. But the stability
oF the antitoxin is so dependent upon that of the
I^rolein to which it is attached, that whenever the
protein molecule is split, the antitoxin splits with it.
The results are summarized below :
1. Tetanus antitoxin in 0.5 per cent, sodium car-
bonate solution was slowly and completely destroyed.
At the same time no significant chemical changes in
the proteins were detected.
2. In solutions amphoteric or faintly acid to
litmus paper, trvpsin destroys the antitoxin and at
the same time the associated proteins are digested.
The rates of antitoxin destrttction and protein split-
ting were substantially the same.
3. The results were the same with solutions con-
taining trypsin and 0.5 per cent, sodium carbonate
solution.
4. Tetanus antitoxin in 0.2 per cent, hydrochloric
acid was completely destroyed in three or more days.
During this time no significant chemical changes in
the proteins were detected.
5. In neutral solutions pepsin did not affect the
anlitoxin.
6. In pepsin-hydrochloric acid, proteolysis and
antitoxin destruction proceed simultaneously.
Medicine and Surgery in the Army and Navy
mobilizinCt the spas and health
resorts of our nation*
By N. Philip Norman, M. D.,
Fort Leavenworth, Kan..
Captaiii, Medical Reserve Corns, U. S. Army; Examiner in Neuro-
psychiatry, U. S. Disciplinary Barracks, Fort Leavenworth.
This country faces a medical problem, in com-
plexity, magnitude and seriousness, never before
encountered in its history. That problem is the
efficient disposition of its soldiers who have become
incapacitated because of surgical, medical, neurologi-
cal and mental diseases engendered by and incident
to the extraordinary stress and strife of this war.
To solve this problem, the following plan has been
outlined in the July, 1917, issue of Mental Hygiene,
by Major Pearce Bailey, M. R. C, U. S. Army,
chairman of the War Work Committee for Mental
Hygiene. It is proposed to keep only soldiers suf-
fering from ailments that will soon react to treat-
ment and who can be returned to their organizations
in a short time, in the overseas hospitals. It is ob-
vious that it would be impracticable to maintain
large base hospitals and special hospitals overseas
because of the difficulty of transporting adequate
facilities for their construction and maintenance,
and of supplying the extensive medical and nursing
care necessary. Therefore, it is planned to trans-
port home the majority of the afflicted. These cases
will be received in a special depot at the port of de-
barkation and there will be diagnostically classified
by an examining board composed of specialists.
.After definitely establishing a diagnosis, this board
will refer cases to the distributing board which will
either discharge those adjudged physically or men-
tally unfit for further service or refer suitable cases
to general hospitals, special hospitals, convalescent
camps, and reeducation centres for treatment. After
the necessary treatment and observation, they will
finally be surveyed by the board of review, which
will effect the ultimate disposition of all cases.
We are realizing that our successful evolution in
this conflict depends upon the proper understanding
and application of "efficiency." The present day
conception of efficiency constitutes the excellence of
disposition of problems and the conservation of
assets, potential or kinetic, for the further dynamic
evolution of the individual, the institution, the state
and the nation. This being true in the efficient dis-
posal of the incapacitated we solve a portion of the
problem of requisite hospital facilities in a most ex-
cellent way by utilizing our well organized and
equipped spas and health resorts, so best converting
our potential assets into kinetic assets for the good
of the individual, the institution, the state, and the
nation.
For the efficient treatment of the incapacitated
our specialization must have no confines. Orthodox
treatment must not satisfy our therapeutic needs. At
best, orthodox medicine is inadequate to cope with
diseases promulgated by the stress, strife and dra-
* Puhlished by permifsion of the Surgeon General's Office, Wash-
ington.
niatic incidents of the war, so intense that they are
beyond all possible conception of nonparticipants. It
is necessary that we reach beyond the limits of the
commonplace and orthodox, and after having
reached, that we intensify and amplify the special
forms of treatment that heretofore have been avail-
able only to the wealthy because of their expense,
and intimately known only to those members of the
profession who, by reason of their scientific attain-
ments, treat that fortunate class of patients demand-
ing supertherapeutic resourcefulness for the relief
and cure of their varied ailments.
This article suggests that the nation mobilize these
institutions and utilize them for the good of the in-
capacitated. It is obvious that great sums of money
would be saved if these institutions were drafted
into the service of constructive restoration of the
incapacitated. To build special hospitals that would
be as comfortable, well equipped and organized as
the existmg institutions would require time, expense
and unnecessary effort. The sites of predilection
for such institutions are occupied by institutions
hereinafter named. Why, then, build and organize
new institutions that will be practically worthless to
the nation after the war?
That these spas and health resorts are efficiently
organized and managed is attested to by the fact
that they have flourished in past years in active
competition with European spas. That their thera-
peutic principles are based on sound physiological
fundamentals is admitted by anyone whose know-
ledge justifies an opinion on the subject ; that their
therapeutic efficacy is established is attested by their
reputation which is in direct proportion to results
eft'ected. In selecting hospital bases from the num-
ber of available spas and health resorts, several fac-
tors must be taken into consideration. The chief
ones are briefly: i, equipment for sj^ecial work;
2, natural resources, commendable for special work ;
3, capacity ; 4, kind of special work or class of pa-
tients best treated at each place ; 5, proximity to the
port of debarkation ; 6, accessibility to the port of
debarkation ; 7, elevation ; 8, climatic conditions.
In this article, we classify as spas institutions
having a natural mineral water for bathing pur-
poses ; as health resorts, those places having drink-
ing waters, desirable geographical location and suit-
able equipment, using artificial or plain water for
bathing purposes. Therefore, the following institu-
tions are designated as spas: i, The Glen Springs,
Watkins, N. Y. ; 2, The Saratoga Springs, Saratoga,
N. Y. ; 3, White Sulphur Springs, White Sulphur
Springs, W. Va. ; 4, The Hot Springs, Hot Springs,
Va. ; 5, The Hot Springs, Hot Springs, Ark. ; 6,
Mount Clemens, Mich. ; 7, French Lick Springs,
French Lick, Ind.
And the following are designated as health re-
sorts: I, Jackson Health Resort, Danville, N. Y. ; 2,
Clifton Springs, N. Y.; 3, The Hotel Chamberlain,
Old Point Comfort, Va. ; 4, Asheville. N. C. ; 5,
Aiken, S. C.
To avoid useless repetition, discussion of feature
treatments will be given and other treatments noted
420
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
SO as to g^ive an idea of equipment and facilities for
treating other conditions that may complicate the
primary condition treated by feature treatments.
For example, under the heading of The Glen
Springs, the Nauheim technic and indications for
carbonated brine bath therapy are discussed. Sara-
toga .Springs, because it has a like therapeutic use-
fulness and because of its richly carbonated waters,
merits the remaining discussion of the Nauheim
method — the physiological action. These two places
feature the same treatment and the discussion is
divided so that it may not appear that favoritism is
shown. The mineral water of the Glen Springs con-
tains the chief chemical constituents and a strong
radioactivity with a weak saturation of carbon di-
oxide gas ; the waters of Saratoga are strongly sat-
urated with carbon dioxide gas and are radio-
active but are weak in the essential chemical con-
stituents. Discussion of physiological action may be
said to be too lengthy ; but the readers' pardon is
begged, the author attempting to clarify the con-
ceptions of some few to the extent that the idea of
mystery or empiricism, usually linked with hydro-
therapy, mav be obviated by explaining the physi-
ology of the bath in question.
Criticism has been avoided as far as possible and
the little that had of necessity to be mentioned, is
more explanatory than critical.
THE GLEN SPRINGS, WATKINS, N. Y.
The Glen Springs is situated at Watkins, N. Y.,
at the head of Seneca Lake. It is located in a park
that consists of more than lOO acres of woodland
and lawn. There are miles of shady and well built
walks throughout this park. The paths are meas-
ured, graded and furnished with frequent signs
showing the distance and elevation from the hotel.
They are utilized in the Oertel hill climbing exer-
cises.
An attractive nine-hole golf course is within a
short distance of the main building. South of this
park is found a famous gorge known as Watkins
Glen. Because of its natural beauties and its unique
geological formations, architecturally expressed in
its crude arches, galleries, pools, grottos, amphi-
theatres and waterfalls, this marvelous gorge ranks
in importance with the natural wonders of the
world. This glen is owned by the State of New
York and is accessible at all times during the year.
Seneca Lake, known as "the gem of the finger
lakes," is thirty-six miles long and from two to
five miles wide. It maintains, at a depth of 200
feet, a uniform temperature of seven degrees
above freezing throughout the year. Because of
this relatively low temperature, evaporation is
slight and the air unusually free from humidity. The
records of the Weather Bureau, extending over
twenty years, give the mean temperature for mid-
winter as 23° P'.. and for midsummer as 69.8° F.
For similar seasons, the mean total precipitation
was, respectively, 2.5 and 3.95 inches. Elevation,
750 feet.
The first floor of the main building is devoted to
public rooms — a spacious lounge room, music room,
lobby, dancing parlor, library, and other attractions.
The roof garden covers the north wing of the main
building. It is a quiet place and affords most rest-
ful eiivironment with superb views in all directions.
All floors are connected l^y elevators.
J"or the maintenance of this establishment, a
complete power ])lant with accessories is operated.
Natural gas is the fuel used for the power plant
and cooking. A dairy farm adjoins the park and
is under the direct supervision of the Springs com-
pany.
'ilie mineral water that has served to establish
the fame and reputation of this spa, and deservedly
earned for it the name of "The American Nau-
heim,"' is a brine soring originating about 1,600
feet below the surface. It is a radioactive, ferru-
ginous, iodo-bromo. muriated brine, similar in anal-
ysis to the water of Bad Nauheim, but about five
times as strong. It is free from calcium sulphate.
The important ingredients of this brine are the
chlorides of calcium and sodium, the combinations
of these two salts being essential to the Nauheim
bath. Other ingredients are the chlorides of mag-
nesium, potassium, and ammonium ; iron bicarbon-
ate, sodivmi bromide, sodium iodide, and some car-
bonic acid gas, both free and half bound. The
total mineral content of this brine is about 10,525
grains to the gallon.
The radium emanation was determined by Pro-
fessor John S. Shearer, Department of Physics,
Cornell University. He reported that its radio-
activity was high and constant, 68.6 mache units.
This water has the property of recharging itself
after its emanation has been exhausted by physical
means. This property is due toi the radium salts
in solution.
The Nauheim treatment method at The Glen
Springs will be elaborated upon so as to emphasize
that, in the treatment of the cardiorenal and cir-
culatory diseases and disfunctions, the method em-
braces more than hydrotherapeutic measures.
Therefore, in speaking of the treatment, the fol-
lowing measures are inclusive in varying com-
binations, to fit individual requirements : mechano-
therapy, Oertel hill climbing exercises, Schott re-
sistance exercises, graduated calisthenics, electro-
therapy, eliminative baths, the various rubs and
massage. It is recognized by the more progressive
members of the profession that there is no form of
treatment in the range of medicine which, when
applied to chronic cardiac and circulatory dysfunc-
tion, can show a larger percentage of improved,
and sometimes cured, patients than this method.
It is necessary to preface the brief remarks on
indications, physiological efifect and technic by em-
phasizing the fact that the success of this mode of
treatment depends upon the exact determination of
the feasibility or unfeasibility of its application in
a given case, and upon a physiological conception
of the dynamic forces at work during a bath.
Irreparable harm may be inflicted upon a patient
if tb.is treatment be entrusted to the unskilled, who
think that it is just the question of a bath, which
symbolizes to their perception nothing more or
less than a ritual of immersion reputed to benefit
the immersed.
The determination of the fitness of a given case
for treatment by this method entails a careful
study of the history, physical condition, blood pres-
September 7, 1018 ]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
421
sure, urine, blood, polygraphic tracings in some
cases and functional tests to determine the amount
of reserve possessed by the myocardium. It is not
in the province of this article to discuss in detail
the indications and contraindications of this treat-
ment, or to describe in minutiae how indicatory or
contradictory conclusions are evolved. For the
benefit of those interested, reference is made to an
article by the author in the March 23 and 30,
1918, issues of the Nev^^ York Medical Journal,
where this method is described in detail.
Briefly, the conditions for which the Nauheim
treatment is adapted, are as follows:
I. Myocardial weakness and circulatory dis-
orders incident to chronic valvular heart disease
in which a failure of compensation is threatened ;
selected cases of cardiac dilatation and hyper-
trophy from various causes ; the pseudoanginas,
whether of psychoneurotic or endocrine origin;
cases of true angina in which there is not excessive
myocardial and vascular degeneration ; the so
called toxic hearts ; conditions underlying disorders
of the heart beat manifested by rapid and irregular
heart beats, sinus irregularities, paroxysmal tachy-
cardias, premature contractions, auricular fibrilla-
tion; derangement of arterial tension; arterio-
sclerosis and other degenerations incident to age,
strain and stress. 2. Secondary cardiac involve-
ment: following acute infections such as typhoid
fever, influenza, scarlet fever, tonsillitis, rheumatic
fever, and pneumonia ; following severe hemor-
rhages or surgical operations ; accompanying consti-
tutional diseases, as the so called chronic rheuma-
tisms, the anemias and the diseases of the endocrine
system. 3, Functional nervous diseases with so-
matic expression of cardiac and circulatory dysfunc-
tion, usually secondary to an endocrine disturbance ;
the vagotonias and sympatheticotonias.
The general effect of this form of treatment upon
suitable cases may be summed up as follows : a
diminution in the size of the heart ; a permanent
strengthening of the heart muscle (the baths being
essentially a circulatory gymnastic) : sometimes the
disappearance of a murmur ; slowing of the pulse,
increasing systolic phase ; equilibration of blood
supply, thereby regulating blood pressure and in-
creasing the nourishment and functional activity of
the various organs, depleting the congestion of in-
ternal organs and decreasing the relative ischemic
condition of the skin, due to spasticity of the super-
ficial blood vessels ; a diuretic action and a sedative
effect upon the nervous system.
The technic constitutes at times a preliminary
course of treatment so as to prepare a case under
observation for the baths. The baths are given in
tubs and range in duration from four to twenty
minutes and in temperature from 99°F. to 78°F.
There are five series of baths. The first, or pre-
liminary, series is a noncarbonated brine bath about
eight minutes in duration and at about 98° F. to
99 °F. The other four series are carbonated, the
degree of carbonation increasing with the number
of baths given, excepting in some cases of pro-
nounced arteriosclerosis in which a palliative effect
is the objective. The temperature decreases as the
carbonation and brine strength increase. After the
bath the patient is required to rest for one hour in
a quiet room and is instructed to sleep, if possible.
It is the custom to give these baths in the morning.
The afternoons are devoted to accessory measures
such as electrotherapy, massage, the various rubs
and exercises and eliminative treatments.
In the severer cases, it is advisable that after-
tre:itment be taken following the Nauheim treat-
ment for the purpose of building up the general
strength so as to fit the patient for the resumption
of his duties and occupation. This consists mainly
of a carefully regulated diet, graduated exercise,
eliminative hydrotherapy and mental hygiene.
To my mind, there is no place in this country that
rivals the efficacy of The Glen Springs in the
treatment of selected cases of circulatory and car-
diac disorders. Its method of treatment has been
evolved from years of observation and experience.
As long as this institution has been established, it
always has featured this treatment for the above
named disorders. There is but one other place in
this country possessing natural advantages for the
treatment of heart and circulatory . diseases, that
being Saratoga Springs at Saratoga, N. Y. This is
now under the supervision of the State of New
Yo'-k and, though still primitive, bids fair to come
to the front in the next few years.
In addition to the Nauheim treatment, many
other condirions are treated at The Glen Springs.
The Nauheim brine is utilized without carbonation
in varving temperatures and strengths for the pur-
poses of ehmination, sedation and tonic effect. It
has been found to be particularly beneficial in the
treatment of the neuroses and disorders of meta-
bolism and in restoring health and vigor to the
overv/orked and overworried. This institution is
well fitted with appliances for giving the various
showers, douches, packs, cabinet baths, electrical
baths, continuous flow, Vichy and Aix baths. No
comment will be made upon these as I wish to em-
phasize only the method for which this spa is par-
ticularly commendable.
There are four drinking springs. Three are min-
eral and possess tonic, alterative, radioactive and
diuretic properties. Another is a pure deep-spring
water with a capacity of more than 100,000 gallons
a day.
There is no spa in this country endowed with
natural advantages that qualify and commend it for
special work more than The Glen Springs. It is
accessible from practically any port on the Atlantic
seaboard. Its capacity, roughly estimated, is for
about 300, but possibilities for increased capacity
are many. Cardiopaths will be £tft"orded the best
of opportunities for the improvement and cure of
their complaints at this spa.
SARATOGA SPRINGS.
Saratoga Springs is located at Saratoga, N. Y.,
and occupies a central position in the state. It is
hardlv necessary to expatiate upon the scenic
beauty of the place and its environs, for most have
heard of this place, famed for so long as a health
resort in early days, then as a sporting centre, and
latterly agoin as one of the country's most valuable
spas. The important features that commend Sara-
toga as a spa are the number of mineral springs to
MEDICINE AND SURGERY IN THE ARMY AND NAVY
[New York
Medical Journal.
he found in a comparatively small area. Unfor-
tunately, for many years the springs have been
subjected to the most destructive type of commer-
cialism, which retarded their development and
growth. Fortunately, the legislature of the State of
New York in 1909 realized that this natural asset
should be conserved and, as a result, the state res-
ervation was created. Provisions were formulated
for the control and protection of all natural assets.
In 1916 a further step was taken when the reserva-
tion v,'as transferred to the jurisdiction of the con-
servation committee. The reservation comprises
approximately 450 acres of land including 122
■springs and wells. Since the conservation plan has
been in cfTect, many of the most valuable springs,
depleted by excessive pumping, have been, so to
speak, rejuvenated. Their capacity has been re-
stored to an apparently inexhaustible quantity, and
without deterioration of quality.
No attempt will be made to describe each spring
as to its chemical composition and therapeutic ac-
tion, as it is obvious that space is not adequate in
this article and time, too limited. Remarks will be
confined to essentials and to representative springs
of the most important spring groups. The waters
are classified as being either saline or mildly, med-
ium and strongly saline-alkaline, with a moderate
amount of iron. They are all naturally carbonated ;
the degree of carbonation, however, varies over a
great range. The constituent properties that com-
mend these waters are : carbonic acid gas ; the in-
organic salts, chiefly sodium chloride, the alkali
bicarbonates, the chlorides of lithium and potassium,
moderate quantities of iron and traces of sodium
sulphate and nitrate ; and radioactivity.
In studying the analysis of the various springs,
it is noteworthy that the same constituents are pre-
sent in each one, but in proportions varying the
combination so that no two springs may be said to
be the same. The carbonic acid gas renders the
water palatable and facilitates the copious intake
vvithout effort.
Hathorn No. 1 has long been famed as the cele-
brated Hathorn laxative. In addition to its laxa-
tive properties, it is claimed that it is the strongest
diuretic of all the Saratoga waters. Hathorn No.
2 possesses similar qualities to No. i, with the ex-
ception that the medicinal properties are not as
strong. Coesa is laxative, antacid and diuretic.
Congress No. 2 is mildly laxative, chalybeate and
alterative. Geyser is chiefly antacid and diuretic.
Polaris, Karista. Emperor, and Lincoln are chiefly
Mitacid and diuretic and promote digestive secre-
tion. At Saratoga drinking of the waters consti-
tutes a part of the cure and is of almost as much
importance as the bathing, yet in relative value is
not to be compared with the hydrotherapeutic and
accessory measures. Ry bathing in and drinking
the waters, prescribed to suit the individual need,
the following conditions are benefited : disorders of
tlic digestive tract, the subacute and chronic rheu-
mati.sms, arthritis, the neuritides, anemias, ex-
haustions following infections and operations, al-
coholism, selected cases of arteriosclerosis, cardiac
nnd circulatory disorders. Unfortunately the
Saratoga Springs lack the most essential chemical
constituent of the so called Nauheim bath — calcium
chloride. If it possessed this constituent, it would
be a par rival of Bad Nauheim.
Carbonic acid gas, being the most important prop-
erty of Saratoga's waters, deserves a brief mention
of the part it plays in the physiological action of a
Nauheim bath, as well as an explanation of how
this action is effected. Critics have been given to
making humorous remarks and deprecatory asser-
tions and assuming scornful attitudes toward the
stated effects of carbonated baths. However, it
must be said that their attitude differs but little from
that of most critics who usually know but Httle of
the subject or object criticized. He revels in destruc-
tive and cynical ridicule ; yet it is significant that he
oft'ers no suggestion for construction and his own
eft'orts are not creative.
First, one must understand what is meant by the
term "point of thermic indifference or comfort."
This expression is a means to define a degree of
temperature of a given medium to which the nude
human body, at rest, may be exposed without re-
acting to thermic stimuli of either heat or cold. It
's that temperature at which heat production and
heat loss equilibrate. In air, this point of thermic
comfort is approximately 85°F. In water, it aver-
ages about 93° F. In carbonic acid gas it is 75 °F.
Tlierefore, in giving a water bath below 93 °F. the
thermic stimulation of cold is felt and it is obvious
that in cardiorenal dysfunctions, vasomotor dis-
turbances, arterial hypertension or any condition in
which there is a predisposition to congestion or an
associated congestion of internal organs, harm
would be inflicted because of the mcrease of the m-
ternal organ congestion and the lack of peripheral
reaction because of the chilling of the periphery.
However, it is possible to give baths under these
conditions with the aid of carbonic acid gas satura-
tion of the water. This is possible because the car-
bon dioxide, in minute bubbles, clings to the skin
and may be said to form an envelope about the
body. Therefore, coexisting side by side, one finds
small areas of skin covered by water and like areas
protected by the carbon dioxide bubbles. The point
of thermic indifference of carbon dioxide being
about 75 °F. and the bath temperature, say 85 °F.,
thermic stimulation of heat will be imparted by the
carbon dioxide gas because the water in which it
is saturated is of a temperature ten degrees above
the gas's point of thermic comfort. The water, be-
ing eight degrees below its point of thermic com-
fort will impart a thermic stimulation of cold.
However, this thermic effect of cold is neutralized
by the coexisting thermic effect of heat produced by
the minute and numerous gas bubbles clinging to
the skin and the end result may be summed in the
expression that the patient had a cold bath that
was warm.
Therefore, the physiological action of the bath
is, first, on entering the bath tub. say at 85°F., a
sense of chilliness with a contraction of superficial
capillaries and arterioles ; then, a sense of warmth
as soon as the body is enveloped and the reaction of
the skin which is intensified by the chlorides of
sodium and calcium, causing the superficial capillar-
ies and arterioles to dilate. The skin absorbs mi-
September lOif-]
MEDICINE AND SURGERY IN THE .IRMV AND NAVY.
423
nute amounts of the salts and gases, and this pro-
duces a general rubefacient action on the skin
whicli continues for a time after the bath. The
effect upon the heart is first to whip it up, because
of the thermic stimulation of cold on the sensory
nerves, causing the primary contraction of super-
ficial blood vessels thereby increasing the peripheral
resistance and resulting in a rise of blood pressure;
ami as a secondary elYect, after the reaction, to
lessen arterial tension, and decrease peripheral re-
sistance, thereby lessening the cardiac efforts and
equalizing the circulation, with a decrease of in-
ternal congestion. The effect upon blood pressure,
however, may be varied in accordance with tem-
peiatures, the colder the bath and the milder the
degree of carbonation, the greater the cardiac stim-
ulation, and the arterial tension, of course, is rela-
tive.
It seems apropos at this time to mention the part
that sodiuin and calcium chloride play in the physiol-
ogy of a Nauheim bath. That the success of Nau-
heim therapy is due to these two salts and carbonic
ncid gas saturation is admitted by any one whose
observations have been intelligent enough to justify
an opinion on the subject. The salts aid very much
in keeping a bath at a uniform temperature. They,
especially calcium chloride, produce a decided rube-
facient action on the skin with dilatation of the
superficial capillaries and arterioles. They pene-
trate the superficial layers of the epidermis and
continue the rubefacient effect for some time after
the bath. That the natural mineral water, with the
proper constituents in solution, is superior to the
artificial bath is explainable when one devotes
time to acf|uaint one's self with the physiological
action of radium emanation on the human organ-
ism. The Nauheim method of Glen Springs is
followed in a general way at Saratoga, including
the accessory measures, excepting details as per-
taining to the method developed at this spa to meet
existing conditions. Therefore, remarks concern-
ing technic, etc., will be limited to the other dis-
orders benefited at this spa.
Three bath houses are maintained by the State
and are well equipped with adequate appliances for
the various baths and accessory measures. Here is
to be found a feature treatment in the way of car-
bon dioxide baths, especially used for the treatment
of rheumatism and allied conditions. The func-
tional nervous disorders derive much relief and
much benefit from the carbonic acid gas baths. The
patients live in hotels nearby and report to the
bath houses at appointed times for treatment. Of
course, this is disadvantageous, especially during the
winter season and in inclement weather. Another dis-
advantage is that patients are not under the im-
mediate care of their physicians at all times and
facilities for close observation and supervision are
'■endered difficult unless the physicians have their
offices in the bath houses.
In the institutional plan, patients are colonized
and this facilitates the observation of bath reac-
tions. There, from observations of reactions to a
treatment, the next bath prescription is determined
as to strength, duration, temperature and in-
terval. Dietary supervision is obviously impossible
under this plan and too many of us know the mania
of patients for breaking diet rules and limitations.
However, under military control a great many of
these disadvantages could be obviated, and we must
not discount the value of Saratoga, one of the
national assets, because of these disadvantages.
This state reservation, with its many springs of
therapeutic value in the treatment of conditions that
arc most unsatisfactorily treated by orthodox meas-
ures, deserves earnest consideration as a potential
national asset. With its ample hotel facilities that
could be remodelled to suit requirements and its
accessibility to the most important ports of the At-
lantic seaboard, thousands could be well housed and
treated at this spa. The approximate capacity at
the present time is 5,000. The bath houses will
accommodate an average of 100 to 150 patients an
hour. The average elevation is 325 feet, and the
annual mean temperature is 48° F.
(To be continued.)
MEDICAL NOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
BACTERIOLOGY OF GAS GANGRENE.
Not long since, the Italian physician G. de An-
gelis carried out some very instructive researches
on the microbic flora of gas gangrene. These re-
searches included ten cases of this infectious pro-
cess, seven of them being considered genuine ex-
amples of the disease ; the remaining three were
looked upon as false gas gangrene. The latter
offered a particular type of suppurative process
with the development of gas. The results of these
researches may be summed up briefly as follows:
Besides gas gangrene in the true sense of the
word, there are other forms characterized by the
presence of suppurating or necrosing foci, of local-
ized extent, and having a relatively mild evolution
without tendency to diffusion. The bacterial flora
present in these localized forms of the process is
absolutely different from that of true gas gan-
grene. It comprises almost exclusively the ordinary
pyogenic organisms, such as the staphylococcus,
streptococcus, colon and typhoid bacilli, to which
are added some aerobic or anaerobic gasogenous
saprophytes. Consequently, in contradistinction
to what occurs in ordinary true gas gangrene, the
development of gas is only a phenomenon of sec-
ondary importance.
The bacterial flora of true gas gangrene is most
varied and there is no specific type of organism
for this process. Usually, anaerobic bacteria,
combined with the ordinary aerobic germs, are
found, but exceptionally one may find only aerobic
organisms, of which some are gasogenous. In true
gas gangrene, the organism most commonly en-
countered is the perfringens, in sixty-six per cent,
of cases, after which comes the septic vibrio,
thirty-three per cent. The perfringens may be
the only anaerobic organism present, but it may
be associated with other nonpathogenic anaerobic
germs, such as the putrificus coli or the bacillus
424
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
Clostridium foetidum. In the more serious cases,
which were usually fatal, the perfringeiis alone
was present. On the other hand in a case where
the patient recovered, the perfringens was associ-
ated with other nonjjathogenic anaerobic bacteria.
The above remarks do not apply to the septic '
vibrio, for which the gravity of the infection ap-
pears to depend entirely on the degree of virulence
of the germ itself. From this it would appear
that the special pathogenic power of the perfrin-
gens is to cause gas gangrene, and therefore its
importance is greater in this respect than that of
other bacteria.
A bacteriological examination must be made in
every case of gangrene because a prognosis can
then be reached and the proper treatment applied.
If the perfringens alone is present, the prognosis
is very serious and immediate energetic therapeu-
tic measures must be used. If, on the other hand,
the perfringens is associated with other anaerobic
germs of a nonpathogenic type, the prognosis is
better, while the treatment may be less radical.
The same indications cannot be derived from bac-
teriological examination when the septic vibrio
alone is present, because in this case the gravity of
the infection depends entirely upon the degree of
virulence possessed by the vibrio.
INTOLERANCE TO ANTITETANIC SERUM.
I will now refer to the important work done by
Tizzoni on anaphylaxis and intolerance for anti-
tetanic serum, a subject which has not been studied
sufhciently. The initial injection of antitetanic
serum, be it a prophylactic or curative dose, can
always be given with impunity, but if, on account
of the gravity of the wound, prophylactic injections
must be repeated, it is better to give the second
injection as soon after the initial one as possible and
at all events before the lapse of ten days.
When a prophylactic injection is given more than
ten days after the preceding injection, the disturb-
ances which may accrue are never of very serious
moment. They usually consist in local anaphylactic
phenomena, the so called minor anaphylaxis.
Therefore, no hesitation is permissible as far as
giving a second prophylactic injection is concerned.
Before removing foreign bodies which have been
embedded for a considerable length of time in soft
structures, a prophylactic injection should be given,
whether or not the patient has received an initial
injection at the time of the injury and regardless of
the lapse of time since it was given. The injection
given before a surgical interference prevents the
lighting up of a latent tetanic infection, because the
toxin may very well have remained inoffensive be-
cause of its inclusion within the fibrous envelope
which develops around retained foreign bodies and
appears to be an et^cacious barrier to the diffusion
of the toxin.
"When, in the treatment of confirmed tetanus,
phenomena of minor anaphylaxis appear, the injec-
tions of the serum may be stopped if the patient has
received a sufficient . quantity and if the tetanic
phenomena have commenced to regress. Otherwise,
the injections of serum should be continued in
fractional doses, at the same time employing local
and general carminatives for the seric disease. If
the prophylactic injection has been given a consid-
erable length of time before the beginning of the
treatment of the tetanus, a prophylactic injection
should always be given a few hours before admin-
istering the curative dose. Intravenous or intra-
spinal injections of the serum should never be at-
tempted unless the subcutaneous administration
proves itself insufficient in therapeutic action.
If, in spite of these precautions, serious ana-
phylactic phenomena develop, a condition which
rarely is observed, all known means at our disp>osal
should be employed against the anaphylactic shock,
particularly artificial respiration and cardiac stimu-
lants. When because of an individual intolerance,
which is most exceptional, the patient cannot be
made accustomed to the serum injections even when
given subcutaneousiy and in small doses, the serum
should be given per rectum once or twice daily at
the dose of from fifty to lOO c. c.
MEDICAL NEWS FROM WASHINGTON.
Nc7v X Ray Army Ainhtilancc. — Lieutenant-Colonel Ray-
mond P. Sullivan, M. C, and Major Franklin H. Martin,
M. R. C, Promoted to Colonels. — Promotion of Naval
Medical Officers in September. — Universal Enrollment
in Volunteer Medical Service Corps.
Washington, D. C, September 2, igi8.
Improvements in the army mobile x ray outfits,
designed by Colonel Christies, chief of the x ray
division of the Surgeon General's Office, and Major
George C. Johnson, his assistant, are giving gen-
eral satisfaction, and after trials in this country
fifty of the new type have been sent to France.
The motor vehicle in which the apparatus is in-
stalled is a standard army ambulance with a few
modifications, and among other features is a dark
room wherein plates and films can be developed
expeditiously. Unlike previous equipment for
this purpose, power to generate the current for the
apparatus is derived from a separate engine, in-
stead of from the vehicle propelling engine. Re-
cently at Camp Meade, Md., one of the outfits made
between sixty and seventy exposures a day for
several days.
Prior to that time, the vehicle made a 900 mile
trip from Washington to Hamilton, Ontario, where
a meeting of the British medical association was
being held, the journey being taken partly as a road
test. The machine made an average for the entire
trip of twenty-four miles an hour, which means
that for much of the distance it made a speed of
forty miles. The car stood the test satisfactorily
and it arrived at Hamilton in practically perfect
condition. The car is about to be sent to Fort
(^glethrope, Ga., for instruction use at the medical
officers' training camp.
The crew consists of one officer and two en-
listed men, all of whom have comfortable sleeping
accommodations connected with the vehicle.
^ ^ ^ ^ ^
Since appointment of Brigadier General Merritte
W. Ireland. Medical Corps, as assistant surgeon
general, with the rank of major general, for ser-
vice in I'rance, interest has centered on the filling
of tlic otiier j^laces of high rank for medical
September 7, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
425
officers provided by recent legislation, including
two from the regular army with the rank of brig-
adier general, and two with the rank of major
general, and four with the rank of brigadier general
to be appointed from the Medical Reserve Corps,
but so far no indication has been had as to the
identity of the appointees.
Lieutenant Colonel Raymond P. Sullivan, medi-
cal corps, in charge of the surgical division of the
Surgeon General's Office, and Major Franklin H.
Martin, chairman of the general medical section of
the Council of National Defense, have been pro-
moted to colonels.
^
After much delay, the Secretary of the Navy
has directed the convening of boards to select staf¥
officers of the navy for promotion to the grades of
rear admiral, captain, and commander.
The board to select medical officers will meet on
September 3, and it consists of Medical Directors
Cary T. Grayson, Edward R. Stitt, and George H.
Barber, with Assistant Surgeon Arthur C. Stanley,
retired, as recorder, to select for the rank of rear
admiral, and the same board with the addition of
Medical Directors A. M. D. McCormick and L. W.
Spratling to select for the ranks of captain and
commander.
The board will select for permanent promotion
seven for the rank of captain and fifteen for the
rank of commander, and for temporary promotion
two to the rank of rear admiral, fifteen for the rank
of captain, and forty-one for the rank of com-
mander.
As a result of recent promotion of "running-
mates" in the line, certain staff officers below the
rank of commander become due for promotion by
seniority. In the medical corps of the navy, the
following are thus due for promotion : To the
rank of commander (permanent). Passed Assistant
Surgeons R. W. McDowell, L. C. Whiteside, George
C. Thomas, Micajah Boland, J. R. Phelps, A. L.
Clifton, H. W. B. Turner. R. B. Henry, L. W.
Johnson, A. H. Dodge, C. W. Smith, G. F. Cottle,
W. L. Mann, jr., Roy Cuthbertson, G. B. Whit-
more, D. H. Noble, T- G. Ziegler, G. F. Clark, W.
M. Kerr, J. B. Polla'rd, and G. A. Riker ; to rank
of lieutenant commander (temporary), Passed
Assistant Surgeons W. W. Hargrave and C. S.
Stephenson; and to rank of lieutenant (temporary)
over one hundred assistant surgeons commencing
with A. A. O'Donohue on the list.
Blanks for the use of physicians and surgeons
throughout the country in becoming members of
the Volunteer Medical Service Corps, have been
prepared and they will be distributed shortly to
local organizations of the Council of National De-
fense.
Dr. Franklin H. Martin, chairman of the general
medical board of the Council of National Defense,
has been instrumental in perfecting the details of
the organization, which is controlled by a central
governing board composed of the surgeon generals
of the army, navy, and public Health Service and
other prominent officials and medical men.
It is the earnest desire of the governing board
that every physician and surgeon in the country,
man or woman, promptly execute the blank pre-
pared and send it in to the board. The board thus
will be enabled to classify the members of the medi-
cal profession and to place them where needed,
either in some branch of the military or naval ser-
vice, or in civil practice, if an assignment is deemed
necessary.
United States Battle and Disease Death Rates.
— The Official Bulletin is the source of information
for the following data : In the Mexican War, as
is shown in the accompanying diagram, more than
seven American soldiers died of disease to every
soldier killed in battle. Eleven in every hundred
fell victims to imperfect sanitation. In the armies
of the North during the Civil War, the battle mor-
tality increased more than 100 per cent, over the
Mexican War average, while the mortality from
diseases was reduced nearly eighty-five per cent. ;
but the disease mortality was still nearly double the
battle mortality. The Spanish-American War wit-
nessed a reversal of the downward curve, with more
than five deaths from disease to each in battle.
During the first ten months of American participa-
tion in the present war the records of the American
Expeditionary Forces show an exact parity between
battle mortality and disease mortality, with a com-
bined mortality which, if projected throughout a
year, would be only a little more than half of the
battle mortality and less than a third of the disease
mortality of the Civil War. Reports from the
Allies show that of all the soldiers sent to the hos-
pitals only forty-five in every 1,000 die; this in-
cludes those who die of disease as well as those who
die of wounds. Of soldiers wounded in action more
than eighty per cent, return to active service. It
is necessary to discharge for physical disability only
14.5 per cent.
Comparison of Disease and Battle Mortality.
Meningococcus Carriers. — Medical Inspector P.
S. Rossiter and Assistant Surgeon A. J. Min-
aker publish in a recent issue of the United
States Naval Medical Bulletin, April, 1918, the re-
sults of the examination of 8,518 men as meningo-
coccus carrier at the U. S. Naval Training Station
at San Francisco. Recent reports indicate that
there is in the community at large a varying per-
centage of carriers of the meningococcus who,
under certain conditions of crowding and inade-
quate ventilation, transmit the organism to others.
Out of this number they found 261 carriers, or 3.16
per cent.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Under Domestic Postage. $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, SEPTEMBER 7, 1918
THE SUPPLY OF NURSES.
At the opening of the war, the hospitals of the
British territorial forces had nurses in the pro-
portion of one to 5.7 beds. In the regulations for
1915, the ratio of nurses was one to 8.5 beds. In
the larger civil hospitals of England, the ratio of
nurses ranged from one to 2.5 to one to four beds.
All these are graduate nurses, fully trained. But
as the demand for nurses has increased, it has
been found necessary to supplement the gradu-.
ate nurses by volunteer assistants, and in this
way it has been possible to raise the proportion
of nurses above the low point of 8.5. The gen-
eral practice in the British hospitals is to give
two volunteer assistants to each trained nurse.
These volunteers, after six months c^r a year of
service, become very proficient and have proved
of great value.
In the German army three classes of female
nurses are recognized: the professional, fully
trained nurse, tlie auxiliary nurse who receives
six months' training, and the volunteer nurse's
aid, who receives a six weeks' course of training,
supplemented later by special courses as oppor-
tunity offers. Within forLy-eight hours after
mobilization in 1914, 5,000 graduate nurses and
about 1,200 assistant nurses reported' for duty in
Germany, besides large numbers of those who
had taken the six weeks' course of instruction.
These, after four months' experience, were pro-
moted to the class of "sister" and were given
opportunities to complete the course of instruc-
tion required of professional nurses. After a
two years' course these were graduated as army
nurses and wear a full uniform. Those, who are
usually spoken of as "I'ed Cross nurses" or '"vol-
unteer nurses," work under the supervision of
older professional nurses who have received full
training-. They are the best type of yoimg
women, twenty to twenty-five years of age, well
educated, intelligent, anxious to learn and to
serve. In commenting on these volunteers. Ma-
jor John R. McDill in his Lessons from the Enemy
says :
They are the only material from which reliable war
nurses in large numbers can be developed in any coun-
try. The older, trained, professional nurses cannot be
relied upon as a class to carry the burden of all the
work of war hospitals, demanding long and irregular
hours, changing of stations, sometimes involving hard-
ships and new environments in a foreign country with
a foreign language. The mature, experienced, trained,
professional nurse should bear the same relation to the
younger army nurses that officers do to their soldiers.
Their positions should be those of superintendents,
chief nurses, dietitians, anesthetists, or matrons, and
all should be selected with reference to their ability to
manage young people and to instruct them during their
ctjurses of training. The latter qualities are most im-
portant and should be insisted on or discontent, un-
happiness, and failure in discipline will seriously dis-
turb the service.
The rapid increase in the forces of the United
States has prompted a call for 25,000 additional
nurses by Surgeon General Gorgas, but it is
doubtful whether we can spare from civil life
25,000 fully trained nurses without seriously im-
pairing the efficiency of our civilian service. In-
deed, it is already difficult to find a trained nurse
for private work who is disengaged.
General Gorgas has undertaken to meet the sit-
uation by providing for the engagement of stu-
dent nurses in certain army hospitals, where they
will receive systematic instruction leading to a
diploma, should the hospitals be continued long
enough. If the hospitals should be closed on
account of the termination of the war before the
September 7, 191 8.]
EDITORIAL ARTICLES.
student has completed a three year course of
training, she will be given a certificate which will
entitle her to a credit in a civilian training school
for the time she has spent in training in tlie mili-
tary training school.
While this plan is an excellent one in many re-
spects and will do something toward supplying
the necessary number of trained nurses, it is open
to the objection that it makes no provision for
the utilisation of that vast number of intelligent,
well educated women of leisure who would glad-
ly serve in the hdspitals for the period of the war,
but wlio have no desire to devote their lives to
the profession of nursing. This class has been
made use of in the British hospitals to a large
extent as volunteer assistants. These are put
under the supervision of trained nurses and thus
broaden the usefulness of these nurses. Ger-
many also has found it necessary to call others
than the fully trained nurses as set forth above.
The members of the American Hospital Asso-
ciation have become alarmed at the prospect of
the disintegration of the civil hospital service
through the demands of the army and have peti-
tioned the Surgeon General not to carry out the
plan which has been proposed of taking over a
certain number of advanced and intermediate
medical and nursing students for training in the
army school of nurses. The New York Hospi-
tal Conference has petitioned the Surgeon Gen-
eral to standardize a six months' intensive train-
ing course for nurses of a highly practical char-
acter whose students will be in a position to be
of immediate aid in the army. It is understood
that the original program of the Surgeon Gen-
eral, which contemplated the utilization of fully
trained nurses only, has already been modified
and that the proposal of the New York Confer-
ence will probably be approved.
The United States would do well to profit by
the example of other nations in this matter and
make some provision for the utilization of the
thousands of intelligent and devoted women who
would gladly give their services in the army hos-
pitals but who could not be induced to undertake
a three year course of training looking toward
qualification as a professional trained nurse. The
program laid out by the Surgeon General is an
excellent one as far as it goes. We need army
training schools for nurses, but we must go fur-
ther than this and avail ourselves of the services
of the women who do not care to enter the pro-
fessional training school, whether that school be
in the civilian hospital or in the hospital under
military discipline. We must also find a place —
there is none provided yet — for the large number
of so called practical nurses who now perform
such valuable services in home nursing and
many of whom have already sought in vain to
enter the army medical service, being barred l)y
a lack of the prescribed training school di])l()!iia.
MONOTONY AND HEALTH.
The word "lugubrious" applied to the present
war by some prominent English writers is espe-
cially appropriate, and its lugubriousness is due
chiefly to its monotony. It is for this reason
that so much must be done to break this inter-
minable succession of splashes of trench mud,
explosions of shells, rain of bullets, and recuper-
ation in camp. The time spent in camp is the
most monotonous part to the soldier, or would
be without the efforts being made to keep him
amused. Never were these efforts so needed
and never did they play such a role in maintain-
ing the health of the troops.
War is a business which has for its object
the sundering of soul and body — to use the old
and unavoidable terminology. It is the business
of medicine to cement body and soul, and the
more closely they are associated, the more of
health is present. The war is helping to dissi-
pate old views of life and to make clearer the
oneness of the human organism, its body mind-
edness or its mind embodiedness, as we may care
to consider it.
As was carefully pointed out by the speakers
at the association meeting in Chicago, there is
nothing new in the abnormal conditions met with
in the men at the front, and much of the abnor-
mal is begot of monotony of the daily experience.
We at home should remember that very much of
the abnormal in ordinary life is also due to mo-
notony, and it is the business of the physician
and nurse to combat these in domestic life as
much as in the army. We all need a change, and
often when we are ailing it is all we do need.
Perhaps cyclic phenomena in human conduct,
such as periodic alcoholism, are the result of
nothing more than the unl:)earable craving for a
decided change, and some other experience might
be substituted for the spree.
Nor does this principle apply solely to what
we are pleased to term mental ailments. How
often the sick room is lacking in change ; the bed
is kept in the same spot, the objects in the room
are never shifted, old subjects of conversation are
worn threadbare, etc. How often tlie visit of
tlie physician is a source of the utmost help solely
428
EDITORIAL ARTICLES.
[New York
Medical Journal.
because it breaks the monotony of the day. Per-
haps it is as a breaker of monotony that the doc-
tor does most good, and certainly his success is
much to be measured by his abiHty as, shall we
say, a variety artist. Variety is more than the
spice of life, it is a vitamine of healthy existence.
METABOLISM IN NERVOUS TISSUES.
Although muscle and liver are perhaps the
most potent elements in the general metabolism
of the body, all tissues, of course, have a share in
it. Up to very recently brain and nerve tissue
were thought to play most insignificant parts in
metabolic processes. Nevertheless, various sub-
stances have been recommended as brain foods
on the assumption that the brain had a special
affinity for them, and that they stimulated growth
of brain tissue. Cephalin, lecithin, nuclein, phos-
phorus, fatty acids, etc., have been among the
substances recommended. It is true that these
substances are prominent constituents of nervous
tissue, but there is as yet little clinical or physio-
logical warrant for supposing that the ingestion
of these substances can influence growth or
activity of nervous tissues. Data on the influ-
ence of diet or other substances on nervous tissue
are very meagre. Starvation seems to have no
effect. It seems that the weight of these organs
is maintained at the expense of muscle, adipose
tissue, etc. In young animals imderfeeding does
not affect medullation. On the other hand, the
feeding of certain foods such as polished rice or
food containing a relatively low amount of pro-
tein and high carbohydrate will cause polyneuri-
tis and pellagra respectively with the nervous
degenerations accompanying these diseases.
Metabolic activity is quite marked in brain tis-
sue. While water forms a very large part of the
nervous tissue content, the protein and lipoid
content take part in the metabolic activities.
Protein is found chiefly in the cellular part of the
brain, the cortex, while the lipoids predominate
in the white portions. Sodiimi, potassium, mag-
nesium, etc., present in nervous tissue as dissoci-
ated ions or in combination with organic tissue,
have a marked influence in nervous function, par-
ticularly in tlie propagation of nerve impulses.
The phosphatides contribute to this function by
being oxygen carriers. Chemically they are un-
saturated fatty acids. They are colloidal in na-
ture and have an instability toward heat, and
therefore imdoubtedly play a great part in the
vital processes. A great many enzymes have
been isolated in nervotis tissue, but they probably
play a very minor part in this metabolism. Me-
tabolic activity in the brain may be influenced by
a great many circumstances. Hyperthermia,
asphyxia, convulsant drugs stimulate, while hy-
pothermia, chloroform, morphine, diphtheria
toxin, etc.. depress. Increase in nervous activity
augments nitrogen catabolism ; diminished nerv-
ous excitability lowers the amount or the in-
tensity of protein disintegration. In regard to
nervous activity, the consumption of oxygen by
nervous tissue is as great as by muscle, which is
of course the organ of internal respiration where
the ultimate exchange takes place. It is the large
amount of imsaturated substances with autoox-
idative properties present in nervous tissue that
indicates the great amount of oxidation going on
there. The large amount of these oxidative sub-
stances in the nervous tissue would in themselves
accoimt for the metabolic activity even without
the intervention of the enzymes.^
There is little doubt that brain and nervous tis-
sues are not inert as far as the metabolic activity
of the body is concerned. There is now ample
evidence that in metabolic diseases such as pel-
lagra, polyneuritis, etc., the brain symptoms are
due to metabolic disturbances taking place here
as in other parts of the body. Metabolic disturb-
ances in brain and nervous tissue must be borne
in mind not only in these specific conditions but
in any pathological conditions ; they must be
taken to explain the mental and nervous symp-
toms present in nearly all diseases. More exten-
sive study of the composition and the chemical
changes taking place in the brain normally and
in disease will clear up much of the confusion of
ideas concerning the brain metabolism.
TUBERCULIN IN DISEASES OF THE EYE.
Though the therapeutic employment of tuber-
culin in other parts of the body has fallen into
deserved disuse, thanks to the unjustified over-
confidence of its enthusiasts, there are no doubt
certain conditions in the eye where its use, if not
a specific, is of well recognized value. Some of
the poor results claimed from its use are properly
blamed on those who administered it, as it is a
very powerful agent, which when not properly
used is capable of doing a great deal of harm.
Hence its dose, mode, and frequency of adminis-
tration are to be very carefully considered before
treatment is instituted ; and while we may not
fully agree with Verheyden {British Journal of
Ophthalmology, April, 1918) that the treatment
of the patients is best given in a hospital, it is
^Hygienic Laboratory Bulletin, No. 103.
September 7, 191S.]
EDITORIAL ARTICLES.
429
not to be denied that extreme care is to be exer-
cised, whether the patient is a hospital case or an
ambulatory one. The old tuberculin is used, or
the bacillary emulsion, the initial dose being as
small as one five thousandth of a milligram, or
even one ten thousandth, such small doses being
obtained by gradual dilutions with a normal salt
solution to which one half of one per cent, of a
lysol solution had been added, until the desired
strength of the solution is obtained. After the first
injection, and frequently even after the subse-
quent ones, there may be a reaction either at the
site of the injection (local) , or in the eye (focal).
This should serve as a contraindication to the
continuation of the treatment until the signs of
the reaction subside: the dose is then gradually
and cautiously increased. A reaction during the
course of treatment would indicate a return to a
smaller and safer dose. In fact, it is advisable
to examine carefully both the exterior of the eye
and the fundus with an ophthalmoscope after
each injection. The adjuvant treatment, such as
dionin, yellow oxide salve, subconjunctival saline
injections, the routine employment of atropine,
and so on, is not to be neglected by any means.
Eczematous or what used to be called scrofu-
lous afifections of the cornea, with or without in-
vasion of the conjunctiva, are the cases, par ex-
cellence, which are benefited by tuberculin treat-
ment. A plea is made for a more frequent and
methodical use of tuberculin in these cases, which
frequently resist the old established methods of
treatment, and in which corneal opacities of vari-
ous degrees of density are apt to be left, with
consequent impairment of vision. The ready re-
sponse of these cases to the treatment is a clear
indication that the affection is tubercular in na-
ture. This is not at all at variance with the
gradually prevailing views on this disease. For
the last quarter of a centurythe etiologyof eczem-
atous eye afifections has claimed the attention
of ophthalmologists, and an undoubted relation
has been established between tuberculosis and
these diseases. The prevailing notion is that the
eczematous nodule is a local manifestation of a
toxemia arising from a tubercular focus situated
somewhere in the body; this has been found to
be the case in a great many of the patients ex-
amined, though no tubercle bacilli were ever
found in the nodule itself. It is also claimed
that in a certain class of patients suflfering from
phlyctenular disease the opsonic index for tuber-
cle was lowered and that it gradually rose with
improvement in the condition. A great percent-
age of these cases respond to both the von Pir-
quet and the Moro tests. Cridland quotes Be-
lenky-Raskin to the efi'ect that out of one hun-
dred cases of phlyctenular disease subjected to
the von Pirquet and Moro tests, the first was pos-
itive in ninety per cent, and the second in eighty-
five per cent, of the cases. Cases of episcleritis
and scleritis of obscure origin are also greatly
benefited by the tuberculin treatment, thus prov-
ing that some at least of these cases are of tuber-
cular origm. As they are usually very resistant
to treatment, and are apt to be followed by very
serious consequences to vision, the improvement
under this treatment is a distinct gain. A more
or less similar improvement has been noted in
afTections involving the iris and the ciliary body
(iritis and iridocyclitis) : in these cases, when re-
cent, and before profound organic changes have
been established, improvement under tuberculin
was undoubted.
COMMISSIONS FOR BANDMASTERS, BUT
NOT FOR PHARMACISTS.
In a recent issue of the Spartanburg, S. C,
Herald, announcement is made of the issuance of
commissions as lieutenants to three band leaders.
Pharmacists complain, and with some degree of
justice, that they are still without recognition in
the Army. Since the physical welfare of the troops
is admittedly a matter of primary importance, it
would seem reasonable to expect that the pharma-
cists would receive commissions rather than band
leaders, but so long as the Surgeon General opposes
the organization of a corps of pharmacists with
commissioned rank, it is improbable that such a
corps will be organized by Congress — though in-
deed we believe that the organization of the dental
corps was not recommended by the Surgeon Gen-
eral. In view of the excellent service which has
been rendered by the pharmaceutical corps in all
the European armies except that of England, Con-
gress would be justified in ignoring the wishes of
the Surgeon General in this matter. In at least
one instance, that of the elaboration of a formula
for an application to neutralize mustard gas poison-
ing, the Chemical Service Corps has received credit
which is due to a pharmacist working in that corps.
The very great improvement in the specifications
for medical and surgical supplies which has taken
place since the United States engaged in this war,
is due largely to the advice of the expert pharma-
cists who represented the manufacturers of medi-
cinal products. There are a number of excellent
pharmacists in the service, a few of whom have
been given commissions in the Sanitary Corps, but
the best results cannot be achieved by these isolated
appointments. The Navy has recognized the need
of a higher grading for the pharmacists and has
given at least temporary commissions to some of
its chief pharmacists. It is to be hoped that the
Surgeon General will distinguish his term of of?ice
by a reconsideration of his present views on the
subject and recommend the introduction of a
pharmaceutical corps in the Army.
NEWS ITEMS.
[New York
Medical Journal.
News Items.
Positions in the State Department of Health. — The
Civil Service Cominissioii of the State of New York will
hold examinations on October 5th for a number of posi-
tions in the Division of Laboratories and Research of the
State Department of Health. For full particulars and ap-
plication blanks address the Civil Service Commission, Al-
bany, N. Y.
A Chair of Tuberculosis at Edinburgh. — Edinburgh,
the birthplace of the modern teachinR of anatomy and
pathology, is again the pioneer in the establishment of
a chair of ttiberculosis. Sir Robert Philip, whose repu-
tation is world wide, delivered the inaugural address at the
recent institution of the chair with the topic Present Day
Outlook on Tuberculosis.
Psychopathic Institute in Winnipeg for Returned
Soldiers. — A psychopathic institute is to be established
in Winnipeg, Manitoba, for the care and treatment of
soldiers who return from the war suffering from mental
disorders. Two years ago the provisional government
voted $=;o,ooo for the work, but this sum was found to
be insufficient and the additional money needed is to be
appropriated. The work of construction will be started
at on-^c.
A Red Cross Hospital in Jerusalem. — The American
Red Cross Society has established a general dispensary
and hospital, with a children's clinic, in Jerusalem, and at
the request of the government of Jerusalem the organiza-
tion has taken over two orphan asylums with four hundred
children. Three hundred Russian refugees, thousands of
Armenian refugees at Pert Said, and many homeless fami-
lies near Jenisalem are also being cared for in Jerusalem
by the Red Cross.
Courses in Bacteriology for Laboratory Assistants.
— The special three months' course in bacteriology to train
laboratory assistants for immediate war service, both here
and overseas, began on Wednesday, September 4th, at the
University and Bellevue Hospital Medical College and
other medical colleges throughout the country. The
courses, which are open to both men and women, were ar-
ranged at the request of Surgeon General Gorgas The
course at New York University was arranged by Dr. W^il-
liam H. Park, director of laboratories of the Department
of Health, and his assistant, Dr. Anna W. Williams.
Physicians Urged to Buy Radium. — Dr. Richard B.
A'loorc, of the U. S. Bureau of Mines, in an address de-
livered at a meeting of the American Institute of Mining
Engineers, on Tuesday, September 3d, urged the physicians
and surgeons of the country to buy up all the rad-um that
is not needed for war purposes. There are only about
three ounces of radium in existence at this time, according
to Doctor Moore, and it will be six or seven years before
new deposits of ore can be mined. Ra4ium, Doctor Moore
said, was being used on the faces of watches, clocks, and
electric light push buttons, which is obv'ously dissipating
the snpplv of a material of medical and militarv value.
Volunteer Medical Service Corps. — Membership
blanks in this corps are now being mailed to all legally
qualified men and women doctors in the United States.
The General Medical Board of the Council of National
Defense urges that every doctor not already in govern-
ment service fill out. sign, and return the blank sent him
to the offices of the Central Governing Board, Council of
National Defense. Washington. This is a volunteer move-
ment instituted among the members of the medical profes-
sion in order to have a record of those doctors who are not
members of the Medical Reserve Corps, and who will
pledtre tlTemselves to apply for a commission in the Medi-
cal Reserve Corps of the Army, the Naval Reserve Force,
or for appointment in the Public Health Service, when
called upon to do so by the Central Governing Board ; and
TO complv with any request made by the Central Governing
Board. It is estimated that at least 50,000 doctors will be
necessary eventually for the Army. There are now 28,674
medical officers commissioried in the three services. This
record of doctors will afford the government the means of
obtaininir quickly men and women doctors for any service
reipiircd »
Oregon State Medical Association. — At the recent
annual meeting of this association the following officers
were elected: Dr. Charles M. Barnee, of Portland, presi-
dent; Dr. Frank E. Boyden, of Pendleton, first vice-presi-
dent; Dr. Louis Buck, of Portland, second vice-president;
Dr. Benjamin A. Cathey, of Condon, third vice-president;
Dr. Andrew J. Browning, of Portland, secretary; Dr. Jesse
M. McGavin, of Portland, treasurer.
Gifts and Bequests to Hospitals. — A bequest of
$15,000 to the Germantown Dispensary and Hospital for
free beds in memory of Frederick J. Kimball; her mother,
Elisa M. Needles, and her father, William Norwood Nee-
dles, was made in the will of Helen Mary Hathaway Graf-
flin, of Germantown. The will includes a number of
private bequests and provides that any balance left from
the $80,000 estate shall be divided between Johns Hopkins
L^niversity and Johns Hopkins Hospital. She left $15,000
to the German-Franklin Square Hospital, of Baltimore,
and to the Maryland Society for the Prevention of Cruelty
to Animals.
Personal. — Colonel Raymond P. Sullivan, recently
promoted, has been appointed chief of the surgical di-
vision of the Surgeon General's Office, succeeding Colonel
William H. Moncrief.
Surgeon J. A. Nydegger, United States Public Health
Service, has been detailed to supervise the Baltimore Quar-
antine Station, which was recently placed under federal
control.
Doctor Delorme, director of the School of Military
Medicine, has been elected vice-president of the Paris
Academy of Medicine, to succeed the late Professor Pozzi.
Lieutenant Frank Harrison MacGregor, Medical De-
partment, L'nited States Army, has been awarded the Mili-
tarv Cross and cited by a British general for his services
during the operations from July 21st to July 28th, north-
west of Nanteuil.
Medical Students in the United Kingdom.— Accord-
ing to a statement from the General Medical Council there
is no shortage of potential doctors in Great Britain and
Ireland. The student registration for 1917 exceeded that
for any year since 1891. The grand total for 1016 was
6,10,3; for January, 1917, 6,682; October, 1917, 7,048; May,
1918, 7,630. Of the 1918 students 2,250 are women. Al-
though the number of women students is definitely on
the increase, the total is not so large as had been expected.
The increase is more decided in Ireland than elsewhere,
the increment after Ireland being most noticeable in the
London district. The number of women students for each
of the five years is as follows: First, 665; second, 610;
third, 484; fourth, 275; fifth, 207. In Ireland the number
of women students is as follows: First, 114; second, 104;
third, 73; fourth, 30; fifth, 12.
Effect of the War upon the Population. — The birth
and marriage rates for the first six months of 1918, com-
pared with the first six months of 1917, show that New
York city is already beginning to feel the effect oi the en-
listment and drafting of so many young men of marriage-
able age. According to reports published bv the Depart-
ment of Health of the City of New York, from the first
of January to the first of July, 1918, there have been 410
fewer births in New York city, and 2,804 fewer marriages,
than for the same period of 1917. The exnerience of New
"S'ork city in this follows closely that of Europe since the
war started in T914. Sir Bernard Mallett, Registrar Gen-
eral of England, states that in England and Wales the
birth rate has fallen. The rate for IQ17 showed a decline
of twenty-four per cent, over that of 1013. or a total of
66.*^. 346 fewer births. He feels that it will be a long- time
before the birth rate again reaches the figure which ob-
tained before the war. and states that, serious as this loss
is to the cominff rrcnerations in his country, there is reason
to believe that Grent Britain has suffered less than the
other belligerents. Germisny has lost in potential lives the
equivalent of 4.5 per cent, of its total pre-war population,
.Austria five per cent, and Hungary seven per cent. Sir Ber-
nard Mallett calculates that the present war has cost the
belligerent countries of Flurope not less than twelve and a
half millions of potential lives at the present time. He
says that every dav the war continues means a loss of
ceven thousand T)otential lives to the United Kingdom,
Frpnce. and the Central Powers. '
Modern Treatment and Preventive Medicine
A Compendium of Th erapeutics and Prophylaxis, Original and Adapted
VICIOUS CIRCLES IN RESPIRATORY DIS-
ORDERS AND THEIR TREATMENT.
By Louis T. de M. Sajous, B.S., M.D.,
Philadelphia.
{Continued from page j88)
PULMONARY TUBERCULOSIS.
The vicious circles established in hemoptysis of
tuberculous origin have already been referred to
under a separate heading. In addition to these
there are a number of others that may arise in tuber-
culosis— some of great importance, as they may
exert a marked general influence on the course of
the disease. Certain facts relative to the incidence
of tuberculosis may be mentioned. Poverty and its
results, viz., overcrowded living quarters, an insuf-
ficient diet, ignorance and filth, are well known as
factors favoring an increased incidence of the dis-
ease; on the other hand tuberculosis as a cause of
poverty was shown by Kingsbury, 191 2, to have led
to an appeal for charitable assistance in no less than
thirty- four per cent, of a series of 1,600 families in
New York city. These facts definitely suggesr a
vicious circle, poverty favoring tuberculosis while
tuberculosis, in turn, promotes poverty. Again,
overstrain, as Baldwin, 1913, specifically stated, may
inhibit the mechanism of protection against tuber-
culosis and not only lead to spreading of an old
tuberculous infection but render possible a fresh in-
fection. Such augmented or new infection, we may
add, increases the susceptibility of the individual
to overstrain under continued labor, thus complet-
ing another vicious circle which tends to aggravate
the disease and, incidentally, may combine with the
preceding circle by reducing or interrupting the in-
come derived from the subject's daily occupation.
A third probable factor to be borne in mind is the
influence of an unstable or defective nervous sys-
tem. Individuals with a delicate nervous makeup
are known to fall readily a prey to the disease, and
the defective nutrition resulting from nervous or
mental disorders has been thought to open the door
to tuberculous infection. In the developed disease
nervous disturbances may take part in an actual
vicious circle.
The prejudicial influence of the several factors
just referred to on the incidence and progress of
tuberculosis is confirmed by the equally marked
favorable influence of opposite conditions, which
prevent or interrupt the vicious circles. Good food
and an ample diet reduce the incidence of tuber-
culosis and oppose its progress when established.
Fresh air, whether inhaled in the course of the daily
work or employed as a curative measure, again
greatly promotes resistance. Muscular exercise,
where engaged in under conditions such that it will
not overstrain but actually strengthen the body tis-
sues by promoting cell nutrition, serves a useful
purpose, but where pushed to the degree of exces-
sive fatigue, or where any exercise adds to the
already morbid cell consumption, as in the well
established disease, must be replaced by rest, which
efifectually interrupts the vicious circle.
In fully developed, open tuberculosis several
important vicious circles relating to the disposal of
the infected material coughed up may become estab-
lished. Essentially these are all manifestations of
failure of the natural process of protection by elimi-
nation, the primary object of which is to get rid of
loosened tissue, bacteria, and secretions through the
respiratory channels without infecting the latter. A
salient example of failure of this process of pro-
tective elimination is met with where a cavity emp-
ties its contents into a bronchus. The importance
of this particular incident in the course of tubercu-
losis is clear when we confront two statements of
MacCallum, 1913, viz., that "one can at autopsy al-
most invariably pass a probe from any tuberculous
cavity directly into a bronchus," and that emptying
of the cavity contents into a bronchus "is usually
the first step in the wide involvement of the lung
in the tuberculous process." The violent respiratory
movements and cough induced by the material lying
in the bronchus, acting in conjunction with gravity,
lead rapidly, according to M>acCallum, to a distri-
bution of the tubercle bacilli in bronchi previously
not infected, with corresponding enlargement of the
diseased area. This, in turn, not only tends to
weaken the resisting powers of the body against fur-
ther progress of the disease, but gives opportunity
for the formation of new cavities, from which fur-
ther rapid extension is likely to occur, a vicious cir-
cle being thus completed and the prognosis as to
duration of life rendered more unfavorable. Mani-
festly no direct measure for overcoming this vicious
circle is at our disposal, except in so far as reduc-
tion of coughing to a necessary minimum may be
helpful in this direction. The main treatment of
this circle may be said to be prophylactic, all pos-
sible efforts being made to detect and check the dis-
ease before cavity formation has occurred.
Vicious circles resulting in rapid extension of the
infection are by no means limited, however, to the
process of cavity formation. During paroxysmal
cough, even in the absence of cavities, sputum may
be aspirated into previously healthy bronchi, pro-
mote infection there, and increase the cough, form-
ing another vicious circle. Again, infective sputum
may lead to the production of a secondary disease
focus in the larynx, whence secretions may be aspi-
rated not only in the afifected but also in the sound
lung, thus accelerating the morbid process. Simi-
larly, involvement of the trachea may result in ex-
tension to the opposite lung. Entrance of sputum
into the pharynx or, by swallowing, into the stom-
ach and intestine, may initiate one or more vicious
circles, if not by establishing new tuberculous
lesions, at least by setting up functional disturb-
ances, such as, e. g., may be associated with phar-
yngitis, gastritis, fermentation in the alimentary
tract, and diarrhea, which may seriously weaken the
resisting powers of the body. Mere absorption of
432
MODERN TREATMENT AND PREVENTIVE MEDICINE'.
[New York
Medical Journal.
the irritants of the sputum into the circulation may,
as stated by Lawrason Brown, 1913, cause anemia,
neuritis, and atrophy and fatty degeneration of the
muscles, including the heart — all conditions con-
stituting in a sense, part of a vicious circle, the
resisting powers being impaired, the amount of dis-
eased tissue and sputum increased, and toxic ab-
sorption correspondingly accentuated, thus complet-
ing a circle.
In the treatment, the possibility that any of the
morbid conditions referred to may be reinforced in
its harmful effects through the operation of a vicious
circle should be borne in mind ; as already pointed
out, where such a circle can be artificially broken,
gratifying curative, or at least retardant, results are
hkely to accrue. Excessively violent paroxysmal
cough should be curbed, medicinally or otherwise :
laryngeal involvement constantly watched for and
suitably treated if it appears; all measures favoring
easy and rapid elimination of sputum instituted, and
the dangers of swallowing sputum carefully ex-
plained to the patient and guarded against. Postural
measures may assist greatly in facilitating expecto-
ration, as may also simple respiratory exercises be-
tween meals. The cilia of the respiratory passages
should be availed of as completely as possible in
their natural function of sputum raisers, cough,
with its tendency to beget further cough, being cor-
respondingly reduced and repressed.
{To be continued.)
Subcutaneous Homohemotherapy. — J. A. Si-
card (Presse medicale, June 13, 1918) points out
the feasibility and utility of this procedure, not
as a substitute for blood transfusion, but in the
treatm.ent of hemorrhagic and hemophilic diatheses
or certain anemic states. It consists in injecting
subcutaneously whole blood from another human
subject. It is held superior to other methods of
blood or serum administration in being simpler, in
not requiring citrate or other chemicals, in avoiding
the delay entailed by separation of serum, in more
ready asepsis, in greater therapeutic efficacy be-
cause the blood cells are included, and in obviating
anaphylaxis. The donor is generally a member of
the family, free of syphilis, tuberculosis, malaria,
and diabetes, and in good general condition. The
apparatus required is limited to hypodermic needles
four cm. long and of 0.9 to one mm. diameter ; two
or three sterile twenty c. c. glass syringes ; one or
two thirty c. c. porcelain dishes, sterilized and
paraffin coated ; a rubber tube and hemostat. and a
vessel of distilled, sterilized water. With the sub-
jects in the recumbent position iodine is painted
over some area of the recipient's abdomen and a
needle passed into the cellular tissue. With
a band around the donor's arm, the most prominent
vein is punctured and blood collected in the por-
celain dish. The syringe is filled from the latter,
at once adapted in the needle in the recipient's
abdomen, the injection quickly made, the syringe
washed with distilled water, and the process re-
peated until as much as eighty or 120 mils of
blood have been injected. To prevent reflux of
blood through the needle in the intervals between
injections it may be plugged with the tip of a
small glass syringe. The injections are painless
and produce a hematoma which becomes absorbed
in the course of three to five weeks. No trouble
from infection or cystic transformation was ever
experienced ; absorption ran its usual course even
in weakened or debilitated subjects. Three infec-
tious cases with purpura and internal hemorrhages
treated in vam by injections of horse serum re-
covered rapidly after homohemotherapy — 100 c. c.
— repeated on four successive days. In two hemo-
l^hilics in whom horse serum had caused anaphy-
lactic reactions the treatment was well borne and
permitted safe dental extraction and an operation
for appendicitis, respectively. Some cases of cryp-
logenetic chloranemia and three cases of extreme
posthemorrhagic anemia were also treated, with
rapid results in the latter and slower improvement
in the former.
Management of Constipation among School
Girls. — M. E. Rrydon {Virginia Medical Monthly,
June, 1918) comments on the frequency of con-
stipation among otherwise normally healthy school
girls, and ascribes it to five causes, viz., dietary in-
discretions, insufficient exercise, insufficient inges-
tion of fluids, lack of regularity in defecation, and
cathartic drugs. The first of these consists in the
ingestion of enormous amounts of sweets, pickles,
crackers, and other prepared foods looked upon as
a necessary adjunct to the monotonous school fare.
Most of this material is readily assimilated and
lacking in residue. In the treatment, a list of foods
rich in cellulose is given, viz., cabbage, tomatoes,
onions, spinach, corn, string beans, lettuce, cu-
cumbers, asparagus, wheat and rye bread, and the
coarser cereals, oatmeal, corn meal, and hominy.
Bran is a valuable help and should be used as an
addition to cereals, breads, etc. Some fruit should
be taken at each meal, if possible, and before re-
tiring. To be avoided, in a general way, are excess
of eggs or milk, sweets, pastries, nuts, cheese,
crackers, new white bread, hot bread, toast, mac-
aroni, rich stews and gravies, most chafing dish
products, condiments, and soda fountain drinks.
The reasons for these dietetic recommendations are
carefully explained. As regards lack of exercise,
most girls, in spite of having gymnasium work
twice a week, lead almost sedentary lives. A half
hour walk, covering a certain distance, must be
added by the girl patient in her daily schedule. In-
variably these patients do not drink enough water.
The necessary corrective suggestion is best effected
in the form of questions, bringing out the fact that
the body loses twelve glassfuls of water a day,
while the fluid in solid foods only makes up about
four. Irregularity of defecation is overcome only
by impressing the proper mental attitude on this
point on the patient. As regards drugs, their dan-
gers should be explained as impressively as pos-
sible, and the girl required always to report if she
needs a laxative, as well as at regular intervals.
In those already inured to the laxative habit cas-
cara is given, three minims three times a day, in-
creased one drop daily until a good daily movement
results, then reduced one drop daily to complete
cessation. Suppositories, enemas, abdominal mas-
sage, and calomel are to be avoided.
September 7, 1918.] MODERN TREATMENT AND PREVENTIVE MEDICINE.
433
The Treatment of Acne Vulgaris. — James W.
Miller (Urologic and Cutaneous Review. July,
1918) examines the scalps of these patients very
carefully. When the scalp shows seborrhea a pre-
liminary shampoo of a solution of potassium car-
bonate (14.2 grams to the htre), followed by the
use of green soap tincture once a week and the
daily use of a sulphur pomade, should be employed.
The following is a good formula :
Sulphur precip dr. i ;
Sodii bibor., dr. v ;
Aquae rosae dr. iii ;
Cerate alba dr. i ;
Petrolatum dr. v.
All comedones are to be carefully expressed.
Before expressing them it may be well to apply a
hot towel to the face for a period of ten minutes.
Pustules must be opened and drained, best done with
a von Graefe cataract knife. The hyperkeratotic
layer must be removed by sulphur. One of the best
preparations is lotio alba. When stimulation is
evidenced by a mild dermatitis, cold cream or cal-
amine lotion should be substituted. Vaccine treat-
ment is used at times. If the acne vaccine uncom-
bined does not give results, the staphylococcus vac-
cine may have to be added. The initial dose should
be five million of the acne vaccine, which is in-
creased to one hundred million. The initial dose of
the staphylococcus vaccine is one hundred million,
which is increased to a billion or more. "For acne in-
durata or blind boil. Bier's suction cup should be
used. The diet should be carefully restricted.
Plenty of water should be taken between meals.
Exceptionally the x rays or the Kromayer lamp
may have to be employed.
Local Reactions in Arsenical Treatment. —
Lacapere (Presse medicale, May 13, 1918) states
that Herxheimer's reaction appears not only in the
secondary stage of syphilis, but also, less strikingly
in the primary and tertiary stages. The chancre
becomes congested after the first injection and
yields a copious serous discharge before undergo-
ing retrogression. In the tertiary stage similar re-
actions are observed, e. g., in gummata, in tabetic
oculomotor paresis, in laryngitis with stenosis, in
specific myocarditis or nephritis, etc. Paretics often
develop curious excitement after an injection, due
to reactive cerebral congestion. Tabetics exhibit
on the day after an injection what they describe as
"fireworks pains" ; this is repeated for months after
each successive injection, because the spirochete is
so firmly established in the nerve roots ; but finally
the tendency to reaction disappears. In all in-
stances these reactions are produced as long as the
spirochete remains, but diminish in intensity as the
spirochetes become reduced in number. The re-
actions are so constant as to be a positive sign of
the syphilitic nature of a lesion. In subjects in
whom arsenical treatment is just being begun, the
reaction varies, in general, with the dose injected.
It begins suddenly and reaches its height about one
day after the injection. Its duration does not usu-
ally exceed one or two days, but there are ex-
ceptions. It is slower in passing ofif in long stand-
ing tabes than in the case of secondary eruptions.
It may assume great intensity where in the course
of treatment the arsenical dose is too rapidly in-
creased. Infinitesimal initial doses and slow ascent
should be the rule where manifest or even latent
nervous lesions exist. To overcome the developed
reaction where it entails danger, as in cases with
cerebral, cardiac, or renal lesions, adrenalin is best.
As soon as such symptoms as delirium, mental
hebetude, cardiac arrhythmia, increased albumi-
nuria, etc., appear, subcutaneous injections of one
milligram of adrenalin should be given, and re-
])eated two or three times a day in severe cases.
Before subsequent arsenical injections one half to
one milligram of adrenalin should be preventively
administered.
Glucose Applications in Certain Superficial In-
fections.— T. H. C. Benians (British Medical
Journal^ June 15, 1918) points out that most patho-
genic bacteria are able to ferment glucose with the
production of a definitely acid medium. Many of
the toxic products of bacteria are best formed in
an alkaline medium and their production is inhib-
ited by an acid reaction. The tryptic digestion of
proteins which causes the stinking discharges of
wounds and in infections is inhibited in an acid
medium. On the strength of these facts Benians
has tried the local application of glucose solutions
in the following conditions : In bromidrosis it was
effective in the only case on which it was tried. In
ozena the application of twenty-five per cent, solu-
tion of glucose to the interior of the nose twice
daily has led to the production of an acid nasal se-
cretion, the partial or complete destruction of the
specific bacilli, and the disappearance of the foul
smell and the crusts. Better results, however, seem
to follow the similar use of glycerin. Some cases of
chronic otorrhea seem to have responded well while
others have not. Long standing purulent vaginal
discharges have been cleared up completely in most
cases by douching twice daily with twenty-five per
cent, solution of glucose, or by the nightly introduc-
tion of a vaginal suppository containing twenty-five
per cent, of glucose in a gelatin base.
Embedded Missiles in the Walls of Large Ves-
sels.— R. Le Fort (Bulletin de V Academie de mede-
cine, June 11, -1918) notes that while the elastic
fibres of large vessels easily arrest almost spent
missiles and shell fragments are very frequently
found in vascular sheaths, secondary or late hemor-
rhages from ulceration of a projectile through a
vessel are rare. The fact is that a missile wears into
or perforates a vessel only where the latter is un-
able freely to escape from the fonner. This is sel-
dom the case with small or medium sized missiles ;
practically the only ones which could become em-
bedded in a vessel wall. Diffuse secondary hema-
toma is observed, however, as a result of compres-
sion of a vessel on a sharp foreign body because of
external violence, excessive massage, or muscular
contractions. Late vascular ulceration is almost al-
ways due to infection ; most bullets and metallic
fragments, even after being embedded for years,
carry on their surface pathogenic organisms from
which infection may arise, Vascular walls defend
themselves against foreign bodies in three ways.
In the first, operative especially in the case of large
veins, a part of the circumference of the vessel and
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal,
the missile itself l)ecome surrounded by a mass of
eonncctive tissue. In the second process, the pro-
jectile is surrounded by fibrous tissue separated
from the elastic layers of the vessel, usually an ar-
tery, by a plane of cleavage, an actual serous bursa
resulting which eliminates all the risks of friction.
Thirdly, a small missile may be included in the thick-
ened arterial wall itself, the latter preserving a soft
adventitia free of adhesions. These methods of
vascular defense protect against both hemorrhage
and obliteration of the vascular lumen. The arterial
pulsations not only offer no obstacle to protection,
but facilitate the return of function by favoring lib-
eration of the vessel wall. Thrombosis and oblit-
eration are apparently no more frequent than late
hemorrhage. Partial penetration of a retained mis-
sile into the lumen of a permeable vessel, except in
aneurysm, must be exceedingly uncommon. These
effectual protective dispositions should be borne in
mind when one is attempting to decide whether or
not to remove a missile long embedded near a ves-
sel. Pulsation of a retained projectile is not, in it-
self alone, an indication for operation.
Blood Transfusion. — Dupuy de Frenelle and
Paychere {Prcsse medicale, May 13, 1918), in con-
ducting transfusion, employ merely a 125 or 250 mil
receptacle with its lower end bent at an obtuse
angle and brought to a point. Special ten to twenty
mil ampoules of anticoagulant solution are pre-
viously prepared. The following* solution was used
with complete success :
Sodii chloridi 4.75 grams;
Glucosi, 60.00 grams;
Sodii citratis, 50.00 grams;
Aquae destillatae, 500.00 grams.
Fiat solutio.
The glucose is of value to promote leucocytosis, as
a diuretic, as an antisepticemic, and to increase the
density of the solution, thus keeping it constantly
in the lower portion of the receptacle where clotting
usually occurs. The glucose also adds to the solu-
tion a degree of viscosity which is of importance.
The specific gravity of the ten per cent, citrate
solution is 1.072. To obtain a solution of the same
specific gravity as the blood, a formula containing
ten grams of citrate per 120 grams of solution would
be recjuired.
Blood Transfusion in Hemophilia Neonatorum,
— R. Lewisohn {American Journal of Obstetrics,
June, igiS") states that the mother's blood is just
as efficient for transfusion in these cases as that
of any other donor. The mother should, indeed,
be used as donor in every case, Cherry and Lang-
rock having shown that it can be employed safely
without hemolytic tests in newborn infants, whereas
the father and other blood relatives require a care-
ful test to prevent hemolysis and agglutination.
This fact is of the greater importance because it is
almost impossible to obtain enough blood from the
infant for the necessary tests. Furthermore, val-
uable time is saved, the mother being always avail-
able. Of eight cases treated by the author, six
were permanently cured by a single injection. The
citrate method can be safely used in the newborn ;
no reaction or chill occurred in any case. The in-
fants are usually brought to the hospital by the
father on the second day after birth. A member
of the house staff' is sent to the patient's home and
returns with 100 mils of citrated blood from the
mother. A superficial vein in the elbow region of
:he baby is then exposed by a very small incision.
The blood, heated to body temperature by immer-
sion in warm water, is then introduced through a
fine cannula. In a number of cases transfusion
stopped the bleeding immediately and permanently
after subcutaneous injections of serum had failed to
reduce the bleeding. Serum and intramuscular in-
jections of blood may be tried, as they seem to stop
the hemorrhage in a certain percentage of cases.
If bleeding recurs, however, immediate transfusion
is indicated.
An Emergency Method of Transfusion of
Citrated Blood. — P. Thevenard (Presse medicale.
May 9, 1918), in an extremely urgent case resorted,
in the absence of special transfusion apparatus, to
a very simple technic, which yielded excellent re-
sults. Into a graduated receptacle for saline solu-
tion, previously sterilized, is placed an appropriate
amount of sodium citrate, e. g., 1.5 grams for 500
grams of blood. The blood is collected directly
into the receptacle. The outlet communicates,
through rubber tubing, with an injecting needle hav-
ing a short bevelled portion. If a graduated recep-
tacle is not available, any receptacle with an outlet
can be used, its capacity having been determined be-
fore use by means of water poured from a litre
bottle. The donor is placed on a bed near the re-
cipient, tincture of iodine is applied at the bend of
the elbow, and the blood is obtained in requisite
amount by the old fashioned method of venesection.
Meanwhile the receptacle is constantly shaken or
the blood agitated with a sterile rod or instrument
to distribute the sodium citrate well through it. The
blood is then at once transfused into the recipient
by intravenous injection. The latter is generally ad-
ministered in one of the veins at the elbow, but
where more convenient the external saphenous at
the malleolus can likewise be utilized. With the re-
ceptacle placed about 1.5 metres above the bed, 500
grams of blood will flow into the recipient's vein in
about ten minutes. In this procedure local anes-
thesia is not required. If necessary the receptacle
can be replaced by a sterile funnel of known capac-
ity and the vein puncture needle by a large hypo-
dermic syringe needle.
Preoperative Purgation. — Max Minor Peet
(Journal A. M. A., July 20, 1918) contends that
preoperative catharsis has very little in its favor
and survives by virtue of its being a routine prac-
tice. It has many disadvantages among which are r
the physical and mental depression which follow
catharsis ; loss of sleep preceding the operation ; the
exertion required in the repeated use of the bed
pan ; the loss of intestinal and body fluids which is
greater than can be compensated for in several
hours bv the use of the Murphy drip; increase in
sensitiveness of the lower bowel and its reduced
ability to tolerate the rectal tube and saline or tap
water ; increased postoperative thirst which is mor?
difficult to relieve in the purged patient on account
of the preceding; the appearance of the condition
of hypotonicity of the small intestine through the
removal of the normal stimulus of semisolid mat-
September 7, .9.8.] MODERN TREATMENT AND PREVENTIVE MEDICINE.
435
ter, the loss of fluids and the temporary increased
peristalsis; and, finally, the alteration produced in
the intestinal flora with the preponderance of fer-
mentative organisms. The patient who has had a
laxative or purge before operation is more prone
to the development of gas distention, postoperative
ileus and severe gas pains than the one not so
treated. Comparative observations for the past six
years have shown that patients receiving a simple
enema before operation are in much better condi-
tion than those receiving laxatives or cathartics and
have much less thirst, nausea, vomiting, gas pains,
and abdominal distress. The experience of all
surgeons in those cases demanding operation im-
mediately, before there has been time for the
administration of a cathartic, is also in agreement
with these comparative observations. In fact,
theoretical, experimental, and clinical evidence is all
in favor of the abolition of purgation as a preopera-
tive procedure.
Medication in Children. — Herman B. Sheffield
(Medical Record, June 22, 1918) writes that diges-
tants are rarely needed in children while the bitter
tonics are not commended except nux vomica in
small doses. Quinine may be given by the intramus-
cular method in severe malarial fever in five grain
doses dissolved in fifteen minims of water two or
three times daily. Of the iron preparations the
tincture of the chloride, the syrup of the iodide, the
solution of the peptomanganate and the dried sul-
phate are preferred. Syrup of the iodide of iron
and codliver oil are well taken by young children.
As to alteratives, iron arsenate, one quarter to one
grain, is beneficial in the anemias, while Fowler's
solution may be pushed in the neurotic type of
chorea. Except in luetic aflfections the syrup of the
iodide of iron and the syrup of hydriodic acid
should be preferred to the iodide of sodium and
potassium.
Treatment of the Wounded by Means of Elec-
tricity.— H. T. Seeuwen {Archives of Radiology and
Electrotherapy, June, 1918) has treated paralysis,
paresis, neuralgia and neuritis with the faradic,
galvanic or sinusoidal current. Every case of recent
paralysis is carefully tested and subjected to one
month's treatment, even if there is no response to
electric current. Splints are used to keep the par-
alyzed muscles relaxed. When a muscle does not
respond at all the interrupted galvanic current is
used. Neuralgia is treated with the galvanic current
combined with the whirlpool bath and massage for
the limbs. Facial neuralgia is at times treated with
a galvanic current of great intensity, from sixty to
TOO milliamperes. For cases of neuritis the electric
treatment consists of galvanic baths of from fifteen
to twenty minutes' duration. A current of twenty
to fortv milliamperes is sufficient and for the last
two or three minutes slow interruptions with a
metronome and a milliamperage just sufficient to
contract the muscles are given. Treatment must be
carried on over a long period of time, from ten to
twelve months. Hysterical paralysis is best treated
with suggestion and strong faradic current applied
with a roller or the brush. Paralysis following
injury to the brain or the spine is treated by massage
and general and local applications of electricity.
Comparative Efficiency of Local Anesthetics. —
Torald Solhnann (Journal of Pharmacology ond
Experimental Therapeutics, February, 1918) asserts
that the wheal method of testing local anesthetics
in the human subject, is the most accurate, and can
be applied directly to injection anesthesia, though
not to surface anesthesia, for which the corneal
test is not suitable. The author's tests showed that
for injection anesthesia, cocaine, novocaine, tropaco-
caine, and alypin are about equally efficient. Beta-
eucaine is one half and quinine and urea hydro-
chloride one fourth as active. Apothesine, antipyrine,
and potassium chloride are but one eighth as active.
There are fairly large differences in the duration of
action, but these are insignificant when compared
with those resulting from addition of epinephrine.
The latter prolongs the action very greatly, except
with tropacocaine ; it does not, however, change the
minimal efficient concentration. Addition of soduim
bicarbonate to cocaine oi^ novocaine does not in-
crease the activity, in contrast to its effect in sur-
face or intraneural anesthesia. Mixtures of cocaine,
novocaine, and quinine and urea hydrochloride give
somewhat deficient summation without potentiation,
and are therefore without advantage. Mixtures of
the anesthetics with potassuim sulphate give only
simple summation ; this would be of some advantage
in reducing the amount of anesthetic required.
Quinine and Metallic Ferments in Malaria. —
J. Bouygues (Presse medicalc. May 13, 1918)
states that subcutaneous injections of quinine in
doses of three grams a day yield very favorable
results during the febrile periods in Macedonian
malaria. In the intervals of apyrexia, however, the
remedy seems useless. Some cases of the disease
completely resist large doses of quinine. The two
main causes of this quinine resistance appear to be
albuminuria and some ordinary infection coexisting
with the malarial infestation. Frequently there are
digestive and hepatic disturbances, as shown by
persistent headache, simple diarrhea, coated tongue,
rapid pulse, subicterus, and slight urobilinuria.
Addition of treatment with electraurol, collobiase
of gold or platinum or collargol given intraven-
ously to the quinine proved of great service in the
cases resistant to quinine. The doses of collobiase
of platinum and of collargol mentioned as having
been used are two and ten mils, respectively. The
immediate effect of such an injection is a febrile
reaction greatly resembling the actual malarial par-
oxysm. This is followed by a subjective feeling of
well being and within ten or fifteen hours by a drop
in temperature, generally to a point below normal.
The secondary effect is a stage of normal tem-
perature lasting thirty-six hours or longer, or even
permanently. Where the disturbance recurs, it is
invariably less severe than before, and the general
condition is greatly improved. The effect of the
injection is looked upon as an artificial crisis similar
to that of pneumonia ; there results the same copious
sweating, diuresis discharge of urea and uric acid,
loss of chlorides, and general euphoria. The only
contraindication to the metallic ferments is myocar-
ditis with feeble heart action. The quinine was
always continued for at least one day after the in-
jections of metallic ferments.
Miscellany from Home and Foreign Journals
Traumatic Shock. — Brechot and Claret {Bulle-
tin dc I' Academic de medicine, May 28, 1918) do
not regard as fundamentally different the hemor-
rhagic, toxic, and infectious forms of shock. The
hemorrhage, intoxication, and infection are mere
complicating conditions. The true criterion of ner-
vous, traumatic shock is not only a reduction of
blood pressure, but a reduciton of the differential
or pulse pressure, i. e. the difference between the
systolic and diastolic pressures. The extent of
diminution of the pulse pressure is of prognostic
significance. Of seven shocked wound patients
where the pulse pressure on admission was at least
thirty mm. of mercury with the Pachon instnunent,
six recovered and the seventh died after thirty-six
hours, not of shock, but of peritonitis. Of seven
cases with a pulse pressure of twenty-five mm. or
less, but one recovered, and this only with the help
of adrenalin, which rapidly increased the pulse
pressure. Above twenty-five mm. the prognosis re-
mains favorable in the absence of infectious com-
plications. At twenty-five mm. precisely, the prog-
nosis is doubtful, and becomes the more unfavor-
able the less persistently the patient reacts to cam-
phorated oil, saline solution, adrenalin, and perhaps
pituitrin. Below twenty-five mm. the prognosis
seems to be fatal. Another sign of shock, likewise
apparently related to vasomotor paralysis and the
resulting exosmosis, is a marked rise of intraspinal
tension. Among seven wound cases in grave, pure
shock, Claude's apparatus showed tensions ranging
from 303/2 to fifty, and averaging 39.6.
Bacteriological Examination of Chancres. — L.
Tribondeau (Paris medical, June 8, 1918) empha-
sizes that microscopic examination of a chancre for
detection of the spirochete of syphilis or Ducrey's
bacillus is easily carried out by any physician and
can be done in less than five minues. The procedure
is of extreme importance because it is the only one
permitting of early, efficient treatment of the true
chancre and abortion of the disease before secon-
dary symptoms appear. The public should be im-
pressed with the fact that any genital ulceration,
however insignificant in appearance, shonld be
shown to a physician without the least delay and
should not be treated with even mild antiseptics im-
til the bacteriological examination has been made. In
obtaining material for examination the chancre
should be wiped clean with moist, then dry, pledgets.
In its most suspicious and indurated parts, at its mar-
gins, a few small parallel scarifications, two or three
mm. long, should be made with a scalpel or vaccinat-
ing instrument, and the secretions brought up by
pinching and flattened out with the instrument on
two glass slides. These are to be dried without heat
or other artificial form of fixation. In the Fontana-
Tribondeau procedure three reagents are used :
First, a mixture of pure acetic acid, one mil, com-
mercial formaldehyde solution, two mils, and dis-
tilled water, 100 mils ; secondly, a mordant solution
of one gram of tannic acid in twenty mils of water;
thirdly, Fontana's solution, consisting of crystalline
silver nitrate, one gram, in twenty mils of distilled
water with ammonia gradually added until the
brownish precipitate first formed becomes decolor-
ized and passes into a slight opalescence. In stain-
ing the slide for spirochetes, hemoglobin is thor-
oughly removed with the first solution ; the prepara-
tion is next washed with strong alcohol and fixed by
igniting the alcohol on the slanting slide and almost
at once blowing it out again ; then the mordant solu-
tion is poured on and the preparation heated until
it steams but does not boil ; the slide is now removed
from the flame, but the solution not poured off for
thirty seconds more ; the preparation is next washed
for thirty seconds with tap water, rinsed quickly
with distilled water, Fontana's solution applied and
first allowed to act a few moments in the cold, then
renewed and heated until steam begins to arise ; the
stain is allowed to act fifteen seconds, then dis-
carded ; finally, the slide is washed with distilled
water for a few seconds, dried with filter paper, and
examined under oil immersion. The specific spiro-
chetes are distinguished from others by their gracile
form and fine undulations. For staining the Ducrey
bacillus on the second slide, polychrome blue with
ammonia is recommended.
Adrenalin Test of Cardiac Resistance to
Stress. — Loeper, Wagner, and Dubois-Roquebert
(Bulletins et meinoires^ de la Societe medicale des
hdpitanx de Paris, February 7, 1918) believe this
test serviceable for ascertaining in any individual
the capacity of the heart to withstand the stress im-
posed upon it in active mihtary service. The pro-
cedure consists in injecting one milligram of adre-
nalin and securing a tracing of the cardiac outline
with the x rays, immediately before and one-half
hour, one hour, and one hour and a half after the
injection. The first and third observations are the
crucial ones, the peripheral vasoconstriction induced
by the adrenahn, and its reaction on the size of- the
heart, often attaining a maximum one hour after the
injection. ' Tests were made in over one hundred
subjects. In normal individuals the heart outline
obtained one hour after the injection was identical
with the first outline, though occasionally after an
hour and a half the outline showed a slight reduc-
tion in size, ascribed to the secondary constricting
action of the drug on the heart muscle. In un-
dovibted cardiac impairment the test regularly
showed a striking enlargement of the heart, amount-
ing to one cm. or one cm. and a half one hour after
the injection. In seventeen out of twenty-three
cases the enlargement involved the entire heart ; in
six the left ventricle alone. In the clinically more
doubtful cases, viz., those of tachycardia, dyspnea,
or erethism without appreciable disease of the myo-
cardium, or pericardium, the adrenalin test permits
of making a decision as to the actual availability of
the heart for military exertions. The results of the
test cannot be clinically foretold, cases of arrhyth-
mia and extrasystole at times showing no cardiac
dilatation where those of simple tachycardia or fa-
tigue give a positive test. Dilatation under adrenalin
is thus thought to indicate a weakness of the heart
muscle, either intrinsic or of nervous origin, and
September 7, 191S.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
AZ7
arising from myocarditis, simple fatigue, or a valvu-
lar lesion. The test is positive sometimes in valvular
disorders, especially in mitral lesions ; in three out
of ten cases of aortic insufficiency it was negative.
Among cases of aortitis and aortic ectasia the aorta
was observed to dilate under the influence of the
adrenalin.
Thyroid Instability of Maximal Degree. — Leo-
pold Levi {Prcsse mcdicalc, June lo, 1918) re-
ports the case of a woman aged thirty-three, 164
cm. tall, and weighing but forty kg., who exhibited
alternately, and at tmies even in conjunction, pro-
nounced symptoms of hypothyroidea and hyperthy-
roidea. Under the influence of the nocturnal re-
duction in temperature, the patient passed into a
condition verging on myxedema, while in the post
menstrual period her condition suggested Graves's
disease. Intervening between periods of hypothy-
roidea and hyperthyroidea were normal periods, the
latter amounting, however, only to a few days in
each month. The instability witnessed is ascribed to
variations in the circulation through the thyroid, in-
ducing alternate states of inertia and overactivity in
its function. A partial hyperemia of the gland
awakens a paroxysmal hyperthyroidea upon a sub-
stratum of h3'pothyroidea. The patient also pre-
sented evidences of lowered ovarian activity and of
adrenal instabihty. She showed all the earmarks of
a lack of nervous equilibrium and of angioneurosis,
— in brief, a state of neuroendocrinic instability in
which participates to a predominant degree in-
stability of the thyroid itself.
Edema with Chloride Retention, Sequel to
Dysentery.— M. Labbe and M. Marcorelles
(Fresse mcdicalc, June 10, 1918) report two cases of
this description. In the first the edema appeared in
the stage of decline of an attack of dysentery of in-
termediate severity. In a few days the edema as-
cended from the feet to the scrotum, prepuce, ab-
dominal wall, and lower thorax. The urine was
scanty, but contained no albumin, sugar, nor casts.
The lungs and heart were normal, and the liver
small, the conjunctivae, however, showing a subic-
teric hue. Under a diet of milk and vegetables, with
salt restriction, and theobromine, the output of urine
rapidly rose to above normal and the edema
promptly disappeared. That chloride retention had
existed was indicated by the elimination of thirty-
seven grams of salt in a single day during the period
of diuresis. The cause of the edema might have
been a disturbance of the hepatic functions, the
case then belonging to the group of hydro-
pigenous hepatitis studied by Le Damany, in
which the liver cell creates the chloride re-
tention as does the renal cell in hydropigenous
nephritis. The dysentery might, however, also have
been the cause of the edema. In the second case
anasarca again appeared as a complication of dysen-
tery, in this instance a severe case with profound
anemia. Treatment was similarly effectual. In this
patient there were no traces of hepatic disturbance,
and the cause of the edema was quite obscure.
Cases of edema with chloride retention occurring in
the course of severe, nondysenteric enterocolitis in
children have been reported by a number of pedi-
atricians.
Involvement of the Cervical Cord through
Vertebral Luxation. — Roussy and Cornil (Presse
rncdicale. May 13, iyi8) report the cases of two
soldiers who showed immediate quadriplegia, the
one after dislocation of the atlas and axis with
fracture of the odontoid process, the other follow-
ing backward luxation of the fourth cervical ver-
telara. The second case developed sphincter dis-
turbances. After a period of spinal coma, lasting
six weeks in the first patient and four months in
*^he second the quadriplegia underwent retrogression
in a crossed manner, return of motion taking place
sinmltaneously in the upper extremity of one side
and tlie lower extremity of the other. Ten months
after thfe injury motor recuperation was almost com-
plete in both cases, the first patient still showing
traces of left sided hemiplegia and distinct hyperes-
thesia in the great occipital distribution, the second
a right sided brachial monoplegia and hyperesthesia
of the third cervical. These cases, corroborate the
(••jservations of Marie, Benisty, Claude, and
L'hermitte to the effect that quadriplegia from in-
volvement of the cervical cord is far from being
always as grave as it was thought before the war.
The earlv clinical signs often greatly exceed the
actual lesions, and a prompt unfaTprable prog-
nosis may prove erroneous.
Visceral Manifestations in Congenital Syphilis.
— H. Barbier (Bitlleti)is et memoircs dc la Societe
medicalc dcs hopifaux de Paris, March 7, 1918)
directs attention to certain nervous symptoms en-
countered by him in numerous cases of inherited
syphilis, viz., attacks of vomiting or of abdominal
pain, and incontinence of urine. The vomiting attacks
are most common among patients between the ages
of five and ten years. The attack starts suddenly,
while the child, perhaps, is playing or talking, and
without relation to meals. Usually it begins early in
the morning. It is preceded by prodromes, gener-
ally a frontal headache, sometimes very severe,
which appears a few hours or even days before the
vomiting. The headache disappears, as a rule,
rather rapidly after vomiting has set in. Some-
times there are also nervousness and peevishness.
Sleep is less sound than usual. Vomiting may be
repeated a number of times, up to twenty times
a day : in the latter event blood may appear in the
vomitus. The attack as a whole may last from a few
minutes to two or three days. When the vomiting
ceases, the child returns to its playthings. The attacks
are not periodic ; many of the patients have two or
three a year, but longer intervals may elapse. At
times a transitory meningeal syndrome supervenes,
with somnolence, irregularity of breathing and heart
action, and disturbed reflexes. The cerebrospinal
fluid yields a positive Bordet-Wassermann reaction,
but the blood reaction is variable. The attacks tend
to diminish toward puberty, but are previouslv amen-
able to systematic antisyphilitic treatment. Barbier
gives biniodide or small doses of potassium iodide
by mouth, avoiding inunctions which he has found
dangerous in these cases. Sudden attacks of enter-
algia with liquid stools, passing off suddenly, and
enuresis occurring alone or in conjunction with gas-
tric attacks in children of four or five years, are
other manifestations of inherited syphilis.
438
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Cerebrospinal Fluid in Nervous Commotion. —
Alestrezat, Bouttier, and Logre {Bulletin dc I'Aca-
demic dc mcdccine, May 14, iyi8) studied the con-
dition of the cerebrospinal fluid in a large number
of cases of nervous commotion due either to the air
disturbance attending explosion of a shell or to a
localized shock, without external wound. Over
eighty per cent, of such cases showed a manifestly
abnormal cerebrospinal fluid, characterized by hy-
peralbuminosis unaccompanied by pronounced other
changes, chemical or cytologic. This condition in-
dicates some degree of nervous disintegration, with-
out participation, however, of the meninges and
without infection. The number of cells per micro-
scopic field being diminished — doubtless by dilu-
tion, the intraspinal pressure being high — a signifi-
cant condition of albuminocytologic dissociation re-
sults. The increase of albumin in the spinal fluid
generally begins within two or three days and passes
off after a few weeks or months. Study of the
fluid is of diagnostic service, e. g., in cases of
wound or severe contusion of the scalp, in which the
pressure of a marked accompanying nervous com-
motion might otherwise be overlooked. Absence
of changes in the spinal fluid does not definitely ex-
clude nervous commotion, but their presence, and
especially the characteristic course of the disturb-
ance, conclusively prove that commotion resulting
in organic changes has actually been produced. The
information thus obtained is of importance in rela-
tion to medicomilitary and medicolegal decisions.
Alcoholism, malaria, meningeal reactions of auricu-
lar origin, and central nervous syphilis, should be
excluded as causes of any changes in the cerebro-
spinal fluid found in the individual case.
The Effect of Painting the Pancreas with
Adrenalin upon Hyperglycemia and Glycosuria.
—Israel S. Kleiner, Ph. D., and S. J. Meltzer, M. D.
{Journal of Experimental Medicine, June, 1918)
attempted to confirm the results of Herter and his
coworkers on the sugar producing effect of adrenal
substance when introduced intraperitoneally. The
present work does not unqualifiedly bear out Her-
ter's views. Three of twelve experiments by
Kleiner and Meltzer in which the pancreas was
painted with adrenalin showed no glycosuria, and
the remaining nine did not indicate anywhere near
so high a degree as Herter reports. They cannot
supjwrt the chief contention of Herter that the
"pronounced nature of the glycosuria following in-
traperitoneal injections appears to be mainly attri-
butable to the adrenalin which comes into contact
with the pancreas," particularly as when the pan-
creas was isolated from the rest of the peritoneal
cavity the glycosuria was about one third, and the
rise in blood sugar about two thirds, that obtained
by painting the unisolated pancreas. It therefore
appears that the increase in sugar is not of pan-
creatic origin following the painting of that organ
by adrenalin. Kleiner and Meltzer suggest the pos-
sibility that Herter's results might have been due to
the escape of adrenalin to the celiac ganglion, and
further, that in their own experiments the larger
production of sugar after painting the unisolated
pancreas may be owing to the fact that a large part
of the adrenalin escapes to the peritoneum.
Parotid Enlargement among Troops. — C. Alat-
tei {Prcsse mcdicale, June 13, 1918) states that
among a large number of men referred to military
hospitals with a diagnosis of mumps, only forty per
cent, proved to be true cases of mumps, while ten
per cent, were false parotid enlargements; the re-
maining fifty per cent., apart from rare instances of
parotiditis complicating infectious diseases such as
typhoid and scarlatina, were cases of continuous
parotid enlargement, without general disturbance or
any other clinical manifestation. These are patients
admitted often two or three times within a short
})eriod, presenting one, or more generally both, paro-
tids more or less prominent. The enlarged glands
are firm to the touch and feel lobulated. There is
no adhesion to the skin, no filtration of the sur-
rounding cellular tissue, and no pain nor trismus.
The enlargement appears insensibly and thereafter
rarely varies, the men being sent back to the front
after a few weeks with their parotids exactly as be-
fore. The condition might be termed an hyper-
trophic cirrhosis of the parotids, but whether it is
due to mouth infection, certain unsuspected general
infections, an intoxication, or some other cause is
as yet unknown. Of fifty cases carefully studied,
none had a clear history' of mumps earlier in life,
nor did any develop an orchitis in the course of the
protracted parotid enlargement. Arabs and the
Indochinese are known to be predisposed to parotid
swellings which subside upon the advent of spring.
The soldiers suflFering from parotid swelling ar2
generally over thirty years of age.
Polyneuritis and Hyperesthesia in Poliomyeli-
tis.— J. C. Regan {Archives of Diagnosis, July,
1918), from experience with numerous cases in New
York during the epidemic of 191 6, is convinced
that a polyneuritic form of the disease occurs. The
condition resembles very closely an acute multiple
neuritis. In the difl"erential diagnosis it is important
to remember that the latter affection is rare in
childhood, and occurs only after the acute specific
fevers, especially diphtheria. The main distinguish-
ing features are the history of the onset, the clinical
symptoms, the findings upon analysis of the cere-
brospinal fluid, and the progress and termination of
the disease. A distinct lymphocytic increase in the
spinal fluid — over forty cells per cubic millimetre —
strongly favors poliomyelitis. The so called acute
infective neuritis is frequently due to the virus of
poliomyelitis, though hitherto unrecognized as such.
Polyneuritis as a sympton occurs in probably over
one-half the cases of poliomyelitis, usually appearing
in the early paralytic stage when the initial hyperes-
thesia begins to subside : it may last a week or two.
or rarelv, for months. The upper limbs usually
escape. The condition is best detected by pressure
over the involved nerves, especially the sciatic, and
by passive motion. The movements in eliciting an
ankle clonus and Kemig's sign are notably painful.
A position of talipes cquinus my be voluntarily
assumed. Marked polyneuritis is exceptional in
tuberculous and cerebrospinal meningitis — a diflfer-
ential feature. Hyperesthesia is almost con.stant in
the preparalytic stage and is very marked in the parts
later to become paralyzed. It is not a specific sig^n,
however, as it may occur in any form of meningitis.
Proceedings of National and Local Societies
ASSOCIATION OF AMERICAN
PHYSICIANS.
The President, Dr. F. H. Williams, of Boston, in the
Chair.
Thirty-third Annital Meeting, Held in Atlantic City,
N. J., May / and 8, 1918.
{^Continued from page 399-)
The Serum Treatment of Meningitis. — Dr.
Simon Flexner said that the serum treatment
of epidemic meningitis began in 1907, coincident
with the decHne of the severe wave of epidemic
meningitis which spread over Europe and America
in 1904-5. Weichselbaum had found that the men-
ingococcus was the etiological factor. Figures were
obtained as to the mortality of the disease, accord-
ing to localities, and the fluctuations in mortality
and incidence according to districts. A definite
basis was established for a conception of the value
of therapeutic measures. There was no agreement
as to mode of penetration of the germ to the men-
inges. If blood cultures were made in persons in
the first days of the disease, positive cultures were
often obtained. The significant point was obvious
— either the meningococcus first got into the blood
and from thence invaded the meninges, or, perhaps
secondary infection of the blood occurred. At cer-
tain periods of the disease metastatic infections oc-
curred ; with involvement of the meninges were
seen lesions of joints, thorax, eye, etc. On the whole
the opinion had been held that the blood infection
was secondary, and that the meningeal infection
was lymphatic, by direct extension. Practice, based
on the older opinion, was influenced by clinical ob-
servation on cases observed for hours, days, or
weeks before diagnosis of meningitis could be made,
when infection of the central nervous system was
well established. Under these circumstances, an-
tisera, to be effective, must be injected directly into
the subarachnoid spaces. If the antiserum, how-
ever, was effective in the meninges, it would prob-
ablv also be so in the blood. Many cases could be
aborted by early intravenous injection of the serum.
According to Dopter's work in IQ09, the menin-
gococcus was not a fixed form, but involved a
group. Two strains might be distinguished cultur-
ally, but not clinically. Each strain had a number
of variants. Specific therapy, to be effective, must
be trulv specific. The dose must be in accordance
with immunological relationship and antibodies
must be adopted to the antigenic properties of the
organism. A movement was on foot to substitute
a monovalent serum for the polyvalent menin-
gococcus serum now used, just as soon as the ex-
act type of organism could be ascertained.
Intravenous Serum Treatment of Cerebro-
spinal Meningitis. — Major W. W. Herrick, of
Now York, said that in the military cantonment life
there had been an unusual opportunity for clinical
research and this had been used as a means of mak-
ing and keeping men fit for active service. Epi-
demic cerebrospinal meningitis cases had been seen
early and so it had been possible to control them
effectively. The disease was not primarily a men-
ingitis, but took the form of sepsis in the blood
stream which later localized in the meninges. Forty-
five per cent, of the cases were discovered fti the
premcningeal stage, with generalized infection and
no local involvement;^ About two weeks after the
blood stream infection, meningitis developed. One
patient, the head nurse in the ward, who had poly-
arthritis due to meningococci, was treated with
antiserum intravenously and made complete re-
covery. Complications of the diseases were many
— pleuritis, orchitis, pericarditis, arthritis, etc.
Cases in early stages responded at once to intraven-
ous treatment. The method of treatment was simi-
lar to Cole's method with lobar pneumonia. The
patient was given a desensitizing dose at the earli-
est possible moment, then after a dose of morphine
and atropine, a test dose of serum intravenously.
The serum was introduced slowly at a rate of not
more than one c. c. per minute. If untoward signs
appeared, the treatment was suspended, but re-
newed a little later. A 150 c. c. dose had been
given in serious cases. Treatment with large doses
had proved of value ; patients receiving 500 c. c.
did better and there were fewer deaths. If the in-
travenous treatment was to have any success at all,
the serum had to be used boldly and in large
amounts. The intraspinous method had not been
neglected, but it was not used in the premeningitic
stage. The combined treatment had been success-
fully applied. In serious cases, with the patient
unconscious and covered with a rash, recovery to
the point of being out of danger had taken place
within forty-eight hours. The largest intravenous
dose that had been given was 705 c. c, and the
greatest number of injections, ten. Disappearance
of the meningococci occurred within a few days.
There was very little of the delirium which had
characterized the 1904 epidemic. If the cases were
diagnosed early and treated by the intravenous
method, and the later cases treated by the com-
bined method, the mortality could be kept down to
fifteen per cent. These epidemics would in future
therefore be considered with more equanimity than
thev had been in the past.
A Potent Antimeningococcic Serum. — Captain
H. L. Amoss, M. R. C, discussed three essential
points : The passage of immune bodies from the
blood to the spinal fluid ; the mechanism of infec-
tion and the essential properties of the antimenin-
gococcic serum. The passage of immune bodies in
poliomyelitis had been studied and was considered
possible only under conditions of increased per-
meability of the choroid plexus. This would per-
haps be true of the meningococci. Increased per-
meability was measured by the agglutinin reaction
of the cerebrospinal fluid ; with a greater degree of
inflammation the agglutinin would go through in
greater concentration. After an intraspinous injec-
tion there was disappearance of agglutinin from the
blood in seven hours. There was noticeable a block-
ing effect on the immune bodies in the cerebrospinal
fluid after intravenous injection, though this had
t
440
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
not been definitely measured. Unless the permea-
bility of the meningochoroid plexus was increased
there was no passage of antibody. A certain accu-
mulation of immune bodies was first necessary in
the blood stream to produce this efifect of increased
permeability. A virulent culture of meningococci
intro(kiced intraspinously would cause meningococ-
cemia in a few hours but it remained to be seen
whether the organism in tlie blood stream would
produce meningitis. This did'hot follow, although
the organism remained viable for forty-eight hours.
Meningitis was not produced in the monkey by this
means, but it should be remembered that the
monkey was a comparatively insusceptible animal.
Antiseric reactions were always complicated by dif-
ferences in the strains. The sera produced by the
parameningococcus were very different from those
produced by the meningococcus. To get a potent
serum, the antibody zone should be raised. Less
specific antibodies as well as the agglutinins were
necessary factors. In sera which gave markedly
different results in treatment, there was no differ-
ence to be detected except that of agglutination. In
making a monovalent .serum the difficulty of getting
cultures was a great drawback, not more than fifty
per cent, of cultures being obtained. It was doubted
whether a high enough titre could be obtained with
the monovalent serum to warrant the efforts spent
in its production.
Dr. William H. Park, of New York, said that
the laboratories producing serum were in great dif-
ficulties as to how to get the best. Doctor Amoss
had said that the agglutinating properties were the
chief differences in the antisera and the agglutinat-
ing power was a measure of the curative power.
This was not the case with the pneumococci. Why
should the agglutinating power be a measure of the
curative power? The antiinfectious power was the
curative power. The agglutinative power did not
show whether the serum matched the strain, nor did
the complement fixation test. In the treatment of
cases at the Board of Health Laboratory in New
York, they had not been able to prove that the serum
produced from a large number of strains differed in
curative power. That, it was thought, was borne
out by the pneumococcus serum where the best were
those weak in agglutination.
Dr. Henry Koplik, of New York, said that the
differences in the civil and military aspects of the
disease were interesting. Granting that, as Doctor
Herrick had said, there was at first generalized sep-
sis, in some instances this was so mild as to be inao-
preciable. In a majority of cases of children in
civil life, the localized manifestations would call for
more intensive treatment than that for general sep-
sis. Several cases had recently been seen, however,
where the constitutional element was more predomi-
nant than the meningitic element. A child, in ap-
parently good health, was taken with a convulsion,
was covered with petechial rash, became unconscious
and then died. No meningococci could be shown in
the smear nor in the cerebrospinal fluid. Such cases
could be reached by intravenous injection. In spite
of the low mortality from the disease, these meth-
ods would be of value.
Dr. S. J- Meltzer said that he had expected to
hear from Major Herrick how the epidemic termi-
nated and the reason for it. This was an omission
of a very important point. In regard to the passage
of the infection through the choroid plexus, he coul(|
not understand why the choroid plexus alone was
affected; if the blood stream was reached and the
arteries, the cord and the parts below the cord would
be involved.
Dr. Lewei.lys F. Barker remarked that compli-
cations like polyarthritis, pericarditis, etc., came late
in the disease. If bacteriemia were present, compli-
cations of that kind might ensue. In the gonococcal
bacteriemia after urethritis there often occurred a
polyarthritis which later became suppurating. In-
fection might occur early and only become apparent
late in the disease. In addition to giving intravenous
treatment when general sepsis was present, it could
be used to combat local infections and to discourage
any foci that had become established as the result
of the bacteriemia.
Dr. Emanuel Ltrman, of New York, thought an
advantage might be gained by using combined intra-
venous and intraspinous treatment even in mild
cases. Recently he had seen a small group of cases
with panophthalmia and loss of sight which might
not have occurred if treatment had been instituted.
Dr. Augustus W.adsworth, of the New York
State Board of Health, said that there was great
variation in the potency of the sera produced by
different laboratories. It was important for the
physician to know the potency of the serum as indi-
cated by the agglutinin reactions and the comple-
ment fixation test. The only complete statistics
were those of the Rockefeller Institute. They kept
in touch with the distribution of the serum and clin-
icians who used it and received reports on all cases.
Regidations now required that the potency of the
serum be recorded.
Major Litchfield, M. R. C, Camp Upton, said
the use of intravenous injections in all cases had
been adopted very early at the camp. He would
utter a word of warning : Young men were apt to
be overconfident when they had given many injec-
tions without ill effects being seen, but with the
growth of the antipneumococcic and antimeningo-
coccic therapy, trouble would be encountered and
accidents would occur again and again if desensi-
tization was not carried out.
Dr. Simon Flexner recommended in civil life
applying the principles taught by military practice.
When meningeal involvement existed the combined
treatment could be used. The extent to which an-
tibodies might pass from the general circulation to
the choroid was an important question. In reply
to Doctor Meltzer, he would say that Doctor Amoss
had spoken of the meningochoroid complex, not of
the choroid alone as having affected permeability.
The measurement of antibodies was not perfected
as yet and anv test had to be used that would bring
out the important point of specificity. If the or-
ganisms produced disease, this had to be counter-
acted. The only test showing specificity was agglu-
tination.
Major W. W. Herrick, M. R. C, said it was
important to keep in mind any focus of infection
in the body. The intravenous treatment cleared up
September 7. 19.8.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
441
the picture entirely. The intraspinous method was
used when the meningitis was established. The
subcutaneous method was used on infants. Doctor
Meltzer asked how the epidemic terminated. It had
not yet terminated. In regard to potency of the
serum, physicians should know both type and po-
tency. Several types were necessary so that if the
case failed to respond to one, it might be changed
quickly to another. The price should be standard-
ized by the government. Major Litchfield's advice
as to care in injections was very timely. The
syringe had been abolished and a device for giving
one c. c. per minute adopted. In this way accident
was avoided.
ThrombDsis of the Coronary Artery. — Dr. J. B.
Herrick, of .Chicago, stated that death need not
immediately follow obstruction of the coronary ar-
tery. Cases on accurate diagnosis were more com-
mon than had been supposed. Patients were
arbitrarily divided into four groups : Those with in-
stantaneous death ; those in which death soon fol-
lowed : those in which death occurred weeks or
months later ; also a hypothetical group — in which
symptoms were very slight, being merely an ob-
struction of the twigs of the artery. The third
group was important. In such cases, patients had
frequently had angina pectoris and they described
the occurrence of the coronary obstruction as the
most acute and prolonged attack they had ever
had. The pain usually was referred to the epigas-
trium. Occasionally it simulated an acute ab-
dominal syndrome and careful differentiation was
necessary, as otherwise unnecessary operations were
sometimes performed. In experimental work on
this subject, it had been found that dogs could live
weeks and months after the ligation of the coronary
artery or might finally even recover. In certain
ligations, the lesions were produced in the myocard-
ium. They were most marked in the endocardial or
subendocardial locality, or conductive region of the
heart. Such phenomena as auricular or ventricular
tihrillation were produced with changes in the elec-
trocardiogram in the T-wave. This work might in-
terpret abnormalities in the human electrocardia-
gram and later work might serve to show just
which branch of the coronary was obstructed. The
work, it was hoped, would be confirmed by autopsy
findings and studv.
Dr. George Dock of St Louis, gave a case his-
tory of a patient, a man of sixty-one, who had
never had occasion to consult a doctor for any ill-
ness and had been doing active work for forty
years. He held an administrative position at a
university. He ate heavily, but took little exercise.
He was apparently vigorous, but was arterio-
sclerotic. He denied syphilis, and had no scar, but
the Wassermann was four plus and it was found
that he had a marked arteriosclerosis. After a
Christmas dinner he was returning to his house and
climbing a small hill, when he felt a very severe
pain radiating down the left arm and was obliged
to stop. The physician who attended him said it
was angina pectoris and high blood pressure, and
gave him nitroglycerin. The man went to work
until January 6th, when he had another attack and
wxis brought to the hospital. He had air hunger to
a marked degree and the larynx worked with ex-
treme violence. Morphine and atropine relieved
the symptoms. He did not recover from the or-
thopnea. Later he developed hydrothorax. Doctor
Robinson took the electrocardiogram and without
knowing that a diagnosis of coronary thrombosis
had been made, stated that the absence of the T-
wave would suggest coronary obstruction. The
patient died of double hydrothorax twenty-three
days after the first attack of angina pectoris. Post
mortem examination showed very marked syphilitic
arteriosclerosis.
Dr. H. A. Christian referred to the two groups
of patients mentioned by Doctor Herrick. The
first, those with symptoms below the diaphragm,
simulated abdominal conditions. These were fre-
quently operated upon. A diagnostic point was the
remarkable fall in systolic blood pressure ; the dias-
tolic pressure was little altered. The pulse pres-
sure was strikingly small. The second group was
that in which thrombosis took place with very few
symptoms ; the patient, while ill, did not present a
characteristic picture and death was caused by rup-
ture through the softened heart wall and hemorrh-
age. From a pathological study, it was evident that
a chronic thrombosis had taken place, but it had
produced very few symptoms.
Dr. S. J. Meltzer spoke on the experimental
side. It should be kept in mind that human cases
were not identical with ligation cases. Ligation
affected other tissues. It might be nervous struc-
ture (in spite of the myogenic theory) or it might
be the conductive system. One could not be sure
that the ligation was thorough enough or permanent
enough. It would be well to repeat the old ex-
periments from a new light, to occlude the coronary
artery without ligation. To Doctor Meltzer's ob-
jection that experimental ligation cases did not
duplicate the diseased condition of the patient. Dr.
J. P.. Herrick replied that it was not possible to
duplicate exactly the diseased condition as it oc-
curred in man. The method of ligation of the
coronary with silk was used, the dog was etherized
and tracheal insufiflation was performed. A great
field for experimental work in the way of produc-
ing chronic obstruction was thus opened. In the
human subject, the occlusion of the coronary was
not always complete. In animals many remained
healthy for some months with occlusion.
Myrtol and Eucalyptol Poisoning. — Dr.
Levvellys F. B.\rker, of Baltimore, made this re-
port, saying that in view of the fact that myrtol,
a preparation closely allied to eucalyptol, was used
in treatment of putrid bronchitis, it was worth while
to mention that symptoms of poisoning had been
recorded from these preparations. Eucalyptol pois-
oning had followed both overdoses and small doses
of the drug ; some persons had an idiosvncracy for
it. Two different syndromes were noted in the after
eft'ects : First, nervous system involvement with col-
'lapse ; second, dermatitis. In the nervous type the pa-
tient became seriously ill shortly after the dose.
Vomiting, diarrhea, and coma might follow. Vomit-
ing should be induced to prevent further absorption
of the poison. .Skin lesions were often associated
with the nervous lesions. Several fatahties had been
442
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
reported from time to time. A greatly increased use
of eucalyptol had resulted from its employment as
a solvent for the Dakin solution, dichloramine-T.
It would be interesting to know if any ill effects had
been observed from its use. Doctor Flexner re-
marked that paraffin had now supplanted eucalyptol
as a solvent for dichloramine-T.
Myelocytic Leucemia as Influenced by Splenec-
tomy.— Dr. H. Z. GiFFiN, of Rochester, Minn.,
said in the history of splenectomy for myelocytic
leucemia few cases with recovery had been re-
ported. There was a ninety-three per cent, mor-
tality. If reduction of the spleen by means of rad-
ium could be effected, before operation, the mor-
tality could be considerably lowered. Twenty cases
were now reported in which preliminary radium
treatment had been given. Of these, nine patients
had died after varying lengths of time. Of the
living patients the disease had apparently pro-
gressed as it would without splenectomy. The only
advantage of the operation was an addition to the
comfort of the patient.
Rontgen Ray Diagnosis of Peptic Ulcer. — Dr.
Julius Fkiedenwald, of Baltimore, and Dr. F. H.
Baetjer, of New York, presented this report of
753 patients who were examined first clinically
and then sent for x ray examination, without note
of clinical findings, to see how closely the x ray
findings corresponded. There were three groups :
First, those operated upon where the diagnosis was
proved ; second, cases with positive x ray and clini-
cal signs; and third, doubtful cases. It was found
that duodenal ulcer was easier to diagnose than
gastric ulcer. The functional signs were important
for diagnosis, hyperactivity indicating presence of
an ulcer. Complications, such as abdominal adhe-
sions were apt to mask the findings and the clinical
history must be considered before making diag-
nosis. On the other hand the x ray would often
clear up misleading clinical signs. In the differen-
tiation between gastric ulcer and malignant condi-
tions, the clinical history had to be carefully
weighed. Indurated ulcer often tended to become
malignant, but a microscopical examination at opera-
tion was necessary to clear up the diagnosis. Ab-
sence of X ray signs excluded ulcer from the diag-
nosis. It was shown by the x ray that a long period
of complete rest was necessary in order that the
ulcer might heal.
Dr. L. F. Barker, of Baltimore, said that in re-
gard to the motility of the stomach as shown by
the x ray, they always made a rule at an examina-
tion to have plates taken at short intervals, so as
to gel a better idea of the gastric function. It was
difficult to make a diagnosis between pyloric ob-
struction and. malignancy. Other evidence was
needed in addition to the x ray ; a laparotomy was
often necessary.
Dr. T. R. Brown, of Baltimore, considered the
fluoro.scopic examination of the stomach the ideal
method. The series of pictures showed the exact
function of the stomach. He had used the fluoros-
cope in ten thousand cases and the percentage of
correct diagnoses was as great as with the x ray.
Dr. F. H. Baetjer said that the rontgenographic
diagnosis was in accordance with the clinical find-
ings in seventy-five per cent, of cases. It ought to
agree up to one hundred per cent. The adhe-
sions of chronic appendicitis often gave confus-
ing symptoms. The reflex activity of the stomach
from other conditions could not be ruled out. The
stomach could not be considered as a fixed organ ;
it was variable as to its position and motility. What
was normal for the mdividual must be considered.
The X ray could never give exact findings of the
stomach as it could of fixed organs. Diagnoses
could not be made from x ray findings alone ; these
must be associated with all the other clinical signs.
Healing of Peptic Ulcer. — Dr. B. W. Sippy, of
Chicago, read this paper. The protection of the
ulcer from the digestive action of the gastric j^uice,
by hourly feedings and the early giving of alkalies,
formed the basis of treatment outlined. This treat-
ment had been applied to 2,000 cases, of varying
duration from one month to thirty years. The
average duration was four years. The ulcers were
of varying degree of penetration. The ulcer healed
rapidly by cicatrization. It could be said that opera-
tive procedures had a definite mortality which
weighed against this method of treatment. Un-
less the cases were to be operated upon, healing
must take place. Three points were connected with
the healing of tdcers : What were the causes of
ulcer ; what prevented their healing ; what could
be done to promote healing? By answering these
(|uestions one could arrange a rational method of
treatment. As to cause, the mucous membrane of
the stomach, from lowered resistance (perhaps
vascular or perhaps from bacterial invasion) became
digested and an ulcer was formed. Pepsin had a
solvent action on albumin sensitized by free acid.
In ulcer cases, therefore, it was necessary to de-
=;troy the digestive action of the juice. This could
be done by the method outlined. In pyloric ob-
'■truction ninety per cent, of the patients had been
relieved in from one to three weeks.
Case of Bulimia. — Dr. George Dock, of St.
Louis, in presenting this report reminded his
hearers that the textbook descriptions of this
condition agreed mainly upon the polyphagia, and
that goitre was supposed to be a factor in this
condition. In the case presented, the patient, an
architect, aged thirty-six, was obliged to eat ab-
normally to avoid intense headaches which de-
veloped when he felt hungry. Apparently he had
no regular eating time, but always carried with him
a quantity of toasted bread cubes and six to eight
shredded wheat biscuits. The history was vague.
He was well until twenty-one, then began to suffer
from eructations of gas, a condition which he called
"gastritis." At twenty-two he had paralysis of the
right arm. He now weighed 215 pounds. Gland
extracts had no effect on his condition. He was a
large man, but with no pathological distribution of
fat or hair. There was evidently a slight neuras-
thenic element in the case. Upon examination it
was found the man had marked nasal obstruction
by polyps, with suppuration of both antra and ex-
tremely bad teeth. There was a slight polycythemia.
The Wassermann test was negative. The stools
were very large and full of undigested fibre. Bulky
vegetables were supposed to relieve the patient's
Septcml)pr 7, 19 iS.]
BOOK REVIEWS.
443
hunger better than meat. In twenty-four hours he
consumed about 7,000 calories. The stomach and
ahmentary canal were normal, but rather large.
The patient showed marked impatience with tests
that interfered with his eating. No metabolic, in-
testinal, or pancreatic diseases were discovered.
The marked sinus disease suggested irritation by
an impulse such as known in itching diseases.
Treatment was instituted and consisted of removal
of bad teeth and draining of the sinuses, which
were full of foul pus. After this the headaches
and abnormal appetite disappeared within one
month. The patient had a normal weight and was
without symptoms. It was a platitude in medical
teaching that diagnosis meant covering the whole
condition of the patient. In this case there seemed
no connection between the disease and the cure ;
tiie condition was mentioned as being unusual in
its cause and treatment.
Comparative Food Value of Protein, Fat, and
Alcohol in Diabetes Mellitus. — Dr. H. O. Mosen -
TiiAL, of Baltimore, in this paper said it was de-
sired to maintain the protein tissue in spite of using
a carbohydrate free diet. The patient was put
upon 1,000 calories with a constant proportion of
protein and fat. Then 500 calories of protein, fat
or alcohol were added. Three periods were used :
fat period, alcohol period, protein period. Finally
there was a control period. On 1,000 calorie diet
there was a constant loss of nitrogen. When 500
calories of fat were added there was no great im-
provement in the nitrogen balance. The fat was
assimilated, but did not spare the protein. The
same held true with alcohol. The alcohol possibly
saved the body fat but not the nitrogen. The re-
sults with protein addition were strikingly dififerent.
The positive nitrogen balance was very marked in-
deed with 1,500 calories. There was thus opened
up a method of therapeutic treatment for these
patients, which seemed to be brought about in a
way which did not occur in the ordinary individual.
The previous diets had evidently affected the pro-
tein. Two patients who had not taken the alcohol
did not get the results. The fat and alcohol had
been used to conserve the fat of the body, while the
protein preserved the protein.
Fractional Examination of the Duodenal
Contents. — Dr. Max Einiiorn, of New York, re-
ported this subject. The duodenum, it was stated,
played an important role both physiologically and
clinically. In this organ the acid contents of the
stomach became alkaline. The duodenal juice was
studied with regard to alkalinity : First, in patients
under duodenal alimentation ; second, in those who
had duodenal instillation with water. The tubes
being already in place, examinations were easily
made. Fluid food was used, beef bouillon : thirty-
two persons were examined. Fastmg duodenal
contents were aspirated. Beef bouillon was then
introduced and the contents aspirated again. The
degree of alkalinity and the amount of amylopsin
and trypsin were determined. Cases were graded
according to acidity. It was supposed that alkal-
inity would be less with hyperacidity of the stomach,
but this did not hold good.
(To be concluded.)
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to reviczv them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
The Proteoniorphic Theory and the New Medicine. An
Introduction to Proteal Therapy. By Henry Smith
Williams, R. Sc., M. D., LL. D., Member of the Na-
tional Committee for Mental Hygiene, and of the Hy-
giene Reference Board of the Life Extension Institute;
successively Patliologist to the Iowa State Hospital at
Independence ; Assistant Physician to the Blackwell's
Island and Bloomingdale Asylums, and Medical Super-
intendent of New York Infant Asylum and the Randall's
Island Hospitals, New York City. New York: The
Goodhue Company, 191 8. Pp. viii-304.
This elaborated m.onograph, in which the author sets forth
his theor}' of the proteoniorphic or proteal treatment of
cancer and the application of it as a practical measure, is
of wide interest. It reveals a careful examination and
consideration of his subject as he has occupied himself
with it scientifically in the laboratory and in clinical prac-
tice. He has chosen for it so wide a basis of comparative
study of the results heretofore achieved in laboratory re-
search and experimental therapeutic work that it would
stand alone in interest and in scientific merit as a review
of investigation, discovery, and therapeutic use of the prin-
ciples and facts of protein hydrolysis, immunization, and
the mechanism through which these are carried out. Upon
such a background he bases his own discoveries, theories,
and his attempt to make these practical and effective in all
conditions where lie believes the diseased condition may
be suspected or proved to be the result of a disturbance of
the protein metabolism of the body so that insufficient
proteolysis is taking place. His interest and attention
have been chiefly given to this in regard to cancer, which
he believes to be explained under such an hypothesis, "as
a systemic condition characterized by the development of
neoplastic cells of a somewhat embryonic type, in con-
junction with an excess of leucocytes in the blood and a
deficiency (actual or relative) of red blood corpuscles."
For he considers this state of the cells of the blood to
be the cause to a large extent of the disturbance of the
protein metabolism. In order to substantiate this he dis-
cusses at length the production of antibodies, the probable
defense hydrolysis of all cells of the body and the setting
apart for this work of cells whose function is particularly
this defense, in which they to a marked extent support and
supplement the other cells. These are the leucocytes and
the red corpuscles, and each has its special function in this
process, the red cells completing the process begun by the
leucocytes.
Cancer imder this conception is not viewed as the result
of a specific pathological entity, but rather of a specialized
condition produced by the failure of the successful carry-
ing nut of the proteolytic process by both leucocytes and
erythrocytes. Thus a state of veritable malignancy may
be attained by any neoplastic growth not sufficiently over-
come by the cooperation of the cells whose function it is
to defend the organism against such proliferation. The
malignant effect lies not in the neoplasmic growth but in
the products liberated in the system by imperfect hy-
drolization of these cells by the body enzymes. Therefore
the whole therapeutic theory becomes one of increasing
this protein hydrolysis by the parenteral introduction of
foreign proteins and protein byproducts, to constitute anti-
gens stimulating the defensive activities of the system
against such a condition.
It is possible only briefly to indicate the author's careful
and detailed discussion of this whole principle as worked
out step by step in the history of investigation and dis-
covery in biochemistry, and his cautious presentation of
claims as to- its applicability, theoretically and clinically,
to the problems of cancer. His survey is a broad one, not
only historically and in the consideration of the possibili-
ties which lie within the theory and the proteal therapy;
but he also considers the various factors within the organ-
ism which play their part in metabolism and its disturb-
444
BIRTHS, MARRIAGES, AND DEATHS.
*
[New York
Medical Journal.
ances or assist in tlie reestablishment of a sufficient protein
hydrolysis. These, among other things, are the influence
of the hormones from the endocrinous glands and vasomo-
tor influence. He might have added something still fur-
ther in regard to the action of psychic influences largely
through these mechanisms supplied by the vegetative
nervous system. These influences bear perhaps strongly
upon the production of cancer as well as of other disor-
ders, asthma, psoriasis, and so on, to which he believes
the protein therapy applies. The book is well worthy of care-
ful study, both in its broad perspective and because of the
carefulness and restraint with which the author presents
his theory and reports his experience.
Diseases of the Heart. With a Chapter on the Electro
Cardiograph. By Frederick W. Price, M. D., F. R. S.
(Edin.), Assistant Physician to the National Hospital
for Diseases of the Heart, London ; Late Lecturer on
Poiygraphic Methods at the Medical Graduates' Col-
lege and Polyclinic. With 245 Figures. London : Henry
F^ipwde (Oxford University Press) and Hodder &
Stoughton, 1918. Pp. 470.
This book is unique in that it lays special emphasis on the
use of the sphygmograph and ink polygraph as an aid in
diagnosis. A special chapter on the electrocardiograph is
added at the last, since, as the author says, the general
practitioner would find little use for it in routine work.
Sphygmographic tracings are used throughout the book
and substantiate only too clearly the fact that general use
should be made of these appliances. It is refreshing to
find so thoroughly scientific a work written in such a clear
and lucid style.
The first chapters discuss in detail, with illustrations,
the anatomy of the heart, and many cardiacycle diagrams
are demonstrated. The interpretation and significance of
physical signs and murmurs are discussed. In the chapter
on the venous pulse the making of cardiograms and phlebo-
^rams is explained by the use of either a tambour at-
tached to a Dudgeon's sphygmograph and a smoked paper
drum, or by the use of MacKenzie's ink polygraph. Chap-
ters are given on the prognosis and treatment of functional
disorders of the heart, on sinus irregularity, extra systole,
heart block, auricular fibrillation, auricular flutter, and
paroxysmal tachycardia. The essential cause of heart fail-
ure lies in the weakness of the myocardium. The best
test of the heart state is the functional efficiency test, that
is, how the heart responds to exertion. The author says
that partial heart block occurring in infectious diseases
may be the only sign of myocardial involvement and
should be watched for. Some polygraph records are given
that show this. Chronic valvular diseases are also fully
considered, and there are chapters on pericardial affections
and myocardial diseases, which last the author considers
the most serious of all.
The book, in its clearness and definiteness, takes one
back to the physiological laboratory. But in addition to
the new methods it handles with great thoroughness the
more ordinary methods of diagnosis. Its advantage lies in
its manner of illuminating a subject so often left befogged
in the discussions and controversies of a book of less ex-
perimental method.
Hotv to Enlighten Our Children. By Mary Scharlieb,
M. D., M. S., Author of A Woman's Words to Women,
etc. New York: Fleming H. Revell Company, 1918.
Pp. 192.
Much practical common sense is here combined with a
clear scientific presentation of important considerations
for parents in the sexual training of their children.
The facts are presented in their everyday bearing upon the
growth and development of the child of either sex. Partic-
ular emphasis is laid upon the increase of growth and de-
velopment at puberty with the problems that present them-
selves then and throughout the period of adolescence.
Particularly clear and fearless and sane is the discussion
of the relation of the child's development to its socially
sexual function and its preparation for matriage and re-
production with training to avoid the dangers which beset
this pathway. This includes a particularly clear discus-
sion of syphilis and gonorrhea and their relation to the
parents' responsibility in training, as well as the existence
and extent of syphilitic and gonorrheal injury to the un-
born and the developing child. Eugenics is mentioned in
a brief and practical manner.
The tone of the book, even with its scientific value, yet
lays too much emphasis upon some rather overstrained
points of view, which have proved themselves more ef-
fectually dealt with in a more direct fashion based upon
very definite genetic facts. There is not sufficient recogni-
tion of the fact that children are unfolding very definite
sexual impulses, even if not of an adult type, throughout
the years before puberty ; there is not, for instance, enough
penetration into the instincts and impulses which make for
unnatural practices, such as masturbation. The discussion
of this condition is somewhat limited, and its physical
results are somewhat overemphasized, while the psychical
results are not dwelt upon to any extent. The tendency
throughout the book is to emphasize the external or physi-
cal, in spite of the fact that there is need of a more pene-
trating psychology in this study of development.
<$>
Births, Marriages, and Deaths.
Died.
Banks. — In Nashville, Tenn., on Tuesday, August 6th,
Dr. David F. Banks, aged sixty-four years.
EoYNTON. — In Los Angeles, Cal., on Tuesday, August 2d,
Dr. Sumner Hamilton Boynton, aged seventy-two years.
Broome. — In Los Angeles, Cal., on Tuesday, July 23d,
Dr. William John Broome, aged thirty-four years.
Bry\n. — In Coming, N. Y., on Saturday, August 24th,
Dr. Edward W. Bryan, aged eighty-six years.
Clardy.. — In Hopkinsville, Ky., on Saturday, August
loth. Dr. John D. Clardy, aged ninety years.
Cleckley. — In Augusta, Ga., on Sunday, August 4th, Dr.
Marsden A. H. Cleckley, aged eighty-six years.
CoLCORD.. — In Port Allegany, Pa., on Wednesday, August
7th. Dr. Joseph B. Colcord, aged fifty-six years.
Darrough. — In Kansas City, Mo., on Friday, August 9th,
Dr. John Niven Darrough, aged thirty-one years.
Day. — In Newark, Ohio, on Tuesday, July 30th, Dr.
Henry Day, aged seventy-nine years.
Dietrich. — In St. Joseph, Mich., on Tuesday, August
13th, Dr. William A. Dietrich, aged sixty years.
GiBBS. — In Mason City, la., on Saturday, August 17th,
Dr. Harry Emmons Gibbs, aged thirty-six years.
Greenfield. — In Westfield, Pa., on Saturday, July 27th,
Dr. Arthur M. Greenfield, aged sixty years.
Halsted. — In New Brunswick, N. J., on Wednesday,
August 28th, Dr. Byron David Halsted, aged sixty-seven
years.
Jeffrey. — In Mount Kisco, N. Y., on Monday, September •
2d, Dr. Alexander MacLean Jeffrey, aged fifty-nine years.
Kempster. — In Milwaukee, Wis., on Thursday, August
22d, Dr. Walter Kempster, aged seventy-seven years.
Kent. — In West Liberty, Ohio, on Sunday, August nth,
Dr. Guy Jacob Kent, aged forty years.
King. — In Mayesville, S. C, on Wednesday, July 17th,
Dr. Claude Evans King, aged forty-six years.
Martin. — In American Red Cross Hospital No. 4. Liver-
pool, England, on Sunday, July 28th, Lieutenant William
Joline Martin, M. R. C, U. S. Army, of Wilkinsburg, Pa.,
aged forty years.
Massman. — In Chicago, 111., on Monday, August 12th,
Dr. John Massman, aged seventy-nine years.
Norton. — In Lake Village, Ark., on Friday, August 9th,
Dr. Marion Madison Norton, aged forty-five years.
Perkins. — In Lynnhaven, Va., on Saturday, July 13th,
Dr. Richard C. Perkins, aged ninety-five years.
Peters. — In Kokomo, Ind., on Thursday, July 4th, Dr.
Daniel C. Peters, aged fifty-eight years.
Ream. — In Effingham, 111., on Saturday, August 24th,
Major William Roy Ream, M. C, U. S. Army, of San
Diego, Cal., aged forty-one years.
Southward. — In Carey, Ohio, on Tuesday, August 6th,
Dr. James D. Southward, aged fifty-seven years.
Spiegleberg. — At Qiateau-Thierry, France, on Monday,
July isth. Lieutenant Sidney Lehman Spiegleberg, M. R. C,
U. S. Army, of New York, aged thirty-seven years.
Thompson. — In New York, on Thursday, August 29th,
Dr. William L. Thompson, aged forty-one years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal r^i Medical News
A Weekly Review of Medicine, Established 1 843
Vol. CVIII, No. 11.
NEW YORK, SATURDAY, SEPTEMBER 14, 1918.
Whole No. 2076.
Original Communications
THE RELATiyE VALUE OF PASTEURIZED
AND CERTIFIED MILK.
Especially in Relation to a Limited Outbreak of
Intestinal Infection at Atlantic City, and the
l^'aliie of the Certificate of the Milk Com-
mission of the Pediatric Society of
Philadelphia.
By Solomon Solis Cohen^ M. D.,
Philadelphia.
THE INFECTION.
Dr. X. has four children. These, after weaning,
were, during the remainder of their infancy, fed
upon cow's min<, pasteurized and modified at home.
They continued through childhood and youth to use
home pasteurized milk in rather generous quantities.
The milk was obtained from a trustworthy dealer.
The children's diet, of course, was at all times prop-
erly varied. It included, among other things, a suffi-
cient amount of uncooked fruit juices and also,
during the transition period from infancy to child-
hood, a daily quantity, greater or less, of fresh beef
juice, i. e., juice pressed from a portion of the lean
round that had been heated — but not cooked — in
the wire broiler. These children had their fair
share of the ailments of childhood and youth,
measles, whooping cough, scarlet fever, diphtheria
5hd the like ; but they did not have any gastro-
enteric infections. Neither did they suffer from
scurvy or any other nutritional disorder or blood
dyscrasia. Also, Dr. X. saw in his practice a fair
number of children of various ages. Their feeding
was conducted on the same lines as that of his own
children. Neither scurvy nor rickets developed in
any of the children so fed, nor did gastroenteric
infections appear among them. Cases of scurvy,
rickets, and gastroenteric infections were met with,
but not among those whose feeding had previously
been controlled. »
Dr. X. is not a specializing pediatrist, but a gen-
eral physician, or as the current term goes, an
■'internist."
Dr. X.'s eldest son in due time arrived at man-
hood and married. His daughter, after weaning,
was, under the direction of a good pediatrist, placed
upon milk modified at home, but not pasteurized.
Instead, milk certified by the Milk Commission of
the Philadelphia Pediatric Society used; and
in due time, other appropriate articles were added
Copyright, 1918, by A.
to the diet. The child thrived, and escaped any
serious illness, until in her twenty-sixth month,
namely, August, 191 7, while summering at Atlantic
City, when she was suddenly seized, one hot Sun-
day afternoon, with severe griping pains, followed
in a few hours by fever, vomiting, and purging.
Dr. William J. Carrington was summoned, and
diagnosed an acute ileocoHtis, probably caused by
milk. The stools were examined both microscopic- •
ally and bacteriologically, and the results confirmed
the diagnosis. Unfortunately, the milk supplied for
the child had all been used and could not be studied.
It was from the same highly reputable concern
which had supplied the family in the city, and was
likewise certified by the Milk Commission of the
Philadelphia Pediatric Society. The little girl suf-
fered so severely and became so much prostrated
that the grandfather was recalled from his vaca-
tion to consult with Doctor Carrington, whose
diagnosis and treatment were approved. In due
time, after protracted and dangerous illness, evi-
dently the result of virulent infection, the child
recovered.
Doctor Carrington was called the same day to
see the infant child of another Philadelphia physi-
cian whom we will call Doctor B. The household
of Doctor B. received its milk from the same con-
cern that had supplied Mr. X., and with the same
certificate. Doctor B.'s child also had a virulent
intestinal infection ; and while the ultimate result
was likewise a happy recovery, the illness, as in
the case of the X. child, was severe and dangerous.
In the B. case, Doctor Carrington consulted with
a physician whom we will call Doctor M., and was
informed that there was at the time in a certain in-
stitution at Atlantic City attended by Doctor M.,
a small house epidemic of ileocolitis, presumably
from infected milk. This institution is supplied,
in part, by the same milk company which supplied the
families of the two children attended by Doctor
Carrington ; but as no individualizing record of food
was kept, it is impossible to prove — however prob-
able it seems — that all the sick children got this
milk, or that all the children who escaped received
milk from other dealers.
Doctor X. wrote to the milk concern calling at-
tention to all the facts, and asking it to try to
locate the source of contamination.
The Dairies Company promptly replied, express-
ing regret and promising investigation. Later the
R. Elliott Publishing Company.
446
COHEN: PASTEURIZED AND CERTIFIED MILK.
[New York
Medical Journal
proprietor of the farm from which the milk had
come, wrote denying responsibiUty, detailing the
care he gave to his cattle and their surroundings,
and citing the high average merit (the low average
bacterial content) of his milk. . Still later, the sup-
plying company again wrote and stated that in
view of the high reputation of the farm mentioned
and the fact that no other child had been infected
by the milk in question, the fault must lie else-
where. To this the reply was made that the com-
pany's attention had already been called to one
other specific and simultaneous instance of milk in-
fection in a household supplied by it, namely, that
of Doctor B. ; and that as soon as Doctor X. could
verify his impression that Doctor Carrington knew
of still other cases he would again communicate
with the company, which he did* as follows :
DOCTOR X TO MILK CONCERN.
August 27, 1917.
Dairies, Philadelphia, Pa.:
Dear Sirs — Referring to the illness of my granddaugh-
ter at Atlantic City, apparently traceable to your milk, I
beg to report that I have been informed that many chil-
dren at the Home were taken ill on the same Sun-
day night, in the same way, and that the home is partly
supplied with your milk from the same dairy. The case
against you seems to be conclusive. I do not pretend to
apportion the responsibility, whether it is in the collection,
the bottling, or the distribution.
When the milk wagon is dirty and the driver slouchy,
one feels that perhaps all the minutiae of asepsis are car-
ried out in just as slouchy and uncleanly a way (which
means not carried out at all) at the distributing centres.
I would strongly urge this matter upon the personal
attention of your highest officer.
Very truly yours, X.
THE MILK DISTRIBUTOR AND THE PEDIATRIC SOCIETY.
A few days after the events related in the pre-
ceding chapter, the vice-president of the milk con-
cern (whom we will call Mr. G.) called on Doctor
X. to renew the expression of regret and incident-
ally, if one may use the expressive slang of the
day, to pass the buck.
He made no attempt to repeat the denial of other
cases. His alibis were two. i. His corporation
was a distributor, not a producer. 2. The milk
was probably contaminated in the household after
delivery.
In answer to the first excuse it was pointed out
that the important matter is the condition of the
milk when it reaches the consumer, which it is the
distributor's business to safeguard. In answer to
the second excuse, Mr. G. was informed of the
care taken with the children's milk both in Mr. X.'s
household and in Doctor B.'s household. In the
course of conversation Dr. X. remarked "I much
prefer ordinary pasteurized milk to the best cer-
tified milk, unpasteurized. It is safer. One of these
days 1 shall read a paper on the subject before the
Pediatric Society and try to convert it."
Whether or not as a result of this remark there
shortly ensued the following correspondence :
•The reasons for publishing Ihis and other letters are (i) to
ill limine tlie statement of the Dairies Company that **there was no
other case of illness." (2) tn en.phasizc the dangers introduced into
milk suprlies by the distributor, (3) to explain, if possible, the
"dragging in" by the n-.ilk concern of the Milk Commission of tlie
Pediatric Society, (4) to show just how carefully and scientifically
that body dealt with the matter.
MR. G. TO DOCTOR X.
September 2i, 1917.
Doctor X., Philadelphia, Pa.:
Dkar Sir — At the suggestion of Doctor O., secretary of
the Philadelphia Pediatric Society, I am enclosing copy of
his letter to the writer.
Again thanking you for the privilege of the interview
which the writer had with you a short time ago, we are,
Very truly yours,
Dairies.
(Per G., Vice-President.)
[Enclosure.]
DOCTOR 0. TO MR. X.
[Copy.]
Dear Mr. G. — At the meeting of the Milk Commission
yesterday afternoon, I was instructed to thank you for hav-
ing called the attention of the commission to the state-
ments of Doctor X. and to your correspondence with him;
and to inform you that the Milk Commission had investi-
gated the bacterial contents of — • Farm milk as deter-
mined at the laboratory of the Veterinary School of the
University of Pennsylvania by our bacteriologist during
the past ten weeks, finding an average of 900 bacterial
colonies to the cubic centimetre, a very low count indeed.
It would seem to us, therefore, especially in view of the
fact that no other cases of illness occurred among those
using the rest of the output of 400 bottles of this milk
delivered in Atlantic City that day, that the probable
cause of the possible harmful change in the milk must have
been due to negligence in the care of the milk after its
delivery.
We have no objection to your mailing Doctor X. a copy
of this decision.
I have the honor to be, Respectfully yours,
(Signed) M. O., Secretary.
ig, IX, 1917.
DOCTOR X. TO DOCTOR O.
September 21, 1917.
Doctor M. 0., Philadelphia, Pa.:
Dear Doctor O. — I have received a copy of your letter
of September 19th to Mr. G.
In the first place, 't is not correct that there was no
other case of illness in Atlantic City, among the users of
's niilk, on the day my granddaughter sickened. I
would refer you to Doctor B., whose child was taken ill
at the same time, from the same milk; also to the physi-
cian in charge of the Home, where there were sev-
eral children taken ill at the same time, and probably from
the same source of infection.
In the second place, I know that there was no fault in
the care of the milk after delivery. This is my personal
testimony, and must be accepted as such. 9
In my judgment, all milk that is to be carried any dis-
tance in the summer should be pasteurized. I know that
this not the most modern view, but it remains true.
Very truly yours, X.
doctor X. TO doctor o.
October 3, 1917.
Doctor M O., Philadelphia, Pa.:
Dkar Doctor O. — I met Doctor B. at the hospital yester-
day and asked him whether you had written him in rela-
tion to the matter mentioned in my letter of September
2ist, commenting upon your letter of September iQth to
Mr. G., copy of which was sent by him to me. Doctor B.
t«ld me that he had not heard from you.
I did not ask the Pediatric Society to investigate this
matter, but since Mr. G. has initiated a one sided inquiry,
I purpose seeing that it becomes thorough. To this end
I would also respectfully insist that the house endemic at
the Home, which receives part of its milk through
Mr. G.'s company, be investigated, and that Doctor M. be
asked to tell what he knows about this. I would also sug-
gest that Mr. G. give a list of the families to whom his
milk was delivered during a reasonable time before and
after the illness under investigation, and that inquiry be
made directly of the persons concerned, as to whether or
not there was any other illness caused by the milk.
I would also ask why your committee accepted Mr. G.'s
September 14, 1918.]
COHEN: PASTEURIZED AND CERTIFIED MILK.
447
interested statement in tliis matter without making any
further inquiry.
I am sending a copy of this letter to Doctor B. and one
to Mr. G. Very truly yours, X.
DOCTOR B. TO DOCTOR X.
October 4, 1917.
Doctor X., Philadelphia, Pa.:
Dear Doctor— Thank you very much for permitting me
to see the correspondence concerning the near tragedy you
had in your home and we experienced in ours. I shall be
very happy indeed to say just what I think about this mat-
ter when the opportunity presents. When is the meetmg
to be held ? Very sincerely yours, B.
Nothing further having been heard by him from
the Pediatric Society, Doctor X., sometime in No-
vember, asked Doctor B. whether the latter had
received any inquiry from the Milk Commission.
He had not. Neither had Doctor Carrington nor
Doctor M. A formal communication was therefore
sent to the Secretary of the Pediatric Society call-
ing attention to the unasked decision of the Milk
Commission made without investigation or inquiry,
and requesting that the Commission be no\v directed
to make proper investigation and inquiry; and
specifically that it call upon Doctor Carrington, Doc-
tor B., Doctor M., Doctor X., and those persons
in the households of Doctor B. and of Mr. X., who
had had charge of the milk and its preparation, to
state the facts within their knowledge. To this
letter no reply was received, nor was its receipt
acknowledged.
A second letter was therefore addressed to the
President of the Pediatric Society.
On December twenty-first, 191 7, the president
telephoned that Doctor X.'s letter had been mislaid
and asked that a copy be sent to be laid before a
meeting of Ttie directors of the Society that ^ay.
Doctor X. complied.
APPENDIX
Milk is daily supplied to thousands of children
in Philadelphia and vicinity under the fancied pro-
tection of the Milk Commission's certificate. Is
its action as set forth in this narrative an index of
its usual care and thoroughness? If so, what is its
certificate worth? Doctor X. still holds to the opin-
ion expressed to Mr. G. : Distribution of milk
should be supervised with the same care that is
given to production. There are too many chances
of contamination, too much opportunity for bacter-
ial proliferation, between cow and infant. Cer-
tified milk as well as other milk is dangerous, if
not pasteurized. With proper supplementary feed-
ing the use of pasteurized milk involves no danger
of scurvy or other nutritional disorder.
The writer is Doctor X. His personal interest
in the case is strong. But the subject, surely, is
not one of personal interest only.
Since the foregoing was put into type, a cour-
teous letter has been received from the chairman
of the Milk Commission, which, apologizing for
delay, goes on to say :
"I regret that I was unable to be present at the
September meeting of the Milk Commission, when
your first communication was received, so that I am
not sure what the comments were, which led to the
form of the answering letter to which you took ex-
ception. . . . Our reply should have been limited
to what we knew for facts, which were, that the
weekly bacteriological examinations of milk from
the . . . Dairy as delivered in Philadelphia, were
exceptionally low during August and September,
and the conditions at the Dairy as shown by month-
ly inspections, were excellent. . . . You will agree
with me that it is impossible for our Commission
... to supervise the conditions surrounding the
delivery of [certified] milk in the suburbs and at
the seashore. . . . We can and do watch over the
delivery of it in Philadelphia County, where we
have the authority, because the Board of Health
stands back of us. . . . The summer population at
Atlantic City ought certainly to have a supply of
certified milk available, and the local conditions
ought to be watched ; so that if you could stir up the
profession there to a sense of their duty, it would
be a good piece of work."
It will be seen from the above that the chairman
of the Milk Commission, notwithstanding the very
explicit text of the letters addressed to it and to the
Pediatric Society, still remains under the mistaken
impression that the matter was brought before the
Commission by a letter from Dr. X. in September,
1917; and that his plea in extenuation of its fail-
ure to investigate is virtually one of want of juris-
diction.
As the narrative makes clear. Dr. X. wrote no
letter to the Commission until after that body had
"butted in," assuming to make a decision on a
question which the chairman now states was out-
side its jurisdiction, and concerning which, he
frankly admits, it had no information. This action,
as the record shows, was taken at the request of a
distributor, whose delivery methods were under
suspicion. No record appears to have been made
of the manner in which the subject came before the
Commission, or of the statements upon which its
decision was based. Is any further comment nec-
essary ?
OVARY: CORPUS LUTEUM,
Oliver T. Osborne, M. A., M. D.,
New Haven, Conn.,
Professor of Therapeutics, Medical Department, Yale University.
(Contmued from page 405.)
SYMPTOMS CAUSED BY ADMINISTRATION OF OVARIAN
AND CORPUS LUTEUM SUBSTANCE.
Just how much of the activities of the ovaries may
be given a female patient by feeding preparations of
the ovaries is difficult to determine, but many times
the precipitated menopause symptoms of ovarian
extirpation are largely ameliorated by ovarian
extract.
These disturbing symptoms are vasomotor dis-
turbances, hot flashes, sweatings, head flushings,
indigestion (perhaps due also to circulatory dis-
turbance), the addition of weight mostly in the form
of fat, sometimes nervous irritability, sleeplessness,
or the reverse, i. e., unusual daytime drowsiness and
mental sluggishness. How many of these sympn
toms are due to loss of ovarian secretion, or how
many to the sudden cessation of menstruation
without pregnancy and consequently a storing in
448
OSBORNE: OVARY— CORPUS LUTEUM.
[New York
Medical Journal.
the system, without physiological need, of the nu-
triments and salts of the blood which were previ-
ously periodically lost, has not been determined, but
both are factors in the condition. The normal meno-
pause or the cessation of menstruation without
pregnancy at a younger age will cause more or less
of these symptoms, and ovarian feeding may mark-
edly improve the condition.
It should be constantly noted that not only the
ovarian secretion is either lost or becomes greatly
diminished in these conditions, but many other
endocrine glands are disturbed, and consequently
seme of the symptoms are caused by their disturb-
ance. Feeding ovarian extract, therefore, may not
be as valuable as is treatment directed toward the
other glands, especially toward the thyroid, which
is always disturbed and may hyper secrete or hypo-
secrete, and cause corresponding symptoms.
Ovarian feeding may lower a high menopause
blood pressure ; it may awake to energy a lackadaisi-
cal woman ; it may cause menstruation in simple
amenorrhea, but in this condition it is not as valu-
able as is corpus luteum.
Toxic symptoms are rarely causeo by feeding
ordinary doses of ovarian extract ; this is not true
of corpus luteum. In undeveloped girls ovarian
and corpus luteum administration have not been
tried cut side by side sufficiently to determine which
is better. Certainly, for most purposes, the most
active part of the ovary, the corpus luteum, is the
gland to use.
Corpus luteum extract is certainly an active physi-
ological and even at times a toxic preparation. It
mav cause menstruation in amenorrhea, but it prob-
abily cannot cause abortion. It readily causes
nausea, and even vomiting, when fed in too large
doses or for too long a time. It lowers the blood
pressure.
There is probably no great difference between the
action of the corpora lutea of pregnancy and of
those of nonpregnant animals, although this is dis-
puted. .Some clinicians are sure they get better
results from extracts of the corpora lutea of preg-
nancy. For the sake of discussion, even if prepara-
tions from corpora lutea of pregnancy are more
active, it would only be necessary to give a little
larger dose of preparations from glands from non-
pregnant animals. Also, preparations from th?
corpora lutea of pregnancy would probably be more
toxic. A.s a matter of fact, commercial preparations
of corpora lutea on sale in drug shops are of a
mixed variety, and the only correct dose is that
sufficient for results. In other words, if one causes
therapeutic success the other should, even if the dose
is different: if one fails, the other should fail.
Corpus luteum extracts may cause a little dizzi-
ness or faintness. This is especially true if they are
allowed to lower the blood pressure too much. The
pulse rate may be increased. This extract may
cause loss of weight, but it should not be used for
this object, as corpus luteum should not be admin-
istered for too long a time, and. thyroid extracts are
safer and better for this purpose. While corpus
luteum seems to contain vasodilator stuff, still it
may stimulate the glands that lower blood pressure,
notably the thyroid ; or it may inhibit the pituitary
and suprarenals — vasopressor glands.
USES OF OVARIAN EXTRACTS.
I. After extirpation of the ovaries. — Some thera-
peuticians believe that ovarian extract is the best
and most successful treatment after double ovari-
ectomy. Such treatment would certainly seem
more logical than the administration of corpus lu-
teum alone, as the patient has lost all ovarian activ-
ity. She will need ovarian treatment for some time,
and such treatment is much safer than continued
corpus luteum treatment. The dose need not be
large, and it should be remembered that the amount
of "secretion of any of the internal secreting glands
is not large in anj one twenty-four hours. A tab-
let representing two grains of the dried gland,
administered three times a day, all tablets being
crushed by the teeth before swallowing, thouid be
sufficient. The length of time the ovarian extract
should be given with this dose would depend on
the amelioration of the symptoms; of course the
dose of any preparation is that enough to- do the
work desired. If the above dose is found to be too
small, it could be increased, but as soon as the dis-
turbing symptoms of the artificial menopause have
been improved, the dose should be gradually dimin-
ished to two tablets a day, and then to one tablet a
(lay. In many instances, on account of the disturb-
ance of other, endocrine glands, a combination of
extracts from two or more of these glands is better
treatment. If the blood pressure is not high and
the patient is adding weight, and the heart is not
fast, and there are symptoms of slowed thyroid
secretion, a combination of thyroidj'^ovaries, and
suprarenal may be given. If, on the other hand,
ihe blood pressure is high and there are some signs
of subthyroid secretion, a combination of thyroid
and ovarian substance may be used. Or, in this
condition of high blood pressure, a small dose of
coipus luteum may be used instead of the thyroid.
If, however, there are signs of increased thyroid
secretion, the treatment of hyperthyroidism becomes
part of the treatment of the menopause, viz., the
paiient should eat no meat of any kind, should not
be allowed tea, coffee, or any stimulant, should
receive extra amounts of lime in some form, and
cvarian extract, either in combination with supra-
renal or not, depending on the blood pressure.
The dose of the combination of these glands must
be decided for each individual patient, it cannot be
dogmatically determined ; in other words, the physi-
cian should write his prescription for such combi-
nations of two or more glandular extracts, just as
lie would write a prescription for any other combi-
nation of drugs. The amount of thyroid depends
on the need and susceptibility of the patient. Some-
times it is well to stimulate the thyroid gland with
iodine rather than with thyroid extracts. The
amount of suprarenal and the amount of ovarian
extract must be determined by the condition of the
paiient; both are stimulants. When corpus luteum
is selected, it should be remembered that it lowers
hlood pressure and is a depressant, sometimes even
in small amoimts.
September 14, 191 8.]
OSBORNE: OVARY— CORPUS LUTEUM.
449
2. For menopause symptoms, especially when the
onset is abrupt. — Almost the same discussion as in
indication one is applicable for this condition. It
should be constantly borne in mind that more than
one gland is disturbed when ovulation and men-
struation cease. The symptoms of the various
gland disturbances should be carefully studied, to
determine which glands need help and which glands
need to be inhibited, if possible, in their activities.
Many times a combmation of small doses of differ-
ent glandular extracts acts' better than when a single
one is given, but the physiological action of each
gland should be studied and noted to know, i, if
it is needed, and 2, when its administration is caus-
ing unnecessary or unpleasant symptoms. In an
abrupt menopause, many times the corpus luteum
extract is more efficient than is ovarian extract.
This will be again discussed later under the indica-
tions for corpus luteuni.
3. for too slouly dei'eloping girls. — These young
gitls do not yet need corpus luteum; they may need
more ovarian secretion. They may also need thy-
roid extract ; and it is possible that they need thymus
extract. Pituitary and suprarenal extracts seem to
inhibit ovarian perfect secretion, and therefore delay
puberty : consequently they are not needed. Tliese
young girls, then, may be given small doses of ova-
rian extract, and perhaps thyroid if they seem to
need it. However, at times, they have an increased
secretion of the thyroid instead of an undersecre-
tion. If they are not nervous and the heart is not
fast, small doses of iodine, as sodium iodide in o.io
gram doses once or twice a day, is good treatment,
with or without ovarian extract.
4. When there is an apparent suhsecretion of the
ovaries in older girls and zvomen, especially when
a long course of treatment is necessary. — If the girl
or woman requires treatment but a short time, cor-
pus luteum acts more efficiently than ovarian ex-
tract, but corpus luteum should not be given any
great length of time. Such girls and women may
receive ovarian tablets, with or without a combina-
tion with thyroid or iodine as seems advisable.
These girls and women so readily show hyperirrita-
bility that generally thyroid should not be given.
If, on the other hand, they are adding weight and
becoming sluggish mentally and physically, thyroid
is what they need. These girls are likely to have
amenorrhea or scanty or delayed menstruation, and
may be very thin and anemic and require tonics and
iron treatment; or, on the other hand, they may
be stout, have very large, fat breasts, headaches,
indigestions, and various nervous disturbances. It
should be again emphasized that each individual of
this class should be very carefully studied, not once
but repeatedly, during treatment. When the right
medication is found, they respond very quickly. To
decide upon the right treatment, all of the functions
of the various glands should be known, and the
symptoms and signs' of undersecretion and over-
secretion should be recognized. When the proper
treatment is given the results are sometimes so phe-
nomenal that they cannot be understood by the care-
less or "too busy" clinician who does not study his
cases well, or by one who always diagnoses these
conditions as neurasthenia, hysteria, or plain
"cussedness."
5. In menstrual disturbances. — Sometimes in dys-
menorrhea and in disturbances preceding menstru-
ation, such as nausea, headaches, etc., ovarian treat-
ment is of value in preventing pain and these toxic
symptoms. Sometimes corpus luteum seems to act
better for this condition ; but all local physical con-
ditions disturbing the menstrual function should be
eliminated before one depends on glandular extracts.
USES OF COliPUS LUTEUM.
T. In amenorrhea. — As above stated, in delayed
puberty in girls, ovarian, or ovarian and thyroid
combined, treatment is better than corpus luteum
treatment, but in amenorrhea or delayed menstrua-
tion of girls or women who are not pregnant and in
whom there is no apparent constitutional cause,
corpus luteum is a valuable and efficient treatment.
These patients may be thin, perhaps anemic, and
have poor appetites, and need, besides the corpus
luteiun treatment, a general building up by tonics,
food, iron, and, often, better hygienic surroundings.
On the other hand, many of these patients with
functional amenorrhea are nervous, irritable, and
feel generally disturbed because of this inability to
eliminate the toxins or increased elements of met-
abolism which should normally be lost once in four
weeks. These patients may have disturbed thyroid
secretion at this time, an irritability of the thyroid
without all of the usual hyperthyroidism symptoms.
Iodine may help such a patient, as well as corpus
luteum.
Another class of girls and women with amen-
orrhea add weight, are sleepy, lack initiative, and are
lackadaisical. Such patients may show more or less
signs of hypothyroidism, and will all be improved by
more thyroid activity and by corpus luteum. Either
thyroid or corpus luteum, or both, will generally
incite menstruation, and the patient soon becomes
normal.
Women who have delayed menstruation, even
only a few days, who become very nervous and irrit-
able just before menstruation, are many times bene-
fited by corpus luteum given in small doses of two
two grain tablets a day for a week preceding the
(late that the period is due. It often hastens men-
struation and prevents this nervous irritability. If
this small dose is not successful, larger doses may
be given for tAvo or three days before the period is
due, as four or five grains, three times a day. Very
large doses are not needed ; and if the blood pressure
is low, even the dose just mentioned should not be
given; or, if it is found by experience that a given
dose causes faintness, dizziness and nausea, the dose
to be given before the next period should be much
smaller.
While corpus luteum in small doses may be of
benefit, in disturbances caused by removal of both
ovaries, it is generally not of as much benefit as are
preparations of the whole ovary.
2. In overweight. — Anything that causes normal,
complete and sufficient menstruation will prevent
the deposit of fat and may cause loss of weight in
the overfat, hence corpus luteum may be tried to
regulate this function. However, for the purpose of
450
OSBORNE: OVARY— CORPUS LUTEUM.
[New York
Medical Journal.
reducing weight corpus luteum is a dangerous prep-
aration, and it should not be given in large doses,
and should not be given for any great length of time.
Diet and thyroid treatment, exercises, and various
measures to produce sweating constitute the best
management of these cases. Corpus luteum ^could
be given for two or three days each month, before
the expected period.
3. In dysmenorrhea. — Corpus luteum has been
recommended to prevent this kind of pain. If
there is any physical reason for the dysmenorrhea,
of course this treatment is useless. Ovarian pain
due to delayed menstruation, and uterine pain from
clots due to a sluggish flow of menstrual fluid may
be benefited by corpus luteum. It should be again
urged, however, that in all instances of dysmenorr-
hea the pelvic condition should be very carefully
studied to exclude physical causes before reliance is
placed upon organotherapy.
4. In pregnancy. — The relation of the corpus
luteum of pregnancy and its secretion to the vomit-
ing of pregnancy has already been discussed. While
some clinicians have had success in feeding corpus
luteum in the pernicious vomiting of pregnancy, a
good physiological excuse has not been proved for
such treatment. The blood pressure in these cases
should be watched ; the twenty-four hour excretion
of the kidneys should be studied ; and the presence
of acidosis should be noted. Anything found ab-
normal in these lines should be properly treated. If
there is an increased blood pressure, in combination
v.'ith a proper diet and alkaline treatment, corpus
luteum might be tried for a short time. The daily
dose should be small, and the blood pressure should
be watched. In other words, the treatment of this
serious condition by the administration of corpus
luteum is still experimental.
5. In menopause cases. — This condition has al-
ready been largely discussed under the heading of
ovarian treatment, but certainly when the meno-
pause is precipitate, with hot flashes, sweatings,
nervous irritabilities, etc., corpus luteum treatment
seems many times to be of great benefit. This is
especially true when there is high blood pressure,
and in the severe headaches occurring in this con-
dition. Even when these headaches are not asso-
ciated with high blood tension, but occur periodi-
cally, showing that they are more or less toxic,
corpus luteum many times is very efficient in pre-
venting them. It will not stop a headache that has
begun, unless it is a continuous headache of several
days, but if corpus luteum is administered for sev-
eral days before the cyclic period when menstrua-
tion would have occurred, it may prevent these
periodic pains. Excessive nervousness and irrita-
bility may also be prevented by corpus luteum treat-
ment.
The very high systolic pressure which so often
occurs in women at or soon after the menopause,
without arteriosclerosis, and without apparent kid-
nev cause, is often very markedly benefited by cor-
pus luteum. However, the absolute necessity can-
not be too much urged of studying each and every
case of menopause with disturbing symptoms from
the standpoint of all our present knowledge of the
internal secretions.
The disturbance is polyglandular ; with the loss of
corpus luteum several glands are disturbed, notably
the ovaries, thyroid, suprarenal, probably the pituit-
ary, and perhaps the mammary glands — if they have
an internal secretion. Whether the patient adds or
loses weight, whether or not there is disturbance in
the digestion of carbohydrates or in the digestion of
proteins, with possibly traces of sugar in the urine
on the one hand, or an increased or disturbed pro-
tein or purin metabolism on the other hand, whether
the blood tension is high or low, whether there are
palpitations, anemic or plethoric headaches, profuse
perspirations or dry skin— a careful tabulation of all
these many symptoms and signs will suggest a prop-
er combination of the organic extracts to meet the
condition, often with consequent rapid improvement.
During such treatment the patient must be fre-
quently seen and carefully watched, and modifica-
tions in the treatment must be made at each visit,
depen.iing on the improvement or lack of improve-
ment in her symptoms, or on a change in her symp-
toms. It should be urged that small doses of iodide
in the form of sodium iodide, two or three grains
a day, may be better for some individuals than the
administration of thyroid. The iodine will activate
I he thyroid to more normal secretion. When the
thyroid substance is fed, the patient receives all of
the thyroid activities. It should be again repeated
that the dose of any one of these glands when they
are given for some time, should be very small, as
the secretion from these glands is always in small
amount for each twenty-four hours.
ADMINISTRATION.
Ovarian extracts are perhaps best made from the
glands of the pig, and the dried powdeY may be or-
dered in such doses as are deemed advisable. The
two grain tablets (each representing two grains of
the desiccated ovaries) seem to furnish ordinarily
the proper dose. Erom three to six of these tab-
lets may be given per day, all tablets being crushed
by the teeth before swallowing.
When ovarian extracts are needed, the dose found
proper may be given for a long period. Although
feeding ovarian substance seems to slightly reduce
the blood pressure, there are apparently no toxic
symptoms caused by reasonable doses of the whole
ovary. Some patients are surprisingly stimulated
by the ovarian treatment, whether from the ovarian
substance itself or because this substance stimulates
other glands, cannot now be stated ; but such symp-
toms should be noted and the dose greatly reduced.
A few patients are stimulated mentally and physi-
cally by even as small a dose as two grains per day.
Corpus luteum is perhaps also best prepared from
Ihe glands of the sow. While some clinicians find
that the preparations from the corpora lutea of preg-
nant animals are more active than those from non-
pregnant animals, for ordinary clinical purposes the
mixed preparations from both pregnant and non-
pregnant animals seem perfectly satisfactory, al-
though the dose of the mixed glands may be a little
larger to produce active symptoms than the dose
of a preparation of the glands from a pregnant
animal.
This substance is perhaps best administered in
September i,), igiS.]
OSBORNE: OVARY— ^
CORPUS LUTEUM.
451
powder or put into capsules in such dose as the
physician desires. Five grain tablets or capsules are
not needed ; the dose is too large, except in rare in-
stances. Two grain tablets are perhaps also too
large, i. e., each tablet representing two grains of
the powdered corpus luteum. One grain tablets
would be better, or perhaps even half grain tablets.
The dose could then be multiplied to suit the in-
dividual patient. In the writer's opinion, the dose
of corpus luteum should be reduced much as was
the dose of thyroid when thyroid was first offered.
This substance in large doses or long continued
becomes toxic. The syniptoms are low blood pres-
sure, often palpitation ( although the heart may be
at first slowed), and there may be nausea and vomit-
ing, and a general feehng of depression. If the
blood pressure becomes low under the treatment,
it is Hkely to continue to fall for some time after
the treatment is stopped; therefore, the blood pres-
sure of patients under active corpus luteum treat-
ment should be frequently taken. Even if the blood
pressure is high, a fall of iifteen to twenty mm.
should cause the cessation of the treatment, for a
time at least. If the blood pressure is low, 120
systolic, for instance, a fall of not more than five
mm. should be allowed before the treatment is
stopped. If the systolic blood pressure is no mm.
or lower, it is doubtful if corpus luteum should be
administered.
OVARIAN EXTIRPATION.
Total removal of both ovaries is only justifiable
in very rare instances.
It is unimportant whether it is the ovarian sub-
stance or the corpus luteum that furnishes the secre-
tion that is most necessary for the mature woman's
mental and physical health ; it is a fact that many
internal secreting glands are disturbed .by the re-
moval of the ovaries. Total removal of the ovarian
tissue before puberty stops the development of the
genital organs and of the breasts. Total removal
after puberty stops menstruation, causes artificial
menopause, and multiplies the menopause symptoms
and disturbances. The younger the adult woman so
castrated, the more serious are the symptoms.
Castrated women are 'often wrecks, both mentally
and physically. They may gain weight ; they may
lose weight ; they may be ravenous ; they may have
no appetite ; they may be loquacious ; they may be
morose ; they may be drowsy ; they may be sleepless ;
they may be hysterical ; and they may become to all
intents and purposes actually insane. Feeding these
sufferers ovarian and corpus luetum extracts is only
partially successftil in ameliorating their condition.
The rules for operation for tubal and ovarian
disease should be :
1. To leave as much of the ovaries as is found
healthy.
2. If the operation of necessity destroys the cir-
ctilation and therefore nutrition of the whole of both
ovaries, large grafts from the healthy part of the
ovaries should be placed in some location that will
allow the ovarian tissue to readily obtain a blood
supply and therefore live. If the ovarian transplant
lives and functions, it should be remembered that it
periodically swells, and hence, in tense, nondilatable
tisstie, may catise severe pain. The uterine wall, the
])eritoneum, the labia niajora, the mons veneris, the
abdominal wall, and even the axilla have all been
places suggested for implantation.
3. If there is no healthy ovarian tissue for auto-
grafting, and as total extirpation of both diseased
ovaries is not an emergency operation, the surgeon
connected with a large hospital generally coulcl ob-
tain a piece of healthy ovary from a nonsyphilitic
and nontuberculous patient for transplantation into
the woman to be castrated. The necessity for ob-
taining such ovarian tissue would be rare, as total
extirpation is rarely needed. Of course the surgeon
cannot decide that there is no healthy ovarian tissue
until the time of the operation, but he should be pre-
pared for such an emergency when there is a prob-
ability of the necessity of total extirpation. Ovaries
removed from healthy women after sudden acciden-
tal death, and properly preserved, would seem to be
ideal tissue.
If these engrafted ovaries or ovarian tissues live
and function it may be* two or three months before
the fact is known by any symptoms or signs in the
patient. The signs of success are a general feeling
of health, absence or diminution of menopause
symptoms, and menstruation. Such grafts may live
for a time and then die, but more or less embryonic
ovarian tissue may have had time to mature and to
begin to furnish the secretion so much needed by the
patient.
Properly selected patients who have had their
ovaries removed for disease and who have psychoses
which are not cured by the administration of organic
extracts, might be well treated by grafts of healthy
liuman ovarian substance.
Presystolic Thrills in Soldiers. — Roger S.
Morris and Alfred Friedlander {Journal A. M. A.,
August 3, 1918) record the fairly frequent observa-
tion of a presystolic thrill in soldiers otherwise per-
fectly normal. They contend that this thrill is
jairely functional and is of no significance with rela-
tion to the integrity of the heart. Men who have
I eceived the rigorous training of the military camps
are found to have the thrill and yet to be in perfect
physical condition and capable of the most strenuous
exertion. The functional thrill is characterized by
being definitely presystolic, of short duration, lim-
ited to the apex of the heart, and ending with the
shock of the first sound. It is never as intense as
that of well marked mitral stenosis, is best felt
when the heart's rate is increased and the patient is
in the erect posture, often disappearing with slowing
of the heart and in recumbency. It is common
in persons with long, slender chests. The systolic
shock following the thrill is usually fairly marked,
sometimes slightly exaggerated, sometimes split.
With this thrill there is almost constantly an audible
reduplication of the apical first sound, which also
becomes less evident or disappears in the recumbent
position. In this reduplication the second part of
the sound is often louder than the first, suggesting
a crescendo character. There is also often a soft
systolic, apical murmur in recumbency. Presystolic
murmurs are never found, irrespective of exercise
or position. The pulmonic second sound may be
accentuated and reduplicated in recumbency.
452
RREDE- TOXIC NONEXOPHTHALMIC GOITRE.
[New York
Medical Journal.
TOXIC NONEXOPHTHALMIC GOITRE *
By Edward Hiram Reede, M. D.,
Washiiiiiton, D. C
Toxic nonexophthalmic goitre is a neurosis of
that branch of the vegetative nervous system termed
variously the greater vagus, or the craniosacral of
the parasympathetic system, accompanied by perver-
sions of metabolism and associated with a goitre
more or less distinctive in pathology. A year ago
I called attention to the evidence that so called
exophthalmic goitre was a disturbance of that
branch of the vegetative nervous system variously
termed the thoracicolumbar or true sympathetic, as-
sociated with activity of the thyroid and suprarenal
glands, and a goitre of a distinct pathological pat-
tern.
The actions of the two divisions of the vegetative
or autonomic nervous system are irreconcilably
opposed to each other, so that it is most unwise to
speak longer of the sympathetic nervous system
imless the branch in mind' is indicated. I shall
speak of the thoracicolumbar as the sympathetic
system, and the craniosacral as the parasympathetic
system. The sympathetic system carries the fibres
which are the accelerators of action and it is as a
whole an exploiter of energy, whereas the vagus
system carries the fibres which are the depressors of
action and it is as a whole a conservator of energy.
The hormones of the ductless glands are diffused up
to a certain level apparently autonomously, at least
that is the conclusion inferred from the autotrans-
plantation and nerve excision experiments. The se-
cretion which is produced by nerve stimulation, i. e.,
the supersecretion or emergency secretion is elicited
only through the sympathetic system and not at all
through the vagus system. The hormones secreted
through stimulation of the sympathetic system are
found in turn to react upon the sympathetic system
making it in turn more sensitive to stimuli, the
process acting as it were in a manner of auto-
catalysis.
Activities of the great energy producing glands,
the gonades, the suprarenals, and the pituitary are
accompanied by expressions of sympathetic nerve
stimulation. Inactivity or insufficiency of these
glands is associated with signs of sympathetic nerve
depression. The children of great energy expres-
sion who later become the adults envied by their
business associates because of their "pep," are
probably endowed not only with sympathetics of
superior quality, but also with ductless glands
capable of superior mobilization. I doubt that the
thyroid secretion has any direct toxic influence upon
either of these nerves. The influence of the thyroid
obtains either through its indirect effect through
metabolic variations in the nerve tissue or through
metabolites produced in the course of thyreogenic
metabolism. Injection of the active principle of the
thyroid into the blood stream elicits no effect before
a period of about thirty hours, nor does this injec-
tion, as Levy shows, have any immediate influence
on the cardiac vagus nerves. This corresponds
closely with the massive intoxication occurring on
the second day after thyroidectomy. The para-
sympathetic and sympathetic nerves are theoreti-
• Read Before the Washington Medical Society, May 29, 1918.
cally in balance, but this poise is seldom found in
practice.
Many children are readily assigned to one or
other of these divisions. If a sympatheticotonic
child develops an active goitre it becomes more
sympatheticotonic; if a vagotonic child develops an
active goitre it becomes more vagotonic. The in-
creased function following the metabolic accelera-
tion produced by thyroid was greater in the tissue
which was naturally stronger. Recent work by
Kendall suggests that the sympathetic stimulation is
not only a suprarenal stimulation but that the active
suprarenal produces in the course of protein metab-
olism a preurea compound which is also highly
stimulative. The absence of the preurea compound,
i. e., the presence of inactive suprarenals, is accom-
panied by depression, and this depression comparable
to suprarenal removal is, he thinks, due to the sub-
stance which is not split into preurea. The sympa-
thetic depression suggests a result of inactive supra-
renals plus the action of a substance stimulative to
the parasympathetic system. This experimental
depressive hyperthyroidism is so comparable to
depressive hyperthyroidism in man as to merit
notice.
Kendall's experiment consisted in feeding intra-
venously thyroid hormone and aminoacids and ob-
serving the nitrogen metabolism. Proteins from
food are taken into the blood as aminoacids and
after accomplishing their purpose are excreted in
the urine as urea. Kendall finds that the work of
the thyroid hormone ceases when it has broken the
aminoacids . up into ammonia compounds. To
change the ammonia into urea there is needed a new
factor and this factor he finds to be the adrenal
cortex, which produces an almost urea substance,
the preurea. Aminoacids in the presence of thyroid
hormone always break up into ammonia compounds.
Whether an excess of ammonia or an excess of
preurea occurs depends upon the rapidity with
which the suprarenals act. In the animals thus fed,
Kendall, was able to produce a symptom gradient
the summit of which was represented by an excess
of preurea and signs of great stimulation, and the
base of which was indicated by extreme prostration
and an excess of ammonia in the tissues ; and the
decisive factor was the ability of the cortex to
reduce ammonia.
The obvious fact was that some animals de-
veloped an exaggerated metabolism with great
stimulation, while otlTcr animals with an equally
great excess of circulating thyroid hormone devel-
oped a perverted metaboHsm and signs of depres-
sion. An animal whose one cortex was found to be
most inactive after being thoroughly angered
furnished from the remaining cortex an example of
great activity. Kendall feels justified in making
this statement: ''Thyroid activity in the absence of
a simultaneous suprarenal cortex activity does not
produce the usual so called hyperthyroid symptoms
but instead a condition of depression." The phe-
nomenon which puzzled Kendall was the absence of
the well known stimulation signs of experimental
hyperthyroidism in the presence of a known over-
secretion and the occurrence of a deiiression in-
stead ; the phenomenon which has puzzled clinicians
has been an obviously oversecreting th}'roid not pro-
September 14, 1918.]
REEDE: TOXIC NONEXOFHTHALMIC GOITRE.
453
ducing an exophthalmic goitre but on the contrary
associated with asthenia and depression of func-
tions. Analysis of the semistimulated or nonstimu-
lated cases in this experimental series approximates
closely the classes into which nonexophthalmic
goitre is divisible. One feels that in both groups,
the experimental and the clinical, some agent is
active which either depresses the sympathetic or
stimulates the parasympathetic, resulting whether it
be relative or absolute in a practical superiority of
the parasympathetic.
The pathological histology from the standpoint
of the epithelium is that there is never a primary
hyperplasia and hypertrophy but always a primary
retention of colloid, with atrophy of epithelium and
with, sometimes, a regeneration. Grossly consid-
ered, the goitre may be a colloid, an adenoma, a
carcinoma, or an adenomatosis (3, 4, 5).
The primary enlargement of the thyroid, I still
feel as 1 have previously expressed (6), occurs in
childhood as a reaction to a neighborhood infection
quite analogous to lymph gland enlargement and
its later activity is due to other stimuli. The en-
largement of the gland does not determine its
activity. Enlargement may also occur as part of a
general infection, as syphilis or tuberculosis. The
enlargement of the gland secondary to dental or
tonsillar sepsis may be observed by any one seeing
a fair number of children. The work of Burget
(7) which is accepted as evidence against the infec-
tion theory fails to reproduce similar conditions to
those at work in children. In this connection the
conclusions of Marine (8) which are being made
the basis of a rather radical departure in school
hygiene in a large community in the Great Lakes
goitre district should be noted. Marine considered
the occurrence of goitre in fifty-six per cent, of the
school children as quite analogous to the Michigan
sheep goitre, the brook trout goitre, and the goitre
of hairless pig malady, all of which are due to an in-
sufficient iodine ration, and he has instituted an
iodine medication through the medium of school
nurses (9, 10, 11). The preadolescent goitre re-
duces under iodine in this latitude but is not always
unattended by untoward signs of increased meta-
bolism and is not prevented from a postadolescent
toxic expression.
The inciting stimuli to thyroid oversecretion are
practically three : toxic, metabolic, and psychic. The
toxic stimulus may be a recurring neighborhood
infection, a distant focal infection, or a general
systemic infection and its influence may be due to
increased oxidation or metabolism of the body as a
whole. The metabolic stimulus arises in a woman
in connection with the institution of puberty and
periodicity of menstruation, the demands of preg-
nancy, and changes at the menopause. In the man
a less but still distinct influence is alsO' exerted by
gonadal maturation. The psychic stimulus arises
from those affects which correspond to primitive
animal instincts and are usually recognized by the
individual ; however, the stimulus may none the less
strongly arise from afifects which are displaced be-
low the level of consciousness through repression.
The symptoms v/hich occur are in part an appan-
age of the original stimulus and not essentially
thyreogenic and are in part a reflexion of diffuse
metabolic disturbance, but in the main represent
expressions of parasj-mpathetic dysfunction. Col-
lateral endocrine disturbances also occur but these
are probably vegetative in origin. The simplest
classification is the blood pressure grouping of
Plummer (12) into i, constantly toxic high
pressure ; 2, constantly toxic low pressure ; 3, incon-
stantly toxic low pressure, and, 4, an intermediate
group. This simple classification features that
factor which is of vital moment in the prognosis,
i. e., the cardiovascular degeneration.
Krumbhaar, of the University of Pennsylvania,
in a recent electrocardiographic study of fifty-one
toxic goitres found changes in fifty-seven per cent,
and concludes that the myocardial degeneration
"may be manifested by any type of cardiac irregu-
larity ; sinus arrhythmia, premature contractions,
auricular flutter, auricular fibrillation, heart block,
etc." (13). The occurrence of a thyreogenic cardi-
opathy from thyroid oversecretion without appreci-
able goitre is a physiological possibility. Symmers,
professor of pathology in Bellevue Hospital Medi-
cal College, identifies the lesion familiarly known
among pathological anatomists as idiopathic dilata-
tion and hypertrophy of the heart, as a thyrotoxic
cardiopathy and associates with it a definite
structural alteration in the gland and terms it a
chronic interstitial and hyperplastic thyroiditis
(14). If this is substantiated it may be considered
with interest in relation to some myocardial anoma-
lies occurring in the course of the anxiety neuroses.
The toxic high pressure goitre group may be
clinically subdivided into i, a stage of vascular
stimulation ; 2, a stage of fixed vascular hyperten-
sion, and, 3, a stage of cardiovascular degeneration.
The original distinction between sympathetic and
parasympathetic nerves was made upon a pharmaco-
dynamic basis and this is still the method of exacti-
tude. The results that follow the intravenous
injection of adrenalin are accepted as evidences of
sympathetic stimulation, whereas the effect of
acetylcholine is analogously the same for the para-
sympathetic and both correspond to the effects of
electric stimulation of the respective nerves.
Roughly, however, one may find clinically that in
certain cases the predominating symptoms are
those of a stimulated sympathetic or vice versa.
This clinical evidence is sufficiently definite to group
cases in certain classes and led me to the statement
that the incipient exophthalmic always showed
heightened sympathetic tone and that the vagus
symptoms which occur late in tliat disease represent
an exhausted sympathetic and do not indicate a true
vagotony in the sense of primary vagus tone. The
suggestion was made that the activity of the supra-
renals v/as an index of the severity of the sympa-
thetic disturbance.
In the group of cases not distinguished by an ex-
ophthalmos I have been impressed by the number
of instances in which the nervousness was of the
spastic type associated with stimulation of the para-
sympathetic and by the fact that it in a measure
antedated the goitre and was increased by its ap-
pearance. I offer a tentative clinical classification
with some evidence in support of this theory. This
does not pretend to be a pharmacodynamic study
454
RFEDE: TOXIC NONEXOPHTHALMIC GOITRE.
[New York
Medical Journal.
and llic terms sympatlieticotonic or vagotonic can
only ue applied in an acceptable clinical sense.
The toxic high i)ressurc goitre group never be-
comes exophthalmic, apparently because the ca-
pacity of the suprarenals are inadequate to stand
^he quantity production essential to that sympathetic
superstiinulation. The impression of a high degree
of sympathetic stimulation which however cannot
quite overcome the antagonistic control is felt by
the observer. It quite suggests the upper reaches of
the Kendall symptom gradient in his experiments.
Many of these cases are mistaken for exophthalmics
because of naturally prominent eyes or because of a
protrusion due to retrobulbar edema.
The first stage or stage of vascular stimulation in
the high pressure group is characterized by the
presence of an active focus of infection in the body,
the occurrence of a psychic repression of high
potential, often sexual, and evidences of increased
metabolism with psychomotor acceleration and
heightened mental tension. The subjective feeling
is rather one of strength than of weakness accom-
panied with much restlessness. The patient's
friends consider him nervously energetic.
Case 321. — Constantly toxic high pressure goitre. Stag?
of vascular stimulation, chronic infection of tonsils, infec-
tion of impacted molars, gingivitis, vasomotor rhinitis,
hypertension (150-65), tachycardia (100). Service of
Doctor Ecker, throat examination by Doctor Walker, den-
tal examination by Doctor Sharp.
Male, age twenty-two, bookkeeper. This young man's
attention v/as directed to his health two years ago by
reason of a life insurance rejection which led to his refer-
ence by the Life Extension Institute to a physician. He
was treated one year by this physician for heart disease.
He was later treated by another physician for sexual
weakness. He was rejected at the Plattsburg Training
Camp a little later.
He complains now of being nervous without cause, of
trembling on slight occasion, of being emotional, of feeling
that he is losing time and must hurry. He feels better
when in violent exercise and when fully occupied with
work. He does daily gymnasium work, daily swimming,
and a daily walk of an hour. He works hard at his desk
for eight hours, does overtime work, and studies engineer-
ing at night school as well as taking lessons in Spanish.
On first view one attributes much to the overwork. Fur-
ther consideration elicits the information that he is en-
gaged but defers marriage from fear that his manhood has
been impaired by auto-se.xual habits. He has been auto-
sexual from childhood until two years ago. At sixteen he
developed anxiety over his habits from reading the usual
advertising literature on lost manhood, repressed his fears
as much as possible, became religions, became active in
basketball and sprints, but at nineteen was having attacks
of marked depression. The insurance rejection and the
treatment consecutive thereto fully crystellized his belief
in his physical ruin.
In this case no treatment was directed to the thyroid
per se. The tonsils were removed, four infected wisdom
teeth were extracted, the work, the study, and the physical
exercise were standardized, and his sexual knowledge was
revised and amplified. Two months after operation the
blood pressure is 130-60, heart rate 72, and the general con-
dition indicates a parallel and progressive betterment. The
chronic coryza is absent. The thyroid is diffusely enlarged
and of colloid consistence.
The stage of fixed hypertension is quite identical
in symptoms with the condition to which Janeway
gave the name of primary hypertensive cardiovascu-
lar disease with the added feature of a goitre. There
is generally present a more or less progressive in-
fection and often psychic factors of undeniably
irritative import. Mild vagotonic symptoms appear
after periods of definitely [)rodigal energy expendi-
ture.
Case 365. — Constantly toxic high pressure goitre, stage
of fixed hypertension, cardiac hypertrophy, hypertension,
180-115. Heart rate 88, sinus infection, frontal. Dental
sepsis consisting of gingivitis under crowns and bridges and
periapical infection. Service of Dr. Mead Moore. Dental
examination and radiography by Doctor Sharp.
Woman, age forty. This lady recently detected an asym-
metry of the neck which has since caused some annoyance
because of the cosmetic defect. She is a cultured student,
a teacher of languages, always very active, and noted
among her friends for alertness of mind and energy of
body. This patient suffered from rheumatism at the age
of eleven, was ill four months; at seventeen the tonsils
were removed ; at twenty-five again had rheumatism, after
a stillborn child; at the age of thirty-seven a third attack
of rheumatism was definitely ascribed to her teeth, and
she was treated for pyorrhea. Eighteen months ago con-
tracted a frontal sinus infection in the attention to which
she has been dilatory and which still shows some indica-
tions of irritability. She reacted to vaccine therapy with
marked serum sickness. One year ago she undertook the
rehabilitation of a rundown private school, an undertaking
fraught with much physical and psychic strain : one
month later she developed an attack of pityriasis. She has
no complaint to make of her health, feels better than ever
before in her life, and often wonders at her own tirelessness.
She believes that ill health is largely a matter of auto-
suggestion and lives accordingly. She keeps her weight
down by doing 100 bending exercises daily. This lady is
unwilling to accept any suggestion for treatment. The
focal infection is undoubtedly in the mouth, .the psychic
factor presumably in her overwork. Considering that this
lady's father died at sixty-four of paralysis, and the
mother at sixty, of angina, the prognosis is not bright.
The thyroid is diffusely enlarged and shows in addition a
lime sized adenoma in the right lobe.
The stage of cardiovascular degeneration is a
picture of arteriosclerosis and myocarditis with
their appropriate symbolism plus an asthenia, a
pigmentation of the skin, and a slowing, both mental
and motor, that suggests Addison's disease. A
vascular nephritis adds an albuminuria which often
deludes the observer. The thyroid is often far
spent at this time and may welcome artificial as-
sistance. It is the efficacy of small doses of thyroid
powder in analogous cases which has originated the
fallacy that thyroid medication is beneficial in ne-
phritis. Boothby cites a pseudonephritis in which
albumin and casts cleared and the functional tests
improved (15). A partial heart block in this type
of case improves under thyroid medication.
In a personal communication dated December 2,
IQ15, Dr. R. G. Hoskins, of Northwestern, whose
experimental knowledge of the suprarenals is not
excelled in this country, queries, "In cases of long
standing hyperthyroidism could not the asthenia be
best explained as due to over stimulation of the
suprarenals leading to final atrophy?"
Case 147. — Male, age seventy-two, civil engineer. Serv-
ice of Doctor Balloch. Relief was sought in this case for
extreme and incapacitating shortness of breath associated
with numbness of the legs after walking much. This con-
dition had been progressive during the last two months,
following an exhaustion in the field, since which time he
has been at a desk. This man has led a most active and
most interesting life in his duties as government engineer,
particularly in the building of lighthouses such as Hopkin-
son Smith idealized, and with whom he was associated.
His life story is one of unending tirelessness, endurance
and optimism. He has never been sick.
Upon examination one is impressed by the extreme
breathlessness and by the irregularity of the heart. The
heart extends to the axilla, is irregular in force and rhythm
September 14, igiS.]
REEDE: TOXIC NONEXOPHTHALMIC GOITRE.
:nid the arteries of the arm arc overly hard. There is a
lieavy trace of albumin with casts. There is no peripheral
edema. A large cystic goitre occupies the left side of the
neck. The pulse is sixty. The picture is that of a ter-
minal cardiovascular sclerosis with fixed heart block. He
remained in bed a week without improvement. He was
then put upon atrophine and thyroid dried substance, Y2
grain three times a day. There was marked improvement
in the course of a month. He returned to office work and
has worked since August, lOi^, without a recurrence. The
rate and regiilarity of the heart seems maintained by the
small doses of thyroid.
In this case the thyroid has acted as a cardio-
vascular stimulant over a long period and the cessa-
tion in part of its*'secretion has allowed a vagus
disturbance of the heart to appear, which by reason
of the collateral arteriosclerosis simulates a sclerosis
of the bundle of His. It is not unlike a similar
alcoholic vascular condition. The additional thyroid
influence starts the drive again but defers the pay-
ment of the penalty.
The toxic low pressure group of goitres include
the great majority of cases of parasympathetic
stimulation with goitre. I imagine that ninety per
cent, of all toxic goitres belong to the nonex-
ophthalmic class ; certainly the proportion of true
exophthalmics is very small.
There are three prerequisites to the study of the
toxic goitre : First, an adequate conception of the
role which the vegetative or autonomic nervous
system plays in the human body and an intimate
acqitaintance with its functional expression ; second,
a familiarity with the physiological evolution of the
normal individual from child to adult with the usual
reactions in the great epochs of puberty, adoles-
cence, pregnancy and the climacteric and some
knowledge of the goitrous individual's variants:
Third, an elementary study of personality as de-
termined by the phylogenetic instincts and especially
by those aspects of the instincts termed, cognitive,
affective, and conative (17).
It is of the utmost value for one from time tO'
time to give thought to the quantity and kind of
work which is being done by the great vegetative
nervous system. Its duty lies, on the one hand, in
accelerating the processes of life by way of its
thoracicolumbar division, and on the other hand, by
means of the craniosacral, in retarding these pro-
cesses. The theoretical balance which gives perfect
physiological poise is seldom attained, for the gift
of our inheritance is apt to be a balance of power
on the one side or the other.
The action of the vegetative nervous system is
primarily automatic but this automatism is gravely
perverted through three agents, the hormones of the
ductless glands, the actions of toxins, and the effect
of psychic stimuli transmitted through the central
nervous system, and often through the combined
action of all three factors. This survey, v. i., of
the field of action of the autonomic nervous system
follows Barker. It includes secretory processes of
the digestive glands (salivary, gastric, intestinal), as
well as the secretory action of the organs that sep-
arate the urine, the sweat, and the milk ; the work
of the heart and the distribution of the blood in the
body through changes in the calibre of the vessels
m the different parts ; the work of the respiratory
mechanisln ; the propulsion of food through the
digestive canal, the emptying of the secretions from
the digestive glands, the muscular activities of the
ureters and bladder and of the system of genital
ducts in both sexes; the state of nutrition of the
muscles, the carbohydrate metabolism, the nitrogen
metabolism, the heat regulation, the deposition of
fat and the growth of bone.
Conditions of craniosacral irritability are largely
but not exclusively exhibited within the confines of
one svstem of vital function. Like the branches of
a tree, one limb is not violently shaken without oscil-
lations in other divisions. The relation of the
thyroid to a psychoneurosis is a debatable point.
Its relation is probably threefold ; it may sensitize
latent tendencies ; it furnishes a soil for luxuriant
growth ; or it inay be an end product. Many cases
of so called endocrinopathy need reviewing by a
psychoneurologist for the material being offered as
examples of endocrine dysfunction comprises a
melange of neurasthenias, cyclothymias, neuroses
and psychoneuroses.
The vegetative neuroses which show major para-
sympathetic symptoms in the gastrointestinal field
include, digestive migraine, salivation, continued
vomiting, pharyngeal anesthesia, esophageal spasm,
cardiospasm, gastric angina, pylorospasm, hyperacid-
itv, intestinal coHc, appendix and hepatic colic,
colonic spasm, mucous colitis ; in the respiratory
field, vasomotor sinus congestion, sinus headache,
vasomotor rhinitis, recurring noninfectious coryza,
rose cold, hay fever, laryngospasm aphonia, idio-
pathic cough, bronchial asthma, bronchial gland irri-
tation, Bryson's dyspnea ; in the cardiac group,
pseudoangina, sinus arrhythmia, premature systoles,
bradycardiac palpitation, syncope, hypotensive
crises, precordial anxiety, brachial neuralgia, carotid
neuralgia, tinnitus, vertigo ; in the field of the skin,
vasomotor instability, pruritus, paresthesias, ery-
thema, eczema, acrocyanosis, Raynaud like appear-
ances, hyperidrosis, erythema multiforme, etc.
Ocular disturbances with headache almost univer-
sally occur at some stage and seem dependent on
disturbance of accommodation, disturbance of the
circulation or on retinal irritation. In some the
gynecological aspect is most in evidence including
spasmodic dysmenorrhea, amenorrhea or a flow be-
tween periods, recurring miscarriages, inordinate
ill health during lactation and anomalous climac-
terics, and sexual anesthesia.
Experimental evidence is constantly accumulating
relative to the important role that the vegetative
nerves play. Of interest is the observation made
by Porter and Newburgh that in dogs with pneu-
monia a Iter section of the vagi the violent dyspnea
is succeeded by quiet breathing. From a pharmaco-
dynamic study of typhoid fever Matsuo and
Murakami conclude that in the majority of cases a
state of vagotonia or one of sympatheticotonia
exists ; that the bradycardia is a vagotonic phenom-
enon ; that in their cases all the deaths occurred in
the sympatheticotonic cases and that this may form
a basis for prognosis.
Case i?,o. — Constantly toxic low pressure type. Major
cardiovascular symptoms. Minor skin symptoms. Service
of Doctor Lamb. Female, clerk, age thirty. Decisive
symptom, fainting spells. Goitre noted at fourteen, taken
from school because of palpitation of heart. Tonsillitis at
seventeen with recurrences. At twenty in contact with
!)rother and sister who died of consumption. At twenty-
456
REEDE: TOXIC NONEXOPHTHALMIC GOITRE.
[New York
Medical Journal.
four had a pulmonary hemorrhage. Four months ago
jilted by fiance for a younger girl. Present condition: As-
thenia, palpitation, dyspnea, chok-ng feelings and fainting
spells. B. P.. 128-70. Rate 88. Heart negative. No al-
bumin. Alarked flushing of face and neck. The most
marked fact in this girl's history was the cardiovascular
asthenia. The notable thing in the family history is that
the mother died from cystic suprarenals with symptoms of
pernicious anemia and achylia gastrica. The x ray shows a
small arrested focus in the right apex.
Ca.sf. 189. — Constantly toxic low pressure type. Major
gastrointestinal symptoms. Minor respiratory symptoms.
Service of Dr. Saffold. Female, aged thirty. Decisive
symptom — goitre. During childhood there were recurring
attacks of tonsillitis. At twelve was treated for intermit-
tent heart. A goitre was noted at fourteen. At twenty-
two was treated for rose colds. At twenty-four tonsillitis,
followed by rheumatism. At twenty-seven the turbinates
were removed to remedy attacks of hay fever. At twenty-
eight was treated for chronic appendicitis, later for movable
kidney. During these years from twenty to thirty there
occurred at intervals run down spells after overdoing,
characterized by loss of strength, loss of weight, and dimi-
nution in the size of the goitre. At present there is gas and
pain after eating, low colicky pains three hours after eat-
ing, acidity, esophageal spasm with pain to the shoulders,
pain in the appendix region Morning nausea. B. P. iio-
60. Rate 88. The goitre is in part colloid, in part adeno-
matous in feel. There is much vascularization. Removal
of tonsils was advised.
Case 371. — Constantly toxic low pressure type. Major
gynecological symptoms. Minor cardiac symptoms. Decisive
symptom-presence of goitre. Service of Dr. Whitson. Fe-
male, stenographer, aged thirty-eight. This girl menstru-
ated at fourteen and not since. Goitre noted at twenty-
four. Married at twenty-five. Shortly after marriage was
warned of the probable sudden cardiac death of husband.
This fear was a daily reminder until its realization two
months ago. At twenty-seven patient miscarried in the
fifth month. At twenty-nine patient miscarried in the sec-
ond month. At thirty-one was treated for cardiac symptoms
with thyroid extract and digitol, at thirty-four the tonsils
were removed, at thirty-five was treated for cardiac symp-
toms with thyroid and digalen. Five months ago the thy-
roid was rontgenized.
Patient is obviously near point of exhaustion. Face ery-
thematous and marred by an eczema. Body sweating pro-
fusely. Coarse tremor. B. P. 120-75. Pulse 112. Heart
moderately enlarged, very irregular pulse from premature
systoles. No albumin. Operation — bilateral lobectomy Tjy"
Doctor White. In the two months since operation the
heart has steadied, the face has paled, and there is great
general improvement in wellbeing. Operation was advised
in this case to protect the myocardium.
The inconstantly toxic low pressure group dii¥ers
from the preceding group only in the history and in
the less destructive effects of the intoxication. In-
termittent nervous breakdowns are separated by
periods of good health. The history demonstrates
that there is not a high health threshold but that
specific infective or psychic trauinata anticipate the
several breakdowns. There is usually an adenoma
present. Goetsch has described a typical case in his
suggestion that the presence of mitochrondria is an
index of thyroid activity (18). No comment on
low pressure or dilator phenomena is complete with-
out reference to the work of Hunt on acetylcholine
isolated from the suprarenal glands. This substance,
the most powerful vascular depressant known,
which is active in a dilution of one part to one
trillion, j)lays as yet an unknown role in the vascular
regulation (19).
Case 41. — Inconstantly toxic low pressure type. Female,
aged twenty-nine. Employee at bureau. Service of Dr.
Lamb. Decisive symptom — headache. This girl suffered
from recurring otorrhea in childhood, had a nervous break-
down at sixteen, and was taken from school because of
rapid heart. A goitre was noted at nineteen. One year
ago had nervous breakdown and was unable to eat or sleep,
very restless, felt impelled to keep moving, and continually
felt as if she had been running. Since that time has had
lieadache n::d weakness. B. P. 108-75, rate 72. Egg size
adenoma in middle lobe of thyroid. Eye signs: left slit
noticeably wider, asynchronism on closing. Incomplete
closure in winking. The removal of this goitre two years
ago has been followed by marked increase in endurance,
lictter spirits, and less nervousness.
Low pressure and high pressure, using as Plum-
mer did an arbitrary standard of 160, does not cover
all the cases. There is an intermediate group be-
tween 130 and 160, which *• suggests probable
terminal hypertension and vascular degeneration
like the high pressure cases, but which also lux-
uriantly exhibits the vagotony of the low pressure
group.
Case 114. — Constantly toxic intermediate pressure. Early
major cardiac symptoms. Late major gastrointestinal
symptoms. Service of Doctor Clark. Female, aged fifty-
five, professional matron. ^\t age of thirty-five, after un-
usual emotional strain felt a sudden throbbing of heart,
with cessation of beat and premonition of death. During
the succeeding three months these sensations recurred at
times with diarrhea. Was out of health a year. At age
of forty-one after anxiety in work, a pain appeared in the
left shoulder with rapid heart ; patient was in bed two
weeks, stopped work for some months. At age of forty-
eight, gradual development of pain at left costal margin,
general weakness and nervousness, and for nine months
mucous colitis. An exploratory laparotomy gave negative
findings. At fifty-two goitre was noted. Cardiac dullness
16 cm. to left. Marked sinus arrhj'thmia and premature
systoles, much increase in forced expiration. B. P. 150-100.
Rate g6. The right lobe of the thyroid is composed almost
entirely of an adenoma winch is losing the rubbery feel
peculiar to them and at the advancing edge along the isth-
mus is almost stony. The right lobe is ylA cm. by 5 cm.,
extends below the clavicle and is apparently anchored at
the base. The left lobe is about 2 by 2'-^ cm. and is soft
and colloidal in feel. This was considered to be a fetal
adenoma with malignant degeneration. Operation by Doc-
tor Kerr. Pathological report, carcinomatous change in an
adenoma. Since operation there has been a great improve-
ment in health and in the cardiac symptoms.
Case 112. — Constantly toxic intermediate pressure type.
Major gastrointestinal symptoms. Minor cardiac symp-
toms. Pressure cough. Female, aged fifty, clerk. Men-
struated at sixteen. Dysmenorrhea relieved by dilatation.
Frequent tonsillitis during adolescence. At thirty-two had
nervous prostration and was sick for five years. At forty
had attacks of morning diarrhea continuing since. These
consist of eight to ten liquid stools before going to work
with freedom until the next day. Major Russell made an
extensive search for parasites. At forty-eight a constant
harassing cough began. At the same time attacks of heart
pang occurred, excruciating, more so in cold weather and
out doors and impelling her to stand still. Three years ago
neck began to resemble tanned leather. B. P. 140-Q5. Rate 88.
Mass felt rising from below at episternal angle, apparently
a substernal goitre. Tracheal sounds suggest pressure and
are influenced by posture of head. Heart enlarged. No
murmurs. Broad band of dark tan pigmentation around
neck, patches on face. No albumin.
As to treatment, the consideration in class one is
as to the degree of vascular and myocardial damage
present or imminent. As a rule surgical inter-
ference is the surest way of blocking a process
which is very intensive in its progress. In the low
pressure class where the question is more as to the
degree of ill health than actual duration of life, a
wider latitude is permitted. The following steps
should be taken: i, the removal of focal infections;
2, the relief of psychic irritation ; 3, surgical inter-
vention. One or both of {he first two suggestions
September 14, 191 S.]
CORCIA: PAPILLARY CYST ADENOMA OF THE OVARY.
457
may suffice. The operation should be a bilateral
lobectomy. Much good is done by the various
specialists and many cases arrested, since nowadays
steps one and two are combined with various local
treatments. Vagotonic disorders aside from their
cause are alleviated by local palliatives in many
cases. This can be noted in the reports of gastro-
enterologists, gynecologists, laryngologists, etc.
The discussion is not complete without a word as
to prophylactic treatment. First, goitre in children
should be prevented. I examine i,5cx) children a
year and I am more firmly convinced than when I
made the statement some years ago that goitre is
largely a result of deciduous dental sepsis. I feel
that young girls from five to twelve should be ex-
amined yearly and the cephalic extremity kept free
of all infections, gingival, otic, tonsillar, adenoid,
etc. If a goitre is already present the transit of the
girl through puberty demands protection.
The demands upon the thyroid by the processes of
sexual maturation are heavy enough without the
added irritation of the myriad of physical, mental,
and psychic adjustments which arise at this time.
During the period of adolescence the appearance of
pseudochorea, palpitation and fainting, nervous
breakdowns, asthenopia with intractable headache
and other nervous phenomena should call for an
estimation of the thyroid activity.
Especial care should be exercised to keep the
body free from focal infection, especially around
the teeth, during pregnancy. The physiological
activity of the thyroid of pregnancy ceases normally
during lactation, but it may be extended by infec-
tion or by the influence of anxiety beyond this
period. The condition of the thyroid after child
bearing merits observation. Another age period
marked by thyroid vulnerability is at the meno-
pause; very many stormy changes of life are thyre-
ogenic and not ovarian.
REFERENCES.
I. E. C. Kendall: Experimental Hyperthyroidism, Journal A. M.
A., 1917, l.xix, 612. 3. E. H. Reede: The New Status of Exoph-
thalmic Goitre, Medical Record, March 17, 1917. 3. Louis B.
Wilson: The Pathology of the Thyroid Gland in Exophthalmic
Goitre, American Journal of the Medical Sciences, 1913, cxlvi, 781.
4. Louis B. Wilson; A Study of the Pathology of the Thyroids
from Cases of Toxic Nonexophthalmic Goitre, American Journal of
the Medical Sciences, 1914, cxlvii, 344. 5. Louis B. Wilson and
E. C. Kendall: The Relationship of the Pathological Histology
and the Iodine Compounds of the Human Thyroid, American
Journal of the Medical Sciences, 1916, cli, 79. 6. E. H. Reede:
The Relation of Mouth Infection to Goitre, Washington Medical
Annals, loif', xv, 2311. 7. G. E. Buroet: Attempts to Produce
Experimental Thyroid 'typerplasia, American Journal of Physiology,
1917, xliv, 492. 8. D. Marine and O. P. Kimball: Journal of
Laboratory and Clinical Medicine , 191 7, iii, 40, Prevention of Simple
Goitre in Man. 9. D. Marine and C. H. Lenhakt: Observations and
Experimt-n*s on the So Called Thyroid Carcinoma of Brook Trout and
Its Relation to Ordinary Goitre. Journal of Experimental Medicine,
1910, xii, 311. 10. G. E. Smith : Fetal Athvreosis: A Study of the Iodine
Requirements of the Pregnant Cow, Journal of Biology and Chem-
istry, 1917, xxix, 215, II. E. P. Hart and H. Steenbock: Thyroid
Hyperplasia and the Relation of Iodine to the Hairless Pig Malady,
Journal of Biology and Chemistry, 19:8, xxxiii, 313. 12. H. S. Plum-
mer: Blood Pressure and Thyrotoxicosis, Transactions of the Asso-
ciation of Air.erican Ph.vsicians, 191 xxx, 450. 13. E. B. Krumb-
iiaar: Electrocardiographic 01)servations in Toxic Goitre, American
Journal of the Medical Sciences, 1018, civ, 175. 14. D. Symmers:
The Relationship of the So Called Idiopathic Cardiopathy to Exoph-
thalmic Goitre, Archizcs of Internal Medicine, 1918, xxi. 337.
15. W. M. Boothey: The Clinical \'alue of Metabolic Studies of
Thyroid Cases, Boston Medical and Surgical Journal, 1916, clxxv,
564. 16. J. M. Blackiord aiul F. A. Willius: Chronic Heart
Block, American Journal of the Medical Sciences, 191 7, cliv, 585.
17. L. Barker: Discussion of Treatirent of Neurasthenia, Johns
Hopkins Hospital Biillelin, ioif>, xxvi. 288. 18. E. Goetsch: Func-
tional Significance of Mitochondria in Toxic Thyroid Asenomata,
Johns Hopkins Hospital Bulletin, 1916, xxvii. 129. 19. Reid Hunt:
Vasodilator Reactions, American Journal of Phvsiologv, 1918, xlv,
197-
815 Connecticut Avenue.
PAPILLARY CYST ADENOMA OF THE
OVARY.*
With Report of a Case.
By John Corcia, M. D.,
New York.
Whether cystic papillary growths are malignant,
or to what extent they undergo malignant changes,
is not fully determined. Cases, apparently innocent,
have had sometimes a very rapid recurrence, prov-
ing to be malignant, while cases which clinically
presented all the character of malignancy have un-
expectedly been permanently cured by operation.
The following case of mine seems worth report-
ing on account of its peculiar features :
Miss V. A., aged thirty-two years, school teacher. Men-
strual history not itnporlant, with the exception that
she was amenorrheic for six months before coming under
my examination. She told me that Iter abdomen had been
gradually increasing for a year, reaching at the present
time such distention as to interfere seriously with her
digestion and respiration. She complained of no pain, but
of weakness and extreme emaciation, her weight having
dropped from t6o to 120 pounds within a short time. She
also had dyspnea and vomiting, not being able to retain
any kind of food ingested. At the physical examination
the abdomen appeared to be very much distended, causing
enlargement of the costal arch. It showed a considerable
quantity of free fluid in the peritoneal cavity. Vaginal
and rectal bimanual examinations were entirely negative,
it being impossible to locate the uterus and annexa. Only
a very careful palpation gave me the impression of the
presence of something solid or semisolid in the abdominal
cavity, the origin and nature of which it was quite impos-
sible to establish. I made a diagnosis of probable ovarian
cyst or abdominal tuberculosis.
At the operation the case seemed quite hopeless. I
found in the peritoneal cavity about five gallons of clear
liquid and an extraordinary number of cysts of different
size, surrounding with racemose disposition a central and
larger cyst and containing more than a gallon of fluid.
On the external and internal surfaces of these cysts were
numerous papillomata which extended also on to the peri-
toneum, intestines, bladder, and to the ovary on the other
side. After tapping the central cyst, I delivered and re-
moved the whole mass, which originated on the left side.
No traces of the ovary could be found. I removed also
the right ovary, which was studded with papillary growths
and a fev/ small cysts, and as much as I could of the
papillomata scattered on the peritoneum and other or-
rrans, closing the abdomen without drainage. The patient
had an uneventful recovery, and after three weeks was
able to leave the hospital.
T have often examined this patient since the op-
eration and liave found that at present she is en-
joying good health seven years after the operation,
and is presenting no sign of recurrence. This is a
typical case of papillary cystadenoma of the ovary,
and although its histological examination does not
show real sarcomatous or carcinomatous degenera-
tion, it has to be considered clinically malignant
belonging to the class of the proliferating cysts on
.Tccount of the ascites and of the implantation of the
l^apillomatous growths upon the peritoneum and
other organs of the abdominal cavity ; and because
of the cachectic condition of the patient. To ex-
plain the pathogenesis of the proliferating cysts it
must be remembered that their walls are formed of
three layers, the external of fibrous tissue, the
middle of connective tissue, and the internal by a
*Read before the Medical Association of the Greater City of New
York, April 15, 1918.
458
I.EIKAUF: FOOD VALUE OF CANDY.
[New York
Medical Journal.
capillary plexus covered by epithelium. According
to W'aldeyer, this epithelium is formed of very
short cylindrical cells. But Mallassez and De
Sinety insist on the polymorphism of these cells
and have demonstrated also a subepithelial en-
dothelial layer proving that on the same type of
cyst the most varied forms of deformed epithelium
can be found. Besides, they have established a
certain relation between the epithelial cells of these
cysts and that of the epithelioma of the breast.
The most hybrid forms of degeneration might be
found in such cysts. The main forms, according to
Waldeyer, are the papillary and the glandular, or
both, according as they originate from the middle
or internal layer. When one or both of these forms
exist it is easy to understand how these cysts may
also have a carcinomatous or sarcomatous degen-
eration at any moment, presenting a complete pic-
ture of malignancy. While the dermoid cysts may
be quiescent for many years, the papillomatous
cysts have a marked tendency to multiply, thus
seriously affecting the general health of the patient.
But unfortunately we cannot judge yet to what
extent these cysts have to be considered malignant.
Even the pathological examination may fail owing
to the hmited area of degeneration in the neoplasm.
But when the affection is bilateral and when the
barrier of fibrous tissue forming the external layer
of the cysts is broken and there exist ascites and
implantation of the papillary growths on the per-
itoneum and other organs, they must be considered
malignant and as allied to carcinoma. Some time
ago papillomatous growths were considered as
forming a special class of malignant tumors and
many times it happened that cases which presented
a verv extensive process, after opening the abdomen,
have been declared inoperable, with lethal termina-
tion. Pfannenstiel was one of the first to demon-
strate that papillomata may not be originally malig-
nant and may be cured by operation.
Doctor Hyde in his paper advocating the Pozzi
drainage method for the treatment of papillomata
complicated with ascites, states that it is a well
ascertained fact that numerous cases of papilloma
simplex have been cured, but that the medical
literature on this subject is still very scant. Still
less numerous are the cases of papillary cystade-
noma reported permanently cured. It seems that
almost fifty per cent, of cystadenomata undergo
malignant degeneration. Schauta says that all the
cases of papillary cystadenoma operated on by him
had had recurrence with real malignant metastasis
within a short time.
Kelly, in his textbook, reports fifty-four cases of
papillary cystadenoma operated on by him, but does
not give the number of the permanently cured
cases. He mentions the case of Thornton which
remained free from recurrence for nine years, and
that of Lorner in which two papillomatous tumors,
the size of a double fist, were removed, leaving
scattered on the peritoneum papillomata, and in
which after four years and a half no trace of re-
currence could be found. Doctor AIcGlinn of
Philadelphia reports two cases. He operated on a
woman for racemose cyst of one side, leaving the
ovary of the other side which appeared healthy.
One year later he had to operate on the same woman
for papillary cystadenoma with probable carcino-
matous degeneration of the side which was healthy
at the first operation. The woman recovered. The
other case was a woman on whom he operated for
papillary cystoma and she died shortly after from
cancer of the uterus. Doctor Oastler reports three
cases ; one was papillomatous cyst, one multilocular
cystadenoma, and one psuedomucinous cyst of the
ovary. Of these three cases the third did not show
recurrence after two years. My case which pre-
sented all the clinical characteristics of malignancy
(ascites, cachexia, etc.), and which after ' seven
years has shown no sign of recurrence, can be
counted among the cases of papillary cystadenoma
reported permanently cured.
CONCLUSIONS.
First : Papillary cystic growths must always be
considered clinically malignant, because we do not
know their outcome, but the operation may give
unexpectedly good results.
Second: Early operation is always desirable
when a diagnosis of cyst is made.
Third : In the advanced state, when ascites and
great emaciation are present the diagnosis of cyst
is difficult, if not impossible, being confused with
a general cancerous or tubercular affection of the
abdomen.
REFERENCES.
I. C. R. HYDE: Tlie Treatment of Pi^pillomatous Growths of the
Ovary After the Pozzi Method, American Journal of Obstetrics,
March, 1017. 2. HOWARD KELLY: Operative Gynecology, 1906.
3. JOHN McCLINN: New York Medical Journal, Tune, 1912. 4.
F. R. OASTLER: What Constitutes Malignancy in Ovarian Cyst?
American Journal of Obstetrics, March. "917. 5. POZZI: A System
of Gynecology, 1906. 6. SCHAUTA: Handbuch dcr Gynaekologie,
Vienna, i?96.
212 East Si.xty-First Street.
THE FOOD VALUE OF CANDY.*
By John E. Eeikauf, Ph. D.,
New York.
wh.\t is food?
Some one has said, "Tell rne what you eat and I
will tell you what you are," which is just another
way of saying that there is a direct relation between
what a man eats, his physical condition, his char-
acter, his temperament, and perhaps even more so,
his temper. A sour stomach and a bad temper
epitomize cause and effect. Historians tell us that
it was stomach trouble and not mental trouble that
caused Napoleon to lose the battle of Waterloo.
We are beginning to realize the great importance of
carefullv selecting our daily foods, not only to see
to it that they are pure and wholesome, but that
they are harmonious and best adapted to our indi-
vidual requirements, and that the various nutri-
ments which they contain are in the right propor-
tions to produce the greatest nutritive value.
Food is life; and that we may have life more
abundantly, the food question is receiving more
consideration and attention than at any other time
in the history of the world.
The technical schools and colleges during the
'An address delivered to the city emiiloyces, May 8, 1918, under
the auspices of the New York Municipal Civil Service Commission,
i-eonhard Feli.x Fuld, Ph. D., Assistant Chief Examiner.
September 14, 1918.]
LEIKAUF: FOOD VALUE OF CANDY.
450
past few vears have been giviijg special attention to
rhe principles of dietetics. This is due in part, no
(lonl)t, to the fact that modern physicians give
greater importance to the diet than they do to ad-
ministering drugs. The proportion of carboiiy-
(Irates, fat and protein, which represents the fuel
value of different kinds of foods, is carefully
ascertained in order to determine what kinds are
best adapted to the needs of persons in various oc-
cupations and different conditions of health. The
determination of the food value of any kind of food
is an exact science. The food analyist, therefore,
occupies a very important position in our social
economics.
Our ordinary foods are composed of from fifteen
to twenty elements, which are combined in the right
proportions to form a great variety of foods. The
most important of these elements are carbohydrates,
fats, protein, water, and minerals. These difYerent
materials are necessary for the purpose of building
up and repairing the body tissues and to supply the
body with heat and energy. The carbohydrates
include the different kinds of sugars, such as cane,
beet, maple, corn syrup, and molasses. The sugars
and starches are easily digested and are important
food elements as sources of bodily heat and muscu-
lar energy, and are often converted into fat. The
fats are found chiefly in animal foods ; they are also
found in olive oil and various kinds of vegetable
oils, and in various kinds of nuts. They furnish the
body with heat and muscular energy. Protein is
found principally in lean meat, gluten of wheat and
whites of eggs ; it is also found in many of the
cereals, and notably in the legumes, peas, and beans.
It builds bone and muscle and furnishes muscular
energy to the body. Water, although a most im-
portant food element, being a part of all the body
tissues, does not supply energy. It is, however,
indispensable, as are also the minerals which supply
the body with little or no heat or muscular energy.
It is, therefore, apparent that many different
kinds of foods are necessary in order to have a
complete dietary. The body is like a machine and
requires difil'erent kinds of materials to repair the
worn out tissues, to build up its different parts, and
to serve as fuel to supply heat and energy. Carbo-
hydrates and fats are the chief fuel elements of
food. The transformation of these and other ele-
ments into heat and energy are measured with a
respiration calorimeter. In ascertaining the amount
of heat given oft" by any food element, the unit com-
monlv used is the calorie, the amount of heat which
would raise the temperature of one kilogram of
water i° C, or what is nearly the same thing, one
pound of water 4° F. Instead of this unit of heat
a unit of mechanical energy may be used — for in-
stance, the foot-ton, which represents the force
required to raise one ton one foot. One calorie is
equal to very nearly 1.54 foot-tons; that is to say,
one calorie of heat, when transformed into mechani-
cal power, would sufifice to lift one ton 1.54 feet.
The United States Department of Agriculture has
made very extensive and complete scientific tests
and experiments to determine the correct food
values of various kinds of foods. These experi-
ments demonstrate that the carbohydrate, fats and
protein all furnish fuel which supplies energy to
the body in the form of heat and muscular power.
The nutritive value of any kind of food, therefore,
depends upon its composition and digestibility, e. g-.
granulated sugar is 100 ])er cent, carbohydrates and
butter is eighty-five per cent, fat ; both are easily
digested, although, neither is a perfect food if taken
alone, but when combined with other foods that
contain protein and minerals in the right proportion,
a complete and satisfactory dietary is obtained.
Candy being composed principally of sugar, choc-
olate, and nuts, is very high in food value, and the
different kinds vary in the proportion of carbo-
liydrates, fat, and protein they contain.
Sugar is highly concentrated food : its pleasant
flavor and high nutritive value make it one of our
most popular daily foods. The natural craving for
"something sweet" is common in all classes and the
per capita consumption of sugar is in direct propor-
tion to purchasing power — they will eat all they can
afford to buy. The absolute purity of sugar is un-
questionable. Several years ago, the Bureau of
Chemistry of the United States Department of
Agriculture carefully analyzed 500 samples of
sugar, every one of which was found to be abso-
lutely pure. Sugar is easily digested ; the experi-
ments made at the Minnesota Experiment Station
show that 98.9 per cent, of its total energy is avail-
able to the body. On account of the rapidity with
which it is assimilated, sugar ciuickly relieves
fatigue. Sugar is a favorite food with farmers,
lumbermen, and others, whoAvork hard in the open
air. which unquestionably proves its high fuel value.
Six ounces of sugar are equal in food value to one
quart of milk, or 1% pounds of lean beef. It has a
fuel value of 1,810 calories.
(Chocolate is made from cacao beans, the fruit or
beans from the cacao trees, several species of which
grow in the countries extending from Mexico to
Brazil, the most important of all the species being
Theobroma cacao, which is chiefly cultivated for its
good quality and yield. The Aztecs, the aborigines
of Central America, used cacao beans as currency,
the value of the bean depending on its size. In
appreciation of the delicious flavor and the food
value of the beverage, chocolate — from "choco"
(cacao) and "late" (water) made from the cacao
beans, they called it "Theobroma" which name was
derived from two Greek words, "theos" (god) and
"broma" (food) — "food of the gods." With the
exception of prepared cocoanut, chocolate is higher
in food value than any other ingredient used in the
manufacturing of confectionery, having a fuel value
of 2,860 calories per pound.
It is a fact of common knowledge that nuts are
very high in food value, those used principally in
manufacturing confectionery being almonds, fil-
berts, pecans, peanuts, and walnuts, averaging aj)-
proximately 1,500 calories per pound.
Corn syrup, erroneously called glucose, used
largely in manufacturing gum drops, hard candies
and taffies, is a pure, wdiolesome transparent heavy
syrup, manufactured, as the name indicates, from
corn. Its purity, wholesomeness, and food value
have been the subject of searching scientific investi-
gations by the United States Department of Agri-
460
I.EIKAUF: FOOD VALUE OF CANDY.
[New York
Medical Journal.
culture, food departments of the various States, and
by noted food chemists, all of which have demon-
strated that it is : "readily and completely absorbed
by human beings, that it is the normal blood sugar,
and the cheapest food fuel known." The food value
as expressed in scientific terms is 1,559 calories per
pound.
Candy is composed of various raw materials of
high food value; it is, therefore, apparent that
candy being composed of combinations of two or
more of these raw materials is exceptionally high in
food value. The food values of several well known
kinds of candy are shown. The food value of each
kind has been carefully estimated from standard
formulas used by prominent manufacturing confec-
tioners.
FOOD VALUKS OF DIFFERENT KINDS OF CANDY.
Calories.
\'an\c. per pound.
Sugar coated Jordan almonds 2410
Caramels 145 1
Chocolate dipped cream caramels 2155
Chocolates, cream centres 2092
Chocolates, nut centres 24Q8
Chocolate tablets, etc 2860
Cocoanut bonbons 1750
Cocoanut caramels 1675
Cream filberts 1913
French burnt peanuts 2040
Fudge 1587
Gumdrops 1685
Hard boiled candies 1587
Jelly beans 1708
Lozenges 1795
Marshmallows 1737
Stick candy 1745
FOOD VALUE OF DIFFERENT KINDS OF RAW MATERIAL.
Jordan almonds .3030
Chocolate 2860
Cocoanut 1730
Corn starch 1675
Corn syrup 1559
Walnuts 3300
Filberts 3290
Gelatine 1705
Pecans 3455
Peanuts 2560
Sugar 1810
On comparing the fuel values of the dififerent
kinds of candies with the fuel value of some of the
common daily foods, shown by the food value
charts, such as whole milk having a fuel value of
only 315 calories per pound, cream 881 calories,
whole eggs 695 calories, beefsteak 1,090 calories,
corn 1,685 calories, rice 1,620 calories, white bread
1,180 calories, and corn bread 1.175 calories, it
will be seen that with but three exceptions, the
different kinds of candies are very much higher in
fuel value than any of these foods.
The high nutritive value of chocolate candy is
recognized by the leading military authorities of the
world, and the "boys at the front" are satisfying
their craving for "something sweet" with chocolate
cakes and tablets and candies of various kinds.
Scientists have demonstrated by careful experi-
ments that during violent exercise or exhausting
labor, the sugar in the blood is very heavily drawn
on to supply the body with the necessary fuel, hence
the longing for "something sweet," which can be
readily assimilated, and which is most easily and
conveniently supplied in some form of candy. The
Swiss guides for mountain climbers consider lump
sugar and sweet chocolate an indispensable part of
their outfit. Brigadier General L. W. Waller, of the
United States Marine Corps, referring to the food
value of chocolate, says, "I never went into a cam-
paign without my chocolate. I always have a few
cakes of it in my kit when I go into service. Men
fight like the devil on chocolate. It is particularly
good in hot weather. Seasoned fighting men take
it on the march with them."
Referring to the emergency ration for the army,
suggested by Doctor Vedder, the Scientific Ameri-
can says : "The problem of rationing the soldier is
of the utmost importance, not merely for the pur-
pose of preserving his physical health, but of con-
serving his military effectiveness. Regardless of
what the civil population subsists upon, the ration-
ing of the soldier must not be reduced so as to
curtail his food requirements. An emergency ration
must be balanced and possess a reasonable energy
value and tissue building power. Palatability must
not be sacrificed. Vedder has suggested as an
emergency ration ten ounces of hardtack and six
ounces of sweet chocolate. The total weight of the
ration is one pound, while it supplies approximately
2,100 calories of which 180 calories arise from
protein sources. The general food value of sweet
chocolate has not been thoroughly appreciated. The
fact that six ounces of sweet chocolate provided 823
calories attests its high nutritive value and recom-
mends it as a valuable foodstuff for the service of
the civil population as well as those engaged in
military services. To be sure hardtack requires
mastication, but hunger provides sufficient impetus
to guarantee that it will be properly prepared for
the action of the digestive fluids. The high carbo-
hydrate content makes thorough insahvation of
pronounced value as the first stage in its digestion.
Taking it all in all this combination of hardtack and
sweet chocolate commends itself as being particu-
larly well adapted to the needs of the soldier and the
requirements of an emergency ration." The British
Army Officer reports that the canteens at the front
have experienced five times the demand for candy
that was expected. On a recent cruise, the Atlantic
Squadron carried no liquor but had on board the
various ships 40,000 pounds of chocolate and other
kinds of candy.
Children are especially fond of candy and find
it hard to resist the desire to eat all they want.
The}^ can eat a reasonable quantity of any kind of
candy, just the same as they can eat a reasonable
quantity of any other kind of good food ; with the
absolute assurance that it is pure and wholesome,
that it furnishes their energetic bodies with quick
burning, fatigue relieving fuel, and that it is high in
food value and good for them. Children should
have candy frequently. It is better to give them
candy frequently than to give only occasionally,
when the craving for it creates an almost irresistible
temptation to overeat. It is especially desirable that
candy should be served for dessert. A moderate
amount frequently is better than an occasional over-
indulgence.
The purity and wholesomeness of candy are un-
questionable. The importance of protecting the
purity of our daily foods, candy included, was given
official sanction by Congress, when the National
September 14, 191S.]
MICHEL: PAINLESS MEATOTOMY.
461
Pure Food Law was enacted June 30, 1906. The
legislatures of the various States have also recog-
nized its importance by enacting State Pure Food
Laws, which, for the most part, are substantially the
same as the National Pure Food Law. The purity
and wholesomeness of manufactured food products
are, therefore, carefully safeguarded. Gone forever
is the day of the disreputable food faker. The raw
materials used in making candy are pure and whole-
some in every respect.
Colors have a direct effect on palatability. Na-
ture colors berries, apples, peaches, plums, and other
fruits, not only to make them more attractive, but
also to increase their palatability. For the same
reason, pure colors are used to color various kinds
of candies. The United States Department of Agri-
culture certifies the purity of the colors used in candy
and other food products. The food products made
by present day manufacturers are pure and whole-
some and made with the greatest care as to cleanli-
ness, quality, and sanitary conditions.
Candy is good food, pure, and wholesome. It is
the universal food, it speaks all languages ; it dries
the tears in the eyes of httle children ; and wreathes
the faces of old age in smiles ; it is the unspoken
message from the lover to his sweetheart ; it brings
joy to the home ; it is the advance agent of happi-
ness in every clime. Can as much be said of other
kinds of food?
PAINLESS MEATOTOMY.
By Leo L. Michel, M. D.,
New York,
Attending Genitourinary Surgeon, Hospital for Deformities and
Joint Diseases; Attending Surgeon, West Side Hospital; Instructor
in Cystoscopy and Urethroscopy, Polyclinic Hospital.
A successful meatotomy is not so much depend-
ent upon the size of the external incision as upon
the divulsion of the membranous band or collar
back of the fossa navicularis at its junction with
the urethra proper. The operation is performed
painlessly and with respect for the after appearance
of the glans in the following manner :
After preparation of the part the urethra is dis-
tended with one quarter per cent, cocaine solution.
Eight c. c. of fluid usually distends the entire an-
terior urethra, and this is held at the meatus for
about three minutes. A cotton applicator as wide
as the urethra will permit to enter, soaked in the
cocaine solution, is introduced for about one inch
and pressure is made downward on the floor of the
canal. A very fine hypodermic needle is then in-
troduced under the integument in the median
raphe at the margin of the glans and frenum, and
infiltration with the cocaine solution is made up tO'
the very edge of the meatus. If desirable a spray
of ethyl chloride can be placed at the point of entry
of the needle. The cotton applicator is removed
and a thin, straight, blunt pointed bistury is in-
troduced. The constriction or band is first severed,
then the glans is incised through the infiltrated area
sufficient to permit a twenty-six to twenty-eight
bougie a boule to enter. This must pass the in-
ternal constriction or further divulsion is made
within the urethra until the constriction is passed.
J liis is the most important point in tlic entire pro-
cedure: Cut just sufficient to pass the meatus with
a medium size instrument, twenty-six to twenty-
eight, but freely incise the constriction within the
urethra.
Bleeding is controlled by placing a pledget of
cotton well oiled with vaseline within the urethra.
15 Central Park West.
TWO NEW FRENCH METHODS FOR
STAINING BLOOD FILMS AND BLOOD
PARASITES.
By L. Tribondeau, M. D.,
Corfu,
Medetin principal de la marine hopital de rAchilleion. Corfu.
I have undertaken in France a struggle against
the use of German dyes for microscopical work. I
wish to extend this attempt to America, the friend
and ally of France. The methods given in this ar-
ticle are very practical, not only because the technic
of the coloration is simple, but especially because the
staining solutions — Tribondeau eosinates I, II, and
III — can be prepared without difficulty by anybody.
They are related to the well known methods of
Leishman, and provide efficient substitutes for the
secret processes of Giemsa and the other German
writers. A further account of this work may be
found in the accounts of the Societe de Biologic
(May- June, 1918) where they have been presented
by Professor Mesnil of the Pasteur Institute.
I. COLORATION METHOD WITH THE TRIBONDEAU
STAIN III.
This is essentially a neutral solution of eosinate
of methylene blue converted by ammonia. Of the
two Tribondeau methods, this one is the more rapid
in execution and gives more complete results. It
only offers the inconvenience of requiring the em-
ployment of a very pure and neutral distilled water.
Now, certain commercial distilled waters do not
possess these qualities. (It is true that one can
correct a defective water by redistilling, after the
addition of a little silver carbonate got by precipita-
tion of a silver nitrate solution with carbonate of
soda; but this is a complicated procedure.)
Preparation of the Tribondeau stain III. — Heat
some distilled water to boiling point. Divide : A —
fifty c. c. in an enameled basin ; add 0.20 gram pure
medicinal methylene blue ; shake to dissolve : B —
seventy-five c. c. in a glass ; add 0.30 gram water
soluble eosin (French eosin) ; shake to^ dissolve.
Pour B into A by successive fractions. After
each addition of B mix for some time with a glass
rod ; then, place on a glass slide the drop of the
mixture from the end of the rod. This drop is at
first deep blue and free from precipitate ; then, as
the proportion of eosin is increased, the blue be-
comes paler and a precipitate appears ; finally, the
precipitate increases and the color of the liquid turns
from blue to rose. Stop the addition of the eosin
as soon as this change occurs. It generally requires
a little more than fifty c. c. of B to obtain this result,
which is quite easy to observe even to the unprac-
tised eye.
462
TKIBONDEAU: NEW FRENCH DYES FOR MICROSCOPY.
[New Vork
Medical Journal.
Add four c. c. of ammonia to the mixture thus
ohtained. Mix. Meat to 120° C. in the autoclave
for twenty minutes, in the enameled basin covered
with an inverted glass funnel. Remove from the
autoclave ; stir with a rod and allow to cool com-
pletely.
Filter through a small white filter paper, well
folded, all the contents of the basin.
Discard the filtrate. Keep only the precipitate,
which is almost entirely retained on the filter and of
which a small portion remains deposited on the side
of the basin. Dry the precipitate by placing in an
incubator at 37^^ C. the filter widely open on sev-
eral layers of absorbent paper, and also the basin.
When the drying is complete (no trace of water
must remain in order that the ammonia may be
completely volatilized), place the filter in the basin
and dissolve as much as possible of the dried stain
by pouring into the basin, in successive fractions,
100 c. c. of glycerinated alcohol (absolute ethyl
alcohol ninety c. c. ; neutral glycerine ten c. c.) and
crushing the powder with a large glass rod.
Transfer the 100 c. c. of solution into a flask,
taking care to transfer also all the undissolved
stain. Shake the flask from time to time. Filter
after twelve to twenty-four hours.
Technic of staining. — First fix the preparation
with the undiluted stain Tribondeau III. For this,
the slide carrying the blood (previously spread in a
thin film, dried simply by moving in air, and marked
ofif by a glass pencil line ) is placed on the table,
film upward. Cover the film with 0.2 c. c. of Tri-
bondeau III (approximately twelve drops). Cover
with the half of a Petri dish to prevent too great
evaporation, especially in summer. Allow to act
three minutes.
Then stain by adding to the Tribondeau III, on the
slide itself, 0.6 c. c. of distilled water (approximately
twelve drops). Mix water and stain by a few
movements of the slide. Replace on the table.
Allow to act for an average time of twelve minutes,
without moving.
Wash rapidly with a jet of distilled water.
Dry immediately (by passing the wet preparation
for two seconds over the flame and blowing vigor-
ously on it).
II. — COLOPATIO.M METHOD WITH THE TRIBONDEAU
STAINS I AND II.
These stains are respectively a neutral solution
of eosinate of natural methylene blue, and an
alkaline solution of eosinate of methylene blue con-
verted by ammonia. When a suitable distilled
water is not available, this second method is prefer-
able to the first, because it is less delicate.
Preparation of the Tribondeau stain /. — Pour
into a heat re.sisting flask :
Neutral glycerine .Sec.
Absolute etiiyl alcohol 45 c. c.
Pure medicinal methylene blue 0.20 gm.
Water .soluble eosin (French) 0.05 gm.
Dissolve rapidly by plunging the flask into a very
hot waterbath and shaking. Allow to cool. Pour
into a glass graduated measure; make up to fifty
c. c. with absolute ethyl alcohol. Filter, and cork
in a flask.
Preparatio)! of the Tribondeau stain II. — Pour
into a heat resisting flask :
Neutral glycerine 25 c. c
Ethyl alcohol Q5% i.Sc. c.
Pure medicinal methylene blue 0.20 gm.
Water soluble eosin (French) 0.05 gm.
Dissolve in a waterbath as with I. Allow to cool.
Pour into a glass graduated measure, and make up
to forty c. c. with ninety-five per cent, ethyl alcohol.
Return to the flask.
Add four c. c. of ammonia. Mix. Heat to
120° C. in the autoclave for twenty minutes, in the
open flask. Remove from the autoclave and allow
to cool somewhat. Pour into a glass graduated
measure and make up to fifty c. c. with ninety-five
per cent, ethyl alcohol. Return to a flask which is
corked only after a day or two.
Tcclinic of staining. — First fix the preparation
with the undiluted Tribondeau I. For this, place
the slide on the table, film upward. Cover the film
with the stain I. Cover with a Petri dish. Allow
to act for three minutes.
Wash with a jet of distilled water. Get rid of
the surplus water by shaking; wipe the under side
of the slide ; place it on the edge of a glass or crys-
tallizing dis.h without drying the film.
Stain by pouring on the preparation Tribondeau
II diluted and hot. For this, have a small test tube
of one centimetre diameter marked at two c. c. ;
pour distilled water to the mark ; heat the tube
held aslant in the flame until the appearance of the
first bubbles of air ; add to the two c. c. of hot water
four to five drops of Tribondeau II ; pour hot over
the film. Allow to act fifteen minutes.
Wash with a jet of distilled water. Dry im-
mediately (heating and blowing).
Remove the excess of blue by pouring on the dry
preparation, held aslant, a watery solution of tannin
(one in twenty), until the film becomes rose col-
ored. It is necessary to avoid dififerentiating moist
films because the preparations would become spotted
with blue. The solution of tannin is prepared by
dissolving one gram of tannin "a I'alcool" in twenty
c. c. of very hot water. A little camphor is added
to prevent the growth of molds.
W^ash at once with distilled water. Dry imme-
diately.
N. B. — One can omit Tribondeau I, fixing simply
with alcohol, but this is disadvantageous because it
is then necessary to stain with Tribondeau II for
thirty minutes instead nf fifteen.
Chronic Hypertrophic Rhinitis. — E. J. Stein
{Pennsylvania Medical Journal, June, 1918) con-
cludes that: I. The treatment of this condition
must be begun in childhood when a tendency to
narrow nasal cavities is first observed. 2. The
chemical cautery still holds otit a definite relief in
some of the milder cases. 3. The .surgical treat-
ment is the more poptilar and gives definite relief.
4. The electric cautery, when the technic is ac-
qtiired, promises to be the most efficient because it
is more readily controlled and more adaptable to
all cpses. 5. Vaccine therajiv is useless unless
the bncillus rhinitis of Tunniclifif is definitely proved
lo be the actual causative agent.
Medicine and Surgery in the Army and Navy
MOBILIZING THE SPAS AND HEALTH
RESORTS OF OUR NATION*
By N. Philii' Norman, M. D.,
Fort Leavenworth, Kan.,
Captain, Medical Reserve Corps, TI. S. Aniiy; Examiner in Neuro-
psychiatry, U. S. Disciplinary Barracks, Fort Leavenwortli.
{Continued from page 42^.)
WHITE SULPHUR SPRINGS.
White Sulphur Springs, West Virginia, is located
in the most picturesque part of the Alleghany
Mountains, near the boundary line of the Virginias.
It is perhaps the oldest and one of the best known
of American spas. Apart from Indian traditions
and the experiences of the early settlers, there are
authentic records of persons actually treated there
as early as 1778 and since that time people have
journeyed there for the benefits to be derived from
its climate, altitude and waters and for participa-
tion in its social life.
Because of its altitude of 2,000 feet above sea-
level, the climate is bracing and little debihtating
weather is experienced, even in midsummer. There
are two hotels at White Sulphur Si)rings, The
White and 'I'he Grecnbriar. The W'nito is a sjja-
cious colonial building with a history that is per-
vaded with iwtc bellnm romance. The Greenbriar
is a modern, fire proof, s^eel structure. Its archi'
tectural style is Georgian and it is not too much to
say that it may be rivaled but not excelled in the
completeness and artistry of its ajjpointments by any
resort hotel. In addition, there are between fifty
and sixty cottages surrounding the hotels, most of
them having five rooms and baths, particularly use-
ful for those desiring seclusion and rest.
J'he domain of the White Sulphur Springs Com-
I)any comprises an area of 7,000 acres. Within this
park are an eighteen hole and a nine hole golf
course. The larger course may be said to be for
the real golfers and the smaller, for amateurs.
There are five excellent tennis courts and miles of
foot paths, bridle paths and roads. A casino is
situated near the golf greens and tennis courts and
offers amusements to those not inclined to exercise.
There are several springs at White Sulphur with
considerable variation in constituents and physio-
logical effects. However, in this article we will
confine discussion to the two White Sulphur
springs, the radiochalybeate spring and the alum
spring. The older White Sulphur spring is the
best known and may be said to be the one upon
which the reputation of White Sulphur is founded.
It is clear and palatable, and maintains a tempera-
ture of sixty degrees Fahrenheit. It is classified as
sulphoalkaline, the chief constituents being the sul-
phates and bicarbonates of magnesium, sodium and
calcium with free carbonic acid gas and traces of
sulphuretted hydrogen. Another sulphur spring is
adjacent but the waters are not as strong, although
of similar composition.
The radiochalybeate spring possesses a greater
*Pnblis!icrl Ir
Washington.
pemii.ssion of the Surgeon General's Office
degree of radioactivity than the other springs and
contains iron in an assimilable form. It is used for
drinking purposes.
The akim spring, as the name implies, is different
in constitution from the others, its chief constituent
being the sulphates of aluminium, magnesium, cal-
cium and manganese.
The White Sulphur springs' waters are all radio-
active to some degree, the radiochalybeate spring
being the most highly charged.
The cure at White Sulphur is effected by bathing
in and drinking the waters. The sulphur waters
are mildly laxative, diuretic and alterative in effect
and are used in conjunction with hydrotherapeutic
measures for the treatment of diseases of the
stomach, liver, kidneys and other metabolic dis-
turbances, the outgrowth of the disfunctions of the
organs concerned with vital processes. The radio-
chalybeate spring is prescribed in conditions that
need an assimilable form of iron as well as its
radioactivity. The alum spring water, being astrin-
gent, finds a usefulness in conditions of the gastro-
intestinal tract requiring a sedation of hyperactive
function.
The sulphur water baths are the feature baths of
this resort and are particularly efficacious when
used with the drinking waters, in conditions of dis-
turlied metabolism because of nutritional disorders,
infections or insufficient elimination, as the gouts,
the neuritrides. the chronic rheumatisms, arthritis ;
malnutritional states, from whatever cause, chiefly
gastrointestinal disorders ; intestinal inactivity, kid-
ney irritations, obesity, diseases of the skin and the
functional nervous diseases and convalescence.
The bath establishment of White Sulphur may be
said to excel in completeness of equipment and ap-
pointments any bath house in the country. It is a
three story structure, located near the hotels and is
connected with both by enclosed loggias. The
ground floor contains the swimming pool, one him-
dred by fifty feet, and the gymnasium with dress-
ing rooms at each end and wide balconies on each
side of the swimming pool. The two upper floors
are devoted to the bath proper and are connected by
elevators with the lower floors. On the second
floor are the physicians' offices, the Zander room,
inhalation room, and radiutn room. Equipment pro-
vides for giving almost any form of bath, including
special baths as are given at Nauheim, Aix les
Bains, Vichy, Carlsbad, Baden-Baden, and other
luiropean spas. The eletrotherapeutic depart-
ment is well equipped for accessory treatments.
The radium room contains the latest apparatus for
radium emanation and for artificially charging
water for drinking purposes, and is especially use-
ful in the treatment of arthritic conditions. Ap-
paratus for superlieated air treatment has been in-
stalled and is an important accessory in the treat-
ment of painful joints, nerves, and muscles. The
sulphur baths are given to meet individual require-
ments and in the rheumatoid conditions massage is
practised during the bath. The baths exercise a
specific influence upon the skin and circulation, due
464
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
to the presence of the salts and gases. Exercise
may be had in the Zander room or the gymnasium,
or by wall<ing, golfing, tennis, and riding.
This institution is particularly commendable for
conditions of intoxication etiology, especially the
neurodigestive intoxications in conditions of ner-
vous exhaustion and shock and conditions that may
be called preshock. The intoxications may be due
to microbic activity that may be flourishing in the
intestines, the liver, the oral cavities, and other tis-
sues. They may be luetic, or may arise from ex-
cessive use of tobacco or what not and may have
diffused throughout the body during a crisis and are
best eliminated by eliminative baths, exercise, and
out door life. The climate of White Sulphur is
such that out door life is possible the year round,
the average seasonal temperatures being approxi-
mately: Winter, 36° F. ; spring, 51° F. ; summer.
65 F°. ; fall, 52° F. Its elevation insures a relatively
low humidity. The capacity of the two hotels and
cottages is easily several hundred, with adequate
bath facilities. It is easily accessible, being on the
main line of the Chesapeake & Ohio Railroad.
THE VIRGINIA HOT SPRINGS.
These famous springs are located in the most
beautiful mountain section of Virginia. In this
article, description will be confined to the institution
known as The Virginia Hot Springs Company.
This plant is situated in a valley, in a park of 5,000
acres. The elevation is 2,500 feet at the foot of
the mountain ; in a comparatively short distance,
one may be led by well kept paths to an elevation of
more than 4,000 feet.
The Homestead Hotel, inclusive of its new wing,
has more than six hundred rooms. The beauties of
its lounge, corridor de luxe, ballroom, Japanese
room, and other features need no extolling ; there is
excellence in appointment everywhere. A solarium
and casino are maintained for rest and amusement,
respectively.
At the Virginia Hot Springs, the cure is eflPected
by drinking and bathing in the waters which con-
tain chiefly calcium bicarbonate, magnesium car-
bonate and sulphate, with a slight trace of sodium
chloride. One spring has a minute trace of sulphur,
and the bathing spring contains a small amount of
carbonic acid gas and nitrogen with a maximum
natural temperature of 106° F. This bathing spring,
known as Boiler Spring, has an output of about
130,000 gallons a day. The drinking springs are
diuretic in efi'ect and their copious intake may be
said to produce a depurative ef¥ect, thereby aiding
materially to accomplish the therapeutic objective in
■view.
The radioactive content of the various springs
at Hot Springs, Virginia, has been extensively
studied by Hemmeter and Zueblin. who published
their findings and conclusions in the February, 191 5.
issue of the Archives of Internal Medicine. Their
article is too lengthy and technical for extensive in-
sertion. However, those interested may apply to
the management of the Springs Company for this
reprint, and I take the liberty to state that their
requests will be complied with immediately.
Briefly, their findings were that the springs
possess a high and constant radioactivity. From
njjservation on patients, they concluded that the
beneficial result of the so called chronic and sub-
acute rheumatisms, gout, and metabolic diseases
nmst, to some extent, be attributed to the radio-
emanation of the water used for drinking and bath-
ing purposes.
Diseases that liave been most benefited by the
cure are the so called rheumatisms, gout, obesity,
the neuritides, the psychoneuroses, and the func-
tional stomach disorders that are perhaps but a
form of somatic expression of the psychoneuroses
and, in other cases, the expression of dietary and
imbibitory abuses.
The measures instituted for the benefit of the
above named disorders are chiefly corrective and
restorative. The aim of the treatment is to pro-
mote a full, free, and abundant action of the skin.
The bath may be given at a temperature not ex-
ceeding 104° F. and, after this bath, there is pro-
vided means for the spout bath, which has for
many years been the feature treatment at Hot
Springs. The water is spouted at a patient at a
pressure of from twelve to eighteen pounds and at
a temperature of about 104° F., mechanically
massaging the body. The effect of this is stimulat-
ing and, in some cases, may be employed before
the tub bath. Following this, a customary pro-
cedure is a hot pack, followed by cool sponging or
a cool douche, and an alcohol rub. The patient
then is placed in a recumbent position for half an
hour or more. It requires from thirty to forty-five
minutes to give this treatment. Of course, if the
individual case demands, massage may be added.
Usually, during a bath, it is customary for the at-
tendant to massage and passively manipulate the
afifected joints or parts. Let it be understood thai
this is by no means the routine procedure for every
case. Each case has a careful supervision by a
physician who prescribes the baths and the drinkino
waters to meet the requirements of the individual.
In addition to this feature treatment, the bath house
is well equipped with douche tables for giving the
various forms of circular, jet, Scotch, rain and fan
douches which are used in conjunction with the hot
air and electric light baths.
Accessory measures include diet and suitable ex-
ercise, mechanical and physical. A set of thirty-
six devices of Zander apparatus for active and
passive exercises has been installed in recent years
and is most complete in detail. Apparatus for giv-
ing local superheated air baths has been installed
and is particularly useful in some cases of arthritis
deformans, neuralgia and neiiritis. Massage of the
Swedish type is counted as one of the valuable ac-
cessory measures.
The bath house is connected with the hotel by an
enclosed viaduct, facilitating the passage of the pa-
tient to and fro without fear of exposure. It is
furnished with spacious rest rooms. The solarium
constitutes a large, open air hall on the upper floor
of the bath house, so that a patient, unless other-
wise directed, may select his site of predilection for
rest.
The swimming pool, eighty-five and one-half by
thirty and one-half feet in dimension, and ranging
from four to seven feet deep, is supplied from the
Sei)teml)cr i.;. igiS.l
MEDICINE AND SURGERY IN THE ARMY AND NAin'.
several springs and has an average temperature of
about 85 °F.
In conclusion, it is obvious that patients suffering
from the chronic ailments heretofore described may
be expected to improve in such fine surroundings.
Without doubt, results do not depend entirely upon
environment and the major portion of benefit re-
ceived must be ascribed definitely to the hydro-
therapeutic and accessory measures as they are
practised in this institution. With an almost un-
limited water supply and with such an extensive
amount of acreage at their disposal, it is readily
appreciated that more than a thousand patients
could be taken care of. The annual mean tempera-
ture is about 59° F. A great advantage of Hot
Springs is that the climate is such that the class of
patients treated may take the cure all the year round.
This place is easily accessible to all ports on the
Atlantic seaboard.
MOUNT CLEMENS, MICHIGAN.
Mount Clemens is located about twenty-two miles
from Detroit, Michigan, and for a great many years
has been noted as a watering place. Unfortunately,
because of the lack of time, I was unable to ac-
quaint myself thoroughly with the several bath es-
tablishments of this resort when visiting there during
the 1916 session of the American Medical Associa-
tion held at Detroit. However, the establishments
visited were representative of the whole and were
found to be hygienic, well fitted with bathtubs,
dressing rooms and rest rooms.
Mount Clemens gave the general impression of a
city of several large hotels, a number of smaller
hotels and boarding houses and a place where peo-
ple of varied financial success sojourned in an effort
to regain their health, comfort and efficiency. It
is a regrettable fact that Mount Clemens has not
been incorporated and supervised as a large institu-
tion or that a state reservation has not been created
after the fashion of the reservation of the State of
New York at Saratoga Springs, where medical ef-
forts could have been better concentrated and an
individual method evolved, with necessary acces-
sories, substantially representative of the advanced
equipment of modern spas. That its reputation has
not diminished speaks more for the value of its
waters than for the technic of their use and the
accessories employed to aid in the accomplishment
of their therapeutic objectives. However, it is not
the purpose of this article to berate this spa, for
the author is fully cognizant of the good work that
has been done there as a whole, recognizes the
handicap of the resident physicians in handling pa-
tients, and has nothing but praise for their indi-
vidual efforts to systematize their work on a scien-
tific basis ; and it is to be hoped that their efforts
vs'iW be expressed in constructive creations.
No attempt is made to give the analysis of the
v/aters used in the several bath houses, for they
are essentially similar in composition and vary but
little in saturation. They ^re obtained from wells
ranging from 800 to 1,3,00 feet in depth. They are
strongly impregnated with salines, chiefly with the
chlorides of calcium, sodium, and magnesium, and
with hydrogen sulphide and carbonic acid gas. The
degree of saturation averages from 11,000 to 12,000
grains per gallon. They are classified as sulpho-
saline and are used for what may be called the
M(nmt Clemens bath.
This is a hot tub bath of ten or fifteen minutes'
duration, rubbing being practised during its pro-
gress in suitable cases. This usTially is followed by
a pack and in some cases with fomentations to local
parts, and then a spray, brisk rubbing, and drying.
The patient then is allowed to cool in a rest room.
The actual time spent in administering this treat-
ment averages about thirty minutes.
The physiological action of the baths is brought
about by the salts and gases in solution. The skin
reactions are local and reflex — a soothing effect
upon the epidermis and a promotion of peripheral
circulation because of the dilatation of the super-
ficial capillaries and arterioles. Because of the
thermic effect, a profuse diaphoresis is brought
about and prolonged by the use of the pack and
fomentations.
The chief action of the baths being eliminative
and as a promoter of elimination through the
emunctories, it follows that their greatest value is in
conditions due to faulty elimination where the tox-
ins, of either endogenous or exogenous origin, have,
=0 to speak, mobilized, overwhelmed the organism
because of the neutralization of the enzymes, an-
tibodies, and what not, and precipitated disease
entities, such as the rheumatisms, gout, skin dis-
eases, the so called autotoxic conditions, alcohol-
ism, the neuritides, and industrial or occupational
diseases.
Accessory measures are too few and inadequate
in number and variety. Additional apparatus for
electrotherapy, mechanotherapy, and control tables
for the various douches and showers are needed.
On the whole. Mount Clemens may be said to be
primitive and not to have been developed in keeping
with its advantages. The waters are particularly
useful and, with the aid of the proper accessory
measures, their efficacy could be improved consider-
ably. Facilities for the accommodation of several
hundred guests are available and the bath capacity
IS adequate for the number accommodated. It is ac-
cessible, via Detroit, from the probable ports of de-
barkation. Climatic conditions may be a little se-
vere in winter, but do not detract materially from
the advantages. The elevation is 602 feet.
(To be concluded.)
Nitrous Oxide in Childbirth. — Moses Salzer
(Ohio State Medical Journal, July 1918) draws
these conclusions: Nitrous oxide can be safely used
for hours without fear of any immediate or remote
danger to mother or child. 2. Its effects are under
absolute control at all times. 3. The mother re-
coA'ers from the confinement with a clear mental
state and without any unpleasant recollections. 4.
The babies when born are of good color. 5. It is
successful in the elimination of pain when properly
administered in practically every case. 6. It does
not retard labor and cannot therefore be a cause
of uterine inertia. 7. Cyanosis must be carefully
avoided.
466 MEDICINE AND SURGERY IN THE AKMY AM) NAl'V
SOxME NOTES ON DRUGS AND
TREATMENT.
A Rcviczv of Recent Progress in Therapeutics.
By Mark Sadler, M. D.,
Montreux, Switzerland.
• IV.
Tll'i TREATMENT OF INFECTED WOUNDS.
The present war has given ample opportunity for
studying infected wounds, since wounds on the bat-
tlefield must be considered from the beginning as in-
fected. I shall only give such formulae and treat-
ments as I know from personal experience and from
that of others to have been of real value. Asepsis
having failed after faithful trial during the early
months of the war, and as the wounds were fre-
quently the starting point of serious complications,
attempts were made in all directions and by all
known means, to obtain as perfect a disinfection as
is humanly possible. Taking up all the various med-
icaments employed, Deguy divides them into three
classes: i, Disinfection by sera; 2, chloric disinfec-
tion ; and 3, disinfection by the usual antiseptics.
Antiinfcctloiis sera. — The best known is that of
Leclainche and Vallee. From experimental study
these writers have shown that the digestion of mi-
crobic agents in the wounds could be brought about
by bringing the organic cells to the wound by a spe-
cific senmi, preserving all their vitality and apti-
tude for tissue repair. This serum contains anti-
bodies corresponding to the various forms of
suppuration, .such as the staphylococcus, streptococ-
cus, colon bacillus, and septic vibrio. Therefore, it
is a polyvalent sertmi and is only to be used for
dressing the wound, either in liquid or powder form.
Very rarely indeed, in certain staphylococcal or
sterptococcal septicemias, can it be tised in intra-
venous injections or subcutaneously.
The use of this serum is exclusive of any other
antiseptic, as the latter would interfere with the
]ihagocytic and opsonizing action of the serum. The
wound is first washed with a g:i,ooo salt solution
r.nd is then dressed v/ith gauze, imbibed with the
serum, introduced into the fistulous tracts. Sim-
ple injections may also be made. The dressings
should be changed twice daily. This polyvalent
serum has given remarkable results, especially in
streptococcal infection, but in other types of infec-
tion, due to other bacteria, its efifects have been prac-
tically nil, this being above all true in the case of
anaerobic organisms.
Used in the form of moist dressings on erysipelas
wounds, it checks the spread of the inflammatory
process. In intravenous or hypodermic injections
it has certainly been effective in certain septicemias.
It should be understood that if the ef¥ects of this
serum are not soon apparent by a change for the
better in the state of the wound, it is useless to per-
sist in the treatment.
Chloric di.<;infcction. — For some time the chloric
compounds have been emploj'ed for disinfection of
gangrenous or fetid wounds, and war injuries have
given this medication a new impetus. The preserv-
ative action of ordinary sea salt for certain meats,
particularly pork and fish, is well known to all, so
L-New Vokk
Medical .Tour.val.
that it is a natural consequence that salt solution at
from seven to ten per 1,000 should be employed for
irrigation of woimds. The sera devised respec-
tively by Ringer and Locke have the following for-
mulae :
^. Sodii chlorid 9.00 grams ;
Potass, chlorid 0.42 gram;
Calcii chlorid., ....0.24 gram;
Sodii bicarb., 0.15 gram;
Aq. dest., i. 000.00 (i litre).
(Ringer.)
TJ Sodii chlorid., 8.00 grams;
Calcii chlorid., )
Potass, chlorid., y aa 0.20 grams;
Sodii bicarb., )
Glucose 1 .00 gram ;
Aq. dest., i litre.
(Locke.)
These sera are now being much used, and al-
though there is some difference of opinion as to
their actual utility, nevertheless they have rendered
valuable service.
The well known liquor Labarraque of the French
Codex is composed as follows :
5 Calcii chloric, sic 100;
Sodii carbonat., 200;
.\c{. dest., 4,500.
Dakin maintains that the above solution contains
an excess of free alkali which renders it irritating,
and he therefore has proposed to neutralize it with
boracic acid. Here is the formula :
ly Sodii carbonat. sic, 140;
Calcii clilorid. 200;
Acid, boracic, .40 ;
Aq. dest i litre.
(Dakin.)
Magnesium chloride has been introduced by Del-
bet, who is well satisfied with its efifects in a solu-
tion of 12.50 grams' to i litre of distilled water. De-
guy recommends ammonium hydrochlorate, in a one
per cent, solution in irrigations and wet dressings.
Zinc chloride is caustic when in a concentrated solu-
tion, but in a dilute solution it is antiseptic. For
local application to wounds it is formulated as fol-
lows :
Tic Zinci chlorid., i.o;
Acid, tartaric 9.0;
Glycerini, lO.O ;
Aq. dest ,S0 to lOO c. c
(acording to the desired result to be obtained).
In irrigations or moist dressings, a i or 2 per
1,000 solution is used, or the following formula may
be employed :
Zinci chlorid i.o;
Acid, tartaric, 9-0;
.A.q. dest., 1,000.
The old antiseptics. — These have been divided
under three headings by Deguy, the use of each
f)eing different : Watery solutions for irrigations and
inoist or wet dressings ; alcoholic solutions for wet
or moist dressings ; ether solutions, which, by evap-
oration, leave behind a thin layer of the antiseptic
on the wound. Among the watery solutions, iodine
water must be mentioned, which is prepared by add-
ing twenty c. c. of tincture of iodine at ten per cent,
to one litre of water, or one gram of trichloride of
iodine to one litre. Irrigations with iodine water
are highly disinfectant, but they are painful, some-
times irritating, and cannot be frequently used. The
mercurial salts are also being employed, sublimate
SeptcnilAr 14, 1918.I
MEDICINE AND SURGERY IN TflE .-IRMV AND NAVY.
467
solution at i per 4,000, the oxicyanide at i per
2,000, hermophen)'! at i per 1,000, etc. One should
always be on the watch for possible toxic accidents
due to absorption from wound surfaces.
Formalin (five c. c. per litre) is an excellent anti-
septic in cases of profuse suppuration or blue
]nis. Carbolic acid i per 200 and coaltar in emulsion
in tinct. quillayje (coaltar 10 per 200 of the tincture)
has important indications. The two following for-
mulae are highly spoken of by Deguy for irrigations
and dressings :
Thymol lo.o;
Tinct. eucalypt, j -- ^^^^
Glycenni, )
Sodii borat., )
boclii benzoat., j
Sodii bicarb., 25.0;
Methylen. blue q. s. for coloring.
TO c. c. of this solution to two litres of water.
These various prei)arations are efifectual in very
septic, atonic wounds, but they are painful and
irritating, causing redness which is an indication to
stop their use. The treatment may be resumed later
if required, after the symptoms of irritation have
subsided.
Another good preparation in granulating wounds,
but with much suppuration and no tendency to heal,
is :
1> Argent, nitrat. cyst., I.o;
Glycerini neutral, lo.o;
Alcohol, go°, 40.0.
This sol^ition should remain perfectly limpid in
a colored glass bottle if the three products used
are C. P., which they should be. It is used for
moist dressings with gauze pads (ten thicknesses
of gauze) wrung out with the solution and applied
to the wound, over which absorbent cotton is placed.
These dressings are not to be applied more than
once or twice in succession, as they dry the wound
very quickly and the epidermis rapidly appears.
This solution is of little use in irregular and un-
dermined wounds.
Ether solutions play a good part in the treatment
of wounds. By these the drugs can penetrate into
all the corners and tracts of the wound, and by
evaporation of the ether, leaves a thin, even coating.
The following formulae can be recommended
Iodine, i.o;
Ether, 1,000.0.
This solution is not often employed because iodine
is caustic, but occasionally it will be indicated.
^ Iodoform or thymol, diiodi (aristol), lo.o;
Ether, 100.0.
This is a good disinfectant and deodorizer. Salol
or resorcin in a ten per cent, ether solution, or a
ten per cent, ether solution of camphor are also
useful, likcAvise benzoin in the same proportion.
Oil of cade has also been well spoken of to clean
up wounds which resist or offer gangrenous areas
which do not become eliminated. The following
formula is due to Deguy :
R Oil of cade, )
T J r ) aa 12.00 ;
Iodoform, f
Oil of vaselin, ) ^ --
T 1 • } / aa 30.00 :
Lanolm, j •' '
Ether, 150.00.
Regarding technic, and, in the first place, irri-
gations, these are indicated in dirty wounds contain-
ing foreign bodies and when they are the seat of
severe suppuration. However, although most ex-
cellent, irrigations must never be lavish. Continu-
ous irrigation is very useful, but, unfortunately, dif-
ficult of application unless in a well supplied hos-
pital or clinic. Interrupted irrigation with Dakin's
fluid, and following his technic, has been thoroughly
described in the medical press, and therefore needs
no comment here.
Wet dressings should not be continued for too
long a time, on account of the resulting irritation to
the surroimding structures. Moist dressings have
been more generally employed during the war, rep-
resenting about seventy-five per cent, of all dress-
ings used.
Occasionally one may resort to astringent or oily
dressings, which prevent the gauze from becommg
adherent to the wound surface. For this a one per
thirty glycerate of tannin, glycerate of alum one to
five per cent., or glycerate of resorcin at two per
cent, may be used.
When there are burns the blisters should be
opened and the following prescription applied :
R 01. hyoscyami comp.,* 50.0;
Adepis benzoin 20.0;
01. amygdal. dulc, q. s. ad 250.0.
After a few days this prescription is changed to
the following ointment :
R Zinci oxid., 6.0;
Zinci peroxid., ; 4.0;
Lanolin loo.o ;
Vaselin, 200 0.
In some cases of septicemia with persistent ele-
vation of the temperature regardless of the local dis-
infection, general disinfection may be essayed by
the use of colloidal gold or silver, or one of the fol-
lowing formulas :
R Acid, carbolic, C. P., lo.o;
Glycerine at 30° C. P 40.;
Aq. dest 50.0.
Inject subcutaneously once a day for one week one
c. c. of the solution. The following is recommended
at the same dose and for the same duration as the
above :
R Formol, 40%, 010;
Potass, sulphoguaiacolat i to 2 grams ;
Sodii sulphat., i gram ;
Glycerini 5 grams ;
Aq. camphorae, 100 grams.
Tonic treatment must also be exhibited. Injec-
tions of normal .salt solution, camphorated oil, ether,
cafteine and sulphate of sparteine have their indica-
tions. This caffeine serum is recommended by
Marfan:
R Caffein. citrat. 75 centigrams;
Normal salt solution, 300 grams.
An excellent general stimulent is :
R Strychnin, sulph., 25 milligrams;
Camphorae, 5 to 10 grams;
Guaiacol 10 grams;
Ether,_ 40 grams;
01. olivse 100 grams.
*01 liyosciami comp. of the Pharmacopoea Helvetica is composed
as follows:
01. hyoscyami 1,000.0;
01. lavandulas i.o-
01. mentha? j qI
01. rn'smarini j q !
01. thymi .1.0!
This balsam is green in color with an aromatic odor. It is an old,
well tried preparation of real value as a local carminative. (Transla-
tor's note.)
468
MEDICINE AND SURGERY IN THE AKMV AND NAVY.
[New York
Medical Journal.
Inject one c. c. twice daily for several days, ac-
cording to indications. The following prescription,
given at the same dose as above, will be found of
value :
?£ Sodii phosphoglycerat 5 grams;
Strychnin, arseniat., 20 centigrams;
Caffein, benzoat 5 grams;
01. eucalypt., ) .. .
Ess. gaultheds, 1 centigrams;
Magnes. carbonat., 95 grams;
Aq. dest., q. s. ad 100 c. c.
The various treatments above described are not
only useful in war surgery, but also in all cases of
wounds occurring in civil practice.
MEDICAL NEWS FROM WASHINGTON.
Nt'TV A pf" ointments in the Medical Corps. — Members of
Naval Medical Corps in France Recommended for Dis-
tinguished Service. — A'aval Base Hospital No. 3 Now
Established in Scotland. — Health Conditions in the
Navy. — Reduction in Pay of Chief Nurses to Be Rem-
edied.—Rank to Be Provided for Members of Army
Nurse Corps. — Young Surgeons Ready for Service. —
Sick and Wounded Cared for bv the Navy on Trans-
port.';.—Dr. C. E. Gibbs, Dr. C. W. Mitchell, and Dr. R.
B. Norment Appointed in the Public Health Service.
Washington, D. C, September g, igi8.
Lieutenant Colonel Charles F. Morse, Medical
Corps, in charge in the Office of the Surgeon Gen-
eral of the Army of matters relating to the Veterin-
ary Corps, and Lieutenant Colonel Samuel J.
M orris, Medical Corps, in charge of matters relat-
ing to Medical Training Camps, have been promoted
to colonel.
Colonel William F. Truby, Medical Corps, just
relieved from command of Walter Reed General
Hospital, D. C, has been assigned to the sanitation
division of the Surgeon General's Office.
The recent promotion of Lieutenant Colonel Ray-
mond P. Sullivan to colonel was the forerunner of
his appointment to succeed Colonel William H.
IMoncrief as chief of the surgical division of the
Surgeon General's Office. All officers now in the
division hold temporary commissions in the Medical
Corps, having come from civil life since we entered
the war and being selected on account of their pro-
fessional and administrative qualifications. Colonel
Sullivan, after several years' experience as a sur-
geon in the I\Iayo clinics at Rochester, Minn., was
in active practice in New York City.
It is not generally known that any of the per-
sonnel of the Medical Department of the Navy is
serving on the battlefields of France, but such is
the case, for officers of the Naval Medical Corps
and members of the Naval Hospital Corps constitute
the sanitary forces of the marines fighting in that
country, and the highest praise for them has come
from those with whom they are serving.
Recently an officer of the Marine Corps, who
visited wounded marines now at the Naval Hospital
at Brooklyn, wrote to the Surgeon General of the
Navy an account of what these men said of the
naval medical personnel. The officer reports that he
heard several of them talking in the highest terms
of the Naval Medical Corps. These marines,
wounded in the fighting at Chateau Thierry, cannot
sufficiently praise the Naval Hospital men for their
first aid work during the desperate fighting from
June 6th to 14th. According to one of them, "these
naval men deserve a gold medal, the highest honor
they can receive ; before we could reach our objec-
tives the navy boys were right out in the field pick-
ing up and tagging the wounded. They exposed
themselves to the greatest dangers and had no pro-
tection, not even guns with which to combat the
Germans they might encounter, since it was open
fighting."
The commandant of the ^Marine Corps has sent
to the Surgeon General of the Navy a copy of a
letter from the commander of one of the marine
regiments to the brigade commander recommending
a number of Hospital Corps men for distinguished
conduct for service in the face of the enemy.
^ ^ ^
Naval Base Hospital No. 3, under command of
Captain C. M. De \'alin. of the Naval ^Medical
Corps, which was organized sometime ago with per-
sonnel mostly from Los Angeles, Cal., has arrived
on the other side, and it now is located in Scotland,
where it has been established in a building formerly
occupied by the Royal Army Hospital Service. It
has hospital accommodations at present for 625
patients, with possibilities of expansion to accom-
modate 825 if necessary. It will look after patients
from the naval personnel and from the personnel of
the British and American expeditionary forces.
*****
The health and mortality conditions of the navy
continue most satisfactory, the latest reports show-
ing a death rate for the entire service of i.o per
1,000 per annum. The latest reports of diseases
recorded for shore stations in the United States :
One case of cerebrospinal fever, seven of diphtheria,
eighteen of malaria, twenty-three of measles,
twenty-two of pneumonia, five of scarlet fever, and
one of typhoid, the latter being of a recruit at a
naval training station, who probably contracted the
disease before entering the service.
It has been brought to the attention of the War
Department that in that part of the army appro-
priation act of July 9, 1918, which relates to the
army nurse corps, all nurses were given an increase
of pay of $10 a month, except those already chief
nurses. For these their monthly pay was reduced
$10.
Before approval of the act, the annual base pay
of a chief nurse was $600 with $360 additional as
chief nurse, which gave $960 for a year. Under
the new law, her base pay is $720 and her pay in
addition as chief nurse is $120 a year, making the
annual pay for chief nurses $840, or $70 a month.
It is believed that this was due to inadvertence,
but this actual reduction in the pay of chief nurse?
is causing much discontent, as they feel that they
have been singled out for a reduction, particularly
so as all other nurses received an increase in pay.
The War Department has submitted to Congress a
draft of a bill to remedy the situation.
*****
Efforts are being made in behalf of the women
of the army nurse corps to provide rank for them..
September 14, 191S.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY
469
At present, the Army Regulations prescribe that
the members of the women's nurse corps take rank
•next after cadets. There is some talk of providing
an intermediate grade for the nurses between that
of the lowest commissioned rank and the highest
noncommissioned rank, similar to the warrant offi-
cers' grades in the navy. However, the nurses
prefer relative rank as commissioned officers. This
is the plan understood to have been adopted in the
Canadian and Australian Forces. A bill to that
effect has been introduced in the House.
According to reports from the surgical division
of the Surgeon General's Office, the development of
young surgeons for service with the American ex-
peditionary forces in France has more than met
expectations. Those that have shown special fitness
are working not in isolated cases, but are operating
in teams of eight, these teams being formed into
groups of fifty. These young men, some of them
only a few years out of medical schools, now are
performing the class of surgical work that ten
months ago would have been trusted only to the
older men of the profession. Endurance and vigor
are the characteristics that place these men in a
special class of usefulness for surgical work in the
hospitals, and their success has met with high praise
from their seniors in the medical corps.
^: ^:
When the navy took over the handling of the
army transports, it at the same time assumed the
work of caring for the army sick and wounded being
brought back from France. Inasmuch as the navy
has nothing to do with the transportation of these
invalids to the port of foreign embarkation, it re-
ceives them as they are sent and at once attempts to
make them as comfortable as possible on board the
returning transports.
At the end of every voyage, the invalids are in-
terrogated by inspectors concerning their treatment
on the transports, and every suggestion that wil'
make conditions better for these men receives care-
ful consideration. However, the conditions of clean-
liness, good nursing, and rest on the transports com-
pare so favorably with those on the railroad trains
that take them to the ports of embarkation, that
nothing but satisfaction is heard from the men.
The good work on board the transports is the
result of the provision by the naval medical corps
of the best facilities that could be placed on ship-
board for caring for sick and wounded. The Sur-
geon General of the Navy foresaw the indispensa-
bility of having everything in readiness for the time
W'hen the number of wounded to be returned would
be great, and the navy has been ready with every
surgical need for their treatment and care.
At times it was thought that the navy was carrv-
ing a larger number of physicians and surgeons in
its medical corps than was necessary, but thev were
under training, so that, when they are needed, thev
not only are available, but trained in the duties they
are called upon to perform.
The transportation of the sick and wounded of
the army was taken over bv the naw after we en-
tered the war. Returning transports, rather than
special ho"=pital ships, are used in the service, be-
cause, owing to past performances, it was believed
that the Germans would be no less apt to attempt to
sink hospital ships than transports. Besides, it saves
the drain on the available ship tonnage that would
occur in the setting aside of vessels for special
service as hospital ship.
Dr. Charles Edward Gibbs, Dr. Claude William
Mitchell and Dr. Richard Baxter Norment, Jr., have
been appointed assistant surgeons in the Public
Health Service.
Vaccination against Bacilli Dysenteriae. — Peter
K. Olitsky (Journal of Experimental Medicine,
July, 1918) considers that an oily medium for the
suspension of dysentery bacilli is a practical method
of actively immunizing or vaccinating against this
organism. The toxicity of this group of organisms
is such that it is not wise to employ them in simple
saline or aqueous solutions. The addition of im-
mune serum and certain chemicals to diminish the
toxicity of the bacilli cannot be recommended, but
almond oil was found to be a very satisfactory
passive agent, capable merely of suspending the
bacteria without altering their properties ; further-
more, the oily suspension fulfils all the requirements
of a serviceable vaccine, as no local or systemic
toxicity was caused by it ; agglutinins were formed
regularly which persisted, and protection was se-
cured for at least one month after a single dose of
vaccine. Two factors of importance must be con-
sidered in using a vegetable oil for this purpose :
First, the rate of absorption, since when it is too
slow less satisfactory results are obtained ; and
second, complete neutralization, as otherwise, severe
local irritation occurs caused by the local deposition
of soaps. The slow absorption of the dysentery
bacilli from the oily suspension results in only a
slight local and general reaction, the local reaction
taking the form of a subcutaneous indurated area,
corresponding to the unchanged oil and bacteria.
This recedes in from one to three weeks, during
which time no inconvenience is felt. Agglutinins
usually appear after the seventh day and increase
from that time to the third week, after which they
persist for a month at least. Olitsky thinks that the
introdiKtion -by Le Moignic and Pinoy of an oily
medium for suspending killed bacteria marks a
definite advance in the technic of bacterial vaccina-
tion
Rontgen Examination of Kidney Tumors. —
Paul Eisen (Illinois Medical Journal, July, 1918)
states that the rontgenologist has at his disposal
three ways of applying x rays in diagnosis of
tumor of the kidney. The first is the direct ex-
amination by means of rontgenograms which may
show the tumor outline, and foreign substances con-
tained therein. The second is visualization of the
renal pelvis by injections of substances giving
opaque shadows, and noting changes in the config-
uration of the kidney pelvis. The third is the in-
troduction of shadow producing substances into the
gastrointestinal canal to bring -out displacement bv
a renal tumor. The importance of stereoscopic
rontgenograms must be emphasized.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Under Domestic Postage. $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post oifice or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
t,Ttion through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, SEPTEMBER 14, 1918
THE VOLUNTEER MEDICAL SERVICE
CORPS.
The Council of National Defense has sent out
many thousand blanks to physicians, both men and
women, for the enrollment of the legally qualified
physicians in the reorganized Volunteer Medical
Service Corps. This application blank provides for
a complete record of the age, qualifications, experi-
ence, and special training of the applicant, and with
the information contained in the answers the gov-
erning board of the corps will be able to make
assignments to duties which will instire the greatest
measure of effectiveness with the least possible dis-
arrangement of existing conditions. Every legally
qualified doctor not now in the government service
is invited and expected to join this corps. Through
it, it is hoped to adjust medical service in such a
way as to get the best possible results with the
medical personnel of the country both in civil and
in military life.
There are, in the United States, about 144,116
men who are qualified to practise medicine and
about 5,000 women. Up to the first of this month.
al)out 40,000 of these were either in the govern-
ment service or had offered their services. Up to
July 12, the Surgeon General had recommended
26,733 doctors for commissions in the Medical
Reserve Corjjs, while about 9,000 had applied and
been rejected. Deducting those who had declined
commissions, or who had been discharged for physi-
cal disability or other causes, the Medical Reserve
Corps, on August 23d, numbered 23,531 officers,
22,232 of whom were on active duty. Adding the
1,194 officers of the Medical Corps of the National
(iuard and the 1,600 in the navy, this gives a total
of 38,527 physicians who were either in the service
or had applied for commissions, constituting 26.73
jjer cent, of the legally qualified physicians of the
I'nited States who had volunteered in the service
of their country.
Commissions in the army, navy, and Public
Health Service are being issued to doctors at the
rate of 540 a week. There are now 28,674 medical
officers in the three .services, and it is estimated that
50,000 will eventually be necessary for an army of
5,000.000 men.
These figures show clearly the need for the sys-
tematic organization of the entire medical profes-
sion so as to make the best possible use of the
personnel of the profession and to prevent the in-
fliction of any unnecessary hardships on the civilian
population. The withdrawal of so large a propor-
tion of the active men of the profession from civil
practice will necessarily lead to much inconvenience
and even to occasional hardship. Unless some
widespread and farseeing system is put into opera-
tion, some communities will be left without adequate
medical service. This condition exists in many
sections of England and France. Through the
organization of the service into the Volunteer Med-
ical Service Corps, it may be possible to so coordi-
nate the work of the physicians still left in civil
practice as to prevent the imposition of any real
hardship upon any section of the people. The mem-
bers of the profession should therefore give their
hearty supjwrt to this movement.
IMPORTANT STUDIES IN PIGMENT
FORMATION.
Certain important studies by Bloch and his
fellow workers are made the subject of discus-
sion by Arthur Whitfield in the British Journal of
DcniwToloqx and Syf'hilis', January-March, 1918
[On Some Recent Researches on the Nature and
lY)nnatii)n of Pigment]. These contain some
September 14, 791S.]
EDITORIAL ARTICLES.
\ aluable discoveries in regard to skin pi^^inenta-
tion. 1"he reagent used for the studies is 3.4-
dioxyphcnylalanin, called l)y IMoch, for con-
venience, "dopa." Sections of skin are placed
for twenty-four hours at room temperature or at
37° C. in a one per cent, watery solution of dopa,
after which they are washed and mounted.
Various elements of the cutis, such as sweat
glands or sometimes nerve cells, are partly af-
fected by the stain, but it is the epidermis which
shows the more important efifect. There is
change in the basal layer especially and, varying
with the depth, there is a continuous grayish
brown to a deep black wavy band corresponding
to the epidermis, or isolated patches more or less
separated by lighter areas between. The nuclei
of the involved cells are unaffected, only the rest
of the protoplasm being stained. The staining
appears in a diffuse form with which a granular
form is often combined, or rarely the latter is
seen alone. In human skin the reaction may be
slight and is usually discontinuous, with varying
intensity of reaction in different cells, even to no
reaction in some cells. This reaction is strong-
est in the germinative layer, but extends upward
in a varied measure. The nevus cells are the
only ones in the cutis vera in which there is any
reaction, no cells of mesodermal origin being af-
fected.
The process which constitutes this reaction is
the result of the oxidation of the dioxyphenyl-
alanin as a related agent, the molecule being
changed by oxidation and condensation into a
dark melaninlike substance, dopa melanin. This
is brought about by a ferment in the cells called
dopa oxidase, whose presence in the skin Bloch
succeeded in establishing. Dioxyphenylalanin
was proved to be the only body found which
could be acted upon by this ferment.
Bloch believes that the natural function of this
oxidase is to form the normal pigment or mela-
nin of the skin, and he finds that the reactions
vary according to the difference in activity of
pigment formation in the skin. The oxidase can
be demonstrated in the pigmented area in brown
and white variegated animals, but not in the al-
bino portions. Moreover, in case of vitiligo
where there is loss of pigment there is absence of
dopa reaction.
Pigment can probably be explained chemically
as the result of the action of the oxidase on some
substance related to dioxyphenylalanin, and
adrenalin is by its structural formula a pyrocate-
chin derivative, which is one of the substances
entering into the composition of dopa. Hence a
close relationship exists structurall}' between
])igment and adrenalin. The hyperpigmentation
of the skin after destruction or disease of the
suprarenals finds an explanation related to these
facts. There is probably an increased supply of
the substance which is the source of pigment.
The skin serves a regulatory function in regard
to the suljstance out of which both pigment and
adrenalin are produced, appropriating that which •
the suprarenal is no longer able to utilize.
Whitfield records in this connection a case
which might seem to confound Bloch's conclu-
sions, since in this instance there was a typical
leucoderma, with exaggerated surrounding me-
lanoderma, and autopsy revealed a tuberculous
destruction of the suprarenals. He suggests,
however, that there might have been a coinci-
dence of an ordinary leucoderma along with Ad-
dison's disease, the latter accounting then for the
increased melanoderma on the portions unaffect-
ed by the leucoderma.
THE ESTABLISHMENT OF A BUREAU
OF VENEREAL DISEASE.
New York State has definitely stepped up to
the front in the matter of venereal disease. The
legislature of 19 18 has passed an amendment to
the pu.blic health law giving power to local
boards of health to exercise control in this very
important province. A new article. Article 17-B,
is inserted into Chapter 49 of the laws of 1909, a
public health law. This new article provides for
the examination of suspected persons by a pub-
lic health officer or other licensed physician, this
examination being, however, restrainable by a
magistrate at his discretion. Examination shall
be made of persons convicted of vagrancy under
provisions already on the statute book or of fre-
(juenting disorderly houses or houses of prosti-
tution, before such persons are released by court
or magistrate. Treatment of those found infect-
ed with or suffering from venereal disease is also
to be required and regulated, with free treatment
provided for indigent persons.
Only licensed physicians shall be allowed to
prescribe for or to treat svich persons, and pre-
scriptions shall be carefully guarded. Provision
is also made that all reports- and information
shall be confidential as far as the carrying out of
the provisions of the article will permit. Viola-
tion of any of these provisions or of any rule or
regulation made under them is to be accounted
a misdemeanor, while special protection is ex-
tended to the naval and military service by mak-
4/2
EDITORIAL ARTICLES.
[New York
Medical Journal.
ing it a felony for any person aware of a venereal
infection to have sexual intercourse with any
person in either of these two branches of service.
A Bureau of Venereal Diseases has already
been established in the New York State Depart-
ment of Health in accordance with this new law.
Its purpose is to assist in carrying the act at
once into force in the most practical and far
" reaching manner. Its efforts will be chiefly edu-
cational, the arousing of public interest in the
prevalence of the disease, its communicable na-
ture, its far reaching effects upon individuals
and the community, and to train the public in
methods for the control and suppression of these
diseases. These efforts will be directed to the
public through organization work or public ad-
dresses. ]\Iothers' Clubs, Y. W. C. A., and other
women's organizations may be reached through a
public health nurse, who is one of the members of
the bureau. Literature will be provided and dis-
tributed and other means will be used as may
seem desirable.
The bureau also contains an organizer and in-
spector of clinics and dispensaries, for an impor-
tant step will be to provide clinics and dispen-
saries for the treatment of indigent persons.
This must include the furnishing of arsphenamine
(salvarsan) for the treatment of such cases, and
on the production of this substance the State
laboratory is now experimenting. A small ap-
propriation will soon become available for this
purpose.
The definiteness of program and vigor of cam-
paign take their place among the most important
of war measures, while at the same time they
strike directly at one of the most crying needs
of the civil population. The campaign will later
extend itself to the dividing of the state into sec-
tions, where each section will be made a unit for
carrying on the work.
MONTREAL AND INFANT MORTALITY.
The number of deaths among infants in a large
city like Montreal is a disgrace to modern pre-
ventive medicine. Either that city needs clean-
ing up or else it is lacking in determined arid in-
telligent direction of effort. That it easily leads
all other North American cities in the annual
death rate among infants is not a matter for
pride. That it has been doing so is notorious.
Surely the medical profession of that city should
search out the cause and remove it. Fifty thou-
sand children have died in the past thirteen years
without attaining the first anniversary of their
birth; and thirty-five hundred infants died in one
recent year. It is a glaring fact also that this
depletion of the infant life of that city is continu-
ous from year to year, although some slight im-
provement has been evidenced in recent years,
which may be presented as follows: From Jan-
uary 1st to July 13th in each of the years 1914 to
1918, the totals have been 2,352 deaths; 2,425;
1,883 ; 2,231 ; 1,820.
Comparisons may be according to Shakespeare
odorous, or as commonly put, odious — which is
Smollett — but when put forward they are gener-
ally meant to be for betterment somewhere, and
that betterment is sorely needed in Montreal.
Some time ago Toronto established health cen-
tres, and an active, well directed campaign was
instituted. The result is that Toronto's infant
mortality is about one half that of her big sister
in the east. Where Toronto spends seventy
cents per capita in modern preventive medicine,
Montreal spends thirty cents. Given Montreal
a double financial, or even a treble, arm, the re-
sults would be correspondingly satisfying.
Recently a municipal expert was investigating
the conduct of affairs in the city of Montreal. He
found out that Montreal had a so called Board
of Health that scarcely ever met, and recom-
mended that it be abohshed, and that a new
one composed of prominent citizens interested in
public health should take its place. When the
new board is in active working order, and more
money is forthcoming, then Montreal may ex-
pect to free itself from this lamentable stigma
which now clings to its skirts. To the commu-
nity belongs the blame and the disgrace !
Statistics have been published by the Immigra-
tion Department at Ottawa, which show the in-
fant mortality rate in the largest centres in Can-
ada, and which, incidentally, show that Ottawa
cannot be too self congratulatory in this respect.
Vancomer had sixty-one deaths per 1,000 of births
in 1917; Calgary, seventy-seven; Toronto, eighty;
Edmonton, ninety-nine; Winnipeg, 108; St. John,
N. B., 118; Montreal, 185; Ottawa, 222. Inquiry
of the Records Branch, Department of Health,
Toronto, elicits the information that in Toronto in
1917 there were 12,110 births, and that the mor-
tahty under one year was 1,112 cases, which would
give a rate about ninety-two per thousand births.
Perhaps Doctor Bryce, of the Immigration Depart-
ment, Ottawa, should look more carefully into his
statistics.
As there never was a time when the conserva-
tion of human life should be so emphasized, espe-
cially in all English speaking comrjiunities, it
September 14, 1918.]
EDITORIAL ARTICLES.
A7Z
most assuredly behooves the medical profession
as a body to be active in spirit and active in do-
ing. It is to the man and woman of action that
the cry of the youngsters should appeal. See
what action has done for Toronto: Up to 1913
infant deaths had been increasing year by year. In
that year they reached 421 for every 100,000 of
the population. The Health Department became
very active. In 1914 there were 331 deaths; in
1915, 300; in 1916, 293; in 1917, 235.
MALIGNANT GROWTHS OF THE SKIN.
The history of cutaneous sarcomata is of re-
cent date, the first case report Iiaving been pub-
lished by Kobner in 1869. This was followed by
the epoch making papers of Vidal, Perrin, Hallo-
peau, and Kaposi. But, with all that has been
written on this subject, the question is still very
obscure.
Cases of sarcoma are far from being compar-
able with each other, their structure and clinical
picture presenting marked differences. In one
group the evolution and generalization of the
process are sufficiently fixed so that they can be
compared to a definite disease. On the other
hand, there is a second group comprising neo-
plastic forms having little similarity either in
their evolution or development.
In sarcomata assuming the form of a disease
may be placed the generalized pigmentary sar-
comatosis of Kaposi and the multiple hypoder-
mic sarcomatosis of Perrin. Pigmentary sarco-
matosis begins on the limbs, at first in the form
of a hard edema accompanied by "wine spots."
Then gradually these infih rated areas assume a
dark color and coincidently slowly growing no-
dules appear. In a short time the sarcomatosis
has become generalized, no viscus escaping its
ravages.
The type described by Perrin is quite different.
In this variety the process begins at any point of
the body surface excepting the extremities. The
onset may be either slow c rapid. At first only
a few nodules are found, but soon they multiply
in the areas involved. The hands and feet are
always exempt from the process.
In the case of sarcomata developing as a cuta-
neous growth a distinction should be made be-
tween the melanotic and the nonmelanotic sar-
coma. The first are characterized by their pig-
ment content, melanin, a pigment quite different
from that present in Kaposi's pigmentary sar-
coma. Melanin is found normally in the iris,
choroid, in certain parts of the meninges, in the
basal membrane of Malpighi's bodies, and in cer-
tain small congenital neoplasms. Therefore, this
type of sarcoma frequently arises in the above
named structures, particularly in pigmented
nevi.
At the outset a melanotic sarcoma is usually
single and very small in size, gradually increas-
ing to the volume of a small orange. It is oval
or spherical in shape. It is frankly black in hue.
It may remain stationary for a certain lapse of
time, but its generalization is not long in making
itself manifest. These growths are malignant in
the highest degree, their recurrence after re-
moval is practically a certainty, and the patient
is doomed to an early death.
The nonmelanotic sarcoma of cutaneous origin
occurs in the form of a primary nongeneralized
unpigmented sarcoma and in the form of a sec-
ondary sarcoma. The latter form is merely a
cutaneous metastasis of a sarcomatous growth in
some viscus, so that only a few words are neces-
sary regarding sarcomatous transformation of
primarily nonmalignant cutaneous neoplasms.
Now, since nonmalignant and malignant
growths are connected by near relationship, it is
evident that nonmalignant tumors of the skin
very frequently undergo malignant transforma-
tion. In point of fact this has been clinically
known for a long time and pathologically has
been but imperfectly explained. Renoul, for ex-
ample, has published the account of 120 cases of
papillomatous growths on the skin out of which
thirty-four showed epithelial degeneration, while
the same condition has been met with by Rap-
pock in 182 cases of facial or labial cancer.
Pigmented nevi easily transform into pigment-
ed cancers ; they have been shown to be an epi-
theliomatous transformation by Renoul and pig-
mentive connective tissue neoplasms by Trasbot,
Perrin, and others.
The neoplasms termed hydradenomata by Da-
rier and Jacquet have been shown to be an epi-
thelial transformation, and similar data have
been published by Balzer and Menetrier in re-
gard to cutaneous adenomata, while Malherbe
has even maintained that a chancroid is always
derived by transformation from a sebaceous ade-
noma.
From all that has been written on the subject
of malignant cutaneous growths, it may be said
that the nonmalignant skin growths tend to epi-
thelial transformation, while connective tissue
transformation is far less common, although a
number of authentic cases have been recorded in
recent years.
474
NEH^S JTEMS.
[New York
Medical Journal.
N
ews
Items.
Medical Society of Woman's Hospital, Philadelphia.
— Tlie following have been elected as officers of this so-
ciety: President, Dr. Anna H. Thomas; treasurer, Dr.
Mar\- Gilbert-Knovvles ; secretary. Dr. Mary R. H. Lewis.
General Gorgas in France. — Announcement was
made from Washington on September 9th that the Secre-
tary of \^'ar, accompanied by Major General W. S. Gorgas,
Surgeon General of the United States Army, arrived in
France on a tour connected with the work of the War De-
partment.
Navy Medical Corps Examinations. — Examinations
for permanent appointment in the Navy Medical Corps
will be held on October 30th and 31st. The examinations
will be held at the naval hospital at Washington and at
such places as the candidates are at present on duty. The
candidates must be physicians who are now members of
the Naval Reserve Forces or temporary medical officers
of the U. S. Navy. No one will be permitted to take the
examination whose application was not received on or be-
fore September 5th.
U. S. General Hospital No. 16, Enlarged.— This hos-
pital at yVzalea, in the mountains of North Carolina, near
Asheville, was designed for the treatment of tuberculous
sailors and soldiers, but since the climatic conditions have
proved to be advantageous in gas cases, it has been de-
cided to enlarge the scope of the institution to admit gassed
soldiers. The hospital was opened on August 20th, with
accommodations for 1,000 patients, and orders have been
given to add twenty-two buildings, which will provide for
an additional 500 patients. The cost to date is $1,500,000.
Leave of Absence for Medical Officers.— Secretary of
War Baker early in the summer sent a memorandum di-
rectly to the Surgeon General requesting that all medical
officers, who have been engaged for six months contin-
uously at their desks on department business, be required
to take at least two weeks' leave of absence, such leaves
to^ be enforced in a manner to give the least interference
with the operations of the Medical Department. This order
applies to all medical officers, and any officer who comes
within the scope of the order may obtain his leave on ap-
plication to the Surgeon General.
Volunteers for Pennsylvania Hospital, Philadelphia.
— Daniel D. Test says that the institution has lost more
than seventy-five per cent, of its medical and surgical staff
in service overseas and that in all the other departments
the employees have left to obtain situations with concerns
turning out work for the government. Those serving in
the hospital are doing a patriotic service since the hospital
has offered its wards to the United States for disabled,
wounded, or sick. At present two wards are filled with
sailors from the immediate naval district. The superin-
tendent calls on patriotic citizens to volunteer their serv-
ices and relieve this serious situation.
Special Registration Rules. — The Committee on Pub-
lic Information' has supplied the following information
from the office of the Provost Marshal General : Any per-
son, within the designated age limits, who on account of
sickness cannot register in person on Registration Day.
must cause some person to apply to the local board for a
copy of the card and for authority to fill it out. When
made out the card will be mailed by the sick person, or
delivered by his agent to the local board having jurisdic-
tion of the area in which the sick person permanently re-
sides. 2. Inmates of every penitentiary will be registered
by the warden, but the reports will not be included by the
.Adjutant General in the consolidated state report; nor will
the registration cards be consolidated with the records of
the local boards, nor copies with the cards of the state;
they will be kept in a separate file, i. e., felons will not
be drafted into the army. 3. Persons awaiting trial, and
those convicted merely of misdemeanors, are not to be
regarded as felons; they will be treated as absentees, and
their cards must be forwarded to the respective local
boards of the areas within which they permanently reside.
4. Inmates of asylums will also be treated as absentees,
and their registration cards must be forwarded to their
resnective local boards.
Increased Pay for Officers. — A bill has been intro-
duced into the House of l^epresentatives by Mr. Dyer pro-
\iding for an increase in pay for officers of the army as
follows: Colonel, $4,500; lieutenant colonel, $4,000; major,
?3,500; captain, $2,900; first lieutenant, $2,500, and second
lieuter.ant, $2,200.
Philadelphia Doctor Awarded the Croix de Guerre. —
Lieutenant Wilfrid B. Fetterman, commanding health
service unit No. 581, has been cited for gallantry in action
and awarded the Croix de Guerre. He was educated in
St. Joseph's College, Clougowes College, Ireland, and the
University of Pennsylvania Medical School. The citation
declares him distinguished for the rapid clearance of the
wounded in the midst of difficult and dangerous surround-
ings.
Sick and Wounded of the American Expeditionary
Forces. — Only thirty-seven sick and wounded soldiers
were invalided home to the United States during the week
ending September 4th. This compares favorably with 423
for the preceding week. Many convalescent American
soldiers are being transferred from English hospitals to
the American Red Cross Hospital at Paignton, on the
South Devonshire coast. The hospital is the former coun-
try home of a wealthy American, has a capacity of 300
beds, and is in charge of American doctors and nurses.
Death of Bacteriologist Noted for His Work in Lep-
rosy.— Moses Tran Clegg, formerly laboratory director
in the Health Officers' Department, Port of New
York, has just died at Honolulu, where he was super-
intendent of Queen's Hospital. Mr. Clegg was graduated
from the University of Arkansas. In March, 191 1, he
joined the United States Hospital Corps, serving through
the Philippine insurrection. He was assistant bacteriolo-
gist in the Bureau of Science, Philippine Civil Service,
from 1902 to 1910. From 1910 to 1915 he was assistant
director of the United States Leprosy Investigation Station
at Hawaii, and he is accredited with the discovery of the
leprosy germ in 1909, which achievement revolutionized
the further research work in leprosy. Mr. Clegg was a
member of the Far Eastern Society of Tropical Medicine,
Philippine Island Medical Association, and Honolulu Med-
ical Society.
Health of the Troops. — According to the War De-
partment, the health conditions among troops in the United
States, including Porto Rico, for the week ending August
30th, were as follows: Noneffective rate per 1,000: Divis-
ional camps, 46.1; cantonments, 40.1; departmental and
other troops, 29.5. Annual death rate per 1,000 (disease
only) : All troops, 3.35; divisional camps, 5.4; cantonments,
3.7 ; departmental and other troops, 2.5. The admission
rate continues to show a decline, while the noneffective
rate is slightly higher than last week. The death rate for
disease continues low (3.35), though slightly higher than
last week (2.96). Pneumonia continues as the cause of
the majority of deaths occurring during the week. Pneu-
monia shows an increase in the number of new cases as
compared with last week. Malarial admissions are remark-
ably few, considering the season of the year. Forty-two
less cases of measles are reported over last week.
Personal. — Dr. Charles B. Penrose has been made
the head of the Philadelphia Municipal Court's new de-
partment of diagnosis v.hich has been formed from the
court's various medical agencies. Associated with him are
Dr. D. J. McCarthy, Dr. Charles S. Potts, Dr. S. W. D.
Ludlum, Dr. John C. Da Costa, Jr., Dr. Thomas A. Shal-
low, and Dr. J. M. Baldy.
Colonel Herbert Alexander Bruce, Consulting Surgeon
of the British Army in France, who was recently in the
I'nitcd States as a member of the special British medical
mission, has been cited by Field Marshal Haig for bravery
in the field.
Dr. .Seth Lake Strong, who was graduated from the
Harvard Medical School in 1913, has been appointed lec-
turer in surgery at the Royal Medical College at
Banglcok, Siam, and will also act as surgeon to the Siravaj
Hospital there.
Dr. Samuel T. Darling, a member of the International
Health Board, has been appomted professor of hygiene
and director of laboratories in the School of Medicine and
Surgery, Sao Paido, Brazil.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
VICIOUS CIRCLES IN RP:SPIRATORY DIS-
ORDERS AND THEIR TREATMENT.
By Lcuis T. de M. Sajous, B. S., M. D.,
Philadelphia.
PUL.MONARY TUBIiRCULOSIS.
{Continued from page 432.)
An important part is played by nervous influences
in the rapidity of progress of pulmonary tubercu-
losis. Poisoninor of the nerve centres through ab-
sorption of toxic material from the involved tissues
accounts for a variety of attendant disturbances,
both physical and mental. The early loss of gen-
eral muscular tonicity and strength is ascribed by
Lawrason Brown, 191 3, to toxic action on the
nervous system. Sweats in early tuberculosis are
attributed in general to intoxication of the sweat,
heat, and vasomotor centres by the tuberculous
poison, though later the sweat glands, it is stated,
may themselves be directly excited. Toxic changes
in the nervous control of the heart are responsible,
in part, for the marked instability of the pulse and
tendency to tachycardia in this disease ; disturb-
ances of the alimentary tract may at times arise
upon a nervous basis. Excessive irritability of periph-
eral neurons may be manifested in exaggeration
of certain reflexes, and tremor may occur. Neuras-
thenic manifestations, unusually common in tuber-,
culosis and at times so pronounced as to distract
attention from the earlier local changes, are thought
due to intoxication of the higher centres. The
psychic disturbances vary in their nature and
degree. While unwarranted hopes of recovery are
frequent in the minds of advanced cases, many pa-
tients develop a nervous pessimism or melancholia
which, occurring sometimes relatively early, is of
greater practical significance in its harmful in-
fluence than is the opposite condition — spes phthis-
ica. — where present as a helpful factor in cases al-
ready far advanced.
In all of the above nervous disturbances there
lurks the possibility, if not the probability, of a
vicious circle. Reduction of muscular tone, exces-
sive sweating, tachycardia, disordered digestion,
and nervous depression — each of these, if suffi-
ciently marked, w^ill tend to disturb and weaken
one or more functions upon the maintenance of
which at a normal level the maximum defensive
efi^ort against the invading infection must depend.
Where, as a result of such functional impairment,
the defensive process does suffer, progress of the
disease is likely to be more rapid, with extension
of tissue involvement, increased liberation of toxic
material, and consequently, enhanced toxic effects
upon nerve centres, thus completing the vicious
circle. A pessimistic mental attitude, where pre-
sent, seems to exert a particularlv harmful influence
by precluding a firm determination to recover on
the part of the pntient. The marked significance,
from the prognostic standpoint, of a proper psychic
state in this disease has been widely commented upon
and is indirectly confirmed by the striking benefit
often noted from new therapeutic measures, in-
dependently of their actual organic value as shown
by subsequent events. To whatever extent mental
depression is here the result of toxic eitects on
nervous tissue, by so much will its harmful influence
be likely to operate in the form of a vicious circle,
mental depression weakening resistance to the dis-
ease, and this in turn, resulting in increased toxic
action on the centres. The mental condition, ac-
cording to Lawrason Brown, directly afifects the
weight in tuberculous cases. '
Interruption of the vicious circles just alluded to,
however m.anifested, is most directly accomplished
through reduction, or at least prevention of increase,
of the amount of tuberculous poison exerting its
harmful effects upon the nerve centres. Such a result
is obtained more or less successfullv by persistent
application of the general hygienic dietetic treatment
of tuberculosis. In addition, however, it will doubt-
less often be worth while to attack other segments
of the circles by, e. g., the prevention of exhaustion
from excessive sweating, in so far as possible; pre-
servation of the patient from influences which aug-
ment further an already increased heart rate, and
appro])riate treatment of disturbances of the ali-
mentary tract. States of mental depression may im-
]:irove along with a reduction of toxic absorption,
but in any case, cheerful surroundings, encourage-
ment by the physician and attendants, and a care-
ful explanation of the aim of each measure in the
treatment, with stress on the hopeful outlook af-
forded by careful observance of hygienic rules,
slfould prove helpful in overcoming pessimism and
its prejudicial eft'ects on the course of the disease.
An im])ortant prophylactic precaution consists in
careful avoidance of nervous excitement and undue
exercise, which increase the absorption of tuber-
culous poison from the disease foci.
Probably the most important of all the vicious
circles that may aggravate pulmonary tuberculosis
are those involving the alimentary tract, for proper
cell nutrition has admittedly a preeminent influence
on recovery, and conversely, interference with diges-
tion and assimilation reacts most unfavorably and
rapidly on the morbid condition. According to
Hays, a vicious circle may be initiated through the
direct eft'ects of the tuberculous poison upon the
alimentary canal, a deficiency in the digestive fer-
ments being produced, with loss of appetite and
conserjuent prevention of repair of the waste of the
body, this, in turn, favoring extension of the disease
and increased liberation of tuberculous poison,
which completes the circle. E. E. \\'atson, igi8,
explains the hyperacidity, hypermotility, and spas-
tic constipation frequently met with in early tuber-
culosis as being due to increased vagus tone through
irritation of the vagus nerve endings in the diseased
kmg parenchyma. In advanced cases, on the other
476
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
liand, toxemia may centrally excite the sympathetic
system and cause decreased motility and secretion,
with resulting symptoms sucli as coated tongue,
hypoacidity, poor appetite, and atonic constipation.
Again, as Watson sees it, lessened depth of inspira-
tion and diaphragmatic excursion in advanced cases
may cause retardation o'f blood flow through the
abdominal organs ; combined with the usually weak-
ened heart action, this results in actual passive con-
gestion, impaired secretory functions, and ac-
celerated malnutrition and emaciation. A general
visceroptosis from malnutrition of the abdominal
muscles, loss of panniculus, and cough may here
complicate matters. Lessened tone of the muscula-
ture at the cardiac orifice has been thought to ac-
count for the ease with which food in the stomach
is vomited during cough in pulmonary tuberculosis ;
malnutrition through insufficient retention of food
because of emetic cough may appreciably reduce
the general capacity of resistance and hasten the
progress of the disease.
In each of the above mentioned disturbances the
elements necessary for the formation of a vicious
circle are plainly evident. The opportunities offered
the practitioner to impede the progress of the dis-
ease and strengthen the patient's resisting power
for the final decision against it are correspondingly
numerous. In those vicious circles in which the
tuberculous poison forms part of the circle, hygienic
dietetic treatment will tend to arrest aggravation of
the circle. Deficiency in the digestive ferments
may be artificially compensated. For hyperacidity
and hypermotility, Watson reports gratifying re-
sults from alkalies, atropine in doses of 1/200 to
i/ioo grain one half hour before meals, and the
usual diet. The subsequent hypomotility and re-
duced secretion he treats with nux vomica and a
bitter tonic before meals, and hydrochloric acid and
pepsin after meals. Intraabdominal circulatory
stasis and heart weakness may be favorably affected
by digitalis and the effects of visceroptosis by
mechanical support. Emetic cough forming part of
a vicious circle is best treated by a rest in bed, hot
water half an hour before meals, limitation of
fluids at meals, quiet after meals, and if indicated
anesthetizing applications to the pharynx. To be
carefully avoided, because they may sooner or later
aggravate one or more vicious circles, are excessive
forced feeding and the overuse of laxatives.
(To be continued.)
Transfusion with Preserved Red Cells. — Os-
wald H. Robertson (British Medical Journal, June
22, 1918) uses the method of preserving human red
cells which was described by Rous and Turner. The
blood is obtained only from donors of Group IV
and is drawn directly into a mixture of a five and
four tenths per cent, solution of glucose with three
and eight tenths per cent, solution of sodium cit-
rate. These solutions are used in the proportions
of 500 mils of the isodextrose and 350 mils of the
isocitrate for each 500 mils of blood. After the
blood is drawn it is mixed with the solutions, stored
in the icebox and allowed to settle. By the end of
about four days the red cells will have settled to
about 800 to 900 mils and tliis portion can be used
after siphoning off the supernatant fluid. Smaller
amounts of blood may also be drawn and kept in
readiness. In every case when a transfusion of the
red cells is to be made the desired volume is taken
and made uj) to a total bulk of one litre with a
two and five tenths per cent, solution of gelatin in
normal saline. The transfusion, as well as the col-
lection of the blood can be carried out easily by one
physician with the aid of an attendant. The blood
cells thus obtained can be preserved and used up to
about thirty days after their collection. They can
be transported readily and blood thus becomes
available for use in emergencies near the front.
Blood collected and preserved in the manner de-
scribed was used by the author for twenty-two
transfusions in twenty patients. The blood varied
in age up to twenty-six days, and the age did not
seem to have any influence on the results obtained.
The patients selected for its trial were such as
would have died without transfusion, yet such as
offered some hope of recovery if it were done. Of
the twenty men transfused eleven were discharged
to the base in good condition and nine, or forty-
five per cent. died. All of the patients who died,
however, showed the immediate stimulating effects
of the transfusion. The effects of giving this pre-
served blood were quite as marked as those seen
in direct transfusion and the method offered many
advantages over the direct. Thus it was possible
to prepare for emergencies by having a supply of
the preserved blood on hand, the blood could be
transported, the transfusion became a simple in-
jection which one man could make, operating
theatre room was economized as the transfusion
could be given at the bedside, and finally the time
saved was of very great value, especially under
rush conditions.
Gunshot Wounds of the Knee Joint. — Richard
Charles (British Medical Journal, June 29, 1918)
urges the desirability of operating upon every
wounded knee that needs it at once and before trans-
ferring the patient to the base, especially since the
results are so much better when the operation can
be performed within twenty-four hours of the
wound. The present conservatism depends upon
improved technic. In every case before operation
an accurate radiographic study of the location of
the missile and the extent and nature of the dam-
age to the joint should be made. For the operation
the field should be made perfectly bloodless by an
Esmarch bandage and the skin all about the joint
should be well washed, shaved, cleaned with alcohol
and painted with a five per cent, alcoholic solution
of picric acid. The wounds should then be packed
lightly with gauze to prevent leakage of fluid on to
the skin. Attention must be given to every detail
which contributes to the excision of the damaged
tissues without contamination of the fresh tissues.
It is usually possible to excise the entire wound
track down to the joint capsule without having the
glove or instruments touch the infected wound sur-
face. But should such happen the soiled instru-
ment or glove is to be discarded at once. The skin
wound is first isolated by an elliptical incision and
then undermined close to the wound track. Then
September 14, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
A77
the incision is carried down into the joint cavity on
one side to give a view of the deep end of the track.
Finally the entire wound track is excised according
to these landmarks. This part of the operation re-
quires the most patient dissection under severely
aseptic conditions. Next all used instruments and
gloves are replaced by fresh ones, the original open-
ing is enlarged, and the condition of the joint is
investigated. If the missile is loose in the joint
cavity it is removed, the cavity irrigated and if there
is no injury the joint is closed in layers for primary
healing. If the missile is impacted in bone the in-
cision may have to be enlarged even by division of
the ligamentum patellae to give free access. The
site of the missile is isolated with moist saline gauze
and the missile is removed by clean excision of the
bone containing it. At times the original opening is
closed and one made on the opposite side to reach
the foreign body, which is removed by excision.
Grooved bone injuries are treated by complete ex-
cision. In deep bone injuries in the centre of the
joint, excision is sometimes not possible but the ap-
plication of the Carrel treatment will often save the
joint, or the wound can be curetted and the joint
closed after free irrigation. In some cases of com-
minution the patella may have to be excised, which
should be done in one piece with the primary ex-
cision. Small injuries to the patella should be re-
moved cn masse with a metacarpal saw. The irri-
gation fluid for the joint should be normal saline.
In clean cases fat can profitably be transplanted into
holes in the articular surfaces. In closing the joint
the most important step is the complete closure of
the synovial membrane without tension, which may
require the loosening of its lateral reflection, or the
use of the suprapatellar pouch. The remainder of
the M^ound is then sutured in layers and the leg is
put up in a Thomas splint.
Treatment of Empyema at Camp Lee. — The
Empyema Commission, headed by Major Edward
K. Dunham {Journal A. M. A., August 3, 1918),
has investigated 140 cases of empyema due to hemo-
lytic streptococcic infection and has found the fol-
lowing general plan of treatment to be the most
rational and to give the best results, both with
reference to life and to restoration of lung function.
During the acute stage of the illness the patient
should be confined to bed and treated and nursed
carefully with the object of maintaining his strength
and enabling him to combat the infection. The
chest should not be opened at this stage because of
the poor general condition and the danger of caus-
ing septicemia. If necessaTy the chest may be as-
pirated through a needle from time to time to re-
lieve mechanical embarrassment. When the fluid has
changed from a serofibrinous one to frank pus and
the patient's general condition has improved, as
shown by drop in temperature and respiration and
disappearance of cyanosis and air hunger, opera-
tion may be undertaken. In a few cases it will not
be necessary because of the total disappearance of
the fluid after one or more aspirations. The opera-
tion should be done under local anesthesia by infiltra-
tion or blocking or both. The site of the incision
should be chosen with reference to drainage in both
the recumbent and sitting positions. The incision
must be long enough to give good access to the
underlying structures, which are divided as ex-
posed, the pleura usually being incised in an inter-
costal space. A double drainage tube of large cali-
bre may be used, permitting both drainage and
irrigation through the insertion of Carrel tubes, or a
single tube may be inserted and connected with a
series of water, bottles and a reservoir for Dakin's
solution to permit of continuous suction and the in-
stillation of Dakin's solution. The cavity should be
irrigated with Dakin's solution every day until the
washings return clear, and the tubes and dressings
should be changed daily, the strictest asepsis being
observed. After the cavity has become sterile and
the discharge has almost disappeared its diminution
in size usvially goes forward with remarkable rapid-
ity and it is seldom necessary to perform secondary
operations for its obliteration. This is especially the
case when the interval has not been too long be-
tween the operation and the beginning of the use of
Dakin's solution.
Oil of Chenopodium in Amebic Dysentery. —
Mil ford Edwin Barnes and Edwin Charles Cort
(Journal A. M. A., August 3, 1918) record a num-
ber of cases of amebic dysentery, or of carriers of
cysts, which were treated with oil of chenopodium
as the result of a casual observation that the oil
had promptly relieved dysentery when given for
hookworm disease. In most of the cases in which
it was tried there was very rapid relief of the
clinical symptoms, the cases having been subacute
or chronic. The drug was proved to be a powerful
amebicide when given either bv mouth or per rec-
tum, as shown by the prompt disappearance of the
amoeb?e from the stools. The tendency to relapse
was not greater in the series studied than under
the use of emetine. Oil of chenopodium would
seem to be of distinct value for dysentery, since it
can be given with safety when combined in a single
dose with castor oil. Emetine has been shown to
be somewhat dangerous in doses sufficient to cure
amebic dysentery and has also not proved entirely
satisfactory as a specific in any of its forms. The
oil of chenopodium should be given in doses of one
to two mils in forty-five mils of castor oil, in one
dose, or it can be given by rectum in an emulsion
with acacia. In the latter case the enema should be
given slowly with the buttocks raised ; should be re-
tained for at least an hour, and the anal mucosa
and skin should be protected from irritation by
liberal application of petrolatum.
Abuse of Drainage Tubes. — Frank Hathaway
(British Medical Journal, June 29, 1918) urges
surgeons to take courage and give up the use of
drainage tubes, practising primary suture and thus
preventing the dangers of secondary infection. In
wounds of the extremities he practises complete
primary excision followed by suture. Where bone
is involved he cleans out part of the medullarv cav-
it}' and fills the dead space with a mixture of thy-
mol, petrolatum and candle wax, closing the wound
by suture. He even has gone so far as to close the
incision in cases of perforated gastric ulcer, pus
tubes, gonococcal peritonitis, and empyema after
treatment and mechanical cleansing of the peri-
toneum or pleura. His results have been excellent.
4/8
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[Xew York
Medical Journal.
Sterilization of Local Anesthetics. — M. Mac-
naughton-Joncs {Lancet, June 29, 1918) advocates
the preparation of any of the local anesthetics in
the form of very concentrated solutions along witli
sodium chloride, which in the high concentrations
employed not only preserves sterility, but also rend-
ers contaminated solutions sterile in a few days.
The solutions should be made of such strength that
they will require dilution forty tiriies with sterile,
distilled water for use. These concentrated solu-
tions should be kept in sealed glass tubes. Since
the reduction of the osmotic pressure of the solution
to a point ecjual to that of a four tenths per cent,
solution of salt materially enhances the anesthetic
property of any solution, the most desirable solu-
tions to be used are such as will have this osmotic
pressure. The amount of drug to be used along
with the salt can be determined by its molecular
weight. Thus the molecular weight of procaine is
four and six tenths times that of sodium chloride,
and therefore one part of sodium chloride is eqttal
m osmotic pressure to four and six tenths parts of
procaine. The simplest method of preparing the
concentrated solutions is to use the quantities of the
anesthetic, salt, epinephrin, etc., which are desired,
per 1000 parts of solution and to make them up to
twenty-five parts. Two most serviceable formulas
for concentrated solutions follow, each requiring
dilution with forty parts of distilled water for use :
I.
Procaine, 3-25 ;
Sodium chloride 3-25 ;
Epinephrin hydrochloride (i-iooo), 8.00;
Water tc make 25.00.
II.
Cocaine hydrochloride, 2.0;
Sodium chloride (approximate), 375;
Epinephrin hydrochloride (i-iooo), 6.0;
Water to make 2,=;.o.
Achylia Gastrica. — J. L. Mortimer (Colorado
Medical, May, 1918) says that dietetic management
is the foremost factor in the treatment of this
condition and that this must be strictly individual-
ized, according to the predominating symptoms.
Since meat is generally poorly tolerated it should
be served minced or hashed, if at all, and should
be of the white variety by preference, including
fish. Such vegetables as potatoes, spinach, carrots,
string beans and asparagus should be given in the
form of purees. Excepting butter and cream, the
fats are poorly tolerated and should be reduced to
the minimum. The flow of the gastric juices may
be stimulated by the use of bouillon, meat broths
and carbonated waters. All milk taken should be
boiled, and cocoa, malted milk, rice, tapioca, eggs,
buttermilk, toast, zwieback, and reheated stale bread
may be allowed. Medicinal treatment is of less
importance, but the efifort should be made to sub-
stitute some of the hydrochloric acid and pepsin by
administration of these two agents. The bitters are
useful at times Gentle lavage with normal salt
solution, or salicylic acid or resorcin in i :i.ooo
solution should be practised about three times
weekly, where there is gastric fermentation and
accumulation of mucus. Gentle abdominal and
areneral massage, alvloniinal faradization and the
Priessnitz or hot alxlominnl cnmnress, or alternat-
ing hnt and cold abdominal douches may be of value.
Treatment of Empyema. — S. M. Rinehart and
Anton W. Oclgoet? ( Journal A. M. A., Julv 27,
1918) say that, like pus anywhere, empyema re-
,|uires drainage. The practice of thoracotomy or
costectomy is the common one, but except in some
very virulent cases requiring rapid drainage it does
not seem necessay or desirable to resort to either if
other means are available. The disadvantages of
both operations are the formation of dense adhe-
sions which interfere with lung expansion ; pro-
longed convalescence ; chest deformity ; etc. To
provide drainage and aid the control of the infec-
tion the authors have tried the plan of immediate
aspiration of the chest through a large needle with
the injection of two per cent, formaldehyde in
glycerin. The aspiration was done every other day
so long as there were physical signs of fluid, and
quite without reference to the presence or absence
of constitutional symptoms. This treatment should
be instituted when the diagnosis is made and should
be continued until fluid no longer accumulates or
until the very small amounts are sterile. The
method has given most excellent results, avoids the
disadvantages of the operative methods, and is
followed by much more rapid recovery than either
of the operative methods. The aspirations are
done under ethyl chloride local anesthesia and can
be repeated as often as necessary.
Antimeningococcic Serum. — G. W. McCoy,
N. E. Wayson and Hugh B. Corbitt (Journal A.
M. A., July 27, 1918) point out that there has re-
cently been much discussion of the therapeutic
value of antimeningococcic serum and that the
question of its potency is still under debate. In
recent outbreaks of meningitis in England and con-
tinental Europe the use of serum of American
manufacture was followed by conflicting reports
as to its value. The failures and confusion seem
to be due in part to the occurrence in the epidemics
of strains resistant to the serum and in part to low
potency of the serum. In an effort to render the
various commercial scrums more uniform the au-
thors took up their standardization at the Hygienic
Laboratory and it was required that all serum be
polyvalent, that is tliat it represent all of the re-
cognized strains of organisms. Since the grouping
of meningococci is not definitely established re-
presentatives of each group in the broadest classifi-
cation yet adopted were included. The methods of
testing, hitherto employed, have dififered widely, liut
in the interest of uniformity of product the agglut-
ination and complement fixation tests were adopted.
Each manufacturer wae provided with the mater-
ials for the tests and was required to subject his
preparations to the tests before sending them to
the Hygienic Laboratory for final test and release
for sale. In the examination at the Laboratory of
1 01 lots of serum twenty-five have failed to come
up to the standards prescribed, nine of which were
produced early in 1917 and six by an institution
not licensed for interstate traffic. As a result of
this work all serum now for sale is required to be
|)olyvalent and to meet certain standards of potency.
Much y£t remains to be done, however, for diflfercnt
lots of serum from the same manufacturer may
vary widely in potency.
September 14. rgiS.]
MODHUN TREATMENT AND PREVENTIVE MEDICINE.
479
Delayed Primary Suture.— W. Girling Ball
{Lancet, June 29, 1918) says that the ideal method
of treating a wound after cleansing and excision of
damaged tissue is primary suture, but that there
are conditions which render this method impossible
and in such cases it is most desirable to practise the
so called delayed primary suture. In order to
bring the desirability of this method of treatment to
the notice of surgeons the author presents his own
results in a series of 100 consecutive cases. Among
the 1 00 cases there were fifty-nine complete successes,
twenty-six partial successes and fifteen failures. A
partial success was recorded when there was any
stitch suppuration or an opening of the wound
without suppuration. An adequate primary excis-
ion of the wound is essential as a prerequisite of
delayed primary suture. Those wounds, which on
the removal of the packing have a dry or slightly
moist surface and are free from pockets of pus
or unexcised damaged tissues, are suitable for de-
layed primary suture. Suture should be carried out
on the second to fourth day from the receipt of the
wound. A dry, clean wound should be sutured
without being touched, but a moist one should bo
washed out with an antiseptic. Old or fresh blood
should also be washed from the wound before
suture. Before removing the wound packing the
skin must be scrupulously cleansed with ether and
some antiseptic, preferably two per cent, picric acid
in alcohol. All dead spaces must be obliterated,
for which deep sutures of catgut or thread may be
used if required. Fascia or the muscle sheath
should be sutured over muscle if possible. Where
there are fractures as many tissues as possible
should be drawn together over the break. The
skin should be sewed with silkworm gut. Every
wound should be completely immobihzed by splint-
ing, plaster, extension, or other suitable means. The
skin sutures generally should be removed on the
eighth day, but may have to be left longer. The
method has manv advantages among which are : The
greatly increased rapidity of healing, the average
time having been less than ten days ; the shortening
of the period of healing even in the cases which
are only partially successful ; the avoidance of large
and deep deforming scars ; the immediate covering
in of exDOsed vessels ; the conversion of compound
into simple fractures ; and the avoidance of many
painful dressings. The criteria for the selection of
wounds suitable for delayed primary suture should
be the clinical appearance of the wound, not its
bacteriological cleanliness.
Bronchopulmonary Spirochetosis. — H. Violle
(Bulletin de V Academic dc medccinc, June 4, 1918)
from a naval hospital at Toulon, France, reports
thirty cases of this affection, originally described by
Castellani in India over ten years ago. The most
striking feature of the disease, which is due to the
.Spirochieta bronchialis, was the constant reddish
coloration of the sputum, due to blood, and causing
the fluid to resemble currant juice. This peculiarity
is in itself pathognomonic, and occurred in every
case of the author's series. Half the cases had been
diagnosed as tuberculous, but tubercle bacilli were
never found, while smears stained with silver nitrate
l)y the method of Fontana, as modified by Tribon-
deau, showed mnumerable spirochetes of varied
.«izes and shapes, often with practically no other
bacterial accompaniment. These spirochetes do not
occur in the nasal mucus, urine, nor blood. The
Bordet-Wassermann reaction is negative. The af-
fection begins insidiously, and the signs are those of
ordinary bronchitis or at times of apical bronchitis
or of basal congestion. Cough is frequent, raucous,
and chiefly nocturnal. The general condition re-
mains good and there is no fever, and but slight
lieadache. The affection runs its course in an aver-
age period of one month, but relapses are frequent.
It is mainly dangerous because it favors tuberculosis,
pneumonia, and bronchopneumonia, the germs of
which enter the lung tissue at the points of' bleeding.
This danger is transmitted to other individuals by
the spirochete carriers. The disease seems to be
very contagious, was probably brought to France
by Asiatic contingents, and appears likely to become
acclimated there, one fourth of the author's thirty
cases occurring in Frenchmen. It is transmitted by
spores.
Spinal Anesthesia. — Desplas and P. Millet
[Presse meditalc) state that experience in 550 cases
since August, 191 5, has only served to confirm their
])revious impression that spinal anesthesia is a rapid,
efficient, and safe procedure. They use a ten per
cent, stovaine solution in ampoules; inject at most
0.5 mil of the solution (0.6 mil where the anesthesia
is repeated), introduce the needle between the sec-
ond and third lumbar vertebr?e, mix the solution with
the spinal fluid in the syringe, inject slowly, and ad-
minister a preliminary injection of o.oi gram of
morphine. Some have held that spinal anesthesia
entails greater immediate danger than general anes-
thesia, and may induce late complications involving
the Cauda equina. The authors, however, had no
deaths from spinal anesthesia on the operating table,
nor any serious aftereffects. Headache almost al-
ways yielded readily to pyramidon or aspirin, and
bladder paresis, in the exceptional cases where it
was present, to suprapubic hot compresses. In the
severely wounded, the authors are convinced that
spinal anesthesia gives better results and greater
safety than general anesthesia. Chemical tests
showed the stovaine already largely eliminated at
the second hour after the injection, and completely
in eight hours. Blood pressure estimations in forty
cases showed a fall of pressure only in three, or 7.5
per cent. Of ten cases in which the pressure was
studied every four hours for one day after the oper-
ation, none showed any pressure cjisturbance. In
those gravely injured, shock already present ran its
course without being influenced hy the anesthesia.
The reputation credited to spinal anesthesia of in-
creasing shock is not justified.
Should the Sphincter Muscles Be Divided? —
Rollin H. Barnes (Interstate Medical Journal, Jan-
uary, 1918) asserts that anatomical study of the
ischiorectal space has convinced him that it is not
only unnecessary but even inadvisable to divide the
sphincters in the surgical treatment of infection in
that space. He maintains that an infection in any
part of the ischiorectal space can be satisfactorily
drained by direct skin incision.
Miscellany from Home and Foreign Journals
The Influence of Menstruation on Acidosis in
Diabetes Mellitus. — George A. Harrop, Jr., and
Herman jNIosenthal {Bulletin of Johns Hopkins
Hospital, July, igiS) report a case of diabetes
mellitus in which menstruation seems to have ex-
erted a marked eft'ect on the condition of the pa-
tient. The case is especially interesting as the
authors, in a search of the literature, were not able
to find any references to the effect that menstruation
may have on acidosis. The patient was a girl eigh-
teen years old who entered the hospital on Septem-
ber 21, 1917, was discharged on November iith, and
died on November 27th. On admission she was suf-
fering from a severe type of diabetes mellitus with
a marked degree of acidosis. The urine could
be made only temporarily sugar free by starva-
tion ; the acid substances in the urine were fairly
high ; the percentage of ammonia nitrogen of the
total urinary nitrogen was above the normal and the
carbon dioxide tension of the alveolar air was low,
in spite of the fact that she was given large amounts
of bicarbonate of soda. Although the patient
was weak, she showed none of the subjective
symptoms accompanying marked acidosis and im-
pending diabetic coma. Every attempt was made
to improve her condition, so that at the end of one
month the acidosis was less, though it was impossible
to increase her carbohydrate tolerance. On the 28th
of October, at the beginning of the menstrual
period, her condition changed completely. There
were marked hyperpnea and twitching of the facial
muscles ; slie was extremely drowsy, and very rest-
less at times, and the carbon dioxide tension of the
alveolar air was twenty mm. The following day
the symptoms were the same. On the third day
she began to improve and when menstruation had
ceased all the symptoms had disappeared. She was
given large doses of bicarbonate of soda by mouth,
rectum, and intravenously, and was subjected to
starvation treatment. During this time the tests
showed no appreciable increase in the degree of
acidosis, though there was a slight rise in the amount
of acid substances and ammonia ; the glycosuria
and the quantity of nitrogen in the urine were both
much increased. The patient left the hospital and
at the next menstrual period the same sequence of
events occurred. Deep coma came on at this time
and the patient died. Harrop and Mosenthal sum
up the case by saying that menstruation was ac-
companied by an increase in acidosis, the symptoms
becoming more marked with each successive men-
strual period, until fatal diabetic coma occurred.
They suggest that possibly diabetic patients should
be closely watched during the menstrual period.
Nervous and Mental Symptoms in Exophthal-
mic Goitre.— Lewellys F. Barker (Journal A. M.
A., August 3, 1918) makes the statement that
nowhere is the intimate interrelationship between
the endocrine glands and the nervous system better
illustrated than in the symptomatology of exoph-
thalmic goitre. Three of the four cardinal svmp-
toms — tachycardia, exophthalmos, and tremor— are
due to abnormal innervations. Many of the symp-
toms now viewed as nonneural may later be found
to have some neural link. It is in the vegetative
nervous system that the greatest deviations from
normal are found and the greatest number of symp-
toms of nervous origin. Among those referable to
the vegetative nervous system are : Von Graefe's
sign, Dalrymple's sign, protrusion of the eyeballs,
epiphora, dry eyes, Loewi's phenomenon, excess or
lack of saliva; asthmatic attacks, dyspnea or
tachypnea ; tachycardia, pulsus irregularis respira-
torius, vasomotor angina, palpitation, transitory
changes in blood pressure, vasomotor skin symp-
toms ; gastrospasm and pylorospasm, hyperacidity,
hypoacidity, spastic constipation, unmotived diar-
rheas and vomiting ; pollakiuria, polyuria, oliguria,
menstrual and lactational disturbances, disturbances
of sexual libido and potentia ; and profuse sweating.
These symptoms are referable to one or the other
of the two divisions of the vegetative nervous sys-
tem, the sympathetic or the autonomic, but it is
remarkable that in a single patient there may be
symptoms due to stimulation of both symptoms
present simultaneously. On the other hand, certain
of the symptoms enumerated are opposites and can
never exist simultaneously. While the greatest
number of nervous manifestations in this disease are
referable to the vegetative nervous system, the pe-
ripheral cerebrospinal neurons may also be affected.
Thus there may be toxic degenerative changes in
both motor and sensory neurons, and palsies of the
several cerebral nerves are not infrequent. Finally,
the neuron systems of the brain and cord may be
affected as manifested especially by various neurotic
and psychotic symptoms. Of the conative, aft'ective,
and cognitive components of the instinctive mechan-
isms it is striking that in exophthalmic goitre the
affective conative processes seem to be involved
much more than the cognitive. The author leans to
the belief that the nervous symptoms arise chiefly
as a result of the indirect effects on the higher
nervous apparatus of an intoxication of the vegeta-
tive nervous system.
Sarcoma of the Uterus Arising from the Endo-
metrium.— Leo Brady (Bulletin of Johns Hop-
kins Hospital, July, 1918) reports the case of a
woman who entered the hospital complaining of
slight uterine bleeding and a small tumor in the left
breast, the latter condition being the one for which
she sought relief. Her history was negative. The
menopause had occurred several years before, but
for the last six months there had been a scant bloody
discharge from the uterus. Frozen section of
uterine curettings showed a typical round cell sar-
coma, so that the uterus, tubes, and ovaries were
removed. The case is interesting in that the sar-
coma arose from the connective tissue of the
endometrium rather than from a malignant degen-
eration of a fibroma, as is usual, and also because it
emphasizes the importance of paying attention to
any menstrual irregularity occurring in women of
the cancer age. No matter how obvious the ap-
parent cause it should be carefully examined into to
make sure that there is no cancer.
Seplembcr 14, lyiS.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
481
The Acetonemic Syndrome in Children. — A.
Remond and R. Poux (Bulletin dc l Academic de
medicine, May 28, 1918 ; deem cyclic vomiting only
a single, separate manifestation of tlie acidosis of
children. The cases of acidosis in which it is ab-
sent are more nvmierous than those in which it is
present. The underlying condition is an essential
functional disturbance of the liver, small intestine,
and pancreas. Passage of the fecal matter from
the small to the large bowel suddenly stops. The
stools consist merely of epithelial debris and mucus,
are colorless and practically odorless, varj- greatly
in frequency and amount, and may later become
blood stained or of the green color of spinach. At
once or within five or six hours, acetone and diacetic
acid begin to appear in the urine, and in a da}' or
two the breath is found to have an acid or stale
odor. The temperature may be markedly subnor-
mal or febrile, and often exhibits a paradoxical
curve. A few of the cases encotmtered manifested
nervous s\Tnptoms suggesting meningitis. Others
simulated beginning typhoid fever or cholera in-
fantum, while still others were first seen in a con-
dition bordering on coma. The treatment applied
consisted regularly of subcutaneous injections of a
total extract of fresh pancreas and of sodium bicar-
bonate in large doses. In one particularly grave
case a one per cent, alkaline solution was adminis-
tered intravenouslv. In the remainder, from
twenty to sixty grams of bicarbonate a day were
given by mouth as well as by continuous rectal in-
stallation. Temperature, ner\-ous condition, stools,
and urine returned to normal in a few days. Ace-
tonemia through pancreatic insufficiency plays, as
shown by cases previously wrongly diagnosed and
treated unsuccessfully by other measures, a far more
frequent role in children's diseases than has hith-
erto been thought. In all intestinal or nervous af-
fections in children, an acetone diagnosis should be
promptly made. The condition being recurrent,
prophylactic measures should be instituted, such as
elimination of cooked fatty articles from the diet,
as well as of excess of meats, and the systematic
ingestion of alkaline waters. The \'ichy treatment
seemed highlv efficacious.
Significance of Cardiac Murmurs. — Claude
Wilson (British Medical Journcl, June 22, 1918)
says that not very long ago practically all cardiac
murmurs were regarded as evidences of serious
trouble, but that, especiallv since the beginning of
the war, murmurs have become rather generally
suspected as to their significance. He discusses
various physiological or functional murmurs, citing
illustrative cases to show their want of serious sig-
nificance. Even systolic murmurs of endocarditic
origin may be of relatively slight significance when
there has been little or no associated damage to the
myocardium, but the determination of the true im-
portance of such murmurs earlv in their develop-
ment is not easy and prognosis must therefore be
guarded at first. Their association with other mur-
murs, with pericarditis, myocarditis, and with vege-
tations naturally imparts a serious import to their
discovery. The occurrence of auricu'ar fibrillation
alone with such murmurs adds gravity to their
significance. In all cases in which systolic murmurs
are found a careful general survey must be made
and no heart is to be condemned upon a solitary
sign. The point is emphasized that murmurs which
occur during the period of ventricular diastole are
always of graver significance than those occurring
in systole, all being indicative of serious disease.
Thus it may be stated as a generahzation that
systolic murmurs are often negligible while diastolic
ones are seldom so, if ever. Mitral and tricuspid
systolic murmurs are often physiological though
due to an actual regurgitation of blood. The reason
for their being of relatively little import, even when
the regurgitation is considerable, Hes in the im-
mediate filling of the auricles from the overdis-
tended veins through relaxation and dilatation, for-
ward pressure in the veins, and aspiration by virtue
of reduction in the intrathoracic pressure. A fur-
ther reason, when the murmur is mitral, lies in the
fact that the nutrition of the heart is unimpared.
Aortic systolic murmurs alone are of relativelv
shght importance because the slight narrowing of
the orifice can be readily compensated by slight
hypertrophy and because the stenosis does not in-
terfere with cardiac nutrition. When the stenosis
is m.ore than slight the adhesion and thickening of
the cusps leads to regurgitation. . The grave import
of diastolic murmurs such as those of mitral sten-
osis and aortic insufficiency is because of the fact
that they are due to conditions which materially
hamper the mechanical action of the heart and be-
cause they impair the circulation through the cor-
onaries and hence interfere with the nutrition of
the myocardium.
Successive Transplantation of Thyroid Tissue
into the Same Host — Cora Hesselberg and Leo
Loeb { Journal of Medical Research, March, 1918)
dunng the past four years have carried on a series
of experiments in which a lobe of thyroid of one
guineapig was transplanted into a subcutaneous
pocket of another, and usually nine to eleven davs
after this first transplantation' a second lobe from' a
third guineapig was transplanted subcutaneously
mto another part of the first guineapig. In some
cases the second lobe of thyroid from the third
guineapig was transplanted into a control guinea-
pig, which had not pre^^ously received a first lobe
ot thyroid. The hTnphoc}-tic reaction in and around
the homeotransplants of thyroid tissue seems to de-
pend upon the condition of the host and the im-
planted tissue, while the factor of time has some
efi'ect on the reaction. The lymphoc}tic reaction is
not prevented by such conditions as pregnancy, loss
of v.-eight, dying state, or a greater age of the ani-
mal. It ma}- be modified by a change in either host
or transplant, and the authors hope through suc-
cessive homeotransplantations to determine the
significance of these factors. The transplanted
thyroid shows such variations from the normal
structure of the thyroid as the development of solid
strands from acini, connective tissue growth into
and destruction of acini, and cells phagoc}-ting col-
loid. It was noticed that if fat tissue is transplanted
\y\th the thyroid the part of the transplanted acini
adjoining the fat usually becomes necrotic. In dis-
cussing the conclusions deduced from their work
the authors state that while there is some re-
482
MISCELLANY PROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
semblance between the lymphocytic infiltration
brougiit about by certain tumors and the homeo-
transplanted thyroid tissue, yet the second homeo-
transplant and the second transplantation of tumor
are different in their reaction, since an acceleration
of the l}mphoid infiltration could not be definitely
established in the case of the second homeotrans-
plantation of the thyroid. In some cases the
lymphocytic reaction was stronger about the second
than about the first transplant, so they believe it
may be possible that immune homeotoxins play
some part in the production of the lymphocytic re-
action.
Action of Adrenalin on Gastric Motility. —
Pron [Pressc medicalc, June 10, 1918) reports good
results in dyspeptics with gastric atony by prescrib-
ing eight to ten drops of one in one thousand ad-
renalin solution one hour before each of the two
main meals, lunch and dinner. The results con-
sisted in a diminution or disappearance of post-
prandial discomfort or sensation of weight, a dim-
inution of splashing sounds, and cessation of pain.
The Retina in Hemeralopia. — Magitot {Paris
medical, May 11, 1918) states that the power of
adp.ptation of the eyes to a reduction of light de-
pends closely upon the state of nutrition of the pig-
mented epithelium of the retina, which in turn
nourishes the rods and cones. Hemeralopia is not
due to a single cause, but to many. Sclerosis of
the choroidal capillaries, e. g., may produce it by
reducing nutrition of the pigmented epithelium,
and toxic material in the blood, by poisoning the
epithelium and arresting the secretion of visual
purple. Lavron has reported that in a certain dis-
trict of Russia eighty per cent, of all adult males
are afflicted with night blindness, due to poor food
and excessive physical labor. Hemeralopia may occur
with or without ophthalmoscopically visible lesions
of the retina. It is constant in retinitis punctata and
in detachment of the retina. It is especially impor-
tant in certain frequent syphilitic conditions, such as
retinitis or chorioretinitis pigmentosa, which may be
ascribed to parasitic thrombosis of the nutrient cap-
illaries. Hemeralopia unaccompanied by visible
lesions may be due to various causes. One variety is
the so called essential hemeralopia. congenital and
often inherited. In old men partial hemeralopia is
due to retinal capillary sclerosis; premature senes-
ence particularly in alcoholics, produces the same
result. Powerful electric shocks cause hemeralopia
by arresting the secretion of visual purple and qui-
nine, either by direct toxic action or spasm of the
capillaries. Certain nephritic and hepatic affections
are also toxic causes of it. Among soldiers it is
rather frequent. Some of these cases have had a
relative hemeralopia in civil life, due to myopia and
thinning of the choroid, the condition being then
aggravated by hard trench life, a diet almost ex-
cursively of meat, and attacks of enteritis. Chronic
alcoholism has proven an important factor, acting in
conjunction with fatigue and lack of sleep, generally
in men between the ages of thirty-five and forty-five.
Rest in bed, a milk diet, and diuretics, followed by a
meatless diet, soon improve bona fide cases. Maling-
erers can be detected by inquiry among their com-
rades in arms.
Heat Stroke.— Pierce McKenzie and E. R. Le
Count {Journal A. M. A., July 27, 1918) have in-
vestigated several of the problems of heat stroke
and find that the condition is most common in the
river valleys and the lowlands of the Mississippi
and the eastern and souther coast states. Excessive
humidity combined with high temperature are
chiefly responsible both for insolation and simple
heat stroke. Causes of less importance are
heavy and tight clothing, and the consumption of
too little water. From post mortem examination of
the bodies of thirty-seven persons who died of heat
stroke the following were found to be the common
changes : Edema of brain, leptomeninges, or both ;
marked general passive hyperemia, especially of the
brain and lungs; edema of the lungs; hyperplasia
of the spleen ; cloudy swelling of the liver, kidneys,
and myocardium ; and petechial hemorrhages in the
mucous membranes and skin, with irregular and
lessened yellow material in the suprarenal cortex.
The spinal fluid was clear and colorless in all the
cases and usually increased in amount. Actual de-
termination of the water content of sections from
the brains of a number of the cases showed that in
practically every instance this was appreciably above
the normal. The prophylaxis and treatment of heat
stroke should include a diet largely of carbohy-
drates, of low caloric value and low protein and fat
content ; the wearing of loose, Hght clothing, pro-
tection of the head from the sun ; abstinence from
alcohol ; avoidance of extreme muscular exertion
when the air is hot and humid ; and especially the
drinking of large amounts of water, up to three
gallons daily for a man working in the hot sun.
In treatment, in addition to the use of cardiac
stimulants and the application of cold baths or ice
packs, the rectal or intravenous administration of
a solution of sodium chloride and sodium bicarbo-
nate seems of value. Where coma has lasted for
several days lumbar ])uncture is sometimes bene-
ficial.
Traumatic Neurosis. — Walter F. Schaller
( Journal A. M. A., August 3, 1918) from a careful
investigation of the literature of this subject, and a
painstaking study of a series of civil cases, suffi-
ciently long after the accident to determine the final
outcome, concludes that traumatic neurosis is cur-
able but that many factors influence the prognosis.
Of the psychic factors, that of compensation is one
of the most important and recovery is more rapid
after the final settlement or following an early lump
sum payment than under the periodic payment plan.
Influences which also favor recovery include favor-
able environment for the patient, the absence of un-
favorable suggestion; the absence of a fixed belief
on the patient's part that he has been seriously and
permanently injured or has received improper treat-
ment ; the absence of organic disfigurement or de-
fect ; the presence of a cheerful frame of mind ; and
the occurrence of predominantly neurasthenic,
rather than hysterical symptoms. The nature of the
original injury seems of little significance so far as
recovery is concerned. These observations are of
importance in guiding us in the handling of the
cases of war traumatic neurosis and they should be
borne in mind in treating military patients.
Proceedings of National and Local Societies
ASSOCIATION OF AMERICAN
PHYSICIANS.
The President, Dr. F. H. Williams, of Boston, in the
Chair.
Thirty-third Annual Meeting. Held in Atlantic City,
N. J., May 7 and 8, 19 18.
{Continued from page 443-) '
The Relation of War Wounds to Acute Endo-
carditis.— Dr. H. T. Karsner, of Cleveland, re-
ported that the incidence of acute endocarditis
following wounds of the war justified calling at-
tention to its bearing on pathology, clinical medi-
cine, and surgery. In France, during the early
months the surgery was much as is seen in civil life
and the great contamination of war wounds was
not sufificently considered. In eight months' ex-
perience Doctor Karsner said he performed autop-
sies on all deaths, eighty-eight in number, occur-
ring in a military hospital. At first they were handi-
capped by lack of laboratory facilities, but later
exact measurements were taken of the weight of
organs. Fourteen of the eighty-eight showed le-
sions of acute endocarditis following septicemia
and pyemia. The organisms responsible were
mostly streptococci. Three showed staphylococcus
aureus. In one case the perfringens was found
in the blood stream at death. These infections fol-
lowed multiple extensive wounds, not of any par-
ticular type, where an attempt was made to save
the injured parts and where the wound was al-
lowed to drain pus for weeks. In the effort to save
the joint, extensive damage was done to the heart
and kidneys. In the later months of the war, an
effort was made to determine whether the age of
the soldier and the length of his term of service
had any influence on these conditions. It was
found that if the man was less than twenty-seven
years of age and had less than twenty-two months
service, the kidney weight and the heart weight
was normal. The principal factor was the length
of service, prolonged service leading to a great in-
crease in the weight of the heart.
Dr. W. W. Ford, of Baltimore, stated that in
experimental work with the gas bacillus there was
a failure of the organism to multiply in the blood
stream but if one introduced a young culture into
rabbits or guineapigs the animals died. Rapid
multiplication of the organism was found at the
site of inoculation. Smears of the blood of heart,
liver, or kidneys showed a Gram positive, encap-
sulated organism, or the gas bacillus. No multi-
plication was found in the blood stream. The or-
ganism was anaerobic and multiplied at the site of
inoculation.
Trench Fever. — Dr. Eugene L. Opie, of St.
Louis, gave the result of his studies by himself and
Doctor Strong, Doctor Swift, Doctor MacNeal, and
Doctor Pappenheimer. From the beginning of the
Avar, in 1914, and more in 191 5, there had appeared
outbreaks of an ill defined fever, observed first by
Graham, and named trench fever. Studies on the
infectivity of the disease were convincing, and it
was proved capable of transmission to human be-
ings. The disease was characterized by sudden
onset, inability to continue work, and paroxysms of
fever. It was thought at first to be a modified form
of typhoid in inoculated men. Pains in the limbs
and skin spots occurred with the fever. The spleen
became palpable and there were marked vascular
disturbances. The disease might last for several
weeks or months. Sincef it was thought that the
disease was transmitted by lice, experiments were
made by allowing lice which had bitten trench
fever patients to bite healthy persons. The role
of lice had been the subject of much discussion,
and no steps had been taken by the British
authorities to effect their extermination. Major
Strong therefore obtained Red Cross funds for an
investigation, and volunteers, from the American
Expeditionary Force, offered themselves for exper-
imental purposes. The volunteers were subjected
to careful physical examination and charts were
kept for a week preceding the experiment. Care-
ful studies of the urine and feces were made, to
exclude possibility of typhoid. Two problems were
studied : First, infectivity of the blood, and sec-
ond, transmission of the disease by hce. Of six-
teen men inocvilated with infected whole blood,
fifteen developed trench fever. Of five inoculated
with clear plasma, all contracted the disease. The
corpuscles of the blood, then, did carry the infection.
Inoculations of plasma, passed through a Berk-
feldt filter, did not cause infection, i. e., filtered
virus, did not produce the disease. The inocula-
tion period was from five to twenty days. The dis-
ease was transmitted through three generations
subsequent to the first inoculation. The second
problem was to determine whether lice transmitted
the disease. Of twenty-two volunteers, bitten by
infected lice, fourteen developed the disease ; eight
volunteers, not bitten, did not develop the fever.
Lice from trench fever patients were put upon the
volunteers and kept there thirty days till the fever
developed. After forty-eight hours lice were re-
moved from half of the volunteers, and put on other
volunteers, to exclude possibility of mechanical
transmission, directly from patient to individual. It
was proved that the virus carried the infection.
The lice were put on the arm in a piece of old
undershirt, so that eggs and larvae were repro-
duced normally, and these were strapped on and
the men were allowed to scratch so that normal
skin irritation was produced. The inoculation pe-
riod after biting was nineteen to twenty-five days as
compared with five to six days with the plasma in-
fection. The conclusions from these experiments
were that first, direct transmission was not essential ;
secondly, if lice carried the disease, measures
should be taken to eradicate the lice, a not imprac-
ticable procedure. In connection with this paper.
Dr. Thomas B. Futcher, of Baltimore, told how he
had had an opportunity of seeing cases of trench
fever in an English base hospital. Distressing noc-
turnal pain was a symptom of the disease. Sir
David Bruce had conducted some experiments in
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
the Hanipstead hospital. He found that if h!ce that
had bitten trench fever patients were allowed to
bite volunteers, the results were negative as far as
transmission of the disease was concerned. It was
not stated how long the lice had fed on trench
fever patients. In discussing these experiments it
was asked if the patients had been allowed to
scratch and it was found that they were prevented
from scratching. Another series of experiments
were then started. The arms of the volunteers
were scarified. The lice were allowed to bite and
the bodies of the lice were rubbed into the abraded
surface. In seven days the volunteers developed
trench fever.
Dr. E. L. Opie, in conclusion, said that he had
not tried scarification experiments. It seemed to
add little to the knowledge obtained by injecting
whole blood, but there was obviously possibility of
introducing the virus directly through the skin.
The incubation period of seven days corresponded
to that when whole blood was injected into the
circulation.
Pneumonia in the Army Camps. — Dr. Rufus
Cole, of New York, gave his experience in one
army camp where Doctor MacCallum had charge
of the pathological work. Pneumonia among
soldiers was a most serious disease. Previous ex-
perience on the Mexican border had convinced the
authorities of the seriousness of the condition. The
past winter had shown alarming increase of pneu-
monia and a high incidence of measles. In study-
ing types of pneumococci, many abnormal types
were encountered. At Camps Wheeler and
Bowie Doctor Zinsser and Doctor Dochez found
that many cases were due to streptococci. Under
the direction of Colonel Russell, a study was then
made of all types of pneumonia. Two definite
types were discovered. The first type occurred in
the measles ward, where there were many cases of
severe pulmonary infection. These were similar to
cases seen by the pediatrician and not usually seen
in adults. The patients were mentally alert and
extremely anxious. There was intense respiratory
disturbance and deep cyanosis. The physical signs
differed greatly from lobar pneumonia, there being
few signs of consolidation. In cases which came to
autopsy Doctor MacCallum found small hemor-
rhagic spots on the lungs. The alveoli were con-
gested and contained blood. The later lesions
showed small punctate areas with opaque forms
resembling miliary tubercles. Purulent exudate
was found in the bronchioles. This pneumonia
following measles was often mistaken for miliary
tuberculosis. Streptococci were found in the
sputum of these patients, and shortly before death
in the blood stream. The second type of the dis-
ease, in the pneumonia wards, resembled the cases
seen in civil life. These cases had pneumococcus
infection and the mortality was lower. There
was increased prevalence of empyema. Often
there was double infection. At autopsy both
streptococci and pneumococci w^ere found. Three
types were distinguished at autopsy : Acute pneu-
monia, of the ordinary type ; bronchial interstitial
pneumonia, due to streptococci, and interstitial
bronchopneumonia. In other camps there had
been cases of streptococcic empyema without pre-
vious involvement. It was of the utmost impor-
tance to know if infection* spread from one man
to another, or if there was a common cause. It
was known that puerperal infection, wound in-
fection, and septic sore throat spread by direct
transference. Epidemiological evidence showed
that the latter infection followed the milk routes,
but direct transmission could not be excluded. In
rfce camp wards direct transmission evidently took
place, as in fifty-five per cent, of throats strep-
tococci were present. In the measles ward on ad-
mission eleven per cent, of patients showed strep-
tococci in the throat ; after ten days this rose to
thirty-eight per cent. ; in two weeks to sixty per cent.
The question now arose as to whether this form of
infection was spreading into civil life and whether
the streptococci were becoming more virulent to
man, so that more normal persons were becoming
infected.
The Serum Treatment of Lobar Pneumonia. —
Major C. N. B. Camac, M. R. C, presented this
subject. A marked difference existed in the pul-
monary involvement in measles and in lobar pneu-
monia. Four hundred cases of measles were studied
in hospital No. 6. There were forty-three pulmo-
narv complications with twefve deaths. One
marked condition was a serositis, the lung appear-
ing like a sponge dipped into blood. The term
pneumonia could hardly be used for the pulmo-
nary^ complication of measles. Colored troops were
especially susceptible to this form. In serum treat-
ment a desensitizing dose was first given. Six
hours later fifty c. c. of serum were gradually given,
by a holder, a syringe not being allowed. Only
one case of anaphylaxis occurred. The cHnical
features of this treatment were: Marked variations
in temperature ; rapid recovery ; absence of toxic
syrnptoms. It was not found advisable to wait for
tile return of the type of infection, a polyvalent
serum was used at once, and if type I were re-
turned, type I serum was used later. The mor-
tality was much higher in the streptococcus in-
fection cases. It was found that the fatal cases
were those that came to treatment late. These
men were stevedores, husky men who did not
easily complain. Therefore an important point
was early diagnosis, with immediate use of serum.
If cases did not respond to one type of serum, they
were cjuickly changed to another. The pneu-
mococcus infection was comparatively harmless
compared with streptococcus infection. The leu-
cocytes were not a reliable guide as to the con-
dition. An immunizing streptococcus vaccine might
be tried at the same time as the serum treatment.
The patients should receive 2,000 calories of food
and 3,000 c. c. of water daily.
Major E. P. Jocelin. M. R. C. remarked that
the increased number of cases at Camp Devens
was due to the arrival of 5,000 negroes in the
camp. The morbidity for the negroes was twenty
per cent, higher than that for white troops. Hemo-
lytic streptococci were prevalent among the officers.
Seventy-one per cent, of the officers and sixty-two
per cent, of the nurses showed positive throat cul-
tures of this organism. The question arose whether
September 14, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
485
to protect the patients against the officers or the
officers against the patients. During April, sixty-six
negroes came into hospital with pneumonia; the
mortality of fourteen per cent, rose later to twenty-
five per cent. T^re were no fatal cases of type I
pneumonia. Jn llll negroes that came to autopsy
lobar pneumonia was found.
Major H. Brooks, M. R. C, said that when
he heard colored troops were going to Camp Devens,
he had remarked that trouble was coming to Major
Jocehn in the shape of a black cloud. One colored
regiment had furnished more patients than seventy-
seven white divisions.
Dr. Augustus Wadsworth, of the N. Y. State
Health Department, told how he had studied the
effect of different organisms in conjunction with
the pneumococcus, experimentally, in the rabbit
and dog. There was a difference in the progress
of the lesion induced by pneumococci and that by
streptococci. The induction of a true exudative
type of lesion followed by complete recovery in the
lung tissue and complete disappearance of the or-
ganism was seen in the former case. Following the
introduction of large numbers of pneumococci and
streptococci, in many instances, there was con-
siderable destruction of tissue.
Major W. W. Herrick said that they had had
hundreds of cases of streptococcus pneumonia fol-
lowing measles at Camp Jackson. They found that
patients with measles were extremely susceptible to
cold. It was best to keep these cases at an even
temperature with beds carefully screened. The
cough must be thoroughly controlled, and, under
these conditions, a vtry much lower percentage of
streptococcus pneumonia followed.
Dr. Rt'fus Cole, in conclusion, said that the
streptococcus form of the disease was spreading to
the civil population. There were probably many
types of hemolytic streptococci, but at the present
time differentiation was impossible. There was no
doubt of the significance of the studies made at
Camp San Antonio. Whether the men were becom-
ing more susceptible to the disease was not known.
Major C. N. B. Camac remarked that if di-
chloramine-iE" was used for a throat spray there were
very few pulmonary complications. The process of
infection seemed to be from above down and seemed
to run like wild fire through the respiratory passages.
If it could be controlled in the throat, it did not
spread downwards.
Antiscorbutics and Intravenous Therapy for
Scurvy. — Dr. Alfred F. Hess, of New York, em-
phasized the necessity of antiscorbutics in any diet.
In ships, in the days of sailing vessels and prolonged
voyages, there were always cases of scurvy. The
civil population was also dependent upon antiscor-
butics in the food, and it was not always realized
how narrow the margin of safety was. In Ireland,
when the potato crop failed, scurvy at once appeared.
From the military point of view antiscorbutics were
important. In Russia, during the war, there had
been thousands of scurvy cases. In France, in one
sector, of i,ooo men, 850 had the disease. If the
war kept on this might assume serious aspects, and
it was necessary to consider what foods were anti-
scorbutic. Experiments showed that dried vege-
tables soon lost antiscorbutic properties. Orange
juice, if preserved, also lost this property. Orange
peel, which was a waste product, seemed to have
the property of staying antiscorbutic in action. Its
use in asylums where the price of oranges made their
use prohibitive, would be an economic measure. It
was found also that boiled orange juice, given in
intravenous injection, acted hke a charm in scurvy.
Scurvy could be absolutely controlled by giving
heated' and neutralized orange juice intravenously,
on a large scale.
Thyroid Hormone in Relation to Metabolism.
• — -Mr. E. C. Kendall reported that a definite chem-
ical substance had been isolated from the thyroid
gland, containing six per cent, of iodine. This was
found to have a marked effect on cretinism and
myxedema. The substance existed in two forms, an
amino group and an acetyl one, which bore to each
other the same relation as creatine did to creatinine.
In the myxedematous patient the metabolism was
forty per cent, below normal and could be increased
to normal by the injection of this hormone. The
iodine content of the hormone did not enter into its
action, but merely increased the reaction of the
functioning groups.
Unusual Types of Diarrhea. — Dr. T. R.
Brown stated that the mechanism of normal peri-
stalsis was easily disturbed. Vasomotor abnormali-
ties, abnormal substances, psychic stimuli, etc., were
all causes of diarrhea. Diarrheas were of many
kinds — gastroenterogenous, achylic, of Graves's dis-
ease, of tabes, of sprue, of cholecystitis. In the
thyrogenous diarrhea the nervous syndrome was the
cause. In the diarrhea after cholecystectomy the
stools showed absence of trypsin and diastase.
These diarrheas were pancreatogenous in origin, but
gastric diarrheas were not. In tabes there was the
true neurogenic type. In sprue there was no trypsin
or diastase in the stools ; pancreatin could be given
with good result. In appendicitis and colitis there
were probably erosions of the mucosa, due to bac-
terial infection. Open drainage for three months
would cure these cases by changing the bacteria of
the lower valve from anaerobic to aerobic.
Chronic Septicemic Endocarditis and Spleno-
megaly.— Dr. David Riesman, of Philadelphia,
pointed out in his paper that patients with this dis-
ease might become bacteria free and yet succumb.
The symptoms often included anemia, joint pains,
albuminuria, nephritis, abdominal pain, and heart
murmur. The spleen was always enlarged and ob-
scured the underlying heart effect. The disease
might be mistaken for splenic anemia. The accumu-
lation of bacteria in the spleen often prevented the
cure of the disease. If this focus could be con-
trolled, the heart lesion might be improved. In the
case of a man fifty-seven years of age, in whom
Doctor Deaver removed the spleen, the condition
cleared up after operation.
The General Theory of Clinical Diagnosis,
with Special Reference to the Application of a
Key Principle to Major Groups of Mental Dis-
ease.— Dr. E. E. Southard, of Boston, said that
books on medical logic were dust covered, ,or even
remained with pages uncut. The question of
"what is diagnosis" was rarely considered. There
486
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
were various methods of diagnosis and different
factors such as inspection, and type matching
formed part of these methods. Other forms, such
as diagnosis by exclusion, were used, and the form
called "ex javantibus" which was to treat the
patient for syphilis, and if he got well to say that
he had syphilis, was often in use. In mental dis-
ease type matching was impossible as any symp-
toms of mental disease would match all forms of
mental disease, in other words, there was no in-
dicator. In regard to exclusion, every mental case
deserved to be tested for syphilis. This should be
excluded if possible. In most mental diseases' there
was no difference in treatment, and therefore there
was not much use in differentiating the disease.
About fifteen per cent, of mental disease was due
to syphilis. Some sort of pragmatical scheme for
orderly arrangement in diagnosis should be fol-
lowed, first observation, then comparison, then ex-
clusion, then addition of statistical data. This
method was largely neglected in the text books and
even in class A schools.
Dr. Lewellys F. Barker, of Baltimore, hke Doc-
tor Southard, urged a pragmatical method. It was
necessary to work from the pragmatical standpoint.
There was only one real diagnosis, the one which
considered the patient as a whole. The somatic,
psychic, and all other systems must be considered.
The steps in diagnosis were briefly : Feeling of a
difficulty; suspension of judgment until evidence
was collected ; making of an anamnesis ; laboratory
tests; X ray tests. All this should be done before
thinking of the diagnosis. The whole man should
be studied, and then the data arranged in order to
stimulate suggestion. The different systems should
be next considered, cardiovascular, nervous, ali-
mentary, etc. The mind could now range over
facts and leap to certain conclusions in which pro-
cess, experience and intuition would play a large
part. Then by process of deduction and reasoning
the diagnosis could be made.
Clinical Types of Paralysis. — Dr. J. Ramsay
Hunt, of New York, said that paralysis agitans
was one of the types of paralysis due to effect on
the corpus striatum. Associated movements were
due to effects on the striospinal system, and dis-
sociated movements to the cortical system. In
normal individuals these systems worked together,
in pathological conditions they became dissociated.
Paralysis represented this phase. There were two
types of movement : in the cortical type clonus was
present, in paralysis agitans it was absent. Often
the two types were combined owing to tke juxta-
position of the corpus striatum to the internal
capsule. Recognition of the two types of paralysis
would help in diagnosis.
Certain Phases of Hypertension. — -Dr. E. S.
Smith, of Boston, read this paper. To avoid
brain disaster, hypertension must be controlled.
Factors entering into normal circulation were the
peripheral resistance of the vessels, the propulsion
of the blood through the arteries, and the vaso-
motor control. Hypertension was often caused by
accumulation of toxic end products of bacterial pro-
teins. If it persisted it caused strain on the heart
and cardiac fibres. The cases where arterioscler-
osis had resulted from hypertension were different
from the luetic type. In regard to treatment, at-
tention was paid to focal infection, absolute rest
was ordered, and the protein intake of the diet was
limited. Digitalis was given, b^ no vasodilators,
unless in extreme emergency.
Function of the Thyroid Gland.— Dr. H. S.
Plummer, of Rochester, Minn., said that the pro-
ducts of the thyroid were thyroxin, a hormone, and
colloid. The latter did not play any part in general
functioning. Hypertrophy was an indication that
the thyroid was over stimulated and was supplying
the body with too much hormone. Colloid de-
posit in the glaa^ showed it was hard worked to
make enough hormone. It was either normal or
subnormal. The thyroid contained fetal rests and
thyroid adenomata developed post natally and
were not coordinated with the needs of the body
tissues. Increased metabolism would stimulate
these adenomata to erratic functioning. If the
adenomata were removed from the thyroid the
metabolism would at once drop to normal. These
cases constituted one third of exophthalmic goitres.
x\ metabolic laboratory had been begun to carry
out this work. Twenty-five cases of exophthalmic
goitre were examined and it was found that the
m.etabolism was running one per cent, above normal.
Removal of the adenomata caused the metabolism
to drop to normal ten days from operation.
COLLEGE OF PHYSICIANS OF
PHILADELPHIA,
Section on Industrial Medicine and Public
Health.
Meeting Held Wednesday, May 15, ipi8.
Dr. James M. Anders, Head of Section, in the Chair.
At this meeting Dr. A. J. Lanza, U. S., P. H. S..
Pittsburgh, Pa., read a paper on the hazards of
metal mining, which was later the topic of a dis-
cussion. Metal mining in contradistinction to coal
mining had always been recognized as hazardous to
health. Moreover, metal mining had contributed to
medical science an occupation disease of the first
magnitude, the so called miners' consumption, not
confined, however, to the miner. Miners' consump-
tion, silicosis, was a pneumoconiosis caused by the
inhalation of siliceous dust. It was among hard rock
miners, however, that it had become the scourge of
mining camps. Hippocrates spoke of the metal dig-
ger who breathes with difficulty and is of pale com-
plexion. From twenty to thirty-five per cent, of
hard rock miners were affected, a condition taking
precedence over any other occupational disease. In-
dividual susceptibility played little part. The
amount of silica in the dust, the duration of ex-
posure and the intensity of work were the determin-
ing factors. The cardinal symptoms of silicosis
were dyspnea on exertion and pain in the chest as-
sociated with diminished expansion. The dyspnea
appeared insidiously in from two to ten years and
grew gradually worse until total disability might re-
sult. It might be the only symptom. Pain in the
chest became definitely located and there was gen-
September 14, i9i8.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
487
erally a bronchitis with cough ; in some cases cough
was not present. Loss of weight was not as great as
in tuberculosis. Aside from their dyspnea the pa-
tients felt and looked well ; they had no fever or
night sweats ; hemorrhage was occasionally present.
Physical examination showed little except in ad-
vanced cases. At any stage of a silicosis, tuber-
culous infection might occur and this disease usu-
ally ran a fairly rapid course. In Joplin, where the
type of silicosis had been very severe, tubercle ba-
cilli practically always appeared in the sputum
before death. In Butte, where the silicosis was not
of such an aggravated type, tubercle infection was
not so frequent. The prognosis was bad after sili-
cosis had been once well established and when
tuberculous infection had occurred the prognosis
was usually hopeless. An outdoor life seemed to
afford the only chance for recovery in early cases.
In the pathology of the disease there was first a
peribronchial thickening, followed by small nodular
fibrous areas tending to coalesce in dense fibrous
areas which might undergo anemic necrosis. The
relation of the tubercle bacillus to this process was
not clear. Inability to obtain necropsies prevented
study of this feature. It had been shown that dust
particles lodging in the lungs were not larger than
from two to five microns and even smaller. The
prevention of the disease lay in the use of water in
drilling, a matter not always as simple as it would
appear to be. It was evident from the small size
of the dust particles that the use of respirators was
futile.
Dr. Henry K. Panco.ast said that he had had the
privilege of interpreting for Doctor Lanza about
fifty pairs of stereoscopic plates made among the
hard rock miners at Butte, Montana. A great simi-
larity was noted in the appearance of these plates
and those made in connection with the investiga-
tions of Doctor Landis, Doctor Miller and Doc-
tor Smyth and himself in dusty occupations in
this part of the country. The rontgen ray
was the most accurate method of determining
the condition of the lung in the living sub-
ject. Authorities were practically agreed upon
the interpretation of the x ray plates in pneumocon-
iosis. Three stages of the disease had been found.
In the first the appearance was that of an enlarge-
ment of the hilus shadow and an increase in the
thickness of the linear markings. The age of the
patient and place of residence had to be considered :
those living in large cities were apt to have more
or less evidence of pneumoconiosis with advance in
years. In the second stage there was mottling in
the parenchyma of the lung due to small deposits
of dust and an associated circumscribed fibrosis.
These spots gradually enlarged and finally coalesced.
In the third stage there was a diffuse fibrosis which
picked out certain portions of the lungs and seemed
to originate fron^a coalescence of the small areas
just mentioned. There seemed to be certain an-
atomical distributions for the mottling and the dif-
fuse fibrosis and the findings in this connection had
been fairly uniform, both in Doctor Lanza's plates
and in his own. In the appearance of the second
stage the mottling began especially around the root
of the lung and in most cases there was greater
progress on the right side. Then the mottling
spread around the lung from base to apex. In the
plates examined for Doctor Lanza the most intense
mottling was a little above the centre of the lung
from the second to the fourth interspace, and in
this region most of the diffuse fibrosis was to be
seen in the older cases. In some of the more ad-
vanced second stage cases it was often most difficult
to find very marked enlargement of the hilus shadow
or thickening of the bronchial trunk shadows. This
was true also of the third stage cases. It seems as
though some of the cases progressed rapidly in the
second stage, while others remained in the first stage
for a long period of time. Fluoroscopic examinations
were always valuable in this study and explained
in large measure the difficult breathing. In some in-
stances the diaphragm seemed not to move owing
to the fibrosed condition of the lungs, particularly
in a line with the linear trunk shadows running to
the bases. The real cause was, no doubt, an in-
ability of the lung to expand. In some cases the
inner portion of the diaphragm was fixed, whereas
the outer portion moved to a certain extent and
seemed to be hinged at the point of contact of the
linear trunk shadows.
Dr. H. R. jM. Landis remarked that the cases
studied by Doctor Lanza in Joplin, presented the
most serious cases of silicosis, even outranking
those of South Africa. The x rays had done much
in discriminating between dusts entirely harmless
in the sense of producing no definite pathological
changes in the lungs, and those causing serious and
crippling lesions. They dift'erentiated the effects
produced by the organic and the inorganic dusts.
At one end of the scale was pure silicosis, which
of itself and entirely aside from any secondary
tuberculous lesion, was sufficient to cause absolute
incapacity. There were other forms of inorganic
dust, however, exposure to which did not prevent
workers from being able to follow their trade for
forty to sixty years. In one instance a potter who
had been apprenticed when a boy of ten had worked
at the trade until he was seventy. One slide ex-
hibited by Doctor Pancost showed the lungs of a
man who had been working in a coal mine for
thirty-two years and another had worked outside
on a breaker' for thirty-eight years: While there
was much dust in the work on the breaker, being
outside, there was not the same concentration as
in the mine. In the case of the man working out-
side for thirty-eight years there was probably not
one quarter of the pulmonary change as shown in
the man working for thirty-two years underground.
The only explanation of the susceptibihty to tuber- ,
culosis of the cases studied at Joplin was that the
condition was so very acute. There was no means
of knowing whether the great irritation produced
an acute inflammatory change rendering the tissues
,more susceptible to the tubercle bacillus. As Doc-
tor Pancoast had said, physical signs were absent
or extremely indefinite in the first stage. In the
advanced stage abiHty to elicit marked physical
signs was of no particular moment so far as the
patient was concerned, as the damage had already
been effected.
Dr. Alfred Stengel spoke on the subject of man-
488
COLLECTANEA.— BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
agcment of industries under war conditions. There
had been excessive speeding up of industries with
an associated degree of carelessness excused on the
ground of war conditions. We had sooner or later
to take cognizance of this prevailing form of ex-
cuse. Fortunately the Government through various
agencies was taking up the regulation of industries.
The new industrial poisons, suddenly let loose, and
concerning which there had been until very recently
the most inadequate knowledge, had occasioned
many cases of illness and perhaps a considerable
number of deaths. Physicians, apart from the few
who happened to have special knowledge of in-
dustrial medicine, were familiar with even the
scanty literature which existed upon this subject.
Cases of apparently obscure illnesses, located at
times some distance from the industrial plant, were
A'ery ordinary instances of industrial poisoning and
perfectly apparent to those experienced with them.
It was time that the medical profession realized the
probability of encountering such industrial disease.
Doctor Stengel suggested that there should be in-
stituted public meetings to which physicians should
be encouraged to come that an educational program
might be enforced. Many hundred thousand in the
industrial centre of Philadelphia were exposed to
fumes of the most intense poisons, and were in the
habit of going from place to place, as mentioned by
Doctor Patterson, in each industrial plant having re-
newals of the poisoning, so that the amount of in-
capacitation and death was a serious matter. Doctor
Stengel believed all medical schools had consented to
incorporate in their curriculum, definite courses of
lectures with examinations and tests, to make it in-
cumbent upon students to acquaint themselves with
these diseases.
^
Collectanea
Standards for Discharge in Venereal Disease.
— The following are the minimum requirements for
a complete cure in syphilitic cases as given in Public
Hralth Reports, July 19, 1918: No treatment for
one year, during which time there have been no
.symptoms, no positive and several negative Wasser-
mann reactions ; a negative provocative Wasser-
mann reaction ; a negative spinal fluid examination ;
a complete negative physical examination, having
special reference to the nervous and circulatory sys-
tems ; a luetin test may also be included. A pa-
tient may, however, be discharged as noninfectious
when a complete clinical examination in which spe-
cial emphasis is laid on thorough exploration of the
skin and mucous membranes, particularly those of
the orifices of the respiratory, gastrointestinal, and
genitourinary tracts, shows the absence of any area
from which infectious matter can be disseminated.
Such a discharged patient should be warned to re-
main under observation until such time as a com-
plete cure is efifected by a proper course of treat-
ment carried on for a definite period ; because al-
though noninfectious at the time, he may become
again infectious to others through contact, and the
disease will be probably transmitted to his ofifspring
until he is actually cured.
In gonorrhea, before discharging male patients as
noninfectious, the following requirements must be
met : [""reedom from discharge ; clear urine, no
shreds ; the pus expressed from the urethra by pro-
static massage must be negative for gonococci on
four successive examinations at intervals of one
week; after dilatation of the urethra by passage
of a full sized sound, the resulting inflammatory
discharge must be negative for gonococci. In fe-
male patients there must be no urethral nor vaginal
discharge ; and two successive negative examina-
tions of secretions of the urethra, vagina, and the
cervix, with an interval, of forty-eight hours, and
repeated on four successive weeks. The patient
should i)e requested to return at frequent intervals
for examination. Careful technic should be followed
in procuring smears from female patients. Fre-
quently smears are made by doctors which have ab-
solutely no value — the whole field is so filled with
contaminating organisms that no diagnosis can be
made, either positive or negative.
Pharyngeal Hemorrhage Due to Leeches. —
J. M. Biggs (Journal of Tropical Medicine and Hy-
giene, April I, 1918) reports the case of a white
man who had been in Egypt eight months and had
taken a drink of water in his cup from a running
stream. A few hours later he began coughing and
brought up some blood. This continued up to the
time of his admission to hospital, ten days later.
The pharynx was congested and the voice hoarse.
During the fourth night after admission he com-
plained of a choking sensation and coughed some-
thing into his mouth which he did not expectorate,
as he "feared it was a piece of his lung." Next
morning he found it had stuck to his upper gum,
and was a leech about one and a half inches long,
presumablv swallowed a fortnight before. There-
upon all discomfort and hemorrhage ceased. In a
second similar case the patient complained of a
tickling cough, sore thi-oat, dysphagia, and blood
spitting. A leech was found attached to the upper
jaw and resting in a cavity left by two extracted
teeth in the lower jaw.
«)
Births, Marriages, and Deaths.
Died.
Chard. — In Jersey City, N. J., on Friday, August 30th,
Dr. John A. Chard, aged fifty-four years.
Fries. — In Philadelphia, Pa., on Friday, August 30th,
Dr. Charles J. V. Fries, aged fifty-five years.
GiRARD. — In San Antonio, Tex., on Sunday, August
25th, Colonel Joseph B. Girard, M. C, retired, aged sev-
enty-two.
Jefferis. — In Chester, Pa., on Monday, September 2nd,
Dr. Daniel W. Jefferis, aged seventy-seven years.
Lawrence. — In Summit, N. J., on Tuesday, August 6th.
Dr. WiHiam H. Lawrence. ^
MacKei.lak. — In Philadelphia, Pa., on Sunday, Septem-
ber 1st, Dr. James MacKellar, aged fifty-four years.
Markley. — In Belvidere, 111., on Sunday, July 28th, Dr.
Robert William Markley, of Winnebago, aged forty-six
years.
Moore. — In Kennett Square, Pa., on Tuesday, August
27th, Dr. Rebecca Moore, aged eighty-three years.
ScoLLAY. — In Brooklyn, N. Y., on Saturday, August
3rst. Dr. Maria V. M. Scollay, aged forty-five years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal S Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII, No. 12. NEW YORK, SATURDAY, SEPTEMBER 21, 1918. Whole No. 2077.
Original Communications
THE GENERAL DIAGNOSTIC STUDY BY
THE INTERNIST.*
Cooperating with Groups of Medical and Surgical
Specialists.
By Lewellys F. Barker, M. D.,
Baltimore.
INTRODUCTION.
The making of a diagnosis, whether by a general
internist or by a specialist, involves the application
of the methods of reflective thought to the solution
of a problem. But the problem of a general diag-
nostic survey by the internist is very different from
the problem that confronts the specialist who is
asked to make a diagnostic study in a single domain.
The duty of the internist is to survey the patient as
a whole psychophysical organism ; whereas the task
of the specialist, in the more limited study men-
tioned, is to confine his attention to a smaller or
larger part of the structure and functions of the
organism. The internist who undertakes to make
a general diagnostic survey should know enough
about the methods of all the medical and surgical
specialties to realize how to value their application
in a given case ; he should gain the cooperation of
groups of skilled specialistic examiners whose objec-
tive findings he can rely upon, and he should learn
how to judge of the importance or unimportance, in
relation to the patient's whole state, of the reports
that come in to him from the several specialists.
In such studies there should be closest coopera-
tion between the general diagnostician and the spe-
cialists. Even a surgeon, viewed from the stand-
point of the general diagnostician, is to be regarded
mainly as a specialist in therapy, though, in many
instances, on account of an intensive experience in
a special field, his opinion regarding the diagnosis
in some special domain may be sought and prove to
be important as a part of the general diagnostic
survey. As my experience has grown I have be-
come ever more convinced that it would be well if
more patients could be first studied as a whole by a
cooperating group of specialists, associated with a
broadly trained general diagnostician. After a full
diagnosis has been arrived at, the general deviations
from the normal having been properly coordinated
and subordinated, the. therapy should be compre-
hensively planned ; and for carrying out this therapy
some division of labor among experts in special
domains will often be necessary.
•Add ress delivered at the New York Academy of Medicine, Decem-
ber 6, 1917.
The five steps in diagnosis. — In this analysis 1
have been much helped by the study of the simpler
books on logic and on the psychology of thinking
(i). As in reflective thinking in general there are
five main steps in the process of diagnosis. This
statement applies not only to the general diagnostic
study, but also to the study of a single domain by
the specialist. The first step is the feeling of a
diagnostic difficulty, the recognition that we are con-
fronted by a problematic situation. The second step
is the collection of data that will permit a more
precise diagnostic problem. It begins with restraint
of inference and suspension of judgment until
enough facts have been collected to make the nature
of the diagnostic difficulty clearer before we try to
solve it. As medical students, we have all been
trained in methods of collecting facts regarding a
patient. In the accumulation of such data we do
best to follow some systematic plan. The third step
is the summarizing of the more important facts, the
arrangement of these facts in a certain way, and the
recording of suggestions that arise in our minds
that will help us to describe them more briefly and to
understand their meaning. The process may consist
largely in a hunt for general conceptions that will
permit us to classify and, in a sense, interpret the
problematic phenomena that we have encountered.
If no general notion that is accepted or unques-
tioned can be found to apply, we may try to form a
new one that will be satisfactory. The fourth step
is the development, by reasoning, of the bearings or
implications of each of the several descriptive or
explanatory suggestions that occur to us. We con-
sider what the facts should be in the case if any
one of the conjectures formed were really applicable
to it. The fifth step 'is the testing of the several
suggestions as elaborated by reasoning to see which
of them are corroborated by the facts and which of
them are not corroborated. In making these tests,
we often find that further observation, or experi-
ment may be required before we are justified in
arriving at a concluding belief. For though some
of the suggestions may quickly be accepted or re-
jected, others may demand an extension of the fact
accumulation before acceptance or rejection is per-
missible. In complex situations, in which several of
the conditional suggestions are found to be applica-
ble, an arrangement of these in the order of their
importance for the patient is desirable.
To summarise. — We feel a diagnostic difficulty;
we locate and define the diagnostic problem ; we
stop observing and begin to think, allowing sug-
Copyright, 1918, by A. R. Elliott Publishing Company.
490
BARKER: GENERAL DIAGNOSTIC STUDY BY INTERNIST.
[New York
Medical Journal.
gestions of possible explanation to occur to us; we
develop by reasoning the implications of each of
these several sugestions ; and, finally, we accept or
reject the conceptions suggested, according as they
are, or are not corroborated by the facts already
collected or by the facts obtained through further
observation and experiment.
Feeling a diagnostic difficulty. — You may ask
why I consider this feeling of difficulty important
enough to record it as a separate step in the process
of diagnosis. I do it to arrest attention, for one of
the main causes of insufficient diagnostic study is,
in my opinion, a failure in many instances to realize
that there is a difficulty at all in arriving at a diag-
nosis, in other instances to recognize fully how
difficult it is to make a sufficiently comprehensive
diagnostic survey of a given patient.
To be a good diagnostician, one should be en-
dowed with a strong instinct of curiosity with its
associated emotion of wonder, and its accompany-
ing impulse to approach and to examine more
closely the object that excites it. The innate
strength of this impulse closely to examine things
varies greatly in diff'erent persons. Moreover, it is
an impulse that grows weaker if not made use of;
fortunately it grows stronger through exercise. The
curious mind is ever on the alert, always exploring,
ever seeking new material for thought. It remains
.sensitive to all that is doubtful or unsettled. It
should be a fundamental pedagogical principle to
cultivate a healthy curiosity, to encourage a normal
eagerness for experience and to protect the spirit of
inquiry in medical students.
It is not so very long since a single symptom,
namely, the complaint of the patient, sufficed for the
making of a diagnosis by certain physicians. If a
patient complained of a cough, or of a pain in the
back, no diagnostic perplexity was felt but therapy
could at once be undertaken in accordance with
some supposedly universal principle or dogma. Such
extreme naivete of diagnosis, it is true, does not
obtain among practitioners who have had a training
in scientific method as applied to medicine. But it
must be admitted, I fear, that even men who have
been educated in modern medical schools sometimes
fail to appreciate the extent of diagnostic investiga-
tion that may be necessary, in an obscure case, to
ensure the patient's getting the full benefit of the
diagnostic and therapeutic knowledge that exists
today. It should not require much clinical experi-
ence to make one acquainted with the dangers of
"snapshot" diagnosis. We soon find out that condi-
tions that at first sight appear to be simple may be
very complex, requiring a thoroughgoing analysis
before the exact nature of the diagnostic problem
can be discerned. Unless the feeling of difficulty is
adequate, the diagnostic study is likely to be detri-
mentally curtailed.
A. — COLLECTION OF DATA FOR THE MORE ACCURATE
LOCATION AND DEFINITION OF THE
DIAGNOSTIC PROBLEM.
It is because, when confronted by a patient with
a complaint, suspension of judgment pending in-
vestigation to determine more exactly the nature of
the diagnostic difficulty is essential for good diag-
nosis, that we are all, as students, taught to follow
.-^ome systematic plan of questioning and examining
the patient to ensure the accumulation of data that
will suffice to locate and define the problem. While
engaged in this work, suggestions of solution are
likely to arise in our minds as we go along, but no
matter how plausible they may be, we do well not
to yield assent to them at this stage of the diagnostic
procedure, though we may make use of them in
determining the direction in which the explanation
shall be especially extended, or in deciding that in
the case before us certain methods of collecting
facts need not be applied. Though a systematic
plan of studying a patient is highly desirable, one
must take care that his curiosity does not become
fibrosed by too rigid adherence to a routine process
of examination. This is one of the dangers to
which the instinct is subject, and one must safe-
guard himself against it, especially as he grows ever
busier in practice. The routine that an expert in-
ternist uses today is very diflferent from that fol-
lowed by skillful diagnosticians five or ten years
ago; each year the routine followed will to a cer-
tain extent require change in order that practice
may keep pace with the growth of knowledge and
that inquiry may conform to needed alterations in
emphasis.
For convenience of discussion, the methods of
collecting the facts for a general diagnostic survey
may be dealt with under the five headings of the
following table :
A. — COLLECTION OF DATA.
1. Recording the anamnesis.
2. Dictating the results of a general physical and psychi-
cal examination.
3. Requesting the application of certain laboratory tests.
4. Requesting certain x ray examinations.
5. Requesting examinations by experts in certain special
domains.
I. Recording the anamnesis. — The better ac-
quainted one becomes with the processes of accum-
ulating facts that may prove to be helpful in the
making of a diagnosis, the more emphasis he is
likely to lay upon an orderly recording of the
anamnesis, that is, of the data that can be secured
from the patient or his friends regarding himself,
his family, and his environment previous to the time
of the diagnostic study. As one gets busier in prac-
tice, the tendency is to make short cuts, but this
is to be done only with great caution for the most
experienced worker may easily overlook important
chies if he fail to follow a definite systematic plan of
inquiry or if he limit too greatly the number of
questions that he asks. Besides becoming ac-
quainted with the family tendencies of the patient,
his occupation and habits, any earlier illnesses or
experiences that could have an important bearing
upon his condition, it is the object of the anamnesis
to record accurately any abnormal sensations,
moods, or acts that the patient may have observed
himself or that others have noticed ; the time of
appearance of these, their duration, and any modi-
fications in them that have occurred spontaneously
or as the result of treatment are also important
anamnestic data. It is surprising how often the
precise chronology of the appearance of dififerent
symptoms throws light upon the diagnosis ; as a
single striking example of this, I may mention the
September 21, 1918.]
BARKER: GENERAL DIAGNOSTIC STUDY BY INTERNIST.
491
time relations among the symptoms of a tumor of
the acoustic nerve developing in the cerebellopontine
angle. It is always interesting, too, to record any
explanation or interpretation of the illness, or of
the single symptoms, that the patient may give him-
self, no matter how improbable or how erroneous it
may be. An interesting article might sometime be
written upon the interpretation delusions that
patients harbor. When asking about the presence
or absence of special symptoms, it is well to include
in the questionnaire the principal symptoms that
occur in different diseases of the several anatomical
systems of the body ; by so doing we throw out a
dragnet that is likely to enclose all the self observed
pathological phenomena of the patient that may be
serviceable in directing the further progress of the
diagnostic investigation. A general outline of the
principal points of the ordinary anamnesis is given
in the accompanying table :
a. Main complaints of the patient.
b. Family history (parents, brothers, and sisters; chil-
dren; other relatives).
c. Personal history (habits; education; experience; dis-
eases; operations; traumata).
d. Present illness (onset; causes; course; previous treat-
ment; epitome of symptoms referable to definite do-
mains).
Among the symptoms and signs to be asked about
in every case, I include the following :
PROMINENT SYMPTOMS.
Pain (topography; time relations; severity; quality; modi-
fying mtiuences ; associated phenomena).
Headaches.
Dizziness.
Tinnitus.
Otorrhea.
Nasal catarrh.
Sore throat ; hoarseness.
Cough ; sputum, including hemoptysis.
Dyspnea.
Palpitation; irregular action of heart.
Retrosternal or precordial oppression (relation to effort).
Swelling of ankles or face ; varicose veins.
Ingesta (quality; quantity; disturbances of appetite and of
deglutition; teeth and gums).
Nausea ; vomiting, including hematemesis.
Gaseous eructations ; flatulence.
Constipation ; diarrhea ; blood or mucus in stools.
Hernia ; hemorrhoids ; fistula.
Dysuria ; pollakiuria ; polyuria ; nocturia ; hematuria ;
pyuria.
Disturbance of sexual functions (male; female).
Symptoms referable to muscles, bones, or joints, including
the spine.
Skin eruptions ; pigmentations ; loss of hair.
Disturbances of motility (paralysis; weakness; wasting;
rigidity; twitching; tremor; spasms; cramps; fits;
ataxias; dysarthria; aphonia; apraxia).
Disturbances of sensibility (anesthesia; hyperesthesia;
parathesia ; defects of smell, taste, sight, and hearing).
Mental disturbances (nervousness; insomnia; amnesia;
losses of consciousness ; delusions ; exaltation ; depres-
sion ; fears; indecision; feelings of unreality; social
maladjustments) .
Obesity ; emaciation ; changes in weight.
Signs of infection (fever; chills; sweats; petechiae; etc.),
• Any one who has difficulty in holding in mind
such a catalogue of prominent symptoms in sys-
tematic sequence will be helped by keeping the list
before him on his office desk while he is recording
the anamnesis. I do not need to refer to the re-
duction or the extension of the questionnaire that
may be necessitated by the single case. The ex-
perience and the common sense of the questioner
must guide him in this, especially in his interroga-
tions regarding sexual, psychical, and social details.
Even the wisest and most tactful inquirer will err
in judgment sometimes; and the beginner especially
will do well to be on his guard to' avoid making the
impression of being oifensively prying or inquisi-
torial. In psychoneurotic states, patients are often
very sensitive to questions bearing upon their per-
sonal life and their social adaptations, and it is
among these hypersensitive ones that it is. unfor-
tunately, most often necessary to make a thorotigh
search for so called psychogenic data. When the
approach to such material is difficult, it is usually
wise to postpone the inquiry into the more intimate
life of the patient until the sympathetic attitude of
the physician and a better acqttaintance have es-
tablished full confidence and the rapport necessary
for the breakdown of reticence.
If the net of questions that I have just referred
to be carefully drawn, the information disclosed will
go far toward enabling the examiner to appraise the
physical, the psychical, and the social status of the
person under stttdy. The facts thus decided will be
most helpful too as a guide to the systematic physi-
cal, chemical, and psychical study of the patient
which is next to be taken up.
2. Dictating the results of the general physical
and psychical examination. — The general physical
and psychical examination as at present conducted
incltides so many details that the examiner ought
not to trust his memory of the results, even in so
far as to attempt writing or dictating the report af-
ter the examination is made. Instead, he should
dictate his notes to a stenographer familiar with
medical terms, or to a stenotypist, item by item, as
his examination proceeds, for only in this way can
a full, objective record be obtained.
In making the general physical and psychical
examination, it is most convenient first to note cer-
tain general points and then to examine the body by
regions. After this has been done, the regional
method may to a certain extent be departed from in
order to supplement the record with details regard-
ing the state of the nervous system (or any other
anatomical system that may require an especially
intensive study).
The general points that should be noted in every
case are summarized in the accompanying table :
a. General points.
i. Body temperature ; pulse at both wrists ; res-
piration.
ii. Height ; weight ; calculated ideal weight ; build
or habitus ; nutrition ; musculature.
iii. Posture ; gait ; behavior.
iv. Skin (color; thickness; moisture; eruptions;
ulcers: pigmentation; scars; strise; super-
ficial blood vessels; edema).
V. Lymph glands (epitrochlear ; cervical; axillary;
inguinal); bones; joints; muscles,
vi. Blood pressure (systolic; diastolic).
Continuing the general physical examination, I pre-
fer exploration at first by regions rather than by sys-
tems, for at this stage of the inquiry it is desirable
to suppress, as far as possible, explicit diagnostic
inferences, confining one's attention strictly to the
accumulation of facts in a systematic way without
too much regard to their bearings upon the con-
clusions toward which the whole examination is
492
BARKER: GENERAL DIAGNOSTIC STUDY BY INTERNIST.
[New York
Medical Journal.
aimed. Examination by regions rather than by
systems helps to maintain that preliminary suspen-
sion of judgment regarding the nature of the
patient's ailment that I have already referred to as
desirable.
The points to be noted in the regional examina-
tions and in the examination of the nervous system
are indicated m the accompanying table :
b. Regional examination.
i. Head (skull; face; eyes; ears; nose; mouth;
throat; glands).
ii. Neck (form; thyroid; tracheal tug; esopha-
gus ; blood vessels ; lymph glands ; cervical
spine; cervical ribs; tumors; wry neck).
iii. Thorax (form; bones; coverings; breasts;
axillary hirci and glands ; lungs ; pleurae and
mediastinum; heart and aorta).
iv. Abdomen and pelvis (inspection; palpation;
percussion ; auscultation of abdomen and ab-
dominal viscera ; examination of rectum and
of urogenital apparatus).
v. Extremities (skin; bones; joints; muscles;
nerves) .
c. Examination of the nervous system.
i. Sensory functions (cutaneous and deep sensi-
bility, stereognosis ; special senses).
ii. Motor functions (muscular power; finer
movements, including speech and writing ;
coordination; tonus).
iii. Reflexes (pupils; deep reflexes of extremities;
superficial reflexes ; plantar and abdominal ;
sphincters).
iv. Autonomic functions (vasomotor; secretory;
trophic).
vi. Mental state' (orientation; memory; calcula-
; tion ; attention ; sense deceptions ; pathologi-
cal ideas; mood; psychogenic data; etc.).
Such a general, physical, and psychical examina-
tion can be made very quickly by any one who has
been thoroughly trained in internal medicine and
who has worked long enough to acquire skill in the
technic of the methods of examination. The report,
when typewritten, is placed in a numbered folder,
along with the record of the anamnesis, and to these
records are added, as they come in, the reports of
the laboratory exammations, x ray examination,
and examinations by specialists. All this material
is accumulated before any attempt is made to sum-
marize the data and to arrange them according to
the anatomical physiological systems to which they
may especially be related.
3. Requesting the application of certain labora-
tory tests. — The clinical laboratory is now so firmly
established as an indispensable part of the outfit
necessary for clinical studies that pretend to any
kind of thoroughness that one no longer assumes
that any internist can do satisfactory work without
calling upon it extensively for aid. Many internists
make their own laboratory tests, especially in the
earlier years of their practice, and it is certainly
important that every working internist shall have
had an extensive first hand knowledge of the pro-
cedures of the clinical laboratory and that, even
after he becomes too busy to make the routine tests
himself, he should keep in close touch with men
working in clinical laboratories, inform himself
thoroughly of the principles, advantages and limita-
tions of new tests as they are devised and, prefer-
ably, continue through his lifetime to engage at
^If the exploration in this direction has been full enough and
systematic enough in the recording of the anamnesis, it may be
omitted here.
least to some extent in laboratory practice himself.
The time soon comes, however, as well for the suc-
cessful general practitioner as for the consulting in-
ternist when it is impracticable for him to make his
laboratory tests, either routine or special, for him-
self and he is compelled to choose and to rely upon
either assistants or colleagues who specialize in
laboratory work to make these tests for him and to
send him reports of the results. It is essential that
whoever makes the laboratory tests shall be not
only conscientious but well trained. Very serious
diagnostic errors are often the result of reliance
upon reports from unreliable laboratory workers.
The number of possible laboratory tests that may
be made is legion, and each internist must decide
for himself which he will choose as a minimum
routine requirement in a general diagnostic survey.
i\ly own practice for some time past has been to
have made as a routine in every case in which there
is no contraindication the tests listed in the follow-
ing table :
a. Routine tests.
i; Examination of the blood.
Red blood corpuscles count.
White blood corpuscles count.
Examination of the hemoglobin.
Differential count of white blood corpuscles
in stained smears.
Search for parasites.
Wassermann reaction.
ii. Examination of sputum, especially for tuber-
cle bacilli.
iii. Examination of stomach contents.
Free HCl, combined HCl, and total acidity.
Occult blood.
Lactic acid.
Oppler-Boas bacillus.
iv. Examination of feces.
Macroscopic appearance.
Undigested food.
Occult blood.
Bile.
Parasites or their eggs.
v. Examination of urine (night and day speci-
mens.
Physical (color; reaction; specific gravity).
Chemical (albumin; sugar; diacetic acid).
Microscopical (red blood corpuscles; white
blood corpuscles; casts) ;
In addition to these routine tests, applied in every
case,- it is often desirable to have certain other lab-
oratory tests made. Thus, an examination of the
cerebrospinal fluid may be thought necessary if
there are meningeal symptoms, or if nervous symp-
toms exist in a man who has had lues, though no
one would be so foolish as to think of examining,
the cerebrospinal fluid of every patient as a routine
matter. Again, when continued fever is present it
is advisable to have a blood culture made ; when the
blood pressufe is high or other signs suggestive of
renal disease are present, special tests of renal func-
tion may be applied ; when a peculiar cardiac ar-
rhythmia is fotmd on physical examination, poly-
graphic tracings or electrocardiographic studies will
be indicated. And of the like many more instances
might be cited. Among the special laboratory tests
that I employ most often I would mention particu-
larly those in the following table :
^Sometimes, of course, no sputum can be obtained for examination.
In certain instances, too, the passage of a stomach tube may be
contraindicated.
September 21, 1918.]
BARKER: GENERAL DIAGNOSTIC STUDY BY INTERNIST.
493
2. Special tests (in certain cases).
i. Cerebrospinal fluid (lumbar puncture).
ii. Tuberculin tests.
iii. Excision of gland, muscle, or nodule for
histological examination.
iv. Bacteriological cultures (blood; sputum;
urine; pus; cerebrospinal fluid, etc.).
V. Blood chemistry and other special blood ex-
aminations.
vi. Renal function tests.
vii. Metabolic studies.
viii. Protein sensitization tests,
ix. Pharmacodynamic tests.
X. Electrocardiography.
xi. Sphygmography.
xii. Exploratory punctures.
xiii. Animal inoculations.
Now and then the findings obtained by laboratoty
examinations are pathognomonic. But this is only
occasionally true, and the mistake is often made by
practitioners of expecting too much of their co-
workers in the laboratory. The results of the tests
made in the laboratory should be valued only in
association with the results obtained by other meth-
ods of investigation. The same remark holds true
for the results of rontgenological examinations, to
which we may now turn.
4. Requesting certain rontgenological examina-
tions.— When X rays first came into clinical use they
were employed chiefly by surgeons. Today intern-
ists make even greater use of x ray examinations
than do their surgical colleagues. Indeed so exten-
sively are rontgenological examinations made in
diagnostic studies in general medicine that most in-
ternists either install a rontgenological department
in their own offices, or form a close working alli-
ance with a colleague who is an x ray specialist.
Rontgenological apparatus has recently been so
greatly improved and the technic has been so much
simplified that any intelligent person may after a
relatively brief training become competent to make
good rontgenograms of the skull, paranasal sinuses,
teeth, chest, alimentary canal, bones, joints, etc.
But the satisfactory interpretation of the rontgen-
ograms is a far more difficult matter, requiring, like
rontgenoscopic interpretations, long experience,,
much clinical knowledge and sound judgment. It
seems to me desirable that internists themselves be-
come skilled in the reading of rontgenograms and
in^he interpretation of what can be viewed on the
rontgenoscopic screen. It is hard to see how other-
wise they are to become able to value the findings
in a proportionate way in their diagnostic work,
even wlien objective reports of the findings are
made to them by skilled rontgenologists. There is
an immense autodidactic advantage in the combin-
ation of personal rontgenological interpretation with
one's general clinical work. Of course, the major-
ity of internists can never expect to become as pro-
ficient in plate and screen interpretations as are
those professional rontgenologists who give their
whole time and energies to x ray work. But close
association of the expert internist with the expert
rontgenologist is essential to the best work of each.
The internist who does not see the plates made from
his own patients misses much ; and the rontgenolo-
gist who only reports on his x ray examination and
knows nothing of the clinical history of the patient
is not likely to grow rapidly in power of interpreta-
tion. I am afraid that rontgenologists are often
pressingly solicited by physicians for specific diag-
nostic judgment and that they too often yield to
the importunity when they should make it plain that
their duty is done when they give an objective de-
scription of their findings. So common has it be-
come for rontgenologists to attempt to arrive at
diagnostic conclusions from their studies alone that
it is sometimes difficult to get from them the objec-
tive description that one desires, either alone or
accompanied by a diagnostic impression. Instead,
the reports of "chronic infectious arthritis," "pul-
monary tuberculosis," or some other diagnosis come
in. That this unsatisfactory state of affairs, which
still exists in many places, will soon be remedied,
every one who desires that rontgenology and inter-
nal medicine reciprocally benefit one another to
the utmost will hope.
Certain x ray examinations I have made as a
rotitine in every case in which I attempt a general
diagnostic study: i. paranasal sinuses; 2, dead teeth
and unerupted teeth ; 3, thorax with heart, aorta,
Itmgs, pleura:, and mediastinum ; and, 4, gastrointes-
tinal tract after ingestion of barium. In addition,
special x ray examinations are made according to
indications derived from the anamnesis and the gen-
eral physical examination. .
4. Rontgenological examinations.
a. Routine.
i. Rontgenogram of paranasal sinuses.
ii. Rontgenogram of dead teeth and of unerupt-
ed teeth.
iii. Rontgenogram of thorax.
iv. Rontgenogram of gastrointestinal tract.
b. Special (when indicated).
i. Stereoscopic rontgenograms of skull and
sella turcica.
ii. Stereoscopic rontgenograms of lungs and
pleurae.
iii. Telerontgenograms of heart.
iv. Serial rontgenograms of gastrointestinal
tract.
, V. Rontgenograms of gallbladder area,
vi. Rontgenograms of bones, joints, and spine,
vii. Rontgenograms for renal calculi,
viii. Pyelograms and uretorograms after thorium
injection.
The reports from the several rontgenological ex-
aminations are filed with the other reports until
the data from specialists' examinations have been
collected.
(To be continued.)
Surgical Treatment of Tuberculous Peritonitis.
— L. J. Hammond (Pennsylvania Medical Journal,
June, 1918) advocates a median abdominal incision.
In the adhesive form care must be taken not to
injure the intestine which ni3.y DC adherent to the
peritoneum. In the ulcerative form the results are
not particularly good as intestinal fistulas are liable
to develop. Contraindications to operations are
fever, advanced ptilmonary disease or amyloid
changes in the kidneys and intestines. Tuberculous
lesions in the abdomen should not be removed until
after the patient has recovered unless they are
localized^ the appendix, ttibes, or omentum. In-
testinal anastomosis may have to be performed.
The helpful factors are probably the relief of the
tension by the evacuation of the fluid exudate, the
irritation of the serosa, and the estabHshment of
collateral circulation.
494
LUTTINGER: LOCOMOTION AS AN AID IN DIAGNOSIS.
[New York
Medical Journal.
LOCOMOTION AS AN AID IN DIAGNOSIS.*
By Paul Luttinger, M. D.,
New York.
There is a group of diseases, mostly of the nerv-
ous system, which at a certain point of their evohi-
tion, stamp the sufferer with a characteristic mode
of locomotion. To ohserve such a modification of
the normal walk is often sufficient to make a cor-
rect diagnosis. It is strange, however, how little at-
tention this important subject has received from the
medical profession. In fact, other than the work
of the brothers Weber who established the physi-
ology and mechanism of human locomotion, of Neu-
gebauer and of Gilles de la Tourette, who developed
the ichnogram method of gait study, scarcely any-
thing of importance has been done along these lines
for the last quarter of a century. The study of the
mode of locomotion in various diseases and ailments
remains, therefore, a fertile field of research for
the podiatrist.
The act of locomotion or the power of progres-
sion is not a simple one. Various correlated move-
ments combine to form what we ordinarily term the
walk. The three chief elements are: i. Posture;
2, station, and 3, gait. These three factors may be
influenced by local or general diseases, either sepa-
rately or together.
Posture is the term applied to the position of the
body in space and is not of much interest to the
podiatrist except as corroborative of the two other
elements of locomotion. It has, however, its value
in diagnosis and the new practitioner of podiatry
will do well to learn to observe the position of the
body at various angles and in various diseases. One
should learn early, for instance, that immobility is
not always due to paralysis. It may be due to pain,
as in rheumatism or to a disinclination to move as
in scurvy, rickets or any condition causing dyspnea.
The restlessness in fevers and in large hemorrhages,
as well as the throwing about in renal, gallstone or
intestinal colics, is known to all. Equally char-
acteristic are the agitation and irregular movements
in chorea and hysteria ; the gunhammer posture in
cerebrospinal meningitis, and the opisthotonos in
tetanus and strychnine poisoning.
Station is the power of standing more or less
firmly on one's feet. It includes attitude, which is
the manner of standing, i. e., the relation of the
rest of the body to the erect position. The carriage
of the head and shoulders should be noted ; the
shape of the entire body, whether bending forward,
as in "stooped shoulders" (faulty attitude habit)
and in paralysis agitans, or bending backward, as in
ascites and abdominal tumors, should be closely
studied and differentiated from the actual lordosis
which is seen in spinal diseases, in advanced preg-
nancy, in pseudohypertrophic paralysis and in cret-
inism. The strictest attention should be paid to the
attitude of the lower limbs, their shape and their re-
lation to each other when the erect position is as-
sumed. The degree of firmness with which the in-
dividual stands should always be taken into con-
sideration before a final diagnosis is made. Sway-
*An advance chapter from a textbook on Practical Podiatry pub-
lished by The First Institute of Podiatry, 213 West lasth Street,
New York.
ing is the term applied to any departure from the
ideally rigid erect attitude and perpendicular station.
The normal individual, with eyes open and heels
close together, sways about one inch forward and
three quarters of an inch from side to side. In
functional and static ataxias, the swaying may be-
come so extreme as to produce absolute incapacity
to stand.
Gait means the specific manner of walking.
It is a narrower term than locomotion which is the
power of walking. It is, however, the chief factor
in the act of progression and in the majority of
cases it is characteristic enough to stamp itself in-
delibly on the normal as well as on the diseased in-
dividual. While in character reading gait expres-
sion may not be as popular as face expression, it is
often more reliable and in certain diseases it is sim-
ply invaluable as an aid in diagnosis.
Methods of Diagnosis
The observation method. — This is the usual
method of ascertaining the gait of an individual.
It is practised by the average physician and podi-
atrist and consists in observing the patient while he
or she walks up and down the room, taking notice
of the peculiarities of gait which may develop. The
patient may be allowed to roam freely about the
room or should be directed to follow a carpet seam
or a crack in the floor at right angles to a previous
line of vision. This may be varied by opening or
closing the eyes, stretching out the arms, with legs
wide apart, or keeping them close together. Brisk
walking should alternate with a slower gait and the
effect of stopping abruptly and turning sharply at
command should be closely observed. It is best to
have the patient uncovered from the hips down. In
women, the nightgown or chemise can be pulled
tightly between the thighs and fastened anteriorly
with a safety pin. Due allowance should be made
for nervousness and a careful watch must be main-
tained against a serious fall.
The ichnogram jnethod. — -This consists in study-
ing the impressions left by both soles (previously
colored) when walking on paper for a dis-
tance of about twenty-five feet. Ichnograms (from
the Greek — ichonos — trace, and gramma— io write)
as a method of gait diagnosis are more exact t^an
the method of observation and should supplement
it. Besides, they inform us, at the same time, of
the state of the plantar arch as each pelmatogram
fthe impression of a single foot) shows more or
less clearly a posterior oval which changes but
little, and an anterior oval, as well as toe marks
which undergo characteristic contour changes, de-
pending on the state of the ligaments, of the tarsal
and metatarsal bones and phalanges, and the rela-
tion of these structures to the musculature and in-
nervation of the foot.
Classification of Gaits.
Strictly speaking there are only three types of
gait: 1, the paretic; 2, the ataxic and 3, the choreic.
In some diseases there may be a combination of
the three, while in others one type of gait predom-
inates during the early stage and another during
the later developments. At times, one comes across
a gait that combines characteristics of the three
types and hence is difficult of classification.
September 21, i-jiS.]
LUTTINGER: LOCOMOTION AS AN AID IN DIAGNOSIS.
495
I. PARETIC GAIT.
Paresis means a lessening of the normal motility
of a muscle, while the term paralysis denotes entire
absence of motor power. We may have, there-
fore, two or three distinct paretic gaits according
to whether the muscle is slightly or severely weak-
ened or entirely paralyzed : a. The mild paretic gait ;
•
A B
Fio. I. — A. Pelmatogram of a norma! female foot. B. Modified
pelmatogram showing weight bearing points.
b. the moderate or flaccid paretic gait ; c. the severe
or spastic paretic gait.
A. The mild paretic gait is caused by muscu-
lar weakness due to a large number of etiologic
factors. It results in slowing of locomotion, the
steps being shortened on
l»« account of an exaggerated
flexion at the knee joint.
The following are exam-
ples of mild paretic gaits :
1. The pompous gait. —
The upper part of the body
leans backward, the back is
f hollowed, the abdomen is
protuberant, the feet are
widely separated and ap-
pear to move with delibera-
tion and dignity, giving the
impression of conscious im-
portance— hence the name.
This gait may be seen in
obesity, pregnancy, ascites,
"*» large abdominal tumors,
cretinism and rickets.
2. The hobbling gait. —
The pelvis tilts toward the
sound side, while the trunk
leans over to the afifected
side, causing more or less
pronounced limping. This
gait is limping. This gait
is seen in people afflicted
with corns, rheumatism,
gout, sciatica, plantar neur-
algia, Morton's neuralgia,
metatarsalgia, hip or knee
nfrl^ai g^;^^''''""^''^'" °^ joint disease or injury (re-
cent or old), sacroiliac dis-
ease, sprains, inflammatory diseases of the lower
extremity, chimation, short leg, paralysis of one leg,
abdominal aneurysm, and subacute and chronic ap-
pendicitis.
3. Intermittent limping (disbasia angiosclerotica
or intermittent claudication) may be classified here
and is a curious limping gait which develops in ar-
teriosclerosis of the lower extremities. There are
pain and fatigue on walking, which disappear after
a short rest, to reappear again soon after walking is
resumed. The pulse is weak or absent below the
knee.
4. The waddling or goose gait. — The ])elvis and
head of femur are jerked forward at each step, knee
advanced and extended only after foot is flat upon
the ground. There is more lordosis and swinging
of the body from side to side at each step, than in
the pompous gait. It resembles the gait of a goose.
The patient cannot stand on tiptoe. Jt is seen in
congenital dislocation of both hip joints and ir
pseudohypertrophic muscular paralysis, an heredi-
tary disease seen mostly in boys under ten years of
age, and characterized by inability to get up from
the floor.
5. The wobbly gait. — Resembles the above and is
due to atrophy or paralysis of the three glutei
muscles and prevents the patient from climbing.
This inability to climb is also seen in those exhibit-
ing the waddling gait.
6. The tottering gait. — Seen in those who have
taken large doses of bromides for long periods ; also
in hydrocephalus, in Korsakof¥'s disease (psychosis
polyneuritica) and in idiopathic muscular atrophy.
Fig. 3. — Pelmatogram of a male, showing flat foot.
7. The shuffling gait is the gait seen in normal old
age or senility and is associated with slowly pro-
gressive loss of strength and mentality. It is also
seen in general paresis and is the usual gait of the
longterm prison inmate. The patient gives the im-
pression of being too lazy to lift his feet and instead
pushes them along with his legs.
8. The "Charlie Chaplin" gait has been errone-
ously described as an ataxic gait. It is rather a
combination of the "funny part" of several gaits in
which the waddling, shuffling, tottering paretic gaits
predominate and to which some elements of the
spasticparetic, as well as the ataxic gaits, have been
added. The inspiration must have come originally
to the celebrated movie star from some waddling
cripple whom he proceeded to imitate and later bur-
lesqued.
B. The moderate or flaccid paretic gait. — In
this form of the paretic gait there is commonly a
paresis of a certain group of muscles, usually the
extensors of the foot or the peronei, causing toe
drop and apparent lengthening of the afifected ex-
tremity. It corresponds to the wrist drop of the
upper extremity. To compensate for the lengthen-
496
LUTTINGER: LOCOMOTION AS AN AW IN DIAGNOSIS.
[New York
Medical Journal.
ing of the limb, overflexion at the hip or knee, or at
both joints, takes place. The limb is flaccid or
flabby. The foot is lifted high up with each step in
order to raise it clear off the ground and avoid trip-
ping. As the foot is brought down, heel first, this
gait may sometimes be confused with tabes and is
therefore sometimes referred to as the pseudotab-
etic gait. It is, however, easily differentiated from
the true tabetic gait by its characteristic high action
or high stepping quality which made Charcot com-
pare it to the gait of a horse and call it :
1. The steppage gait, mostly seen in the chronic
intoxications producing neuritis. It resembles the
gait of a man walking through thick grass or brush-
wood and stepping over constantly recurring but
nonexistent obstacles. The typical steppage gait is
seen in arsenical neuritis with ankle drop, also in
alcoholic neuritis, polyneuritis potatorum (ataxia
of drunkards) and in lead neuritis (lead palsy,
plumbism, saturnism), in which first the peroneal
muscles are affected, later the extensor communis
digitorum and finally the extensor proprius hallucis.
Phosphorus, copper and grain (ergotism) poisoning
may give rise to a neuritis in the lower extremities
and produce the characteristic steppage gait.
Tuberculosis, malaria, diabetes, and diphtheria
(motor form) may sometimes produce this gait.
It may also develop as a sequel of sunstroke (ther-
mic fever, insolation) and in fact following any
disease which will cause peripheral neuritis of the
anterior tibial nerve.
2. The prancing gait is an exaggeration of the
preceding gait. It is seen in epidemic anterior
poliomyelitis (infantile paralysis) when the disease
affects the anterior horn cells of the lumbar cord,
causing atrophy of the extensor muscles of the foot,
resulting in foot drop. It is also seen in acute
ascending paralysis (Landry's disease), which is
probably a form of poliomyelitis, and in progressive
hereditary muscular atrophy of the leg (Charcot-
Marie-Tooth type) when the muscles of the leg,
not the foot, are primarily affected, i. e., first the
peronei become atrophied, later the extensors of
the toes and finally the calcaneal muscles. Finally
the prancing may be seen in connection with certain
tumors of the cord, unilateral hip disease, disloca-
tion, or injury, and in multiple neuritis and beriberi
(epidemic multiple neuritis).
C. The spastic or severe paretic gait. — The
spastic gait is due to the hypertonicity of the weak-
ened muscles, the resulting stilTness causing a slow-
ing of locomotion and diminished excursion of the
affected limb. The hypertonicity is produced either
by direct stimulation of the motor cells in the an-
terior horn of the spinal cord, as in traumatic
myelitis, or by impulses coming down from the
cerebral cortex. The limb is spastic or rigid, due to
the tonic spasm. Wlien the tonic spasm is of long
standing, it is termed a contracture. The lower ex-
tremity moves as a whole, the toes clinging to the
ground, scraping it, and very often catching. Con-
trary to the moderate paretic gait, this group pre-
sents difficulty in flexion which is partly overcome
by the elevation of the pelvis on the side of the
swinging leg.
I. The mowing or hemiplegic gait.- — ^This is the
prototype of all spastic gaits and is encountered in
its simplest form in all hemiplegias, i. e., in paralysis
of one side of the body, which may be caused by
cerebral hemorrhage, embolism, thrombosis, syphilis,
brain tumor, multiple sclerosis of a cerebral hemi-
sphere, meningeal hemorrhage or suppuration, Ray-
naud's disease, general })aresis of the insane ; some-
times it may be due to hysteria (functional
hemiplegia), or to uremia (transient hemiplegia).
No matter what the cause of the hemiplegia, there
is always the typical mowing gait. This mowing
movement is due to the fact that the spastic limb
swings lateralward, describing an arc of a circle,
outward, and strikes the ground in a flail like
manner. Technically speaking, circumduction takes
place by tilting of the pelvis and the swinging of the
foot outward and around to the front. The patient
afiflicted with hemiplegia makes the same movement
with his limb as does the reaper with the hand in
which he holds the scythe. The only paralytic gait
in which there is no mowing movement occurs in
hysterical (functional) paraplegia, which is very
rare. In this condition the leg is dragged forward
instead of outward. An important shoe sign in
paraplegia is that the sole of the shoe is worn down
on the inner side.
2. The small step gait (La marche a petit pas). —
This gait is seen in cerebral softening following an
apoplectic stroke, especially in pseudobulbar par-
alysis ; the steps are very short and the feet are
lifted from the ground with difficulty, the patient
seeming to count his steps.
3. The crosslegged gait. — This gait is due to a
spasm of the adductors of the thigh causing the
knees to rub against each other, resulting in cross-
legged progression, the lower limbs having a tend-
ency to cross during locomotion. It is seen in both
Little's congenital and Erb's syphilitic form of
lateral spinal sclerosis. In the syphilitic form a
dragging and shuffling gait is often associated with
the crosslegged type.
4. The ill defined spastic gaits. — 111 defined spastic
gaits are seen in tetany (paroxysmal tonic spasm)
from any cause, and in amyotrophic lateral sclerosis,
which is the spastic form of progressive muscular
atrophy (Charcot's disease). This involution dis-
ease, due probably to developmental defects of the
lateral pyramidal tracts, has the combined symptoms
of spastic spinal paralysis, anterior poliomyelitis and
bulbar palsy, hence the difficulty in classifying it.
Myelitis (inflammation of the spinal cord) may be
due to trauma, alcoholism, syphilis, vertebral caries
(compression myelitis), tumors, aneurysm, hemor-
rhages into the cord, etc., and will exhibit various
gaits according to the stage and severity of the dis-
ease. It may begin with a mild paretic gait passing
through several stages of the spastic gait on to com-
plete paraplegia (paralysis of both lower extremi-
ties). In complete paraplegia there is of course no
gait, as the patient cannot walk, there being a loss
of the power of locomotion but not of progression
(a patient so afflicted may still move from place to
place on his hands).
5. The dragging gait. — In hemiplegia one foot
only is dragged. Dragging of both feet is seen in
multiple neuritis, hereditary peroneal atrophy, spas-
September 21, 1918.] LUTTINGER: LOCOMOTION AS AN AID IN DIAGNOSIS. 497
modic spinal paralysis, and spinal and syphilitis
spinal paralyses.
6. The dromedary gait, so called on account of its
resemblance to the gait of a camel, is seen in children
suif'ering with progressive torsion spasm (Flatau-
Sterling disease).
Finally, spastic paretic gaits are often observed in
pellagra (maidism, Italian leprosy, Alpine scurvy)
and in lathyrism (lupinosis), where the slow toxic
spinal sclerosis finally leads to spastic paraplegia and
loss of the power of locomotion ; also in caisson dis-
ease (diver's paralysis).
11. THE ATAXIC GAIT.
The ataxic gait may be either the static ataxic
gait or the functional ataxic gait, and these are
termed either i, spinal or 2, cerebellar, according to
the location of the lesion.
A. The static spinal ataxic gait. — This is the
most easily recognized gait, and once seen, is never
forgotten. There is an exaggeration of all the move-
ments of locomotion. The hips are overflexed and
rotated laterally, the foot is raised suddenly and too
high, the toes are lifted and the whole limb is thrown
suddenly forward with unnecessary vehemence and
is then brought down heel first or flat footed, with a
stamping sound. The feet are kept wide apart and
while in the air they move in an undecided manner,
as if the patient was doubtful where to put them.
The eyes of the afflicted person are glued to the
ground or fixed to the limbs so as to supplement the
lack of muscular and articular sensation by the sense
of sight. In the cerebellar type of this gait the
movement excursion is not as extensive as in the
spinal type. A sudden turning movement or an
abrupt sitting posture is difficult or impossible to as-
sume in this type of locomotion. In order to test
static ataxia, the patient is made to stand heels and
toes together, whereupon marked swaying takes
place. The swaying is increased when the eyes are
closed and the patient looks like a "chicken on a
clothes line." If there is more than one inch for-
ward swaying and more than three quarters of an
inch lateral swaying, the patient is considered ataxic.
In the disease known as tabes dorsalis, or locomotor
ataxia of syphilis, the swaying may be so pronounced
as to produce absolute incapability to stand or to
walk.
B. The cerebellar (functional) ataxic gaits. —
These gaits are produced by a disturbance of the
equilibrium accompanied by vertigo resulting in a
very irregular swaying from side to side, resembling
the gait of an intoxicated person. The patient
makes short steps, keeps his feet wide apart, stag-
gers, rolls, sways to and fro, and reaches a set point
by zigzagging toward it. The swaying is relieved
when support is given under the armpits.
I, The titubating gait is a form of functional
cerebellar ataxic gait seen in the following affec-
tion: Friedreich's (disease) ataxia; hereditary
cerebellar ataxia ; dementia paralytica ; ataxic para-
plegia ; labyrinthine disease and to some extent in
vertigo ; syringomyelia ; and in some cases of gen-
eral paresis, and various chronic intoxications like
lead or arsenic or alcohol affecting the cerebrospinal
system.
2. The reeling or staggering gait is seen in acute
alcoholic intoxication and Mesniere's disease (dis-
ease of the middle cerebellar lobe).
III. THE CHOREIC GAIT.
The choreic gait, which is sometimes referred
to as the spasmodic or hysterical gait, is very
variable in quality depending on the cause of
the tremor. It consists of a series of quiver-
ing or trembling movements of varying intensity,
but nearly all due to clonic spasm and dis-
appearing during sleep or passive motion. This
distinguishes it from the spastic or paraplegic gait
in which the spasm is tonic in quality, lasting from
one minute to one month. The clonic spasm, on
the other hand, consists in rapidly alternating con-
tractions and relaxation of the muscle.
1. The r.tumbhng gait is seen in chorea (St.
Vitus's dance) and Huntington's (hereditary)
chorea, in Friedreich's paramyoclonus multiplex
(which is not to be confounded with Friedreich's
ataxia), in Unverricht's progressive myoclonus, and
in multiple sclerosis of the spinal cord. The gait
resembles that of a schoolboy, who clown ishly
stumbles or trips over his heel to attract attention.
Technically, there exists rotation of the legs, which
soon renders locomotion impossible. When these
abrupt twitchings and jerking movements, which
are involuntary and purposeless, affect only one
half of the body, we speak of the condition as
hemichorea. The patient appears restless, unsettled
and fidgety.
2. The festination gait is typical of the disease
known as paralysis agitans (Parkinson's disease,
shaking palsy) and is an advanced choreic gait in
which there may be observed the curious phenomena
of propulsion and retropulsion, i. e., the impossibility
of stopping, once the patient is pushed either for-
ward or backward. In some instances, when pulled
suddenly backward, the patient will take a few
backward steps with increasing rapidity, while the
body remains in the characteristic posture of para-
lysis agitans ; namely, in the forward leaning atti-
tude. In festination "the body tries to overtake its
centre of gravity" (Trousseau).
3. The saltatory gait ("the jumpers") is a
very rare condition occurring the instant the weight
of the body is put upon the feet. It consists in
strong and rapid contractions of the muscles of the
thigh and leg causing the patient to jump up vio-
lently. It is probably an hysterical spasm.
4. The myotonia gait occurs in Thomsen's dis-
ease and consists of tonic, painless spasms when-
ever a certain group of muscles begins to function,
The steps are first checked and delayed ; but this
gradually wears off. This curious condition re-
turns again when the same grouji of muscles is
called into action. Owing to the tonic spasms, this
gait might have been properly classified as a spastic
paretic gait, were it not for the fleeting and irre-
gular character of the spasticity.
5. The hysteria gait, known also as astasia-
abasia, is notable by the ease with which it mav
simulate any and all of the gaits described above,
the spastic as well as the flaccid types of paralyses,
— even the cross legged gait, ending in complete
498
HERB: TECHNIC OF INTRAVENOUS A'EDICATION.
[New York
Medical Journal.
inability to stand or walk. It dififers from all of
them, however, in the abilit}- of the patient to per-
form all the nervous functions of the limb when
lying in bed. The hysterical gait may also end in :
Catalepsy which is a state of muscular rigidity
enabling a limb to maintain a posture in opposition
to gravity for one hour or more (waxy flexibility).
This curious phenomenon of retaining the leg or
any other part of the body in a fixed attitude (given
to it by the operator) is sometimes seen in catatonia,
general paresis, brain tumors and, (rarely) in
meningitis.
T265 Boston Ro.ad.
THE TECHNIC OF INTRAVENOUS MEDI- -
CATION.
p By Ferdinand Herb, M. D.,
Chicago.
The ever increasing importance of intravenous
medication, especially in the treatment of syphilis,
makes it desirable to simplify, if possible, its technic
sufficiently to make this promising therapeutic
measure safe and reliable at the hands of the less
experienced physician. The part that seems most
dit^icult and, therefore, needs improvement more
than any other is the introduction of the needle into
the vein. As simple as it may seem at the hands of
the expert, it has frequently proved disastrous and
is fraught with serious consequences if performed
under unfavorable conditions by any one who lacks
experience. Not only should the vein be entered,
but the point of the needle must be properly placed ;
it should neither perforate the opposite wall nor
should a part of its outlet be left outside of the
vessel.
The success of introducing the needle into the
vein and placing its point correctly depends mainly
upon the degree of the filling of the vessel. If it is
filled well and is hard, the introduction of the needle
is easy and oflfers no difficulty. However, as the
filling grows less and the vein flabby, the trick of
introducing the needle gets more difficult and uncer-
tain, until finally, when the filling gets below a cer-
tain point, even the expert will fail at the attempt.
Theoretically and practically, the best filling of the
vein is obtained if the constriction of the arm is
regulated so that the pressure remains just below
the point at which the arterial flow is interrupted.
If this is done, the blood enters the arm under the
full force of the arterial pressure and, after passing
the capillaries, crowds into the veins until they are
completely filled and hard. On the other hand, if the
pressure is too high or too low, so that either the
arterial flow is interrupted or the venous flow in-
sufficiently blocked, the filling of the vein becomes
incomplete and, in a corresponding measure, the in-
troduction of the needle grows more difficult or is
impossible.
Of a technic, that may be depended on by the less
experienced physician, we must, consequently, de-
mand that this optimum degree of pressure can be
obtained in any and all instances quickly and accur-
ately. Taking this stand, it becomes evident that the
customary rubber tube, universally used as a tour-
niquet for the constriction of the upper arm, is not
the best instrument for the purpose. Even the most
experienced and skilled operator can at best but
make a guess that the pressure is right. There is no
possibility of controlling with this tube to any degree
of accuracy the variations in pressure and the proper
tilling of the vein must, of necessity, be left to the
uncertainty of good luck.
Looking for a better and more satisfactory instru-
ment I decided to give my Tycos a trial. With this
as well as with any other sphygmanonieter the very
degree of pressure needed for our present purpose
is easy to find and readily obtained at the point of
the systolic pressure ; the artery is Of>en and the
veins are tightly closed. It seemed to me to be the
ideal instrument to supplant the rubber tube.
So it proved to be. The results of the trial have
been most satisfactory and pleasing to myself and to
my patients. This is due to several reasons: i.
The selected vein being always filled to its maximum
degree, the introduction of the needle is easy and
readily accomplished. Its point can safely be
pushed forward into the lumen without fear of
])erforating the opposite wall. 2. As the pressure
rises gradually and is applied to a broad surface
by means of the cuff, the well known pain, due
to the constriction of the arm by the rubber tube,
is conspicuous by its absence. A number of pa-
tients who had had experience with the rubber tube
have expressed their surprise and gratification at
rhe improvement. 3. The release of the pressure
by simply opening the air valve is handier and
easier than taking off the rubber, an advantage
readily appreciated by those who make intravenous
injections without assistance. 4. Should need be,
the constriction of the arm is readily restored with-
out much manipulation and without disturbing the
needle by simply reinflating the cuff.
The technic I employ is as follows : The patient is
placed upon the operating table with the upper body
fairly well elevated and with the arm slightly slant-
ing downward in the direction from the shoulder to
the finger tips. In this position, a better filling of
the vein is secured without interfering with the in-
jection. Then I apply the cuff, attach the inflating
bulb and manometer, disinfect the arm and put on
pressure. If the blood pressure is known — and it
should be — the pressure may be raised immediately
to this point ; if the blood pressure is not known, the
oscillations of the hand on the dial may serve as a
guide. As they cease, just enough air is released to
make them reappear. I wait and watch, my left in-
dex finger controlling the selected vein. No hurry is
necessary. There is no pain. I give plenty of time
until the vessel is full and hard. Then the needle is
introduced. As the blood begins to show, I make
connection with the glass cylinder containing the
solution, release the pressure of the cuff by opening
the air valve and proceed with the injection.
The sphygmanonieter, thus used, improves and
simplifies the technic of intravenous medication or
of taking blood for the Wasserniann test. It has
proved to me of decided avantage over the plain rub-
l)cr tube ordinarily employed. It obviates unneces-
sary pain and does away with guesswork.
30 North Michig.\n Boulev.\rd.
September 21, ip.s.] REDFIELD: ANIMAL POWERS NOT MENDELIAN CHARACTERS.
499
ANIMAL POWPJRS NOT MENDELIAN
CHARACTERS.
By Casper L. Redfield,
Chicago.
Chemical compounds are made up of unit char-
acters. Thus, H^O represents two units of hydro-
gen combined with one unit of oxygen to form
water. NaCl is one unit of sodium and one unit
of chlorine combined to form common salt. And
H.,.S04 is composed of two units of hydrogen, one
unit of sulphur and four units of oxygen, the com-
pound being sulphuric acid.
All of these things, and all chemical substances,
are physical bodies which occupy space. This divi-
sion into imits such as molecules, atoms, or electrons,
is characteristic of every thing which we classify as
matter. But changes in velocity are not similarly
divided into units. A cannon ball passes through
all conceivable changes in velocity from zero to
maximum. Velocity is a factor in measuring energy,
the amount of energy in a moving body being de-
termined by multiplying its mass by one half of the
square of its velocity. Because a factor of energy
is not of unit composition, is follows that energy
itself is not of unit composition.*
An Austrian monk named Mendel made some ex-
periments on the physical characteristics of plants
and discovered that they were composed of unit
characters which combined and separated in heredity
very much as chemical bodies combine and sepa-
rate. The men to whom Mendel communicated his
discoveries were not very brilliant. They either
could not or would not understand him for thirty-
five years. Apparently they wanted to wait until
he was dead before they would admit that an out-
sider could dig up facts which they had overlooked.
But ultimatelv the biologists discovered that unit
characters were a real factor in heredity, and they
proceeded to apply such characters to everything
without any discrimination. Like the scientists of
a hundred years ago who thought that heat was
some kind of matter the biologists of today try to
represent animal energy in terms of physical bodies.
They trv to explain the inheritance of human in-
telli gcnce, physical strength, resistance to disease,
and other forms of energy, in terms of unit char-
acters, when, as a matter of fact, energy is not
divisible into natural units. It belongs in a dif-
ferent order of things and demands different
methods of measurement.
If a man winds up a spring he stores work in
it. The work so stored is plain mechanical energy
and is known to be subject to the laws of thermody-
namics. But that identical energy came out of the
muscles of the man, and it is certain that is was
subject to the same laws when in those muscles
and on its way to and from those muscles. If a
man performs a mathematical calculation he per-
forms mental work. But a calculating machine
driven by ordinary mechanical power does the iden-
tical work. Things which are equal to the same
thing are equal to each other, and things which may
*The idea that an electron is a natural and definite unit of elec-
tricity and that electricity is a form of energy, is not necessarily
opposed to what is stated Here. The electron may be nothin? el^e
tnan the amount nf electricity which is normally associated with the
smallest unit •f matter.
be transformed into the same thing are different
forms of the same thing. Human intelligence is
simply a form c5f mechanical energy, and is subject
to the laws of thermodynamics.
Resistance to disease, the process of digestion,
and all other physiological processes, are operations
in which work is performed. That work involves
the energy known in mechanics, and comes under
the laws of thermodynamics. All of these pro-
cesses depend upon heat units, and heat units are
nothing else than ordinary mechanical energy.
Changes in the heat of a body are nothing else than
changes in the velocity of the molecules of which
the body is composed. Velocity is not divided into
natural units. The heat units are artificial units
used for convenience, and not the natural units of
a chemical composition. Similarly, while we may
represent animal powers by units, such units are
artificial and do not correspond to the natural unit
characters dealt with by the Mendelian theory.
Mendel experimented with tall and short peas,
and peas of different colors. When he crossed tall
and short, green and yellow, etc., he found that
tallness and shortness and greenness and yellow-
ness acted as natural units which would separate
from each other in later generations just as the
elements of a chemical compound will separate
under certain conditions.
When a horse is put into training as a trotter he
will gain in trotting power year by year, but such
training adds nothing to either his tallness or short-
ness, and does not in any way affect the color of
his hair. The muscular strength gained as a result
of exercising the muscles belongs in an entirely dif-
ferent order of things from those investigated by
Mendel. There is nothing of the unit character in
such gain in muscular strength. The assumption
that the presence or absence of developed trotting
power in a horse would act as a Mendelian unit has
no foundation in ascertained fact.
The same thing is true for mental development in
the human being. The child gains in mental power
year by year as a result of mental Efforts. The
Binet system recognizes this in the child up to six-
teen years of age. The aerial service in war recog-
nizes tlje same development of mental power from
eighteen to thirty. The authorities have found by
experience that while a man less than eighteen is
commendably daring, he lacks judgment and too
frequently falls a victim of older men in that life
and death struggle in which intelligence is the main
deciding factor. On the other hand, they find that
a man over thirty is too cautious, which means that
he lacks in that daring which is of advantage to the
army as distinguished from advantage to the in-
dividual. The same continued mental development
is recognized in the old saw about a young man for
war, and an old man for counsel.
From feebleminded parents we get -feebleminded
offspring, and from powerful minded parents we get
powerful minded offspring. That statement recog-
nizes the fact that mental power is an inherited
quality, and that the offspring inherits the kind of
power which exists in the parent. It should be
evident that the child cannot inherit something
which the parent does not have. To assume that a
child can be born wnth something not inherited from
500
REDFIELD: ANIMAL POWERS NOT MENDELIAN CHARACTERS.
[New York
Medical Journal.
the parent is to assume spontaneous generation, or
special creation operating tlirough the germ. No
one boldly assumes either of these things, yet much
of the present day eugenic teaching necessarily in-
volves such assumptions.
The mutations which have been observed are
distinguished from the matter here under con-
sideration in two ways. First, they relate to physi-
cal bodies and not to power. The two things are
in different orders, and it is not legitimate to de-
termine one from the other without direct evidence
of a relationship. Second, a mutation is properly
a change in form of something already in existence,
and not the production of something which did not
before exist. A lump of putty may be molded into
many different shapes, but no amount of molding
will make one pound of putty into two pounds.
Neither will any change in the shape of a piece of
putty add to or subtract from its temperature. The
quantity of putty represents matter, and its tem-
perature represents energy.
There is room here for a lengthy discussion on
the science of Energetics as applied to animal
powers, but that is not the present object. What is
intended here is to point out some fundamental
distinctions which have been overlooked in the
current teachings on heredity and evolution. Prob-
ably some persons think that I am claiming to have
discovered all that there is and am giving the last
word in science. Quite the contrary. I have
opened a door and pawed over a few of the nearest
facts as samples. I am now pointing to a great
mass of untouched facts, a mass great enough to
keep thousands of men busy for many years to
come. I ain pointing instead of digging because
I realize the utter hopelessness of any one person
doing anything more than scratch the surface. And
the way I am pointing is to tell something of the
samples I found.
It is recognized that man descended from a com-
mon ancestor with the ape, and that that common
ancestor had much less mental ability than the man
of today. Also, that still further back the ances-
tors had still less mental ability. As a consequence
there must have been, during the ages, a gradual
increase in mental ability from generation to gen-
eration. This means that later generations inherited
more power than earlier ones. How did that power
get in? Was it a special creation, or a spontaneous
generation? Or did it get in in some other way?
Perhaps some one will say that this assumed de-
scent from inferior ancestors is mere theory and not
a fact scientifically established like the law of gravi-
tation or the rotundity of the earth. Very well
then, we can take another case in which it is posi-
tively known that animal powers have increased
from generation to generation. The American
trotter is such a case. During the nineteenth cen-
tury he improved from the three minute trotter to
the two minute trotter, and we have detailed records
of scientific tests for every year from 1818. The
later generations inherited more trotting power than
the earlier ones. An inherited quality got in some-
how.
In this case we have detailed pedigree records,
and a large amount of detailed horse history. From
these records and this history we can tell under
what conditions trotting power gets in, and under
what conditions it does not get in. This is not
theory, hypothesis, or speculation as some persons
want the public to believe. It is a plain demon-
strable fact that, under certain definite conditions,
new trotting power will get in and be inherited by
later generations. Under certain other definite con-
ditions, no new trotting power will get in. In fact,
trotting p>ower previously in will be lost and later
generations will inherit less than previous ones.
A later generation will inherit more power than
rai earlier one provided the earlier one develops
that particular kind of power by exercise before re-
producing. A horse driven regularly and continu-
ously at the trot will develop trotting power regu-
larly and continuously up to at least seventeen years
of age. We have official records for that matter
up to that point. It can be determined with a close
degree of accuracy just what is an average sire
and an average dam in the horse breeding industry.
.\n average so established is a standard for com-
parison. When any generation has its trotting
powers developed more than this standard, then the
next generation inherits more than the previous
generation inherited. When any generation has its
trotting powers developed less than this standard,
then the next generation inherits less than the pre-
vious generation.
What I am saying here is not based on personal
experiments conducted in a private laboratory. It
is based on public records open to every one. I am
pointing to where those records may be found, and I
am explaining just how my statements may be
tested. I am willing that a test should be made in
any other way, provided it is carried out with some
regard for scientific accuracy and is directed to the
point.
Let us return to a consideration of human beings.
Mental power develops year by year up to a high
age, provided there has been mental activity. The
child inherits the kind of mentality which exists in
the parent. The average parent, male and female con-
sidered together, is about thirty years of age when
the average child is born. Hence, a standard par-
ent is one who has a mental development (at birth
of child) which corresponds to normal mindedness
in a thirty year old. That is a definite standard for
comparison, and that standard can be used in pedi-
grees of different kinds for the purpose of deter-
mining the circumstances under which the race im-
proves or degenerates.
Perhaps some one will say that we have no stand-
ard for what is normal mindedness in a thirty vear
old as distinguished from normal mindedness in a
sixteen vear old, and have no means for establish-
ing the difference. Don't be so helpless. We know
that muscular strength develops as a result of mus-
cular exercise, and the records for the trotter show
that this development will continue as long as the
exercise continues. An analysis of those records
shows that we mav measure the amount of acquired
trotting development in terms of the trotting work
required to obtain it. The Holstein-Friesian records
show that a cow's milk producing power will con-
tinue to develop under milk producing work, and
September 21, loiS.]
BOWER: APPENDICITIS IN CHILDREN.
501
an analysis of these records shows that we may
measure the amount of acquired milk producmg
power in terms of the milk producing work neces-
sary to obtain it. Mental power develops as a re-
sult of mental work, and if the amount of such
development is not measurable in terms of the men-
tal work necessary to obtain it, then nature must be
guilty of some extraordinary self contradiction.
But tests of heredity show that there is no self
contradiction, and that mental development may
be measured directly in terms of the work nec-
essary to obtain it.
It is quite possible and practicable to estimate
with a fair degree of accuracy what would be the
average mental activity of the average person be-
tween sixteen and thirty. If a person who is nor-
mal minded at sixteen is mentally active to the
average degree, then at twenty he will have the
mental status of a twenty year old ; at thirty he will
have the mental status of a thirty year old ; at forty
he will have the mental status of a forty year old ;
and so on. Even when we do not know or cannot
express the average degree of mental activity with
certainty, we can determine that certain degrees of
activity are above the average, and certain other
degrees are below the average. Thus in ten years
of time, a lawyer, or physician, or editor would do
more than the average amount of mental work and
consequently would acquire more than the average
amount of mental development as a result of that
work. On the other hand, a coal miner or a street
sweeper would probably be below the average in
mental activity and consequently in acquirement.
The average individual would be a normal-minded
person at twenty, but he would not be a normal-
minded parent at that age because the average par-
ent is a thirty year old and has the mental develop-
ment of a thirty year old. At twenty he would be
a relatively feeble minded parent. But the same
person at forty would be beyond the thirty mark
and would be a relatively powerful minded parent.
Hence, the same normal person may be a feeble
minded parent in early life, a normal minded par-
ent in midlife, and a powerful minded parent in late
life.
Try this out, and compound it so that it applies
to parent, grandparents and greatgrandparents. Also
remember that each person has eight greatgrand-
parents, each one of whom has an ef¥ect upon the
heredity of the greatgrandchild. When this is done
it is found that superior stock arises from suc-
cessive generations in which the mentality of the
parents is above the thirty year mark, and that
inferior stock comes from successive generations
in which the mentality of parents is below the
thirty year mark.
525 MoNADNocK Block.
Pediculosis Capitis. — E. A. Sainz de Aja (Re-
vista de Medicina y Cirugia Practicas, May i8th,
1918), as parasiticides advises kerosene, two per
cent, phenol, 1-500 bichloride, i-i.ooo sublimated
vinegar, and five per cent, xylol. In men or chil-
dren with short hair ointment of balsam of Peru,
of calomel or yellow oxide of mercury in one per
cent, strength may be used.
APPENDICITIS IN CHILDREN.
By John O. Bower, M. D.,
Philadelphia,
Associate in Surgery at the Tem;)Ie TTniversity; Assistant Surgeon,
Samaritan Hospital; Acting Oral Surgeon to the Phila-
delphia Dental College.
Appendicitis in juveniles, under fifteen years of
age, is interesting to the surgeon because the liability
to err in the diagnosis varies inversely as the age.
Finney calls attention to the fact that with adults
the usual tendency is to mistake something else for
appendicitis, while with the child appendicitis is
mistaken for something else. The percentage of
clean cases in adults who come to operation is grad-
ually increasing, the diagnosis is easily made, and
few are treated medically : consequently peritonitis,
either local or general, is the exception and not the
rule. It has been our experience, however, that
clean cases in children are unusual.
Two years ago on reviewing the case records of
patients operated upon for appendicitis under
fifteen years of age at the Samaritan Hospital, I
found that the percentage of clean cases (those in
which it was not necessary to insert a drain) was
less than ten per cent. At least ninety per cent, had
peritonitis, either local or general, and the mortality
was four times greater than the mortality in a corre-
sponding number of cases among adult patients.
Referring to case reports we find that H. C. Deaver
(Journal A. M. A., December 24, 1910), reported
500 patients operated on under fifteen years of age.
His statistics show, that of the acute cases, which
numbered 403, 343, or eighty-five per cent, had
abscess formation ; and the mortality was 4.6 per
cent.
In a similar number of operations on adults the
mortality was less than five tenths per cent. These
facts show the importance of early diagnosis. In
an adult, we now know that an individual who com-
plains of severe abdominal pain is not suffering
from acute indigestion or gastritis — diagnoses such
as these have had their day ; we must now eliminate
appendicitis, internal strangulation, gallbladder dis-
ease, renal colic, acute perforation of the stomach
or duodenum, and acute pancreatitis, before we are
justified in attributing his ailment to a functional
disturbance. The same is true in children, and
acute pancreatitis, perforation of the stomach and
duodenum, renal colic, gallbladder disease, and in-
ternal strangulation (except in the very young) are
rare. Therefore after excluding the gastrointestinal
toxemias, acute inflammation of the appendix
should be considered as the probable diagnosis.
But, in many cases some member of the family
remembers that the child had eaten a green apple
the day before he was taken sick, and one begins
to doubt, and perhaps (it has been known to occur)
will barken to the grandmother who says. "Oh, give
him a dose of castor oil and he will be all right in
the morning."
ETIOLOGY.
In considering the etiologv in children, the pre-
disposing factors play an important role: I. Ap-
pendicitis in children is not infrequently associated
with other infectious diseases: Influenza, measles,
acute rheumatism, enterocolitis, typhoid, and tonsil-
502
BOWER: APPENDICITIS IN CHILDREN.
[New York
Medical Journal.
litis. It is the opinion of many that the excess of
lymphoid tissue togeth(5r with a thinning of the
submucous coat accounts for the frequency of asso-
ciated appendicular inflammation in these cases. 2.
Abdominal injury predisposes to appendiceal in-
flammation in the young adult, 2.5 per cent, of cases
giving such a history. 3. Fecal concretions are
usually larger and are more frequently found in
early life. 4. Intestinal parasites are uncommon but
are more frequently associated with appendicitis in
juveniles. 5. Foreign bodies are more frequently
found in appendices in children than in adults. We
have seen lemon and grape seeds, toothbrush
bristles, toothpicks, and, within the past month a
common pin. In this instance the patient, two and
a half years of age, entered the hospital with a his-
tory of lower abdominal pain, nausea, vomiting, and
frequent urination, of four days' duration. At op-
eration we found a localized abscess with a rusty pin
well down in the pelvis. The tip of the appendix
was markedly hypertrophied, the pin undoubtedly
having lodged in this portion of the organ for some
time prior to its passage into the peritoneal cavity.
The direct causative factors are the bacillus coli,
staphylococcus, streptococcus, bacillus pyocyaneus,
and the tubercle bacillus. This is the order of fre-
quenc}' with which the above mentioned germs at-
tack the appendix. It must be remembered, how-
ever, that tuberculosis of the appendix in adults is
invariably secondary to a pulmonary lesion, while
in young adults it usually follows or accompanies a
general abdominal tuberculosis.
SYMPTOMS.
The symptoms of appendicitis in children are the
same as the symptoms in adults, the sequence being
pain, nausea and vomiting, localized tenderness,
rigidity, temperature, leucocytosis, and at times uri-
nary frequency. The initial symptom of pain is of
a variable quality in children. As a rule general
abdominal, primarily ; later, in the majority of cases,
localized in tlie right low'er quadrant. Owmg to
the relatively greater length of the appendix in
children, a certain percentage complain of right
hypochondriac, or left iliac pain, which renders a
correct diagnosis rather difficult at times. Vomit-
ing is more variable in appendiceal inflammation in
children, due to the fact that children are more
liable to gastrointestinal disturbance than the adult.
In a fair percentage of cases the history shows that
nausea and vomiting preceded the usual initial
symptom pain, but after careful investigation it is
found that in the greater percentage of cases nausea
and vomiting followed the initial symptom. The
severity of the nausea and vomiting depends upon
the causative germ. In streptococcus infection the
most severe vomiting occurs, less in staphylococcic,
and least in colon and tubercle infections. The
usual history is that there are one or two attempts at
vomiting which subside and do not recur unless the
peritoneum is involved. When this takes place the
vomiting recurs and is more persistent, the vomitus
consisting of the contents of the upper intestinal
tract above the site of inflammation.
Localized tenderness before the involvement of
the parietal peritoneum is not constant. It must be
reirembercd that the appendix in children is more
liable to vary in position, so that we frequently en-
counter cases where, because of a post cecal posi-
tion, or one low in the pelvis, we have very little
abdominal rigidity. When, however, the parietal
peritoneum becomes involved, the abdomen becomes
rigid and distended. Temperature in children is
more variable than in adults, and inasmuch as the
colon bacillus is the most frequent of¥ender, the tem-
perature is usually of moderate degree ; the staphylo-
coccus producing a higher range, and the strepto-
coccus the maximum degree of temperature, in these
cases a sudden drop being indicative of perforation
or gangrene. I would call attention to the fact that
one may have a tubercular involvement of the
cecum and appendix with little or no temperature,
perhaps only an afternoon rise to 99.3°, or an en-
tire absence of temperature for several successive
days. A blood examination is valuable when one is
in doubt about the diagnosis. A leucocytosis can
frequently be obtained before there is involvement
of the peritoneum and often before the appearance
of temperature. Urinary frequency is a frequent
accompaniment of the above mentioned symptoms
and is undoubtedly due at times, to the position of
the appendix low in the pelvis in a certain percent-
age of cases, its close proximity to the bladder ac-
counting for this symptom.
Given a sequence of symptoms as previously
narrated, one should be suspicious of appendiceail
inflammation, especially if within the first eighteen
hours a leucocyte count of 15,000, or upwards be
present. If pneumonia can be excluded, the diag-
nosis is almost certain. Leucocytosis above 15,000
is unusual with catarrhal inflammation of the in-
testinal tract, cystitis, acute pyelitis, salpingitis,
ruptured duodenal ulcer, strangulation, intussus-
ception, ruptured graafian follicle, gallbladder
disease, etc. The importance of a rectal ex-
amination should not be forgotten, it being pos-
sible at times to palpate a pelvic mass from below,
when abdominal examination is practically negative.
In very young children where the possibility of
a chest condition has been eliminated, one is justified
in administering enough ether or chloroform to
overcome the spasm of the recti. Careful palpation
will invariably reveal in the early stages a mass
of omentum near the inflamed organ. If, how-
ever, the process has advanced to abscess forma-
tion, palnation may not be necessary, increased
abdominal fullness being distinctly noticeable in the
right lower quadrant in the majority of instances.
Of course, if the appendix is abnormally situated
the value of this examination is considerably
diminished.
ri}l-FERh:NTIAL DIAGNOSIS.
I. Ptomaine poisoning or acute gastrointestinal
colic is the usual diagnosis in the large percentage
of cases that come to operation. In^these cases the
presence of diarrhea rather than constipation, the
absence of leucocytosis, and the cessation of vomit-
ing following stomach lavage, together with a his-
tory of some indiscretion in diet, make the diagnosis
of toxemia evident. 2. Acute pyelitis is common
and not infrequently associated with abdominal
pain. In these cases, however, the dominant symp-
tom is usually fever, which, with a careful micros-
copic examination of a centrifuged specimen of
September 21, 1918.!
UPHAM: MUCOUS COLITIS.
503
urine, is sufficient for making a correct diagnosis.
Here one must exclude a possible vaginitis. 3.
Intussusception in children may be ushered in by
a sudden cry, (Murphy). A sausage shaped mass
which varies in position, the presence of the char-
acteristic overflow vomiting of intestinal obstruc-
tion, together with the bloodstained mucous stools,
and the absence of rigidity, leucocytosis, and tem-
perature, are the main features to be considered in
diagnosing this condition. 4. Pneumonia: During
the past eight years, at least four cases of pneumonia
in children reached the etherizing room with a
diagnosis of appendicitis. The points to be remem-
bered in the differential diagnosis are the respira-
tion, pulse ratio, and the intermittent spasticity
rather than the continuous rigidity, of the recti ;
also herpes, and an excessively high leucocyte
count. 5. Acute perforation of the stomach and
duodenum : Two years ago I reported a perfora-
tion of the duodenum in a boy of fourteen years
of age who was referred to the surgical service
of the Samaritan Hospital. The diagnosis liad
been made by the attending physician prior to opera-
tion. The pain experienced is usually so severe that
the patient cries out, falls to the floor, and writhes
in agony. There is marked abdominal rigidity.
And it is well to remember that these patients vomit
immediately the drug or laxative which is given to
them by mouth. This alone is suspicious of a per-
foration high up in the intestinal tract. H seen
early these cases have a subnormal temperature and
a pulse which is unusually slow compared to the
severity of the shock present.
6. /Vcute pancreatitis: A girl fifteen years old,
entered the hospital with a history of having had
several attacks of abdominal colic which confined
her to bed for several days at a time. These were
associated with nausea, vomiting, and slight tem-
perature. The last attack which occurred three
days before she was admitted to the hospital was
more severe than the preceding; ones. The pain
was markedly severe, and accompanied with vomit-
ing of bilestained mucus. On one occasion she
vomited a considerable quantity of dark blood. On
admission to the hospital she showed evidence of
general peritonitis. Her temperature was 100°,
pulse 140, leucoc>i:osis 15,600. A diagnosis of ap-
pendicitis was made. A low incision revealed a
slightlv engorged appendix with no adhesions, and
free fluid of turbid quality in the abdominal cavity.
A vertical incision above revealed advanced fat
necrosis of the upper right abdomen, the gall
bladder thickened, inflamed, and filled with small
.stones, about 200 in number. The head of the
pancreas was thickened and engorged. In this case
the history of preceding attacks of colic, followed by
one of unusual severity, which was accompanied by
a rise in temperature, rapid pul.se, and vomiting of
blood, should have lead to a diagnosis of pancreatic
inflammation.
7. Abdominal tuberculosis : Experience has
shown that in ninety per cent, of the cases where
a physician has made a diagnosis of appendicitis
in a child who has had previous attacks of similar
nature, characterized by general abdominal colic,
nausea and vomiting of a moderate degree of sever-
ity, obstipation and temperature, we find abdominal
tuberculosis of one type or another. On opening,
in this type, one usually finds an apparently normal
appendix, which together with the rest of the con-
tents of the abdominal cavity may look rather anemic.
There is generally free fluid which varies in amount
and is usually^ observed before the appendix is
located. Enlarged mesenteric glands are a fre-
(|ucnt accom])animent, these being more noticeable
in the neighborhood of the cecum, or the bowel
itself may be studded with numerous tubercles.
Corner, in The Lancet, has called attention to the
frequency with which these cases come to oi>era-
tion, and the universal improvement which follows
appendectomy (the proper treatment in early tuber-
culosis of the abdomen being an exploratory lap-
arotomy).
TREATMENT.
Immediate operation is generally accepted as be-
ing indicated in practically all types of appendiceal
inflammation, the exceptions being: i. Early
perforations with widespread peritonitis due to the
streptococcus. 2. Cases of general peritonitis of
several days' duration, where an operation might
turn the tide against a favorable outcome. In
these cases many institute the Ochsner treatment
with excellent results, (not easily carried out in
children). At the Samaritan Hospital, however, it
has been our experience that these cases do better
if drainage is instituted. This may be accomplished
with a minimum amount of shock to the patient by
using- either local or intraspinal anesthesia. The
advantages gained by the use of the latter are: i.
The patient's emunctories are not interfered with
as they unquestionably would be if ether were ad-
ministered. 2. Relaxation of the abdominal mus-
cles permits the insertion of a drain with the least
possible amount of manipulation of the abdominal
contents. 3. Paralysis of the bowel and sphincter,
permits evacuation of contents of the lower bowel.
2033 Walnut Street.
MUCOUS COLITIS.
By Roy Upham, M. D., F. A. C. S.,
Assistant Professor of Gastroenterologv. New York Homeonathic
College; Attending Gastroenterologist, Prospect Heiehts Hospital;
Consulting Gastroenterologist, Jamaica Hospital.
The condition covered by this title has been one
of the battlegrounds of medicinal pathology and
treatment for the last two decades, proof of this fact
being the many synonyms by which the condition
is known, membranous colitis, pseudomembranous
enteritis, tubular diarrhea, mucous colic, etc.
The first consideration of this condition must be
from a combined etiological and pathological view.
Nothnagel in describing this condition based his
premises on the fact that the condition was one
of a pure neurosis and that there was no concomi-
tant colitis. The cases which have come to the
autopsy table ha\'e been few and the pathological
findings at variance, some authorities demonstrat-
ing a well marked enteritis and another school of
pathologists determining a normal condition of the
intestines.
In carefully analyzing the history of a large num-
ber of cases there has always been a stage of pre-
liminary enteritis not characterized by the later
504
UPHAM: MUCOUS COLITIS.
[New York
Medical Journal.
manifestations of mucus and colic. The diagnostic
feature of this enteritis is the fact that the patient
has noticed a tendency toward the easy occurrence
of diarrhea and the further fact that, on careful
([uestioning, it is found that, on waking, there was
an uncomfortable sensation in the abdomen which
developed into a cranipy condition of more or less
intensity, which was relieved by the passage of
gas. The characteristic feature of this condition
was that it appeared the first thing in the morning
on the patient getting out of bed and undertaking
active movements.
The next step in the pathology, after the con-
dition of mild enteritis is established with the ap-
pearance of the aforementioned symptoms, is a
consideration of the so called vagotonic and sympa-
theticotonic states. It has been amply demonstrated
that stimulation of the vagus in health produces
motor activity along the gastrointestinal canal.
This activity is held in check and controlled by the
inhibition from the sympathetic nervous system.
The wonderful phenomenon in this occurrence is
the nerve balance in the normal individual whereby
stimulation is combated by just enough inhibition
tc produce a condition of nervous balance with re-
sultant normal functioning of the gastrointestinal
systeni. But in an individual who has an over
active vagus, which may be due to an excess of
nerve activity of that structure, there occurs a
series of spasmodic activities throughout the gas-
trointestinal canal. These spasmodic activities
when in the stomach produce areas of ischemia and
are the foundation of deficient circulation which
makes possible the location of infection from any
systemic source and the production of gastric ulcer.
The same series of phenomena occurs in the large
intestine : a condition is brought about which gives
rise to spasmodic contractions of the colon, which
are a feature of the condition of mucous colitis.
The radiograph has shown that the characteristic
feature of these cases is spasmodic contractions
occurring along the course of the descending colon.
These spasms cause areas of stasis in the gut and
with these areas of stasis there occurs, due to irrita-
tion, an excess mucus formation which is preci-
pitated in the form of mucous masses varying in
size from small masses of one centimetre in di-
ameter to actual tube casts of the entire large gut.
The secondary factor which allows this precipita-
tion of mucus is the absence of a substance called
mucikinase, which is one of the secretions of the
liver which is deficient in these cases, probably due
to the same motor phenomena. Thus we have
brought about the conditions which explain the
pathological and etiological sources of the disease.
Symptomatically, the condition is characterized
by pronounced constipation, the features of the con-
stipation being the passage of hardened masses of
fecal matter which are of small calibre and often
broken into small pieces like the stool of sheep ; a
prolonged retention of the fecal matter in a spas-
modic area of gut extracts entirely the fluid con-
tents of the stool, leaving a very small mass in the
gut, this producing the constipation by the fact that
there is very little content of the intestine to stimul-
ate motor action and produce a normal desire to
empty the bowel. This is further increased by the
spasmodic contractions of the intestine, which have
already been enumerated. This condition of motor
.spasm may be so severe as to simulate left sided
renal colic and require narcotics in order to produce
relief. The characteristic location of the spasm is
along the descending colon and it usually occurs
several hours after the intake of food. With the
ribbon shaped stools masses of mucus are passed
which are characteristic in their appearance, and
due to fecal retention. The group of symptoms of
a condition of intestinal autointoxication are pre-
sented : the cachectic skin, offensive perspiration,
poor appetite, compression and distention, due to
the complicating gastritis which is associated with
belching of gas and the passage of gas per rectum,
and nausea which rarely progresses to the stage
of vomiting. Due to the poor elimination, these
cases always undergo a voluntary diet with result-
ant loss of weight, approaching almost a cachexia,
and with the most pronounced mental symptoms — ■
depression, amounting even to melancholia, head-
ache and dizziness, drowsiness after meals, periods
of protracted sleeplessness, and irritability of the
most pronounced variety.
The prognosis given by most authorities is very
discouraging, but with the following treatment most
encouraging results have been attained.
TREATMENT.
The first condition of treatment is to rid the in-
testine of the spasmodic colitis. A number of con-
tinental clinicians have based their treatment upon
the ground that the first essential is to rid the in-
testine of all sources of irritation by means of a
bland diet, rest, and elimination of nerve hyper-
tension. After much experimenting along this line,
this treatment appears to me to be radically in-
efficient, and the most effective method, in my
opinion, is to disregard this stage of colitis and ap-
]jroach the problem from the standpoint of under
nutrition and resultant nerve exhaustion. With
this in mind the first step is to attempt super-
alimentation of the patient, which can be accom-
plished most readily by increasing the caloric intake
of the patient in a systematic manner. The patient
is instructed to have weekly weight records kept
and is given a diet list by which all articles of food
can be readily determined in units of loo calories.
The patient is then instructed to start with a definite
number of calories, depending upon his weight,
arbitrarily speaking 3,000. This is increased 200
calories a week until the patient is gaining a pound
a week. The success of the treatment depends not
alone on the patient keeping an accurate list of the
foods which are taken, but also the exact amounts
in tablespoon fuls, or ounces, that the caloric value
may be summed up after the evening meal. Should
there be a deficiency in the required num.ber of
calories, before retiring the patient takes concen-
trated nourishment in the form of cream, milk
sugar, malted milk, eggs, etc., to produce the re-
([uired number of calories for the day, the whole
success of the operation depending upon an accur-
ate caloric record being kept by the patient. Un-
less the physician insists on this, no considerable
degree of success will be attained.
A person beginning this line of work must not
think that patients will gain weight steadily each
September 21, 1918.]
UPHAM: MUCOUS COLITIS.
505
week, nor should an immediate increase in weight
be expected. There may be no gain in weight for
several weeks, and then in one week there may be
an increase of three or four pounds, and similar
spasmodic increases may occur until sufficient
weight has been gained.
The principle of the high caloric intake is sup-
plemented by the second factor in the treatment,
the rapid passage of food through the intestine by
natural means, unassisted by any of the so called
cathartics. Success cannot.be attained in these
cases as long as cathartics are used, as practically
every one is a spasmodic remedy and only ag-
gravates the spasmodic condition already present.
The bowels can be made to have normal times of
functioning if in addition to the high caloric in-
take, articles of food are added which can not be
absorbed and leave a large bulk to the stool, thus
stimulating the intestine, as by a foreign body, to
extrusion of its contents. The substances which
are most effective are the agar-agar preparation,
bran and flaxseed given in some form. Large
quantities of these sho;;ld be taken, especially agar-
agar in its flake form, in the proportion of one
to four tablespoonfuls in some kind of stewed fruit.
This can be taken with one meal and Jackson's
Roman meal, which is a cereal containing flaxseed
may be used for the breakfast cereal, with the even-
ing meal of grape nuts, combined with a half a cup
of bran. This together with a Colax wafer at
every meal, is usually a sufficient amount of in-
soluble substance to produce a desire for bowel
movement. This can be further aided by the use
of mineral oil, given in doses of from one to four
tablespoonfuls several times a day. Undoubtedly
every one who has had much experience with min-
eral oil has had patients complain that, sooner or
later, the oil escapes while passing gas and causes
distressing results, saturating the clothing and do-
ing damage to the location that the patient happens
to be in at the time. The author has overcome this
unpleasant sequence by combining the mineral oil
with ordinary grape juice and holding the oil in
suspension by mucilage of acacia. This is a mixture
of equal parts of oil and grape juice with one
eighth the quantity of mucilage of acacia. Taken
immediately before meals, no unpleasant results fol-
low the use of the oil and the fme subdivision of the
oil produces far more effective results.
On rising, the patient is instructed to take two
glasses of water, in which is dissolved one table-
spoonful of milk sugar. This is followed by a break-
fast consisting of raw fruit, followed by a Jackson's
Roman meal for a cereal and the free use of rye
bread or Boston brown bread, upon which butter is
used to enhance the caloric intake. Then if a weak
cup of coffee, to which a large quantity of cream or
condensed milk is added, be taken we have a break-
fast which has a high caloric value and contains
very little proteid matter. For the protein intoxica-
tion which these cases usually have, a Kellogg
wafer should be taken with each meal. The patient
is also instructed to take in the middle of the morn-
ing eight ounces of butter milk, preferably home
made, because home made buttermilk contains the
fat which is eliminated in commercial buttermilk.
Lunch consists of not over lOO calories of meat,
to which are freely added green vegetables, such as
string beans, Brussels sprouts, cauliflower, carrots,
parsnips, etc., and a simple salad or lettuce con-
taining a large amount of sweet oil and lemon juice,
to be followed by a dessert of stewed fruit, with
which is eaten one of the commercial varieties of
laxative biscuits containing bran.
In the middle of the afternoon a glass of milk,
containing a half a cup of bran, should be taken.
Dinner is much the same as lunch, adding not
over four ounces of a cream soup, with lOO calories
of proteid, the same green vegetables, the plain
salad with plenty of sweet oil, and for dessert
grape nuts and agar-agar softened with cream.
With this meal are also eaten several slices of Bos-
ton brown, rye or whole wheat bread, covered with
thick layers of butter, wheat bread being inter-
dicted. Before retiring, stewed figs and Kellogg's
laxative biscuits are taken, or agar-agar, also with
stewed fruit, is taken as an auxiliary dessert with
the evening meal, the patient being reminded all the
time to keep an accurate record and if necessary to
supplant these meals with other food sufficient to
produce the large caloric intake suggested in the
early part of the paper.
From the standpoint of drugs applicable to these
cases, the best results have been attained from the
use of magnesia salicylate in eight grain doses,
combined with one fifteenth grain of powdered
leaves of belladonna, taken three times a day. Oc-
casionally the author has used eumydrine in place
of the powdered leaves of belladonna.
Favorable results have also been attained along
the line of liver stimulation ; the precipitation of
mucus in these cases is due to deficient hepatic ac-
tivity. The relation of the hydrochloric acid secre-
tion of the stomach to the functions of the liver and
gallbladder, is just beginning to receive the atten-
tion it deserves. Whether the gallbladder is an
activator of the secretion of hydrocholoric acid, as
stated by one authority during the past few months,
or, vice versa, whether hydrochloric acid is not the
stimulator of the liver and the gallbladder, is a
point open to discussion. It seems more logical
to believe that the stomach stimulates the organ
further along the digestive tract than the opposite
state of affairs, and this has been verified by the
beneficent effects of the free use of dilute hydro-
chloric acid in most liver conditions. When a
study of tl^e gastric findings already made in the
diagnosis of such a case fails to reveal a condition
of hyperacidity, fifteen drops of dilute hydrochloric
acid with forty-five drops of essence of pepsin
are given immediately after meals, taken well
diluted through a glass tube. The deteriorating
effect of hydrochloric acid on the teeth, if it is
taken over a long period of time, must be re-
remembered. This treatment is supplemented by the
use of the various bile salts, glycolate of sodium,
succinate of soda or acid sodium oleate and last,
but not least, the free use of oxgall by mouth.
These substances certainly enhance liver activity,
and with the liver taking up its part of the diges-
tive work conditions much more readily return to
normal. Medicinal soap given in three grain pills
several times a day is also of value in this type of
case.
5o6
UFHAM: MUCOUS COLITIS.
[New York
Medical Journal.
Extensive experiments have been made with
lactic acid cultures and it is but fair to state that in
my experience all varieties have been distinctly dis-
appointing in their effect. It seems far more logi-
cal when beginning, even in small fluid doses or
tablets of medicine, to supply them in large amounts
of buttermilk if results are to be expected. A
French preparation called "Antimucose" has re-
ceived its share of attention, but the results have
not warranted its continued use.
To all operators the magnificent stimulating ef-
fects of pituitary solutions used hypodermically in
post operative cases to promote peristalsis and the
expulsion of imprisoned intestinal contents, have
made welcome the preparation of liquid pituitrin
which is taken in from one to five drop doses under
the tongue two or three times a day. In using this
preparation in this class of cases we must be mind-
ful of the double action of endocraniological reme-
dies and must be wary of producing over stimula-
tion of the motor powers of the gut. Therefore,
with this pituitary liquid, very small doses, even
of a drop or a half drop, must be used in the be-
ginning, and an advance to a substantial amount
may be made only after prolonged use of the drug
and careful observation of its effects.
Auxiliarv treatment, consisting of night injec-
tions into the bowel of a ten per cent, gelatin solu-
tion, eight ounces of which are taken as hot as can
be borne and retained until morning, or, similarly,
eight ounces of cottonseed oil taken warm and re-
tained until morning, produces most satisfactory
results. Hot applications, for their antispasmodic
effects, are given in the form of hot flaxseed poul-
tices, which can be further assisted by the use of
hot water bottles over a prolonged period, or by
use of the electric heating pad. Hot sitz baths and
Presnitz compresses may also be used, and oxygen
irrigations of the intestines, taken through a duod-
enal tube. There is no question but that oxygen
does much to bring about a normal condition of
intestinal flora, if it is gotten into the small and
large gut. By means of a cylinder of oxygen at-
tached to a duodenal tube, the patient takes treat-
ments for about a half an hour in the morning, al-
lowing the oxygen to pass slowly through the tube ;
the patient experiences no discomfort, is conscious
of a fullne,=s in the abdomen and passes the gas
from the rectum within a few minutes of the time
that the instillations are begun through the mouth.
The author is indebted to Schmidt for this sugges-
tion and has found it of extreme value in these
cases.
Treatments can be taken at home, the patient
, readily learning to pass a duodenal tube, and the
ordinary commercial cylinders of oxygen used for
anesthesia are readily at hand. This can be sup-
nlemented by encmata of carbon dioxide gas, which
has a wonderfully antispasmodic action on the large
bowel, and which can be taken by using a rectal
tube, attaching it to an ordinary siphon and invert-
ing the siphon after enough water has been allowed
to pass out so that the glass tube in the siphon is
above the water level area ; then the contained car-
bon dioxide gas is liberated and passes out into the
rectal tube through the bowel.
Several vears ago I conducted a prolonged series
of experiments on the use of autogenous vaccines
in intestinal autotoxemic conditions. A report of lOO
such vaccines failed to show any improvement in
the intestinal condition, and I do not think that the
patients should be subjected to the expense incident
to such procedure. However, a suitable mixed vac-
cine is a valuable adjunct in the treatment of these
cases.
The use of saline mineral waters has not ap-
peared to be of especial value, the laxative waters
especially being interdicted, but if after a careful
urinary examination a condition of acidosis is
found, the use of bicarbonate of soda in teaspoon-
ful doses several times a day, combined with a
lactose solution, produces a cure of the acidosis,
and commercial Kalak water is most effective along
this line.
The subject should not be left without tribute
being given to electric modalities in producing re-
sults in these cases, Geiser reporting a series of
cases in which there was marked relief from the
use of the high frequency current applied by the
diathermic method. Surpassing even this in benefit
is the method of using the sinusoidal current, and
the author, despite its irritating effect, uses a com-
bined abdominorectal faradization, the important
point being to use only a current with a long thin
wire secondary coil, which is sedative in its effect,
the ordinary commercial coarse wire secondary coils
Ijcing irritating and doing more harm than good.
Supplementing this the various actinic lights may
be used, and where they are powerful enough to
produce a sharp dermatosis over the abdomen with
subsequent tanning of the skin, beneficial results are
undoubtedly attained by the sedative effect pro-
duced on the irritated intestinal mucous membrane
and musculature.
The clinical results attending surgery in this class
of cases are not at all favorable, and surgical treat-
ment of these cases should be discouraged. The
hypertensive nervous system is only aggravated by
the psychic shock incident to operation, and cases
have been seen that have been put back a year on
the road to recovery by the too free apphcation of
surgical measures.
Tt would be useless to attempt the treatment of
anv of these cases without iirst determining whether
or not there is displacement of the stomach or intes-
tines, or whether a general splanchnoptosia is pres-
ent ; and the fact has been repeatedly emphasized by
the author that cases of misplaced abdominal vis-
cera are not appealing from the alteration of their
geographical position, but from their physiology,
and efforts should be made to determine the point
where the motility of the gastroin.testinal tract is in
error and correction brought about by the suitable
application of supporting bands and corsets. An
inflated air pad, which is placed in the lower seg-
ment of the corset, from the navel down, is the most
effective present method of producing intraabdomi-
nal pressure. The musculature of the anterior ab-
dominal wall, despite the spasmodic conditions below
it, must be vigorously attacked to produce increased
strength, and the general setting up exercises, and
the use of the shot bag apron, will remedy this dis-
tressing feature.
300 McDoNOUGii Strekt.
Medicine and Surgery in the Army and Navy
MOBILIZING THE SPAS AND HEALTH
RESORTS OF OUR NATION*
Bv N. Philip Norman, M. D.,
Fort Leavenworth, Kan.,
Captain, Medical Reserve Corps. U. S. Army; Examiner in Neuro-
psychiatry, U. S. Disciplinary Karracks, Fort Leavenworth.
(Continued from page 465.)
THE HOT SPRINGS OF ARKANSAS.
Nestled in a valley in the Ozark mountains, the
famous thermal springs are found, flowing- in seem-
ingly endless quantity.
Frequented first by the aborigines, whose tradi-
tions credited the dwelling of the Essence of the
Great Spirit in the hot waters, and more recently
by the ''pale face" for the relief of conditions un-
improved by the usual incantations and dispensa-
tions of primitive and modern "medicine men,"
respectively, these springs have a reputation that
dates from primeval times. When we speak of Hot
Springs, Arkansas, we
think of that metropoli-
tan resort, with its many
hotels, boarding houses,
bath houses, drinking
fountains, wide streets
and roadways winding
to the mountains, and
the dehghtful social at-
mosphere of that city
accustomed for so many
years to entertain the
thousands who fl o c k
there in quest of health.
Surrounded on all sides
by scenic grandeur, nat-
ural and artificial, one
may revel in the artistic
creations of nature and
man with hygienic effect
upon mind and relaxa-
tion of the nervous ten-
sion that wears so many
physiques. The golf
links are noted as one of
the best in the country
and many other attractions have been provided for
the entertainment of guests.
In 1832 the government set aside a reservation,
thereby protecting the springs and exerting a super-
vision of their control. In 1882 the Army and
Navy hospitals were erected and have been in opera-
tion since that date — a substantial attestation of the
regard that the Medical Departments of the Army
and Navy hold for the therapeutic value of the
waters. Numerous drinking fountains have been
erected throughout the reservation, facilitating the
use of the waters at all times and places. A system
of graded paths, modeled after the scheme of Oer-
tel, has been built.
There are forty-three thermal springs and a num-
ber of cold mineral springs. The thermal springs
issue from the groimd at temperatures varying
from 135° F. to 145° F. They contain no mineral
ingredients, and the therapeutic principle is chiefly
radium emanation. One spring has a maximum
charge of 265.6 Mache units. The waters are used
for- drinking and bathing. The cold springs are
used for drinking purposes. The thermal waters
are collected and mixed so that no bathhouse can
be said to have a better water than another and
claim superiority.
Since radium emanation is the feature property
of the thermal springs of Hot Springs, Arkansas,
a brief summation of what we know about the phys-
iological effects of this therapeutic force is ne-
cessitated in order to understand the physiological
action of the baths. While Hot Springs, Arkansas,
may justly claim radioactive superiority over the
other springs m this country and demonstrate be-
vond a doubt the therapeutic action of radium em-
anation on the diseased organism, it is by no means
the only spa in this country that may ascribe results
to this force. However,
r——\ HoibiUl favi.Uim.s
Plan
*Published by permission of the Surgeon General's Office,
mgton.
Wash-
it is the only spa that
can claim results due en-
tirely to radium emana-
tion, becatise its waters
are free from other
chemical ingredients.
The physiological ac-
tions of radium are
many and varied. That
it is a metabolic accelera-
tor is shown by its effect
upon the blood making
organs — increase of the
blood cells, of hemo-
globin and of the coagu-
lability of blood; its
stimulation of digestive
processes, especially
when taken internally ;
the increase of the func-
tional activity of the kid-
neys, with a better
elimination of the urea
and tiric acid, due to its
promotion of their com-
plex chemical processes ; favorable influence on the
ductless glands, the liver, the lymphatics, and
serous cavities. Respiratory rate is increased
with a corresponding increase of carbon diox-
ide elimination. Blood pressure is lowered an.-l
the overburdened heart relieved. The sexual
organs are stimulated.
Summed up in few words, the physiological effects
of the baths are - Marked metabolic activity, mani-
fested by an increase of body temperature, usually
from two to three degrees Fahrenheit, in a bath of
from five to fifteen minutes' duration, and persist-
ing on an average for forty minutes, when it re-
turns to normal ; acceleration of circulatory activity,
the heart rate increasing from thirty to fifty beats a
minute ; perhaps the increase of the opsonic index
because of this metabolic activity ; a profuse dia-
phoresis following the bath and, in this way, effect-
ing a return of body temperature to normal, and the
for spoke Base Hospital of 50,000 beds, near Hot
Springs, Arkansas.
5o8
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
usual reaction of hydrotherapy at the given tem-
perature of the baths. For a more extensive trea-
tise, the reader is referred to Dr. E. H. Martin's ar-
ticle in the March, 1916, issue of the Southern
Medical Joitrnul and to Dr. William H. Deaderick's
article in the ^larch i8th, 1916. issue of the New
York Medicai, Journal.
Methods of administration: i. Tub baths, usu-
ally at a temperature ranging from 97° F. to 99° F.
and with a duration ordinarily of from five to fif-
teen minutes. Rubbing during the bath is a custom-
ary technic unless contraindicated. Doctor Martin
of Hot Springs emphasizes that a more accurate
way of determining bath duration is by observing
the temperature reaction with the clinical ther-
mometer instead of prescribing a definite time. 2.
Vapors : The patient sits in a small cabinet, head
inside, and inhales the vapors that arise from the
water that rushes by. not touching him, at a tem-
perature of 145° F. — a true emanatorium. 3. As a
drink: Drinking of the radioactive waters is en-
couraged and is a definite way of introducing the
emanation into the system. 4. Packs : Local ap-
plications of special cloths saturated with the water
and applied as hot as can be borne by the patient.
Medical conditions, with a bacterial or metabolic
etiology, chiefly benefited at this spa are the rheu-
matic group types ; gonorrheal, the subacute and
acute articular conditions following infections ;
chronic arthritis, gout, syphilis, malaria, nephritjs ;
chronic skin deseases, especially of the squamous
A-ariety ; cardiorenal disturbances secondary to ex-
cessive arterial tension ; the functional nervous dis-
orders, and the neuritides.
Hot Springs can accommodate approximately
20,000 guests, and its bath house capacity is adequ-
ate in proportion. Because of its location on the
isothermal line its climate is neither too hot nor too
cold, the average seasonal temperatures being ap-
proximately: Winter, 47° F. ; spring, 60° F. ; sum-
mer, 78° F. ; fall. 64° F. The Government Reser-
vation is large enough for any additional hospital
unit that may be planned. I am indebted to Dr.
J. C. Minor of Hot Springs, Arkansas, for the ac-
companying drawings which illustrate concisely the
proposed plan originated by Doctor ]\Iinor and Doc-
tor Deaderick and Mr. Belding of Flot Springs
( composing a committee selected by the Business
Men's League of that city), for a psychiatric unit
and base hospital of a capacity of 50,000 beds. This
l^roposition has been submitted to the Surgeon Gen-
eral for consideration. There is no doubt that Hot
Springs has natural advantages that commend it
strongly It is accessible from practically all direc-
tions.
FRENCH LICK SPRINGS.
The Springs are located in a beautiful valley in
southern Indiana, amid charming and picturesque
.surroundings. The proj)erty of The Springs Com-
pany comprises 2.000 acres, including the springs,
lawns, golf course, gardens, dairy farm, and sur-
rounding hills.
The climate is that of the lower Ohio River val-
lev. The average mean temperatures are as fol-
lows : Spring, 53.9° F. ; summer, 76.6° F. ; autumn,
55-9° ^- ; winter, 33.3° F. The elevation is 500
feet, and tins determines the climate as neither too
bracing not too enervating.
The Springs hotel is a fireproof structure of six
stories, and contains more than 600 rooms, each
with a bath and all modern conveniences. This
hotel is elaborately decorated and furnished in every
department. In addition, there are two convention
halls with a seating capacity of 400 and 150 persons,
respectively, which can be adapted easily to the
purix)ses of recreation and occupation.
The three springs, Pluto, Bowles, and Proser-
pine, are of the sulphated-sulphuretted-alkaline-
saline type, and contain the same ingredients in
varying concentrations. They are all radioactive.
Pluto and Proserpine flow at a constant temperature
of 55° F. ; Bowles, at a temperature of 50° F.
Ihe medicinal properties of the springs are derived
from the mineral salts and other constituents in
solution : The sulphates of sodium and magnesium,
sodium chloride, the carbonates, and small quantities
of iron. The chief components are the sulphates of
sodium and magnesium and the chloride of sodium.
Pluto water is the strongest of the spring waters
in all properties except radioactivity, and is the one
most largely used. Its laxative effect is more
marked than that of the others, and it is especially
valuable when used for digestive disturbances,
functional and inflammatory diseases of the
stomach, intestines, and liver, and in the derange-
ments of niitrition. Bowles water has the smallest
mineral content, but much the greatest radioactivity,
and is chiefly diuretic in effect. Proserpine may be
said to be a prototype of Pluto, but less intense in
action.
The drinking of the waters, when properly pre-
scribed, is valuable in the following conditions and
diseases : Diseases of the stomach, the hyperchlorhy-
dnas, the so called gastric catarrhs, the gastric
neuroses, atonic stasis and dilatation coming within
the field of the waters' usefulness through the tonic
and cleansing effects obtained ; diseases of the in-
testines, constipation and disorders secondary to
this dysfunction, and colitis ; disorders of the liver,
those incident to constipation and in the early stages
of cirrhosis of the liver, and in the catarrhal jaun-
dices ; disorders of nutrition, as the so called gouts
and rheumatisms, and obesity of the metabolic
type ; functional nervous disturbances, especially
tliose somatically expressed by complaints of in-
digestion, hyperacidity, or hyponiobility and hyper-
mobiHty.
The bath department is in harmony with the
general excellence of the rest of the establishment.
Rest rooms are well arranged for the use of pa-
tients. The e(|uipnient includes Aix, Vichy, Scotch,
fan, rain, circular, steam and perineal douches with
rooms for colon irrigations, massage and swimming
])oo].
The effects of the baths, in general, are classed as
tonic, sedative, eliminative and local. These results
are brought about by reactions through the vaso-
motor system and reflex stimulation of heart action,
!)roduced by the effect of temperature, mechanical
stimulation of pressure and impact, friction and im-
I)act and by the chemical action of the salts and
gases, hydrogen sulphide and carbon dioxide. The
September 21, 191S.I
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
509
sulphur baths given in Phito are the feature Ijaths
and, because of their soothing effect upon the skin,
are vaUiable in certain forms of skin diseases.
The sulphur baths are used cooperatively with the
drinking of the water, for the following conditions :
Diseases of the stomach and intestines ; diseases of
the hver and bile passages ; diseases of the kid-
neys ; neurogenic blood pressures ; chronic rheu-
matism and allied disorders ; obesity and disorders
of the nervous system, the functional and neuri-
tides type. The diseases of the skin successfully
treated are dry eczema, urticaria, psoriasis, pruritis
and the toxic rashes.
their geographical location and their i)Osscssion of
the equipment necessary for cHminative, sedative
and tonic measures. In addition, facihties for re-
creation, outdoor life, exercise and rest abound.
Descriptions will be brief and will concern only the
salient features.
IHE J.ACKSON HEALTH RESORT, DANSVILLE, N. Y.
This institution is located in the western part
of the state, overlooking the Genessee valley and
is surrounded on all sides by miles of picturesque
country. The elevation is 800 feet above sea level.
The climate is bracing and little debilitating weather
is experienced, the winter being cold but not so
kemg and Havy Oeneral
Haspltal
Sxpanda'ble wheel aid apsiM hsspltal
City af Springs
Chalybeate spring
cut.' 3f Xrxh:\w\
i-iDok Island E.H.
Site of proposed Base Hospital near Hot Springs, Arkansas.
Accessory measures include diet and exercise on
graded walks, golfing, tennis, bowling, and gymna-
sium work.
Summing up, we find at French Lick Springs
a large institution equipped with every modern
convenience for the comfort and entertain-
ment of patients. Its hydrotherapeutic de-
partment is well established and, in conjunction with
the drinking of the spring waters, one of them,
Pluto, known to practically every one in this coun-
try, is particularly efficacious in the treatment of
disorders of the gastrointestinal tract as well as for
the relief of secondary pathology and dysfunction
of the accessory organs of nutrition and elimination.
Its capacity is easily yoo patients and without much
trouble this could be increased by a couple of hun-
dred. It is accessible from the Atlantic seaboard
and occupies almost a central position with regard
to the centre of population of the United States.
THE HEALTH RESORTS.
As Stated in the introduction, the following in-
stitutions are classified as health resorts because of
much so as to be forbidding. Hygienic conditions
are ideal and there is an abundant supply of pure,
fresh drinking water.
Well built walks, the roof garden, golf course,
tennis courts and the lounging platforms in the
woods offer inducements for out of door life. The
buildings and cottages are commodious and there
is a restful environment wherever one may go.
Treatment equipment includes apparatus for
hydrotherapy, mechanotherapy and electrotherapy,
and is adequate in number and variety. However,
Jackson has a treatment, in the Moliere-thermo-
electric bath, that has been featured for more than
thirty years and is particularly efficacious as an
eliminative measure and in equilibrating circulation
in vasomotor disorders. This place finds its use-
fulness particularly in functional nervous disorders
and allied conditions that require rest, regulated ex-
ercise, diet, tonic, sedative and eliminative treat-
ment and a cheerful and pleasing environment. Its
capacity is easily a couple of hundred or more and
it is accessible from Eastern ports.
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
TIIE SANITARIUM, CL1I-~T0N SPRINGS, N. Y.
Clifton Springs Sanitarium is located not far
from Rochester, N. Y. This institution has been
in existence sixty-seven years and is noted for its
thorough work. Strictly speaking, it is a sanitarium
on the cooperative plan, having several departments
that devote their energies to special branches of
general medicine. However, it is included here as a
health resort because of its location and equipment.
The sanitarium atmosphere is eliminated as much
as possible by encouraging general community as-
sociations and there is absence of general wards.
Clifton's underlying prmciple has been to lead peo-
ple back to a normal life, to diagnose accurately the
great variety of ailments that come for treatment
and to give the patient the advantage of a specialist's
care, as well as the advantage of the most approved
and advanced therapeutics. Solariums, walks, gym-
nasium, golf green, tennis courts and other at-
tractions invite outdoor life and exercise. Hydro-
therapeutic, electrotherapeutic and mechanothera-
])eutic equipment is most complete, and is of great
usefulness in this general sanitarium. The build-
mgs are commodious and the environment is most
pleasing. The institution's usefulness for certain
forms of functional nervous diseases is great; yet,
because of its equipment, a variety of conditions can
he treated successfully.
THE HOTEL CHAMBERLAIN. OLD POINT COMFORT,
VIRGINIA.
Mention is made of this institution because of
its location. Its environs are most restful and the
climate is such as will promote convalescence.
There is a moderate amount of equipment for
hydrotherapy, and electrotherapy. It is easily ac-
cessible, either by boat or by rail, to all ports on
the Atlantic.
ASHEVILLE, NORTH CAROLINA.
Because of its altitude, climatic conditions and
hotel facilities, this resort deserves consideration as
a possible aid in solving the country's new medical
problem. Possibilities for the treatment of a certain
type of cases may be substantially enhanced if the
proper equipment for hydrotherapeutic, mechano-
therapeutic and electrotherapeutic measures are in-
stalled.
AIKEN, SOUTH CAROLINA.
This Southern mountain resort also could be
utilized for the treatment of the same kind of
cases. It has the same advantages ofifered by Ashe-
ville. North Carolina, and its needs for additional
equipment and more elaborate handling of cases
are the same.
SUMMATION.
Our methods of prosecuting our part of the war
have been suggested, in large measure, by the lessons
learned by our allies from their blunders, successes
and experiments. The English, the French and the
Canadians are utilizing their spas and health re-
sorts for the treatment of certain conditions not
easily or successfully cared for in the overseas hos-
pitals. It probably will be our own experience that
great num1)ers of such cases will arise among our
officers and soldiers, and there are already in this
country establishments particularly and especially
adapted to their care. It may be said that the value
of the therapeutic measures discussed in the fore-
going is limited. While this may be true, it also is
a fact that orthodox medicine is even more limited
in its method of coping with these conditions. Be-
cause of this very fact the institutions which prac-
tise these advanced therapeutic measures are especi-
ally commended for use in connection with our
war problems.
Following are roughly classified condition groups
which it would be impracticable to treat in the over-
seas hospitals because of the nature of the illnesses :
1. Conditions of nervous exhaustion and shock, also
what may be termed ])reshock, usually associated
v/ith neurodigestive intoxications in which the
toxins are the product of microbic activity that may
be flourishing in the intestines, the oral cavity, the
gallbladder, the glandular system and other tissues,
and which, during a crisis, somatic or psychical,
correlate their energies, become kinetic and are dif-
fused throughout the tissues, their clinical display
comprising many disease pictures ; 2, cardiorenal
and circulatory dysfunctions (functional or or-
ganic) ; 3, metabolic disorders, secondary to mal-
elimiiiation, with a mobilization of toxins of either
endogenous or exogenous origin, precipitating a
disease entity ; 4, convalescent states secondary to
infections, wounds, hemorrhages, exposures, burns,
and surgical operations.
Cases in Group i require rest, much outdoor
life, exercise, eliminative and tonic measures, such
as are afforded and administered at White Sulphur
Springs, West Virginia, French Lick Springs, In-
diana, and Hot Springs, Arkansas. These places
also are especially cjualined for the handling of
cases of this group — which probably will be by far
the most numerous of all the groups — by their
large capacities.
Cases falling within Group 2 are best treated by
the Nauheim method, the feature treatment given
at The Glen Springs and Saratoga Springs.
Cases in Group 3 require especially the use of
waters that stimulate metabolic activity and promote
profuse and regular elimination through the emunc-
tories. The waters of the hot springs of Arkansas
and Virginia and of Mount Clemens, Michigan, are
particularly suited to these requirements.
Conditions in Group 4 will, perhaps, be composed
of those who are convalescent prior to their final
disposition and need rest, outdoor life, diet, and
tonic measures. The following places are well fitted
for these needs : Jackson Health Resort, Clifton
Springs; Aiken, South Carolina; Asheville, North
Carolina ; the Hotel Chamberlain, Old Point Com-
port, Virginia.
Since the outbreak of the war, my energies have
been devoted to the good of the country and this
article was planned for several reasons — my interest
in the future of the incapacitated, my interest in
the spas of this country and their methods, and
my belief that the government can use to advantage
the knowledge which I have of the spas and these
methods. With such motives in view, I have pre-
pared this article as a brief, unbiased, and disin-
terested compendium of information concerning the
September 21, ig.s.l MEDICINE AND SURGERY IN THE ARMY AND NAVY.
resources which we have to meet the medical prob-
lems of the war.
Already the merits of the spas and health resorts
as national assets have been recognized by certain
institutions, individuals and groups of individuals —
in many cases, those to whom benefit would accrue
from the adoption of such plans — who have sug-
gested to the Medical Department of the Army
various propositions for the government control of
these institutions. Such plans so far suggested lack
a vision of the extent and importance of the whole
problem involved, and are not comprehensive in
their provisions for solving that problem. Further-
more, no single institution of this sort possesses
qualities and advantages varied enough to meet all
the requirements of the case. And any plan which
provides for the utilization of only one or a few
of these hospitals will not facilitate the group-case
disposition and the administration of specific thera-
peutic measures for definitely classified complaints.
It occurs to me that these objections would be
obviated and that the nation would be given an ex-
tensive and adequately correlated system of hospitals
for the treatment of these special classes of cases,
by the appointment of a committee — a committee
of medical men who are familiar, on the one hand,
with the requirements of the nation in this respect,
and, on the other hand, with the methods used by
the various spas and health resorts — to make an ac-
curate survey, first of the conditions as they de-
velop, and, second, of the measure in which our
institutions can take care of these conditions. Fur-
ther use of this committee might be made after it
had studied the situation and worked out a compre-
hensive plan for meeting conditions, in that its
members could be retained to act in a supervisory
capacity over the operation and maintenance of the
institutions mobilized. The committee's study of
the work accomplished will enable it to decide as to
a given establishment's efficiency and to make rec-
ommendations on merits alone, not swayed by the
interests of the civilians who otherwise might have
a hand in the administration. And at the time for
demobilization, a process even more complex, in
some respects,, than the commandeering of the spas
and resorts, the advice of such a committee would
be especially valuable.
Numerous plans for financing this scheme, when
once it is adopted, probably will be forthcoming.
But the simplest, as well as the most economic plan
that suggests itself is government control of the
institutions chosen, during the period of the war.
This is essentially an era of government control of
public utilities. There are good reasons why this
control should be extended to these therapeutic in-
stitutions, if they appear to be of great enough value
to the nation. Assuming that this value will become
apparent as the United States is drawn more and
more into the war,' it will be obvious that the cheap-
est way of obtaining their services will be to com-
mandeer them and to pay a fixed rate of interest
upon the investments involved. The only other plan
would be to construct, maintain, and operate special
hospitals with special apparatus for the same use.
And the needless expense, time, and experimenta-
tion necessary for this are the obvious objections.
MEDICAL NOTES FROM THE FRONT. '
By Charles Greene Cumston, M. D.,
Frivate-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
DESTRUCTION OF MUSCLE IN GUNSHOT WOUNDS.
A man is struck by a missile with full velocity
and he falls. Upon recovering from his stupor he
notices a sharp pain and a feeling of increasing
tension at the site of the wound, while at the same
time he finds that there is absolute impotency of a
muscle or a group of muscles. There is dispropor-
tion between the very marked functional phe-
nomena and th.e wound, which is apt to be small
and without hemorrhage.
Then following a latent phase lasting several
days, the impotency persists but the pain will have
subsided. No general symptoms appear and recov-
ery is looked for without any complications. The
cutaneous aperture is occluded by a hard brown
scab and were it not for edema and a disagreeable
feeling of tension, one might look upon the case as
a mere cutaneous erosion. But soon the picture
changes. This deceitful latent phase rapidly or
even suddenly changes to an infectious phase,
manifested by a high temperature, chills, rapid
pulse, and sometimes vomiting and delirium.
Locally, the feeling of painful tension increases,
the brown scab lies on a bed of diffuse edema,
which gives the sensation of indefinite fluctuation.
The skin is bronze colored and violet or even
streaked and if the cutaneous aperture is not closed
some bloody fetid serous fluid exudes, but pus is
not generally present.
It is at this time that the case is treated surgically.
After incision of the integuments if the finger is in-
troduced into the wound a small opening in the
aponeurosis will be felt. By forcing the finger
through this small opening a large pocket will be
discovered 'filled with a dark semiliquid clotted
mass. The superficial layers having been freely
incised, thus thoroughly exposing the pocket, min-
ute disinfection, cleansing and flat dressings will
most usually bring about a regression in the local
and general phenomena. Frank suppuration arises,
the temperature drops with astonishing rapidity and
the muscular pocket becomes quickly filled.
But things do not always go so fortunately and it
is in just these apparently simple wounds that the
frequency and intensity of infectious complications
are most marked. The first of these is gas gan-
grene, which finds its choicest soil in necrosed
muscle. Independently of gas infection, simple
diffuse phlegmon is prone to arise in destroyed
muscles. This infectious process starting in the
focus of muscle destruction and walled in by
aponeurosis, does not remain localized for any
length ot time. It soon extends along the cellular
tissue of the muscular interstices, rapidly reaching
the root of the limb. In spite of the prophylactic
action of antitetanic serum in war surgery, in these
cases of vast destruction of muscle with a slight
external wound when not dealt with radically by
freely exposing the focus, the action of the serum
fails, probably on account of the peculiarly favor-
5'-
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New V'ork
Medical Journal.
able conditions olfcred by tbis particnhir injury for
tbe development of tbe specibc lijicill-js.
Altbougb vast areas ot muscle destruction are
frequently complicated by infections for the reasons
stated, it is possible tbat this lesion may undergo
an aseptic evolution. From this standpoint, con-
siderr-.ble difference exists between bullets going
through the soft parts and making their exit,
leaving only an aseptic Seton wound behind, and
wounds from grenades or exploding shells which
are far more to be feared from the viewpoint of
infection because bits of the missile are embedded
m the tissues. Now, when improperly treated, the
latter wounds ahnost invariably give rise to infec-
tions uf various types. Seton wounds resulting
from rifle or shrapnel bullets may, however, be ac-
companied by extensive muscle destruction, and be
recovered from without infection taking place. In
these fortunate circumstances, the morbid phe-
nomena remain limited to those of the latent phase.
The apertures of entrance and exit quickly close
and the muscular lesions, which are the seat of a
painful diffuse doughiness at the beginning, become
localized, slowly diminish and become absorbed
exactly as in the case of a hematoma, but a marked
and prolonged functional impotency of the involved
muscles will persist. A fibrous cicatrix, occasion-
ally of very considerable extent, becomes organized
and adheres to the deep layers and the exploring
fingers can mobilize it onlv with much difficulty,
bound as it is to the neighboring muscles, superficial
structures and sometimes even to the bones of the
limb.
Given a case of gunshot wound of the soft parts,
the question should always be considered as to
whether or not an extensive destruction of muscle
exists, and not simplv a muscular lesion limited to
the bullet track in the part. A positive diagnosis
can be made at the start from the track of the
missile, as well as from the intensity t)f the func-
tional reaction which is out of all proportion with
the apparent unimportant external lesion.
A slit in the aponeurosis can be detected by palpa-
tion and by signs of a hernia of the muscle through
it, although at the very beginning the collection of
blood and the stupor which attacks the entire
muscle reduce these signs to a strict minimum and
make a correct appreciation of the situation dif-
ficult. The diagnosis will be really difficult only in
differentiating the lesion under consideration from
hematoma. In the latter lesion the tumefaction
takes place progressively, while in extensive muscu-
lar destruction, a painful tumefaction is present
right after the receipt of the injury. A hematoma
is firm to the feel, the contrary being the case of
destroyed muscle; and although in both lesions
active and passive movements are very painful, the
immediate impotency is much more marked in ex-
tensive muscle destruction.
Later on, when infection supervenes, the diag-
nosis is to be examined from another viewpoint, be-
cause at this phase the infectious complication must
be recognized from the increasingly bad general con-
dition of the patient, the rise in temperature and the
local symptoms which become marked and extend.
The propriety of surgical interference arises, and it
will only be after freely laying open the traumatic
tocus that the real process, namely extensive destruc-
tion of muscle, will be discovered. Muscular de-
struction having been found, concomitant lesions of
the neighboring structures must be looked for \^
exploring the sensibility of the nerve areas, search-
ing for possible vascular lesions or fractures or
other lesions to the bones by careful palpation, and
particularly with the x ray.
The patient's life depends upon an early and cor-
rect diagnosis of septic phenomena. It goes with-
out saying that when the septic phenomena have
attained their apogee and the symptoms of gas gan-
grene are manifest any surgical interference, no mat-
ter how extensive, will be useless and the golden
moment for operation will have passed.
To make the subject perfectly clear I shall review
the pathology of the injury under consideration. We
shall assume that an early and extensive incision
has been made and the following morbid changes
will be detected as the surgeon proceeds layer by
layer. The integuments are but slightly damaged
around the aperture of entrance or exit of the mis-
sile, and the subcutaneous cellular tissue is un-
changed during the latent phase of the process, but
when the infection develops it becomes rapidly in-
filtrated with a cloudy, fetid serum. In cases of
anaerobic infection fine gas bubbles can be expressed
by pressure along the edges of the incision. The
aponeurosis will at first only oflfer a small button-
hole, which may be overlooked by an inexperienced
operator. Later on, although the aponeurosis resists
infection for some time, it in turn undergoes patho-
logical changes, tears easily, becomes necrosed,
forming ragged debris which is eliminated with the
pus.
The area of muscle destruction really represents
the all important lesion and this cavity must be
freely exposed, if the case is to be properly con-
ducted. These foci vary from the size of a walnut
to an egg and their long axis lies usually in the long
axis of the muscle. This focus of muscle attrition
rarely involves the entire thickness of the muscle
and some fasciculi will be found to exist intact,
and later on will serve for functional regeneration.
In other cases several muscles will be found in-
volved. The focus of attrition is usually single, but
several may be found quite distinct from each
other, in which case they are the result of the re-
ceipt of as many missiles in the part. In the cases
under consideration the vessels and nerves are usu-
ally intact, even when they pass through the focus
of muscle attrition. However, their destiny is com-
promised, because should they escape the destruc-
tive work of the missile and that of suppuration,
they may in the future become involved in the cica-
trix.
The contents of the focus of muscle attrition are
not liquid and coagulated blood such as found in
hematomata, nor pus, but a rather fluid, blackish
mass, containing clot and muscular debris. There
is no trace of either organization, coagulation or
cyst formation and no wall separates this mass
from the normal muscle. The condition is one of
necrobiosis with infection, as is made evident by
the fetid odor and septic phenomena. Gas may also
September 21, 1918 ]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
be present in the focus and if not dealt with in
time will rapidly extend up the muscular inter-
stices and infiltrate the subcutaneous structures.
These cases are usually due to bits of grenade or
exploding shell, rarely to shrapnel or rifle bullets,
and these pieces are usually to be found in the focus
of muscle destruction.
If i have been somewhat prolix in the treatment
of the subject of muscular attrition in cases of ap-
parently slight injury, it it because I felt that the
question should be made known to those of our
surgeons who are going to the front, as it has been
but scantily discussed in the medical literature of
warfare.
MEDICAL NEWS FROM WASHINGTON.
Delayed Appointments of High Rank for Medical Officers
—Health Conditions in the Navy.— Naval Hospital
Fro jects.
Washington-, D. C, September 16, iqiS.
There is much speculation in army circles, in
connection with the vacancy that will occur in the
Office of Surgeon General of the Army on October
3d, when Major General William C. Gorgas reaches
the retiring age, whether the fact that that officer
went to France with Secretary Baker gives any in-
dication as to the prospects of his being retained at
the head of the Medical Department, as Acting
Surgeon General.
It is understood that General Gorgas desires to
remain at the head of the Medical Department, and
that he has been solicitous to be kept on active duty
in that capacity after transfer to the retired list.
According to those in army circles that are in a posi-
tion to have knowledge of the situation, it is unlikely
that General Gorgas will be retained in his present
position beyond the date of his retirement. Prob-
ably he will be kept on active duty in some other
capacity, possibly in connection with reconstruction
\vork.
Officers also are wondering whether the recent
appointment of Brigadier General Merritte W.
Ireland, now chief surgeon on the staff of General
Pershing, as Assistant Surgeon General, with the
rank of major general, for service abroad during
the present war affects his chances of appointment
as Surgeon General of the Army.
Many rumors are current as to who will be ap-
pointed Surgeon General, among them being that it
is Hkely that some physician of note that came
from civil life since we entered the war and now is
holding a temporary commission in the Medical
Corps will be appointed, and other medical officers
of the Regular Army, including Brigadier General
William H. Arthur, head of the Army Medical
School at Washington, have been mentioned in con-
nection with the plact.
The army m.edical people in France, backed, it is
understood, by General Pershing, have been urgent
in advocating the appointment of General Ireland,
and there is a marked sentiment in his favor among
the regular medical officers in this country.
In the meantime, considerable impatience has
been expressed bv medical officers over the delay in
making appointments to the other places of high rank
authorized for medical officers by the last army ap-
propriation act — two Assistant Surgeons General
with the rank of brigadier general to be appointed
from the Medical Corps of the Regular Army, and
two major generals and four brigadier generals to
be appointed from the Medical Reserve Corps.
Powerful influences in the War Department op-
posed the authorization of these high ranking places
for medical officers, and it has been intimated by
those interested in having the appointments made
that these same influences now are instrumental in
having the appointments delayed.
:I: * * * *
With exception of an outbreak of influenza in the
first naval district, the health of the navy continues
to be excellent. The death rate last week for dis-
eases of all kinds was 1.6 per thousand per annum,
and admissions for all causes 681.2.
During the past two weeks i,.330 cases of in-
fluenza were reported, mostly in Boston, although
an outbreak recently occurred at Newport and an-
other at New I.ondon. About sixty of the cases
have developed pneumonia.
The naval authorities were not surprised at the
appearance of influenza in our Atlantic Coast cities.
Indeed, such an outbreak was predicted in a bul-
letin issued by the Bureau of Medicine and Surgery
under date of August gth, wherein it was pointed
out that the presence of influenza in Spain, Austria,
Germany, Switzerland, France, Great Britain,
Hawaii, and elsewhere indicated another pandemic
of this disease similar in extent to others that have
been reported since the sixteenth century. During
the last century there were four pandemics, suc-
ceeded by epidemics, the last occurring in 1889-
i8c)2. No other communicable disease, which
assum.es epidemic proportions, spreads so rapidly or
attacks indiscriminately so large a proportion of the
population ; and, while the statements that 8,000,000
persons in .Spain have been attacked may be an ex-
aggeration, it nevertheless is true that the disease
is widespread.
Other diseases reported to the Bureau of Medi-
cine and Surgery from the navy shore stations last
week were as follows : Cerebrospinal fever, one ;
diphtheria, nine ; malaria, twenty ; measles, forty-
five ; pneumonia, twenty-five, and scarlet fever, five.
* * * *
Among the various projects for expanding the
facilities of the naval hospitals, the addition to the
hospital at Charleston, S. C., is of importance. This
hospital at present has a capacity of 250 beds, with
an emergency expansion to 350. and on occasion
even to 432 patients. The additions to be made will
increase the capacity to i.ooo beds.
The present hospital, which is only a little more
than a year old, consists of a group of nineteen
buildings, of wood, one story high. The new con-
struction also will be of wood, covered with stucco,
consisting of fourteen buildings, containing twenty-
two additional wards. A feature of the hospital is
a large recreation hall, seventy-five by 150 feet.
Other hospital projects of importance under way
under the auspices of the Navy are those at Pelham
Bay Park. N. Y. ; Paris Island, S. C. ; operating
base at Hampton Roads, Va. : Great Lakes, 111. ;
Ward's Island, N. Y., and Chelsea, Mass.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. dh M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
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Cable Address, Medjour, New York.
NEW YORK, SATURDAY, SEPTEMBER 21, 1918
THE EPIDEMIC OF INFLUENZA.
Influenza has become epidemic in various sections
of the United States. Last month an outbreak oc-
curred in Fort Morgan, at Mobile, Ala. A tramp
steamer arrived at Newport News several weeks
ago with the entire crew prostrated by the disease.
It began to make its appearance in Philadelphia
about five weeks ago. A number of cases were re-
ported in Boston on September iith, and on the
17th sixteen deaths were reported in six hours, ten
of them among the men of the navy. Fourteen
stations of the first naval district, Boston and vicin-
ity, with a total personnel of 20,500, reported 2,331
cases up to September 17th. The men of the
second naval district have been forbidden to visit
Boston and those stationed at Newport are not per-
mitted to go outside of the camp limits. It is re-
ported that 2,000 soldiers are sick at Camp Devens.
Some 170 cases have been reported at Camp Upton,
which has been closed to visitors, and cases have
alsc been reported at Camp Merritt and in camps
in that vicinity. Several cases have been reported
in Jer.sey City.
Colonel J. W. Kennedy, M. C, U. S. A., Surgeon
of the Port of Embarkation, states that several
cases of influenza have been reported among crews
and passengers on the transports returning from
Europe. These cases and the immediate contacts
have been isolated on shipboard, not being allowed
to land. Such cases as have occurred on shore in
the camps and cantonments under his control
have been isolated in cubicles and so far the results
of such isolation and treatment have been satisfac-
tory. He does not think it will be possible, how-
ever, to prevent the further spread of the disease
by any steps which are practicable under existing
conditions. At Camp Upton theatrical entertain-
ments have been discontinued in hopes of checking
the spread of the disease, which is reported now to
be well in hand. Bacteriological studies of the
cases reported are now being carried out in the
Central Laboratory of the Port of Embarkation in
the Greenhut Building, New York, by Major E. H.
Schorer, ]\T. C, Director of the Laboratory.
Examinations carried out in Alfonso XIII Insti-
tution in Spain showed the presence of Pfeififer
Imcilius in many cases and of diplococci from the
meningococcus and pneumococcus group. About
150,000 cases were reported in Madrid in fifteen
days' time.
The Commissioner of Health of the City of New
York has issued an order placing both influenza and
pneumonia on the list of diseases which must be
reported within twenty-four hours, in the hope that
such reports will aid in the eflforts to prevent the
spread of the disease.
The Surgeon General of the Public Health Serv-
ice has issued a bulletin on influenza and its treat-
ment in which he says: 'The disease is character-
ized by sudden onset. People are stricken on the
street, while at work in factories, shipyards, offices,
or elsewhere. First there is a chill, then fever with
temperature from loi to 103, headache, backache,
reddening and running of the eyes, pains and aches
all over the body, and general prostration." He ad-
vises all persons attacked to go to bed at once and
call a physician. He considers every case with fever
as being serious and says that the patient should
be kept in bed until the temperature becomes
normal. Convalescence requires careful manage-
ment, as this is frequently complicated by bronchial
pneumonia, many cases of which have terminated
fatally.
Quarantine seems impractical and ineffective.
The most effective prophylactic seems to be sun-
shine and fresh air. In camps these are assured by
September 21, igiS.]
EDITORIAL ARTICLES.
mushrooming the tents except during rain and in
the prevention of crowding, but no system of
prophylaxis seems to have been effective in prevent-
ing the spread of the disease so far. The treatment
usually given includes rest in bed, Dover's powders,
(|iiinine and aspirin.
FAITH AND ITS VAGARIES IN
MEDICINE.
Walter von der Vogelweide sang whimsically
long ago of how he sat playing with a straw,
testing which way love's favor blew. It was
child's play, he tells us, and worthy of ridicule,
but "This comforts me, yet it belongs to faith."
And faith is the magic charm which extracts
healing, or comfort at least, from many a medical
straw. Tlierein have been and still lie a power
and a tenacity which have often hindered the
course of medical science, which have led to much
futile custom and practice and have established a
strange conservativeness of superstition and
practice on the part of the sufferers themselves.
Yet in this slow movement of faith, credulity
rather, have lain the germs of science, and in this
medium they have managed to grow.
Today this meets us, for one instance, in the
land of China. Dr. K. C. Wong [An Inquiry into
Some Chinese "Sexual Diseases," National Medi-
cal Journal of China, March, 1918] reports some
very curious diagnostic beliefs prevalent in re-
gard to certain diseases, which manifest them-
selves obviously enough to western science as
common afflictions of various sorts, but which
the Chinese attribute to sexual intemperance or
carelessness. This is supposed to exist often
among the newly married or among others, and
involves various external agencies such as the
recent presence of some disease like typhoid in
one of the partners, or the partaking of cold food
too soon after coitus, and so on. The faith which
attributes all sorts of ordinary disease manifesta-
tions to such contracted "sexual disease" dis-
plays itself also in the remedies employed. These
are of this character : The belly of a dove which
has been ripped open and stufifed with musk, laid
on the abdomen, the administration in water of
the ashes of the clothing' of the man or woman
from the genital region, and other such remedies
externally or internally applied.
This is from China, a land which is slowly
making its way up into light after a long somno-
lence and stagnation, since its clocks stopped
centuries ago. The centuries are fewer since our
own predecessors wrote and advised and acted
in similar fashion. H. Silberer [The Homuncu-
lus. Imago, February, 1914] has collected a large
amount of material illustrative of such wide-
spread straw faith or credulity, current even in
the seventeenth and eighteenth centuries, yet full
of a seriousness and spirit of investigation and
experiment which cleared the way finally for a
truer science. A letter of advice, fairly pathetic
in its earnestness and sincerity, accompanies a
gift of a mandrake or earth mannikin from one
brother to another sorely afflicted by a destruc-
tive pest, which has invaded all his worldly pos-
sessions. The value and merits of this precious
object are extolled, with careful directions as to
its treatment and preservation. The water in
which it is bathed may be sprinkled upon the cat-
tle, but especially is it recommended "when a
woman is in childbirth and cannot bring to birth,
that she shall drink a spoonful of this bath water,
then she will bring forth with joy and thankful-
ness."
Not unnaturally it is the mysteries of birth and
procreation which excite the. greatest credulity
and inspire the widest extravagance of interpre-
tation and experiment. Aside from the high spir-
itual significance which undoubtedly lay in the
best alchemistic thought, and the speculations
and efforts which paved the way for chemistry,
there is a peculiar interest for medical practice
and for the faith which so largely still underlies
medical success, in these strange beliefs. In the
writings of the fifteenth and sixteenth Centuries,
rightfully or wrongfully attributed to Paracelsus,
procreation and the growth of the embryO' are so
conceived that they may be transferred over into
unnatural and artificial localities and carried out
through natural means unnaturally employed.
There is in all this the saving grain of truth ex-
panded into the phantastic formation which the
child mind and the psychoneurotic mind often,
unconsciously at least, give to a small amount of
normal knowledge.
"Lac virginis, urina puerorum, faeces disso-
Inta;" are included among the substances which
form the "prima materia" of the alchemists. Ar-
tificial creation can be produced through the in-
fluence of air, blood, stars, through feces, the hair
of a menstruous w^oman, while the sperma of a
man enclosed in a vessel with the magic princi-
ple of human blood will also produce the homun-
culus. The glance of a menstruous woman, or
her breath or touch, cause a wound to become
incurable.
Such is the faith and fear of human kind, not
passed away yet, either in Orient or Occident.
Since it still exerts its influence upon medicine
5i6
EDITORIAL ARTICLES.
[New York
Medical Journai..
and still more, as the psychotherapist knows,
upon the controlling- phantasy which largely
rules the lives and health of mankind, it behooves
us to know more of these actual beliefs, and,
above all, to realize with the poet how much
"This comforts me." . This is the sympathy with
which the physician has to enter into the child-
like desire of his patient for comfort and security,
which lies at the bottom of every appeal for health
and of every fatuous attempt to seek assurance
through false belief.
IN DISPRAISE OF VAGINAL DOUCHING.
This time honored and time increasing custom
is left by Doctor Fothergill no natural leg- on
which to stand [ W. E. Fothergill : The Bad Habit
of Vaginal Douching. British Medical Journal,
April 20,1918]. At the most he permits it an
artificial prop under a few exceptional circum-
stances, when the aid of a nurse must be em-
ployed and conditions must be made fitting for
its administration. This is quite remote from
the easy practise of prescribing a douche in the
most careless and ready manner or from the self
administration at the advice of some more "ex-
perienced" relative or one's own inclination and
ignorant judgment. This has been all too much
winked at or even encouraged by medical advice
and medical sanction.
Fothergill points out from his own experience
the serious mistakes which have come to his at-
tention and which are all too prevalent through
this form of self treatment or through the igno-
rance and indolence of physicians. What the
douching female public does not know and what
the medical man fails to take into account is a
number of physiological facts, ignorance and
neglect of which lead therefore into physiological
abuse. The vaginal secretion, so often mysteri-
ously and fearfully regarded, is simply serum
which exudes from the squamous epithelium and
which normally presents a creamy appearance
because it becomes mixed with leucocytes and
epithelial debris. Moreover, this discharge is in
itself an antiseptic protection against invading
organisms. Douching washes this away, kills
the acid producing bacteria which are otherwise
faithfully performing their function in the vagina,
kills the superficial layer of cells, and irritates
the subjacent layers. In fact, the discharge which
mistakenly leads to douching is abnormally in-
creased by the procedure, as it promotes hyper-
emia of the parts, and menorrhagia, congestive
dysmenorrhea, and intermenstrual congestive
pains are encouraged.
Vaginal douching proves itself no less detri-
mental and contraindicated for the most part in
acute and subacute conditions. The most that
it can do in regard to septic infection of the
uterus is to add to the sum of infectious material
by introducing more germs into the cavity, or, in
case of a vulvar infection, as in gonorrhea, to
carry the infection through the vagina to the cer-
vix. An infection once in the uterus is never
touched by the vaginal douche, but some other
way than even the dangerous intrauterine douch-
ing is needed to cleanse the uterus thoroughly.
The organ then should be let alone.
There are occasions when the author would
advocate douching, as, for example, in the palli-
ative treatment of cancer of the uterus. This,
however, is a far different procedure from the
popularly applied douche. The douche must be
given to the patient while lying flat on her back,
when the fluid can properly reach the vaginal
walls and be applied sufficiently thoroughly to
produce the desired effect. Hot douches at a
high enough temperature not to increase the hy-
peremia and bleeding, for the prevention of which
they are usually prescribed, are so difficult of
administration that they should be left for excep-
tional conditions, when they can be most care-
fully administered at an actually high enough
temperature.
Doctor Fothergill calls attention to the fact
that the slimy condition which leads to the use
of the douche in many instances is also due to a
condition physiological and but little pathological,
one which is aggravated rather than helped b)-
douching. It is caused by excess of mucus com-
ing down from the uterine walls and this is
due largely to a lack of vascular and muscular
tone in these walls. It should be reached by
other means than the further disturbing vaginal
douche.
If we add to this a consideration of the mental
habits into which individuals so easily fall, where-
by they come to rely on practices hurtful in
themselves, followed in ignorance both of physi-
ological laws and in obedience to superstitious
custom and disguised, unacknowledged wishes,
this practical physiological discussion receives
support from an even broader psychical basis.
The douching habit has formed an all too ready
pitfall for the fussy egoism which preoccupies
itself with its own ills, the unconscious eroticism
which busies itself on too slight provocation with
the sensitive bodily organism, particularly the
most sensitive genital region. It thus utilizes
some slight or negligible condition and creates
more serious ones for a manipulatory gratifica-
September 21, iciS.]
EDITORIAL ARTICLES.
tion which is unconscious, but which does much
to increase and make chronic symptoms which to
consciousness may be very inconvenient and dis-
tressing. Psychotherapy very frequently dis-
covers such an unconscious attitude toward the
douche can, which is doing subtly even more di-
rect injury than those of which the physiologist
has spoken, and the mental side of the habit has
much to its account in creating and maintaining
the train of disturbances of which he speaks. If
the simple facts cannot be too strongly empha-
sized from the physiological side, neither can
they be too often insisted upon from the psychi-
cal, until physician and patient come to under-
stand better the subtle working of cause and
effect in the service of inner hidden motivation
and striving, which, because of the deep and
broad connection of a woman's genital organs
with her emotional life, play such a large part in
her genital disorders.
JANITOR OR SANITOR?
A janitor meant originally a doorkeeper.
Many modern janitors cannot serve competently
in even this primitive capacity, and few of them
come up to what should be expected of them in
this generation. One reason is that they are usu-
ally chosen for their- unfitness, or rather janitors
are often janitors because they are unfit for other
positions. Neither we nor they see the dignity
of the situation. It is certainly not always be-
cause of inadequacy of salary that the janitor
does not fill the bill, for in many public schools
he is paid more than most of the teachers and
his position is a sinecure by comparison.
The janitor of the future will be a sanitor and
a teacher by example and often by precept. He
will be a trained man — trained in practical sani-
tation, chosen because he knows his business and
values himself and is valued accordingly. He
will not simply grow up a janitor nor fall from
other jobs into that of caretaker of the working
homes of men, women, and children. He will put
in practice what is known about ventilation,
which is much more essential just now than that
we discover just what is meant by bad air. Every
one knows that if our standards for good ventila-
tion were fulfilled, we would have good ventila-
tion— yet every one who has made any tests
knows that those standards are not maintained.
This is especially the case where good ventilation
is most needed — in schools. Those in authority
at present care little. The superintendents and
teachers know, but are too busy getting; through
their daily "programme," from wliich health con-
ditions and health teaching are largely omitted.
The janitor does not care at all, even if he knows.
Ventilation should be in the hands of some one
who knows, cares, .and does. There will never
be ventilation otherwise.
The cleanliness of the building, not forgetting
furnace rooms, is of more importance to the in-
mates of a building than to most janitors, who
clean as their unsanitary fathers cleaned, and
sometimes let buildings burn down as did their
careless ancestors. The condition (and often the
kind) of toilets depends on the one who cares for
them, and there is no better object lesson in sani-
tation than well kept toilets.
We need schools for janitors which will turn
out sanitors; schools where janitors can have
theoretical and practical training for their work.
So far as public schools are concerned, there
might be one set apart in a city or in a county,
as a training school ; and the satisfactory com-
pletion of a training course might be required.
The time is coming when these things will be,
but not until they are in demand.
BOROUGH AUTONOMY IN HEALTH
MATTERS.
In the growth of a large community there conies
a time when a certain amount of decentralization
of authority becomes necessary for the most
effective administration. In the growth of the
City of New York such a stage was reached when
the adjacent boroughs of Brooklyn, Queens, the
Bronx and Richmond were incorporated into the
Greater City of New York. The wise framers of
the charter of the greater city realized this and
provided for a certain degree of autonomy for the
several boroughs. These provisions have never
been carried out to their ultimate conclusion in the
Department of Health and as a result there has
been more or less conflict of authority and confu-
sion regarding the work of the chief medical officers
of each borough who bear the title of assistant san-
itary superintendents. The Commissioner of
Health, Doctor Copeland, has issued an order which
is intended to give a certain degree of autonomy to
the several boroughs. Hereafter all the employees
of the department in a given borough will be under
the direction, supervision, and control of the sani-
tary superintendent who is the chief medical officer
of that particular borough, and except in cases of
emergency his management of the several bureaus
under him will not be interfered with except upon
special orders direct from the commissioner's office.
In the words of the commissioner, "The purpose of
this order is not to confer power on the assistant
sanitary superintendent, to give new and unusual
duties to the employees now on the pay roll of the
various bureaus, but it is intended to make clear the
question of disciplinary authority."
5i8
NEIVS ITEMS.
[New York
Medical Journal.
News Items.
Hospital Information Bureaus. — The Red Cross will
build small information iionses near the hospitals at each
big cantonment in this country and guides will be supplied
to show \'isitors directly to the ward they seek.
Houses for Army Nurses.— To give army and navy
nurses a comfortable place in which to spend their hours
oft" duty, the American Red Cross will provide special
nurses' houses at all large base hospitals, to cost about
$350,000. Contracts have been let for forty, several of
which are completed, and some more are under contract.
Red Cross War Council Head in France. — Henry P.
Davison, chairman of the war council, American Red
Cross, has gone to Europe to confer with those in charge
of the field activities of the American Red Cross in the
Allied countries, to make sure that nothing is overlooked
in meeting the increasing requirements of the American
forces.
Mourning Brassards. — The Red Cross will provide
the mourning brassards to be worn by the relatives of
men who have given their lives to their country. Bras-
sards will be furnished free to the widows or parents and
at cost to other members of the family. The brassard
is a band of black broadcloth or other material three
inches wide, on which the regulation military star is em-
broidered in gold thread.
No Danger from Spanish Influenza. — Dr. Royal S.
Copeland, Commissioner of Health for New York, does
not think Spanish inliuenza will gain a foothold in this
countr}-. Further investigation is needed before we know
what the disease is, or whether the cases reported can all
he ascribed to the same organism. The immunity of our
troops in France is ascribed to the great resistance which
healthy, v.'ell fed individuals offer.
Red Cross at Jerusalem. — Thousands of Armenian
refugees at Port Said and many homeless families in or
near Jerusalem are now being cared for by the American
Red Cross. A general dispensary and hospital with a
children's clinic has been established in Jerusalem, and at
the request of the government of Jerusalem, the organi-
zation has taken over two orphan asylums with 400 chil-
dren. Three hundred Russian refugees are also being
cared for at Jerusalem.
Military Medical Students. — A letter to the Artny and
Nai'v Journal calls attention to the fact that if the govern-
ment would give intensive courses of medical work at
selected centres, premedical men would not be constantly
dropping out of medical colleges to seek some form of
service where they would not be called slackers. It sug-
gests that the government might take over several medical
colleges ; place the medical students under military disci-
pline and enable men who are now ready to enter Class A
medical colleges to complete the course now requiring
four years of nine montlis each in two years of twelve
iTionths each.
Health Mission to Italy. — The Italian tuberculosis
unit of the American Red Cross, under the supervision of
Colonel Robert Perkins, Red Cross commissioner for
Italy, will conduct a campaign in Italy with the purpose of
stamping out of tuberculosis as its particular object. In-
cluded in the personnel of the unit, which numbers sixty
persons, are many of this country's best known tubercular
specialists, as v.'ell as physicians who have been very suc-
cessful in the lines of work which they will be called upon
to perform. The director of the unit is Dr. William
Charles \\'hite, of Pittsburgh. Others are : Dr. John H.
Lov/man, professor of clinical medicine at Western Re-
serve University, Cleveland, chief of the medical division;
Dr. Lou's I. Dublin, of New York, statistician of the Met-
ropolitan Life Insurance Company, chief of the division of
medical statistics; Dr. Richard A. Bolt, of Cleveland, con-
nected with the health department of that city, chief of
child v/elfare division; Dr. E. A. Paterson, of Cleveland,
chief of division of medical inspection of public schools;
Dr. Robert G. Paterson, of Columbus, Ohio, head of the
tuberculosis branch of the State Health Department, chief
of the division of education and organization; Miss Mary
S. Gardner, head of the bureau of public health nursing
of the American Red Cross, chief of division of public
health nursing.
Increased Pay for Nurses. — A bill has been intro-
duced in the Senate to increase the pay of chief nurses in
the army, making their pay $360 in addition to the pay of
the nurse.
Women Motorists Needed in France. — Three hun-
dred women motor drivers for service in France are wanted
1>\- the American Red Cross within the next six months.
The recruiting of these drivers will begin immediately.
It is expected the first contingent will sail about October
1st for motor messenger service, ambulance service, and,
to a limited extent, for camion service.
Medical Man Power in the English Army. — Sir Wat-
son Chcyne, speaking in the House of Commons, pressed
ihc Government to consent to the publication of the Re-
port of the Committee which last autumn investigated the
question of the employment of medical men in France, and
he further asked the Alinister of National Service whether
he had assured himself that there was not a waste of med-
ical man power in France and he urged him to study the
Report. The Medical Press, of London, remarks in com-
ment that the medical profession has a right to know
whether its sacrifices are necessary or have only been
exalted by a muddling officialdom.
Reconstruction of Wounded. — Rehabilitation of the
wounded will be discussed September 20th and 21st by the
American Academy of Political and Social Science, which
is to meet in Philadelphia. The speakers will include Dr.
W. W. Keen, of Philadelphia; Lieutenant Colonel Charles
W. Richardson; Lieutenant Colonel Harry E. Mock; Lieu-
tenant Colonel James Vordly, Jr. ; James P. Munroe, vice-
chairman of the Federal Board for Vocational Instruction;
Brigadier General Robert E. Noble; Major J. D. Todd,
Board of Pension Commissioners for Canada; T. B. Kid-
ncr, vocational secretary, Invalided Soldiers' Commission
of Canada ; Wallace Buttrick, president of the New York
General Education Board ; Douglas C. McMurtrie, director
of Red Cross Institute for Crippled and Disabled Men;
Alichael J. Dowling, President of the Olivia State Bank,
Minnesota, and James C. Miller, Federal Board for Voca-
tional Education.
27,000 Nurses Enrolled for Army Work. — Miss M.
Adelaide Nutting, chairman of the Committee on Nursing
of the Council of National Defense, announced on Sep-
tember 4th that the Surgeon General's requirement of
25,000 nurses, to be enrolled by January 1st, has already
been exceeded by nearly 2,000, while more than 1,000 stu-
dent nurses, high school and college graduates, have been
enrolled in the Army School of Nursing and will be as-
signed for training this week in ten army camps east of
the Miss'ssippi, Camps Wheeler, Jackson, Sherman,
Dodge, Shelby, Wadsworth, Devens, Grant, and Dix, and
the Walter Reed Hospital in Washington. There are in
the country 100,000 trained nurses and 14,000 nurses were
graduated this year from the hospital training schools.
IMiss Nutting said that the need at the front is for highly
trained nurses. According to one authority, American
nurses have proved 100 per cent, efficient, largely because
their strength was not diluted by untrained volunteers, the
use of which on the part of our government was discour-
aged by the British and French military authorities when
we entered the war.
Personals. — Captain Claude A. Martin, M. C, infan-
try, has been cited for the Distinguished Service Order
for bravery in the field. He operated a battalion dressing
station near \'aux. France, July i, 1918, although the sta-
tion was practically destroyed by shell fire.
The Distinguished Service Order has also been given to
.Sergeant Leroy Morningstar, Medical Department infan-
try, cited for bravery in the field near Vaux. Sick, gassed
and stunned by shells^^ he remained at his post on duty
under heavy fire and bravely assisted in the succoring of
soldiers who had been injured.
Lieut. -Col. Philip P. S. Doane, Medical Corps, is de-
tailed temporarily for duty with the United States Public
Jiealth .Service and the United States Shipping Board.
Dr. Wolff Freudenthal has returned to the city after
a vacation of two months spent mainly on the Pacific
Coast. At San Diego he gave an address on asthma to
the physicians of the city who gave a luncheon in his
honor.
Dr. A. Sturmdorf has been appointed consulting gyne-
cologist to the Manhattan State Hospital, New York City.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
VICIOUS CIRCL]:S IN RESPIRATORY DIS-
ORDHRS AND THEIR TREATMENT.
Bv Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Continued from page 4/6.)
PLEURISY WITH EFFUSION.
Two vicious circles have been held to occur at
times in this condition. The result of either of
them is a tendency toward maintenance or actual
increase of the effusion.
Some of these circles are based on disturbance of
the so called lymphatic pump, by which a physiologi-
cal circulation of fluid in and out of the pleural
cavity is supposed to occur. The pmnping action
is effected by the movements of respiration, these
causing modifications in the pressure conditions
about the superficial lymphatic channels and sto-
mata of the pleura. An effusion may interfere with
this pumping action in three dift'erent ways, and
in two of these a vicious circle may become es-
tablished. A fibrinous exudate may obstruct the
pleural stomata and prevent resorption. The
amount of the effusion may, as a result of this,
increase and the blocking action on the stomata
extend to surfaces previously not aft'ected. Ab-
sorption from these newly involved surfaces is
impeded by fibrinous exudate as before, and in a
sense a vicious circle is thus formed which tends
to perpetuate the disorder.
An effusion, if large, may hinder resorption bv
mechanical pressure upon the superficial pleural
lymphatics, as well as the stomata. Experimental
work has shown that a large quantity of fluid must
be introduced in the pleura before the pressure
changes from the normal negative to a positive
pressure at the upper surface of the fluid.
It seems clear, however, that a positive pres-
sure will exist in the lower portion of even a
relatively small effusion, owing to the pronounced
weight of the superincumbent mass of liquid. The
lympliatics and stomata will, therefore, be definitelv
pressed upon by all portions of the effusion save
its topmost layer. The larger the eff'usion, the
greater is the hydrostatic pressure in the lower
portions of it and the more complete, presumablv,
the arrest of resorption from these portions. Ac-
cording to this, in a large effusion only the top-
most layer will tend to undergo resorption, and all
the rest of the effusion will remain unabsorbable —
because of the excessive pressure at its surface. —
as long as the effusion remains extensive.. If anv
additional condition is present which prevents ab-
sorption of the topmost layer, such as the obstruc-
tion by fibrin already mentioned, or the third fac-
tor, V. ;.. an effectual obstacle to absorption
of all the remainder of the effusion will be inter-
posed. While tending to prevent absorption of the
greater part of a large effusion, this pressure factor
rnanifestly does not in itself give rise to a vicious
circle; yet it may. perhaps, be said to cooperate
with and accentuate the evil effects of other circles.
The third factor in preventing resorption of fluid
is the reduction or arrest by the fluid itself of the
respiratory movement, upon which, according to
West, the efficiency of the lymphatic pump of the
pleura depends. Here, apparently, are the attributes
of a true vicious circle. The greater the reduction
of respiratory movement, the less the efficiency of
the lymphatic pump and the less the resorption of
fluid ; the less the resorption of fluid, the more the
fluid is likely to rise in the pleural cavit>' and the
greater the reduction of respiratory movement,
thus completing the vicious circle. If effusion pro-
ceeds to a point at which expiration on the af-
fected side is entirely prevented, the vicious circle
will, of course, come to a stop, one of its segments
having proceeded as far as it can.
In the treatment of the first factor no direct
measure is available ; absorption of obstructing
fibrinous exudate is necessarily left to nature, un-
less, perchance, potassuim iodide prove of service
in this direction. The second factor is directly
overcome by aspiration, but as this factor does not
in itself initiate a vicious circle, relief is only pro-
portionate to the amount of fluid aspirated, and
there is no consecutive, progressive betterment such
as often resuhs when a vicious circle is broken. In
the case of the third factor aspiration is likewise a
remedy, but its complete effect in subduing the
vicious circle occurs only if a favorable change in
the underlying absorptive power of the pleura —
possibly a change in osmotic conditions — has al-
ready had time to take place. If this absorptive
power remains unchanged, aspiration will remove
a certain amount of fluid but will allow the vicious
circle to resume operation until the pleura has be-
come filled again to the point of arrest of expiration
on the affected side. If, on the other hand, the
absorptive power has increased, tapping, it w'ould
seem, may reverse the vicious circle into a benefi-
cial circle viz., one in which, the possibilitv of res-
piratory movement, and hence of the pumping ac-
tion, having been restored, absorption has begun or
increased in consequence: and the greater the ab-
sorption, the greater the respiratory movement, and
vice versa. The beneficial circle thus established will
rend, apparently, to accelerate the rate of absorption
beyond what it would otherwise have been. The
fact that often the withdrawal of only a small
quantity of a large effusion is followed by rapid
absorption of the remainder might be accounted for
in this way. The underlying absorptive power
might not yet have improved sufficientlv to permit
of actual resorption, yet have become sufiicient for
resorption when aided bv the respiratorv movement
restored through partial removal of the effusion
The improvement of absorptive power per se i^
of course, likely to be favored bv internal use of
purgatives such as magnesium sulphate and di-
uretics such as theobromine, to deplete the blood,
as well as by dry food and limitation of fluids.
(To be concluded.)
520
MODERN TREATMENT AND PREVENTIVE MEDICINE
[New York
Medical Journal.
Mycotic Intertrigo. — R. Sabouraud {Presse
mcdicalc, May 30, 1918) writes concerning eczema
marginatum, the frequent localization of which be-
tween the toes was pointed out by him nearly ten
years ago. All the folds of the region may become
involved, but the condition is most severe between
the fourth and fifth toes, the skin there becoming
thickened, moist, and fissured. There is increasing
dif¥icultv in walking. The disease may spread
anteriorly to the tips of the toes in the form of
moist or dried vesicles, or posteriorly between the
toes and the ball of the foot and also on the dorsum
of the foot. The af¥ection has often been present
for months when the patient is first seen, and is
then frequently treated in vain with protective
ointments and emollients in the belief that it is an
eczema or intertrigo. The condition being actually
a mycosis or tinea, due to the epidermophyton inter-
triginis, strong iodine or chrysophanic applications
are indicated and will soon cure it. All the thick-
ened, dead epithelium should be first carefully
removed with Volkmann's curette and pumice
stone. Cotton 015 a hemostat should then be dipped
in a one in five dilution of tincture of iodine —
French — in alcohol and very firmly rubbed against
the diseased area. After this is dry, the following
zinc cream is applied :
Zinci oxidi 6 grams ;
Petrolati 20 grams;
Adipis lanae hydrosi, ) r u ,
Aqu^ destillat^, 1 5
Fiat cremor.
This dressing is renewed daily for a week, re-
moval of dead epithelium being likewise carried out
each time. To insure against recurrence, a layer
of one ]>er cent, chrysophanic acid in hot lard
should be applied after or in place of the iodine for
a few days longer. Even then the condition may
recur if the removal of horny epithelium has not
been very thoroughly carried out. The parasite
may be demonstrated by heating a thin horny scale
between slides in a solution of three parts of caustic
potash in seven parts by weight of water, allowing
to stand an hour or two, and examining under a
magnification of 300, with the diaphragm closed
■doAvn. Numerous mycelial filaments are then seen.
Calcium Therapy. — A. G. Brown, Jr. (Virginia
Medical Monthly, July, 1918) maintains that in
gastric, bronchial, and nervous cases, calcium
therapy can frequently be applied with advantage.
Special stress is laid on gastric tetany, acute and
latent. Calcium balance in such cases is lost
through parathyroid insufficiency, and there result
certain sudden or chronic symptoms. Paroxysmal
tonic contractions of groups of muscles are the
most spectacular of these, but paresthesia in the
bands and feet, over excitability of certain nerves,
and changes in the teeth, hair, nails, and bones are
also observed in most chronic cases. In acute
gastric cases, tetany may show itself in spasm of
•certain muscles ; the obstetrical hand may be pro-
duced or the thumb may be turned under and held
closely to the hand, with the latter bent backward.
The tetany face may appear, with deepening of the
nasolabial fold and forehead wrinkling. Again
there may be paresthesia of the upper extremities.
numbness and tension being complained of. In the
presence of these symptoms, Trousseau's and
Choostek's signs should be looked for. In chronic
or latent tetany, one may find fragile and ridged
finger nails ; short, stubby, thin hair, and rudi-
mentary, small, irregular, furrowed teeth. Among
the author's stomach cases a number were greatly
improved and relieved of nervous symptoms by
administration of calcium in adequate doses.
Conservative Treatment of the Displaced
Uterus.— 11. A. Wade {American Journal of Ob-
stetrics, June, T918), in intervening surgically for
the relief of uterine displacements, has of late been
confining his procedures as much as possible to the
vaginal tract. Frequently, displacements in aged
and infirm or neurasthenic women have been sur-
gically corrected in the office without anesthesia and
without confinement to bed either before or after
the operation. Where the symptoms complained of
are due to retroversion of the uterus, a well fitting
rubber pessary introduced within the vagina will
often give relief; care must be taken that the
pessary does not merely convert the retroversion
into a retroflexion. In subinvoluted uteri, re-
troversion will gradually disappear if the patient
persistently sleeps in a modified Sims's position. In
a retroflexed uterus with a long cervix, either intact
or torn, a high amputation of the cervix will convert
the retroflexion into a retroversion and eliminate the
dysmenorrhea. This amputation may be done in the
office without an anesthetic, if the calibre of the
vagina be of fair size and the uterine ligaments
sufficiently elastic to permit of bringing the cervix
down to the vaginal entrance. In cases of retro-
flexion causing sterility. Wade cuts through the
angle of flexion between the body and its cervix by
introducing a knife into the cervical canal, and, after
application of fifty per cent, tincture of iodine to the
endometrium of the uterine body and cervix, a stem
is introduced, to be worn for several months to
prevent recurrence. In cases of retroflexion requir-
ing abdominal section, as little intraabdominal sur-
gery as is compatible with replacement is done. The
anteflexed infantile uterus in young unmarried
women is treated merely with animal extracts, in
some cases with apparent benefit. In marked ante-
flexion in a woman desirous of bearing children,
however, the angle of flexion between body and
cervix is obliterated by incision, followed by
iodinization and insertion of a selfretaining stem.
Prolapse in shght degrees causes no subjective
symptoms and requires no treatment. Moderate de-
grees of prolapse are often relieved by removing
the lower portion of the hypertrophied cervix and
replacing the remaining portion of the cervix in the
hollow of the sacrum by the use of a pessary. This
can likewise often be done in the office without
anesthesia or confinement to bed.
Occupational Training of Men Subjected to
Amputation or Other Mutilations. — J. Gourdon
[Bulletin dc V Academie de mcdecine, June 25,
1918) reports on 5,014 cases treated in special
institutions in Bordeaux. Of this aggregate,
seventy-three per cent, were able to resume their
former occupations with or without prosthetic de-
September 21, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
521
vices, and without special training; twenty-seven
per cent, required education or occupational re-
adaptation. In only thirty per cent, of the series
were the upper extremities involved. As compared
with a normal subject the war cripple is charac-
terized physically by a markedly reduced resistance
to fatigue, and mentally, by diminished will power
in beginning and continuing work. Of the series
discussed, sixty-two per cent, were agricultural
workers ; these, of all the patients, returned the most
readily to their former work. Those with an am-
putated hand or forearm showed practically a normal
labor yield ; those with an arm amputation, seventy-
five to eighty-five per cent, of the normal, and those
with disarticulation at the shoulder, forty to fifty
per cent. .Among the men with amputated lower
extremities, only those with thigh amputations
showed greatly reduced efficiency, yielding only
fifty per cent, of the normal. Manual, industrial
work can be performed by all amputation cases and
in many other instances of limb mutilation, with a
reduction of yield not exceeding ten per cent. The
reduction in yield at the close of the training period
of a mutilated subject is due principally to slowness
of execution ; when he is placed in a producing
workshop, execution becomes more rapid. Com-
mercial and administrative knowledge is absorbed
by the mutilated, owing to their greater earnestness
and maturity, much more rapidly than by the normal
pupils in occupational schools. Occupational edu-
cation and readaptation should be instituted as
soon as the wounds have healed and before the
subject is discharged from service. From the
standpoint of yield it is very desirable that the
mutilated should be restored to their former occu-
pations. It would be advisable to grant special
bonuses according to the degree of occupational
capacity attained in comparison with the severity of
the mutilation.
Discontinuous General Anesthesia. — Chaput
(Presse medicale, June 20, 1918) recommends ad-
ministration of the anesthetic — ether, chloroform,
or ethyl chloride — in an amount just sufficient to
overcome sensibility and movements on the part of
the patient. The anesthetic is then stopped and the
surgeon operates until the patient moves enough to
interfere with his work. The inhalations are then
resumed until the condition is such as to permit of
correct operative work, the anesthetic then stopped,
and the surgeon's work resumed, etc. Advantages
of this type of anesthesia are as follows : The
corneal reflex persists throughout, the face remains
well colored, the pupils but little changed, and the
pulse strong. \'omiting during the operation never
occurs, and the heart and respiration never give
way. At the conclusion of the anesthesia, the pa-
tient wakes up almost at once, with the face of good
color and features placid. There is no post oper-
ative vomiting, no malaise nor shock, no icterus ;
and in the case of" operations above the level of the
umbilicus the patient may get up the same day and
go home. The procedure may be combined with
local and spinal anesthesia ; only an infinitesimal
amount of chloroform is then used. Discontinuous
anesthesia was employed by the author in 100 cases
without the least untoward result.
Autogenous Vaccine Therapy in Typhoid
Fever. — Tribondeau {Presse medicale, June 20,
L9i8), having recently pointed out the advantages
of making a bacteriological diagnosis of typhoid and
paratyphoid fevers by a blood culture in bile with
peptone and glucose, now reports encouraging re-
sults from therapeutic use of an autogenous vaccine
consisting of the culture previously made in diag-
nosis. As auxiliary measures he uses cold wet
packs, administered whenever the rectal tempera-
ture, taken every three hours, exceeds 39° C, and
enemas to which Labarraque's solution has been
added.
Large versus Small Doses of Medicinal Agents.
— C. FiESSiNGER {Bulletin de I'Academie dc mede-
cine, July 2, 1919) divides drugs into three groups,
— the specifics and those acting mechanically, of
which large doses are appropriate, and the sympto-
matic or functional remedies, the dosage of which,
as customarily applied, is often too large. Digitalis,
in its relation to myocardial contraction is a sympto-
matic and not a specific remedy, for the cause of
the impairment of contraction continues in spite of
it. Small and subcontinuous doses will gradually
restore contractile power to the muscle, while large
doses excite the muscle temporarily but then leave
it insensitive. Risk of the latter effect begins above
one-tenth milligram of French crystallized digitalin
or one-tenth gram of powdered digitalis. Atropine
sulphate will produce its effects in a dosage of only
one to two tenths of a milligram. Opium in large
doses prolongs bronchitis when it arrests cough,
and weakens the myocardium in heart cases. Hyp-
notics combat insomnia among the nervous while
increasing their restlessness by day. Chloral
hydrate, 0.5 gram, will procure sleep as well
as two grams. The task should be undertaken
of determining for each drug not only the maxi-
mum dose of the formularies, which is the last
guidepost before the lethal dose, but the smallest
dose and also the zone of beginning risk.
Fractures of the Shafts of Bones Caused by
Bullets. — J. Delmas (Presse medicale, June 20,
1918) points out that the finding of only a puncti-
form wound of entrance of the bullet is by
no means a guarantee that serious damage may not
have been produced within the limb and that non-
operative treatment is indicated. The wound of
exit may be more or less extensive and irregular,
with or without hernia of muscle Radical treatment
is necessary whether the fracture be comminuted
fracture or not. In one of the author's cases, with
a clear line of fracture of the humerus, bits of
clothing were found in the tissues in spite of an
absolutely punctiform wound of entrance. Where
the wounds of entrance and exit are both puncti-
form but the X rays show a comminuted fracture,
complete operative treatment is likewise indicated,
as one cannot be certain of the asepsis of the tis-
sues, and because the many loose bone fragments,
projecting into the muscular masses and always
more numerous than the screen shows, play the
role of foreign bodies favoring delayed outburst of
a latent infection and, mechanically, callus forma-
tion. In such cases reduction and maintenance in
good position are less easy than in a clear linear
522
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
fracture. Where both orifices are punctiform and
the tracture is linear, abstention from operation is
permissible, with careful watching. Possible in-
fection must always be feared, the narrowness of
the orifice by no means implying that bits of cloth-
ing have not been forced in. The absence of bone
fragments, however, with the ease of reduction and
maintenance of position, reduces the dangers of sec-
ondary infection, if it later a])pears, to a minimum.
Quinine in the Treatment and Prevention of
Malaria. — Sir Donald Ross {Journal of Tropical
Medicine and Hyiuciic, .April 15, 1918) reports on
the results of treatment in about 2,500 cases of ma-
laria, returned to England, and nearly all of long
duration. The infections were, for the most part,
benign tertian. The treatments tried out were
classified as antirelapse quinine prophylaxis, short
sterilizing treatment, long sterilizing treatment, and
mixed treatments. The treatment in each class
comprised different salts and preparations of qui-
nine, given by mouth and by subcutaneous, intra-
muscular, and intravenous injection. The aggre-
gate result was twenty-seven per cent, of ascer-
tained relapsing cases. .A. control was afforded by
IQ2 men who were watched without any quinine
treatment at all : of these, eighty-six per cent, re-
mained ill and forty-six and five-tenths per cent, re-
lapsed within twenty-seven days. Short intensive
treatment by large doics of quinine — up to 180
grains of sulphate or hydrochloride in three days —
can be very well borne by patients, and, with rest,
stmiulants, and good after treatment, efifect a sub-
stantial proportion of cures. The same applied to
the third group, in which some cases received over
1,000 grains of quinine in four weeks, with large
intramuscular doses at the beginning of this period.
Relapse in these two classes was not any less fre-
quent, however, than in cases treated less heroically
with relatively small doses — about sixty grains a
week. The latter dose gave the best results both
as regards prevention of relapse and the well being
of the patient. The amount must not, however, be
less than a daily dose of about ten grains. As a
w^iole, no conspicuous advantage was found in
either the intramuscular, intravenous, or oral meth-
ods of administration. Urine examinations pointed
to a tendency for the excretion of quinine, in what-
ever doses given, to reach a concentration of seven
to eleven grains per litre of urine, and did not favor
the view that the drug is eliminated with a different
degree of readiness when given by mouth than when
given by other routes.
The Interposition Operation for Prolapse of
Uterus and Bladder. — I. S. Stone (American
Journal of Obstetrics, May, 1918) asserts that this
operation is one of the most useful and satisfactory
of g}mecological procedures. Its indications are
to overcome the bladder prolapse, which generally
precedes that of the uterus, and also to relieve the
urinary incontinence often present ; to restore and
maintain the uterus within the pelvis ; to narrow
and maintain the vaginal walls in nearly their
former normal position, and to readjust the pelvic
floor and possibly overcorrect its muscular and fas-
cial relaxation, and bring the perineum forward
nearer the pubic arch. It is of prime importance
that the bladder mucosa be in good condition. The
uterus is always to be scarified on its anterior and
fundal surfaces. Both the uterosacral and cardinal
ligaments, i. e., the lower portions of the broad Hga-
nients, can be utilized in retracting the cervix. The
stout woman with prolapse is especially benefited
by the interposition operation when not readily
treated by any other. The perineorrhaphy is
scarcely less important than the fixation of the
uterus. Bringing the muscles and fascia together
re.sults in a new and better support and also brings
the vulva and introitus vaginae forward under the
pubic arch. .A much wider separation of the base of
the bladder than is usually practised is advised. The
catheter is generally required for some days after
the operation. To prevent catheter cystitis, irriga-
tions with two per cent, protargol solution are prac-
tised.
Saline Solutions for Gastrointestinal Atony. —
G. Hayem (Bulletin de I' Academic dc inedecine,
June II, iQiS) has for about twenty-five years been
studying the effects of various saline combinations
in gastric disorders. The most effectual have
proven to be those imitating more or less closely
certain natural mineral waters with an already
established reputation in the treatment of such dis-
orders. Five formulas which had given particu-
larly good results were published in 1904. Each
was based on tests made in hundreds of cases. The
author now presents two new combinations modeled
after the waters of Chatelguyon, France, and thor-
oughly tested clinically :
I.
B. Aqua destillat.ie, i litre ;
Sodii chloridi. , , ! .of each, 2.5 grams ;
Masnesii chlondi (cryst.), ) - ^ » t
Sodii bicarbonatis 2 grams.
Fiat solvtio.
IT.
B Aqux destillatse, i litre ;
Sodii chloridi. , , 1 .of each, 2.5 grams ;
Magnesii chloridi (cryst.), )
Sodii sulphatis, 3 to 5 grams.
Fiat soliitio.
These combinations are particularly adapted for
the treatment of gastric dilatation due to myasthe-
nia with or without marked muscular atrophy,
and in the absence of a mechanical impediment ta
evacuation. Generally these cases are of the hypwD-
peptic type, with more or less advanced glandular
atrophy. Most of the patients suffer also from
intestinal atony, which is improved, as a rule, by
the first solution, or if not, by the second. Mag-
nesium chloride appears to act very effectually upon
the smooth muscle of the digestive tract, exciting
its contractions and regularizing its functional
activity.
Nascent Iodine Vapor for Sluggish Wounds. —
Quinsac {Prcsse mcdicale, May 13, 1918) combines-
a thermocautery bulb apparatus with Turret's
urethral cannula and uses a small quantity of iodo-
form and a few particles of pure iodine. The
wound is first carefully treated with moist, aseptic
dressings, and nascent iodine vapor is then brought
in contact with it. A dry superficial layer forms-
under which healing rapidly progresses.
September 21, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
523
The Modern Conception of Diabetes. — Accord-
ing to the Lancet, diabetes has always been charac-
terized by the excretion of sugar in the urine. Pre-
viously the generally accepted treatment has been to
exclude carbohydrate from the diet, but, at that, the
patient still excreted sugar. The source of this
sugar has been traced to protein. Protein consists
of some eighteen aminoacids. Some of these are
converted, in diabetic patients and in experimental
animals (depancreatised, phloridzinised) into glu-
cose. Another origin of carbohydrates in diabetics
in fat ; but this is not of outstanding importance.
The acetone, acetoacetic acid, and oxybutyric
acid which are characteristic of severe cases of
diabetes have been proved to be derived from the
fat of the food, but they may also arise from pro-
tein. Acetoacetic acid is the primary product,
oxybutyric acid being a reduction product of ace-
toacetic acid. The production of acid was formerly
thought to be the cause of diabetic coma, but the
coma is really due to the toxic action of acetoacetic
acid. Since acetoacetic acid is a ketonic acid, the
term ketosis might be used in preference to acidosis.
Though acetoacetic acid may, theoretically, be de-
rived from carbohydrate this source may be ex-
cluded, according to the latest work done by
Hurtley.
Glycosuria is then derived from the carbohydrate
and protein of the diet ; the acidosis, from the fat
and to a small extent from the protein. The diabe-
tic uses the carbohydrate of the food too slowly ;
some of his carbohydrate he derives from the pro-'
tein and fat leading to more decomposition of these
than normal and the production of more acetoacetic
acid, which is reduced to oxybutyric acid, and ex-
creted, instead of being oxidized as normally.
The modern treatment of diabetes as described by
Dr. E. P. Poulton in his Goulstonian lectures is to
reduce the amount of all kinds of food stuffs to
the lowest possible limit, thus reducing the quantity
of the excretory products. The mortality in Guy's
Hospital has been reduced from twenty-three per
cent, in the ten years previous to 1916, to seven
and seven tenths per cent, since 1916, owing to the
adoption of this method of treatment. The carbo-
hydrate disappears from the urine and there is
less acetoacetic acid. By careful addition of car-
bohydrate to the diet the patient's tolerance for
carbohydrate is determined ; similarly the protein
and fat amounts are adjusted. By this method of
treatment the patient may attain a diet of 1,500 to
2,000 calorie value, the lowest possible limit for
the normal individual.
Contraindications to Radiotherapy in Skin
Cancer. — 1. Darier {Bulletin de I' Academic de med-
ecine, June 4, 1918) points out that in some cases
of skin cancer the x rays, or radium, fail, or may
even aggravate the disease. This he accounts for
on the ground that skin cancer includes several
dififerent species of neoplasms which dififer in their
clinical course, structure, and therapeutic indica-
tions. The species cured by radiotherapy is the
tubular or basocellular epithelioma, the common
face cancer of the aged, which may last ten or
twenty years or more but never engorges the ganglia
nor causes visceral metastases. In such cases the x
rays fail only in advanced instances in which ulcera-
tion has invaderl the cavities of the face. On the
other hand, the lobular or spinocellular epithelioma,
the usual form of cancer of the tongue or lips,
smokers' cancer, cancer of the external genitals and
anus, cancer of scar tissues and of lupus, should
never be subjected to radiotherapy. It rapidly infects
the ganglia and kills usually in less than two years.
X rays or radium in these cases cause apparent ame-
lioration for two or three weeks. Then proliferation
is more active, and often the condition, operable at
first, is no longer so after radiotherapy. This form
is amenable only to surgical excision, which should
be extensive and prompt. In nevocarcinoma or mel-
anosarcoma, starting in imprudently irritated nevi
or beauty spots, dangerous through lymphatic and
visceral metastases, and met with even in young
subjects, radiotherapy is likewise useless and should
be replaced by surgery or electrolysis — the latter
seemingly the method of choice. Finally, small skin
tumors secondary to cancer, e. g., of the breast,
whether or not subjected to operation, are treated
by radiotherapy with only apparent advantage ; al-
though they frequently disappear under the rays,
the prognosis of the underlying disease is not in the
'east improved thereby. In all skin cancers an early
diagnosis of the type present should be made, by
histological examination if necessary, and the treat-
ment at once adjusted accordingly.
Bronchial Fistula Follov^dng Lung Resection.
— Howard I.ilienthal {Annals of Surgery, May,
TO'S) summarizes as to this condition, thus: I.
After lobe resection for chronic inflammation a
temporary bronchial fistula may be expected. 2.
The fistula will probably close spontaneously. 3.
It appears that as a general principle we may as-
sume' that, other things being equal, a bronchial
fistula is apt to close in direct proportion to its dis-
tance from the body surface.
Wounds of the Ampulla of the Carotid. — H.
Lefevre {Presse medicale, June 6, 1918) notes that
triple ligation of the common carotid and both its
branches for extensive injury of the carotid am-
pulla is attended with the same degree of risk as
regards the brain as ligation of the internal carotid
alone. In ligation of the common carotid
alone, the condition may be spontaneously im-
proved by reflux of blood through the external ca-
rotid into the internal carotid. Theoretically, anas-
tomosis of the internal and external carotids seemed
to Lefevre advisable, as in injury of the carotid
ampulla necessitating the triple hgature or in liga-
tion of the internal carotid alone, the risk as regards
the brain would thus be reduced to that attending
simple ligation of the common carotid. This pro-
cedure was actually carried out in a case of stellate
wound of the ampulla, suture being impossible. The
two carotids were joined in end to end suture by one
layer of silk thread sterilized in vaseline. Ischemic
paralytic manifestations were noted on the day after
the operation, possibly because of kinking at the
point of suture or a dressing too tight around the
neck. These were transitory, however, and when
the patient left the hospital six weeks later, there
remained only some diminution of power on the
opposite side of the body.
Miscellany from Home and Foreign Journals
Blood Analysis in Eclampsia. — J. M. Siemens
(American Journal of Obstetrics, May, 1918)
notes that methods are now available for accurate
estimation of most of the nitrogenous constituents
of the blood, including the nonprotein nitrogen,
aminoacids, urea, uric acid, creatinine, and creatine.
There is also an excellent method for determination
of the blood sugar, and other methods, though less
exact, yield satisfactory results for the fats and the
lipoids. The question of the chemical reaction of
the blood may be attacked from new angles by de-
termining the hydrogen ion concentration and the
carbon dioxide combining power of the plasma.
Analyses conducted by the author and his assistants
in a series of twenty-three cases of eclampsia and
allied intoxications revealed a normal quantity of
aminoacids and a slight retention of nitrogenous
waste products, such as urea and uric acid. After
convulsions there was an increase in the blood sugar.
The total fat was approximately the same in cases
of toxemia and of normal pregnancy. Usually the
cholesterol was increased and the lecithin dimin-
ished in eclampsia. The carbon dioxide combining
power of the plasma was reduced during normal
pregnancy, indicating a mild acidosis, and the varia-
tions met with in the presence of autointoxications
were insignificant. The results of these blood anal-
yses are held not to support the acidosis hypothesis
nor the derangement of protein metabolism
hypothesis of eclampsia and to indicate that the
cause of the disease must be sought elsewhere.
Lumbar Puncture. — ^J. H. Barach (Archives of
Diagnosis, July, 1918) believes a horizontal lateral
posture during the puncture to be safest for the
patient, and has uniformly obtained fluid with this
posture in over 1,000 consecutive punctures. The
lumbar region should be made prominent. The skin
locally should be thoroughly cleansed with soap and
water, alcohol and mercury bichloride or hydrogen
peroxide ; it may then be painted with tincture of
iodine, as may also the operator's fingers. For an-
esthetizing the skin Barach sometimes uses a fresh
sterile one fourth to one half per cent, cocaine so-
lution by infiltration, but also often employs the
.sharp point of a piece of ice, placed on the exact
spot of puncture and kept there with considerable
pressure. A needle of eighteen gauge does the least
damage to the tissues and is least liable to cause
bleeding. For cell counts the second five mils of
fluid obtained in a separate test tube is to be pre-
ferred. Lumbar puncture should seldom or never
be performed in the dispensary or ofifice. The aver-
age patient usually has several uncomfortable days
after the procedure. Patients with various nervous
symptoms are apt to show the more severe after-
efifects. A delayed reaction may come on after forty-
eight to seventy-two hours. Most of the symp-
toms are relieved by the horizontal position. It is
well to have the patient in bed for at least forty-
eight hours. The foot of the bed may be raised,
and the patient should get along without or with
but one small pillow. In some cases the author has
had good results from fluid extract of ergot, one
dram three times daily, beginning promptly after the
puncture. Acetphenetidin, cafifeine, bromides, etc.,
were without effect. Pituitrin and dried thyroids
were used in severe cases, the former as general
vasomotor stimulant and the latter to stimulate
secretion of spinal fluid. When the symptoms per-
sist longer than usual and the patient is up and
about he has seen benefit from a tight abdominal
band. The author has seen no fatality immediately
following lumbar puncture. Accumulated records
indicate that the procedure may prove fatal in cases
of brain tumor or brain cyst, where the lowered
pressure might alter the relationship of the parts, a
tumor, e. g., shutting off the foramen of Magendie.
Lumbar puncture might induce rupture of a cyst or
aneurysm. Deaths have been recorded in cases with
edema of the brain such as occurs in alcoholism or
uremia.
Poisoning by Alcohol in the Manufacture of
Calcium Cyanamide. — J. P. Langlois (Bulletin
de I'Academie dc medccine, July 2, 1918) states
that the recent marked increase in the manufacture
of calcium cyananide has brought into prominence
certain ill effects that may result among workers
who make or manipulate it. The ingestion of al-
cohoHc beverages, even in small amounts, during or
just after work induces special symptoms, illus-
trated in the following typical case : An emphysem-
atous worker, aged fifty-five, who was occupied in
breaking up cyanamide, took 0.3 litre of red wine
at 11.25 a. m. In three minutes the pulse rate rose
from 69 to 104, the blood pressure fell from 160 to
no, and the rate of breathing rose from sixteen to
twenty-two. Alreadv in the second minute there
was excessive vasodilatation of the face and con-
junctivae, marked pulsation of the temporals, then
nausea ; the man was compelled to stay recumbent,
becoming faint as soon as he attempted to rise. The
pressure remained no for an hour, then rose slowly.
The signs of vasodilatation passed off' in about an
hour. The sensitiveness to alcohol from working
with cyanamide lasts over eighteen hours after
cessation of work, though diminishing during this
period ; it then disappears completely, even in in-
dividuals who have long been working in the fac-
tory. In dogs subjected to inhalation of dust
containing traces of cyanamide, intravenous injection
of but four mils of alcohol per kilogram proved
sufficient to arrest the heart — an effect requiring
eight to ten mils in normal animals. In rabbits
cyanamide seemed to increase the sensitiveness of
Cyon's depressor nerve to stimulation.
Muscular Autolysis and Its Bearing on Shock.
— Pierre Delbet and Karajonopoulos (Bulletin de
I'Academie de mcdecine, July 2, 1918) note that
manifestations of shock among the wounded gen-
erally appear in two or three hours, i. e., before
bacteria have had time to become adapted and
copiously pullulate. Their researches were under-
taken to ascertain whether contused, crushed tissues,
such as those injured by shell fragments, may
rapidly acquire, without the agency of bacteria, a
toxicity capable of inducing effects such as those
September 21, 191S.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
525
of shock. Tissues were taken from animals im-
mediately after sacrifice, finely divicfed in normal
saline solution, placed in the incubator, and after
varying intervals, filtered through fine meshed gauze
and injected intraperitoneally in animals of the
same species. Aseptic autolysates were thus ob-
tained in both rats and guineapigs. Autolysates of
the muscles of gray rats, especially those feeding
mainly on meats — as are the troops — proved highly
toxic. A few seconds after the injection the animal
becomes comatose and shows marked polypnea,
doubtless due to poisoning of the medulla. The
animal remains inert and insensitive to noise, the
respiration gradually descends from no to forty or
thirty, and death follows. The more finely divided
the tissues before autolysis, the greater their tox-
icity. Of twenty-two rats, all became comatose and
twenty succumbed, — fourteen within five to forty-
five minutes and six within four to twenty hours.
The prompt deaths, perhaps analogous to certain
clinical observations, seem due to intoxication of
the nervous system. In the animals dying later,
pathological changes in the liver were found. An
autolysate of the muscles of a single thigh caused
grave shock, often fatal, in another animal of the
same weight. These experiments appear to demon-
strate the occurrence of an autotoxic form of shock,
and lead to the practical conclusion that to the
symptomatic treatment of shock must be added a
pathogenetic treatment which consists in eliminating
the toxic focus by amputation if the limb is in a
hopeless condition, or, if it is not, by resection of
the contused tissues. The operation is thus an
tirgent one ; instead of waiting to operate until the
patient has rallied from shock, one should operate
from the start to eliminate autotoxic shock.
Gastritis and Dyspepsia. — F. Ramond (Bulle-
tin de r Academic dc medccinc, July 9, 1918) looks
upon gastritis as the cause of the majority of dys-
peptic states, and believes that this conception will
render the study of diseases of the stomach more
attractive as well as more scientific. In the first
stage of inflammation there is merely a prolonga-
tion of the normal temporary congestion of the sub-
mucosa. In more advanced stages there are both
congestion and diapedesis in the submucosa and an
inflammatory reaction or cell degeneration in the
mucosa. The author divides the stomach into three
portions, the upper stomach, supplying the peptic
and hydrochloric secretions ; the middle portion,
with part of its mucosa supplying pepsin and acid
and the remainder mucus, and the lower stomach or
pyloric region, secreting chiefly mucus. Experi-
ments showed that a mutual reflex relationship ex-
ists between the upper and lower stomach, so that
when either is stimulated, the other is reflexly ex-
cited to secretion. In the case of a gastritis con-
fined to the upper stomach — as is true in most toxic
gastritides — and merely superficial and irritative,
hyperchlorhydria occurs ; if it is of long standing
and degenerative, acid secretion is, on the contrary,
diminished. Besides, by reflex action, the lower
stomach is excited to the production of mucus. After
a meal, the fluids taken, mixed with the gastric juice,
rest upon the solids and irritate an inflamed upper
stomach, causing early pain, often with regurgita-
tion, nausea, and even vomiting. Palpation of the
upper stomach causes pain at its accessible points,
viz., the xiphoid point and the left infracostal point.
The complete symptom-complex thus described for
the upper stomach permits of locating the gastritis,
predicting the chemical findings, making a correct
l)rognosis, and instituting rational treatment. By
analogous reasoning, the cardinal symptoms of mid-
dle, lower, and total gastritis can be worked out.
Abdominal Pain in Chronic Amebic Enteritis.
— K. Deglos (Paris medical, July 13, 1918) states
that in the chronic enteritis of amebic cases there
may occur, apart from functional disturbances of
the colon, and even when colonic involvement is nor
manifested by localized pain and contracture, symp-
toms due to dragging on the abdominal sympathetic,
in particular the filaments from the solar and celiac
plexuses, through the mesentery. These symptoms
consist of sensation of discomfort, weight, drag-
ging, and squeezing, referred chiefly to the lower
epigastric and paraumbilical regions. At times the
discomfort amounts to actual pain, accompanied by
a profound malaise which reacts heavily upon the
mental equilibrium of the patients, generally deeply
affected when the disturbance is of long standing
and marked loss of weight has occurred. While
aerophagia and the resulting dyspeptic disturbances
are rather frequent, the stomach should not be held
to account for the symptoms just referred to. In
many instances, as radioscopy indicated, enterop-
tosis, and especially transverse coloptosis, play an
important role, assisted, furthermore, by the accom-
panying more or less complete loss of abdominal
fat. The treatment comprises, in the first place, a
proper diet, with emetine and neosalvarsan. Meas-
ures should be taken to promote a gain in weight.
Pain or discomfort are allayed by small doses of
belladonna. To strengthen the abdominal muscles,
often very weak, abdominal gymnastics, very grad-
ually increased under the guidance of a convalescent,
are indicated, e. g., raising the body or the lower
limbs slowly from recumbency. These exercises
should be carried out morning and evening, on an
empty stomach, and followed by half an hour of
complete rest. When the patient begins to get up,
walk about, or work, a tight, broad belt of flannel
or an elastic belt will greatly attenuate the discom-
fort resulting from the enteroptosis.
Renal Function in Acute Infections. — Chan-
ning Frothingham (Archives' of Internal Medicine,
July, 1918) reports studies with the phenolsulphone-
phthalein test, the estimation of blood urea, and the
determination of McLean's index of urea excretion,
in cases of typhoid fever, pneumonia, acute rheu-
matism, diphtheria, etc. In many cases there was
an abnormally high index of urea excretion during
fever, but as it was not associated with an increase
in phenolsulphonephthalein excretion or an abnor-
mally lew blood urea, it probably depended on some
unknown factors peculiar to fever rather than to a
hyperactivity of the kidneys during fever. In gen-
eral, the tests failed to show consistent evidence of
impaired renal function during or after the acute in-
fections, when the clinical picture or urine exam-
ination by the older methods did not suggest acute
nephritis.
526
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Rickets in Its Relationship to Housing. — Leon-
ard Findlay {Glasgow Medical Journal, May, 1918)
thinks rickets may be said to af¥ect at least fifty per
cent, of the children of industrial populations. The
disease, while not directly fatal, increases suscepti-
bility to the respiratory complications of measles
and whoopingcough and is indirectly responsible for
a rather high death rate. Experimentally the author
found that normally fed young dogs could be made
rachitic simply by confinement and lack of exercise,
while dogs fed on a diet poor in fat but allowed to
exercise developed diarrhea and marasmus, not
rickets. Later he conducted a statistical study of
the dietetic and home conditions of 500 rachitic chil-
dren, and now reports still another study of the
same kind. The main etiological factors, in the
order of their significance, proved to be improper
housing, absence of facilities for open air life, and
imperfect parental care. Poverty per se did not
seem a factor of any importance. Most of the
rachitic children were as suitably fed as the non-
rachitic, and in not a few cases even better, both
as to quality and quantity ; the amount spent on rent,
however, was distinctly greater in the nonrachitic
than in the rachitic family. Where rachitic and
nonrachitic occupied the same houses, neither the
number of stairs up, the exposure, nor the question
of through and through ventilation seemed to aflfecc
the frequency of the disease. Quite otherwise was
it, however, when the number of persons to an
apartment and the general cleanliness and care of
the home were considered. With the markedly
rachitic children, 3.93 persons inhabited each apart-
ment ; 3.0 was the average for nonrachitic families.
The average air space for markedly rachitic families
was 422 cubic feet per person, for the mildly
rachitic, 483 cubic feet, and for the nonrachitic
families, 625 cubic feet. Nearly fifty per cent, of the
rachitic children were admittedly not taken out for
exercise, and only thirty per cent, seemed to be suf-
ficiently exercised in the open air. Of the healthy
nonrachitic children, 86.5 per cent, were properly
exercised in the open, and only four per cent, did
not receive the necessary airings. The seasonal in-
cidence of the disease — spring rather than late sum-
mer or autumn — is undoubtedly due to this open air
factor. The incidence of rickets would seem to be
a question of economics. Until proper housing and
reasonable facilities for outdoor life are provided
it is vain to expect that more than a limited number
of poor parents in towns will succeed in rearing
nonrachitic children.
The Lymphocyte in Natural and Induced Re-
sistance to Transplanted Cancer. — James B.
Murphy and Herbert D. Taylor (Journal of Ex-
perimental Medicine, July, 191 8) immunized mice
by an injection of homologous defibrinated blood
beneath the skin of the back. After ten days<a piece
of tumor (adenocarcinoma) was inoculated into
the left groin of each animal and at the same time
nonimmunized mice were inoculated with the tumor
to control the virulence. After three weeks the
immune animals were divided, one group being sub-
jected to repeated small doses of x rays, and the
other used as a control. A week later both groups
were reinoculated in the right groin with the same
tumor strain, its virulence being determined by si-
multaneous inoculation into normal mice. The x
ray dose used was sufficient to destroy the major
part of the lymphoid tissue without ap])arently im-
pairing the animals' general health. The experi-
ments showed that the mice which had been
artificially immunized, inoculated, and proved im-
mune, could be again rendered susceptible to the
same tumor by exposure to the x rays, while the
immune animals which were not subjected to the
X rays preserved their resistance to a reinoculation
of the tumor to a large extent. In discussing their
results the authors say that this work bears out the
theory that the lymphocytes are an important factor
in the immunity to cancer studied in mice.
The Dietary Qualities of Barley. — H. Steen-
bock. Hazel K. Kent, and E. G. Gross (Journal of
Biological Chemistry, July, 1918) remarked that
while their work may not present any striking
peculiarities, yet it may serve to allay the fears of
those dietitians who are concerned over the use of
barley as a wheat substitute. The barley kernel
does not dififer essentially from those of maize, oats,
and wheat. Alone it is not capable of supplying the
needs of the growing animal, or even of permitting
a noteworthy amount of growth. The protein con-
tent of barley is 13.6 per cent., which is too low for
continued growth at a normal rate. The primary
growth determinant in barley is inorganic salts.
Second in importance, but also necessary, are pro-
tein and fat soluble vitamine. Barley contains an
abundance of the water soluble vitamine, but not of
the fat soluble vitamine. There are a number of
charts which illustrate the rate of growth of rats
fed on barley alone, and upon barley supplemented
with other mixtures, such as the addition of a fat
soluble vitamine, in the form of butter fat, salts,
casein, etc. The value of the mineral elements in
nutrition is again brought out by this work, as
only where salts formed one of the additions was
substantial growth noted. When salts, protein, and
fat soluble vitamine were all added, normal growth,
reproduction, and the rearing of the young were
possible.
The Choice betw^een Adequate and Inadequate
Diets, as Made by Rats. — -Thomas B. Osborne
and Lafayette B. Mendel (Journal of Bioloffical
Chemistry, July, 1918) present the results of their
observations on rats who were given a freedom of
choice between mixtures of similar foods, except
that one was inferior to the other for nutrition in
growth. Curves illustrate the rate of growth of the
rats and their food intake. The two foods were
exactly alike except for such variations as the sing'e
protein incorporated in each mixture, or a difiference
in the content of the water soluble vitamine derived
from milk. It is curious that in most instances the
rats chose the food superior from the standpoint of
growth, and that even when this was not the first
choice in some cases they later relinquished the
inferior food for the superior. Naturally no defi-
nite conclusions can be drawn from such a study,
but the desire of a young animal for food means
more than the satisfaction of its calorific needs, the
demand of the growth impulse must also be met hy
food of proper chemical constitution.
/
Proceedings of National and Local Societies
THE AMERICAN PEDIATRIC SOCIETY.
Thirtieth Annual Meeting, Held at the Curtis Hotel,
Lenox, Mass., May 2J , 28, and 2p, ipi8.
The Neglected Period of Childhood. — The
president, Dr. L. E. La Fetra, of New York, stated
that the rejection by medical examining boards
throughout the country of from twenty-five to
thirty per cent, of the men called as recruits for the
army had focused attention as never before on the
physical condition of our people. The experience of
European nations that under v\-ar conditions not
only did the birth rate fall and the infant mortahty
tend to rise, but even older children suffered because
of inadequate food and lowered hygienic conditions,
had impressed on us the danger of war to the na-
tion's children, even though they were at a distance
from the battle front. Already, in this country, the
effect of insufficient food was being felt. The Chil-
dren's Bureau, in prompt recognition of the situa-
tion, had designated this second year of the war as
"The Children's Year," and had inaugurated a
campaign for the saving of 100,000 children's lives.
This campaign laid upon pediatrists and upon the
members of the -\merican Pediatric Society a special
obligation. The whole chain of child welfare work
should be surveyed to see what links were weak and
thought and effort should be given to strengthening
these. The period of infancy, from one and one half
to two years, and the period of school Iffe, from six
to twelve or fourteen years of age were the only two
periods of life that were at all adequately supervised.
When it came to the preschool age, the period from
two to six years, very little had been done. During
this period, if the child was ill he was treated for
the acute condition, but he was not examined after-
ward at regular intervals as when he was a baby.
For four years he might get into all sorts of
troubles, digestive, nutritional, dentitional, glan-
dular, or infectious, without any preventive meas-
ures on the part of the authorities; when he
first went to school the medical inspector would
examine him and tell of all the terrible things he
had acquired since he left the milk station in ex-
cellent condition. A consideration of this period as
regards growth and susceptibility showed that the
impulse to growth is only a little less strong during
this period than during the first and second years.
This was evidenced by the size of the child's skull,
\yhich by the age of six years had attained prac-
tically adult size. It was important for the whole of
the child's life that his food at this time should
contain just the right sort of building material for
the highly organized protoplasm of the growing
nerve cells. Another important organ that showed
great changes at this period was the heart. The
resistance of the child to some diseases at this
period was even less than that of young babies, since
the infant was protected by certain immune bodies,
some inherited and some derived from the mother's
milk. Doctor La Fetra considered somewhat more
in detail certain diseases and conditions found in
children at this age, such as general malnutrition,
hereditary syphilis, tuberculosis, rickets, backward-
ness of various sorts, including cretinism and mon-
golism, which could be recognized at this age and
should have their appropriate treatment long before
the school age was reached. Nervous children,
those with adenoid growths, malformed jaws, cari-
ous teeth, and enlarged tonsils, should have treatment
at this time. The removal of adenoids and tonsils
was the more important because their presence en-
couraged serious complications if the patient should
later contract measles, diphtheria, influenza, or pneu-
monia. Whooping cough was most prevalent during
the preschool age ; seventy-five per cent, of the cases
were reported in children under five years of age.
This disease was often complicated by gastroin-
testinal disease or bronchopneumonia and predis-
posed to asthmatic bronchitis and tuberculosis.
Systemic vaccination against whooping cough had
seemed in some instances to be of great value and
Doctor La Fetra was in favor of employing this
vaccine.
The first step necessary toward bridging this gap
in our micdical supervision was to make a survey of
the actual situation. In New York it was proposed
to make a house to house canvass and to examine all
children with special reference to the presence of
malnutrition, enlarged tonsils and adenoids, carious
teeth, cardiac diseases, rickets, and tuberculosis.
Appropriate treatment would be advised and an
effort would be made to educate the lay public, which
was at the present time in a very receptive frame of
mind as to the necessity of periodic examinations
and care of their children before they enter school.
The importance of protecting children from all
sorts of contagious diseases, including the infectious
cold, would be emphasized. Consultations for pre-
school children would be established by the various
outpatient hospitals and the Department of Health,
where mothers could be taught about proper nutri-
tious food and about clothing and hygiene. There
was the need of fresh air and safe playgrounds, and
roof playgrounds on tenements, as proposed by Doc-
tor Northrup. would be an admirable solution of the
difficulty. The children could be kept under con-
stant supervision bv each mother taking her turn
during a part of the day. There was great need of
supervised playgrounds and kindergartens for the
somewhat older children. To cope with street acci-
dents something more was necessarv than mere regu-
lation of the speed of vehicles. Certain blocks should
be set aside as play streets, where during definitely
fixed hours no through vehicular traffic should be
allowed ; children should not be allowed to play on
streets where through traffic was allowed. From
the time a child could walk he should be taught the
dangers of the street and he should be instructed
in the technic of the street ; he should be cautioned
always to walk and not to run across the street, and
to look each way, particularly to the left, before
stepping from the sidewalk. The best method of
supervising children of preschool age would be to
have the children of each district examined at reg-
528
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES
[New York
Medical Journal.
ular intervals, preferably twice a ye3.r, at the near-
est school, in some room set apart for the purpose.
Hemoptysis Following Exploratory Puncture
of the Chest. — Dr. Augustus Caille, of New
York, related the history of an infant, six weeks
old, admitted to his service in a moribund and
markedly cyanotic condition, with a previous diag-
nosis of lobar pneumonia. Percussion revealed
flatness over both lungs posteriorly and absence of
pectoral fremitus below the scapula on both sides.
To make sure as to the presence or absence of
serum or pus, an aspirating needle of moderate
calibre w^as pushed into the seventh interspace
about three quarters of an inch. This procedure
was followed by a feeble coughing efifort and bv
brisk hemorrhage from the mouth, and in less than
a minute life was extinct. At autopsy the fora-
men ovale was found patent, and beneath the leaf-
let of the mitral valve there was an opening into
the interventricular septum. The cardiac muscu-
lature was of the same thickness on the right as on
the left side. There w^as distinct consolidation of
"both lungs and extensive hemorrhage into the right
pleural cavity. No puncture of a large vessel
could be made out. There was no laceration of
the lung tissue, as the specimen presented showed.
Doctor Caille also reported another fatal sequence
to an exploratory puncture that came under his no-
tice fifteen years ago. This occurred in a poorly
nourished, cyanotic child, two years of age, with
signs and symptoms of right sided pulmonic con-
solidation and urgent pulmonary embarrassment.
Upon withdrawal of the needle in this instance
hemorrhage took place from the mouth, and the
child died within a few minutes. Fatalities from
exploratory puncture were exceedingly rare. In
the writer's experience of forty years, during
which he had performed many thousands of ex-
ploratory punctures, the two cases just reported
stood out prominentlv. In both of the cases there
was extreme congestion of the lungs. In neither
case was the hemorrhage due to faulty technic.
The practical lesson for the guidance of the clin-
ician to bear in mind was' that in acute cases in
which puncture seemed to be indicated, the intro-
duction of the exploratory needle into a thorax
containing a highly congested lung was attended
with some risk when cyanosis and other signs of
cardiac and circulatory failure were present. Ex-
treme collapse and sudden death without visible
hemorrhage following exploratory puncture of the
chest had also been observed and must be attrib-
uted to shock when the autopsv revealed nothing
to account for the fatal outcome.
Breath Holding Attacks.— Dr. Isaac Abt, of
Chicago, said that these attacks might lead one to
believe at first glance that they were manifestations
of spasmophilia or tetany with the associated laryn-
gismus stridulus, but closer investigations would
show that such assumptions were wrong. The
breath holding attack manifested no true laryngeal
spasm. The breathing was restive or stopped sud-
denly in the midst of a crving attack, but there was
no inspiratory spasm. The child usually worked
himself into a rage, cried for a time, and then sud-
denly stopped, finding it impossible to make any
further sound. The inspiratory muscles remained in
a tonic state. The child threw himself about and
became cyanotic or pale, the body became rigid,
and the eyes turned or became set and for a moment
it seemed that the child was asphyxiated. The at-
tack usually lasted a few seconds and then dis-
appeared. In severe cases it was sometimes fol-
lowed by convulsions. These attacks were dif¥er-
entiatcd from minor epilepsy in that they followed
immediately upon severe crying, excitement, or
anger, while epileptic attacks occurred suddenly in
the midst of quiet play or during sleep. Biting of
the tongue occurred in epilepsy, but not in breath
holding. Involuntary evacuation of the bladder or
rectum might occur in either, and the long sleep that
usually followed an epileptic attack might also occur
after breath holding. These breath holding attacks
were brought on in neuropathic children by fear,
anger, fright, or some other psychic trauma. The
children subject to such seizures were as a rule irri-
table and ill tempered and the condition was very
often aggravated by neuropathic parents. Children
who fell ill of acute infectious diseases or who, by
reason of accident or injury, required surgical treat-
ment might be seized with a severe breath holding
attack accompanied by general convulsions. Under
such circumstances the attack might be so severe as
to terminate fatally. Treatment should be directed
toward the general management of the nervous
child. Stimulation of every kind should be avoided,
the child should be ignored as much as possible by
parents and friends, and when the attack occurred
there shol3M be no hysterical manifestation on the
part of mother or nurse. Cold water dashed in the
face had been suggested as a direct remedy. The
patient should be shown in no uncertain manner that
any repetition of the attack would meet with harsh,
if not painful, measures.
Dr. Rowland G. Freeman, of New York, re-
ported a case of breath holding that had come under
his observation. This case occurred in a child
whose parents were healthy, robust people. The
attacks were sometimes prolonged until the child
became unconscious. Two years ago, while suffer-
ing from a cold, the child had one of these attacks,
became unconscious, and died without regaining con-
sciousness. He thought that in this case there might
possibly be some connection between the thymus
gland and the general condition.
Dr. Percival J. Eaton, of Pittsburgh, stated that
some years ago he had had a family of four boys
under his observation, three of whom were subject
to the rage spasms. The eldest of the four boys was
quite a serious case. He had found that by forc-
ing the mouth open and drawing the tongue out and
then pushing the cheeks in, some reflex was excited
which relieved the spasm of the glottis.
Dr. PIenry Heiman, of New York, said that
some of these cases were simply instances of breath
holding, as Doctor Abt had said, but there were bor-
derline cases which presented a condition very much
like spasmophilia, or Erb's phenomena. Doctor Abt
had described the proper treatment for these cases.
Doctor Abt replied that none of these cases of
breath holding occurred until about the second year,
while spasmophilia manifested itself earlier. It was
September 21, 1918.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
529
of course possible to have spasmophilia without the
classical symptoms, but the children he had consid-
ered were first of all ill tempered, would have short
crying spells, and then would develop the attack.
There was not sufficient ground for saying that they
were cases of spasmophiHa.
Dr. L. E. L.\ Fetra, of New York, said that the
important point was that they had assumed that they
could assure the family that these children would
not die as the result of such an attack. They had
now heard of an instance in which a child did die
as the result of such an attack. However, he
thought we were fairly certain in making the state-
ment that these children were not going to die. It
seemed to him that these children were just as Doc-
tor Abt had described them : they were ill tempered,
lacked self control, and they had a nervous inheri-
tance. They were comparable to the children who
vomited at will. Such children, if they were given
food that they did not like, revenged themselves on
the parents by vomiting, while in the breath holding
the child showed its displeasure by turning blue.
Neglect and punishment constituted the proper
method of treatment.
Death from Cardiac Failure in Children, Un-
explained by Post Mortem Examination. — Dr.
John Hovvland, of Baltimore, stated that a form
of cardiac disturbance in adult patients had been
recognized, which resulted in death with marked
evidence of circulatory failure, but with no other
changes other than extreme cardiac hypertrophy
and more or less dilatation. The hypertrophy was
the striking feature. The musculature was intact.
There was no thorough discussion of the condition
in adult medicine and none in pediatric literature.
Doctor Rowland's interest in this condition was
first awakened by a patient, who came under his
care when three months old, weighing little more
than four pounds and suffering from extreme mal-
nutrition, largely due to the fact that she regurgi-
tated her food. It was practically impossible for
her to retain fluid food. She was given semisolid
food with a spoon and thereafter gained rapidly,
and was discharged in fair condition at the age of
eleven months. She continued to gain until the
age of fifteen and a half months, when she began
to lose appetite and to have marked respiratory
distress with an expiratory grunt. The tempera-
ture was normal, but respirations and heart action
were rapid. Nothing definite was ever made out
in the lungs, but the rapid respirations continued
and even became mcreased. Physical examination
and the x ray ascertained that the heart was greatly
increased in size. Nothing could be done to im-
prove her condition, and she eventually died with
the symptoms of circulatory failure without edema,
one month after the onset of her symptoms. At
post mortem nothing was found beyond a very
much enlarged heart, which weighed lOO grams ;
the average weight given for this age was forty-six
grams. All the other organs were normal. Three
other cases were cited in which the hypertrophy
had been very great, as shown by a considerable in-
crease tn the weight of the heart, in each instance
more than loo per cent, over normal weight of the
heart for the corresponding age. An explanation
for the cardiac hypertrophy had been sought else-
where in the body, but none of the conditions with
which cardiac hypertrophy occurred was present
in any of these cases. The myocardium in all of
these cases reported was normal. There might
have been some disturbance on the part of the ner-
vous regulation of the heart similar to that present
in the hypertrophy of Graves's disease. As the
result of some nervous or muscular disturbance, in-
coordinated action of the heart resulted, and loud
murmurs might be heard, not as the result of valv-
ular disease, as shown by post mortem examina-
tion, and apparently not due to extensive dilata-
tion of the valvular orifices. Doctor Rowland be-
lieved that in its milder form this cardiac condi-
tion was much more frequent than was suspected,
for he said he distinctly remembered patients from
two to four years of age with enlarged hearts and
with symptoms of acquired cardiac disease, as op-
posed to congenital disease, in whom it was impos-
sible to demonstrate any etiological cause.
Dr. Charles Hunter Dunn, of Boston, cited a
case similar to those described by Doctor How-
land. This baby was admitted to the hospital with
marked cyanosis, cardiac insufficiency, and a diag-
nosis of double pleurisy or hydrothorax was made.
The X ray showed an abnormal cardiac condition.
The outline of the heart was much larger. in pro-
portion to the size of the child than those shown in
Doctor Rowland's plates. As in Doctor How-
land's cases, the heart muscle in this case was nor-
mal and there was nothing to explain the hyper-
trophy.
Infantilism: Brissaud and Frohlich Types. —
Dr. J. P. Crozer Griffith, of Philadelphia, said
that the term infantilism should be applied not only
to adults and adolescents who possessed in some
degree the bodily and often the psychic characters
of infancy, but to children of any age in whom
there was a persistence of characters, especially
sexual, which belonged to a period of life decidedly
earlier than the actual age of the patient. Fur-
ther, a sharp distinction should be drawn between
infantilism and nanism. The classification pro-
posed bv Hastings Gilford {Lancet, 1914, 1,587)
was worthy of serious consideration. He divided
the cases into the essential forms, including atelio-
sis and progeria, and the symptomatic forms, in-
cluding the Lorain and the Brissaud types. Other
forms of infantihsm had been described, among
them, the intestinal, pancreatic, pituitary, renal,
cardiac, and lymphatic. The pituitary and Bris-
saud types were especially considered, both because
of their intrinsic interest and because the author
had studied them with considerable care.
The first case was that of a child, seven and
one half years of age, who at the age of one
one half years suffered from an attack of whoop-
ing cough, and since that time was said
r^t to have grown any physically, although the
parents thought she was normal mentally. Phys-
ical examination showed the extremities short in
comparison to the size of the thorax and the legs
slightly bowed, the abdomen prominent, a moderate
deposit of fat over the scapulae, moderate harsh-
ness of the skin, and features suggestive of the in-
530
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
fantilism of tlie Brissaud type. The child was in
the hospital under thyroid treatment for several
months, and while she showed some slight increase
in weight and measurement at the end of this time,
her condition showed no very material change.
The second case occurred in a male, eleven years
of age, who was brought to the Hospital of the
University of Pennsylvania because of excessive
obesity. The tendency to undue deposit of fat had
been noticed by the parents since the boy was eleven
months old. This had been gradually progressive
and did not seem to be influenced by diet. The boy
was five feet in height, the normal for his age being
four feet. His weight was 251 pounds, the normal
for his age being seventy pounds. His abdomen
was very fat and the penis was buried in fat, but
seemed very small for his age and for the rest of
his development. The testes were descended, but
very small. The x ray examination of the head
showed a sella turcica definitely smaller than nor-
mal, indicating a small pituitary body. There was
a lowered sugar tolerance. After the administra-
tion of pituitary extract for two months there was
a decided increase in the sugar tolerance. While
under treatment, a period of a little less than three
months, the boy lost seventeen pounds. This pa-
tient was an excellent illustration of pituitarism of
the Frolich type, except in certain particulars ; pa-
tients shovv^ing this syndrome often exhibited a re-
tarded skeletal development, while in this instance
there was a decided overgrowth. This might de-
pend, as Gushing suggested, upon activation of the
anterior lobe of the pituitary body combined with
insuf?iciencv of the posterior lobe. The excessive
action of the anterior lobe was the condition which,
developed in later life, would result in acromegaly,
but appearing earlier, as Brissaud suggested, pro-
duced gigantism.
Dr. Charles Herrm.\n^ of New York, expressed
regret that the term infantihsm had been used so
loosely. The intestinal infantilism of Herter was
not infantilism at all. The term infantilism had
been used for all forms of dwarfism. It might be
better to use the term dwarfism for retarded growth
and infantilism for those cases in which there was
an absence of secondary sex characteristics. It
was a good idea to examine the metacarpal bones in
cases of suspected infantilism ; some of these cases
showed marked improvement under thyroid treat-
ment. The tendency was to give pluriglandular
extracts.
Doctor Griffith said that he thought the- term in-
fantilism was rather thoroughly defined and that we
had accepted it as designating a slowness of devel-
opment and not of growth.
Head Shaking with Nystagmus in Infants. —
A Study of Sixty-four Cases. — Dr. Gharles
Herrman, of New York, stated that this condition
was more common in some countries than in others
and more frequent in large cities. The figures in
New York Gity indicated that the condition was
met with in about one out of every 700 infants com-
ing under treatment. The affection was rela-
tively more frequent among negro than among
white children, probably because of the poorer hy-
gienic conditions under which the former lived and
the greater prevalence of rickets. The disease
showed a very distinct seasonal incidence, and fe-
males were affected slightly more frequently than
males ; in the writer's series there were twenty-nine
males and thirty-five females. The disease was
most common between the ages of four and twelve
months, seventy-five per cent, of all cases occurring
at that time. In very few of the cases was there
a distinct neuropathic history. The character of
the feeding seemed to have no direct relation to the
disease, though as one would expect, the rachitic
manifestations when present were more marked in
artificially fed infants, so that, to a certain extent,
such infants were somewhat more predisposed to
head shaking. Illness, by lowering the vitality, ap-
parently was an etiological factor in those infants
already predisposed. In a small percentage of
cases trauma was an exciting cause in a predis-
posed child. Hygienic conditions, social position,
and the location of play rooms, played an important
role in the etiology. In large cities head shaking
was more common among those who lived in the
poorer tenements and among families living on the
basement and first floor. Not only were these fam-
ilies the poorest, but their rooms were dark and ill
ventilated, and the intelligence of the mother was
lower than that of the average woman. In fifty-
five of the cases in the writer's series the character
of the rooms could be accurately ascertained, and in
forty of these the infant was more or less in the
dark. It must be remembered that in certain sec-
tions of the city a large number of people lived in
dark rooms and only a very small proportion living
in such rooms contracted the disease, so that here
again one must assume an individual predisposition.
The same predisposition had been noticed in miner's
ny.stagmus. During the past eleven years the writer
had studied the same class of patients at the Leb-
anon Hospital in the Bronx and in the Good Samar-
itan Hospital on the lower East Side of the city ;
the disease was more common in the latter section,
due principally, in his opinion, to the fact that in
the Bronx the majority of families lived in sunnier
and better ventilated rooms than did those on the
lower East Side. Head shaking apparently had
some relation to rickets, it being about twice as fre-
quent among rachitic children as among others.
Cases of head shaking were rarely associated with
laryngismus stridulus, facial irritability, tetany, or
convulsions. The pathogenesis of this condition
was still something of a puzzle. In considering the
pathology of this condition, the writer accepted as
a fact the obvious relation of the head and eye
movements and believed that the progress of the
medullary development of the nerves which was go-
ing on very rapidly at this age was interfered with
by disturbance of nerve nutrition, or rendered func-
tionally imperfect through early acquired opacity of
the refracting media, or by congenital absence of a
place in the retina that had more acute and perfect
vision than elsewhere, or by a defect on the recep-
tive cortex.
In this series of cases the movements of the head
were primarily horizontal in forty- four, vertical in
twelve, and rotary in four, and horizontal or vertical
at different times in four. The movements were
September 21, 1918 ] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES
531
more distinct when the child was angry or fatigued.
In thirty-five of the writer's cases the nystagmus
was bilateral, in twenty-three unilateral. The move-
ments of the eyes in these cases were much more
rapid than those of the head, the ratio being about
200 to 300 per minute. Among the associated con-
ditions in these patients were anemia, enlarged
spleen, tuberculous lesion, papular urticaria, eczema,
and geographical tongue. The condition seldom
lasted more than from two to twelve months. In
the treatment the aim should be to improve hygienic
conditions and provide light. Any source of pe-
ripheral irritation should be removed, the diet should
be regulated, and digestive disturbances corrected.
Dr. Augustus Caille, of New York, called at-
tention to the fact that he had demonstrated many
years ago that if the child's eyes were tied up the
head nodding would stop. The reason for this had
never been explained.
Doctor Herrman stated that he had given Doctor
Caille credit for having shown that tying up the eyes
stopped the head shaking. He had found that this
was true in every instance in which he had been able
to employ this device.
Variations in the Lipoid (Fat) Content of the
Blood. — Dr. McKiM Marriott, of Baltimore, and
Dr. Warren Sisson, of Baltimore, presented this
paper, which was read by Doctor Marriott. He
said that even though an infant were fed consider-
able amounts of fat, if he was unable to utilize the
fat he was virtually in a state of fat starvation. In-
formation with reference to the efficiency with which
the fat of the food was digested and absorbed was
obtained by analyses of the stools for fat or its de-
rivatives. Still further information as to the be-
havior of fat in the body could be obtained from a
study of the fat of the circulating blood under vari-
ous states of nutrition and varying conditions of
feeding. Since the fat of the blood was derived from
the tissues as well as from the food, the percentage
might be as high during complete starvation as when
moderate amounts of fat were being fed. One
should know the diet of the patient in order to inter-
pret the analyses of the blood for fat. There was
difficulty in fat absorption if the food taken was
what would ordinarily be adequate and the blood fat
still remained low. A high fat content of the blood
meant a deposition^of fat somewhere in the body.
In this paper they reported the results of fifty-two
determinations of fat on the blood of forty-eight in-
fants in the wards of the Boston Floating Hospital.
In making these estimates they had used Bloor's ne-
phelometric method. They had found that the aver-
age blood fat for the series was 0.68 per cent. The
time after feeding at which the samples were taken
apparently made no difference in the blood fat per-
centages. Other factors being equal, well nourished
and poorly nourished infants had essentially the
same amounts of fat in the blood. Infants fed on
milk mixtures containing no fat showed low blood
fat percentages, much lower than those being com-
pletely starved. Some of the infants being starved
were suffering frorri intoxication and a few devel-
oped acidosis. The mood fat percentage was essen-
tially the same in the infants with acidosis as in other
infants. The results of this study showed that an
infant who was gaining in weight, no matter what
his state of nutrition, would have a higher blood fat
percentage than one who was not gaining. It has
been found that certain groups of infants showed
amounts of blood fats that differed distinctly from
the general average of other groups; this suggested
the need of further study on special types of nutri-
tional disorders. y\ group which would be of spe-
cial interest for further study was that in which fail-
ure to thrive had been attributed to difficulties in the
digestion and absorption of fats.
Dr. Charles Hunier Dunn, of Boston, asked
Doctor Marriott what his findings were in reference
to the blood fat in infants gaining in weight on a fat
free diet.
Dr. F. B. Talbot, of Boston, asked if an attempt
had been made to find if there was any connection
between high carbohydrate feeding and blood fat.
Dr. Henry F. Helhiholz, of Evanston, asked if,
in children with large fat deposits where acidosis oc-
curred, these fat deposits were drawn upon and if it
was only those children with large fat deposits in
the organs that showed a high blood fat.
Doctor Marriott, in reply to Doctor Dunn's ques-
tion, said that he had no infants in this series that
were gaining weight on low fat feeding. In one or
two instances a gain in weight was found to be due
to edema and that eliminated them from this series.
There were no infants in the series on high carbo-
hydrates, but Doctor Marriott said he thought the
blood fat would be low under those circumstances.
Infants with acidosis fell into two classes, the under
nourished and Ihe well nourished ; he had not sep-
arated them in this study, but thought the findings
were about the same in both groups.
Mercurial Preparations in the Treatment of
Congenital Syphilis. — Dr. Walter Reeve Ram-
sey and Mildred Ziegler, M. S., of Minneapohs,
presented this communication, whjch was read by
Doctor Ramsey. He stated that this series of ex-
periments was undertaken to determine, if possible,
the extent of absorption of mercury into the circula-
tion as indicated by the elimination in the urine,
when the ordinary methods and doses were em-
ployed, and the time during which mercury contin-
ued to be eliminated in the urine after the adminis-
tration of mercury had been discontinued. The
idea was to determine the frequency and the size
of the dose necessary to maintain mercury circu-
lating in the body. The effect of the various forms
of mercury upon the kidneys as determined by the
appearance of protein, casts, or blood in the urine,
was also estimated when possible. The series of
experiments shown in charts warranted the follow-
ing conclusions :
In infants and children, mercury when given by
the mouth, by inunction, or subcutaneously, was ex-
creted at least partly by the urine. In new born
infants and older children, mercurial ointment when
placed in contact with the skin, without any fric-
tion being used (protected, sealed by wax paper
from being volatilized and inhaled), was taken up
by the skin and eliminated in the urine and contin-
ued to be eliminated for some time after all treat-
ment had been discontinued. By inunction mercury
was readily taken up by the skin and eliminated in
532
COLLECTANEA.
[New York
Medical Journal.
the urine, and continued to be eliminated for a con-
siderable time. When one inunction was given, the
maximum daily amount of mercury was usually
eliminated during the following twenty-four hours,
smaller amounts being eliminated for a variable
time. Where continuous inunctions were given
there was an accumulation in the system and con-
siderable amounts were ehminated at intervals with
only traces between. It was therefore probable .that
it was unnecessary to have mercury in contact with
the skin, with or without rubbing, as often or as
long as had been generally thought necessary. This,
however, must be determined by further clinical in-
vestigation. Mercury salicylate suspended in oil
and given subcutaneously continued to be eliminat-
ed in the urine in appreciable amounts for as long
as eight days ; the daily amounts eliminated varied
widely. It was therefore probable that a repetition
of the treatment at intervals of eight days would
be sufficient. Mercuric chloride by the subcutane-
ous method continued to be eliminated for eight
days. Calomel, V4 gram every two hours, for four
doses, and gray powder, gram, continued to be
eliminated in appreciable amounts in the urine for
as long as nine days, the maximum amount being
eliminated durinjr the twenty-four hours following
administration. It was therefore probable that the
daily use of any of the mercurial salts in the
amounts usually prescribed was unnecessary and
presumably harmful.
^>
Collectanea
Reduction in Industrial Fatigue. — Great Brit-
ain, after having wasted her industrial forces dur-
ing the first year of the war, through needless and
avoidable fatigue, is now foremost among the .\llies
in realizing her mistake and rectifying it. In our
country the Division on Industrial Fatigue, com-
posed of scientists organized under the committee
of labor of the Council of National Defense is now
engaged in examining munition factories and other
industrial establishments manufacturing war sup-
plies. Some of the main phases of the subject as
considered by these authorities are given in a re-
cent issue of the Public Health Bulletin as follows:
With adequate equipment, administration, and a
proper spirit among the employees, fatigue is the
greatest obstacle to a maximum output. Fatigue
among employees may be detected by a falling off
in the output ; by a fall in the amount of electrical or
other power consumed in the factory ; by the amount
of spoiled work turned out by the workers : by the
number of accidents to the workers, the number of
absences from work, and by records of sickness.
Fatigue may be avoided or reduced by introducing
recess periods during the work ; by introducing
variety into the work ; or by adjusting the speed
capacities of group workers about a medium rate.
Where a single motor operates a number of ma-
chines, the speed of the motor must be adjusted to
the average pace. It may even be advantageous to
transfer to another position an especially slow or
fast person. The position of the worker with regard
to his machine should be so adjusted that all un-
necessary motions are avoided. The seats should
not be of uniform height but should be adjusted to
the individual worker, and should be the shape to
fit and support the worker's back. Ventilation of
the workrooms is also an important aid to efficiency.
Excessive heat and humidity should be avoided and
the air kept in motion. Movement of the air will
not cool the air, but it will cool the skin and there-
fore keep down the bodily temperature to the
healthful level. W^here the heat of the workrooms
rises above 68° in spite of open windows, electric
fans should be used to keep the air in motion. Sat-
isfactory sanitary conditions within the factories
include adequate lighting; an exhaust system to re-
move deleterious fumes and dust ; abundant drink-
ing water, cool but not ice cold ; attractive rest
rooms ; lunch rooms or canteens ; clean, well venti-
lated modern toilets ; and washing facilities, with
abundant soap and clean towels, and shower baths.
The British Health of Munition Workers' Com-
mittee from a careful study of the output has found
that in plants where night and day shifts are em-
ployed, the output is less where the same night shift
continues to be employed, than where there is an
alternation of night and day work in the shifts. Too
frequent changes of night and day time shifts, may
however, also be detrimental to health ; periods at
one schedule should be not less than one month in
duration. Proper adjustment of the daily hours of
labor constitutes a very obvious way of avoiding
fatigue. Women and boys, even when engaged in
very moderate and light types of work are unable to
stand as long hours as men. Whenever, as at the
present time, the greatest output is desired, there is
a tendency to increase hours and introduce overtime
work. But whenever the work is of such duration
that fatigue begins to be pronounced, it has been
shown again and again that shortening the working
period actually increases the amount of work done.
In an English munition factory when the average
weekly hours of men sizing fuse bodies were re-
duced from 58.2 to 51.2, the total output was in-
creased twenty-one per cent. In the English facto-
ries the absences of employees from their work have
increased enormously since the war began. In one
munition factory employing 70,000 hands the em-
ployers gave their hands a whole holiday instead of
a half holiday on Saturday. The absences were
diminished by fifty per cent. These same arguments
apply to the question of overtime work. This should
be resorted to only in times of exceptional emerg-
ency, and even then not for many days in succession.
It is also advised that all workers have one day's
rest in seven. The British committee reports as
follows : "Statements are made by many employers
that seven days' labor produces only six days' out-
put, and that reductions in Sunday work have not
involved any appreciable loss in output. ... If
the maximum output is to be secured and maintained
for any length of time, a weekly period of rest must
be allowed. Continuous work is a mistake and does
not pay." Finally, anything which the employer can
do outside the plant to promote bodily health and
vigor and mental contentment is, in the long run,
profitable. Modern housing, attractive home sur-
roundings, club facilities — whatever will keep
workers away from places deleterious to health —
are all safeguards against industrial fatigue.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal T^i Medical News
A Weekly Review of Medicine, Established 1843
Vol. CVIII, No. 13. NEW YORK, SATURDAY, SEPTEMBER 28, 1918. Whole No. 2078.
Original Communications
CIVILIZATION AND THE LIBERTY LOAN.
By George David Stewart, M. D.,
New York.
It is difficult for Americans to speak of them-
selves br their country except in fervid and glow-
ing terms, and this often makes them appear boast-
ful. For the most part this is not a spirit of vanity,
but has been brought about by the largeness of
everything American, that is, the physical largeness,
conditions which operated on our forefathers even
to the point of changing their vocabulary. An Eng-
lish writer who visited us a few years after the
establishment of our independence complained of
the quality of our language, not recognizing the fact
that a new environment demands a new vocabulary.
He even found fault with the severity of the dress
of our women — a matter upon which, could he revisit
us now, there could surely be no criticism, consider-
ing the generous revelations of the present modes.
Not only do others misunderstand us, however,
but we often misunderstand ourselves, partly be-
cause we compute in decades, or at most in the span
of our own lives and experience, forgetting a dictum
centuries old which announces that "in the sight
of God a thousand years are but as a day." How
often we exclaim over the great improvements
of our time, when their benefits even for us may
be doubtful and for the generations to follow they
may be obviously faults. The truth is that human
beings have a marked capacity for blundering, of
which an amusing example is found in Tono Bungay.
where the author tells of miles of houses erected for
single family occupancy ; regarded by their builders
as wonderful improvements, but soon turned over
to apartments the most inconvenient possible.
The present social system in Europe is a remark-
ably haphazard affair. Like Topsy, it would seem
to have "just growed." We in America too have
many faults to confess ; we had hardly founded a
democracy when we began to shirk our responsi-
bilities and left the government to a ruling class in
the State of Boston, left it to exploit our wonderful
resources, each for himself. We forgot our democ-
racy in what Croly calls Our land of promise
and Our place of destiny — "land of promise" be-
cause there was a virgin wilderness to exploit
where each could become rich beyond the dreams
of avarice, with no tithes to pay to foreign prince or
potentate, from whom we. were protected by the
Monroe Doctrine. Why designated as "place of
destiny" it is difficult to say, but the cry of the
Leech's daughters is always jor more, and we were
so successful that we allowed ourselves to dream
that better things were still to come. Therein lay
our vulnerability, for we had about reached the
limit of our occupancy of this fool's paradise. The
virgin wilderness had been exploited to the vast
advantage of a few, and the Monroe Doctrine had
been broached by submarines. Suddenly we came
to realize the wisdom of an ancient and forgotten
saying, that "man cannot live unto himself alone,"
and in order to win the war we began to take
thought of the morrow, to function collectively as
democrats, suffering wheatless days and gasolineless
Sundays ; we handed over our railroads, our tele-
phones and telegraph, our express companies,
our pocketbooks, our boys, and are ready ourselves
to add, "Master, here am I." Will there ever come
a time when all the socialistic doctrines now extant
will be worth that one patriotic ideal under the im-
pulse of which men front the great darkness and set
out on that crowded but silent road that leads
through the \''alley of the Shadow, a road more
populous than any thronged thoroughfare in Lon-
don, more crowded than any gate of Pekin, silent as
the grave ? Over that road has come no returning
traveler.
The medical profession has always been altruistic
in its principle,-, and to give service is the doc-
trine on which the profession of medicine is
founded. Patriotism and service are so closely al-
lied that the former comes easily to doctors. When
the war broke out it was not long until the 430
members of the medical department of the Army
had been augmented to 20,000 or more by the most
active and honorable of our profession. Now we
are to raise an army of five million men and will
need thirty-five to forty thousand doctors, and there
is no question that we shall find them without com-
pulsion or conscription.
There are two basic ideas of progress and civili-
zation. One regards progress only as a corol-
lary to strife. The philosopher-historian who ac-
cepts this theory points out that all civilizations have
their Spring and attain their Summer only in
strife, their Autumn beginning when strife has
ceased and contentment has been attained. This
is the philosophy of von Bernhardi and Trietschke
and it is essentially harsh and cruel. Another and
more encouraging doctrine is that enunciated bv
Kropotkin, of "mutual aid and support," in which
Copyright, 1918, by A. R. Elliott Publishing Company.
534
TIl.XEY: A MECCA OF MEDICINE FOR THE FUTURE.
[New York
Medical Jouknal.
the countless aids and little acts of kindness and
helpfulness offered by one member of the race to
another and extending over the ages have had more
to do with the development of civilization than all
the wars of history. These acts are not spread on
the records as are exploits in arms, nor can their
influence make itself greatly felt in the span of
time that makes one human allotment — how fleeting
that scan may be appreciated by reflecting that some
of the trees that still greet Spring's return have
held their leafy foliage and the songs of birds for
hundreds of seasons before the Star of Bethlehem
appeared in the eastern skies.
Recentl)', a magazine writer has pointed out that
Gibbon, the historian of the civilization of Rome,
thought it improbable that civilization should ever
again be menaced by barbarians. In hazarding this
prediction. Gibbon, who associated books and learn-
ing with civilization, forgot that other essential,
kindliness, that is to say, charity — the greatest of all
the virtues — and thus did not foresee what has actu-
ally come to pass, that the barbarian might come
from inside.
Which of these doctrines shall we accept, strife
and be a Him, or mutual aid and support and be a
Human? For the medical profession it is not hard
to decide. Kindliness is the very essence of their
practice, and medicine began when sympathy ex-
cited one individual to try to help a suffering fellow
mortal.
The new Liberty Loan about to be launched will
afford another opportunity for medical men to ex-
ercise their patriotism. It will be doubly welcomed
by those who have been denied the privilege of
sacrificing their practice and their families to enter
the Government service. The doctor who has
money should invest it in this best security in the
world today, but more than that he should interest
every one of his patients in the loan, pointing out
strongly and forcefully its advantages. If all the
medical men would do this, the influence would be
so tremendous that the overworked Secretary of
the Treasury would not need to plan bonuses in the
shape of tax exemptions. Now is the time to put
forth our best efforts ; now while the iron is glow-
ing to white is the time to strike and forge
the fetters of brutality so strongly that the thing
shall, like Enceladus, lie forever prostrate beneath
the ashes of its own dreadful fires. May humanity
never again be compelled to listen even to its distant
groans !
60 West T'iftieth Street.
Navy Medical and Dental Students. — The
Office of the Surgeon (ieneral of the Navy reports
that the men who enlisted in the N. R. F. Hospital
Corps and last year were furloughed to pursue their
medical or dental studies, are now to receive the
privileges of members of the Student Army Train-
ing Corps. The War Department makes contracts
directly with the colleges for the education of the
army students, but the navy will provide uniforms
for. and give pay, and allowances to the students
sufficient for them to make their own individual
contracts with the colleges or technical schools.
A MECCA OF MEDICINE FOR THE
FUTURE.*
By Frederick Tilney, M. D.,
New York,
Professor of Neurology, Columliia University.
I will be asked, no doubt, where and what this
Mecca of Medicine of the future is to be. These
questions are important to all of us, and also to
many others who have their chief interest in the
medical profession. They are questions which
touch our lives profoundly ; they search out the kind
of men and women we are, or hope to be, and their
answer formulates a motive of impelling force.
Where is this centre for the future ideals and de-
velopment of medicine likely to be? Its location may
be open to some question. It would be difficult to
find a more favorable place than in this nation which
has contributed so freely that the aspirations and
ideals of men might live, in fact, which has given
so abundantly to secure the blessings of liberty,
which has fought on many battlefields in the just
causes of humanity, and which is today marching
in such spirit as never crusaders marched before,
not as standard bearers of a single faith, not
with thought of selfish gain, but for all faiths, foj
all peoples, and. God grant it, for the last time to
reassert the will of freedom against the greed of
tyranny.
It is not fatuous optimism to believe that this
country is the most fitting place for such a centre
of medicine. Nor is -this belief one of vainglory.
However much the idea may seem to be the product
of overardent patriotism, when looked at earnestly,
it appears nothing of the kind. It constitutes one
of the many demands upon us to prepare ourselves
now for the even greater struggle after the war. To
us it comes as a summons to a duty we should not
neglect.
The. reasons for this are many and easy to dis-
cern. During the past four years war has swept
the world with a destructive power more complete
than ever before in history. If it has revealed a
ruthless plan which menaced the race, at the same
time it has exposed a nation which had lost its men-
tal bearings for many years. The Germans have
been laboring under a delusion of grandeur. They
have been obsessed by the conviction of their own
racial superiority. This eventually led to the paranoid
idea of world dominion. It has been part of their
unfortunate heritage as a people to believe in the
righteousness of might. They were even more un-
fortunate because they have long been under the in-
fluence of rulers who, by cultivating this belief, ex-
ploited a national weakness. Their most serious
misfortune is their present ruler. Prepared for the
coming of a war lord by their successful aggression
in the P'ranco-Prussian War, the German people
were quickly infected by the expansive ideas of the
new ruler. He, on his part, at once began to weld
the old fetters of feudalism and soon had .so con-
trolled public opinion that the German standards of
judgment in morals, religion, science, art, and pol-
itics were no longer matters of independent decision.
•Address delivered at the Opening Exercises, College of Physicians
and Surgeons, September 25, 191 8.
September 28, 1918.]
TILNEY: A MECCA OF MEDICINE FOR THE FUTURE.
535
Our former Ambassador to Berlin, Dr. David Jayne
Hill, epitomizes the tendencies in Germany when he
says that : "Like money put out at usury, power in
government grows with astonishing rapidity. When
it is both concentrated and undisputed, as in the case
of imperial absolutism, it soon Ijecomes irresistible.
No better example of this rapid centralization of
power can be found in history than the growth of
Kaiser William II's personal control not only of
German action, but of German thought." In his in-
structive reference to the Verdun Prise this cele-
brated student of Germany gives a striking illus-
tration of the method by which the Kaiser gained
control over the universities. The prize referred to
was annually awarded for the most meritorious his-
torical work of the year. In 1894 the Academy of
Berlin unanimously awarded it to the famous his-
torian. Von .Sybel, for his work on the Foundation
of the New German Empire. To the amazement
of all, the young Kaiser drew his pen through the
name of Von Sybel, awarding the prize to a Heidel-
berg writer for an inferior work on the Great Elec-
tor, one of the Kaiser's ancestors. Gradually under
such influence the faculties of the universities and
schools came to wear the King's Coat, for in this
way onl}'- was advancement possible. But it did not
stop with the subordination of learning. Soon it
extended to the press and church. In time, baited
by the avaricious expectations of German world do-
minion, commerce and finance came into the net,
until at length allegiance to the Kaiser on the farm
and in the factory, in the banking house and on the
sea, meant power to the arm that was to strike the
swift overwhelming blow for alluring plunder. In
this attitude we see them poised to strike for the pre-
destined day, infector and infected alike charged
with the same venom, filled with Prussian lust for
power.
The blow they struck was neither swift nor power-
ful enough. It did, however, strip off the mask and
finally arrayed against the transgressors the out-
raged humanity of most of the world. In this way
two great forces have, for more than four years,
been engaged in a process of irreparable destruction.
Nearly every line of human activity has been turn-
ing its product into the vortex until the waste in all
materials and intellect has become stupendous. In
the end, Germany, vaunted the most efficient of na-
tions, has shown herself to be the most destructive
organization in history. Through forty years, while
establishing German supremacy in the pursuits of
peace, the government built parallel to this, and de-
liberately planned to use, the destroying engine of
its military power. This power has swept German
commerce from the seas, decimated her manhood,
filled her cities with the maimed and blind, prostrat-
ed her science and industries, and brought her to
soiritual as well as financial bankruptcy. Nor is this
all ! Had the ruin been confined to Germany alone,
the evil record might have been borne. But the de-
struction which Germany begot has drawn all of the
other productive nations into the fire. Their wealth
and man power, their intellectual efforts and enter-
prises which go to make up civilization, have been
diverted into the conflagration. Years of readjust-
ment and recuperation lie ahead, years of we know
not what extreme tests upon our faith, our courage,
and our tenacity to adhere firmly to the right. These
are the times for which we must now begin to pre-
pare ourselves.
There can be no doubt that the struggle through
this period in Europe will be severe. The entire
efl'ort of every European state must be concentrated
upon the rehabilitation of the essentials of Hfe. The
higher pursuits of civilization must for the time at
least stand aside, or bend their energy to the simpler
purposes. The security and plenty upon which
German medical science grew to be the commanding
figure in the world of medicine have gone. Not
for a long time can the Germanic capitols be the
centres of medical learning as they have been in the
past. This distinction must pass into other keeping.
France, henceforth the symbol of heroic sacrifice
and salvation, has given nearly all she had, and being
impoverished by the noble gift, needs time to re-
plenish her resources. England, the bulwark of civ-
ilization throughout the struggle, has stripped her
empire, and for 3'ears to come will be handicapped
in maintaining and advancing*science. This is par-
ticularly true in medical science, for England early
in the war encouraged the mobilization of the entire
medical profession and permitted medical students
to serve with the colors, in this way depriving herself
of a large annual increment to the medical ranks.
Whatever handicaps we may labor under, due to our
present or future sacrifices, we shall inevitably oc-
cupy the point of vantage in this regard as well as
a position of chief responsibility. We can under-
stand how it must be our duty here in America to
carry on the constructive, advance work in medicine
while the nations of Europe struggle through their
period of reconstruction.
But there is a still more cogent reason why we
should accept this responsibility, namely, because we
are now ready and able to take the place v^^e should
hold in medicine. The war has brought about far
reaching changes in the country. It has, as Lord
French says, made a nation of us. Under the great
leadership of President Wilson, the whole essence
of our destiny has been crystallized, and we move
forward unified, no longer North or South, or East
or West, but one people irresistible in the resolve to
accomplish our purpose. The war has brought
about far reaching changes in medicine. We have
also gained a national consciousness. The country
no longer regards medicine merely as a learned pro-
fession, but is coming to consider it one of the essen-
tial industries. Sound public health is a necessary
element in the will to victory. A civil population
unduly enfeebled by disease or discouraged by neg-
lect, could not be expected to support a winning
army. All signs give us confidence that the Govern-
ment in its wisdom will provide adequate medical
attention for the people, prevent relaxation in the
safeguards against epidemics, and restrict the spread
of disease to the limits normal in times of peace.
In another critical relation the efiforts of the med-
ical profession have become indispensable to final
success. The vast detail of the health of an army
is in the hands of its medical corps. Failure here
is almost as serious as defeat by the enemy. "The
selection of the fit and rejection of the unfit, the su-
536
TILNEY: A MECCA OF MEDICINE FOR THE FUTURE.
[New York
Medical Journal.
pervision of sanitation, the prevention of disease,
the stamping out of epidemics, the early detection
of tlie physically and mentally unstable, to say noth-
ing of adequate care and reconstruction of the sick
and wounded, are matters of vital importance to
troops in the field. The war has shown us the possi-
bilities of medicine carried out intensively in all its
branches. From these lessons we have gained more
cohesion as a profession. We understand now more
fully our obligation to civil communities, we recog-
nize our ODDortunities for greater public service, and
see the value in a more complete system whose de-
velopment will better safeguard the public health.
In attributing these changes to the war, it is but just
to indicate that they are in large part due to Surgeon
General Gorgas. He has given us a demonstration
of the efificacy of national organization in med-
icine. The organization of his own department is
one of the real achievements of the war. It is widely
admitted that the Medical Corps of the United States
Army is without peer. The public knows too little
of its development and management to appreciate
the efficiencv of one 5f the most potent forces fight-
ing for civilization today. Over twenty-five thou-
sand Dhvsicians have been called in from all
branches of private practice and given special train-
ing for some particular work in the army. Provi-
sion has been made for the psychological testing and
grading of troops in training; specialists have been
developed for testing the flight" capacities of avia-
tors. Every department and subdepartment in med-
icine is manned by physicians who have had special
courses of intensive training. Each of the larger
crouDS of diseases is orovided with its special base'
hospital, while plans are already perfected for the
rehabilitation of the maimed and blind who unfor-
tunately will return in increasing numbers to our
shores. In a word, every contingency that a farsee-
ing intelligence might anticipate has been provided
for in a scientific manner. With an organization in
all branches of the War Department such as General
Gorgas has built up. the United States Army must
certainly be invincible.
Alive to the significance of our position, we recog-
nize that American medicine can no longer be an
overseas province on the medical map. Our tradi-
tion leads us to feel that we shall succeed. Our
practical instinct compels us, however, to take stock
of our qualifications. As to one of our assets there
can be no dispute. American medicine is supreme
in surgery. In this most direct practical handicraft
of the healin? art. it is probable we have no equals.
American surgery has won its repute not alone for
its ineenuitv and soimd adherence to fundan-vental
principles, but quite as much through the brilliancy
of its technic and enterprise. It has produced a sur-
prisingly large number of surgeons noted for their
exceptional skill in general and highly special re-
gional procedure. The number of these is still
growing. In fact no other country possesses so
manv thoroughly trained surgeons who may be con-
sidered competent to assume the responsibilities of
major operative work. The dominant position of
America in surgery is witnessed by the steadily grow-
ing'influx of foreign surgeons in the past few years
to the famous operating amphitheatres of this coun-
try. Our own surgeons understand that they have
become the instructors in their branch of medicine.
Another valuable factor ready to our hand is the
diagnostic cHnic or group idea in diagnosis and prac-
tice. This is essentially an American conception,
and its successful application as a scientific method
for the practice of medicine is an accomplishment in
which we have a just national pride. Not only is it
the most efficient way of bringing the ailments of
each individual patient under complete medical re-
view through examinations by experts in each par-
ticular department, but it confers a further benefit
upon the patient by furnishing the best medical ad-
vice in the most economical way. To the physicians
engaged in the work it serves as a mutual inspira-
tion and a constant incentive.
In the matter of equipment we are rapidly increas-
ing the number of modern hospitals throughout the
country. These institutions have the advantages of
modern management, which conceives of the hospital
as an educational factor as well as a place to care
for the sick. The idea is becoming more generally
accepted, especially in large centres, that a hospital
that has no teaching facilities does not discharge its
full duty to the public. The personnel of the pro-
fession is fortunate in its admixture of nationalities
and races. This cannot fail to be ultimately advan-
tageous, as it tends to catholicity of viewpoint and
furnishes a variety in methods of approach.
The American system of medical education is con-
spicuous among our assets. It has an efficient or-
ganization which, under the guidance of state boards
and certain large national associations, has effected
a standardization of medical instruction. This gives
a well rounded training in all branches of medicine.
The fifth hospital year, already instituted, is de-
signed to furnish a finishing course in practical work.
During this period the student will live in the hos-
pital, gaining clinical experience under the direction
of resident instructors. The establishment of sep-
arate faculties to increase the opportunities and re-
quirements of post graduate instruction in medicine
is receiving serious consideration. Full time clinical
professorships, as proposed, will materially advance
the interests of research in the clinical branches and
provide more time for teaching. Medical research
has had an unprecedented growth in recent times, as
evidenced by the development of special institutions
for the intensive study of the human body and its
diseases. Notable among these are institutes for the
investigation of cancer, tuberculosis, mental disor-
ders, the development of the body, the anatomy of
the brain, and general experimental medicine. In
connection with these institutes the opportunities for
post graduate teaching have been much enhanced.
We must not, however, neglect the other side of
the question. We have our defects. The most ob-
vious of these, perhaps, is that we have permitted
our vision to become nearsighted and locally intro-
spective. Because of this limited view we have
gained no sense of the possibihties and proportion of
our mission ; it would even seem that we had no
realization of a mission at all. A complacent isola-
tion of the larger medical centres has cultivated an
exclusiveness which does not promote mutual under-
standing or inspire the confidence which engenders
September 28, 191 8.]
TILNEY: A MECCA OF MEDICINE FOR THE FUTURE.
537
the spirit of progress. There has been, in conse-
quence, a lack of broad conception and comprehen-
sive organization. Our national impetuosity, our
desire for quick results have made us intolerant of
delay and often hasty where patience is more
needed as a commodity than as a virtue. We have
had too little confidence in our own achievement
and an overweening regard for foreign work,
especially of German stamp. This is all the more
discomfiting since the quality of German production
has fallen ofif in the past fifteen or twenty years. It
may now be seen how much of the mass of German
medical literature was part of^the ambitious scheme
of exploitation which has sapped so many good
things of their worth and sincerity.
These defects, although serious, should not retard
us. Such is not the American character — as we
know from recent examples. When the call for
men came from France we did not dwell on the dif-
ficulty of the draft, equipment, and transportation,
but putting all obstacles aside we sent an army
which is well on its way to final victory. Let us be
convinced that there is something which must be
done and its accomplishment is practically assured.
When the conviction is established that we owe this
duty to medicine, America will indeed become a new
medical centre.
It may be that the first step to secure this end will
be a national federation of American medical col-
leges and institutes. A council representative of
these institutions would cooperate in the interests
of medical education and medical science. If the
satisfactory diagnosis of the individual patient re-
quires a group of diagnosticians, how much more do
the profound and baffling problems of medicine de-
mand large groups of special workers for their
solution? Coordination of investigation might be
carried to a high level of efficiency by this intensive
cooperation in medical research. The distinctive
advantages of each medical centre would not then
be matters of local reputation, but part of the na-
tional endowment in medicine. The large cities and
the other noted medical localities, making their con-
tributions to a common cause, would attract to this
country a vast number of the seekers for medical
knowledge who formerly would have been found in
the capitals of Europe.
The impetus which such a combination would
impart to the newer, important trends in medicine
would be difficult to estimate. The influences of civic
mterest are becoming continually stronger because
medical supervision is proving itself indispensable
in many fields of community life. The well trained
physician of the future must be versed in the re-
quirements of public service.
Preventive medicine particularly is destined to
undergo much expansion. To its many present
activities others equally necessary will be added.
Among these might be mentioned the need of medi-
cal registration for the detection of disease in its
incipience. Those conivected with draft exemption
boards have been astonished at the inroads into pos-
sible military efifectives made by preventable dis-
eases or disorders that might have been cured in
early life.
Industrial medicine will soon have a field of its
own. The health of operatives is calculated as an
essential of efticiency and medical departments have
already been installed in a number of large corpora-
tions.
Public mental hygiene is an urgent national prob-
lem which must engage medical attention more
seriously in the future. The significance of insanity
as an economic loss will be realized by the fact that
one third of the entire budget of New York State
is annually appropriated for the care of the insane.
Under the guidance of the National Committee for
Mental Hygiene nation wide investigation is being
conducted in order to determine the prevalence and
causes of insanity. The committee has already done
much to improve the care of the insane and has
stimulated a real interest in the efifort to reduce the
prevalence of mental disorders. Feeblemindedness
as a burden to the community has assumed such
proportions as to necessitate the appointment of a
special commission for its management in this state.
The government attaches such importance to this
problem that it has called one of the most dis-
tinguished physicians of this country to the chair-
manship of the committee.
The necessity of medical cooperation in court and
prison matters has become apparent. To dis-
tinguish between the feebleminded, a psychopathic
delinquent on the one hand, and the criminal on the
other, to differentiate between the necessity of
therapeutic and punitive measures in each case and
to study the pathological factors-in the development
of the criminal are necessarv functions of the state.
If the country is to avail itself of the obvious ad-
vantages of universal military training after the
war, military medicine must be still further devel-
oped in the college. It seems advisable that perma-
nent courses in military medicine be introduced into
the curriculum of medical schools.
These higher requirements of medicine make un-
usual demands upon those of us who are working
in this field today. Yet only as we devote ourselves
with intelligence and redoubled energy to our duties
will it be possible for us to reach the object to
which we seem destined by circumstance. In so
large an undertaking the work is not ours alone.
The nation already begins to understand our pur-
poses. When it appreciates the full importance of
our relation to its welfare we shall, as a recognized
economic necessity, have its liberal support. It is
especially necessary in all parts of the country that
those who have the interests of medical development
in their keeping shall make their efforts decisively
constructive. In the future, no doubt, a reliable
index to the intelligence of a community will be the
degree to which it has mobilized its medical re-
sources.
If our eyes seem fixed on the future it is because
we understand that, although civilization must be
defended against the ravages of war, it owes its
continuance and growth to the security of peace.
We remember at what cost we delayed in preparing
for war. We are loath to make the same mistake
again and would prepare in time for the severe
burdens after the conflict is over. Education, the
538
BARKER: GENERAL DIAGNOSTIC STUDY BY THE INTERNIST.
[New York
Medical Journal.
surest guarantee of social stability, should be the
subject of our most earnest attention. How much
the events of the war have converted public opinion
in ILngland to the belief that the future of that
nation depends upon the better education of the
coming generation, has been shown by the reception
accorded the Fisher Education Bill in thfe House
of Commons and in the country. The cardinal fea-
tures of this bill are the continuation of elementary
education for all children and the establishment of
secondary education for girls and boys on a national
basis. It also provides increased emolument and
pensions for teachers, in this way aiming to bring
into the teaching profession and retain there the
brains of the country.
We should cooperate with the government to
prevent any unnecessary interruptions in the work
of our schools and universities, and urge that all
institutions of science and advanced learning shall
be stimulated rather than curtailed in their efiforts.
"Win the war first," says Lloyd George, "but when
peace comes I don't want the nation to be taken
unawares. There must be healthier conditions in
the work shops and more attention to the schools.
There are disturbing symptoms all over Europe
which those at home will be wise to note and pro-
vide against. . . . Let us take heed in time," he
continues, "and if we do we shall enjoy settled
weather for the great harvest which is coming when
the fierce heat of summer now beating upon us in
this great war is over and past. Let us also take
heed of the deni^nds for national health, both
economic and intellectual, and being sure that the
lamps of learning are the lights of the futur(j let us
keep them bright."
We are not unmindful of the supreme task in
hand. A few days ago we made a new consecration
of our strength and we realize the pledge that we
and our Allies by all means in our power shall de-
stroy the German fabric of ruthless force. It is
still a considerable distance to the Rhine and inner
Germany. That nevertheless is our destination.
Neither military resistance nor the wily dealings of
a treacherous enemy shall hold us back. By force
of arms we must crush out vandal militarism, for in
this way only is Germany capable of understanding
that the judgment of the world is upon her; in this
way only is it possible to reestablish peace with
liberty and justice. We already know the cost.
Even while we glory in the achievements of our
troops and colleagues abroad, we cannot shut out
from our eves the sight of those who have fallen.
As this number increases courageous sorrow will fill
many homes. Little that might be said would bring
consolation. In silence we may pay our tribute of
veneration and take solace in the fact that those
who die go forward to join the invisible army of
Washington and Lincoln whose living spirit in the
cause of liberty is the vanguard we follow.
It is not in medicine alone that America looks to
the future. An era of expansion in all our activities
and in our sphere of influence is in sight. But the
day to which we look has none of the German taints
of avarice, for the motives which raised our nation
to a high place of esteem, the sacrifices which have
ennobled the republic, will increase our capacity for
service to mankind. Again, as in our past, after the
wounds of another great war, that day for us is to
be one of justice and without malice. Every calling
has its allotted task. The obligation of the medical
profession is clear and some portion of it rests on
each one of* us. The materials are ready and only
await assembling for the creation of a new Mecca
of medicine. May we have the vision to see the
c)p]X)rtunity, the courage to accept the responsibiltiy,
in this vital hour of medical history, when American
medicine steps forward to fulfill its duty to the
world.
THE GENERAL DIAGNOSTIC STUDY BY
THE INTERNI3T.*
Cooperating zcith Groups of Medical and Surgical
Specialists.
By Lewellys E. Barker, M. D.,
Baltimore.
(Continued from page 493.)
5. Requests for examinations by experts in spe-
cial domains. — The rapid advances that have been
made in diagnosis and therapy in the last fifty years
are in no small measure the result of the division of
labor that we know as the rise of specialism in med-
icine. The field of clinical knowledge is so vast,
tlie instrumental methods that have been introduced
for the investigation of special domains are so nu-
merous, and the technic of their skillful application
in many instances so difficult, that no single person
can hope to be equally conversant with facts and
methods of the several provinces or to attain to
mastership in the practical technical procedures of
more than one or two of them. The result is that
besides general interm'sts and general surgeons,^ we
now have pediatrists, ophthalmologists, otologists,
laryngologists, tuberculosis experts, heart special-
ists, hematologists. dentists (subdivided), gastroen-
terologists, proctologists, gynecologists, urologists,
urogenital surgeons, orthopedists and postural spe-
cialists, neurologists, psychiatrists, dermatologists,
endocrinologists, specialists in disorders of metab-
olism, clinical pathologists, clinical chemists, and
rontgenologists. I dare say others might legiti-
mately be added to the list.
It is true that in the medical schools, it is desir-
able thfit the students should learn the main facts
and principles of all the medical and surgical spe-
cialties and that they should have enough first hand
experience with special instruments, such as the
ophthalmoscope, the nasopharyngoscope, the bron-
choscope, the cystoscope, the ureteral catheter, and
the electrocardiograph, to permit them to understand
their uses and to convince them of the importance
of their application as aids to diagnosis in certain
cases. But in actual practice, specialists tO' do their
best work, and general internists to do their best
work, must submit evermore to that distribution of
dififerent parts of the diagnt)stic task among mem-
bers of a group that has been found necessary for
securing most quickly and accurately the data upon
which a diagnosis should be based. An internist
*Address dcHvered at the New York Academy of Medicine,
December 6, 191 7.
September 2S, ,9,8.) UARKER: GENERAL DIAGNOSTIC STUDY BY THE INTERNIST.
539
v/ho works alone without the cooperation of groups
of speciahsts, is sure to miss facts that may be of
the highest importance for a thorough understand-
ing of his patient's condition. A speciahst who
works alone should not forget that no matter how
expert he may be in his specialty, he is studying only
one part of the body, and that though abnormalities
may be found in his special domain, they may be
far less important for the patient's whole condition
than are abnormalities that, unknown to him, exist
in other domains. How are patients to gain the
advantages of specialization in medicine and at the
same time escape the dangers of a one sided study?
This is a question that must be faced squarely in
order that the right answer rrtay be foimd. The
solution of the problem seems to me to lie in group
work, each member of the group possessing special
skill in some particular kind of work, and one mem-
ber, acting as integrator, combining the single parts
into a properly proportioned whole. The integra-
tor should preferaljly be a person who, though pe-
haps especially skilled in some one branch, is rather
encyclopedic in training and comprehension, sym-
pathetic and tolerably familiar with work in all the
divisions of modern medicine and surgery, free
from prejudices, disciplined by sufficient experience
in hospital wards, in clinical laboratories, and in
the autopsy room, and blessed with that common
«ense which is in the last analysis largely a sense'
of proportion. Specialism, thus resulting in the
orderly cooperation of the members of a group, in-
stead of acting as a disintegrating force, may be
made to contribute to a higher unity, most helpful
both to the public and to the profession. With or-
ganization in groups of the kind mentioned, it would
matter but little to whom the patient applied for
diagnosis ; if the integrator be applied to first, he
will secure the reports from other members of the
group before undertaking the integration; if a spe-
cialist in some single anatomical domain be applied
to first, he may make his own examination, refer
the patient to the integrator for the conduct of the
rest of the study, and receive from the latter the
fnll and proportionate diagnostic report upon which
a rational therapy can be planned. Obviously, mu-
tual confidence and good will must prevail among
the members of such a group. Such groups al-
ready exist and the number of them is, I believe,
destined rapidly to increase. The older competi-
tive methods must give way to the newer coopera-
tive methods in medicine as in all other walks of
life. Nothing could be more unfortunate, however,
than the formation of cliques when arranging for
group work in diagnosis, and I would warn emphat-
ically against this danger. It is obvious, I think,
that such a system as I am referring to does not re
strict any specialist or any integrator to activity in
a single group ; there is no reason why either should
not particijiate in the activities of several different
or overlapping cooperating groups, the important
points being that the group at work on any single
case shall be so constituted as to ensure, first, ex-
pert study in each of the several bodily domains in
which there is an indication of the need of such
study, and, secondly, a combination of the parts of
the study into a well balanced whole, the systematic
analysis being followed by an adequate synthesis.
Now, in most cases there is, of course, no neces-
sity of examination by every member of a large
group of specialists. In addition to the anamnesis,
the general physical and psychical examination, the
rotitine laboratory tests and x ray tests already men-
tioned, there may be required special exajiiinations
in only one or two anatomical domains. In obscure
cases, however, and especially in instances of
chronic infections necessitating the search for hid-
den foci, we may feel the need of calling upon a
number of experts for aid. How many cases of
chronic infectious arthritis, for example, progress
for months because the diagnostic studies have been
limited to too few domains, when more complete
studies might have located the primary foci that
were responsible? No one can lay down hard and
fast rules as to how extensive a study should be.
The judgment and experience of the one who has
the general conduct of the study in charge must de-
cide after the anamnesis has been recorded and the
general physical and psychical examination has
been made. The main thing is that he who con-
ducts the study shall be sensitive to the problems
that confront him and know how to apply the best
skill in attacking and solving them. The greater
the talents and experience of the integrator, the
better his insight and discernment, the more likely
he will be to have a proper sense of the indicative
importance of the various features of a puzzling
case. The greater his familiarity with the making
of general diagnostic surveys, the more he will
avoid requesting examinations that are wholly su-
perfluous, the less Hkely he will be to neglect a test
that is essential in any single case. The taking of
too much pains in one case may be foolish ; the tak-
ing of too little in another may be disastrous.
The choice of experts among those that may be
available is of no inconsiderable significance. In
asking the aid of an expert, one must make sure
that a real expert, not a pseudoexpert, is chosen.
Again, among real experts, one will choose those
that can give the information that is relevant. Thus,
for an opinion on the existence of a proliferative
periodontitis and its importance, one will select
among several expert dentists, neither an orthodon-
tia specialist, nor a bridgework specialist, unless in
addition to his knowledge of his branch of dentistry
he knows also the marks and the significance of
periapical granulomata. Or, for an opinion on the
importance of a pathological idea, or mood, one will
select among neurologists and psychiatrists, neither
one wlio is interested solely in organic lesions of the
nervous system, nor one whose whole outlook on
mental phenomena is colored by some dogma, but
rather one v/ho is broadly trained in psychiatry,
"both descriptive and genetic.
In referring a patient to an expert in a special do-
main, it is well to send with him a note clearly ex-
plaining the nature of the reference, say as follows :
Drar Doctor :
We are making a general diagnostic study of Mr. ■ ,
Would you be kind enough to examine him in your domain
and to send me a report of your findings. Will you mention
especially in your report as to ?
There should be a general understanding among
members of a cooperating group that the patient is
540
BARKER: GENERAL DIAGNOSTIC STUDY BY THE INTERNIST.
[New York
Medical Journal.
to be told nothing abont the findings in the single
domains until the whole study has been completed
and its parts integrated. If this plan be adhered
to, much confusion and, often, embarrassment, will
be avoided.
As soon as reports have been received from
whatever specialists iiave cooperated in the study,
the preliminary collection of data is at hand and
the materials are available for the next step of the
diagnostic procedure, namely, the summarizing and
arranging of the facts and the consideration of th;
inferences that may be drawn from them. In col-
lecting the data, we make use chiefly of the meth-
ods of observation and in order that observation
can be extended and precisely controlled, we resort
to a large number of small experiments — our sev-
eral clinical tests. After collecting the data, we
stop observing temporarily and undertake the next
step of the diagnostic procedure ; we begin to use
the intellect in arranging the facts and in scrutiniz-
ing them ; we allow the thing^s observed to bring into
otir minds things that are not observed, that is, sug-
gestions, ideas, conjectures, or hypotheses of what
the things observed may mean.
SUMMARIZING .\ND ATJRANGIXG FACTS AND RECORD-
ING DIAGNOSTIC SUGGESTIONS TO WHICH A
CONSIDERATION OF THEM GIVES RISE.
After the data above referred to have been col-
lected, it has been found helpful, i, to summarize
the positive points (abnormal phenomena) in the
order of their collection, and, 2, to rearrange the
more important findings, both positive and negative,
in a systematic way, before allowing oneself to think
too much of their significance for the diagnosis that
is actually to be made. Thus, the positive findings
are first epitomized for the purpose of a quick gen-
eral survey under the following headings :
SUMMARY OF ABNORMAL FINDINGS.
_i. Anamnesis.
General physical and psychical examination.
iii. Laboratory tests.
iv. RontgenoloRical examinations.
V. Specialists' reports.
In this summary from the large mass of data col-
lected, only those points are selected that are defi-
nite deviations from normal conditions. Gathered
in the small space given to the summary, the eye
can \new them as a whole, and the mind grasps
more easily the nature and extent of the diagnostic
problem that the case presents. This first sum-
mary really consists, i, in passing judgment upon
the normality or abnormality of the phenomena re-
corded, and 2, in jotting down the several abnor-
malities detected, in the briefest form possible, for
preliminan' general survey. The main value of this
summary is as a control of the collection of data;
one may see at a glance whether in the study as
thus far carried out the application of any impor-
tant method of examination, indicated bv the anam-
nesis or the general physical examination, has been
omitted. One may note gaps in the anamnesis it-
self or in the report of the physical findings that
should be filled in.
For rearranging the more important findings
(both positive and negative") in a systematic way,
one may make use of the following form printed on
a single sheet :
MORE IMPORTANT DATA REARRANGED SYSTEMATICALLY.
Name. Age. Body temperature.
Chief complaint.
Habits.
Infections.
Operations.
Respiratory system.
Circulatory system.
Blood and hematopoietic system.
Dio;esti\e system.
Urine and urogenital system.
Locomotor system.
Mervous system and sense organs.
Metabol'sm and endocrine system.
Remarks.
Here, again, the important points are jotted down
in as brief form as is compatible with quick appre-
hension, use being made of various symbols for pur-
poses of abbreviation. Under the heading Circu-
latory System, for example, will be placed symp-
toms such as palpitation and precordial pains, if
they are present, physical signs referable to the
heart and vessels (e. g., pulse rate, blood pressure,
displaced apex beat, abnormal pulsations, heart
murmurs, thickened radials or arcus senilis), tele-
rontgenographic measurements, and electrocardio-
graphic abnormalities. Under the heading Metab-
olism and Endocrine System will be placed devia-
tions from normal weight in pounds or kilos,
struma, eye signs of hyperthyroidism, hypertricho-
sis or hypotrichosis, glycosuria, uricemia, etc. There
may be some overlapping, for one may place a symp-
tom like dyspnea under the respiratory system, un-
der the circulatory system, and under metabolism,
unless the preliminary survey has already made it
clear to which division the symptom predominantly
belongs. Important negative points are included
in this summary as well as the positive findings of
abnormality.
This systematic rearrangement implies a series
of particular judgments on the part of the integra-
tor, for his assignment of a given symptom or sign
to a definite system must be based upon his knowl-
edge or prior experience as to the meanings of
symptoms and signs. Diagnosis consists, on the
whole, of a search for clues and for the meanings
of the clues discovered. The arrangement of the
clues in groups according to anatomical physiologi-
cal systems makes the facts less isolated. It makes
it easier for us to perceive the relations among the
facts and prepares the way for the consideration
of each of the several groups as a whole.
Thus far in our own study of a patient, observa-
tion has been otir main task ; the drawing of infer-
ences has played onl}' a small and a subsidiary role.
But we have now reached a stage of the inquiry
where permitting the entrance of suggestions into
the mind, forming hypotheses, or drawing infer-
ences must occupy our attention excltisively. Ob-
servation stops for the time being ; thinking begins.
We let cur minds play among the facts. We allow
the things observed to carry us over to ideas of
other things that cannot be observed. From the
contents of our present experience, which we must
try to assimilate to our own past experience and
that of others, are to issue suggestions that we are
tentativelv to entertain concerning things that the
present experience itself does not hold. The situ-
ation calls up in our minds something that is be-
September 28, ,9,8.] HJRKER- GENERAL DIAGNOSTIC STUDY BY THE INTERNIST.
541
yond what our sense organs can contribute ; we leap
from facts to ideas. But our leaping, to be profit-
able, should be most carefully directed. If we have
cultivated both courage and caution as habits of
mind, and if we have taken due care in the selection
and in the arrangement of the facts from the con-
sideration of which suggestions are to emerge, we
may feel that we have done all that is possible di-
rectly and indirectly to control it. This regulation
of the conditions under which the function of sug-
gestion is allowed to take place is in itself very im-
portant, though, as will soon be seen, it is trans-
cended in importance by the regulation of condi-
tions under which credence is yielded to conjec-
tures that occur (vide infra).
When considering a group of symptoms and
signs arranged under a certain system, say the cir-
culatory, suggestions of meaning will begin to occur
to the trained medical mind. A thickened radial or
an arcus senilis will suggest the existence of an
atherosclerotic process, a thrill palpable over the
apex will suggest the existence of a mitral stenosis
due to an earher thromboendocarditis, or a dehrium
cordis may suggest the existence of an atrial fibril-
lation ; a tachycardia without marked signs in the
heart may suggest a hyperthyroidism, or a pro-
nounced bradycardia may make one think of a con-
duction disturbance in the atrioventricular bundle due
to an increased intracranial pressure, to a gumma
in the heart, or to a reflex from an irritated intes-
tine though the vagus. In thinking over the vari-
ous symptoms and signs, one should cudgel his
memory for varieties of possible meaning; it is de-
sirable to harbor a sufficient number of possible
suggestions and to record them as rivals to be pitted
against one another in a contest for supremacy.
Everyone must work out his own method for ac-
cumulating plausible suggestions from the data col-
lected. He must be on the alert to recognize quick-
ly well known uniformities of sequence or of coex-
istence. For myself, as an aid in arousing sugges-
tions, I have found it helpful to think, first, of the
possible immediate pathological physiological sig-
nificance; secondly, of the possible pathological, an-
atomical basis, and, thirdly, of the possible etiologi-
cal and pathogenetic relationship, of a given datum,
or of a group of data.
Individuals will vary as regards the suggestions
that occur to them, even when they have had sim-
ilar training and equality of opportunity for acquir-
ing experience. To some minds, suggestions of
meaning come easily and promptly ; to others they
come slowly and with difficulty. The number and
range of the ideas that occur also vary enormously
with dift'erent individuals ; I have often been struck
bv this diversity in discussing diagnostic problems
with students, with hospital internes and with prac-
titioners. Whereas, some minds seem barren, al-
most incapable of giving birth to an idea of mean-
ing when exposed to the fertilizing influence of a
fact, other minds res])ond with too prolific a pro-
geny, with offspring too numerous and too varied.
What we want is neither paucity nor superfluity of
suggestions, but rather a number and a range of
ideas that will suffice for our purpose and for the
requirements of the case. The quality of the sug-
gestions that are aroused is even more important
than the speed with which they come or the al)un-
dancc of supply. A mind that responds quickly
and prolifically with suggestions may be far inferior
to one in which response is slower but deeper and
more significant. Celerity is good in itself, but it
will not atone for either redundancy or superficial-
ity. The ideal response of the mind — quick, bal-
anced and deep — supplies the substantial ideas that
are worthy of being tested systematically for their
validity.
This process of soliciting suggestions of meaning,
though first applied to the group of facts pertain-
ing to each of the bodily systems (respiratory, cir-
culatory, digestive, etc.), should not stop when the
data pertaining to the several systems have been
examined, but the whole series of suggestions that
have thus arisen must next be surveyed in order
that their relative importance for the understanding
of the condition of the patient as a whole may be
estimated and in order that a final unified conclusion
with appropriate ordination of all the data in the
case may be approached. We must arrange the
suggestions and combine them with reference to one
another and with reference to the data upon which
their validity depends. Through the whole study
we must remember that a human being in difficulty
has applied to us for help, that the object of our
inquiry is to determine what is wrong with him in
order that we may direct him how best to act when
the totality of circumstances is known and has been
carefully considered. This realization of the pur-
pose or end of the diagnostic study will enforce or-
derliness of procedure and will give steadiness and
continuity to our thinking as it moves toward its
goal.
DEVELOPMENT OF THE IMPLICATIONS OF EACH DIAG-
NOSTIC SUGGESTION OR INFERENCE BY REASONING.
No matter how plausible the suggestions that
issue when the facts are arranged and considered,
final judgment should be deferred until the sug-
gested ideas have been traced to their full conse-
quences and their validity carefully tested. Only
an uncritical thinker will allow himself to accept an
idea as valid before elaborating it in order that its
full bearings may be clearly seen and compared with
the facts as they are. The critical diagnostician
will insist on reasoning the thing out, which im-
plies developing all the implications of each tenta-
tive suggestion that he deems worthy of it and com-
paring these with the facts that have been, or are
subsequently, collected. Very often the deductive
process by which the general notion is elaborated
will call to mind particular data not included in our
original collection, and will lead us to a supple-
mentary extension of the facts bv observation or
experiment. Methods not yet applied may have to
be used in the search for new materials to support
or to invalidate the tentative idea that has arisen.
Let us suppose for a moment that in our collec-
tion of facts regarding a patient we have found
that the temperature of his body is 103° F., that
his tongue is coated, that he has headache, loss of
appetite, and disinclination for exertion. He has
a few rales in his lungs, an acceleration of the pulse
rate, a palpable spleen, and a leucopenia. Sugges-
542
FRANKLIN: SEX HYGIENE.
[New York
Medical Journal.
tions of infections associated with enlargement of
the spleen and leucopenia at once occur to us and
we recall that two common infections of this sort
are typhoid and malaria. We then elaborate the
idea of typhoid fever (insidious onset, characteris-
tic temperature curve, relative bradycardia, initial
bronchitis, headache, anorexia, palpable spleen,
rose spots, leucopenia, early bacillemia, time of pos-
itive Widal reaction, epidemiology, absence of co-
ryza and of herpes, etc.). We also elaborate the
idea of malarial fever (intermittent fever in some
forms, continuous fever in others, chills, sweats,
headache, palpable spleen, herpes labialis, neural-
gins, leucopenia, anemia, exposure to bite of Ano-
pheles mosquito, reaction to quinine, parasites in
the blood, pigment-containing leucocytes in the
blood, etc.). We cudgel our memories or refer to
our books and find that paratyphoid fever, measles,
mumps, glanders and dengue are also febrile dis-
eases that are usually associated with leucopenia ;
further, that leucopenia may sometimes occur in
very severe forms of certain infections that are
usually associated with leucocytosis (e. g., pneu-
monia; septicemia). We then elaborate the ideas
of these infections also. These several ideas thus
elaborated are so many intellectual keys with which
we may successively try to fit the lock. If none of
them fit, we must either try some modification of
one of them or seek for still other keys for trial.
The original suggestions that occur to us are always
inchoate. By deduction from principles that have
already been established in medicine we develop the
fullness and completeness of their meaning. We
next have to determine whether the facts we have
collected regarding our patient can be identified
with the suggestions of meaning as we have elab-
orated them. Firmly to establish identity with
some of them, further observ^ation and experi-
mentation may be required. Thus through a con-
.«;ideration of the implications of our tentative gen-
eral diagnostic notions we may be led materiallv to
increase our store of particulars.
{To be cnnthntcd.)
SEX HYGIENE.*
P)Y George W. Franklin,
Albany, N. Y.,
Deputy Superintendent of Prisons, New Vi^rk Staie.
There was a backwoods farmer who had a muck
swamp on his land which the board of health had
directed him to drain. He had always known that
it was a breeding spot for mosquitoes, but he also
knew the stench would be awful were it stirred.
His logic gave him standing with those upon whom
rest responsibilities relative to the clogged cesspools
of homosexuality. Reformatories and prisons may
be designated as sinks of abnormality, yet if we
acce])t the survey of the psychiatrist or prosecut-
ing attorney, deviation is sounding a general alarm,
and we must confess that it is not confined alone to
*The author is indebted to John R. Ross, M. D., Superintendent
of the .State Hospital for Insane Convicts at Dannemora, N. Y.,
whose technical knowledge made hitn actually a collaborator. With-
out his encouragement the article perhaps would not have been
w ritten.
jjenal or other institutions. Moreover, to forestall
■it once any accusatory utterance as to assumption
l)y a layman, this article simply appeals to the medi-
cal profession for help in a big corrective problem
which confronts the Prison Department of New
York State and every other commonwealth.
That leaders in medicine and the laity may have
been somewhat dilatory inferentially hints that,
like the man with the hoe, we all preferred a dor-
mant menace rather than tackle the swamp. There
lire those of the medical profession who insist that
the day is fast approaching when homosexuality in
its symptomatic manifestations, and not restricted
to either sex, will of necessity call for a distinct
and determined branch of psychiatry. According
to the increase affirmed by experts, it would
seem that with proper coordination, medical
and official, some observatory step might locate
definite retarding ground. As a beacon for future
guidance, however, segregation and observation are
surely arc lamps to light the way. "We have
started" ; "We have been working for years," and
other defensive replies may quickly be voiced. If
so, in rebuttal will come this inquiry : "\\'ell, what
have you done ?" The response in Latin derivatives
will not be sufficient to arouse the people and a
successful project needs the mass behind it to push
it to completion.
Within the past twelve months the death chamber
at Sing Sing held a "patient" who was executed.
College bred and intellectually the peer of any in-
male ever incarcerated in the condemned cells, he
tenaciously opposed the endeavor of relatives for a
new trial and requested that the order of the court
be impelled rather than impeded.
This question was put to him one day shortly be-
fore the end: "You are well educated, had you
never thought it wise to take a personal inventory to
check up 3rour moral possessions?" "No," was the
reply, "all I can m.ake out is that I am bad all through
and have been bad since I arrived at the age of pub-
erty. I saw the revolting glances directed at me, but
as days wore on all semblance of humiliation de-
parted. Then even casual remorse was absent. I
was born a degenerate, and with all the schooling
1 had I could not subdue abnormal desires. I tried,
despising myself, yet this was fruitless, and edu-
cation for me did only this: It convinced me that
something congenital caused the delivery into this
world of a pervert. That was me. If it were
consistent to have a grievance, it would be against
my forbears, for they are as much to blame as I
am if any credence is to be given heredity."
This is but one of a hundred incidents which
com.e within the grasp of the prison ofificial who sees
more in his job than his salary. Enough data is
at hand to accentuate the cry for action, not alone
for the direct benefit to reformatories, peniten-
tiaries and prisons, but for the enlightenment of the
farnily doctor who is progressive enough to read the
periodicals of recognized authority which are is-
sued in his interest. In itself this would be worth
a valiant struggle.
The number of deviates in institutions is estim-
ated conservatively at anywhere from five to ten
per cent. ; speculation naturally must enter into the
September aS.'igiS.]
FRANKLIN: SEX HYGIENE.
543
premise. Yet, to diminish the percentage looms in
the (Hstance as a necessity. The salutary effect of
segregation would be more far reaching, decidedly
so, than the noninfornied would imagine. Every in-
mate, it is safe to say, would abhor assignment to a
degenerate ward, and the aversion — that of the ac-
(|uired per\ ert at least — would regidate deportment
mimeasurably more than the agencies that are now
emoloyed and which are without facilities to segre-
gate scientifically to observe.
One of the potent words in the vocabulary of
those treating defectives or criminals is segrega-
tion. The definition, unlike "psychiatry," "orienta-
tion" or "constitutional psychopath," is within the
understanding of the ordinary mortal. People
know that to segregate means to separate, to dis-
unite from the general mass, so that those segre-
gated may be placed where they will have personal
observation. This, regrettably, is just what has
not been done for those commonly referred to in
prison, reformatories, and penitentiaries as moral
perverts. In medicine as well as in criminology,
results are much more convincing than pledges.
Should the foregoing be entertained, it might
be well to ask why there should be delay awaiting
further psychiatric deductions and the construction
of clinical buildings. If segregation is that which is
claimed for it, then it is the opponent of lethargy.
The method applied to save potatoes or apples is
to separate the bad from the good as soon as the
sprouts or the specks show. In every prison in
this state — and in every other state — are defectives
to whom may be traced the major portion of dis-
turbances, cuttings and assaults of more or less
violence. To govern this grade of convict individu-
ally and collectively is the hardest task which con-
fronts the warden. It is only with the utmost dili-
gence that they can be detected. Some of them,
wrecked mentally by sexual desires, will frequently
commit offenses openly, not being deterred by the
deprivation of privileges, which is the only form
of punishment that can be inflicted.
Recently two inmates of Clinton Prison, guilty
of pederasty, resented interference and never moved
until parted by officers. Again, two other convicts,
caught in the act of irrumation, were deterred from
unnatural gratification by the approach of a guard.
These are the more common practices in institutions
which are housing offenders, accepting as accurate
disclosures made at sessions of the American Pri-
son Congress from year to year. Inasmuch as these
conferences are attended by representatives from
all over the United States, it is obvious that the sub-
ject requires nation wide attention. Names of fav-
orite movie stars and actresses are selected and ad-
dressed to each other by the type of convict on
which the text of this article is based. To repro-
duce some of their "love letters" and obscene draw-
ings would shock even those of more intimate ac-
(luaintance with shadowed side of human nature.
The accumulation which should impel action is
almost unlimited. One prisoner dangerously in-
jured another some time since for "stealing his
girl." These "alienations" engender hatred which
is harbored until the outbreak occurs, contributing
some significance as to the professional and moral
demand for intense study of that which can be
termed sex hygiene.
In prison, and out of prison, there is what is
known as the congenital and the acquired pervert.
Of the two, the former seems to be proud of his
homosexuality and is therefore easier to restrict
because he can be isolated. The latter for a while
avoids detection, but during this period he plays
havoc in an institution. Wardens hesitate to ren-
der decisions until they are sure, not wanting to
mark an iiiniare who may be effeminate but not
afllicted with the disease. Acquired perverts, in
contrast with the congenital, cringe from shame and
are therefore "patients" for whom a cure might
be effected were they eliminated from the prison
population and segregated for medical examination
by alienists rather than penologists.
At Clinton Prison, in New York State, to which
the incorrigibles of other institutions are trans-
ferred, one section of a cell block is for segregable
use. The degenerate class, those who are actually
known, are incarcerated in these cells which have
sheet iron aprons on the doors so that there can be
no physical communication by a man inside to an-
other walking along the corridor. This extreme
precaution is imperative, but with it the practice is
only regulated to a scant degree, too many oppor-
tunities being offered the pervert and too few
guards being employed to keep every suspect under
constant supervision. The shops, the yard, the halls,
or any spot wherever the eye of an officer cannot
travel for the time being, offer room for unnatural
gratification.
To mention any particular prison as being an\
better or any worse than another would be foolish,
allowing that some of the wardens would rather
not be forced to bow to the accuracy of this state-
ment. Nevertheless it is so, and the contrast would
not be wide enough to uphold any attempt at dif-
ferentiation. The conclusion that conditions are
practically identical in all penal institutions comes
from experienced officers who have been attached to
many of them and who rigidly maintain that they
are substantially alike.
To check the disease legislation may be essen-
tial, but legislatures are not composed of alienists
and neurologists. Thus there will have to be a well
thought out crusade and one in which the intention
of those interested will not be confusing or any ele-
ment left in doubt. It may be that the whole sordid
story will have to be told, yet if stirring it creates
a stench, attacking it will eventuate that for which
all would plead. It would be a catnpaign of educa-
tion for some and a post graduate course for others.
In the end, with a vigorous drive, professional, legal
and personal, some intelligent advance would be made
and the effort would not become anemic through
too much science. On the bridge to steer the course
there must be a psychiatrist, one who knows his
business and who is not timid in a rough sea, for
surely the responsibility is on the desk of the alien-
ist rather than that of a detective or plain clothes
man.
That anything mandatory can be done without
statutory provision is incontrovertible, but given
enough energy, consistently shaped, corrective
544
ANDRF.SEN: SYPHILIS OF THE STOMACH.
[New York
Medical Journal.
laws would bo passed. Every plain clothes man,
every blue coat and every detective who knows the
underworld could give a revelation on the subject
of commercialized degeneracy, almost defining the
scale of prices and paralleling in depravity the Bib-
lical history of Sodom and Gomorrah. They all
know the degenerate man and woman, and, worse
yet, the boy and girl. They also know the suspects
of more or less social prominence, but what can be
done ? To accost them in a manner to acquire cor-
roborative evidence is not to be thought of save in
rare cases. Arrests are made, but an overwhelming
percentage are sent to jail or the penitentiary sim-
ply as vagrants. Now and then the police lodge a
grand larceny complaint which puts them in State
prison. This is a means to an end, but they are
only gotten out of the way, the commitment not dis-
closing the actual truth. As to changes in legrJ pro-
cedure, when bills are presented to a legislature they
are usuall}' referred to committees, where they die,
legislators apparently not wanting to stir the muck.
The convict in Joliet today is in Sing Smg to-
morrow, San Quentin the next morning and, figur-
atively, twenty-four hours later in Atlanta, proof of
which is in any State bureau of identification. Ob-
viously, the problem becomes nationwide, wander-
lust being n common trait in all classes of offenders.
In correlation to the release of the tubercular in-
mate or the active syphilitic, society is intermit-
tently endangered. This without appending an-
other word or syllable, should be a resoundmg ap-
peal to all states for the segregation of the pervert
who is wiihin reach, and for clinical, not criminal,
observation.
The layman with the temerity to rush into the
field of psychiatry would as quickly enter an auto-
mobile race v^^ith dynamite in his car for ballast on
the lurns. As to treatment, he would remain silent,
but as to segregation and observation, combining the
opinions of the medical superintendents and chief
physicians of the eight prisons of New York .State,
there seems to be no room for dispute. The med-
ical staff of the Prison Department is a unit for a
laboratory for what are commonly known as de-
generates, not only for its value to the prisons,
but for its contributary worth to the science of
medicine.
More than two years ago James M. Carter, Su-
perintendent of Prisons of New York State, urged
that the Farm for Women at Valatie, to which only
female misdemeanants are committed, be made the
one prison for women in the Empire State. This
would permit transferring the inmates of the Wom-
en's Prison at Auburn to Valatie, thereby provid-
ing housing acccommodations for two hundred de-
fectives at Auburn, if there are that many, in the
building which would be made vacant. Here they
would be under medical observation, and some il-
lumination would surely ensue as to diagnosis and
treatment. How luminous it wovild be, he does not
know, being a layman, but that it would be an ex-
tension of the big idea which is pregnant at Sing
Sing is certain. As a constructive policy he averred
that further development should supplement the
clinic at the new Sing Sing prison, where the domi-
nant note is to be psychiatry. To examine men
there, just to send them to other prisons with only
a card index to explain why, would be taking no
stride forward. In his judgment segregable meas-
ures should be broad enough in scope to rid all cor-
rectional institutions of sexual perverts, particularly
when it is undenied that their association with other
convicts is destructive mentally, morally and phys-
ically.
SYPHILIS OF THE STOMACH.*
With Report of a Case.
By Albert F. R. Andresen, M. D.,
Brooklyn, New York.
Until very recent years, syphilis of the stomach
was considered a medical curiosity, references to it
in the hterature being rare, and the diagnosis in
the few cases reported being based either upon au-
topsy findings or upon a disappearance of certain
gastric symptoms under antisyphilitic treatment.
The use of the Rontgen ray and the Wassermann
reaction have made possible a more certain diag-
nosis, so that in the past few years a better imder-
standmg of the frequency of the disease has been
obtained. Writers on this subject are still, how-
ever, very much confused as to which cases should
or should not be reported as gastric syphiUs. On
the one hand some writers claim that only cases dem-
onstrated by microscopic examination of the sus-
pected tissue should be so reported, whereas at
the other extreme are writers who base their diag-
noses entirely on the clinical cures of gastric symp-
toms after antiluetic treatment. Several writers
have reported series of cases with various gastric
symptoms or lesions, associated with positive Was-
sermann reactions, as gastric syphilis, without
stating whether a therapeutic test or a microscopic
section have corroborated their diagnoses. Autop-
sies on one thousand three hundred and eighty-
four known cases of syphilis, compiled from the
literature, revealed but five cases, or less than four
tenths of one per cent., in which histological diag-
noses of gastric S3'philis were made. Among seven
hundred and forty-one of these cases, although
fourteen had gastrointestinal symptoms, only one
was demonstrated to have a luetic lesion in the
stomach. It is to be expected, however, that the
presence of gastric luetic lesions will be more fre-
quently discovered since the prevalence of spiro-
chetes in even the slightly affected tissues of old
syphilitics has been demonstrated by Warthin. The
percentage of patients with gastrointestinal symp-
toms or lesions of various kinds who have been
found to have syphilis has been reported in the
literature as being from three tenths to two per
cent. In the gastrointestinal department of the
Brooklyn Hospital Dispensary the writer found
that out of a total of one thousand patients suffer-
ing from all kinds of gastrointestinal symptoms,
seventy, or seven per cent., had strongly positive
Wassermann reactions. A routine serological ex-
amination was done on nearly the whole one thous-
and cases. Of the seventy syphilitic cases, twenty-
•Read bfrfore the Medical Association of the Greater City of New
York, April 15, 19 18.
September i8, igi8.]
-INDRESEN: SYPHILIS OF THE STOMACH.
545
six, or l.hirty-nine per cent., had demonstrable le-
sions of the gastrointestinal tract, nine having been
diagnosed as gastric ulcer, three as duodenal ulcer,
six having cecal or appendiceal deformities, and the
Fig. I. — Complete pyloric stenosis, with finger marks appearance
of gastric carcinoma.
others various other lesions, such as hepatic, pan-
creatic, and others. The nine gastric ulcer cases
with positive Wassermann reactions represemed
fifteen per cent, of the total number of gastric ulcer
cases in the clinic, the three duodenal ulcers, three
per cent, of all duodenal ulcers, and the six cecal
and appendiceal cases, five per cent, of all cases
with these lesions. Five of the seventy cases had
tabes dorsahs. The others apparently had merely
reflex gastrointestinal symptoms. Of the total of
seventy cases the writer feels justified in report-
ing but one as a definite, demonstrable case of
syphilis of the stomach.
It must be realized that a syphilitic may just as
easily develop an ulcer or a carcinoma or any other
nonluetic lesion as any other individual, and also
that there is nothing to prevent an ulcer patient
from acquiring syphilis. It is therefore unwise to
class all gastric ulcer cases with positive Wasser-
r"iG. 2 — Mass still present at pylorus, gastroenterostomy
patent and fimctioning.
mann reactions as cases of gastric syphilis, which
has been done in some case reports in the litera-
ture.
Pathology. — Syphilis may afifect the stomach in
a number of ways. While it has not been his-
tologically demonstrated to be a fact, it must be
conceded that the frequent and annoying gastric
symptoms of secondary syphilis may be due to
some luetic infection or irritation of the gastric
mucosa, it is perfectly logical to suppose that
mucous patches, or possibly only a hyperemia of
the mucosa, resembling that in the skin, may occur
in these cases. But it is with the congenital or ter-
tiary manifestations that the diagnostician has most
to contend. It is very important to realize that,
as Warthin has demonstrated, the "common pa-
thology of syphilis is not the gumma, but is a mild
chronic interstitial inflammation, leading to paren-
chymatous atrophy, degeneration, and fibrosis."
While the gumma is rare, the above lesions are ex-
ceedingly common in old syphilitics, occurring not
in isolated parts of the body, but generally through-
out all the tissues. Warthin's demonstration of the
spirochetes in these lesions of latent and supposedly
cured cases of syphilis has been a surprise to
syphilographers. He considers the following
Fig. 3. — Gastroenterostomy still functioning, pylorus closed,
defect on tipper surface of pylorus.
changes, which may occur in any or all the tissues
of syphilitics, as characteristic: i, areas of lympho-
cyte and plasma cell infiltration ; 2, fibroplastic pro-
hferation, frequently of the myxomatous type; 3,
vascular proliferations and obliterations. In the
stomach these changes result in localized or diffuse
infiltrations of the stomach wall. The local areas
may break down, producing ulcers which show a
marked tendency to perforate, may contract, caus-
ing hour glass deformities or pyloric stenosis, or
may involve the peritoneal coat, with resultant peri-
gastric adhesions. The diffuse infiltration produces
a cirrhosis of the stomach, with marked reduction
in its size, resembling linitis plastica. Gummata,
single or multiple, occasionally occur, and may, by
their size, or as a result of cicatricial contraction on
healing, produce pyloric or hourglass constriction.
They may also ulcerate, with the subsequent com-
plications of cicatrization or perigastritis.
Symptoms. — Those of gastric syphilis are not
characteristic. In general they depend upon the
character and the location of the lesion. The small
localized areas or small gummata, especially, though
not necessarily, if ulcerating, may produce all the
546
ANDPESEN: SYPHILIS OF THE STOMACH.
[New York
Medical Journal.
symptoms typical of gastric or duodenal ulcer,
namely, epigastric pain, in definite relation to food
intake, sour regurgitation, constipation, and, more
rarely, hematemesis or melena. Perforation, acute
or chronic, will give the same, though possibly not
quite as severe, symptoms as with ordinary ulcer.
Pyloric stenosis usually results in hypersecretion of
a hyperacid gastric juice, just as in pyloric stenosis
due to simple ulcer, and is associated with the same
symptoms of pain and delayed vomiting. More ex-
tensive infiltrations of the stomach wall result in a
reduction of gastric acidity, even to the extent of a
total achylia, with its attendant dyspeptic, diarrheal,
and hemolytic manifestations. Hourglass contrac-
tions, occurring usually in cases with somewhat
more extensive involvement of the stomach wall,
are usually also attended by the symptoms of sub-
acidity or achylia, as well as the usual vomiting of
this type of stenosis. Perigastric adhesions may
produce symptoms of hyperacidity or hypoacidity,
depending on the extent of involvement of the gas-
tric mucosa, and the usual symptoms occur when
stenosis develops. Loss of weight is a constant
symptom in all types of cases, together with a more
or less severe anemia. Other symptoms of .-yjjhilis
occur coincidently. While the gastric symptoms
may be very severe, a fatal termination always
seems a long way ofif.
Diagnosis. — The diagnosis of syphilis of the
stomach is difficult, and is often overlooked. The
lesions most apt to be confused with gastric syphilis
are gastric ulcer and carcinoma. A routine Wasser-
mann test on all gastrointestinal cases, especially
these showing evidence of gastric lesions, will help
to detect many cases. A strongly positive Wasser-
mann reaction does not, of course, establish a diag-
nosis of a syphilitic lesion of the stomach, but it in-
dicates that syphilis is present in the body, and in-
vites further study of the gastric lesion. On the
other hand, a negative Wassermann reaction does
not definitely rule out syphilis, as latent cases, with
negative Wassermann reactions, have been shown
to have spirochetes present in their tissues. The
presence of luetic lesions elsewhere is suggestive :
and, in congenital cases, the family and previous
history and the general appearance of the patients,
should be 'taken into consideration. The fact that
apparently simple symptoms have not been relieved
by ordinary treatment should occasion a suspicion
of their specific origin. An absolute diagnosis can
only be made on microscopic examination of tissue
obtained at operation or necropsy, but even here
sj^philitic lesions cannot always be differentiated
from tuberculous.
Gastric analysis dees not aid materially in the
diagnosis, the findings being dependent, as men-
tioned above, upon the character and site of the
lesion. Because diffuse infiltration of the gastric
wall is probably the most usual lesion, achylia is the
most common finding, but hyperacidity has been
shown to occur in many cases, especially in pyloric
stenosis due to infiltration or gumma localized at
the pylorus. Where there is an extensive infiltration,
finally resulting in pyloric stenosis or hourglass
constriction, the achylia is often associated with the
jiresence of lactic acid, lactic acid bacilli, and a posi-
tive Wolff- Junghans test. Extensive infiltration, re-
sulting in a leather bottle type of stomach, produces
achylia, reduction of the capacity of the stomach,
and rapid emptying of its contents. In the ulcerat-
ing cases, blood is of course found in the gastric
contents and feces.
The Rontgen ray examination is a great help in
diagnosis, although it only indicates the size, loca-
tion, and general character of the lesion. In a gen-
eral way it may be said that the lesions as shown in
this way look much larger and more extensive than
is to be expected from the patient's symptoms. A
patient with a history of recurring ulcer symptoms
finally resulting in obstruction, but with not much
cachexia and no mass, will have the typical findings
of a large carcinoma at the pylorus, with dilatation.
The infiltrations and cicatrices of the syphilitic in-
volvement may occur in any part of the stomach
wall and may cause marked deformities and distor-
tions, resembling by x ray large tumors, although
almost no mass may be actually present, and the
patient's symptoms may not be nearly as severe as
the findings would lead one to expect. In extensive
general infiltrations of the stomach wall, the stom-
ach is shown to be diminished in size, with stiffen-
ing of its walls, with greatly diminished or absent
peristaltic waves, and there is a rapid evacuation
of the barium meal. In hourglass constrictions,
Le Wald has called attention to the dumbbell shaped
deformity, caused by a stenosis over a wide area and
a secondary dilatation of the esophagus.
The therapeutic test will often be the deciding
factor in making the diagnosis. Some authorities
urge that every case of supposed carcinoma of the
stomach be given the benefit of a brief course of
antiluetic treatment to exclude the possibility of
syphilis. It must be remembered, however, that
ma.ny a case of carcinoma may be temporarily bene-
fited by specific treatment. Also, it must be borne
in mind that a syphilitic case with carcinoma of the
stomach may show improvement for some time,
even though the malignant gastric lesion is steadily
progressing. Plowever, if a patient with a definite
gastric lesion, demonstrated by x ray or operation,
and previously resistant to the usual treatment, is
found to have a strongly positive Wassermann re-
action and perhaps other evidences of syphilis, and.
on being put on vigorous antiluetic treatment shows
marked improvement of his symptoms with disap-
pearance of the previously demonstrated lesion, per-
i:a])s with resulting deformity from cicatricial con-
traction, the diagnosis of syphilis of the stomach
can be accepted.
Treatment. — The treatment of gastric lues is
primarily the treatment of the lues itself, that is,
the employment of salvarsan, mercury, and the
iodides in a routine way. The iodides may be
given in full doses, even where ulcer symptoms are
jiresent, these symptoms being promptly relieved,
instead of being aggravated, as would be the case
if there were a simple ulcer present. On the in-
stitution of the antiluetic treatment, especially on
giving salvarsan, there may be temporarily an ir-
ritation of the gastric lesion, causing an increased
swelling, which may result in increased obstructive
symptoms for a time. As a rule, however, there is
September 28, n)iS.]
IVEINSTEIN: INTESTINAL STASIS.
547
an immediate marked amelioration of all symptoms,
with the maximum improvement attained within
from four to six weeks. Pyloric or hourglass
lesions may he cleared up completely, but more
frequently a cicatricial stenosis will develop in these
cases. Patients with perigastric adhesions will be
improved under treatment, but, of course, not
cured, while the cirrhotic type of stomach will
necessarily remain small.
The ulcer or gumma cases are probably the most
favorable for treatment, but in these cases the treat-
ment of the ulcer symptoms should not be neglected.
The diet should be soft, soothing, and concentrated,
with frequent feedings. Demulcents and alkalies
may be indicated, and lavage may be necessary.
Rest is important. Foci of infection in other parts
of the body should be eradicated. Operative pro-
cedures are indicated only in the presence of com-
plications, and should not aim at the radical re-
moval of the gastric lesion, but should be purely
palliative. Deformities or stenoses, whether caused
by the lesions themselves, by cicatrices, or by peri-
gastric adhesions, interfering seriously with the
emptying of the stomach, require suitable opera-
tions, gastroenterostomy being the usual procedure.
More rarely, pyloroplasty may be attempted. Severe
hemorrhages, which threaten the life of the pa-
tient, may be an indication for operative inter-
ference. Perforation is an absolute indication for
immediate operation when acute, for later opera-
tion, when chronic. As a rule, complete and per-
manent relief from symptoms does not occur in
more than forty per cent, of the cases, even where
the best treatment is carried out.
The following is the report of the case observed
by the writer :
J. A., male, single, aged forty, a shipping clerk, born
m this country, first applied at the Brooklyn Hospital for
treatment on February 19, 1917. His family history vvas
negative. He had had no serious illnesses since scarlet
feyer in childhood but had been neglectful of his health,
drinking excessively up to six weeks before his admission
to the hospital, and leading a generally dissolute life. He
denied venereal infection. For two years he had been hav-
ing nycturia and some edema of the feet. He had always
led a sedentary life, had been habitually constipated, and
had eaten meat excessively. One year before, he had had
an attack like the one present on admission, except that it
had been milder and had lasted but one week. After that
attack he had been troubled with ind'gestion, consisting
of epigastric distention and belching, relieved by sodium
bicarbonate. Al)out one month before admission he began
to have epigastric burning pain, beginning one hour after
meals, lasting for two hours, and finally relieved by vomit-
ing of a sour, brownish, slimy material, day and night, al-
though only light food was being eaten. He could not
sleep on account of the pain, and was very constipated. He
had lost seven pounds in weight in two weeks.
Examination disclosed a fairly well nourished man of
alcoholic facies. His head was bald, his teeth rotten, his
palate high arched, and his thyroid moderately enlarged.
His heart was slightly hypertrophied, his lungs normal.
His liver extended to two inches below the rib margin, but
was not tender. No masses were palpable in the abdomen,
and there was no tenderness. All his lymphatic glands
were shotty. "The reflexes were normal. He had a vari-
cocele and a right inguinal hernia, and varicose veins of
both legs. A fractional examination of his gastric con-
tents disclosed a rising curve representing the gastric
acidity, the free hydrochloric acid being thirty and the total
acidity fifty at the two hour point. Blood was present in
all the specimens removed, but no bile occurred. There
was a large residue at the end of two hours. Single
specimens of stomach contents, removed at different inter-
vals after test meals, showed complete retention, with free
hydrochloric acid as high as eighty and total acidity as
high as 105. Microscopic examination of the gastric resi-
due showed the presence of blood, pus, mucus, and sarcinje.
Radiographs (see Fig. i) shou'ed a large, dilated
stomach, with complete pyloric stenosis and the finger
marks appearance supposed to be characteristic of gastric
carcinoma. Barium was obtained on lavage two days after
the radiographic examination. The urine showed evi-
dences of a chronic interstitial nephritis, with thirty-nine
per cent- phenolsulphonephthalein excretion in two hours.
The stools contained occult blood. The blood Wassermann
reaction was four plus.
A dose of 0.6 gram of salvarsan was given on Februarj'
23d. The patient grew steadily worse, rectal feedings were
not retained, and with a threatening acidosis, it was deemed
advisable to relieve the pyloric stenosis, which might pos-
sibly be malignant, by operation. On February 27th, the
abdomen was opened by Dr. H. H. Janeway at the Memo-
rial Hospital, New York city, and a hard, indurated mass
the size of a lemon and typically malignant was found at
the pylorus, adherent behind, causing a complete stenosis.
A posterior suture gastrojejunostomy was done, with the
intention of doing a resection later at a secondary opera-
tion. Two weeks later, radiographs (see Fig. 2) showed
the stomach much smaller and the gastroenterostomy
working nicely, but the mass was apparently still present at
the pylorus. So on March 22d, about three weeks after
the iirst operation and one month after the dose of salvar-
san, the abdomen was again opened, but no sign of the
mass was found, the pylorus being apparently free. Since
that time the patient has been kept steadily under vigorous
antisyphilitic treatment, and has had no more gastrointes-
tinal symptoms. His weight has gone from 139 pounds on
discharge from the hospital after his second operation to
156 pounds at the present time. His Wassermann reac-
tion at the present time is four plus. Radiographs (see
Fig. 3) show the gastroenterostomy still functioning,
and the pylorus apparently closed. There is a defect on the
upper surface of the pylorus, probably due to cicatricial
contraction.
219 Berkeley Place.
INTESTINAL STASIS.*
A Nezv Method of Treatment.
By Julius W. Weinstein, M. D.,
New York,
Attending Physic. an, Department of Digestive Diseases, Vanderbilt
Clinic; Consulting Gastroenterologist, Zion Hospital, Brooklyn.
The treatment of intestinal stasis has ever been
a stumbling block in the path of the general practi-
tioner and the gastrointestinal specialist. The reme-
dies used to combat intestinal stasis had excellent
results in only a few patients ; they did not relieve
the condition in the vast majority. Among the dif-
ferent remedies to combat intestinal stasis we have
time honored dietetic rules ; a large armamentarium
of laxative and purgative drugs and mineral waters ;
massage ; water and olive oil enemata ; vibration with
special instruments ; faradic, galvanic, and sinus-
oidal electricity. Claims were made a few years
ago bv Zueltzer that he had found a special hor-
mone that cured constipation. The results of this
treatment were also negative in the majority of
cases, and disastrous to a good many patients in
whom the hormone was injected. Sir Arbuthnot
Lane and many of his disciples claim that the colon,
in part, or, in toio, must be resected in order to get
rid of this disease which gives rise to so many symp-
toms and which leads, according to the claims of
Lane and others, to numerous afTections. Various
•Read before the Eastern Medical Society, June 14, 1918.
548
irE.'NSTElN :
INTESTINAL STASIS.
[New York
Medical Journal.
schemes of short circiiitinor the colon, such as ileo-
sij^noidostomy, cecosigmoidostomy have been re-
sorted to for the rehef of intestinal stasis.
This condition in many of my difficult and long
standing cases began to yield in a most gratifying
manner to a simple dietetic plan of treatment. It
is evident that the method of treatment is applicable
to the so called idiopathic, primary form of intes-
tinal stasis, whether it belongs to the spastic or
the atonic variety, the hyperkinetic type, as disig-
nated by Schwartz, or the dyschezic form of Hertz.
It is inapplicable in constipation of the obstruc-
tive variety, nor would I recommend it in case of
secondary constipation, i. e., constipation secondary
to cancer of the stomach, ulcer of the stomach and
duodenum, gall stones, etc., though I have seen
it work out in secondary cases just as readily as in
primary cases. Fortunately the primary cases of
constipation give a very distinctive history which
differentiates them from the types that are secondary
to other diseases. The history is as follows: i.
For mild cases : Bowels do not move without arti-
ficial aid, otherwise the patient feels well. No
symptoms. 2. Cases of moderate severity: Bowels
do not move without artificial aid ; headaches ; heart
burn ; heaviness and bloating after meals ; some
feeling of drowsiness after meals. Cathartics or
enemata relieve these symptoms. 3. Severe type of
case : Severe headaches, dizziness, ringing and
noises in the ears, eye ache, expectoration of mucus,
the patient complains that food goes to the head
and he feels as if drunk after eating; fullness and
choking sensation in throat and chest ; marked bloat-
ing and heaviness after meals ; heart burn ; belch-
ing; bad taste in the mouth; very tired feeling;
very drowsy after meals ; pains in the legs ; patient
feels as if food lay on his chest and did not go
down. Bowels do not move without artificial
means. Bowel movements do not relieve these
symptoms. At times they aggravate them.
METHOD OF TREATMENT.
The rationale of the treatment is based on the
premise that the main cause of the failure on the
part of the bowel to evacuate, in the types of con-
stipation under discussion, lies in the fact that
there is too big a load gravitating on the colon to
be discharged, and that when the burden is lightened
the colon regains its ability to carry on its work.
The over bulk of contents in the colon may be due
to the ingestion of too much food by the patient,
while the intestines are able to absorb only a small
fraction of the food ingested for utilization by the
body and the residue, therefore, must be carried
off and_ expelled by the colon. On the other hand
the residue in the colon may also be due to the
failure on the part of the digestive organs, the
salivary glands, the stomach, the liver, the pancreas,
and the small intestines, to carry out their share of
the^ work efncientlv and hence, again, a bulky
residue is left for the colon to discharge. I speak
of the colon as the main organ that fails as scaven-
ger in intestinal stasis, for from my observations
on large numbers of patients with intestinal stasis
both fluoroscopically and radiographically, the
slowing of the current is chiefly noticeable in the
colon.
With this premise as a guide the logical treat-
ment consists in a reduction in the quantity of the
food ingested. There are several adjuvants, how-
ever, employed in this treatment, namely, the in-
gestion of about four glasses of water between
meals ; the ingestion of well known bowel stimu-
lants, such as wdiolewheat bread, fruits, and vege-
tables. I'hese substances act as mechanical stimu-
lants to the bowel, but I consider their main effect
a chemical one. Very thorough mastication of
the food is another adjuvant. The treatment there-
fore consists in following this diet list, which is
given to the patient :
Ept slowly. Chew your food well. Drink about four
glasses of water between meals.
BREAKFAST.
One glass of hot water.
One orange 80 calories
One slice of toasted or plain wholewheat
bread and butter 171
One soft boiled or poached egg 80 "
Six stewed prunes 150 "
LUNCH.
Two slices of wholewheat bread 142 "
Butter ICQ "
Sinall niece of fish, boiled or broiled 180 "
Butter .=0
Veget?bles, such as carrots, string beans, etc.. 160 "
Spinach (including butter) 150 "
SUPPER.
Fruit only, such as apples, pears, figs, oranges, dates,
peaches, prunes. The patient makes the selection from
about three different fruits. Thus he may eat :
Five or six figs ^17 calor'es
Eight or nine dates 240 "
Two apples 80
The lunch and supper ore interchangeable. By
a slice of bread is understood one about one half
inch thick. This weighs about one ounce. The
patient does not eat between meals ; no lunches, no
sandwiches, no sodas, nothing except water be-
tween meals. No seasoning is used except salt and
lemon juice. An apple is allowed perhaps later in
the evening. In eating fruit the patient is ad-
vised to eat skin and all. In eating an orange, not
only the juice, but pulp also is to be eaten. As
soon as the bowels begin to move spontaneovisly,
which is almost invariably at the end of a week,
the diet is slightly increased and the fruit meal is
substituted by a regular one. Thus to the break-
fast one egg and one slice of bread and butter are
added. The fruit meal is replaced by one consist-
ing of : Two slices of wholewheat bread and butter ;
one glass of milk raw or boiled or instead of milk
vegetables or eggs ; some fruit. The diet is to be
strictly followed. It will be noted that I have elim-
inated meat, chicken and soups from the diet. This
is not essential in all cases. In patients that are
sttftering with symptoms of intense autointoxica-
tion, the elimination of meat, chicken, and soup
is essential. In the milder type of cases and those
of moderate severity, some meat, chicken, and soup
are allowed instead of fish. The soup is preferably
vegetable. The meat may be boiled, broiled or
roasted, but not fried, and only a small portion is to
be used at a time. The vegetables should be pre-
pared as follows :
lettuce and celery are to be eaten raw or cooked.
Spinach : Wash the spinach thoroughly in water so as to
^et rid of all the sand. May chop it, or without chopping
September 28, igiS.l
WElh^STEIN: INTESTINAL STASIS.
549
put it in a pot with just the least bit of water. Cook thor-
oughly from twenty to thirty minutes, until tender. Add
nothing to it while cooking. Before serving add some but-
ter and salt. String beans, carrots, cauliflower, asparagus :
Prepare these vegetables by merely cooking in water. Be-
fore serving add some butter and salt. A good plan is to
put the vegetables in just enough water to cover them and
then cook slowly until there is a little sauce left. Eat the
vegetables and sauce. Combinations of the vegetables may
be made. A good combination is carrots, green peas, and
string beans; cauliflower may be added to the three; pre-
pared by putting the vegetables in just enough water to
cover them and then cooking slowly until there is a little
sauce left. Stewed tomatoes: Fresh tomatoes (not
canned) are sliced and cooked as above. Cabbage, cucum-
bers, and radishes should not be used.
Thorough mastication of the food is of great
importance. The acidity of the stomach stops the
action of the saliva on the starches. By masticat-
ing thoroughly the food is finely divided and the
prolonged action of the salivary ferment in the
mouth carries the hydrolysis of the starches to a
considerable degree. Telling a patient however to
chew the food well avails but very little. Fast eat-
ing is a very pernicious habit and patients find it
extremeiy difficult to rid themselves of the habit.
1, therefore, tell the patients that they are not to
swallow their food, but to keep on chewing it, as
long as there is any food in the mouth. They are
to chew the food and not swallow it,' but bring it
to a point of involuntary deglutition.
I instruct the patients to move their bowels in the
squatting position and not on the regular toilet
seats. In this way the pressure of the thighs on
the abdomen assists in expulsion of the feces. The
nature of the evacuations under this regimen of
treatment is quite out of the ordinary. It is a small
stool ; a dry one in the form of small scybalae.
There is no odor to it at all which testifies to the
fact that indol, skatol and other similar products are
not normal, but abnormal byproducts of metabolism.
The stool leaves the anus perfectly dry. The patient
is instructed to go and move his bowels when he
feels the inclination. If no desire is felt the patient
is instructed to walk around a little with the legs
separated and an impulse to defecate is thus brought
about. Should he fail to get a movement the first
day, the same procedure is repeated the next day.
If after three or four days no movement has been
obtained, a suppository is inserted. This method
has seldom to be used. The patient is not given
any medication and the bowels begin moving spon-
taneously either on the next day or sometimes on
the third or fourth day. Since under this diet and
with the thorough mastication the food is perfectly
digested and absorbed, so that only a small residue
is left, there is no absolute need of daily evacua-
tions, and patients who on an ordinary diet had
distressing symptoms, if the bowels had not moved
daily, went without any bowel movement for several
days without discomfort under this regimen.
The total caloric value of the diet, as seen from
the table, amounts to about 1,820 calories. This
figure is below the accepted standard, and most of
the patients do lose a little weight until the body
adapts itself to the new diet, and a condition of
equilibrium is established. The increase in the diet
at the end of the second week increases the caloric
value of the diet by 200 calories. It should be
remembered that in the regular diet of people with
a total aggregate of about 3,000 calories there is a
copious bowel movement which reduces the avail-
able food considerably. In the diet prescribed by
me the stools are very small which raises the quan-
tity of assimilated food considerably. In persons
of weight above seventy kilos we may increase the
diet very slightly along the same lines. After a few
weeks of treatment the diet may be changed to suit
the tastes and desires of the patients.
The results are excellent. The patients invariably
report, a week later, that their bowels move well
daily. Sometimes I give a prescription for glycerine
suppositories with instructions that if the bowels do
not move after a few days the patient is to insert
one in the rectum. The patients however seldom
have to resort to the use of suppositories. I treated
a large number of patients by this method and it
has been successful in almost every case. Heart-
burn yielded very promptly to this plan of treat-
ment. I do not refer to that form of heartburn
which is only one of a long train of symptoms met
with in ulcer of the stomach and duodenum, chronic
appendicitis, etc. I am referring to a class of pa-
tients who complain only of heartburn of a severe
degree. I had a number of such cases and the con-
dition yielded most readily to the plan of treatment
outlined. Gaseous distention of the stomach and
tenderness over the appendicular area, disappeared
under the plan of treatment outlined here, very
readily. As regards the effect on the patient's con-
dition in general I found the following: The mild
type without symptoms except for constipation,
yield most readily to treatment. In the type of
moderate severity, one week after the administra-
tion of the treatment, the symptoms, including the
constipation, disappeared and the patients reported
themselves as feeling well.
The following histories illustrate typical cases.
Case I. — N. U., male, seventeen years old. Shipping
clerk. Habits normal. In good health up to two years
ago, when he began working. He then became rather
coriSti;3ated, but soon recovered. He has been sick for
four and a half months. Bowels ceased moving without
artificial means. Used paraffin and all other physics. Suf-
fers with headaches; bloating and heaviness after meals;
belching; pyrosis; drowsiness; anorexia; eye ache. Physi-
cal examination is entirely negative. One week after the
patient i.s put on treatment he reports he feels well and
that bowels move well.
Cask JI. — J. K., male twenty-five years old. Machinist.
Habits normal, except that he eats fast. Has had some
minor ailments. Has been constipated since age of six-
teen or seventeen. Bowels would move once in a couple
of days. Took a lot of medicine. During the last year his
bowels ceased moving unless medicine was used. Patient
suffered from headaches ; dizziness ; at times tinnitus ;
bloating and heaviness after meals; drowsiness; constant
cold ; anorexia. Physical examination showed the follow-
ing: Pulse mo. Lungs and heart negative. Stomach very
tympanitic anct distended with gas. Tenderness over
pyloric aren. Rectum full of feces. Eight days after in-
stitution of treatment patient reports that bowels move
daily. Pulse 88. Tenderness over pyloric area and tym-
pany of stomach have disappeared.
Case III. — Mrs. E. L., Four children. Habits normal.
Typhoid fever at fifteen years of age. Some miscarriages.
Has had stomach trouble ever since she remembers. Al-
ways took medicine. Suffered from headaches. The con-
dition has grown worse in the last two years. In the last
two years she suffered with headaches ; dizziness bloating
after meals ; hiccough ; a sensation of fullness and clogging
550
JAHSS: CONGENITAL DISLOCATION OF THE Hlf
[New York
Medical Journal.
up in her throat and chest ; heartburn ; sour eructations.
When she eats she feels a little better, but right after the
meal she gets all the above symptoms. Bowels do not
move without medicine, and when she uses medicines diar-
rhea occurs. Physical examination showed a thin, ema-
ciated woman of gastroptotic type. Gastric secretion nor-
mal. Under x ray examination stomach is both ptosed
and dilated. Considerable stasis of food. Loops are seen
in big bowel. Iliac stasis. Rest in bed with milk diet
accomplished little for the condition, while the treatment
described in this paper made the bowels move daily with-
out any artificial means and all the symptoms disappeared.
I shall appreciate criticisms from my fellow prac-
titioners who give this method of treatment a trial.
i6 East Ninety-sixth Street.
CONGENITAL DISLOCATION OF THE HIP
IN THREE GENERATIONS.
By Samuel A. Jahss, M. D.,
New York,
Orthopedic Assistant, Hospital fur Deformities and Joint Diseases.
In reviewing the literature in reference to the
etiology of congenital dislocation of the hip, some
mention is made of the hereditary factor. Lovett
in his book states "The disease is in some cases
hereditary" and quotes Dupuytren, Bouvier, Stad-
FiG. I. — X ray showing congenital dislocation of hip in th-
mother.
feldt, Verneuil and Volkmann. Whitman and Tub-
by declare "Hereditary influence can be established
in a few instances" and both quote Vogel who re-
ports that in thirty per cent, of his cases a similar
condition was found in the mother or father of
these children. No mention is made of this disease
being found in three generations and as such a state
of affairs has come under my notice I thought it
would be worth while reporting.
A young girl about fifteen years old ^-eported at
Fig. 2. — X ray showing congemlal Jislocation of hip in the daugh-
ter, apparently hereditary.
the clinic of the Hospital for Deformities and Joint
Diseases for the cause and possible cure of a limp.
She was accompanied by her mother. They had
been referred to the hospital by Dr. J. LifT. The
walk was with a limp to the right. A similar gait
was noticed in the mother. The history revealed
that this condition had always been noticeable both
in the mother and daughter since walking was first
liegun. The mother also stated that her mother
had a limp exactly similar to that of her daughter
and herself. Physical examination revealed a tilting
downward of the pelvis on the right side when
standing. The trochanter of the same side was
above the anterior superior iliac spines and the
measurements taken from the anterior superior iliac
spines to the internal malleoli showed :
Mother Daughter
Right 29^ inches Right 28)4 inches
Left 31 inches Left .10 inches
X ravs taken of both mother and daughter showed
typical congenital dislocation of the right hip.
As the grandmother has been dead about thirty
years it was impossible to obtain any data exclusive
of the history ; but the history is, I think, suffici-
ently conclusive to warrant the diagnosis.
Medicine and Surgery in the Army and Navy
THE SURGEON OF THE PORT OF
EMBARKATION.
Physical Examination of All Troops Bound Overseas. —
Reception of H'otmdcd Returning from the Battle
Front- -Building and Equipping of Hospitals
High up in the tallest of the buildings of
Hoboken — and they come as high as eight stories
there — in a small bare office at a bare, flat topped
desk, sits a powerfully built, weather tanned and
grizzled man in khaki with silver eagles on his
shoulders, who gives the final "once over" to every
oflicer and every soldier before he sails for the
battle front and who is the first to extend a helping
hand to the sick, the maimed,
and the wounded when they
come back. During the
month of July, he put his
final O. K. on 272,022
soldiers. Without that final
O. K., no oflicer nor soldier
nor nurse, nor Y. M. C. A.
secretary nor civilian worker
may sail from the "Port of
Embarkation" under his
jurisdiction. And the term
"Port" in this case has a
special and wide signifi-
cance, for it covers every
port on our eastern sea-
board and that of Canada
from Baltimore to the North
Pole. The long arm of the
Commanding General of
the Port of Embarkation
reaches over the Canadian
border and we find mem-
bers of his stafif, includ-
ing representatives of the
Surgeon of the Port,
in Halifax, and in Mon-
treal.
Just now. Brigadier General W. V. Judson is the
Commanding General of the Port of Embarkation,
having recently succeeded Major General D. C.
.Shanks, who organized the work and who has now
been assigned to the command of a division which
assures him the opportunity, coveted by all officers,
of active command at the front. The Brigadier
General Commanding the Port of Embarkation has
a stafi; which covers every one of the varied activ-
ities-- which come under his jurisdiction and which
includes ten colonels, twenty-two lieutenant colonels,
124 majors, 489 captains, 824 first lieutenants, and
789 second lieutenants, a total of 2,258 commis-
sioned officers. In addition he has under his
command 22,000 enlisted men, 500 civilian em-
ployees, and 350 nurses entirely aside from the
casuals who are brought under his control by being
detached from their organizations because of illness.
One of the officers of his staff is the Surgeon of the
Port of Embarkation, Colonel J. M. Kennedy, and
it is his work that interests the readers of the Nev^'
York Medical Journal.
On July 6, 1 91 7, Colonel Kennedy assumed the
duties of the Surgeon of the Port with two officers
and one private; on July 31, 1918, he had under his
command, thirty-three medical department organi-
zations, 529 commissioned officers, iio contract
surgeons, 342 nurses, 2,649 enlisted men and sixty-
five civilian employees. Included in his jurisdiction
are thirteen hospitals with an estimated capacity of
12,500 beds, over 11,000 of which are now ready for
occupancy. An additional 3,300 beds will be pro-
vided by the Grand Central Palace at Lexington
avenue and Forty-sixth street. New York, which
has been taken over by the Medical Department at
an annual rental of $385,000
for use as a debarkation
hospital. This does not in-
clude all the army hospitals
in the territory covered, but
only those which are directly
under the control of the Sur-
geon of the Port of Em-
barkation.
THE EXECUTIVE STAFF.
In military parlance, no
officer below the rank of a
brigadier general has a staff.
From a civilian standpoint
Colonel Kennedy has a staff,
and a large and important
one at that. The organiza-
tion of the work being car-
ried on under Colonel Ken-
nedy's supervision is clearly
shown by the accompanying
chart drawn up by Lieuten-
ant Clifton D. Wise, S. C.
who is in charge of the
Historical and Statistical
Division of the office, and
was traced by Corporal L. J.
Savage.
Captain G. C Young, S. C, is the executive of-
ficer, which means that he is one of the busiest men
in four counties, as he must keep track of all the
varied activities of the office and must also do all
that he can to protect the surgeon himself from
lime wasting details.
A liaison officer. Lieutenant J. W. Dennin, M. C.
keeps Colonel Kennedy informed as to the move-
ment of troops and transports so that he can make
the proper disposition of his forces.
The Personnel Division, of which Lieutenant
Colonel M. E. Hughes. M. C, is the chief, consists
of five commissioned officers and twenty-two pri-
vates. The duties of this division are to see that an
adequate personnel of men is detailed for the work
of the office and of all the organizations under its
control ; to see that the proper reports are submitted
at the oroner intervals from all the thirty-six med-
ical organizations ; to supervise the mobilization sta-
tions of the Army Nurse Corps, the preparation of
nurses and civilian employees for overseas service
as regards equipment, identification and inocula-
Pholo /)'.' Magna i
COL. J. M. KE.NNEDY, M. C, U. S. A.,
Surgeon of the Port of Embarkation.
552
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
tion ; prcparatior and certification of their pay rolls
and other money papers ; and the preparation of re-
ports, returns, etc., relating both to casuals and also
to the permanent detachments at the hospitals and
supply depots under the control of the Surgeon
of the Port of Embarkation. In view of the rapid
shifting of this personnel, particularly the casuals,
this is an important, an onerous, and an intricate
task. This division maintains correct lists of all
Medical Department organizations and casuals
ordered to the port for embarkation. It verifies
and transmits all reports and returns, relating to
these organizations and provides adequate medical
attendance for all troops en route overseas. The
division also receives, distributes, and forwards the
personal mail of the personnel.
The Division of Dental Service, of which Captain
Europ^e as a member of a casual command and put
into replacement troops. The probabilities are that
he will never get back to his old command again.
The patient thus detached becomes a casual and is
carried on the pay rolls as such until he recovers
his health and is assigned to duty in some other or-
ganization. Proper provision for his transfer is
one of the multitudinous nonmedical duties which
devolve on the Surgeon of the Port of Embarkation.
The method of weeding out the sick prior to em-
barkation is set forth in the following general order
issued by the ofiicer of the port of embarkation :
Headqu.\rtees Port of Embarkation.
General Orders, ) Hoboken, New Jersey,
No. SI. j May i6, 19 18.
I. I. Upon the receipt of orders for foreign service, or
upon the receipt of orders to proceed to point preliminary
to embarkation, daily physical inspections should be made
I nhrr i
, brr*R<n
r ICMTCRT
1
1 WeUML PIRCtroR
1
I. JMCPHAU INSPECTOR
[Attend injg?urggCTi| poniiciliar/Ho?j'iUl;| | Ho?pitaA?~
[Auirilliir) Ho?piUI*i I \Sti\m\ ho>pilAl *i | |Pcl?arkAlionHi){pitAl 'a
rm-i Mojilil , ., , I I fort htjpitil ~T1
■j^myfn ?iA N.J.I I fori VtwAK N J.
Di.igram of the organization of the work of the Surgeon of the Port of Embarkation.
R. F. Doran, D. C, is director, supervises the dental
service at the various places under the control of
the Surgeon and assigns dental surgeons as the need
demands.
A Historical and Statistical Division, in charge
of First Lieutenant Clifton D. Wise, S. C, is
charged with keeping and tabulating statistical and
historical records. It is largely on his work that
this condensed sumtnary of the manifold and far
reaching work of the Surgeon of the Port of Em-
barkation is based.
When any officer or soldier of troops ordered
abroad is discovered, by the inspectors of the Sur-
geon of the Port of Embarkation, to be ill, he is at
once detached from his command and sent to the ap-
propriate hospital and attached to a casual com-
mand. His name is dropped from the rolls of his
former command, and when he recovers, he is sent to
of all enlisted personnel belonging to the organizations
specified in the orders, and these inspections should be
continued daily until the troops are debarked at a foreign
port. Inspections should be made by the medical officers
of organizations to which they are assigned, or, where
there is no medical officer on duty with an organization,
one or more will be assigned to this duty under the direc-
tion of the senior medical officer, the division surgeon or
the camp surgeon, as the case may be.
2. Medical officers will observe the greatest care in
making these inspections, immediately removing from the
organization all cases, or suspected cases, of communica-
ble disease. They will carefullj' scrutinize all men, watch-
ing for the early signs and symptoms of disease or the
presence of vermin, and will not be satisfied to wait until
a condition has fully developed before making diagnosis
and taking proper action.
3. Cases of communicable disease will not be permitted
to proceed to port of embarkation, nor will known con-
tacts of scarlet fever, cerebrospinal meningitis, and
measles. All cases of venereal disease, acute or chronic,
will be removed from their organizations.
September 28, 1318.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
553
4. Upon arrival at the port of embarkation, or en
route to such point, a final examination will be made by
the medical officers representing these headquarters and
under the direction of the surgeon. Port of Embarkation,
Hoboken, N. J. At this examination the men will be
stripped to the waist and carefully examined for signs and
symptoms of venereal, as well as other communicable
diseases, including vermin.
5. The medical officers making this final examination
will submit a report to the surgeon, these headquarters,
showing the presence, if any, of the disease in question,
with the Name, (Ikgamzation, Nature of DiSEASh, Date
OF I,A5T Previous Inspection-, and the Name of the med-
ical officer by whom it was made, and stating whether in
the opinion of the medical officer detecting the disease the
disease was present at the time of the last previous in-
spection.
6. Known contacts and cases developing among troops
embarking at Portland, Me., will be transferred in the
proper manner to the Post Hospital, Fort \\'illiams, Maine,
arrangements for their reception being first made with
the district commander, Portland District, C. A. C. Head-
quarters, Fort Williams, Maine.
7. Known cases and contacts occurring casually at other
II.
lighted; artificial light will not be used unless abso-
lutely necessary.
2. Men will be stripped to the waist and will be
prepared to lower their drawers and breeches for
inspection of the genitals.
3. The parts inspected will be turned toward the
light and as near the window as practicable, and the
following order followed :
(a) Eyes, noting the presence of conjunctivitis.
(b) Nose, noting the presence of coryza.
(c) Parotid glands, noting the presence of swell-
ing.
(d) Mouth, noting presence of Koplik spots, con-
gestion of buccal mucous membranes, rash or con-
gestion of hard palate, "scarlet tongue," or mucus
patches.
(e) Throat, noting presence of sore throat and its
character.
(f) Chest, abdomen, and back, noting presence of
rash or signs of vermin.
(g) Genitals, noting presence of any venereal dis-
ease or vermin.
General Orders, No. 3, Headquarters Port of Em-
Embarkation Hospital No. I, Hoboken, N. J. This was formerly St. Mary's Hospital,
763 beds.
It has a capacity of
points will be disposed of by the medical officers repre-
senting these headquarters, under direction of the surgeon,
port of embarkation.
8. Known contacts and cases at embarkation camps will
be disposed of as follows :
Cases will be immediately transferred to base hos-
pital thereat.
Known contacts will be held in strict quarantine for
such period as surgeon directs.
g. One barrack building will be required for each of the
folloft'ing dise?se contacts: Scarlet fever, measles, and
cerebrospinal meningitis.
10. At the daily inspections of troops aboard ship,
careful search will be made to detect the presence of ver-
min, especially body lice. Cases of vermin will be promptly
removed from contact with others until they have been
deloused. Where steam sterilization of clothing is imprac-
ticable, clothing will be deloused by boiling, immersion in
gasoline or kerosene, or ironing with hot iron. The body
will be deloused by application of soap, or kerosene, or
gasoline, followed by thorough shower bath.
11. The physical inspections directed in this order will
be made as follows :
I. Place of examination will be warm and well
barkation, Hoboken, N. J., dated January 8, 1918, are
hereby revoked.
By Command of Major General Shanks:
r. e. longan,
Col. A. G..
Acting Chief of Staff.
Official :
D. A. Watt,
Major A. G. R. C,
Adjutant.
EMBARKATION HOSPITALS.
The hospitals are divided into two groups, those
of embarkation and those of debarkation.
Embarkation Hospital No. i is at Hoboken. It
is under the command of Major T. C. Quick, M. C,
with twenty commissioned officers, sixty-three
nurses, iq8 enhsted men, and five civiHan employees.
This hospital, which has a capacity of 763 beds, is
located at Fourth .Street and Willow Avenue, and
was formerly known as St. Mary's Hospital. This
is a general treatment hospital.
554
MILDICINE AND SURGERY IN THE ARMY AND NAVY.
[N'ew York
Medical Journal.
Embarkation Hospital No. 2, at Secaucus, N. J.,
undei the command of Major S. B. Moore, M. C.,
has twelve commissioned officers and fifty-seven
enlisted men on duty. This hospital was formerly
the Hudson County Almshouse. Here are received
the cases of scarlet fever, mumps, measles, etc.
Embarkation Hospital No. s, which has 694 beds,
is the old quarantine hospital on Hoffman's Island
in the lower New York Bay. Major L. A. Walker,
M. C, is in command here, with a staflf of fifteen
commissioned officers and 100 enlisted men, and a
number of nurses. This hospital is especially fitted
for use as an isolation hospital, having been used
for this purpose by the quarantine officials before
the war. To it are sent cases of communicable
disease.
General Hospital No. i, at Williamsbridge, New
York, is the first of the general ho.spitals erected
since we entered the war. It is built on the ath-
letic oval of Columbia University, at Williams-
bridge, and was described in detail in the New
quired clinical study. It is under the direction of
Colonel Simon Flexner, in so far as its scientific
work is concerned. Major Alexis Carrel and others
who have been associated with him, here give clin-
ical instruction to army surgeons on the Carrel-
Dakin method. While the expenses of this hos-
pital are borne by the Rockefeller Institute, and
Colonel Flexner is the scientific director, the pa-
tients come through the office of the Surgeon of
the Port of Embarkation, who consequently has
general supervision of the institution and who is
represented by First Lieutenant E. Stillman, M. C,
as commanding officer with four commissioned offi-
cers and twenty-four enlisted men. This hospital,
which has 150 beds, was described in detail in the
New York Medical Journal for August 11, 1917,
page 268. Such types of cases are sent here as
may be desired by Colonel Flexner to carry out his
scientific program. While the majority of these
are from overseas forces, some are furnished bv
the troops en route to Europe.
General Hospital No. i, formerly known as Columbia War Hospital. Erected under the auspices of Columbia University by private
subscription on Columbia Athletic Oval, at Bainbridge Avenue and Gun Hill Road, New York.
York Medical Journal for July 14, 191 7, page 75.
It has 1,100 beds, is of modern cantonment type,
and is fully equipped in accordance with the most
modern requirement. The stafT includes fifty-six
commissioned officers, 522 enlisted men, and 129
nurses, and is under the command of Lieutenant
Colonel W. L. Sheep, M. C. As its name indicates,
it is a general hospital, receiving all types of cases,
whether surgical or medical, with the exception, of
course, of patients suffering from communicable
diseases.
U. S. Auxiliary Hospital No. i is the official des-
ignation given to the Rockefeller Demonstration
Hospital at Sixty-sixth Street and Avenue A, New
York. This hospital was erected by the Rockefel-
ler Institute for the purpose of providing a place
for the demonstrations of the technic of the Car-
rel-Dakin method of treating septic wounds and
for carrying on scientific investigations which had
])assed beyond the laboratory stage and which re-
The Post Hospital at Port Newark Terminal, N.
J., is organized along the lines of a regular army
post hospital, with a personnel of four commis-
sioned officers and twenty-four enhsted men, under
the command of Captain H. W. Kennard, M. C. It
is intended, principally, to provide hospital accom-
modations for the personnel on duty at Port New-
ark Terminal. This hospital has a capacity of
about thirty patients.
The Base Hospital at Camp Merritt, near Ten-
afly, under the command of Major J. I. Sloat, M.
C, has fifty-nine officers, 107 nurses, nineteen civ-
ilian employees, and 478 enlisted men. It is com-
fortablv housed in Dcrmanent cantonment build-
ings and has generally been utilized to its full
capacity of 1,846 beds, during the recent rush of
troops for the battle front.
The Base Hospital at Camp Mills, near Mineola,
L. 1., serves a similar function to that at Camp Mer-
ritt. The troops move from there direct to the
The Spirit of Our Fighting Men
is OUR SPIRIT
MORALE will win the war. American morale— that spirit
that makes our men sing as they march, take their discomforts
with a joke, meet every duty with their whole hearts, and
fight like heroes.
Whether it is driving a truck, tending the old chow wagon, or
fighting hand to hand in blood and mud, our boys meet it with
American morale— indomitable spirit that is going to win the war.
No task too small, no sacrifice too great — that is the spirit of our
boys. It is our spirit.
We shall save with a song in our hearts, smile at discomfort, fight
waste and extravagance as they fight the Huns.
Morale— THEIR morale and OUR morale together will win the
war. With such a spirit in the American army and the American
people, our fighting men will be invincible.
Buying Bonds is Fighting !
There is Only One Way to Fight!
Buy Liberty Bonds
to Your Very Utmost
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Manufacturers of Dioxogen
10 Astor Place WW YORK CITY
Page N in e t e e
n
TN the fierce fighting in Fere For-
est, a splinter of shell suddenly
found his brave heart. Staggering,
mortally wounded, yet with his
head held , high, he turned to the
fighting man next in command
with these words: "Lieutenant, the
order is ' Forward ! ' "
Could the voices of our million
fighting men send one splendid
clarion call, one ringing message of
encouragement across the sea to us,
it would be that triumphant chal-
lenge of the young Captain who
saw, even on the threshold of death,
the glorious vision of Victory.
The order is "Forward!" We
who toil in office, in factory and in
field are essential to Victory. We
are the support troops without
which the war cannot be won.
And the order is "Forward!"
Let us open our hearts to the
message. Let us go forward with
them to Victory.
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MANUF\CTURERS OF
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With their whole souls—
You are reading every day of our boys
over there
of Pershing's divisions charging into
the Boche trenches —
of small detachments smashing their
way from house to house in ruined vil-
lages— of single-handed deeds of sacrifice
and valor.
One thought, one impulse only fills their
souls to fight and keep on fighting, until
the war is won.
They know that all America is back
of them.
They know that they can count on us
at home to send them all the guns and
supplies they need to win.
There is only one way we can do it.
All of us must work and save and
buy Liberty Bonds, with our whole souls,
the way our men are fighting over there.
No less will win.
There is no other way to provide the
money the Government must have.
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The Spirit of Our Fighting Men
is OUR SPIRIT
ORALE will win the war. American morale — that spirit that makes our men sing
as they march, take their discomforts with a joke, meet every duty with their
whole hearts, and fight like heroes.
Whether it is driving a truck, tending the old chow wagon, or fighting hand to hand in
blood and mud, our boys meet it with American morale— indomitable spirit that is going to
win the war.
No task too small, no sacrifice too great — that is the spirit of our boys. It is our spirit.
We shall save with a song in our hearts, smile at discomfort, fight waste and extravagance
as they fight the Huns.
Morale — THEIR morale and OUR morale together will win the war. With such a spirit in
the American army and the American people, our fighting men will be invincible.
Buying Bonds is Fighting!
There is Only One Way to Fight!
Buy Liberty Bonds
to Your Very Utmost
This space is contributed to the success of the Fourth Liberty Loan by
THE ROESSLER & HASSLACHER CHEMICAL CO.
100 WILLIAM STREET NEW YORK CITY
Lend.
Page T ic c II 1 y - 1 w 0
Sergeant Brown was hard to satisfy
Four machine-gun crews to his credit
was a pretty fair record for one day's work.
But why leave a perfectly good trench
half filled with Germans? Brown didn't.
The hail of machine-gun bullets could
not stop him. • He was not thinking of
them. Shrapnel was bursting all around
hinx He did not heed. His rifle was so
hot he couldn't touch it, so he laid it in
the hollow of his arm and kept on firing;
the Huns kept on yelling "Kamerad!"
and throwing down their guns. Brown
forgot danger and death, he forgot that
he was alone against a hundred and fifty
Germans. He forgot everything but his
job — Victory. And he walked proudly
into camp with one hundred and fifty-
nine prisoners.
We've got a big job over here, too We must provide guns
and shells and food and clothing for men with the spirit of
Sergeant Brown — to send them forward to Victory. JLet's
do our job as he did his — fearlessly, persistently, joyously.
Lefs lend as he fought — let's buy Liberty Bonds to our utmost
This space is contributed to the success of
Bonds
the Fourth Liberty Loan by
THE NORWICH PHARMACAL CO.
NORWICH, N .Y.
"Force, to the Utmost!"
'TPHAT plunging squadron of German cavalry, ex-
pecting to carry all before it in one mad rush,
learned to the full, from a little body of American
troops, the meaning of the President's words.
Force, greater even than the military rulers of
Germany can imagine — the overwhelming, irresistible
force of a great, free Nation aroused to fight for its
Liberty and the Liberty of the World.
"Force, to the Utmost!"
Men by the Million! Shot, shell, guns, airplanes,
tanks, ships — anything and everything required to
drive home the meaning of the President's words.
to make plain, to the authors of the war, the fact
that with such force, of men and of spirit, we must
inevitably win.
Are YOU adding every ounce you can to the force behind our
fighting men — the force ii'c must exert to win the war?
I Lend 1
Lend the way they fight Buy bonds to your utmost
This space is contributed to the success of
the Fourtli Liberty Loan by
WILMOT CASTLE COMPANY
ROCHESTER, N. Y.
Page T w e n 1 u - j o u r
I am only a cog
/ am only a cog in a gianl machine, a link, of an endless
chain:— -
And the rounds arc drawn, and ihc rounds are fired, and
the empties return again;
Railroad, lorry and limber, battery, column and paih^.
To the shelf where the set fuse wails the breech, from the
quay where the shells embark.
IVc hace watered and fed, and eaten our beef, the long
dull Jay drags by,
As I sit here watching our "Archibalds" strafing an
empty sky,
Puff and flash on the far-off blue round the speck °ne
guesses the plane -
Smoke and spark of the gun-machine thai is fed by the
endless chain.
The ammunition carrier is only a link in the great
war machine, but he is as vital a link in the cham as the
man who goes over the top. And back of the ammuni-
tion carrier comes the ammunition maker and the rail-
road worker and the thousands of varieties of war work-
ers until it all comes straight home to the individual man
/ am only a cog in a giant machine, but a vital link of the
chain;
And the captain has sent from the uagon-line to fill his
wagons again;
From the wagon-limber to gunpil dump; from loader's fore-
arm at breech
To the working parly that melts away when the shrapnel
ballets screech.
So the restless section pulls out once more in column of route
from the right
Al the tail of a blood-red afternoon: so the flux of another
night
Bears back the wagons we fill at dawn to Ihc sleeping col-
umn again —
Cog on cog in the gun-machine, link on link in ihc chain'
r,...., GILBERT FRANKAL'.
and woman who helps save the necessities of life and re-
frains from wasteful spending in order to help our fight-
mg men. Every link in the fighting chain, every cog in
the war machine must be of the strongest steel. Every
heart must be steel against waste these days. We are
all part of the great battle — let us each do our part and
make it a great part.
Let us buy the bonds we know they want us to buy!
This space is contributed to the success of
the Fourth Liberty Loan by
THE HOFFMAN-La ROCHE CHEMICAL WORKS
NEW YORK CITY
P a (I e T w e n t y - f i V e
The boys who get the boys across
OVER half a million of these sailor
boys there are, fighting their fight
in a Way that will ring down through
the ages.
Manning giant battleships, swift
cruisers, lithe, lean destroyers that guard
the road to France, they are putting
America into the fight three thousand
miles away — Men — Guns — Food
Ammunition.
And they're keeping us in the fight,
delivering the necessities of war through
seas of danger, winter and summer, with
steady, tremendous power. When the
big fight comes their way, they are ready
to fight, to die, to win.
They don't simply "go across." They
have to fight their way across, to land
the men who will fight clear through
to Berlin
They are seldom mentioned in news-
paper war headings, these sailor boys of
ours; but they are performing, day by
day and hour by hour, a service without
which the war could not be won.
Millions of dollars must be spent each
month to keep that service up; hundreds
of new ships now on the ways must be
manned and fitted out
Liberty Bonds will do it-
will help these boys safeguard the boys they get across
Lend the way they fight
Buy Bonds to your utmost
This space is contributed to the success of
the Fourth Liberty Loan by
McKESSON & ROBBINS, Inc.
NEW YORK
Our men answer this comrriand with a yell
of satisfaction.
Go in with the same determination.
The Boche fears a bond as he does a bayonet;
for deep down in his heart he knows that money
means materials of war. He knows that these
guns and shells and bayonets in the hands of
American soldiers mean THE END!
Lend the way our boys are fighting!
Sacrifice self as they do, and spring to the
attack as readily. Feel the thrill of being on the
offensive.
Save with your whole strength.
Attack the Hun!
BUyBonds
Buy Liberty Bonds to your utmost.
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BORCHERDT MALT EXTRACT COMPANY
217 N. Lincoln St.,
Manufacturers of Borcherdt's Malt Soup-Extract.
CHICAGO, ILL.
Samples and literature on request.
Page T w e n t y - s e v e n
Leap Frog
Maybe you've seen that boy
playing leap-frog over the hydrants
down the home street or yelling like
an Indian while he leaped on the
other fellows' backs in a neighbor-
ing yard.
That day in the bewildering
maze of machine-gun and sniper's
fire, when his companions were be-
ing shot down one by one, he played
his little-boy tricks all over again.
He didn't even know whether he
could reach the other side. Five
others hadn't. And ^jetting there
he had no idea whether he could
get back. He would try. It didn't
occur to him to do anything else,
because he was a soldier and an
American, and somebody needed
him.
«
It was only a boy's life, but he
gave it and his "reinforcements res-
cued what was left of the platoon."
Duplicated by thousands, that
little story is only an incident in
the every-day life of our soldier
lads. We've known them and
laughed with them and loved them
on the coast of Maine and the hills
of California, in the grain fields of
the West and the pine woods of
the South.
"Are you with us. Pals?" That's
the question in their eyes when
their thoughts fly homeward in the
lulls of the fight.
In this Fourth Liberty Loan
we are showing them how we are
with them, showing them that
never so long as they've breath left
to fight shall we leave them alone
or unthought of. Every dollar we
put into Liberty Bonds is a confes-
sion of our faith in them, a pledge
of our gladness to fight with them
to the end.
In companies and platoc^s and
little handfuls our boys are winning
back — and holding — at a cost — a
few feet more of stricken France
every hour of the day and night.
"They must have ammunition and
reinforcements or all is lost"
Let's get help to them quickly.
Let's lend — the way they fight.
Buy Bonds to your utmost — and save to
your utmost to pay for them and keep them.
t-eht
Tills space is contributed to the success of
the Fourth Liberty Loan by
Anedemin Chemical Company
CHATTANOOGA, TENN.
I' a <J € Twenty-eight
V
The fighter has no time to count the
cost as he jumps into the unknown, as
he springs to success — possibly to death.
Ever worry about meeting a Liberty
Bond payment?
Think once more of the man who does
not worry about meeting death.
Tliis space is contributed to the success of
the Fourth Liberty Loan by
BAUSCH & LOMB OPTICAL COMPANY
ROCHESTER, N. Y.
Lend_
a.
buy Bonds
t'Jo^lJTMOSr,
F a g e Twenty - nine
When the Fourth Liberty Loan was
announced, did we hurry down to the
first place Bonds were for sale and
pledge our support with self-denial that
hurt'
We've a lot of brave young pals over
there who have been wounded by the
German guns — many, too, who have
" gone West."
Do we lend — the way they fight?
That is the only way it can be done.
"If you folks back home do your part,
you needn't worry about us," one of
them writes. But they can't win with
empty stomachs or empty guns or
empty hearts.
Faster and faster the brown waves
are climbing up the hills of France,
spreading over the fields and through
the towns. ]^aster and faster the
ships must fly to take them the sinews
of war.
Lend _
efit uoy they
5lSl A
BuyBonds
'0><^11TMOST,
Lend— the way they fight! That is the thing they want
from us. The Fourth Liberty Loan is on. Let's go
over the top with it, cheering— the way they do.
Take it on the run!
This space is contributed to the success of
the Fourth Liberty Loan by
ABBOTT LABORATORIES
CHICAGO, ILL.
P age T h irty
THAT'S the only way to win, and Lieuten-
ant "Pat ' Dowling knew it, when he
plunged into the Ourcq with his little de-
tachment from the "Fighting Sixty-Ninth."
Keep on going with a whoop!
They'll do it our boys over there; whatever
regiment they belong to, whatever section of
this great country they came from.
They 11 GET THERE, too; if we follow their
example and keep going here at home.
Oiu- work is cut out for us, as plain as theirs
for them. Keep them fit; give them every
piece of fighting gear they need, to. do their job
up brown. Send as many million men as can
be used to finish it up quick.
No matter how many Liberty Bonds you have
bought; Keep going -BUY ALL THE BONDS
YOU CAN — and then buy more — and pay
for them out of your future savings. Any
bank or bond booth will tell you how.
K
eep on going
Lend the way they fight
Aw
Buy bonds to your utmost
This space is contributed to the success of
the Fourth Liberty Loan by
REED & CARNRICK,
Jersey City, N. J.
Page Thirty-one
Fight as these American soldiers fought in
the streets of Fismes.
"They covered themselves with glory, " the
papers say. Of course they did — they are
Americans.
They met the finest of the enemy troops in
a terrific hand-to-hand struggle. They used
their guns — their bayonets — their bare fists.
Every American soldier went after his
man desperately, fearlessly, persistently, with
one great driving purpose — to whip that
Prussian Guard, to silence its machine guns —
to win!
It's a pretty good way to fight — this Amer-
ican way. It wins battles over there, it v^ll
win a splendid Victory over here — if we fight
when we fight — if we buy Liberty Bonds to
our utmost.
When you fight— fight !
When you ^uy— buy!
Lend the way they fight
Lend
Bonds
Buy bonds to your utmost
Tins space is contributed to the success of the Fourth Liberty Loan by
P. BLAKISTON'S SON & CO.
Philadelphia, Pa.
P u g c T h i r t y - i ic o
I
I'd like to be there!"
You have said it — as you have
looked at some vivid picture or
read some stirring account of
our boys fighting with American
courage and self-sacrifice. If you
cannot go out to them, you can
fight for them, over here. Smash
open the way for them with
howitzers and big guns. Send
them ammunition, tanks, air-
planes, rifles, clothing, food. Help
to keep^ them victorious.
You can lend as fearlessly, as unselfishly, as they
fight. That is your job as a part of our war machine.
Of course you would "like to be there." They don't
need you yet or you would be there. But they need
guns and shells, every hour they remain on the road
to Berlin.
Absolutely the next best thing to going over is to
BUY LIBERTY BONDS — BUY TO YOUR LIMIT
Lend__
fiSyBonds
This space is contributed to the success of
the Fourth Liberty Loan by
MICAJAH & COMPANY,
Warren, Pa.
Page T h i r i y - 1 h r e e
Get into the figh
—the way he is i
—with your whol
heart.
Lend
Stand
by
Him!
He is fighting for you — fighting with
the spirit of Victory. He will never
quit till his job is done. But he can't
win with his bare hands.
Send up the ammunition! Send up
the hand grenades! Send up the rifles
and bayonets and machine guns that
will help to win new battles.
Buy Bonds to your utmost
This space is contributed to the success of the Fourth
Liberty Loan by the publishers of the
NEW YORK MEDICAL JOURNAL
Page T h i r i y - i i v
'^I^T^ haiRegottolendas weBas Usey
~.ght. Aod we nxBt pidl togjedier
' =1! the strenglii we have now!
•'. t — _i : Ttkr our lives that we
Let as Zemf the way they fight
Let as buy bonds to our utmost
Now — All Together I
r.: :rc:c is c^mirihmUi Ae success 9f Ac Fomrik LSberty 1
PEACOCK CHEMICAL COMPANY
ST. LOUIS, MO.
They're In to Win
ery ooe of tiiese "~" ' ■
:rs ladden befamd ^r^i j-' i -."IN THE IT AY
ire not thmking of tbe
if we are tbe sanoe sti^. let as prove it. Let m fet
into tbe Bgfat as tbey do — to tbe fimit — for Mctonrl
This sr>i:cf is c^frntr^i^td ic :ki- sa^'.-'ss
tkt Fffmrth Ut>€Tty L*M» r
MELLIN'S FOOD COMPANY
BOSTON MAiS
Page Thirty -eight
De£vi? AVo tKe ir
A Letter- from a Nineteen-Year-Old
Illinois Boy to His Mother Back Home
Somewhere in Fr.4nce
Dear Mother:
Gosh! I sure was glad to get the batch
of mail that's just come. It makes me feel so
darned glad that I'm over here that I
wouldn't trade my place for anything.
And let me tell you right here, mother
dear, that you or anybody else at home
doesn't know what real patriotism, real love
of country, is. You haven't any idea. Why,
you can't imagine what a great, wonderful
country the old United States is. You can't
realize what she stands for and means to the
human race until you get a good perspective.
When I am standing retreat at night
and hear "The Star-Spangled Banner" play-
ed, the first thing that comes to my mind is
the Statue of Liberty; then our wonderful
cities, New York, Chicago, San Francisco:
then Washington and President Wilson and
the wonderful cause that all our millions of
Americans are willing to give up everything
for. Mother, we're lucky merely to have
been born Americans. Talk about waves up
your spine! It's enough just to get over here
in Europe and look back over miles of water
at the biggest type of nation, based on liberty
and justice, that can be conceived. Why.
mother, that Statue of Liberty and the
American flag stand for EVERYTHING
that is worth while in life.
Since I've got over here I feel more pity
than anything else for the boys that are
still at home sporting silk shirts. I'd rather
be hanged for murder than be in their shoes.
I figure that I'm the luckiest fellow in thi'
world to be able to stand up as a soldier here
in France and be a part of the greatest coun-
try engaged in the most honorable thing a
country ever undertook. We have all j^vaked
up to what the words "United States of
America" mean.
End of speech for to-hight!
Lots of love,
DICK.
Buy Liberty Bonds today
— to your limit!
Do you realize that this great
awakening — this new understanding
of Right — this dawning of genuine
love of country, that has come to our'
soldiers over there — and to many of
those left behind, over here— has been
made possible by you who have
bought Liberty Bonds?
By lending your money, you have
carried our boys across the perilous
ocean. You are clothing them — feed-
ing them— giving them the weapons
it is their dut/ to use against the
enemy of Trath.
You have brought them into the
soul-awakening experience of War for
Principle. They must be kept there,
equipped for this stupendous task,
until the task is finished.
And your support is the only
thing that will do it. Show them—
over there— that you have awakened,
too.
This Space is contributed to the success of
the Fourth Liberty Loan by
THE SANITUBE COMPANY,
Newport, R. I.
T
Page Thirty -nine
"VJiTK shall have the men, thousands of
" ' them, brave American sailors, fired
with the same spirit that lived in John
Paul Jones.
When danger threatens —
When the searchlight picks the enemy
ship out of the blackness, and the giant
guns begin to roar their message of death.
What comfort can v^e send —
We who lie safe in comfortable beds?
We can put courage and nerve and
daring into the heart of every seaman
as he leaps to his post— and we can do
it now!
We can send him into the fight, know-
ing that there are enough guns, and
enough shells to answer the enemy, shot
for shot— and more.
That up from the hold where the
sweaty ammunition passers toil, round
after round will swing in a never-failing
stream.
That his ship, from bow to stern, is
equipped for Victory.
We can do this for
keep the seas.
the men who
Let us do it. Let us lend the way they fight
Let us buy bonds to our utmost — for Victory
77;;',v sface is cpnlrihuted to the success of
the Fourth Liberty Loan by
GLEN SPRINGS,
Watkins, N. Y.
Victory!
'J^HE word carries a thrill. It touches
our fondest hopes, our deepest
purpose, our pride in doing our part.
It spells freedom, prosperity, a clean
and decent world to live in.
Liberty Bonds equip armies, build
fleets. But they do something far
greater— they buy Victory.
They yield four and one quarter per
cent ?— Yes— and Victory!
Buy Bonds
to your utmost!
Lend .
Buv" Bonds
This Space is contributed to the success of
the Fourth Liberty Loan by
ESKAY'S NEURO PHOSPHATES
Page F o rt y - o n e
»
Berlin or Bust!
That's the way our men are fighting.
Months of weary waiting, watching, and
patrolling they had, before General Foch gave
the order that permitted them to leap out of
their trenches and put the Huns to rout.
Months of hard, gruelling preparatory work
behind the lines in France; months of
strenuous exercise and iron discipline in the
training camps before they sailed.
But, when the word came, they were FIT—
nothing could stop them — "Everywhere along
the line the Germans were in a panic."
Keep them fit — trained to the minute —
wanting for nothing to help them win.
Send them reinforcements, as many million as
may be needed, until that panic spreads through-
out the whole of Germany's forces — until it
reaches the rulers of Germany themselves.
Liberty Bonds will do it Buy them — to your limit!
This space is contributed to the success of
the Fourth Liberty Loan by
BURNHAM SOLUBLE IODINE COMPANY
AUBURNDALE, MASS.
Lend .
Page F o r t y - 1 ic o
—"this destroyer gang is there"—
(From a sailor's letter)
Dear Brother—
T must crash through the censor to tell
you a little incident that happened here
yesterday.
I was on submarine watch covering a
sector of 30 degrees when 10 destroyers
came up over the horizon to convoy us
into port.
Suddenly I heard a gun go off on one ol
the destroyers and then seven whistles
blew; we went full speed ahead and that
brought the action right (under mylnosc;
in less time than I could wmk an eye. there
were four destroyers on the job.
1 just got a glimpse o( two periscope
wakes and Ihey looked just about like a
screen of machine gun bullets sprinkled
along in a straight, searching fire. In a
second the destroyers were on them like
dogs, and Ihey began maneuvering in con-
centric circles, dropping these new depth
bombs off their sleriis as they tore along.
This bomb is about as big as a gasoline
drum and is loaded with TNT. They are
timed to go off at a certain depth, and when
they explode they extend iheir force down-
ward .n the line ol greatest resistance.
Well, these bombs began to drop like
flies, and the result was a couple of oil
blotches and a few pieces of wreckage and
two Fritzies pretty well flattened out on
the bottom ol the ocean.
Let me state right here and now. this
destroyer gang is there strong, and the
Fritzies arc getting about all they can
handle.
The destroyers don't fool "round playing
for a chance; they simply dive right into
them and either run ihem down or flatten
them out. 1 wouldn't take ten thousand
dollars for what I saw yesterday even if
It did look lor a while as if we might take
a swim. • • •
Your broiher. JACK.
One One-Hundred Dollar Bon(
one Fifty Dollar Bond will ciju
enlisted m^n ,n the Navy, or ii
Iced one enlisted man lor a ;
Depth Bombs, the result ol which
IS "a couple ol oil blotches and a
few pieces ol wreckage. " are a good
I lor you at $300 each
This is YOUR fight, too
You are a partner in the most glorious
enterprise in the world's history. A vast
American army is fighting and winning
your battles in France— an invincible
navy guards your rights at sea. It is
your privilege to supply the guns, the
shells, the fighting gear that help our
men win battles.
They cannot keep fighting on to Victory
unless you keep supplying their needs.
Make your dollars fight!
2S
Buy bbnds to your utmost !
This space is contributed to the success of
the Fourth Liberty Loan by
EIMER & AMEND, New York City
P n g e Forty-thre
e
"This is the Last of Wars"
Coming in splendor thro' the Golden Gate
Of all tbe days, swift passing, one by one.
Oh, Silent Planet, thou hast gazed upon
How many harvestings, dispassionate?
Across the many-furrowed fields of fate.
Wrapt in the mantle of oblivion.
The old, gray, wrinkled husbandman has gone,
Sowing and reaping, lone and desolate — m
The blare of trumpets, rattle of the drum,
Disturb him not at all — he sees.
Between the hedges of the centuries,
A thousand phantom armies go and come,
While Reason whispers as each marches past,
"This is the last of wars, — this is the last!"
—LIEUT. GILBERT WATERHOUSE
(Wounded and Missing July i, 1916)
MAKE it the last! Save
every dollar you can and
dig deep into the work of
war. Pour out your resources
—hold back no single dollar
that can help make the vic-
tory FINAL. Make this
''The Last of Wars T
Buy Bonds to Your Utmost!
This space is contributed to the success of the Fourth Liberty Loan by
H. A. METZ LABORATORIES, Inc,
NEW YORK
]' <i (J e F 0 r t y - f 0 u r
y 3
Whose Limit Is All That He Can
This is the song of the plane —
The creaking, shrieking plane.
The throbbing, sobbing plane.
And the moaning, gro.ining u ires:
The engine — missing again!
One cylinder nc\er fires!
Hey ho! For the plane !
(.)
This is the song of the man —
The driMHg, strn ing man.
The chosen, frozen man:
The pilot, the man-at-the-u heel.
Whose limit is all that he can,
And beyond, if the need is real!
Hey ho! For the man !
This !s the song of the gun —
The muttermg. stuttering gun.
The maddening, gladdening gun;
That chuckles with evil glee
At the last long dl\e of the Hun.
W ith Its end in eternity !
Hey ho! For the gun !
This is the song of the air —
The lifting, drifting air.
The eddying, steadying air.
The n ine of its limitless space:
May It ner\e us at last to dare
Even death with undaunted face!
Hey ho! For the air!
■ OBSERVER. R. F C,"
The eyes of the army. The airplanes are going
over, thousands of them. There must be more to fol-
low, thousands of them. Let us turn our own eyes in-
ward— search our own hearts — and see that no selfish,
slacker dollar remains unconsecrated to the service of
the men we love.
Would We Not Die for Them — Our Fighting Men in France ?
Then let us BUY for them — all the bonds we can —
with the same great unselfishness with which they fight
and die. This is the spirit with which they and we —
fighting — working — saving together — will as God
sees us, inevitably WIN!
Our Limit Is All That We Can
Buy Bonds to Your Utmost!
This space is contributed to the success of the Fourth Liberty Loan by
THOMPSON'S MALTED FOOD COMPANY
V
WAUKESHA, WIS.
1' (t (J c F o r t ij - f i V e
When I Come Home!
"IXTHEN I come home and leave behind
Dark things I would not call to mind,
I'll taste good ale and home-made bread,
And see white sheets and pillows spread.
And there is one who'll softly creep
To kiss me, ere I fall asleep
And tuck me 'neath the counterpane.
And I shall be a boy again
When I come home !
LESLIE COULSON, {Killed
"1X7" HEN I come home, from dark to light.
And tread the roadways long and white,
And tramp the lanes I tramped of yore.
And see the village greens once more.
The tranquil farms, the meadows free.
The friendly trees that nod to me.
And hear the lark beneath the sun,
'Twill be good pay for what I've done
When I come home !
in Action Oct. 7, 1916)
" 'Twill he good pay!" It is the onhi reucard tliejf ask — these fighting men of
ours — to come home, victorious. It is the debt tve owe to bring them home victori-
ous— can "xe pay it in full? No. But we can do all we can do.
Save and try in some small way to pay our debt to those who have fallen. Save
honorably — mahe a religion of it — nothing we can do today here at home touches
so closely the heart of life. For saving saves life. Bonds save life. If you buy
greatly you will help some strong, clean American boy in whose heart is ringing the
words "when I come home" — really to win through — to return to us — a victorious
crusader — a mother's son — alive and well and home again!
Buy Liberty Bonds
to your very utmost !
Lend
This space is contributed to the success of the Fourth Liberty Loan by
SHARP & DOHME, Manufacturing Chemists
BALTIMORE, MD.
Page F o f t y - s i x
They got there in time!
Tl^ey are in the fight with every muscle, every faculty
of their minds, every drop of their American blood.
have read in the daily news the
story of what one detachment of
American artillerymen did on the
Marne when their ammunition was
running low.
Every shell in that caisson meant a
speedier winning of the war — all the
horses were killed — but the shells got
there just the same. And they got
there in time.
Where shall WE draw the limit when
we read what THEY are doing over
there ? Now is the time to put our full
strength into it. Our strength, coupled
with the power of our Allies, will win.
Let us not delay even a few months.
Let us get there in time to hasten the
victory, to save every unnecessary
sacrifice of the lives of our sons.
How can we, back here at home, set
ANY limit to the help we ought to
give— for VICTORY? And we must
get it there in time!
We Must Lend the Way They Fight
We Must Buy Bonds to Our Very Utmost .
This space is coTitribiited to the success of the Fourth Liberty Loan by
G. W. CARNRICK COMPANY
NEW YORK CITY '
Page Forty-seven
"Great news this!
"Just what I knew they'd do!
"I'd like to be over there fighting
with those boys myself.
"But there's real fighting to be done
over here, too. They couldn't have
made this drive without the first three
Liberty Loans. Just read what our
dollars have helped these splendid
boys to do!
"They've just begun. And so have
we! We'll raise billions more here in
OUR trenches — the factories, the
offices, the homes of America.
"It means work and self-denial and
saving and sacrifice. Thank God we
have a big and worthy job to do here
at home!
"It's a great thing to be cleaning up
this big job together — making the
world a cleaner, happier place to live
in. The men in France need us and
we need them. Their sacrifice is im-
measurably greater than ours. But
without us they can't win. With us
they can't lose. Fine team work, I
call it."
Lend.
Buy Bonds
Keep on buying Liberty Bonds — let's buy
for the Drive that will cross the Rhine!
Let's buy to our utmost
This page is contributed to the success of the Fourth Liberty Loan by
BRISTOL-MYERS CO. New York
Page Forty-eight
It stirs every American heart
Who was not thrilled to read of
the American soldier who supported
a wounded comrade, and fought his
way with the little detachment back
through the Boches to the American
Lines ?
That is only one deed of heroism
among the many happening every day
and looked on as a matter of course by
the boys fighting for us over there. It
shows the stuff that's in them. They
are our own sons and brothers Is
the same stuff in us over here?
We have the opportunity at home
to show our patriotism by other deeds
of valor. We can fight and we
MUST fight. And we must Win,
no matter how heavy our burdens
may be.
Our former habits are the Huns
we've got to battle with. We can't
go on living as we used to. We can't
go on spending our money for things
we like. We must set up new stand-
ards— war standards — and stick to
them — loyally.
We must buy bonds to our utmost
This space is contributed to the success of the Fourth Liberty Loan by
WM. BANNERMAN & CO., 32 N. State St., Chicago, 111.
Manufacturers of Bannerman's Intravenous Solution
Page F 0 r t y - n i n e
•3it)
0}
#
V*)
MERCK & COMPANY,
Page Fifty
#
%
(4)
#
:>:
' i>J
New York
If Everybody in
This Country Said
'Td like to
buy more
Liberty
Bonds
but^''
Who would
Win this War?
Buy Bonds to Your Utmost
This space contributed to winning the war by
\
September 28, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
555
transports, and all sick, and all who have been in
contact with patients sufifering from contagious dis-
eases, are weeded out by the final physical exam-
inations made on the day of departure. These pa-
tients are placed in the camp hospitals, all cases of
communicable diseases being isolated and promptly
removed. Major A. W. Cutler, M. C, is in com-
mand of the Base Hospital at Camp Mills, and has
fifty-two commissioned officers, fifty-five nurses,
five civilian employees and 443 enlisted men under
his orders. This hospital has 1,506 beds.
The hospital at Schuctzcn Park, N. J., now in
course of construction, will have 400 beds. First
Lieutenant j. R. Downes, M. C, is in command
with one commissioned officer and thirty-seven en-
listed men.
DEBARKATION HOSPITALS.
All of the hospitals named above, with the ex-
ception of Auxiliary Hospital No. i, the War Dem-
York has been taken over by the Army, and is
known as Debarkation Hospital No. i. It required
relatively slight alteration to adjust it to the needs
of a receiving station through which nearly all the
patients returning from Europe pass. Here a pre-
liminary sorting takes place. The Island, being
operated somewhat like an evacuation hospital on
a larger scale, patients are passed on as rapidly as
possible, most patients staying only a day or two
before assignment either to some special hospital or
to one of the other three debarkation hospitals.
Major C. R. Haig, M. C, is in command with thirty-
one commissioned officers, forty-nine nurses, 229 en-
listed men and twenty civilian employees. This
hospital has 1,075 beds.
Debarkation Hospital No. ^ is a new hospital of
cantonment construction which has been built at
Fox Hills, Staten Island. It has a capacity of 1,762
beds and, is under the command of Major C. A.
Auxiliary Hospital No. i, formerly Rockefeller Demonstration Hospital. A portable war hospital of fifty beds, erected and main-
tained by the Rockefeller Institute, the buildings of which appear in the background, for the scientific study of war problems
and for teaching the technic of the Carrel-Uakin method. Now part of the hospital system of the Port of Embarkation,
onstration Hospital of the Rockefeller Institute,
have to do primarily with the sick of outward bound
troops.
The reception and disposition of the sick, the
maimed, and the wounded who are beginning to
return from the battle front in steadily growing
numbers, is another phase of the work of the Sur-
geon of the Port of Embarkation and one which
will grow rapidly in volume and importance. These
are received in a series of debarkation hospitals,
where they go through a process of sorting, and
eventually are sent to the various special hospitals,
sanitaria, restoration clinics, or convalescent homes,
spread out all over the United States.
Debarkation Hospital No. i. — The Immigration
Station at Ellis Island in the upper bay of New
Traylor, M. C, who has a staff of thirty-eight com-
missioned officers, fifty-five nurses, 452 enlisted
men and fourteen civilian employees. To this hos-
]Mtal are sent debarkation cases in general.
Debarkation Hospital No. j is in the heart of
the City of New York, occupying the western part
of the block bounded by Sixth avenue and Eight-
eenth and Nineteenth streets. The building was
erected and occupied by the Greenhut store, and its
conversion into a hospital is not yet complete,
though a temporary staff has been assigned to it
consisting of Major W. J. Monaghan, M. C, three
commissioned officers, twenty-seven enlisted men
and six civilian employees, who at present are in-
stalling hospital equipment, furniture, etc. This
hospital will have a capacity of 3,000 beds and
556
MEDICINE AND SURGERY IN THE .]RMY AND NAVY.
[New York
Medical Journal.
Embarkation Hospital No. 3, cn Hoffman's Island in the Lower New York Bay, as seen from South Beach, Staten Island. This
v/as formerly used by the Quarantine Oflicer of the Port of New York and is now used as an isolation hospital.
It has a capacity of 694 beds.
Staff of suitable size for so large an institution will
then be assigned to it. Here will also be located
the central clinical laboratory of the port, though
there are, or will be, clinical laboratories attached
to each of the hospitals. This hospital is expected
to be ready for patients before this article reaches
our readers.
Debarkation Hospital No. 4. — The Nassau Hotel
at Long Beach, L. I., has been taken over by the
Army and is now being fitted up as Debarkation
Hospital No. 4. It will have a capacity of approx-
imately 1,800 beds. It is still in the course of con-
struction, or rather reconstruction, and the hospital
staff" has not yet been assigned to it. Major E.
Martin Larson, M. C, is in command.
Debarkation Hospital No. 5 exists only on paper
as a hospital. The Grand Central Palace, on Lex-
ington avenue from Forty-sixth to Forty-seventh
street, has just been acquired by the Army at an
annual rental of $385,000, and this will become De-
barkation Hospital No. 5. It has a floor space of
285, 3CX) square feet, and it is estimated that it will
provide 3,300 beds. To operate this will require
approximately sixty officers, 300 nurses, 700 en-
listed men, and twenty civilian employees. A staff
of about the same size will be needed for Debarka-
tion Hospital No. 4, in the Greenhut building.
TJie Transportation Division has three commis-
sioned officers, one field clerk, and thirty-five en-
listed m.en and two civilian employees on duty.
Captain I. R. Ratner, Q. M. C, is chief of the
division. This division furnishes transportation
of men and supplies for the riiedical department,
issues travel orders, transportation requests, tick-
ets, etc., and maintains the liaison between the sur-
geons' office and the Transportation and Marine
Divisions of the office of the General Superintend-
ent of the Atlantic Transport Service and with the
Adjutant of the Port of Embarkation. This divi-
sion has charge of twenty-three ambulances and
two hospital trains. Each of the latter has a
capacity of 250 patients and is completely equipped
in every respect.
The .Sanitary Inspection Division, under I^icuten-
ant Colonel C. T. King, M. C, consists of eight
officers and five enHsted men. This division is
charged with the sanitary inspection of all build-
ings, camps, transports, piers, etc. ; the delousing
of troops and the fumigation of transports and
buildings where this is necessary.
The Domiciliary Hospital Division, under Major
W. J. Monaghan, M. C., is charged with the or-
ganization of a system for the purpose of using the
various homes which have been offered to the Med-
ical Department for use as convalescent hospitals,
with the distribution of the patients and their
medical treatment. So far, some fifty houses have
been offered for this purpose. Some tender the
use of the home only, others provide food, while
some offer to provide both food and attendance.
These homes will accommodate from two to fifty
patients each, the estimated total capacity of the
homes offered being about 1,200.
The Hospital Building Division makes recom-
mendations as to the procurement of suitable build-
ings and inspects all the buildings offered. It has
been much helped in its work by a committee from
the Board of Real Estate Brokers of New York,
whose members have given their expert services to
the Government. Major E. J. Barrett, M. C, is
the chief of this division, which consists of four
officers and three enlisted men.
The Property Division, under Captain F. V.
Gowen, M. C, receives and certifies to all property
and stores needed, makes requisitions for all need-
ed supplies, including blank forms, provides vac-
cines, sera, etc., for use at the headquarters and
for issue to transports and organizations under the
control of the Surgeon. This division also issues
medical supplies to transports on requisition from
the Transport Supply Division.
The Finance Division^ under Captain J. D. Foley,
S. C, checks and modifies or approves all requisi-
tions for medical, dental, and veterinary supplies
from all organizations under the control of these
headquarters. It checks up all money papers for
the Medical Department, that is, vouchers for sup-
plies purchased, services rendered, pay rolls of civ-
Debarkation Hospital No. I, Ellis Island, New York Bay. Formerly Immigration Station. Used as clearing hospital, whence
patients are distributed to various special hospitals.
September 28, 1018.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
557
ilian employees and nurses, and all papers pertain-
ing to the hire, discharge, resignation, etc., of the
civilian help of the Medical Department. It also
supervises the administration of the medical supply
depots at Camp Merritt, Camp Mills, and Camp
Upton.
The Laboratory Division, of which Major E. H.
Schorer, M. C, is director, has supervision of the
clinical labora-
tories of the
Port of Em-
barkation, one
being attached
to each camp
and larger hos-
pital. He is
also engaged
in the estab-
lishment of a
central labora-
tory at the De-
barkation Hos-
pital No. 3, in
the Greenhut
building. New
York. These
laborator i e s
make patholog-
ical, bacterio-
logical, chem-
ical, and mi-
croscopical ex-
aminations and
analyses.
The Trans-
port Supply
Division, under
Captain C. M.
Thomas, M.
C, sees to, the
equipment of
hospitals and
dental infirm-
aries aboard
transports,
places ade-
quate medical
and surgical
supplies, vac-
cines, sera,
etc., and blank
forms of the
medical de-
partment
aboard the
trans])orts and arranges for the shipment of sera,
etc., for the overseas use of the expeditionary forces.
This division also makes contracts for the services
of the civilian surgeons on merchant ships carrying
troops, and certifies vouchers made under these con-
tracts. It also arranges for the medical and sur-
gical supplies of all troopships sailing from Mon-
treal, Quebec, Halifax, Portland, Boston, Philadel-
phia, and Baltimore.
The Transport Division, under Major F. J.
Pierce, M. C, supervises the embarkation of troops.
Debarkation Hospital No. 3, Sixth avenue and Nineteenth street. New York. Formerly
the tireenhut iiiulding. L'Tpacily 3,oou beds. The central laboratory is located here.
conducts the preembarkation physical inspections,
and disposes of such patients as are detained at the
time of embarkation. This division also supervises
the debarkation of the sick and wounded returned
from overseas, turning them over to the Sick and
Wounded Division. In this work, Major Pierce
is assisted by fifty-three officers and fourteen en-
listed men. Some of these are stationed at the vari-
ous camps and
ports other
than New
York under the
command of
the Command-
ing General of
the Port of
Embarkation.
The Sick
and Wounded
Division, o f
which Major
Clarence Quin-
an, M. C, is
chief, receives,
checks and
forwards t o
the Surgeon
General's Of-
fice the sick
and wounded
reports for-
warded from
the medical or-
ganizations of
the port ; keeps
accurate rec-
ords of pa-
tients in hos-
pitals ; of beds
vacant, and of
the disposition
made of the
patients re-
ceived. The
division also
acts as a re-
cruiting office
for the port.
It directs the
classification
and distribu-
tion of return-
ing patients.
The Attend-
ing Surgeon's
Division furnishes medical and surgical treatment,
administers prophylactics and inoculation, makes
physical examinations, maintains prophylactic and
first aid stations, and, of course, keeps records
and makes reports of its work. Seven commisioned
officers and fourteen enlisted men are attached to
this division. There are seven separate first aid and
prophylactic stations, in addition to those main-
tained in the various camps and hospitals. These
are located at Fourteenth Street, Hoboken ; at
Kearney Meadows, N. J. ; at Erie and Pavonia
55«
MEDICliXE AND SURGERY IN THE ARMY AND NAFV,
[New York
Medical Journal.
Avenues, Jersey City ; at the West Forty-second
Street ferry, and at the One Hundred and Thirtieth
Street ferry, and at the Tennis and Racquet Club
on Forty-third Street, New York, and at the Bush
Terminal in Brooklyn. Four officers and twenty-
five enlisted men are attached to this particular
service.
Nurses' Mobilization Stations. — One of these is
at the Hotel Albert, New York, under the super-
vision of Chief Nurse M. C. Jorgensen, A. N. C,
and the other, at 120 Madison Avenue, New York,
is in charge of Chief Nurse Minnie Winslow, A. N.
C. The Nurses' Rest Home at Fairhaven, with
is used for the shipment of medical supplies to the
American Expeditionary Force ; that at Camp Mer-
ritt is in charge of Captain A. T. McKelvey, M. C,
with twenty-two enlisted inen, and the depot at
Camp Mills is in charge of Second Lieutenant R.
H. Wilson, S. C, with twenty-seven enlisted men;
the one at Camp Upton is under the charge of Cap-
lain Burkhardt of the Sanitary Corps.
The Transatlantic Transport Service employs
sixty-nine commissioned officers of the Medical De-
partment, and twenty enlisted men, all of whom
come under the command of Colonel Kennedy.
The Correspondence Division, of which Captain
Debarkation Hospital No. s, at Lexington Avenue and Forty-sixth Street, New York. Formerly known as the Grand Central
Palace. This has a floor area of 285,300 square feet and will accommodate 3,300 patients.
Chief Nurse Edith Hine, A. N. C, in charge, is
also under Colonel Kennedy's command.
Medical Supply Depots. — The troops which are
sent abroad all take their own medical and surgical
supplies, their needs being supplied through the
three camp medical supply depots of the port. One
of these is at Camp Upton, one at Camp Merritt,
and the; last at Camp Mills. These draw on the
depots at Washington or New York, as circum-
stances dictate. The Medical Supply Depot at Pier
45 is in command of Lieutenant Colonel P. W. Gib-
son, M. C, with five commissioned officers, thirty-six
enlisted men, and sixty-five civilian employees, and
G. C. Young, S. C, is chief, has full charge of the
large correspondence involved in the work of the
Surgeon. On July 31st, there were over 2,000,000
communications on file in the division, all of which
are so carefully indexed that they are immediately
available at any time.
Among the medical organizations not previously
named which are under the control of the Surgeon
of the Port of Embarkation are the Overseas Casual
Camp, the Medical Detachment of the Fiftieth
Infantry, the Sanitary Squad at Camp Merritt,
and the Sanitary Inspectors at Montreal and
1 Talifax.
September 28, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
559
MEDICAL NEWS FROM WASHINGTON
New Al'pointments in Medical Corps. — Concern Over
Spread of Epidemic of Influenza. — Cooperation of
American Red Cross With Navy and Marine Corps.
Washinc.ton, D. C, September 23, igi8.
Captain Phillip Leach, Medical Corps of the
Navy, who has been in command of the naval hos-
pital at Boston, for some time, has been detached
from that duty and ordered to Washington as a
member of the naval examininc^ and retiring boards.
He relieves Captain William R. Du Bose, Medical
Corps, retired on account of age. Captain Norman
J. Blackwood, Medical Corps, who has been in
command of the hospital ship. Mercy, has been as-
signed to command the Boston hospital.
*****
The government authorities are much concerned
over the outbreak of influenza at various camps
and stations of the armv and navv. Tlie first re-
while laboratories at Washington, Philadelphia, and
Great Lakes are making bacteriological investiga-
tions with a view of checkmating the disease, which
ai)pears to be in all respects pandemic.
About 1,500 cases and two deaths have been re-
jxjrted from Camp Devens, about 350 cases from
Camp Upton, and about 1,000 from Camp Lee.
*****
The Secretary of the Navy has authorized the
American Red Cross to cooperate with the navy in
carrying out its desire at all times to do everything
possible for the comfort and welfare of the enlisted
men of the navy and marine corps, and particularly
in the following ways :
TTpon request of a mecHcal officer of the navy,
to render service in the naval hospitals, furnish
emergency supplies, communicate with families of
patients, render home service to patients, erect hos-
pitals for convalescents and nurses, and furnish
such other assistance as pertains to Red Cross work.
The Hotel Nassau at Long Beach. Long Island, which is being fitted up as Debarkation Hospital No. 4.
It will furnish beds for 1,800 patients.
ports were limited to the New England district, but
these were followed by reports of cases at Phila-
delphia, Pa., Pensacola, JTa., and Great Lakes, 111.,
and at the army posts of Camp Devens, Mass.,
Camp Upton, N. Y., and Camp Lee, Va.
In the navy the disease is on the wane in the
Boston district, where there have been about 2,600
cases, with 66 deaths from pneumonia. At New
London tliere were 300 cases of influenza, with ten
of pneumonia, and no deaths. In the New York
naval district, the disease is increasing, with over
500 cases so far reported, but up to the present time
the naval station at Pelham Bay has escaped an ep-
idemic, onlv about ten cases having been reported.
Nearlv 700 cases have been reported from the Phila-
delphia navy yard, and reports of about 1,000 new
ca.ses a day have been coming in from the Great
Lakes training station, though of a mild type.
Lieutenant Commander Milton J. Rosenau, Medi-
cal Corps, Naval Reserve Force, a noted specialist,
has been conducting laboratory research at Boston,
When requested by commanding officers, to have
sick and wounded men convej'ed to a hospital and
furnish them relief cn route.
To conduct canteen service stations for furnish-
ing refreshments to sailors and marines when
traveling.
Upon request or suggestion of commanding offi-
cers of ships or stations, to re'.ider emergency relief
to all persons under their command.
To relieve the anxiety and sustain the morale of
the sailors and marines, by taking necessary steps
to promote the comfort and welfare of their families
at home.
*****
At the marine hospital at Detroit, which is under
command of Senior Surgeon H. W. Austin, Public
Health Service, the second floor has been entirely
given over for reception of naval and marine corps
patients. During the past month, over forty naval
patients were cared for. a large number being ad-
mitted for injuries and for major operations.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the A. R.
Elliott Publishing Company, or by registered mail, as the
publishers are not responsible for money sent by unregis-
tered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the inail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, SEPTEMBER 28, 1918
THE LIBERTY LOAN AND THE DOCTOR.
Thirty thousand five hundred and nineteen
physicians are now in the Government service.
Twenty-six thousand nine hundred and eighty-
one of these are in the Medical Corps of the
army, 2,818 are in the navy ; 220 are commissioned
as surgeons or assistant surgeons in the United
States Public Health Service, wdiile 500 are en-
gaged in the service as contract surgeons without
commissions. There are said to be about 76,000
physicians in the United States of military age ;
that 30,519 of them have engaged in the Govern-
ment service voluntarily shows the patriotism of
the members of the medical profession in a most
convincing manner. INIany of these men have
made material sacrifices in giving up an estab-
lished practice to enter the service, for the prac-
tice of a physician breaks down quickly during
his absence, so that these men returning to civil
life after an absence of a year or two must make
an absolutely new start. The man in commer-
cial life can frequently turn over his business to
a subordinate and after serving in the army for a
year or two may return to find his business even
more prosperous than when he left it. There is
no such possibility with the physician. When
he comes back to civil life he will find his prac-
tice scattered and he will have to begin all over
again to build it up.
While it would not be nice to draw invidious
comparisons, we are confident that in no other
calling have more than forty per cent, of its mem-
bers volunteered for service. And surely no
other class of volunteers has done so at so great
a pecuniary sacrifice as have medical men.
Those members of the profession who have
not joined the colors have been called upon for
additional service in the care of those of the civil
population whose medical attendants have vol-
unteered. The staff of every hospital has dimin-
ished and the remaining members have been re-
quired to do extra duty, which is being performed
efficiently, energetically, and, for the most part,
without complaint.
So great has been the service rendered by the
medical profession that the committee charged
with obtaining subscriptions for the fourth Lib-
erty Loan have refrained from any special effort
to obtain subscriptions from the profession, feel-
ing that the members of a calling which had
made such a generous response to the appeal for
personal service would not fail to do their share in
the matter of subscriptions to the Liberty Loan.
There has, therefore, been no special committee
appointed to solicit subscriptions from the mem-
bers of the medical profession, but we bring the
matter to their attention through our special
Liberty Loan number, and through the generos-
ity of our advertisers we place before our readers
the appeal made by the Liberty Loan committee
in the form of advertisements, thirty-two pages
of which form a special section of this issue.
Those who have not been able to give personal
service in the cause of civilization can, by sub-
scribing to the Liberty Loan, give valuable aid
to the cause. It would be impossible to form any
accurate estimate of the aggregate of subscriptions
for Liberty Bonds made by the medical profes-
sion, since they will be made through local chan-
nels all over the United States, but we feel con-
fident that the total volume of bonds subscribed
for will be as generous in proportion to the
means of the members of the profession as has
been the number who have volunteered for serv-
ice in the Army, the Navy, and the Public Health
Service.
September 28, iqiS.l
EDITORIAL ARTICLES.
561
GENERAL ANALGESIA FOR PAINFUL
DRESSINGS.
We are very far away from the days when pa-
tients were held down by main force while por-
tions of their anatomy were violently severed
from them, when surgeons cultivated speed
amounting almost to prestidigitation to shorten
suffering, those days when, according to Bob
Sawyer's friend, Mr. Hopkins, a surgeon, could
take off a boy's leg so unobtrusively that after it
was all over the patient would ask when they
were going to begin. Nowadays the phrase
"painful operation" has a strange sound, but
there are still problems in analgesia unsolved.
For example, what are we to do in cases where
an operation must be followed by a series of pain-
ful dressings? It sometimes happens that these
are almost as severe as the operation itself, and
in their sum productive of much more suffering.
We cannot be giving a general anesthetic for
each dressing: this would hardly be practicable
in private practice and would be out of the ques-
tion in war hospitals, where the demands on the
time of the surgeons are sometimes so excessive
that wounds must remain untouched for twenty-
four hours. The administration of morphine for
each dressing would not dull the pain at the time
greatly, although reducing the suffering after-
ward ; moreover, it would tend to constipate, and,
in addition, there would be the danger of habit
formation.
With this problem in mind Captain Gwathmey
and Captain Karsner, of the United States Army,
have conducted a series of experiments to find a
general analgesic available for painful dressings
and short operations and have published their
results in the British Medical Journal} Such a
therapeutic agent is particularly desirable, they
say, in wounds accompanied by fractures, where
the patient should be kept as quiet as possible.
Animals were used for the preliminary experi-
ments and as encouraging results were obtained
they were further tested on wounded soldiers.
Among the drugs tried were quinine and urea
hydrochloride, trional, morphine tartrate, paral-
dehyde, ether in olive oil, and combinations of
these drugs.
The conclusions reached were that general an-
algesia is safer than general anesthesia and that
the safest example of the former is fifty per cent,
ether in liquid paraffin or other bland oil. Its
effect may be enhanced by the addition of a half
dram or a dram of chloroform. The amount
^General Analgesia by Oral Administration. By Capt. J. T.
Gwathmey and Capt. H. Y. Karsner, British Medical Journal, March
z, 1918, pp. 254-57.
of the ether and paraffin used is three and a half
drams of each. The unpleasant taste of this
mixture may be palliated by taking a mouthful
of port wine, holding it for about thirty seconds,
swallowing it, and then taking the ether mixture,
followed immediately by the rest of the glass of
wine.
The advantages of such an analgesia are incal-
culable, especially in war time. The busy sur-
geon is enabled to complete his redressings in
half the time, thus giving more time to the fresh-
ly wounded as they come in, and the individual
soldier is spared a great deal of suffering.
THE KHAKI UNIVERSITY OF CANADA.
In the matter of education of the Canadian
forces overseas a plan, quite recently devised,
may now be said to be established upon a sub-
stantial footing. Like all othjer projects for the
welfare of the Canadian soldier, which recognize
the principle of preparedness so desperately
brought home to civilized nations in four years
of most horrible warfare, the Khaki University
has definite objects in view. Many returned sol-
diers will not be fitted to engage in their own
vocations, so the main object of the university is
to prepare them by practical study and instruc-
tion for their future vocations. The work has
been organized in various centres in England,
and, to a certain extent, among the troops in
France. If the recent good work of the armies
of p-och, Pershing, and Haig be kept up, then the
Allies may with confidence look forward to the
period of demobilization, when the plan may be
extended to include a system of education for the
whole army.
The Canadian universities recognize the Khaki
University, and the army authorities are also ex-
tending hearty cooperation ; the Y. M. C. A. in
Canada undertakes to finance the movement.
The financial load is somewhat lightened by vol-
unteer instructors, who, in the main, are chap-
lains, Y. M. C. A. secretaries, officers, and non-
commissioned officers; and, in most cases. ■ these
men have already had experience in teaching.
Under the auspices of the Khaki University,
there are already ninety-three libraries estab-
lished in England and France. The registration
totals 8,006 men in England alone, but exact fig-
ures have not been procurable for France. In
commercial subjects, 2,351 are registered; agri-
cultural subjects, 1,363; engineering, 1,503; gen-
eral educational subjects, 2,789. Up to June 30,
1918, 341 lectures on general and practical sub-
562
EDirOKIAL
ARTICLES.
[New York
Medical Journal.
jects liad been given in thirteen army centres in
England, with an average attendance at lectures
of about 400. Between 40,000 and 50,000 indi-
vidual men have attended one or more lectures ;
and the approximate attendance has numbered
170,000.
The source of the above information does not
mention anything in the way of professional
studies, but with the unequaled facilities for clin-
ical instruction, especially m surgery, the oppor-
tunities should not be lost to medical students
who have been called to the service overseas.
THE DIAGNOSIS OF POLYNEURITIS
FROM CARBON SULPHIDE
POISONING.
In all polyneuritides when the muscles, periph-
eral nerves, and cord are examined, the most
striking features are the marked changes in the
peripheral nerves. Among the toxic polyneuri-
tides those due to carbon sulphide are the least
known and their pathological anatomy is yet to
be studied. All that is known in carbon sulphide
poisoning is the change taking place in the blood,
so that when a positive diagnosis of the nerve
lesions is to be made the past history of the case
must be investigated, otherwise a diagnosis will
be utterly impossible.
If the patient has been employed in the manip-
ulation of carbon sulphide a direct diagnosis can
be made or a differentiation between a polyneuri-
tis and poliomyelitis may have to be considered.
In the latter affection the onset is sudden and the
paralysis involves the muscles of the roots of the
limbs as well as the extremities, and disturbances
of objective sensibility do not exist.
The etiological factor should always engage
the attention. But among the paralyses which
may be met with during carbon sulphide intoxi-
cation are some organic paralyses resulting from
a change in the nerve fibre, the motor neuron ;
the others often are merely pure functional par-
alyses, related to hysteria.
One must carefully avoid mistaking these two
types of phenomena, because, from the viewpoint
of the prognosis and treatment of the affection,
there is a capital difference.
It was long since shown by Marie that many
accidents mentioned in carbon sulphide paralysis
should be attributed in reality to hysteria. Toxic
hysteria from carbon sulphide particularly calls
for careful attention and should be detected
whenever a paralysis is due to carbon sulphide
poisoning, since a diagnosis of polyneuritis can-
not be made until it has been ascertained that
hysteria plays no part in the sensitive, sensitivo-
sensorial, or motor phenomena present.
In quite a number of cases the onset of the
liysteric accidents is sudden, because the hysteria
was in a latent state and the causative factor in
the production of its manifestations has been the
toxic action of carbon sulphide. Among work-
men manipulating this product a sort of aura,
consisting of a sensation of heat in the genitalia
and of burning or cold in the scrotum, is well
known.
The onset of toxic peripheral neuritides is slow
and insidious, and no hesit.ition in the matter of
diagnosis should exist when a steadily progress-
ing paralysis occurs, more often involving the
extensor muscles and extremities of the limbs,
without muscular atrophy, with disturbances of
objective sensibility involving the mixed nerve
trunks with marked diminution of the tendon re-'
flexes, leaving the sphincters intact.
An electrical examination will frequently con-
firm the diagnosis by demonstrating the reaction
of degeneration. Proper treatment will almost
always produce a progressive amelioration and
a cure in favorable cases which will leave no
doubt as to the true nature of the paralysis.
The prognosis of polyneuritis from carbon sul-
phide intoxication is favorable in the majority of
cases. While it has a serious aspect from the
fact that relapses are probable, complete recov-
ery may be said to be the rule.
A MORE PRACTICAL STANDARDIZA-
TION FOR PITUITARY EXTRACT.
Simplicity and uniformity characterize a new
method for the biological standardization of pitui-
tary extract reported by Spaeth [Reynold A.
Spaeth : Concerning a New Method for the Bio-
logical Standardization of Pituitary Extract and
Other Drugs ; Journal of Pharmacology and Ex-
perimental Therapeutics, April, 1918] — two features
of practical importance in such a procedure. Spaeth
points out the defects of the two methods now
commonly in use in the testing of the strength of
pituitary extract. The use of strips of virgin
guineapig uterus does not sufficiently take ac-
count of the variation in the strength of the sam-
ples of pituitrin to be tested, even when taken
from individuals of the same species. There is
also great variation in the sensitiveness of the
uterine tissue. Moreover, the repeated use of
the same strip of uterus gives no room for con-
trol experiment. The second form of test, that
September 28, 1918.]
EDITORIAL ARTICLES.
563
of utilizing the normal olood pressure of dogs as
the test object, is open to these same objections.
Too many variable factors exist and there is the
same lack of control experiment.
Therefore, the writer suggests that the test
should be carried out upon units of tissue from
the same animal which could be physiologically
compared, and he proceeds to describe such a
method. Here two groups of pigment cells,
proved to be identical physiologically, are com-
pared as to their reaction time in a standard and
an unknown solution. The detailed physiologi-
cal and chemical studies which have been made
upon the melanophores of F. heterocHtus, the
killie fish or mummiechog, have shown tliem to
be functionally modified smooth muscle cells and
therefore particularly adapted to such test work
in standardization. This little fish, moreover, is
easily obtainable and maintains its normal condi-
tion under very simple artificial surroundings.
Potassium chloride was the solution chosen as
the standard in the test, since it can be easily ob-
tained pure and has a constant effect upon the
melanophores. A definite mixture was selected,
2.5 parts of decinormal sodium chloride solution
and I part of decinormal potassium chloride solu-
tion at a uniform temperature of 22° C. The pre-
liminary tests consisted in finding by experiment
pairs of melanophores with the same contraction
time, which then could be tested in the standard
solution and in a solution of unknown strength.
The same preliminary tests may be used to deter-
mine the strength of the unknown solution. Here
approximate results may be obtained by using
three adjacent scales which may be compared
also in size and number of melanophores, when
the more rapid contraction will denote the ap-
proximate strength of the unknown solution.
Further comparisons are then made between the
solutions by using the pairs of scales already
matched. In order to avoid interference with
standardization through the preservative in com-
mercial solutions these solutions have been di-
luted for experimental purposes with sodium
chloride to a certain concentration, but it is sug-
gested that in commercial practice, for the stand-
ardization of a given quantity of drug, solutions
should be made up for immediate use without
preservative, as far as this is possible. The
writer suggests for pituitary extract an aqueous
solution which when suitably diluted with one fifth
normal sodium chloride solution will have the same
action upon these melanophores as the standard
potassium chloride solution.
It need not be objected, the author claims, that
the action of pituitary extract upon the melano-
phores is not comparable to that upon the mam-
malian uterus, for experiment has proved it
otherwise in the guineapig. Far greater ac-
curacy seems, moreover, to result from the me-
lanophore method. The close relation of potas-
sium chloride and pituitary extract might be
questioned, but so far as experiment has gone in
respect to the variability of these two substances,
they incite the same response in the melano-
phores. The chief advantages established so far
in this method are the elimination of the indi-
vidual variation in the test animals and the pro-
viding of an "exact, quantitative, simultaneous,
control experiment."
THE EPIDEMIC OF INFLUENZA.
The number of cases of influenza originating in
New York continues to grow. On Tuesday 172
new cases were reported, twenty-two more than
were reported on the previous day. Notwithstand-
ing the presence of influenza fewer cases of pneu-
monia have been reported during the past week
than in the corresponding period of last year. Sixty-
five deaths were reported in twenty-four hours at
Camp. Devens, and between 5,000 and 6,000 cases
were reported under treatment on Monday. The
number of cases of influenza reported by the differ-
ent camps is: At Greene, i ; Logan, 175; McClellan,
II ; Sevier, 2; Syracuse, 596; Devens, 10,700; Dix,
1,897; Funston, 181 ; Gordon, 419; Grant, 70; Hum-
phries, 209; Jackson, 794; J. E. Johnston, 14; Lee,
1,819; Lewis, 50; Meade, 223; Pike, i; Sherman,
i; Taylor, 87; Travis, 37; Upton, 1,141; Newport
News, 28; Iloboken, 1,417; Colt, Pa., 32; Edge-
wood Arsenal, 188, and miscellaneous posts, 118.
The commissioner of health, Dr. Royal S. Cope-
land, has sent a letter to all physicians, and to all
hospitals, institutions, and sanatoria in the city di-
recting attention to the fact that influenza, acute
lobar pneumonia and bronchial or lobular pneu-
monia, have been included among the infectious
diseases which are required to be reported to the
Department of Health. Particular attention is
called to the fact that isolation should be maintained
until the termination of the disease, and the coopera-
tion of the medical profession in the prompt report-
ing of cases of influenza or pneumonia and in the
isolation of such cases is earnestly requested.
A press bulletin has also been given out by the
commissioner giving information to teachers in the
public schools, private schools, and other institutions
for the care of children. A press buUetin was also
released giving information to the general public
relative to the nature of Spanish influenza, its pre-
vention, and advising all persons who are sick to
consult their physicians, informing the public that
the epidemic is general throughout the countrv and
that New York city is more free than other places,
and that this freedom can be maintained only by
general cooperation by the public with the Depart-
ment of Flealth.
564
NEWS ITEMS.
[New York
Medical Journal.
News Items.
Women Doctors in a French Hospital. — At the open-
ins exercises of the Woman's Medical College in New
York, Dr. Eleanor C. Jones stated that the French Gov-
ernment is erecting a special building for the use of gassed
patients, where lifty women doctors will be assigned to duty.
The New York Neurological Society. — This society
will hold its first meeting of the season next
Tuesday evening, October ist, with Dr. Frederick Til-
ney, president of the society, in the chair. The principal
address of the evening will be given by Dr. Walter B.
James, president of the New York Academy of Medicine.
The Wesley M. Carpenter Lecture. — This lecture
will be given at the New York Academy of Medicine,
Thursday evening, October 3d, by Professor Graham Lusk,
one of the representatives at the recent meeting of the
"Interallied Scientific Food Commission" abroad. His
subject will be The Scientfic Aspects of the Interallied
Food Situation.
Personal. — Dr. Abraham Jacobi's summer home at
Bolton-on-the-Lake, Lake George, N. Y., was badly dam-
aged ])y fire Friday night, September 20th, and in making
his escape from the flames Doctor Jacobi. who is eighty-
nine years of age, jumped from a second story window,
to the ground, a distance of twelve feet. He sustained
several slight injuries.
Better Care in the Army than in Private Life. — Sur-
geon General Gorgas, who is making an inspection of
the Medical Service of the American Expeditionary Force,
in France, is reported in a cable from Tours, as having
said "I am very much pleased with the care and the health
of the troops. Their sanitary condition is good, the sick
rate is low, and the wounded are excellently cared for.
A large bulk of these men are getting very much better
professional care here than they would have had in civil
life."
Flight Surgeons. — Brigadier General T. C. Lyster,
Chief of the Air Service Division of the Surgeon General's
Office in Washington states that the flight sugeons have
been appointed to the various aviation commands. These
men will be expected to fly, though they need not neces-
sarily become pilots. They will not only examine applicants
for admission to the air service but will keep in close
touch with the flyers, so that any physical deterioration in a
flyer will be noted and corrected before he suff^ers materi-
ally from it.
End of Pasteur Institute. — Dr. George Gibier Ram-
baud, who has been at the head of the Pasteur Institute
on West Twenty-third street. New York, for the past eight
years, has closed the Institute, accepted a commission as
Major in the United States Army and has been ordered
to France on active duty. In closing the Institute, he said
that it had served its purpose in introducing the Pasteur
treatment which is now available in all the larger hospitals.
During the past eight years the Institute has cared for
10,030 patients, 8,292 of whom were treated without charge.
Hospital Assistants Needed. — At a meeting of a spe-
cial committee on nursing composed of the leaders in the
field of nursing and hospital management, which was
held in Washington on September 20th, resolutions
were adopted encouraging civil hospitals to arrange
for the training of hospital assistants in accordance with
the plans of the Army School of Nursing, such assis-
tants to be enrolled through the American Red Cross with
the understanding that they will accept service as may be
required either in the hospital in which they had been
trahied, the American Red Cross or the United States
Army Hospitals.
New Building for Doctor Potter's iMetabolic Labora-
tory and Clinic. — A new wing has been added to the
Memorial Laboratory and Clinic at Santa Barbara, Cali-
fornia, of which Dr. Nathaniel Bowditch Potter, formerly
of New York, is director. This addition to the clinic
has been provided especially for the research work which
is be'ng carried on by Doctor Potter in the study and
treatment of nephritis, gout, diabetes, and allied diseases.
The money has been piovided by C. G. K. Billings, George
Owen Knapp, Clarence A. Black, and Frederick F. Pea-
body, and it is said th.at the institution will be equ'pped
with everything needed in an up to date laboratory and
clinic.
Executive Committee of the Volunteer Service Corps.
— The follovving New '^"ork physicians have been appointed
meniliers of the executive committee of the Volunteer
Medical Service Corps : Dr. George David Stewart, Dr.
Walter B. James, Dr. James B. Clemens, Dr. J. E. Wilson,
Dr. Nathan E. Brill, Dr. Walter F. Chappel, Dr. John E.
Y'irden, and Dr. S. Waterman, of Brooklyn.
American Woman's Hospital. — A letter sent from
France by Dr. Jean Howard Pattison, a member of Hos-
pital Unit No. I, of the American Woman's Hospitals,
states that she and other members of the unit were on
duty at Meaux. They v.-orked eighteen hours one day and
thirteen the next. Some of the wounded had paper band-
ages which they had taken from the German prisoners.
American Orthopedic Hospitals in London. — The
American Red Cross announces that through the liberality
of William Salomon, a New York banker, St. Katherine's
Lodge, formerly one of the homes of King George, had
been turned over to the American Red Cross for use as
an orthopedic hospital. Baroda House, which was built by
the Gaekv/ar of Baroda, has been turned over for the same
purpose, by the present owner, A. Chester Beatty, an
American mining engineer.
Recruits for the Army Nurse Corps. — It is stated that
over 4,000 women have applied for entrance into the Army
Nurse School and more than 1,000 .have been enrolled.
These students are to be sent to the Army Nurse Training
Schools which have been established at various camps in the
Uinted States. Brigadier General Charles Richard, Acting
Surgeon General of the Army, has emphatically denied a
statement given to the press recently, to the effect that the
luirsing needs of the Army have been met. The figures
given out by others have been misleading. More than
i6,oon nurses are now on the rolls of the Army Nurse
Corps, leaving 9,000 still to be obtained. Moreover, it is
estimated that 50.000 nurses v.dll be needed by Tuly i. 1919.
General Richards says it is important that the false impres-
sion that the Array's need for nurses had been supplied
shoulrl be emphatically contradicted. There is a great need
for nurses now and there will soon be a greater need.
Control of Venereal Diseases.^ — One million dollars
will be expended by the Federal Government through the
State boards of health in venereal disease control during
the fiscal year ending June 30, 1919. This sum is made
available for expenditure, under regulations established by
the Secretary of the Treasury, by an act of Congress ap-
proved July 9, 1918. An officer of the Public Health Ser-
vice will have general charge of the work in each State in
cooperation with the State health oflicer. The activit'es
will be the following: a. Securing of reports of venereal
infections; b. control of those infected, so as to prevent
further spread of the diseases; c. establishment of free
venereal clinics ; d. suppression of vicious conditions which
favor the spread of venereal infections; e. carrying out
of a systematic educational program for the general oublic
as well as for those who are infected. The act g'ves
authority for a new division in the Bureau of the Public
Health Service, to be called the Division of Venereal D"s-
eases. Such a divis'on has been organized and a chief
appointed.
War Work of Women Physicians. — A meeting of
women physicians was held in the Hotel McAIpin, New
York, recently for the purpose of inaugurating a campa'gn
to raise $200,000 to enable the New York Infirmary for
Women and Children, 321 East Fifteenth Street. New
York, to reopen its wards, which have been closed tor
lack of funds on account of the war, and to extend its
dispensary and outpatient service to the families of soldiers
from the lower east and west sides of the city. Dr. S.
Josephine Baker, of the Department of Health of the C'ty
of New York, is chairman of the campaign executive com-
mittee. Dr. Marie L. Chard, vice-chairman of the commit-
tee and head of the department of surgery at the infirmarv,
in an iteresting address, told how women physicians were
helping to win the war by vigorous participation in home
service activities, bv taking the places of men physicians, by
working with the Red Cross among the dependents of men
in the service, by joining the medical services of industrial
plants and munition factories, especially those employing
great nimibers of women, and in a number of other ways.
She said that the number of women phvsicians who were
helping to win the war in varied activities at home v.'as
just about one hundred per cent.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
VICIOUS CIRCLES IN RESPIRATORY DIS-
ORDERS AND THEIR TREATMENT.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
(Concluded from page jip-)
BRONCHIAL ASTHMA.
One or more vicious circles are probably involved
in all but the mildest of acute asthmatic paroxysms.
The main factor in the paroxysm is generally con-
sidered to be a spasm of the bronchioles, to which
is likely to be added a swelling of the mucous mem-
brane of the bronchioles, with abnormal secretion.
Whatever the precise origin of the bronchiolar
obstruction, the result is a tendency to abnormal
distention of the lungs.
An important feature of the condition constitut-
ing a basis for the production of added vicious
circles is that, as McPhedran puts it, "the inspira-
tory act is violent, while the expiratory is quiet and
prolonged. The whole endeavor of the patient is
to get more air into the lungs, while he is little con-
cerned to drive it out." Expiration being normally
to a large extent dependent upon the elasticity of
the lungs, while inspiration always demands activity
on the part of the powerful inspiratory muscles,
when an obstruction is offered to breathing inspira-
tion seems likely to get the upper hand over ex-
piration, with the result that every inspiration
begins before the preceding expiration is complete,
and overfilling of the lungs with air follows.
Dixon, 1909, has laid special stress upon this view
of inspiration as a more forcible act than expira-
tion, with consequent overdistention. The action
of the abdominal muscles as factors in expiration-
is believed to be interfered with in asthma because
the overactive diaphragm is relatively depressed
and fixed in these cases, thus preventing the in-
creased intraabdominal pressure caused by contrac-
tion of the abdominal muscles from asserting itself
on the contents of the thorax. Again, according to
some, the obstruction of the bronchioles is more
marked on expiration than on inspiration ; Mc-
Phedran thinks strong efforts at expiration would,
by compression, bring on further narrowing of
these channels. This, if definitely shown to be the
case, would supply another very direct mechanical
reason in accounting for the overdistention of the
lungs in asthma.
A number of vicious circles may, it seems likely,
become superadded.
In the first place, granting the truth of Mc-
Phedran's view, just referred to, that violent ex-
piratory efifort may further narrow the bronchioles,
the probability presents itself that the additional
narrowing will necessitate still more forcible ex-
piratory efl^ort, with resulting further narrowing ;
a vicious circle would thus be established which
could end only when the expiratory muscles had
reached the limit of their contractile capacity.
Again, if the force of inspiration continuously
exceeds that of expiration, the resulting interfer-
ence with breathing, by promoting carbon dioxide
accumulation, will tend to excite further the respira-
tory centre ; as a result, the disparity between in-
spiration and expiration might be rendered greater
than before, carbon dioxide elimination further re-
duced, and the central excitement correspondingly
increased — a vicious circle being thus constituted.
Dixon has emphasized the effect of overdisten-
tion of the lungs in weakening the elastic expiratory
power of their tissues. This is in agreement with
Hewlett's statement that while, ordinarily, pul-
monary distention soon disappears at the termina-
tion of an asthmatic attack, in prolonged and con-
tinued attacks restoration to the normal lung
volume may occur only very slowly. In other
words, the more pronounced the overdistention of
the lungs in an attack, the less becomes their ex-
piratory power and the less is the opportunity for
additional oxygen intake. The greater the demand
for oxygen, the more powerful the inspiratory ef-
forts and the greater the overdistention of the lungs.
A vicious circle is thus established which will tend
to perpetuate the attack.
Another vicious circle, it seems probable, may
depend upon the unusual exertion attending the
patients' abnormally forcible respiratory move-
ments. Such unusual exertion will increase oxygen
consumption and the production of carbon dioxide.
This, in turn, will further excite the mechanical
respiratory function and increase the exertion in
breathing, thereby completing a vicious circle
which ceases operation only when exertion reaches
its limit and tends toward exhaustion of the patient.
The congestive swelling of the mucous membrane
of the bronchioles and secretion into their lumen
which generally accompany the asthmatic broncho-
spasm are ascribed to either local vasomotor
paresis, secretory stimulation through the vagus
nerve, or actual inflammation. The question arises,
however, whether they may not be favored also by
one or more mechanical factors. A rise of systemic
l)lood pressure due to accumulation of carbon
dioxide because of inadequate respiratory ventila-
tion, and reacting upon the vessels of the bronchi-
oles— probably less susceptible to vasoconstricting
influences than the systemic vessels as a whole —
is a possible factor in this connection. Such an in-
crease of systemic blood pressure, by promoting
congestive swelling and exudation in the bronchi-
oles, might increase the respiratory difficulty, cor-
respondingly augment the accumulation of carbon
dioxide, and induce a further rise of systemic vas-
cular tension, thus establishing another vicious
circle. The exertions of the patient in breathing,
by increasing carbon dioxide production, would also
tend toward heightened blood pressure, and were
the latter to promote further congestion of the
bronchiolar mucosa, a connection between the pre-
566
MODERN TREATMENT AND PREVENTIVE MEDiCINE.
[New York
Medical Journal.
ceding circle and that just described would be es-
tablished.
How are these vicious circles in asthma to be
overcome? In the case of the first two circles re-
ferred to, reduction of the bronchial spasm is ob-
viously the most available procedure. For this pur-
pose drugs of the solanaceous series, atropine itself,
nitrites, and adrenalin are of great value. In the
second circle, in which carbon dioxide accumulation
is a factor, absolute rest will probably be of addi-
tional service, tending to reduce the amount of
carbon dioxide liberated in the system. In the
third circle, featured by the excessive inspiratory
efforts arising through the demand for more
oxygen, inhalation of oxygen gas would seem the
proper auxiliary measure to be combined with the
bronchodilators. Segal, 1910, reported good results
in two severe cases from simultaneous use of oxygen
and adrenalin. In the fourth circle, oxygen, lack
and excess of carbon dioxide seem the most vulner-
able points ; the former can be favorably influenced
by oxygen inhalation, and both by medicinal broncho-
dilatation. Finally, in the fifth circle, the belladonna
series is serviceable both through relief of broncho-
spasm and reduction of secretion ; spirit of nitrous
ether, or the more active nitrites, or chloral hydrate
in moderate dosage might be of service by over-
coming a tendency to systemic vasoconstriction and
rise of blood pressure which would promote swell-
ing and exudation in the bronchioles. Morphine in
asthma probably acts by depressing the hypersensi-
tive centres, irritation of which is causing them to
constrict the bronchi through the vagal nerve distri-
bution. It may also benefit through direct (local)
bronchodilatation ; by allaying unduly violent, fruit-
less inspiratory activity on the part of the respira-
tory centre, and by generally quieting the patient,
thus minimizing carbon dioxide liberation. Accord-
ing to Goldschmidt, 1907, one twentieth to one
twelfth grain is usually sufficient. The risk of
eventual habit formation is, however, a serious dis-
advantage. According to some, caffeine and theo-
bromine are serviceable as bronchodilators ; this
clinical view has received some degree of experi-
mental confirmation by Higgins and Means, 191 5.
Prevention and Control of Respiratory Infec-
tions in Military Camps. — Joseph A. Capps
(Journal A. M. A., August 10, 1918) calls attention
to the great frequency of respiratory infections in
our army camps, especially to those due to the
streptococcus, and recommends the following pro-
cedures for their prevention and control. Since
milk, cream and ice cream are well known to be
capable of carrying and spreading various respira-
tory infections, scarlet fever and the streptococcus,
and 'since several outbreaks of these diseases have
been traced to the milks used in the camps, it is
recommended that all milk be properly pasteurized
at the camp. The second important method of pre-
venting the spread of the respiratory infections has
been proved to be by means of the proper use of
the face mask. At the regimental infirmary every
patient .should be masked as soon as the diagnosis
has been made. Every patient, irrespective of his
disease, should be masked on entering the ambu-
lance and should contmue to wear his mask at the
receiving oflice. Patients who walk to the hospital
should be masked before their entrance. All pa-
tients coming to the hospital should wear their
masks during their examination and on their trip to
the ward and should remove them only after enter-
ing their own cubicles. In all wards for contagious
or respiratory diseases all patients, whenever they
are outside of their own cubicles, and all physicians,
attendants, and visitors must wear masks during
their stay in the wards. Finally, less effective means
of preventing the spread of these diseases are the
detention in separate camps of all new contingents
for three weeks, increasing the space between the
beds in the barracks, placing the beds so that the
head of one is opposite the foot of the other, and
the hanging of a curtain down the centre of the
mess table.
Treatment of War Burns Due to Yperite. —
J. Bandaline and J. de Poliakoff {Bulletin de I'Aca-
demie dc mederinc, July 9, 1918) call attention to
the efficacy of hot air in the treatment of burns
caused by yperite, a gas used by the Germans in
their offensive of March, 1918. These burns, even
when very small, cause extremely sharp pain and
sleeplessness. A number of cases were rapidly
healed by hot air after various treatments, includ-
ing ambrine, had failed. The peculiar effects of
the gas are due to the local action of organic groups
it contains and also to a constitutional intoxication.
The first dressing with saline solution is almost im-
possible on account of the pain. To prevent ad-
hesior. of dressings to the burn the authors used
what they term linoserum — 1,000 grams of a 1.5
]}er cent, infusion of linseed with nine grams of
pure sodium chloride, filtered or sterilized in the
autoclave for twenty minutes at 120° C. The prep-
aration is warmed on a water bath before use.
Opened bottles of it must be used on the same day,
as it ferments easily. After two hot air treatments
and in two days' time, local sensitiveness, in an illus-
trative case referred to, had greatly lessened and
the sharp pains had disappeared. " In two cases in
which sleeplessness had been especially troublesome,
sleep was gradually restored after four and five days
of hot air treatment, and after three weeks of hot
air, pain was entirely gone.
Removal of Missiles from the Pleura or Dia-
phragm.— E. Petit de la Villeon (Presse medicale,
[une 13, 1918) thinks that extraction with forceps
through a buttonhole under x ray control should
now supplant thoracotomy in most cases of projec-
tiles in the pleura. Injury to the chest wall and
complete pneumothorax are thus obviated, and the
removal of loose, mobile foreign bodies greatly facil-
itated. The procedure is likewise applicable where
a foreign body is only partly in the pleura, being in
part embedded in the chest wall or lung. A single
pleural region forms an exception, the mediastinal
pleura ; here a wide thoracotomy is indicated. In
removing a pleural missile with forceps, the latter
should never be inserted perpendicularly over the
missile but always passed in in a markedly oblique
direction, through a buttonhole made at some dis-
Septtnilier 2S, 10:8.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
567
tance from the missile. This is to avoid the (hffi-
culty of seizing the missile that may be experienced
if the latter slips behind a rib during the manipula-
tions. Thus, to extract a missile situated beneath
the breast, the buttonhole should be made in the
anterior axillai-y line, and to extract a missile be-
neth the scapula, it should be in the posterior axil-
lary line. At times, to reach the missile it is neces-
sary to have the forceps form a groove at the surface
of the lung; this is better than passing the forceps
directly through lung tissue. These directions do
not apply to cases with suppuration, in which a broad
opening with rib resection is required. Missiles sit-
uated over or in the tissue of the diaphragm should
be dealt with according to their individual situation.
In general, the presence of a missile in the dia-
phragmatic zone can be ascertained by radioscopy,
with intentional changes of the patient's position.
Missiles in the right half of the diaphragm, which
rests over the liver, are best removed through the
chest by the forceps and buttonhole method ; this
applies even if the missile projects from the dia-
phragm into the liver. In the case of projectiles of
the left half of the diaphragm, however, such treat-
ment would be unsafe, and is substituted by removal
from the abdomen through an incision parallel with
the left costal margin. The x rays are seldom re-
quired in such cases. Abdominal removal is also ad-
vised for missiles in the mediastinal portion of the
diaphragm. ^Most of the author's operative re-
movals were effected in men with their wounds
healed, i. e., at least three weeks after the injury.
Nocturnal Enuresis Cured by the Removal of
Adenoids. — Antonio Martin Calderan (Revista de
Medicime y Cirugia Practicas, April 14th, 1918)
reports success in several cases of stubborn noc-
turnal enuresis by removing adenoids. He admits
that the explanation of the mechanism by which
adenoids cause enuresis is difficult to explain, but he
draws attention to the rich nerve supply of the
nasopharynx and the frequent reflex conditions
caused by hypertrophy of its lymphoid tissue, such
as spasm of the glottis, persistent cough, etc. The
most logical hypothesis is that the mechanical ob-
struction to respiration caused by adenoids, which
is worse during the night, produces faulty oxygena-
tion of the blood, and that the excess of carbon
dioxide acts on the medulla, producing enuresis.
This theory is supported by von Mering, Thomson,
Chumier, and Schech. Dalavan claims that chorea
may be caused by adenoids, Thomson adds epilepsy,
while others ascribe to adenoids night terrors, mental
deficiencv. etc.
Nephrotomy and Cassarean Section in Eclamp-
sia.— Clifford White {British Medical Journal, Julv
6, K)i8) believes, on the strength of his own
studies, that the urinary suppression or diminished
flow encountered in some of the cases of eclampsia
is due to swelling of the kidneys producing in-
creased intracapsular tension. The reduced urinary
excretion is insufficient to permit the carrying off of
the toxins from the blood, hence the indication is to
relieve this intracapsular tension before the renal
tissues undergo degeneration. C?esarean section
provides a simple and safe method of rapid delivery.
especially in prirniparae, avoids the dangers of se-
vere perineal lacerations and produces a trauma
less great than that of vaginal delivery. As a result
of these considerations White recommends and
practises in suitable cases the immediate perform-
ance-of a Caesarean section through a high abdom-
inal incision. When this operation has been com-
pleted a retractor of the Doyen type is inserted
and the opening enlarged by retraction upward and
lo the right, ample access to the kidney thus being
possible by virtue of the lax abdominal wall. The
right kidney is then exposed by an incision through
the peritoneum lateral to the ascending colon. The
renal capsule is incised along its convexity for
its entire extent, a small drainage tube is passed
through the skin of the loin, and the abdomen
closed. The results of this method of treatment
have been most favorable.
Lateral Suture of the Popliteal Artery. — Alary
(Prrssc mcdicalc, July 18. 1918) had a case of len-
ticular perforation of the popliteal artery by a shell
fragment, the injury being three mm. in diameter.
In view of the gravity of ligation of this vessel in
ihe popHteal space, he attempted suture ; two per-
forating sutures covered by a superficial purse string
includinsf the adventitia and media were employed.
The results were excellent, no disturbance of the
arterial circulation following. The anterior and pos-
terior tibial arteries, examined daily for eighteen
days until discharge, continued to pulsate normally.
The only signs noticed were slight edema and ting-
ling of the foot, and slight elevation of temperature
above that of the opposite side. In general, in the
case of arteries — ligation of which is dangerous,
suture should be preferred. Circumstances under
which this Drocedure can be attempted are, however,
not frequent ; the injury to the vessel must be rela-
tivelv simple and the condition of the wound must
be such that an aseptic course can be counted upon.
Rodet's Serum in Typhoid Fever. — O. Martin
[Paris medical, fuly 20, 1Q18) has been trying out
the serum of A. Rodet, sale of which is now officially
authorized in P'rance. It is obtained from horses
immunized by serial injections of very active cul-
tures of typhoid bacillus, previously filtered and thus
deprived of almost all bacilli, but very rich in toxin.
The inoculations are continued for three or four
months, and the resulting serum is very strongly an-
titoxic. Clinically it must be employed before the
eleventh day of the disease ; it should be used as early
as possible, as soon as the clinical diagnosis has been
made and before laboratory confirmation. It is in-
jected subcutaneously ; the first injection is of fifteen
mils ; the second, ten mils, and the third, five mils.
The second is given at least two days after the first,
and is not resorted to unless the general condition
becomes worse again or the temperature shows a
tendencv to reascend. The same considerations ap-
plv to the third injection. Usually two injections
suffice. The effects of the serum comprise a rapid
and marked improvement of the general condition ;
lessening of prostration and fever; strengthening of
the pulse ; marked subjective betterment, and a no-
table shortening Of the course of the disease. The
serum is especially intended for typhoid infection.
568
MODERN TRllATMENT AND PREVfiNTIVE MEDICINE.
[New York
Medical Journal.
Urethral Stricture. — Clarence Martin (Urologic
and Cutanvous Rcvic-nj, July, 1918) concludes that
moderate and well executed treatment of [gonorrhea
prevents stricture and that 95 per cent, of strictures
may be treated by dilatation. Thorough anesthesia
and lubrication, coupled with patience, succeed in
seemingly impassable strictures. When a stricture is
undilatable, when urinary abscesses and infiltration
and fistulas are present, urethrotomy should be done.
Where this is necessary the combined internal and
external operation, employing the Maisonneuve
urethrotome for the former purpose is the best.
Any stricture that will permit the passage of a fili-
form bougie may be subjected to an internal uretho-
tomy with the Maisonneuve. External urethrotomy
without a guide is very rarely necessary. A urethro-
tomy should be performed only in cases where
simpler measures fail. C. H. Solomon {Interstate
Medical Journal, July, 1918) affirms that to success-
fully treat strictures of tlie urethra, tbeir character
and location must be diagnosed. Recent soft hyper-
plastic strictures may be gradually dilated with re-
sulting absorption of the pathological deposit and
restoration of the normal calibre of the canal.
Dilators or sounds mav be introduced for i".v- to
ten minutes every four or five days, followed by
an antiseptic wash of weak silver nitrate or i -4,000
solution of oxycyanide of mercury. All strictures
of the hard cicatricial type, located anterior to the
external sphincter should be treated by internal
urethrotomy if not improved by dilatation or if
dilatation is not practicable. After internal ureth-
rotomy the patient is kept in bed five or six days on
a dry diet with a minimum of fluids, and should be
catheterized during this period with a fourteen to
sixteen French soft rubber catheter. Only after
the sixth day after the operation should the patient
be allowed to urinate.
A Preventive and Curative Serum for Gas
Gangrene. — H. Vincent and G. Stodel (Presse
medicalc, July 18, 1018) assert that the short incu-
bation period and rapid course of gas gangrene make
it impossible to rely on favorable results from in-
jection of a specific vaccine. Passive immunization
is therefore necessary. Their "'^w. special serum
Wris put to a severe test before being used in
One or two days after intramuscular inoculation ot
verv purulent BacilVtis nerfringens in guineapigs,
with or without the other anaerobic organisms
causing gas gangrene, the inoculated muscles were
crushed. As shown in a previous research, this reg-
ularly brings on gas gangrene in nonimmunized an-
imals. The animals not protected with the serum
showed TOO per cent, of gas gangrene and a mortality
of 79.07 per cent. Those surviving showed extensive
loss of tissue, v/ith necrosis of the abdominal wall
or loss of the entire limb. Of the guineapigs im-
munized with the serum 95.65 per cent, survived ;
6.52 per cent, developed a mild form of gas gan-
grene, and 4.35 per cent. died. In man equally good
prophylactic and curative results were obtained. It
was injected prophylactically in cases of extensive in-
jury of the thigh or buttock, with infection by dirt
and fragments of clothing and attrition of the tis-
sues. For curative purposes it was injected in thir-
teen cases, of which four were already in a desperate
condition or literally moribund, two having gaseous
involvement of the walls of the abdomen, thorax, or
dorsolumbar region. Eleven of these cases recov-
ered. The twelfth had marked traumatic shock.
Improvement of the local and general symptoms was
very rapid, being manifest already in a few hours
after injection of the serum.
Advantages of Indirect Nerve Suture. — Na-
geotte (Paris medical, July 20, 1918) has found ex-
perimentally that direct nerve suture exposes the
limb to serious trophic disturbances of the muscles
and skin and that these difficulties are obviated by
interposition of a short dead nerve transplant be-
tween the two nerve ends. The number and cal-
ibre of regenerated fibres at the distal end are slight-
ly greater after direct suture, but the functional re-
covery shows that the number of neurites passing
through the scar is not the sole consideration ; the
manner in which they pass is equally important. The
indirect suturing is done with two or three silk
threads passed through the neurilemma. The dead
transplants are obtained aseptically from calf fetuses
fifty to sixty centimetres long, easily obtainable at
abattoirs. They are fixed in fifty per cent, alcohol
and kept in sealed tubes. Only four threads are used
to hold them in place. These transplants remain at
least a few weeks before absorption. Such treat-
ment is practicable only in recent nerve injuries.
Whitman's Abduction Treatment in Fractures
of the Neck of the Femur. — George M. Dorrance
(Pennsylvania Medical Journal, June, 1918) de-
scribes the method as follows : The patient is ether-
ized and placed upon a frame with a perineal bar ;
the thigh is then flexed upon the abdomen, adducted
and extension applied. The thigh and leg are then
abducted until the trochanter strikes the ilium above
the acetabulum. It is then rotated inward and
held in this position and a reen forced cast applied
from just below the axilla to the tip of the injured
foot, the other leg and thigh not being included in
the cast. A pinch of cement applied to the plaster
of Paris from which the bandages are freshly rolled
not only increases the tensile strength but the
rapidity with which the cast hardens. By these
manipulations the fragments, if they are locked, are
first unlocked by the adduction and then by the ab-
duction with the trochanter against the acetabulum.
The inward rotation so pulls the capsular ligament
that the fragments are in approximate alignment.
If the ideal is not obtained, at least they will unite
at a rieht angle and the fractured ends will be in
apposition. It is essential to have an x ray picture
after the application of the cast to be sure the frag-
ments are in apposition. The advantages of this
method are that the fragments are placed in as near
normal position and alignment fls possible and held
there in the ca.st, which not only immobilizes the
fragments but the joints above and below. This
allows the patient to be rotated and turned in any
position without pain. He can rest easily on the
abdomen or back. The patient can be placed out of
bed in a wheel chair the following day. Certain
conditions contraindicate its use — incontinence of
urine or feces and the presence of a larxie hernia.
September 28, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
569
Radium Treatment of Malignancy in the
Mouth and Throat.— Russell H. Boggs {Penn-
sylvania Medical Journal, June, 1918) has used
radium in cases of epithelioma and sarcoma in these
regions and concludes that its value is incontestable.
Treatment varies according to the region and the
nature of the lesion and the condition at the time
radium treatment is instituted. While in many
cases best results are obtained by a judicious com-
bination of different therapeutic agencies, radium
holds its own as a curative measure and supersedes
all other methods as a palliative measure.
Intraspinal Autoserotherapy in Pyocyaneus
Meningitis. — J. Abadie and G. Laroche {Bulletin
de I'Acadcviic de mcdecinc, July 2, 1918) add a new
case of meningitis due to the Bacillus pyocyaneus to
the case reported by Chaufifard and Laroche last
year. The patient had had a penetrating wound of
the skull with flov/ of cerebrospinal fluid, followed
by subacute meningitis. The pyocyaneus origin of
the latter was shown by lumbar puncture and cul-
tures and by the green color of the spinal fluid. The
patient's serum agglutinated this organism in i in
1,000 dilution. Autoserotherapy was practised by
intraspinal injection of three and five mils, respec-
tively, of the patient's serum at an interval of two
weeks. Rapid recovery followed. This form of
treatment is somewhat similar to the isoterotherapy
successfully applied by Netter in epidemic poliomye-
litis, consisting of injections of serum from a con-
valescent or recovered case of the same disorder.
In this case, however, autoserotherapy was indicated
by the known presence of antibodies in the patient's
own serum and the known difficixlty in the penetra-
tration of antibodies from the general circulation
into the meningeal spaces. Autoserotherapy had al-
ready been used successfully by one of the authors
in protracted suppuration of soft parts resulting
from war wounds.
Soamine in Bronchial Asthma. — B. N. Ghosh
{Glasgozv Medical Journal, June, 1918) recommends
soamine in the interval treatment of true bronchial
asthma. Some few cases improved on autogenous
mixed vaccine, but several cases that improved with
soamine failed to improve with vaccines. The cause
of irritation giving rise to reflex paroxysms should
always be sought. In cases in v/hich egg albumen
brings on asthma or urticaria, marked improvement
occurs under calcium lactate and soamine. Cases
.showing no increase of eosinophiles in the blood do
not improve under soamine, but these cases are few.
The plan of treatment consists in giving one grain
of soamine by hypodermic injection and increasing
one grain with each injection until three grains are
reached. At first the injections are given twice a
week, and later, as the conditions improve, once a
week for two or three injections. If paroxysms do
not appear during this period, an injection may be
given once a fortnight, and then once a month for
one or two more injections. The number of injec-
tions required to produce total absence of parox-
ysms varied from six to eighteen — rarely more.
Some patients, who used to have paroxysms almost
daily, have been free from any attack for over one
year. The mode of administration consists in boil-
ing one mil of water in a teaspoon, dissolving a
soamine tabloid in it, and then" injecting the solution
in the arm, after local disinfection with tincture of
iodine. The injection is not very painful; some-
times small nodular masses form, but these eventu-
ally disappear. No untoward results such as dim-
ness of vision or albuminuria were ever noticed.
Cases with chronic kidney lesions should, however,
not be given the treatment.
Treatment of Acute Poliomyelitis with Im-
mune Horse Serum. — E. C. Rosenow {Journal A.
M. A., August 10, 1918) presents further observa-
tions on the curative value of this serum and con-
cludes that the results obtained in sporadic acute
cases, as well as in the epidemic form of the dis-
ease, and in the experimental disease in rabbits are
so striking as to leave little doubt of its merits. It
is of the greatest importance in its use in treatment
to recognize the poliomyelitis at the earliest moment.
The characteristic syndrome of acute poliomyelitis
should lead to immediate lumbar puncture for con-
clusive tests, but if there are symptoms suggesting
involvement of the central nervous system and the
spinal fluid shovv^s increased abundance, increased
cell content with a predominance of mononuclears
and a positive globulin test, the serum should be
given at once, no harm having thus been done
should the further study of the case prove it not to
have been poliomyelitis. In every instance the
serum should be given intravenously and not into
the spinal canal, since this mode of administration
is not only more efifective, but also because the in-
jection into the spinal canal of horse serum may
cause a reaction which will tend to increase the
poliomyelitic involvement. The serum will be sent
free to any one who desires to use it and who will
furnish records of his cases.
Sterilizing Action of Hot Formaldehyde Vapor.
— G. Louis and Rousseau (Presse medicale, June
0, 1918) agree with Chevassu that sterilization with
formaldehyde obtained by heating trioxvmethylene
is unreliable ; this is because the vapor thus formed
becomes at once polymerized. Such is not the case,
however, if one uses dry or but slightly hydrated
formaldehyde gas. If the sterilizer is kept saturated
with formaldehyde vapor throughout the period of
sterilization; if a minimum temperature of 70° C.
is supplied, and if the vapor acts for at least three
Quarters of an hour, perfect sterilisation is obtained,
the process being efifectual even against the most
resistant bacterial spores. In applying this method,
which is especially suited for rubber gloves and in-
struments, metallic boxes are used in which, upon
a double layer of gauze, are evenly sprayed three
mils of forty per cent, formaldehyde solution pre-
viously neutralized with sodium or potassium hy-
droxide. On the gauze are then placed the instru-
ments, which are, covered with another double layer
of gauze. The boxes are now placed in the hot, dry
autoclnA^e for three quarters of an hour at 70° to 80°
C. Finally the formaldehyde vapor in the autoclave
is removed by opening the large inlet for aseptic
air and using the steam ejector for at least ten min-
utes. The efficacy of this mode of sterilization
was shown by numerous bacteriological tests.
570
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Intravenous Injections of Hexarnethylenamine
in Infectious Diseases. — Loeper and Grosdidier
(Pressc fiicdicalc, June 13, 1918) employed intra-
venous' injections of urotropin solution, 0.25 gram
per mil, prepared in the cold with sterile water, in
typhoid diseases, bronchopneumonia, or lobar pneu-
monias, and hepatic and renal disease. The results
were far better than those from oral or hypodermic
administration of the drug. The intravenous in-
jections always exerted a threefold action, antipy-
retic, sedative, and diuretic. More extensive use of
the procedure is recommended.
Magnesium Salts in the Treatment of Cancer.
— Tules Regnault (Bvllctin dc I' Academic dc mcdc-
cinc, July 9, i<;t8) states that, while using arsenic
preparations for epithelioma in the course of the last
eighteen years, he noticed that the best results were
obtained with pastes containing magnesium silicate.
At first he thought the silicate responsible, but when
Robin, in 191 3, called his attention to the presence of
magn'^sia in the zone of natural defense around
neoplasms, he continued the use of the magnesium
salt, adding to it an eosin mordant. He had also
found internal use of magnesia one of the best treat-
ments for certain papillomatous warts. These vari-
ous observations led him to prescribe hydrated mag-
nesia and magnesium silicate — 0.20 to 0.25 gram of
each in a cachet twice daily — first in a case of papil-
loma, then in cases of epithelioma in conjunction
with arsenic pastes locally, and finally in cases of
inoperable cancer. In papillomas and superficial
epitheliomas perfect results were obtained. In inop-
erable cancers the effects Avere not curative, but nev-
ertheless encouraging, viz., arrest and even reduc-
tion of the tumors, marked diminution of pain, and
improvement of the general condition. These re-
sults are ascribed to the phagocytoxic action of mag-
nesium compounds. The author now gives the mag-
nesia and magnesium silicate cachets in all operated
cases of cancer, with the aim of preventing recur-
rence. The cachets are taken onlv five days in every
ten to obviate habituation.
Severe Postmalarial Anemia. — A. W. Harring-
ton and W. Whitelaw ( Glasgmv Medical Journal,
June, T9T8) were impressed in Macedonia by cases
of grave anem.ia, apparently of pernicious type.
Careful examinations were made in eighty cases, all
in Serbian soldiers, with the exception of a few
Bulgar and German prisoners. The twentv-two se-
A-ere cases had red cell counts of two million or
under, the fifteen moderately .severe of three mil-
lions and under, and the remaining forty-three mild
.'ases of over three millions. The severe cases pre-
sented all the signs and symptoms of pernicious an-
emia, but without evidence of oral or intestinal
sepsis. The spleen was enlarged, sometimes coni-
siderably so. The blood showed, besides marked
diminution of red cells, a high color index, leuco-
penia with a relative increase of lymphocytes and to
a less extent of large mononuclears, poikilocytosis,
megalocytosis, polychromasia. occasional granular
basctphilia, megaloblasts and normoblasts, frequently
a small percentage of myelocytes, and myeloblasts
constantly. These cases occurred most frequently
after subtertian malaria, but at times followed ter-
tian. Recovery usually followed ])rompt, energetic
treatment, but sometimes death occurred ; the grav-
ity of the prognosis was found to increase with the
age of the patient. Arsenic proved the best rem-
edy, Fowler's solution being given by mouth in
steadily increasing doses. In the worst cases and
to those patients who could not take arsenic orally,
kharsivan or galyl was given intravenously, with ex-
cellent results. Subcutaneous injections of new
cacodyl proved no more efficacious than Fowler's
solution. Galyl caused the ]iarasites to disappear
from the blood. The arsenic treatment should be
combined with quinine, orally or intramuscularly.
When indicated, iron was combined with arsenic.
Occlusion of Inferior Vena Cava by Hyper-
nephroma.— V. C. Jacobson and E. W. Goodpas-
ture {Archives of Internal Medicine, July, 1918)
note that only forty-three cases of occlusion of the
inferior vena cava by a new growth have up to the
present been accurately described. In thirteen of
these the growth reached as far as the right auricle
or actuallv invaded it. In the authors' case a renal
hypernephroma extended from the kidney into the
ieft renal vein, traversed tiie inferior vena cava
below as far as the iliac bifurcation and grew up-
ward into the right auricle and right ventricle, caus-
ing mechanical embarrassment of the tricuspid valve.
The orifices of the hepatic veins were plugged with
the tumor, and there was acute ceiUral necrosis of
the liver from, thrombosis of the hepatic vein and
its branches. Sudden enlargement of the liver was
accompanied l)y the onset of acidosis, which con-
tinued until death, twenty-four hours later. Where
signs of obstruction of the inferior vena cava al-
ready exist, sudden enlargement of the liver coinci-
dent with onset of acidosis -probably means acute
thrombosis of the hepatic veins.
Prevention of Simple Goitre in Man. — O. P.
Kimball and David Marine (Archives of Internal
Medicine, July. 1918) present reports on the pre-
vention of simple goitre, by small doses of sodium
iodide, in large series of schoolgirls in Akron, Ohio.
In one series, the number of pupils taking the pro-
phylactic treatment was 764 and the number of con-
trols 1,879. May, 1917, and again in November,
two grams of sodium iodide were given in 0.2 gram
doses each school day to pupils from the fifth to the
twelfth grades. Not a single pupil in whom the
thyroid had been normal at the first examination
nnd who took the iodide showed any enlargement of
the gland at the examination in November, 1917; of
those not receiving iodide, twenty-six per cent,
showed definitely enlarged thyroids — some mod-
erately large goitres. Further, a therapeutic efifect
was clearly shown, one third of the enlargements
marked small goitres having disappeared, and one
third of those marked moderate goitres showing a
decrease of two cm. or more. Among over 1,000
girls who took the full treatment only five developed
any noticeable rash. None of these gave any trou-
ble, the condition lasting only tliree or four days.
In not a single instance was the possibility of pro-
ducing symptoms of exophthalmic goitre by the
small doses of iodide substantiated. Results are
held to confirm the authors' earlier conclusion that,
of all diseases, simple goitre is ])robably the easiest
to i)rcvent.
Proceedings of National and Local Societies
THE AMERICAN PEDIATRIC SOCIETY.
Thirtieth Annual Meeting, Held at the Curtis Hotel,
Lenox, Mass., May 2^, 28, and 2^, 1918.
{Continued from page 532.)
Standards for Growth and Nutrition.— Dr. L.
Emmett Holt presented' this paper and showed
charts giving the weight curves from observation
upon over 50,000 boys of different nationalities, both
in this couiitry and abroad. Weight to age variations
were so wide as to make this relationship of very
little value when taken alone. The normal varia-
tions in the weight oi healthy children of the same
race were from ten to fifteen pounds between the
sixth and the tenth years, while from the tenth to
the sixteenth year the range was from twenty to
forty pounds. In a private school in New York for
boys who came from the wealthiest homes, the
weight range from the twelfth to the sixteenth year
was forty to fifty pounds, all being taken with
clothes and by the same physician. Height to age
variations were still less significant. Height was
even more influenced by race and family inheritance
than the weight. Children of the wealthier classes
exceeded those of the less favored in height much
more than they did in weight. The relation of the
height to weight was the only one which was really
important as indicating the state of nutrition, but
here also considerable variation existed in healthy
children. A child's nutrition might be considered
below the normal when he was ten per cent, below
weight for his height between the sixth and the
tenth year, or twelve per cent, below from the elev-
enth to the sixteenth year. The best guide to the
state of nutrition, more important than either of
the foregoing, was the annual rate of increase of
weight and height. The annual increase in weight
was from four to six pounds a year from the
sixth to the tenth year, while it rose to an average
of thirteen pounds in the fifteenth year. Girls
gained at the same rate as boys up to the tenth
year, but surpassed them for the next three years.
The annual increase in height varies normally less
than in weight. The average increase was from
one and three quarters to two inches a year from
the sixth to the eleventh year. It rose to its
highest point in boys from the thirteenth to the
sixteenth year, when it was usually two and one
half to three inches a year. In girls it was highest
from the tenth to the fourteenth year. As a rule
in healthy children, growth in height and weight
were along parallel lines. On insufficient food
growth in height might go on, though observations
on 1,243 school boys between the ages of ten and
sixteen years showed that they increased in weight
one and one quarter pounds more in the six months
from May to November than from November to
May and that the gain in height was 0.38 inch
more during the first named period.
Dr. Fritz B. Talbot, of Boston, said that they
were in great need of just such figures as Doctor
Holt had given, in their work in the Carnegie La-
boratory. In their metabolic work they had found
such a divergence in the basal metabolism that they
did not know where to find the normal and they
first had to come to a conclusion as to what the
basal metabolism was, and the normal relations
between height and weight. There was quite a
variation between height and weight in normal
children. In the new born they had been able to
establish a ratio between the metabolism and the
body weight and it was most probable that there
was some such relation between weight and height
as they had found between weight and metabolism.
Dr. Godfrey R. Pisek, of New York, said there
was need for just such an estimate as Doctor Holt
had given. Many observations had been made in
young children and in children of school age, but
there was a gap between the ages of two and six
years. Many of the observations in reference to
weight and height that had been made were un-
scientific, but when observations were made by a
member of this society or under his supervision,
then the figures were reliable.
Dr. John Lovett Morse, of Boston, stated that
some observations with reference to the rapidity
of growth at dififerent seasons of the year showed
that growth in height was most rapid in the spring
and gain in weight most rapid in the autumn, and
not most rapid in the summer as Doctor Holt had
found in this series of observations.
Dr. J. P. Crozer Griffith, of Philadelphia, stated
that he had been interested in the growth and gain
in weight of children during the neglected period
of childhood — between the ages of two and six
years — and he had made observations on over
200 children. All these children were weighed un-
dressed, while all the observations made on older
children were made with the clothes on. This led
to a discrepancy between the figures for the younger
children and for those who were older unless some
allowance was made for the weight of- the clothes.
Attention should be called to this point so that the
general practitioner would make an allowance for
the weight of the clothes.
Dr. Alfred F, Hess, of New York, said that
during the past six or seven years he had been fol-
lowing the weights and heights of children that
were undernourished. It had been his experience
that they did not gain well in the summer months.
He thought the reason Doctor Holt had noted a
greater gain during the summer might be because
these boys were out of doors and led a freer life
during the summer. To be of practical value he
believed that figures should be based on observa-
tions made on hundreds of thousands of children.
Dr. Charles Hendee Smitxi, of New York, said
that in the nutritional classes of the' outpatient de-
partment of Bellevue Hospital they had charted the
height and weight of the children. These in a
large number of the children ran below the average
standards of Bowditch ; they ran somewhere through
the middle of his curves. They had found that
undernutrition as well as age affected growth in
height. These children could be made to grow in
height as well as to increase in weight by careful
572
J'KOCEEDJXGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
feeding. The factor of heredity also had a great
influence. The children of taller parents if treated
properly could be made to grow more rapidly than
those whose parents were short.
Doctor Holt, in closing the discussion, emphasized
the point that the normal curve was not a line but
a zone and a much wider zone than we had ap-
preciated and that was what the curves he had
exhibited showed. Bowditch made his observa-
tions twenty years ago and it was said that the
children of the present generation were taller than
those of the previous generation. Doctor Griffith
spoke of the weight of the clothes. Doctor Bow-
ditch had shown that the weight of the clothes in
boys and girls averaged very closely to the same
figures. As to the question of more rapid growth
in winter than in summer. The time from October
to May occupied the period of outdoor life and
perhaps that was the explanation of the more rapid
growth during this period. In the records of in-
dividual boys the gain in weight and height was
almost symmetrical, unless there was sickness,
which sometimes made a difYerence. Perhaps in
connection with this subject the Dunfermline scale
should be mentioned, though Doctor Holt said he
could mention it only to condemn it. Doctor Baker
had had 170,000 school children in New York City
examined bv this scale and reached results that
were quite at variance with what was true.
Complement Fixation Test for Tuberculosis in
Infancy. — Dr. Henrv Heiman, of New York,
stated that in the Pediatric Service of Mount Sinai
Hospital the sera of fifty-nine patients from six to
twelve months of ages were tested for tuberculosis,
using the Wassermann system and the antigens of
Miller and Petrofif. Of these cases sixteen were
tuberculous, six probably tuberculous, and twenty-
eight were nontuberculous. Among the former
group were six cases of tuberculous meningitis.
Complement fixation reactions on the blood of these
patients with both antigens was negative in four
and suspicious in only two. Of seven patients with
pleural effusion one was definitely tuberculous,
three were probably tuberculous, and in three others
the causative factor could not be definitely deter-
mined. In these cases the complement fixation
tests were negative with both antigens. The serum
of the three patients in whom the etiology was not
definitely determined gave negative reactions also.
Of six children with pulmonary involvement, two
being cases of miliary tuberculosis, all gave nega-
tive reactions with both antigens. One case of
tuberculous peritonitis gave a negative reaction
with both antigens. The diagnosis was subsequentlv
confirmed by autopsy. Among twenty-eight cases
with no signs or symptoms of tuberculous infec-
tion, complement fixation tests revealed three
strongly positive reactions, one faint inhibition and
one suspicious reaction. In view of the very favor-
able results reported by other men with the same
antigens in general groups of individuals, before
discarding the test for children the experience of
others in this field would have to be ascertained.
Dr. Paul Armand Delille, of France, stated
that some years ago he had made complement fixa-
tion tests in tuberculous children and adults, using
different tuberculins. He had found exactly what
Doctor Heiman had found, namely, that in dif-
ferentiating the tuberculous from the nontuber-
culous the complement fixation test was of no value.
In fact he had obtained more positive results in
healthy children than in children sick with tuber-
culosis.
Dr. J. P. Sedgwick, of Minneapolis, expressed
the opinion that the result' with the complement fixa-
tion test in tuberculosis was largely a question of
antigen. Doctor _ Larsen of the University of
^Minnesota had a better antigen than those now
being used, and one which was giving very remark-
able results. Doctor Larsen had been in France
and was unable on that account to publish his re-
sults. The complement fixation test for tuberculosis
should not be discarded as valueless until Doctor
Larsen had time to publish his work.
Doctor Heiman agreed with Doctor Sedgwick
that the complement fixation test for tuberculosis
should not be discarded but thought that a further
improvement in the technic was necessary.
Pyloric Stenosis : Operation by the Rammstedt
Method. — Dr. Charles Gilmore Kerley, of New
York, said that these twenty-six cases of pyloric
stenosis had occurred in his private practice since
1914. Of the patients seventeen were boys and
nine were girls. The child weighing least at opera-
tion was four pounds, two ounces ; the birth weight
was five pounds, eight ounces. This infant made
an imeventful recovery. The onset of the vomit-
ing was abrupt in all these cases, except one.
Twenty-three were entirely breast fed at the onset
of the vomiting. The vomiting in all cases was
projectile. The peristalitic wave was present in
every case. A tumor was palpable in all the cases
but one. The tumor could best be palpated when
the stomach was empty. It was most frequently
located above and to the right of the umbilicus.
There was no ])nst operative vomiting in seventeen
cases ; nine patients vomited postoperatively, but
these recovered. Postoperative temperature above
loi was noted in seven cases. Four cases ter-
minated fatally, a mortality of 15.3 per cent.
Three of these children were in wretched condition,
and the fourth baby had vomited for ten weeks,'
but in spite of this was in fairly good condition.
Immediate operation was advised, but the familv
persuaded Doctor Kerley to keep the child under
observation for a few weeks. The child developed
a gastrointestinal afifection and in three days the
operative risk had risen fifty per cent. This child
died in collapse five hours after the operation. Doc-
tor Kerley described the post operative manage-
ment of these cases which was that evolved by
Doctor Holt at the Babies' Hospital and was ex-
tremely important. Feeding was begun an hour
and a half after the operation when ten c. c. of
water was given. Two hours later the same quan-
tity of l:i;i.rley water and breast milk was given.
The amount was very gradually increased and at
the end of forty-eight hours the barley water was
discontinued. The baby was not permitted to nurse
until the eleventh or twelfth day, and measure-
ment of the food must be kept up a week longer by
September 28, 19. s.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES 573
weighing the baby before and after feeding. It
was important for an hour or two after the opera-
tion to keep the head of the bed lowered to pre-
vent the aspiration of mucus into the larynx. A
low mortaHty in these cases depended on early
diagnosis and immediate operation. Operation by
the Rammstedt method, which meant a rapid opera-
tion, would in the hands of a competent surgeon
give a mortality of about five per cent. The sur-
gical risk which the patient offered depended in a
large measure upon the duration of the vomiting.
Sudden and unexpected death in the palliatively
treated cases was not uncommon.
Dr. L. E.MjriXTT Holt, of New York, stated that
their experience with hypertrophic stenosis of the
pylorus included about 200 cases, and the more he
studied the matter the more he was convinced that
the treatment was operative. In 100 cases in
which vomiting had not lasted over four weeks the
mortality was forty per cent., while in those in
whom the vomiting had lasted over four weeks it
was fifty per cent. This showed very clearly that
the chances from operation were very mucli better
if the operation was performed early. \Vhile the
risk of operation was something to be considered.^
the risk of not operating was greater than the risk
of operation. Hemorrhage occurred in very few
cases. In their last fifty or seventy-five cases there
had not been a serious complication. They gave
food immediately after the child came out of the
anesthetic, and gradually increased the amount
until at the end of forty-eight hours the child was
getting an ounce of breast milk at a feeding. At
the end of a week the child was getting two' ounces,
but the child was never put on the breast until
nine or ten days after the operation. The after
treatment of these cases was much more difficult
than the operation.
Dr. John Howland, of Baltimore, did not ad-
vise any special method of treatment for these cases
but thought it was possible to cure a great many of
them without operation. In their last thirty cases
thev had had eight operations and all recovered.
Twenty-seven of the thirty cases recovered. He
thought a great deal could be done for these cases
by careful, consistent, patient treatment. There
were some cases that could not be treated in that
way and under serious circumstances operation
should be done at once. Patients with hypertrophic
stenosis of the p)dorus could not be cared for at
home and they cotild not be treated by operation
without breast milk. Operation did not stop the
vomiting in all cases. He had had babies that after
operation vomited for several weeks — almost as
badly as though they had not been operated upon.
One could not necessarily pay that a tumor repre-
sented a large mass of hypertrophic tissue ; the
spasm was what counted most. To have immediate
recourse to operation because there were peristaltic
waves and a tumor was most unwise.
Dr. Alfred F. Hess, of New York, agreed with
Doctor Howland that operation was not always
necessary in cases of hypertrophic pvloric stenosis.
The operation had been so simplified that the ten-
dency was to do it too frequently. The prognosis
depended not upon how long the baby had vom-
ited, but it was a question of the operator. It took
a very skilled man to do this operation and get
good results. He thought the spasm was present
in every case and that active peristalsis did not
necessarily mean hypertrophy. A catheter could
frequently be passed through a pylorus where there
was active peristalsis, and even where there was a
tumor one might be able to get the catheter through.
It had also been noted that during the last forty-
eight hours of life there might be diarrhea and the
pylorus would be found relaxed, so that the cath-
eter could be passed through it easily, whereas dur-
ing the previous week or two this had been im-
possible.
Dr. Henry Dwight Chapin, of New York, cited
an instance in which a child died within forty-eight
houp,s after the Rammstedt operation was per-
formed and at autopsy it was found that the food
had gone through into the peritoneal cavity. The
surgeon had gone too far and cut through the mu-
cous membrane.
Dr. Henry Heiman, of New York, said that
every case of this kind should be treated on its own
merits. He thought that to place dependence on the
length of time that vomiting had lasted was not so
important as to watch the feces.
Dr. Walter Reeve Ramsey, of St. Paul, believed
that a progressive and continuous loss of weight
was always an indication for operation in these
cases.
Dr. Henry F. Helmholz, of Evanston, 111., re-
ported on a series of fourteen cases of hypertrophic
pyloric stenosis treated by himself and his associate,
with thick cereal gruel. He stated that these cases
all showed the typical symptoms of pyloric stenosis.
They found that if the cereal was not thick enough
it would not stay down. Thirteen of the fourteen
cases recovered without operation ; the other case
was operated on and that also recovered.
Dr. H. i\J. McCr.AN^HAN, of Omaha, stated that
he had had, in all, fourteen cases of this condition
and his mortalitv had been higher than that given bv
Doctor Kerley. He believed there were cases of
spasm and cases of stenosis and cases of a combina-
tion of both spasm and stenosis. When the stools
contained nothing but bile and mucus then surgical
interference was absolutely essential. The experi-
ence of the Mayo Clinic had shown that traumatism
and exposure of the bowel was an important factor
influencing the mortality. He had had a case in
which vomiting had persisted after operation and
he had seen two post mortems ; one of these infants
died of hemorrhage on the fifth and the other on
the second day after operation. Dr. McClanahan
emphasized the fact that one might have spasm
without stenosis and these cases would naturally get
well without operation.
Dr. J- P- Crozer Griffith, of Philadelphia, said
he had formerly delayed operation and treated these
cases medically. He had had cause to regret
delay, but he had had no cause to regret operation.
If there was a spasm present and one did not know
whether there was hypertrophy or not he was in-
clined Jo favor operation. He favored operation
more frequently than he formerly did and at an
earlier period.
574
LETTERS TO THE EDITORS.
[\ew York
Medical Journal.
Dr. John I.ovett Morse, of Boston, expressed
surprise at the difference of opinion in regard to
hypertrophic stenosis of the pylorus. He said it
was difficult for him to understand how, with
stenosis still present months after a gastroenteros-
tomy, any method of medical treatment could be
successful. When a- diagnosis of . hypertrophic
stenosis of the pylorus had been made, an operation
was in order. It seemed to him that the Ramm-
stedt was the preferable operation. It required a
good surgeon, who could do the operation in ten
minutes.
Dr. Osc.\R M. SciiLOSS, of New York, called at-
tention to the possibility that in these children with
hypertrophic stenosis of the pylorus the diminished
intake of fluid and the lessened excretion of urine
might cause a retention of waste products and a re-
sulting acidosis that might have a deleterious effect
in case of operation.
Dr. David M. Cowie, of Ann Arbor, said the
advisability of operative treatment depended upon
the degree of stenosis present, whether the stenosis
was of large or small calibre. He thought that the
cases with a stenosis of large calibre might be
treated medically. As time passed the calibre of the
stenosis enlarged with the growth of the stomach.
Doctor Kerley, in closing the discussion, said
that the cases in this series had all been treated pal-
liatively before coming under his care. They were
cases of hypertrophy and not of spasm alone. In
some of the cases a knitting needle could not be
passed through the pylorus. Dr. Kerley said he had
passed through all the stages of palliative, nonoper-
ative treatments, and of waiting to see what would
happen, and he had seen the children die. His con-
clusion had been reached as the result of observa-
tions on sixty or seventy cases. Presence of a well
marked palpable tumor was necessary for diagnosis.
Those who would not accept that as a diagnostic
sign now would do so when they had seen a fev/
more cases.
Value of Auxohormones in Infant Feeding. —
Dr. E. \V. Saunders, of St. Louis, described a
series of cases occurring in his practice in which the
clinical course was as follows : A baby, previously
apparently healthy, was suddenly taken ill and died
unexpectedly. The symptoms presented were in-
somnia, frantic nervousness, vomiting, and loathing
of the particular food upon which the child had
been fed. In addition there would be momentary
slight convulsions, rapid pulse, sHght or no fever,
and acetone breath. Occasionally tetany was mani-
fested in the hands or feet. Death came without
warning. A study of the etiology of these cases
showed one common factor, viz., a history of
prolonged feeding with only a dead food. There
was a class of fat rickety cases due to a certain
tinned food, another class, a peculiar type of Bar-
low's disease, due to another brand of patent food,
and nine tenths of the writer's cases were found
to have subsisted for many months on a third va-
riety of these destroyers. In the treatment of this
condition much might be hoped from the prompt
and vigorous employment of glonoin dropped upon
the tongue, and exclusive tube feedings, using a live
rennet whey containing a rapidly increasing per-
centage of unsterilized cream, autolyzed yeast, and
green vegetable juices. In extreme cases a very
small hypodermic of morphine and atropine was
given, but ordinarily a fractional dose of veronal
acted as a sedative and antiemetic. Calcium bro-
mide and phosphates seemed to be beneficial in all
cases. The author attributed the condition described
to the lack of vitamines in the food and said that if
we did not stop the craze for high sterilization we
would have a nation of rickety dwarfs. To protect
against this tendency we might feed with yolk of
egg, never white ; honey, by which a child would
profit more than by other sugar, and vinegar, which
he had used for the past two years with increas-
ing satisfaction, and which authorities said enhanced
the value of vitamines. Gruels of natural grains,
ground whole, had proved far more acceptable than
the one per cent, decoctions of devitalized grains.
Baby's milk might be constructed out of an ounce
or more of cocoanut oil, emulsified with natural
gruel which had been boiled with cabbage and
sweetened, preferably with honey. The patient
foods for babies were destitute of vitamines and
glandular fat and of an adequate mineral content
and in whole or in part deserved governmental
supervision in the interest of the children. Doctor
Alsberg, chief of the Department of Chemistry,
was anxious to meet a committee of the society
with a view to formulating a bill to be presented to
Congress requiring a label on all patent foods show-
ing whether they contained hormones and anti-
scorbutics. Every parent should be taught the value"
of green vegetable juices and of honey and the
deadly effect of dehormonized cereal foods like
]X)lished rice, which, however, could be rendered
harmless by the addition of domestic yeast.
{To he continued.)
«^
Letters to the Editors.
SPANISH INFLUENZA.
1330 WiLMOT Avenue, Ann Arbor, Mich.,
August 14, 19 18.
To the Editors:
This disease, called in Madrid slang, the Naples soldier,
is rapidly extending all over Europe, especially in Switzer-
land and South Germany. Many foolish things have been
said about this disease especially in the newspapers. Notes
for this article were taken frotn a paper by Doctor Her-
nando, professor of therapeutics in St. Carlos Medical
School of Madrid. Doctor Hernando, together with Doc-
tor Maranon, Doctor Espina, and Doctor Elizagaray from
the General Hospital, Doctor Hinojar from the Medical
School, Doctor Martin Salazar, General Inspector of
Health, and Doctor Cortes, Ex-minister of Public Instruc-
tion and President of the Royal Board of Health, all
think that the epidemic is identical with grippe. Doctor
Pittaluga, on the contrary, thinks that the disease is new.
His position as professor of parasitology and tropical
diseases in Madrid Medical School lends authority to his
statement.
In some cases the period of incubation lasted but twelve
hours ; in others the period was two, three to eight days.
The disease appears suddenly with pain all over the body,
severe headache, asthenia and fever with a temperature
of 37-5° C. to 41° C, lasting for a variable period, ac-
cording to the intensity of the infection and the pres-
ence, of complications. Slight coryza and anorexia were
frequently present. In some patients the disease is gen-
eralized throughout the whole system ; in others, there
September 28, 1918.]
BOOK, REVIEWS.
575
is a marked predilection for one system. Tonsillitis and
bronchitis may develop, and though the attacks are Ren-
erally mild in form, they may become more intensive. The
bronchitis may develop into a pneumonia. This may have
two forms: Ordinary pneumonia, and fibrinous or lobar
pneumonia, giving the bronchopneumonia picture. Vomit-
ing sometimes occurs, associated with either obstruction
or diarrhea with colic and tenesmus. Some patients have
delirium and convulsions tliat together with the vomiting
constitute the pseudomeningitic feature of the grippe.
Frequently Spanish infinenza arouses other latent diseases
to full activity. In tuberculosis, the disease was acceler-
ated when already in the advanced stages, or was set in
evidence when latent.
In the Spanish epidemic, the first cases were more be-
nign than those occurring later ; perhaps because of
exalted microbic virulence. The fatal cases were due to
disease of the respiratory tract. The reports of the mor-
tality have not been exaggerated ; many cases of severe
character are now frequently seen in Switzerland.
Examinations carried out by the Spanish bacteriologists
chiefly by the Epidemiology Section of the Alfonso XIII
Instituto, under the charge of Ranon y Cajal and Tello,
resulted in the finding of the PfeifTer bacillus in a great
many cases and diplococci from the meningococcus and
pneumococcus group, closely associated with Pfeiffer's
bacillus. In many epidemics, however, the Pfeiffer's bacil-
lus was not found (Clemans, Jochmann, Besangon). In
one Leipsic epidemic, studied by Cursmami, no Pfeiffer's
bacillus was found.
Prophylaxis is much too difficult to carry out on ac-
count of the rapidity of the spread of the disease. In
Madrid, in about fifteen days there were about 150,000
patients. Prophylactic measures to be eflicacious would
necessitate the isolation of all cases : but in many cases
the attack is so benign that the patient is unaware of the
disease. Germ carriers would present another difficulty.
The regular hygienic measures must be carried out ; open
air, baths, mouth ajid nose disinfection. Kissing and in-
fectious contacts must be avoided. Thorough disinfec-
tion of handkerchiefs and sputum must be carried out.
No really efficient method of treatment is known. As only
one case in 1,000 is fatal, a useless treatment has an ap-
parent chance of success in 999 cases. Symptomatic ther-
apeusis and treatment of complications as they arise is the
course to be followed.
Jose Luis Carrera,
Former interne of Madrid Medical School, Pensioner of
the Spanish Government in the United States.
MILK AS A GALACTOGOGUE.
New York, September 20, 1918.
To the Editors:
In the August 31, 1918, issue of the New York Medical
Journal there appears an article by Lcroy S. Palmer,
Ph. D., and C. H. Echels, D. Sc., of the Department of
Dairy Husbandry, L^niversity of Missouri, under the title
of Milk as a Galactogogue, referring to an article previ-
ously written by me that appeared in the January 6, 1917,
issue of the New York Medical Journal under the title
of A New and Powerful Galactogogue. There I distinctly
stated, "The technic consists in injecting one c. e. of the
mother's viilk into her subcutaneous tissues, uncffer strict
asepsis. In two days, repeat, and if necessary, in five
days repeat again. This treatment is particularly appli-
cable in cases where the delivery has been recent and in
which the supply of milk is quickly diminished." In this
article the writer reports cases treated successfully both
by him and other physicians. These include three cases
^treated by Dr. A. J. Nossman, of Pasoga Springs, Colo.
The writer commented on these, telling Doctor Nossman
how he believed his technic could be improved. Dr. Har-
vey D. Morris, of Port Arthur, Tex., is quoted as stating,
after treating many mothers whose supply of milk had
become scanty immediately after delivery, "The injection
. of mother's own milk will stimulate the mammary glands
when all other known methods fail."
Dr. Alexander L. Blackwood, of Chicago, 111., author of
several widely used medical textbooks, has been using this
method successfully for several years and values it highly,
as does also Dr. Clement A. Shute, of Pottstown, Pa.
Dr. R. Becerro, in an able article on the subject that ap-
peared in the Revue de thcrapcutique medicio chirurgical,
reports favorable results where there has been a sudden
cessation of mother's milk. He compares it with other
well known and accepted methods of treatment and points
out the superior therapeutic advantages it possesses over
these.
Since then others have verified this treatment. Among
these are Dr. J. H. Wilms, of Cincinnati, Ohio, who not
only reports having treated a number of cases successfully
where the delivery has been recent, by hypodermically in-
jecting a few drops of the mother's own milk, but one
case where the supply of milk had been stimulated a much
longer time after delivery than the writer had any idea
this treatment would prove effective. A review of this
latter case is interesting at this time, in view of this dis-
cussion. Doctor Wilms reported this case and many others
in a paper read before the local County Medical Society
in Cincinnati. "The milk failed thirty-five days after de-
livery. There was scarcely enough at first for the injec-
tion, but a few drops were injected. In a week he injected
five drops ; the supply had increased. In another week
he injected twenty drops. He again made an injection
of the patient's own milk at ihe end of another week.
-After this the supply increased in quantity, and the quality
was good, till the patient was able to nurse her child as
she did before the milk failed."
In the article referred to, in the opening paragraph.
Doctor Palmer and Doctor Echels state (the italics are
ours) : "Two experiments were performed to determine
the effect on injecting the milk of the fresh cow on the
daily milk flow of the cow more advanced in lactation.
One experiment was also carried out to determine whether
the milk has an immediate action on the mammary secre-
tion zvhoi injected from a heavy milking cow zvhich had
recently freshened into one zvhich had lost some of its
natural stimulus, due to advanced lactation." As the re-
sult of these tests they make the following statement :
"Unfortunately it appears no new and powerful galac-
togogue has been found in cov/'s milk." This statement
is based on tests, not one of which is in conformity or
accordance with the technic advanced in my article. They
apparently entirely lost sight of the auto factor that enters
into the technic of all the cases reported in my paper.
Furthermore there is no evidence in any of their tests
that the supply of milk in any animal treated by them had
failed immediately after delivery.
It appears that the Department of Dairy Husbandry of
the University of Missouri is to be congratulated on the
skill and wisdom some of its members possess in inter-
preting plain English. Charles H. Duncan, M. D.
<$>
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]
Civic Biology. A Textbook of Problems, Local and Na-
tional, That Can Be Solved Only by Civic Cooperation.
By Clifton F. Hodge, Ph. D., Professor of Social
Biology in the University of Oregon, Author of Nature
Study and Life; and Jean Dawson, Ph. D., Department
of Sanitation, Board of Health, Cleveland, Formerly of
A'lacDonald College, Canada, and Cleveland Normal
School, Author of Tlie Biology of Physa and Boys and
Girls of Garden City. Illustrated. New York : Ginn &
Co., 1918. Pp. X-.380.
This book strikes a new note in the progressive
chorus that makes for better living and we wel-
come it and would encourage our readers to know
more specifically of its aims and purposes. Never
has there been a time when all kinds of knowledge
could be so utilized by those who have it — by which
civic happiness might be encouraged and made a
practical issue of daily life. Our bird life, the trees.
5/6
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Joukn.m..
(he soil, the water rats, flics, mos([uitoes, the San
lose scale, hookworms, diphtlieria, tuberculosis,
these are among us — in profusion — and causing un-
told distress, discomfort, and unrest.
If individual citizens knew what to do about such
things — that is, knew enough to get together and
stop wrangling about the nonessentials — then these
could cease to be.
The ideal here taught is that of a cooperative
good will in attack on these problems. Thus is built
up a mass of principles of inestimable worth to
society and a sound civic psychobiology is made
efifective. This book is an attempt to get together
on essentials along many of the lines indicated ; a
short, practical manual of things everybody would
do well to know in order to live comfortably.
Essentials of Dietetics. By Maude A. Perry, B. S., for-,
merly Dietitian and Instructor in Detetics at Michael
Reese Hospital, Chicago, Illinois; Corresponding Secre-
tary of the American Dietetic Association; Red Cross
Dietitian for Base Hospital Unit No. 14. St. Louis :
C. V. Mosby Company, 1918. Pp. 160.
This small work is a really excellent elementary
text on dietetics fpr nurses. Its most conspicuous
feature is its perfect adaptation to the pupil nurse's
needs. It is addressed directly to nurses, and
throughout this purpose is adhered to rigidly. Miss
Perry knows her subject and is expert in presenting
it clearly, concisely, and simply. We commend
especially her brief, almost choppy sentences and
her positive style, which tend to clarify and drive
home essential points. Qualifications or exceptions
to statements are taken up immediately and dis-
criminately and without confusing detail. Emphasis
upon individualization is another good point which
comes up repeatedly throughout the book under
many different topics. The material has been well
selected from this extensive subject and serves to
establish a foundation either for successful general
nursing or for further specialization.
Principles and Practice of Infant Feeding. By Julius H.
Hess, M. D., Major, M. R. C., U. S. Army, Active Serv-
ice, Professor and Head of the Department of Pedi-
atrics, University of Illinois College of Medicine ; Chief
of Pediatric Staff, Cook County Hospital; Attending
Pediatrician to Cook County, Michael Reese, and Engle-
vvood Hospital, Chicago. Illustrated. Philadelphia :
F. A. Davis Company, 1918. Pp. xii-3.38.
There is always room for another text in this
highly important field and room for improvement
upon previous texts. Hess's object here is,
modestly, not so much to improve upon the many
excellent but voknninous works covering this sub-
ject, but to present it in concise form in a small
volume. This manual, "to be used in preparation
for clinical conferences by teachers and students,"
should find a definite place for this purpose. In
addition, it is characterized by a clear and work-
manlike style, scientific accuracy, and practical
common sense. A great deal of the latest and most
valuable material is given here and every effort has
apparently been made to make this small work a
real contribution toward solving the problem of
first year infant mortality, always of paramount im-
portance, but at present even more imperative. In-
troductory chapters on the anatomy and physiology
of the digestive tract of the infant and metabolism
in the infant give the necessary foundations. Part
II, on Nursing, contains valuable chapters on ma-
ternal nursing and wet nursing, the nursing infant,
mixed feeding and weaning, nutritional disturb-
ances in the breast fed infant, and methods of feed-
ing premature infants. Part III discusses fully
and definitely artificial feeding and Part IV nutri-
tional disturbances in artificially fed infants. An
appendix contains much important miscellaneous
matter bearing on the subject.
Tl!c Treatment of War Wounds. By W. W. Keen, M. D.,
LL. D., Major, Medical Reserve Corps, U. S. Army,
Emeritus Professor of Surgery, Jefferson Medical Col-
lege, Philadelphia. Second Edition, Reset. Philadelphia
and London : W. B. Saunders Company, 1918.
Major Keen performs a great service in this rapid
up to the minute report on war work. Things are
moving so quickly; scientific progress of a decade
is accomplished overnight; the literature is enor-
mous and one cannot keep up with it and carry at
the same time the increased load of professional
work, both war and civilian. This short, pithy, and
authoritative resume of work at the front "does not
pretend to be complete, but is only a memorandum
on soine of the more important and most recent im-
provements in the treatment of war wounds."
Major Keen has added much very important ma-
terial to his interesting and valuable first edition.
He includes work on acriflavine, proflavine, and
brilliant ereen, and the latest technic on the parafifin
treatment of burns, work with dichloramine-T, and
the simplified technic of Dakin for the treatment of
infection in wounds, and the antitoxin against gas
gangrene. He has condensed from very recent cur-
rent literature and other sources, as, for instance,
personal correspondence with Bowiby, Blake, Crile,
Halsted, and Heiser, in this small volume, the vast
practice of war surgery and leavened it with critical
discussion and judgment from his own rich experi-
ence. Comment on particular phases of the won-
derful development of technic would be unjust and
perhaps unnecessary for readers who are familiar
in a general way with the marvels of the surgery of
loday. We recommend this little work for its gen-
eral surgical interest, as a source of special informa-
tion and for its bibliographies.
Births, Marriages, and Deaths.
Died.
Deimari::st. — In White Plains, New York, on Wednes-
nlay, September iSth Dr. John H. Demarest, aged eighty-
two years.
Denning. — In Boston, Massachusetts, on Wednesday,
September i8th. Dr. Frederic J. Denning, aged thirty-
three vears.
Hands. — In Cambridge, Massachusetts, on Wednesday,
September i8th, Dr. H. A. Hands, aged sixty-six years.
ATcGowAN. — In Philadelphia, Pennsylvania, on Satur-
day, September 7th, Dr. Joseph A. McGowan, aged forty- •
three years.
Shollenbercer. — In Reading, Pennsylvania, on Mon-
day, September i6th. Dr. Louis A. Shollenberger, aged
thirty-three years.
Stfvens. — In Marlboro, Massachusetts, on Wednesday,
September i8th. Dr. Charles E. Stevens, aged forty-three
years.
Warner. — In Red Bank, New Jersey, on Tuesday, Sep-
tember loth. Dr. William B. Warner, aged fifty-eight
years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal ?h1 Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII, No. 14. NEW YORK, SATURDAY, OCTOBER 5, 1918. Whole No. 2079.
Original Communications
THE GENERAL DIAGNOSTIC STUDY BY does not occasionally arrive at a diagnostic conclu-
THE INTERNIST.* sion that he is later compelled to revise? But if
Cooperating with Groups of Medical and Surgical ^^/^ recognize how difiicuk diagnosis is, if we try to
Specialists observe accurately ourselves and enlist the aid of
T^, ,,T^ experts in accurate observation in special domains
By Lewellys F. Barker, M. D., j^^he collection of data, if we develop fully the
Baltimore. implications of the diagnostic suggestions that occur
{Concluded from page 542.) to us and compare these with the data observable
DIAGNOSTIC CONCLUSIONS OR BELIEFS. before permitting ourselves to arrive at diagnostic
To verify a diagnostic inference after having conclusions, in other words, if we apply the method
found out what it implies, we must establish the science to clinical diagnosis, we can feel sure that
identity of the facts with its implications. Corre- we are working in the right way, and that as we
spondence with what has been, or can be, observed grow in knowledge and experience we shall become
is the only legitimate proof of a diagnostic hypoth- '^s good diagnosticians as is possible within the Hm-
esis. We test an idea that we have tentatively itations placed by our natural endowments and our
entertained and rationally elaborated by seeing first opportunities. .\prENDix
whether it can be identified with the conditions ' ' . ' . , , ,
that are actually observable in the patient, and, illustrate my own application of the methods
secondly, whether the distinguishing criteria of everyday diagnostic work, very brief summaries
rival tentative ideas of diagnosis can be proved to ^our cases recently studied may be given,
be absent. In this testing we mav, as we have Case I.— Male, age forty-one ; lawyer ; seen October 19,
o^^,-, 1^^ 1 uv-Ui 4- J J- . i_ 1017. No. 4is=. Complaint: Attacks of 'unconsciousness,
seen, be compelled both to extend our direct obser- Anlmnesis Nummary) : Healthy until present illness ex-
vation ot the patient and to make certain additional cept for recurring tonsillitis, old antral infection (right),
experiments that will permit the making of special and an attack of functional aphonia (1913)- Slight ver-
observations that will strengthen or weaken the ^""^^ °" sudden movement of head. Married four-
c.ii^r^oc;f;^^oi ■-^(^■^^■^^^ T J r.L teen years: wife never pregnant; denial of venereal in-
suppositional mference. In other words, after we fections. Excessive use of alcohol and tobacco. Family
have thought, we must again observe in order to history negative, except that one sister is hysterical. No
corroborate, or refute, a tentative diagnostic con- epileptic ancestry.
jecture. In our infected patient with palpable ^P/'^' ^^''[^ in a restaurant, fell uncon-
cr,i„„„ f^„x^ 1 i„ „• ^ , Fcious (twentv to thirty seconds). During next three
spleen, fever and leucopema, we may on closer j^onths f,ve similar attacks, three at table, two on rising
observation discover some previously overlooked from bed. No more attacks until September, 1917; severe
rose spots ; or we may find on the lip a slight herpes attack while at table eating; fell to floor; unconscious (five
that had been passed over as insignificant- or ""l^ minutes); bit tongue; confused after attack. In
. „i • „ r 11 .Li 1 ^ • i ' ' October, 1917, similar severe attack. Home physician re-
again. on looking carefully through a stained smear garded earlier attacks as psychogenic, but has been led
of the blood \ye may find a single crescent shaped by later attacks to the diagnosis of epilepsy,
malarial parasite, or we may make a culture from Physical examination (summary): Height, five feet ten
the blood in bile bouillon, grow a motile bacillus ^"'^^^^ weight, 212 pounds; calculated ideal weight, 165
„_j „ V i; 1 i. • .Li -11 ' pounds; some dead teeth; gingivitis; pigmented eyehds ;
and on testing it find that it is the Bacdlus para- slight struma with slight eye signs; blood pressure, 125/90;
typhosus; or we may after the application of many phimosis; scanty hirci; transverse crines ; hypoplasia of
tests still remain in doubt as to the cause of the gonads and phallus; small prostate; reflexes normal,
infection until a week or two later oerhaos we Laboratory tests requested: Blood; cerebrospinal fluid;
r;„j 1 ui 1 ^ "cipj, vyv_ gastric Contents; feces; urine.
find ourselves able to demonstrate the presence in x ray tests requested: Stereoscopic of skull; paranasal
the blood of specific agglutinins previously non- sinuses; telerontgenogram ; gastrointestinal tract; teeth,
demonstrable. Diagnostic suggestions elaborated Examinations by specialists requested: Neurologist;
by reasoning have to be tried and tested until some P^y-^-h'^trist ; ophthalmologist ; rhinologist ; dentist ; urolo-
one of them is corroborated and verified. Then, ^'^ ' l.vbopatory reports.
and only then, should we permit ourselves to ac- Blood examination: No. Percent.
cept an inference, to conclude that it is correct to B. C 4,192,000 P. M. N.... 152 60.8
believe it. Even when all these precaution W; B. C.- • • . . . . ,0,700 P-M.E.. 2 .8
taken we shall sometimes make mistakes in diag- R. B. C. and platelets nor- S. M 71 284
nosis. Who among us, including the most careful mal. No abnormal cells L. M ) , „
; seen. Tr j
♦Address delivered at the New York Academy of Medicine
December 6, 1917.
250 100.0
Copyright, 1918, by A. R. Elliott Publishing Company.
£78 BARKER: GENERAL DIAGNOSTIC STUDY OF THE INTERNIST. [New York
O/o " Medical Journal.
Blood IVasscnnann reaction: Antigen — A, cholesterinized
human heart, negative. B, acetone-insoluble lipoids, nega-
tive. C, plain extract beef heart, negative.
Cerebrospinal fluid exatnination: Negative with antigens
A, B, and C. Pressure much increased ; globulin, faintly
plus; fluid clear; colorless; cells, i6 per c. mm., gold, com-
pletely negative.
Gastric analysis: 12 c. c. recovered; colorless.
Free HCl......... 65
C. acid IS Occult blood 0
— Lactic acid o
T. A 80 ac.% Micro., negative.
S'.'ol: brown, soft.
Occult blood, { Ben^i^Vine, +.
Bile, -f
Micro. : negative.
Urine :
Night. Day.
Specific gravity 1034 I0I4
Albumin o trace
Sugar o o
Few finely granular casts, no R. B. C. nor W. B. C.
X RAY REPORTS.
Stereordntgcnogram of skull: Examination shows a very
large, deep sella. It is well formed, however ; no irregu-
larities in its outline can be made out. Sphenoidal sinus is
quite large and clear. Nothing abnormal is noticed in the
rest of the cranium.
Telcrontgenogram :
M. L 9.5
M. R S.
T ii.S
L 15.
A 7.5
Paranasal sinuses: Clear. The right frontal is not quite
as clear as the left, but this is probably due to a shallow
sinus, as the ethmoids on that side are clear. There is an
imusually large development of the ethmoidal cells, espe-
cially of the posterior ethmoids.
T ceth: No definite abscesses could be made out. One
lower molar has a beginning granuloma.
Gastrointestinal tract: Impression: functioning nor-
mally. No definite lesion made out.
REPORTS OF SPECIALISTS.
Neurologist : The only objective finding from my stand-
point is the suspicious L. optic nerve. It is certainly not
normal, and if it is an acquired condition would be of
importance. The nasal edge of the R. one, too, is not abso-
lutely clear. For the rest, the attacks suggest epilepsy,
but why he should have it at his time of life is a mystery.
The history of what seem to be two attacks of scintillating
scotoma is interesting. He is, of course, of a highly neu-
rotic temperament.
Psychiatrist : It does not seem as if there could be any
doubt about the epileptic character of the attacks in this
patient. At the same time there is a psychogenic com-
ponent in his make-up, as shown in an aphonia which he
had about six years ago and which lasted six weeks, and
the fact that the patient has had a great deal of self-re-
proach for autoerotism, which he carried on partly on ac-
count of a peculiar tendency to secretion of his prepuce,
which would come on, according to his impression, when
he did not masturbate. The patient does not, however,
give any evidence that the attacks as such appeared under
any special affective strain. I did, however, emphasize the
importance of relieving himself of the self-reproach and
the ensuing tension.
The mental status does not bring out any deficit. The
patient retains eight digits but fails with nine. His cal-
culation when hasty is somewhat faulty, but correct under
proper attention. There is no evidence of any focal brain
lesion.
It seems that the patient has been taking bromide with-
out any attempt at reducing his sodium chloride. It would
seem very probable that the attacks could be kept in check
better than has been the case in the past.
Ophthalmologist : i. Central vision normal when refrac-
tion error (hyperopic astigmatism) is corrected. 2, Muscu-
lar balance normal. 3. Perimetry (two examinations, on dif-
ferent days) reveals slight bitemporal contraction ; right eye
more involved than left. 4, Eyegrounds : Low grade of
edema at neuroretinal margin on nasal side of each disc,
more marked in right eye than in left, corresponding to
contraction of visual field. Not enough change yet to
demand decompression for the sake of his eyes, but that
need may develop. Advise watching eyegrounds closely.
No signs of retinal arteriosclerosis.
Rhinologist: Tonsils adherent; small mass of adenoids;
si. septal deflection; hypertrophy of left inferior tur-
binate ; sinuses clear ; pharynx and larynx negative. Ears
normal.
Dentist: Marked gingivitis. One inferior molar tooth
has beginning granuloma.
Urologist: Both testicles very small; right smaller than
left; small cyst in left epididymis; prostate very small and
indistinct. Seminal vesicles small. No signs of urogenital
infection. No indication for cystoscopy.
REARRANGEMENT OF THE DATA IN CASE I.
Case I. — (No. 4155.) Male. Age forty-one. Lawyer.
Complaints : Attacks of unconsciousness.
Habits: Excessive use of tobacco (twenty cigarettes,
several pipes) before present illness; alcohol in excess.
Previous infections: Recurring tonsillitis; denies vene-
real disease.
Operations : Cauterization of tonsils ten years ago.
Respiratory system: Morning cough for years; sore
throat frequently; slight nasal obstruction (septal deflec-
tion) ; enlarged inferior concha (left) ; tonsils enlarged and
adherent; small mass of adenoids in nasopharynx; emphy-
sematous thorax ; lungs negative ; x ray of paranasal
sinuses negative.
Circulatory system: Pulse rate 88; radials just palpable;
B. P. 125 systolic, 90 diastolic ; heart negative except for
soft systolic murmur at ape.x ; telcrontgenogram : MR 5 ;
ML 9.5.
Blood system: R. B. C. 4,192,000; Hb. 90 per cent.; W.
B. C. 10.700; WaR. 0 (3 antigens) ; PMN. 60.8 per cent.;
PME. 0.8 per cent. ; SM. 28.4 per cent. ; LM. 6.8 per cent.
Epitrochlear and retrocervical nodes palpable.
Digestive systetn: Free HCl 65; TA. 80; occult blood, o;
stool o; slight gingivitis; tongue coated, tremulous; sev-
eral dead teeth ; x ray of stomach and intestines after
barium, negative ; one lower molar has a beginning granu-
loma (x ray).
Urogenital system: Urine: Sp. gr. 1014-1034; alb. o;
sugar o; few granular casts; W. B. C. o; R. B. C. 0.
SI. nocturia; phimosis; hypoplasia of gonads and phallus;
small prostate.
Locomotor system: Negative.
Nervous system: Aphonia after father's death, four
years ago ; under great pressure of work at the time ; his-
tory of self reproach for autoerotism; occasional dizzi-
ness; occasional scintillating scotoma; attacks of uncon-
sciousness (seven) since April, 1916; attacked most often
when eating at table ; unconscious one to six minutes ; in
recent attack bit tongue and jerked (grand mal) ; one
sister is hysterical; patient always neurotic; deep and su-
perficial reflexes normal ; cerebrospinal fluid under in-
creased pressure, sixteen cells, WaR. and gold-sol. tests
negative ; low grade edema of optic discs ; slight bitem-
poral narrowing of visual fields.
Metabolic and endocrine systems: Former weight 261,
now 212; height five feet ten inches; ideal weight 168
pounds ; narrow lid slits ; pigmented eyelids ; slight eye
signs ; slight struma ; scanty hirci ; transverse crines ; hy-
pertrichosis of trunk; large deep sella in x ray.
DIAGNOSTIC SUMMARY.
1. Epilepsia tarda.
2. Initial stage of bilateral choked disc.
3. Enlargement of sella turcica [struma (?) ; neoplasm
4. Endocrinopathy (dystrophia adiposogenitalis) .
5. Slight oral sepsis.
6. Chronic tonsillitis ; slight adenoids ; hypertrophic
concha.
7. Psychoneurotic state (history of aphonia, of self
reproach for autoerotism, etc.).
8. Slight nephropathy.
9 Gastric hyperacidity (cause not yet determined).
10. Tabagism and potatorium.
October 5. i9<8.] BARKER: GENERAL DIAGNOSTIC STUDY BY THE INTERNIST.
579
Case II. — Male, age 51, coal dealer (seen October 30,
1917). No. 4187-
Complaint : Fever in afternoons for two and one half
months, with headache, soreness in the abdomen, weakness
and stiffness of the neck.
Family history: Negative; married twenty-six years;
wife and three children living and well.
Personal history: Always thin; much trouble with teeth;
otherwise healthy; denies venereal infection. Rapid eater.
Smokes eight cigars daily; whiskey occasionally. Indoor
occupation.
Present illness: Began to feel badly about three months
ago. Fever in afterooons. Treated for malaria. In bed
ten days. Fever ceased but returned ten days later with
headache and discomfort in abdomen. Has had x ray of
stomach, reported negative. Much sore throat lately. Neck
sore. Loss of appetite. Loss of weight. Nervousness.
Insomnia. Home physician suspected i, malaria; 2, intes-
tinal toxemia; 3, septic fever from hidden focus. His
dentist extracted several teeth, but the fever continued.
Finally, his physician suspected the apices of lungs and re-
ferred him for general diagnostic study.
Physical examination: (Summary of positive findings).
Height six feet ; weight 130 pounds. Long extremities.
Straw tint to skin; thickened radials ; B. P. ii.=;/8o; retro-
cervical lymph glands palpable ; slight eye signs ; teeth sus-
picious. Throat injected. Crackles after coughing at right
apex. Accentuated aortic second. Spleen just palpable.
Tenderness of left epididymis.
Laboratory tests requested: Total blood examination, in-
cluding WaR. and blood culture; sputum; gastric juice;
urine ; feces.
X ray examinations requested: Paranasal sinuses; lungs;
C.-V. stripe; G.-I. tract.
Special examinations requested: i, teeth; 2, nose and
throat ; 3, eyes ; 4, lungs ; 5 urogenital system.
LABORATORY REPORTS RECEIVED. .
Blood:
R. B. C 5,232,000 P. M. N..
W. B. C 7,000 P. M. E...
Hb 90% P. M. B..
R. B. C. and platelets nor- S. M
mal. No abnormal cells L. M. )
seen. T. R. j
No. Per cent.
165 66.0
o 0.0
O 0.0
67 26.8
If
7.2
Soft ; brown ; bile + ; occult blood | ,
250 100.0
Blood Wassermann reaction:
Antigen A, cholesterinized human heart, fixation 100
per cent.
Antigen B, acetone insoluble lipoids, fixation 100 per
cent.
Antigen C, plain extract beef heart, fixation 100 per cent.
Gastric analysis:
14 c. c. recovered, colorless.
Free HCl 30 Micros. : negative.
C. acid 20 Occult blood 0
— Lactic blood o
T. A 50 ac.%
Stool:
benzidine. 0
guaiac... o
Micros. : negative.
Sputum: Mucopurulent; colorless; negative for tubercle
bacilli.
Urine analysis: Night. Diay.
Specific gravity 1020 1014
Albumin Tr. Tr.
Sugar o 0
Micros.: Few W. B. C. and one finely
granular cast.
Blood culture: Negative on fifth day.
REPORTS FROM THE RONTGENOLOGIST.
The examination of the paranasal sinuses shows a very
slight clouding of the right antrum, suggesting an old in-
fection. The septum is straight and the air passages are
clear.
The examination of the lungs shows a chronic fibroid
change throughout both lungs, particularly the left upper ;
calcified glands in the mediastinum ; root consolidations.
These changes impress me as being tuberculous in origin
but inactive.
The fluoroscopic examination of the cardiovascular stripe
shows it to be practically normal ; a very slight dilatation
of the first curve, but this cannot be considered as a true
dilatation, but seems a normal variation when the age of
the patient is considered. No evidence of any aneurysm.
Heart is not enlarged.
The fluoroscopic examination of the gastrointestinal tract
shows a prolapsed stomach ; fundus in the pelvis ; very
sluggish and atonic; no filling defects to be made out;
upon palpation the stomach is stimulated and bismuth flows
through freely. Transverse colon prolapsed, lying on the
floor of the pelvis, pulled in and adherent to the cecum
and cannot be separated upon palpation. Patient complains
of pain in this region when pressure is made. Condition
impresses me as being an enteroptosis plus a mild lower
right quadrant lesion.
REPORTS FROM SPECIALISTS.
Denial report: Radiographic review of doubtful areas of
mouth shows that in No. 27, the right inferior canine, and
No. 22, the left inferior canine, there has been complete
destruction of alveolus ; these teeth should be extracted
and the sockets curetted, after which the lower denture
can be arranged. No. 6, the right superior canine, No. 12,
the left superior first bicuspid, show periapical rarefactions,
which are not deep; root canals well filled; present bridges
are so necessary for mastication, would suggest that api-
coectomy be done ; these teeth should be kept under radio-
graphic survey, and if they do not clear up they should be
extracted and the sockets curetted.
Nose and throat specialist: Sinuses, right antrum dark
on transillumination ; left not quite clear. Tonsils, adher-
ent; right tonsil red and injected. Pharynx, injected.
Larynx, normal. Nasopharynx, negative. Nose, slight
septal deflection to left ; hypertrophy of right inferior tur-
binate. Impression: Patient has subacute pharyngitis and
tonsillitis on right side as well as chronic infection of ton-
sils. Probably all his complaints are due to his tonsils.
Right antrum possibly infected.
Qphthalmologist: The chief trouble I have found in this
patient is his refraction error, which I thought insufficiently
corrected. I think he will be more comfortable with his
new glasses. Ophthalmoscopically there was nothing wrong
to note. The only field defect is a slight narrowing of 10°
or 15" for red, up and down, in each eye; of no especial
significance.
Tuberculosis expert: (Details of report not given here,
only the conclusions.) The patient has an old chronic pul-
monary tuberculosis involving the two upper lobes. Judg-
ing from the physical signs, lesion is relatively inactive.
However, the condition of the lungs might easily explain
all the patient's symptoms.
Urologist: No evidence of tuberculosis, either in epididy-
mis, vesicles, or prostate. Patient evidently had an old
simple inflammatory infection of left vesicle and epididy-
mis, now entirely subsided. No inflammatory process in
genitourinary tract that needs attention.
REARRANGEMENT OF THE DATA IN CASE II.
Case //.— F.N., male, age fifty-one, coal operator. (4187.)
Complaints: Fever in afternoon; headaches; cough;
weakness and stiffness of back.
Habits: Eight to twelve cigars daily; almost no alcohol;
rapid eating.
Previous infections: Recurring colds in the head and sore
throat, especially recently ; oral abscesses ; denied venereal
diseases ; malaria suspected since fever began.
Operations : None.
Respiratory system: Cough ; some sputum, negative for
tubercle bacilli ; respiratory rate 22 ; slight nasal obstruc-
tion ; tonsils adherent ; diminution of respiratory move-
ments over both upper lobes, especially the left; left shoul-
der sags; dullness at both apices to second rib on right,
to third rib on left; roughened breathing and prolonged ex-
piration at both apices; a few fine moist rales (after cough-
ing) at each apex, both in front and behind. Tuberculosis
expert reports "both uppers relatively inactive." X ray
of paranasals : si. clouding of right antrum, also dark on
transillumination. X ray of lungs : slight fibroid change in
both upper lobes.
Circulatory system: Pulse 104; hands cold and clammy;
radials thickened, whipcord-like; B. P.: 115 systolic, 80
diastolic ; slight cyanosis ; A 2 + ; rontgenoscopie of C. V.
stripe: si. dilation of aorta; no aneurysm; heart not en-
larged.
58o
DARKER: GENERAL DIAGNOSTIC STUDY BY THE INTERNIST.
[New York
Medical Journal.
Blood system: R. B. C. 5,232,000; Hb. 90 per cent. ; W. B.
C. 7,000; WaR. : Fixation 100 per cent, with three different
antigens ; P. M. N. 66 per cent. ; P. M. E. 0.0 per cent. ;
S. M. 26.8 per cent. ; blood culture o. Pallor ; lemon yellow
tint to skin; retrocervical glands palpable (small nodes).
Digestive system: Free HC1; 30 T. A.; 50. Occ. bl. ; o
stool ; o dysphagia ; gaseous eructations ; constipation ;
soreness in abdomen; subicteric tint ta sclerae; suspicious
teeth, odor of pyorrhea ; tongue coated ; subacute pharyn-
gitis ; spleen palpable ; slight tenderness in R. L. Q. Den-
tist reports proliferative periodontitis (q. v.) and gingivitis.
Rontgenoscopie of g. i. tract: prolapsed stomach, fundus in
the pelvis, sluggish motility, transverse colon adherent to
cecum ; impression, viceroptosis plus mild right lower quad-
rant lesion.
Urogenital system: Urine: Sp. gr. 1014-1020; alb. trace;
sugar o; cyla. ; one seen; VV. B. C. few; R. B. C. o; right
kidney palpable and mobile ; left epididymis tender. Urolo-
gist: No evidence of tuberculosis of epididymis, vesicles,
or prostate ; no genitourinary infections ; thickness of epi-
didymis due to an epididymitis one and one half year ago.
Locomotor system: Weakness; soreness.
Nervous system: Nervousness; insomnia; motility, sen-
sation and reflexes normal; refraction error (corrected).
Metabolic and endocrine systems: Loss of weight; now
forty-five pounds under weight; temperature 98°-i02° ;
long extremities; fingertips quadrangular; enopththalmos ;
narrow lid slits; slight v. Graefe and Dalrymple; no
struma ; hypertrichosis.
DIAGNOSIS.
1. Lues : WaR. = 100 per cent, fixation. Surprise. Pa-
tient, when informed, admitted probable luetic infection
about one year ago and treatment for a skin eruption last
summer ; luetic angina ; retrocervical adenitis ; headaches ;
fever ; palpable spleen. "
2. Oral sepsis : Pyorrhea alveolaris ; periapical rarefac-
tions due to granulomata (proliferative periodontitis).
3. Chronic pulmonary tuberculosis (relatively inactive).
4. Chronic tonsillitis; old infection of right antrum.
5. Visceroptosis ; mild R. L. Q. lesion.
6. Emaciation : Forty-five pounds under calculated ideal
weight.
7. Beginning atherosclerosis : Thickened radials ; slight
dilatation of aorta ; slight nephropathy.
Remarks: In order of importance at present, probably
I, 2, 6, 3, 4, 5, 7.
PLAN OF THERAPY OUTLINED.
1. Lues to be thoroughly treated; rest; diet; salvarsan ;
mercury ; special isolation.
2. Oral sepsis to be overcome. Extract No. 27 and No.
22. Curette sockets. Do apicoectomy on No. 6 and No. 12.
Later keep under rontgenographic survey; if necessary,
extract and curette sockets. Prophylaxis of gums.
3. Rest and feeding cure to gain forty pounds in weight.
Rest in bed four or five weeks. Special nurse. After a
few days of Dubois diet, give three large meals a day, with
two quarts of milk a day and one or two raw eggs after
each meal. Massage thrice weekly. Bed in open air, night
and day. Psychotherapy.
Case IIL — Male, age fifty-one years, merchant, seen Oc-
tober 30, 1917. No. 4186.
Complaint : Watering and weakness of the eyes for two
years ; pain over heart on exercise ; intermittent swelling of
neck and eyelids ; increased saliva ; itching of skin.
Anamnesis (summary): Single man. Always fairly
healthy. Family history negative. History of otitis media,
nasal polypi, bronchial asthma, and gonorrhea ; denies lues.
Habits regular.
Present illness began insidiously about two years ago.
Tendency to increase in weight; noticed increased flow of
saliva and pain in precordial region on exertion. Slight
nocturia. Neck swells diffusely at intervals ; eyelids often
puffy; eyes "watery"; slowing of thought and speech.
Physical examination (summary) : Height five feet eight
inches ; weight 187 pounds ; calculated ideal weight 154
pounds ; pulse rate 68 ; blood pressure 180/140 ; skin dry
and pudgy; tongue large; suspicious teeth; pyorrhea al-
veolaris; pharyngitis; conjunctivitis; scanty hirci and
crines pubis ; transverse crines ; hypotrichosis of trunk and
extremities ; puffy eyelids ; small thyroid ; enlargement of
heart ; accentuated aortic second sound ; reflexes normal.
Laboratory tests requested: Blood count; Wassermann
test; gastric contents ;; feces ; urine; renal function tests.
X ray examinations requested: Paranasal sinuses; teeth;
telerontgenogram ; rontgenoscopie of gastrointestinal tract.
Examinations by specialists requested: Dentist; ophthal-
mologist; rhinologist.
REPORTS OF LABORATORY TESTS.
Blood examination:
No. Percent,
R. B. C =5,212,000 P. M. N i=;g 63.6
W. B. C 6,900 P. M. E 2 .8
Hb 8s% P. M. B 0 .0
R. B. C. and platelets nor- S. M 72 28.8
mal. No abnormal cells L. M. ) gg
seen. Tr. j [_ '_
250 100.0
Blood Wassermann reaction:
Antigen A, cholesterinized human heart, negative.
Antigen B, acetone insoluble lipoids, negative.
Antigens C, plain extract beef heart, negative.
Gastric analysis: 15 c. c. recovered; colorless.
Free HCl.... 60 Occiilt blood o
C. acid IS Lactic acid o
T. A 60 ac. % Micro. : negative.
Stool examination: Small, brown, formed.
Bile +
Micro. : negative.
Urine analysis:
Night. Day.
Specific gravity 1028 1022
Albumin Ft.tr. Ft.tr.
Sugar o 0
Micro. : Few finely granular casts.
Phthalein output:
First hour 100 c. c. 52%
Second hour 80 c. c. 24%
180 c. c.
REPORT OF X RAY EXAMINATIONS.
76%
Tele measurements :
M. L 12.2
M. R .3.6
L 17.8
T 10.3
Examination of the paranasal sinuses shows a slight
clouding of the left antrum and an indefinite shadow in
the right antrum which I believe is a polyp. The sphenoidal
sinus is clear. Septum is straight and air passages are
clear.
The fluoroscopic examination of the gastrointestinal
tract shows a stomach occupying a transverse position, not
prolapsed. This position, however, is due to the large
amount of fat in the abdomen and not due to any adhe-
sions. Stomach is freely movable ; good motility ; good
expulsion of contents ; no evidence of any filling defects.
Transverse colon is in normal position; good motility;
necum, however, contains a small bit of bismuth and the
cecum is apparently fixed to the pelvic wall and cannot be
moved. With this exception the entire examination is
negative.
REPORTS OF EXAMIN.\TIONS BY SPECIALISTS.
Dentist: Radiographic review of doubtful areas of inouth
shows No. 4 the right superior second bicuspid, No. 10 the
left superior lateral. No. 14 the left stiperior first molar.
No. 27 the right inferior canine. No. 29 the right inferior
second bicuspid, to have definite periapical rarefaction with
much damage to alveolar septal crests. Bridge "A" should
be removed and all these teeth should be extracted and
sockets curetted. Well marked injury to the gingival
crests, which should have treatment.
Ophthalmologist : Patient has considerable chronic con-
junctivitis, for which I have given him a collyrium of zinc
sulphate. His cyegrounds are healthy and his vision is per-
fect with correction of his hyperopic astigmatism in the
right eye and hyperopia in the left eye.
October 5, -ais.] BARKER: GENERAL DIAGNOSTIC STUDY BY THE INTERNIST.
581
Rhinologist : Examination of the ears, sinuses, and throat
practically negative except for slight polypoid degeneration
of inferior turbinates. Would advise a two per cent, solu-
tion of bicarbonate of soda as a nasal spray.
REARRANGEMENT OF THE DATA IN CASE III.
Case III (No. 4186). — Male, age fifty-one; merchant.
Complaints: Pain in region of heart on walking one
block ; puffiness of face ; watery eyes ; increased flow of
saliva ; weakness.
Habits: Hard mental work; sedentary; two cigars daily;
little alcohol ; no sexual excesses.
Previous infections: Otitis media (left) twice; gonor-
rhea in youth ; sore on penis then also.
Operations: Nasal polypi removed at three operations
(last, two years ago).
Respiratory system: History of bronchial asthma four
or five years ago ; paroxysms were nocturnal ; lungs now
negative. X ray of paranasals: cloudy left antrum, shadow
in .-ight antrum (polyp) ; tonsils small but adherent; poly-
poid inferior conchje.
Circulatory system: Pulse rate 68; no arrhythmia; B. P.:
180 systolic, 140 diastolic; enlarged heart to the left. Tele-
rontgenogram : M. R. 3.6, M. L. 12.2 ; paramanubrial dull-
ness due to diffuse dilatation of aorta; accentuated aortic
second sound.
Blood system: R. B. C. 5,212,000; Hb. 85 per cent.; W.
B. C. 6,900; WaR. negative (three antigens).
Digestive system: Free HQ 45; T. A. 60; Occ. Bl. o;
stool o; sialorrhea; constipated; gaseous eructations and
flatulence for years; nausea in morning, attributed to swal-
lowing saliva; x ray of gastrointestinal tract (after
barium) negative. Periapical granulomata at roots of five
teeth ; bad pyorrhea alveolaris.
Urogenital system: Urine: Specific gravity 1022-1028;
albumin -I- ; ^ugar 0; cyla. + (granular casts) ; W. B. C.
0 ; R. B. (i. o ; phthalein 76 per cent. Slight nocturia ;
gonads normal.
Locomotor system: Weakness ; no paralysis.
Nervous system: Bradylalia; somnolence; deep and su-
perficial reflexes normal; chronic conjunctivitis; hyperopic
astigmatism (right eye) ; hyperopia (left eye) ; deafness.
Metabolic and endocrinic systetns: Drowsy; sensitive to
cold; slowing of thought and speech; soft parts of hands
increased; obesity (thirty pounds overweight); quadran-
gular finger tips; nose broad and thick; puffy eyelids;
exophthalmos ; lips thick ; double chin ; pads of fat above
clavicles; general hypotrichosis (barba, hirci, and crines
scanty) ; crines transverse ; skin dry and harsh ; thyroid
not palpable.
DIAGNOSTIC SUMMARY.
1. Arteriolar sclerosis.
a. Arterial hypertension 180/140.
b. Atherosclerotic cardiopathy with cardiac hyper-
trophy.
c. Stenocardiac attacks (coronary sclerosis?).
d. Slight arteriolar nephropathy (albuminuria, cylin-
druria, hyperpermeability to phthalein 76 per
cent.) .
2. Multiglandtilar endocrinopathy with dystrophia adi-
posogenitalis.
a. Thyreogenitohypophyseal syndrome,
i. Hypothyroidism.
ii. Hypogenitalism.
iii. Hypopituitarism.
3. Oral sepsis.
a. Proliferative periodontitis (five teeth).
b. Pyorrhea alveolaris.
4. Chronic conjunctivitis and refraction error.
5. Nasopharyngeal catarrh.
a. Hypertrophic and si. polypoid conchae.
b. Pharyngitis.
OUTLINE OF PLAN OF THERAPY.
1. Oral sepsis.
a. Extract five teeth ; curette sockets.
b. Pyorrhea treatment.
2. Hypothyroidism and obesity.
a. Administration of thyroid extract.
b. Reducing diet (880 calories).
3. Atherosclerosis and its effects.
a. Dietetic-hygienic regime.
b. Prevention ar.d management of stenocardiac at-
tacks.
4. Eyes.
a. Correction of refraction error.
b. CoUyrium for conjunctivitis.
5. Nose and throat.
Spray — two per cent, soda bicarbonate ; keep antra
under survey.
Case IV. — Male, age fifty-six, manufacturer. (Seen in
consultation) November 4, 1917. (No. 4436.)
Complaint: Cough; shortness of breath; swelling of
abdomen.
Family history: Negative.
Personal history: Always healthy. Formerly moderate
potatorium. Recently, habits good.
Present illness: Onset in June, 1917, with slight swell-
ing in glands of neck; later abdominal discomfort with
alternating diarrhea and constipation ; low fever ; develop-
ment of cough and shortness of breath; physician suspected
oral sepsis and had rontgenograms of teeth made, reveal-
ing periapical granulomata ; removal of bridges ; gums
inflamed ; isolation of bacillus with morphology of diph-
theria bacillus; extraction of diseased teeth; development
of a slight papular exanthem on trunk, forearms, and
thighs. Liver found enlarged October 4th ; on Octo-
ber 2Tst, pleural eflfusion found on right side; at end of
October, fluid demonstrable in peritoneal cavity ; also be-
ginning edema of lower trunk and genitalia.
SUMMARY OF PHYSICAL EXAMINATION.
Moderate emaciation ; slight fever ; one loose tooth still
present; moderate enlargement of jugular; retrocervical
and axillary lymph glands ; signs of fluid in right pleural
cavity and in abdominal cavity; edema of lower trunk;
edema of genitals ; enlargement of liver and spleen.
REPORTS OF LAB0R.\T0RY TESTS.
Sputum: Negative for tubercle bacilli.
Blood:
R. B. C. 3,820,000 to 4,480,000 ; Hb. 74 — 80 per cent.
W. B. C. 10,200 to 16,400.
P. M. N. 78 — 89 per cent.
Blood culture negative on two occasions.
Wassermann negative.
Urine:
Specific gravity 1011-1025.
Oliguria.
Slight albuminuria at times.
A few hyaline casts.
No blood.
Phthalein output 65 per cent.
X RAY REPORTS.
Mediastinum : No large masses seen.
Right pleural cavity: Shadow (fluid).
Cardiovascular stripe: Displaced to left.
REARRANGEMENT OF THE DATA IN CASE IV.
Case IV (No. 4436). — Male, age fifty-si.x, manufacturer.
Complaints: Cough; shortness of breath; weakness:
swelling of abdomen.
Habits: Formerly moderate potatorium; abstainer re-
cently.
Previous infections : None. Low fever for last four
months. Oral sepsis treated. Diphtheroid bacillus isolated
from inflamed gums.
Operations : None.
Respiratory system: Cough; dyspnea; fluid in right pleu-
ral cavity during past two weeks ; sputum negative for
tubercle bacilli. X ray of mediastinum: no large masses
seen. X ray of thorax reveals shadow on right due to
pleural effusion.
Circulatory system: Right hydrothorax; hydroperi-
toneum ; edema of lower trunk and of external genitals.
X rav of C. Y. stripe shows dislocation of heart to the
left.
Blo'od system: R. B. C. 3,830,000; Hb. 78 per cent.; W.
B. C. 16,400: WaR. negative; P. M. N. 89 per cent. Glands
in neck began to swell in June, 1917 ; now moderate
enlargement of jugular, retrocervical, and axillary lymph
glands ; palpable spleen.
Digestive system: Abdominal discomfort; alternating
constipation and diarrhea ; periapical granulomata ; gingi-
\2 FREUDENTHAL: RECURRENT TERATOMATOUS GROWTH OF THE TRACHEA. „ [New Yowc
Medical Journai„
vitis ; liver enlarged for past month ; fluid in peritoneal
cavity recently.
Urogenital system: Urine: Specific gravity 1011-1025;
alb. si.; sugar o; cyla. ; a few hyaline casts; W. B. C. 0;
R. B. Co; phthalein output 65 per cent.
Locomotor system: Negative.
Nervous system Slight delirium at times. Asthenia.
Metabolic and endocrinic systems: Moderate emaciation;
slight fever.
Skin: Papular exanthem on trunk, forearms, and thighs.
TENTATIVE DIAGNOSTIC SUGGESTIONS AT DIFFERENT TIMES
DURING THE STUDY BEFORE THE CONSULTATION.
1. Oral sepsis with cervical adenitis and metastatic
pleuritis.
2. Diphtheria.
3. Pulmonary tuberculosis.
4. Lymphatic leukaemia.
5. I.ues.
6. Aleukemic leukemia.
Unsatisfactoriness of these hypotheses on rational elabo-
ration and attempts at corroboration. Diagnostic perplex-
ity continued.
ADDITIONAL DIAGNOSTIC SUGGESTION AT CONSULTATION.
Possibility of Hodgkin's disease. Suggestion based upon
memory of a case previously seen, a public ward patient,
in which right hydrothorax, hydroperitoneum, and edema
of the trunk in association with enlarged glands in the
neck proved at autopsy to be due to Hodgkin's disease with
infiltration of the tissue about the vena cava.
Rational elaboration of "Hodgkin's disease" idea.
a. Lymph glandular enlargement.
b. Fever.
c. Enlargement of liver and spleen.
d. Involvement of mediastinum.
e. Infiltration of tissue about vena cava.
f. Diphtheroid bacillus.
g. Papular exanthem.
h. Blood picture.
i. Histology of lymph gland.
Corroboration of the inference: There is identity between
the facts collected and the elaborated diagnostic sugges-
tion, A lymph gland was excised and was studied histologi-
cally. In the histological section, stained with hematoxylin
and eosin, the typical "Dorothy Reed lesions" of Hodgkin's
disease were visible.
Diagnosis :
1. Hodgkin's disease (lymphadenitis; anemia; venous
obstruction) .
2. Oral sepsis.
.3. Undernutrition.
Thrrat'v:
Under radium treatment, the patient rapidly improved.
The swelling of the lymph glands subsided and the edema
disappeared. The appetite improved, the patient is gaining
weight, and is sitting up.
BIBLIOGRAPHY.
J. R. ANGELL: Psychology : An introductory study of the struc-
ture and function of human consciousness, 4th ed.. New York, 1908,
H. Holt & Co., 468 pp. J. M. BALDWIN: Thought and Things.
In three volumes. New York: The Macmillan Company.
B. BOSANQUET: The Essentials of Logic. New York, 1895, the
Macmillan Company. F. H. BRADLEY: The Principles of Logic
(Anastatic Reprint), New York, 1912, G. E. Stechert & Co., 534
pp., 8vo. J. DEWEY: How We Think, Boston, 1916, D. C. Heath &
Co., 224 pp., 8vo. H. H. HORNE: Psychological Principles of Edu-
cation: A study in the science of education. New York, 1906, the
Macmillan Company, 435 pp. W. JAMES: The Principles of Psy-
chology. 2 v.. New York, 1890, H. Holt & Co. W. S. JEVONS:
The Principles of Science: A treatise on logic and scientific method,
New York, 1900, the Macmillan Co., i95/2Cm. W. McDOUGALL:
An Introduction to .Social Psychology, 9th ed., London. 1915, Meth-
uen & Co., 431 pp., 8vo. T. S. MILL; System of Logic, Ratiocina'.ive
and Indvriive , 8th ed . New York, 1900, Harper & Brothers, 24cm.
J. E. MILLER: The Psychology of Thinking, New York, 1917, the
Macmillan Company, 303 pp., 8vo. W. MINTON: Logic: Inductive
and Deductive , New York, 1905, Charles Scribner's Sons, 375 pp., 8vo.
M. V. O'SHE.A: Social Development and Education. Boston:
Houghton Mifflin & Co., 1909. 329 pp. K. PEARSON: The
Grammar o^ Science, 2 ed.. London, 1900, A. & C. Black, 548 pp.
MARY E. RICHMOND: Social Diagnosis, New York, 1917, Russell
Sage Foundation, 511 pp., 8vo. A. SIDGWICK: The Application of
Logic, London, 1910, the Macmillan Company, 321 pp., 8vo. J. A.
THOMPSON: Introduction to Science, New York, 191 1, Henry
Holt & Co., 256 pp., 8vo.
1035 North Calvert Street.
RECURRENT TERATOMATOUS GROWTH
OF THE IRACHEA.*
By Wolff Freudenthal, M. D.,
New York.
The patient, whose history I take the hberty of
reporting here, has been presented to the Section in
Laryngology of the New York Academy of Medi-
cine on several occasions, the last time in February,
As the case is interesting, not only from the point
of view of this society, but also from the standpoint
of the pathologist, the anamnesis will be given in
detail.
Case. — S. F., a tailor, aged twenty-seven, had been
tracheotomized, in Russia, on account of diphtheria, when
he was fourteen years old. Following the operation he
felt well up to the time he presented himself for treatment
in one of my clinics in 1913, i. e,, five years later. Shortly
before consulting me he had suffered from dyspnea, espe-
cially on exertion. His voice was clear. Examination re-
vealed, about an inch below the glottis, a weblike, grayish
looking mass, that included the greater part of the trachea,
with only a small opening anteriorly — all this apparently
due to the former tracheotomy. Nose and throat were
normal.
In order to remove the mass the patient was
placed under suspension laryngoscopy, and it was
interesting to me and to all who saw the case, to
notice the change in the appearance of the web.
While under ordinary inspection it looked like a
thin, grayish membrane, under suspension it ap-
peared reddish and of some dimensions. It seemed
quite easy to remove the mass under suspension, but
the patient absolutely refused any operative inter-
vention without a general anesthetic. This was
given a few days later, but the patient became
cyanotic to such a degree before we had begim the
operation that a hurried tracheotomy had to be
done. All of the visible mass was then removed
and everything thoroughly cauterized. The wound
healed and the patient was soon discharged, breath-
ing normally.
A year later he returned in the same condition,
and again all the visible growth was removed under
general anesthesia, this time under suspension.
Nine months later he again presented himself for
treatment, and naturally we began to be suspicious
of the nature of the condition. The patient was put
under rectal anesthesia and, with a straight tube,
an effort was made to extirpate all of the intra-
tracheal mass. The bleeding, however, was so pro-
fuse that the attempt had to be abandoned before
any large amount of the mass had been taken out.
A few days later, he was again placed under general
anesthesia (rectal), and the trachea opened, three
rings of the trachea being incised this time in order
to obtain free access to the growth. Great masses
of granulation tissue were found and removed with
very little hemorrhage. The pathologist reported
the growth to be an endothelioma.
It was difificult to determine which means to em-
ploy— whether to remove the afifected portion of the
trachea and then apply radium, or to give radium a
trial first. After consulting with several colleagues,
it was decided to use the Ifitter method for twenty-
*Read at the First Annual Meetini; of the Association of Amer-
ican Peroral Endoscopists, Philadelphia, May 31, 1918.
October 5. i9'8.] FREUDENTHAL: RECURRENT TERATOMATOUS GROWTH OF THE TRACHEA. 583
four hours. This seemed to have a very good
effect ; everything appeared in good condition and
the patient was discharged. He reported at the
chnic regularly. When seen in January, 191 5, there
was nothing abnormal to be found in the trachea.
Three weeks later, however, a new mass was found
to be springing up from the lateral wall, and an-
other one anteriorly. I stated at that time that this
was undoubtedly a recurrence of the endothelioma.
The question again arose, whether radium should
be tried or a part of the trachea removed.
At this stage he was demonstrated before the Sec-
tion in Laryngology of the New York Academy of
Medicine, and I remember the remark made by Dr.
Thomas J. Harris, on this occasion, that if he him-
self were the victim of such a condition he would
prefer to be let alone. His statement was based
upon his experience with a similar case seen by him
at the clinic of Professor Chiari at Vienna. But we
could not follow such a course, since the tracheal
stenosis was increasing and the use of radium at this
stage was not without danger. Consequently he was
operated upon again on April 14, 191 5, by Dr. C.
Goodman and myself (intratracheal anesthesia).
A median incision was made, the trachea separated
from the surrounding tissue — which was difficult,
owing to the adhesions — and then opened. The
tumor, which was situated on the right wall of the
trachea, was soft and irregular and extended over
an area of two tracheal rings, both of which were
resected, leaving the posterior membranous wall
intact. Healing again was uneventful and there was
no trouble for several years, for which the patient
was grateful. In fact, he looked and felt so well
that when he was called for examination for the
arm.y early in 1918, he would have been drafted
had it not been for the intervention of one of my
younger assistants, who had been present at the
last operation and recognized him. However, a
slight dyspnea had already set in at that time and
was getting worse quickly. He was planning to get
married and demanded a radical operation.
The tracheoscopic picture now was a most inter-
esting one. Below the glottis there appeared what
might have been (in fact, was) mistaken on super-
ficial examination for another glottis. About an
mch below the glottis on the left side, there was a
whitish mass reaching almost to the centre of the
lumen of the trachea, which looked very much like
a vocal cord. On the right side was a smaller one,
somewhat congested and, of course, also immobile.
On deep inspiration, when nothing was seen of the
true vocal cords, these neoplasms could easily be
mi.staken for them.
What was this white mass on the left side? Was
it cicatricial tissue or was it cartilage, i. e., a portion
of a tracheal ring that had been cut through?
Either assumption was possible. The cicatricial
tissue outside on the neck was very evident and
there had been a great deal of cutting of cartilage
in the different operations. The microscopic exam-
inations of the tissue cleared up these details.
After attempts to stretch the stenosis by long
intubation tubes and von Schroetter's bougies,
which I was. forced to give up owing to the resist-
ance of the patient, it became imperative to operate
again. That was done, but, unfortunately, he died
soon afterwards from a hemorrhage. The sf)eci-
mens that were removed were sent to Dr. J. H.
Globus for microscopical examination, who kindly
furnished me with the following report :
The fragments do not suggest in any way the organ from
which they were removed. Microscopic sections presented
several interesting features which led to the diagnosis of
a teratomatous growth. In certain areas the sections pre-
sent cylindrical structures filled with mucus and lined
with several layered epithelioid cells supported by a rich
stroma of a mucoid character. In other areas solid cords
of epithelioid cells are seen supported by a mucous con-
nective tissue stroma. Still in other fields plaques of em-
bryonic cartilage, the mucous connective tissue, and the
peculiar arrangement of the epithelioid element suggest
the diagnosis of a mi-xed tumor. Diagnosis : myxochondro-
cylindroma (endothelioma).
CONCLUSIONS.
From this description we learn that plaques of
embryonic cartilaginous tissue were present, but no
true cartilage was found. We, therefore, concluded
that the white mass seen intratracheally consisted
both of neoplastic and scar tissues.
In the literature I was able to find only two cases
resembling this one pathologically, namely, the case
of Henrici and that of Heymann. (The one de-
scribed by Doctor Goodman in the Annals of
Otology is my own case.) The nature of the path-
ological structure in Chiari's case is not mentioned.
But there is a doubt in my mind whether Henrici's
and Heymann's patients belong to the same class as
mine, since of late the nomenclature has been
changed. Under the new classification my case here
comes under the general group of teratoma, and its
special nature is that of a niyxochondrocylindroma.
This type of neoplasm has been frequently seen
in the parotid gland, but as far as I could find out,
never in the trachea. It is not actually malignant,
as it does not form any metastases, but it recurs
repeatedly, and in that way renders the prognosis
doubtful.
The great value of the direct methods in opera-
tive work and direct medication in the lower air
tract has been demonstrated at our meeting by the
great variety of reports given. These methods have
come to stay. Is it, therefore, too premature to speak
of some limitations in this field, at least so far as
tracheal work is concerned? In the case here cited
very little was accomplished under local anesthesia,
as the patient was exceptionally unruly ; but even
under a general anesthetic the attempt to extirpate
the neoplasm had to be given up on account of
severe bleeding. In Heymann's case the tumor was
removed in two sittings by the straight method, but
recurred so soon that Gluck had to open the trachea
and extirpate the grov/th radically.
In spite of these exj>eriences I should feel in-
clined to try either one of the direct methods again,
should a similar case come londer my observation.
It seems plausible that in connection with other
means, the galvanocautery, for example, if applied
carefully under a local anesthetic by means of
Lynah's galvanocautery point, should prove of value
in nonmalignant cases.
59 E.\ST Seventy-fifth Street.
584
ROSENBERGER: TEN THOUSAND WASSERMANN TESTS.
[New York
Medical Journal.
TEN THOUSAND WASSERMANN TESTS.
During ipi6 and 1917 in the Philadelphia General
Hospital.
By Randle C. Rosenberger, M. D.,
Philadelphia,
Professor of Hygriene and Bacteriology, Jefferson Medical College,
Jn the New York Medical Journal, June 30,
1917, a report for the year 1916 was made in which
there were 5,106 Wassermann tests recorded; for
the year 1917 an additional 5,829 tests were per-
formed,— making a total of 10,935. A considerable
number (160) of specimens were anticomplemen-
tary and are not included in this report. As three
antigens were used in each test, there were actually
32,805 Wassermann tests performed.
The general percentage of positive results during
1917 upon the blood submitted for examination was
25.9 of 5,110 cases, while of the spinal fluid 23.6
per cent, were positive of 710 cases examined.
Taking the previous year's percentage of positive
reactions obtained with the blood, 27.4, it gives an
average for the two years of over 26.65 P^^ cent. ;
while of the spinal fluids the average for 1916 was
22.2 per cent., making the average for the two years
22.9 per cent.
In 191 7 there were 159 cases in which a positive
reaction was obtained with the cholesterinized an-
tigen alone, while the luetic and acetone insoluble
antigens were negative. A further elaboration of
the cholesterin positive cases will be taken up a little
later, after a general departmental resume is given.
From the men's medical ward, 1,364 specimens of
blood were tested, and 305 were positive, or 22.3
per cent. ; from the women's ward, 277 examina-
tions were made, and eighty-seven were positive,
or 31.4 per cent. From the psychopathic ward, 1,339
cases were studied, and 237 were positive, or 17.6
per cent. ; while from the insane department 284
specimens were received and 16. i per cent, were
positive. From the men's and women's nervous
wards, of 534 tests, 29.7 per cent, were positive and
from the men's and women's surgical wards 284
were studied and positive results obtained in 27.8
per cent. From the men's and women's venereal
wards, of 329 specimens, 67.1 per cent, were posi-
tive, while from the maternity, of 326 cases studied
only fortv-five were positive, or a percentage of
13.8. From the tuberculosis wards (male and ff^
male), 162 specimens of blood were received, and
of these forty-two were positive, or a percentage of
25.9. From the gynecological ward 114 were exam-
ined, and thirty-one were positive, or 27.1 per cent. ;
and from the children's ward 106 were studied, and
eighteen were positive, or 16.9 per cent.
The number of .spinal fluids totaled 710 and came
from the following wards or departments : From
the men's medical, 255. of which thirty-three were
positive, or 12.9 per cent. ; from the psychopathic,
125, of which fifty were positive, or forty per cent. ;
from the insane, sixty-one, of which thirty-three
were positive, or fifty-four per cent.; from the
men's and women's nervous wards 144 were studied,
of which forty-six were positive, or 31.9 per cent. ;
from the surgical wards (male and female) only
twenty-eight were submitted, of which six were pos-
itive, or 21.4 per cent.; from the women's medical
ward thirty-eight were studied, with five positive,
or 13 I per cent.; from the tuberculosis wards six-
teen, of which two were positive, or 12.5 per cent. ;
from the children's ward thirty-five cases with only
one positive, or 2.85 per cent. Six specimens of
spinal fluid were received from the gynecological
ward ; all were negative. From the men's and
women's venereal wards only two were received,
and both were negative.
One hundred and fifty-nine cases gave a positive
reaction in the cholesterinized antigen, with abso-
lutely negative results in the other two antigens. In
a certain number of these cases no history could be
obtained, while in the majority a more or less defi-
nite history of syphilis was given by the patient or
a diagnosis of a syphilitic nature was made before
the test was performed. Where, in a number of
instances, a direct history of syphilis was denied,
after close questioning, exposure was admitted and
alcoholism or drug indulgence was recorded on nu-
merous occasions. The history of having had a
chancre several years previously, up to a period of
thirty-one years, was quite common. Others had
had as many as eight positive Wassermanns ob-
tained in other institutions ; and still others had had
treatment with salvarsan (thirteen doses) or other
medicaments. Numerous instances of dementia
praecox. of spinal lues, of paresis, leg ulcers, and one
or two of tabes dorsalis, are included in this group
of positive cholesterinized antigen.
As in the previous year's work, these tests were
all performed by the technician. Miss McNitt. The
writer is indebted for the efficient manner in which
she has done these tests and for obtaining the his-
tory of the cases, where noted. The same technic
was used as in the previous year's work, and results
were read after placing in the refrigerator over
night. In the spinal fluid 0.8 c. c. was used, and of
the inactivated serum of the patient, o.i c. c.
RESUME OF SPECIMENS OF BLOOD AND SPINAL FLUID
WITH NUMBER OF POSITIVE AND NEGATIVE
REACTIONS OBTAINED DURING I917.
Wards.
— Blood-
, — Spinal Fluids
Pos.
Ncg.
Total.
Pos.
Nep.
Total.
Men's Medical....
.305
1,059
1,364
33
222
255
Psychopathic
237
1,102
1,3.39
50
75
125
Insane
46
2.'?8
284
33
28
61
Men's and Women's
Nervous
375
.534
46
98
144
Men's and Women's
Surgical
79
205
284
6
22
28
Women's Medical..
87
190
277
5
33
38
Men's and Women's
Tuberculosis ....
42
120
162
2
14
16
4S
281
326
0
2
2
Men's and Women's
Venereal
108
221
329
0
6
6
GvnecoloRical
31
83
114
I
34
35
18
88
106
Total
IJ57
3,962
5,119
176
534
710
Total Positive 1157 or 25.9% Total Positive 176 or 23.6%
Total Positive in 1916 — 27% Total Positive in 1916 — 22.2%
Total Positive in 1917—25.9% Total Positive in 1917—23.6%
General Average . .. 26.45% General Average 22.9%
Cholesterinized antigen. — It appears from the
whole number of tests performed (10,935) during
two years and the number of specimens giving a
positive reaction in cholesterinized antigen alone,
292, or two per cent., that this antigen should be
October 5, 1918.!
WALTZ: ACIDOSIS.
the one of selection as of especial value in deter-
mining the presence of any doubtful syphilitic in-
fection.
As mentioned in the previous report (1916), I
believe that the Wassermann test is the most valu-
able laboratory aid in the diagnosis of syphilitic in-
fection. More than one antigen should be used for
the test, as a number of patients showing a positive
reaction in cholesterinized antigen alone would no
doubt have been given clean bills of health if only
the acetone insoluble and syphilitic liver antigen had
been used.
ACIDOSIS.*
By Claude D. Waltz, M. D.,
Cleveland.
To many of us, no doubt, acidosis is a compara-
tively new condition and still one of the most impor-
tant findings in acidosis, a decreased alkalinity of
the blood upon introduction of an acid, was reported
by Walters forty-one years ago and twenty years
before that, in 1857, acetone was discovered in the
urine of a diabetic patient by Fetters. The term
"acidosis," however, was not "invented" until 1906
when Naunyn used it to apply to cases with an in-
creased excretion of acids in the urine, both normal
and abnormal. A thoroughly scientific study of acid-
osis did not take place until 1909 when L. J.
Henderson presented a masterly paper on the sub-
ject.
My own conclusions regarding acidosis are quite
definite. In the first place, acidosis cannot be looked
upon as a definite disease. It is a condition, a
symptom, complex, complicating or resulting from
certain diseased conditions. Secondly, the term
acidosis is not correctly applied to simply one
single symptom. A case showing no other symp-
tom of acidosis but acetone in the urine should
not be called acidosis as it is by many but should
rather be termed ketonuria or acetonuria. In dis-
cussing acetonuria, do not say acidosis ; if talking
about low carbon dioxide states, do not say acidosis.
True, in acidosis acetone is found, and a low
carbon dioxide tension, an increased hydrogen ion
concentration, etc. ; but simply because acetone is
found in the urine the diagnosis of acidosis is not
determined even though it may throw suspicion
that way. A carbon dioxide tension need not spell
acidosis, for it may be due to altitude. It has been
aptly proved that the higher the altitude the lower
the carbon dioxide tension. One investigator (Fitz)
made the statement that the altitude of a com-
munity can be determined by the alveolar carbon
dioxide tension of its inhabitants.
Acidosis, as defined by Van Slyke (i), is a con-
dition in which the concentration of bicarbonate in
the blood is reduced below the normal level. Nor-
mally the blood is in a constant state of equilibrium
as far as its contained acids and bases are con-
cerned. Fluctuations may and do occur ;
e. g., the fluctuation due to the interchange be-
tween blood and respired air, although these
changes are normally so slight as to be of little mo-
*Rea(i at Glenville Academy of Medicine, Cleveland, April i8, 1918.
ment. Lawrence Henderson (2) defines acidosis as
any disturbance of this acid basic equilibrium
whereby the power to resist acids in the body is
lost.
Primary acidosis is unknown. It is always sec-
ondary, arising during pathological processes and
in turn influencing their course. It may be due to
faulty absorption of bases; to an unusual loss of
bases' from the body ; to neutralization by abnormal
amounts of acids, either normal or abnormal; or
to the failure to eliminate acids. This increased
amount of acids may be due to the production of
abnormal acids or an over production of normal
acids, either from ingestion of acids or of foods
leading to an increased production of acids. It is
practically impossible to determine the normal
pmounts of acids and bases in the body although
we can determine their proportion. The main
change in acidosis is the loss of blood bicarbonate
and that this is. a serious change can readily be
seen when you stop to consider that bicarbonate
is the third constituent of the blood, water being
first and salt second. Pritchard, of London, (3)
explains the enlarged ends of long bones in rickets
as due to the depletion of bases. He claims that
the mineral depletion of red cells brings on an
hemolysis or destruction of red cells. A severe
anemia would result if it were not for the com-
pensation of the blood forming centres of the red
marrow of long bones.
Beneath all metabolism is a constant diminution
of bicarbonate in the blood which, unless repaired,
results in acidosis. Even though the reaction of
the blood is alkaline, a certain degree of acidity
(or of acidosis if you so wish to term it) is physio-
logically necessary for stimulation of the respiratory
centres. The marked hyperpnea of acidosis is ex-
plained from this fact. Fluctuations of the acid
basic equilibrium may occur without changing
hydrogen ion concentration of the blood ; the hydro-
gen ion concentration, is as I understand it, the
amount of hydrogen that can be ionized from an
atmosphere of hydrogen into the blood plasma. In
other words it constitutes the degree of acidity of
the blood. A change in the hydrogen ion concen-
tration is only noted when the protective mechanism
is broken down. Rountree (4) has aptly classified
this as uncompensated acidosis. If the blood and
tissues can overcome the decreased alkalinity of
the blood without interfering with the normal ratio
of bases to acids in the blood the acidosis is said to.
be compensated. Hence it is to be seen that the
various degrees of compensated acidosis cannot be
diagnosed by a determination of the hydrogen ion
concentration. The acid basis equilibrium of the
blood is maintained by means of several factors;
namely, the excretion of carbon dioxide by the
lungs, the activity of the kidneys, the formation of
ammonia. Rountree adds a fourth, the "buflfer"
action of the blood (5), by which is meant the
ability of the blood to take up considerable quan-
tities of bases or acids without change in the
hydrogen ion concentration. Even though there is
found in acidosis a decrease in the alkaline reserve,
he also found that the "buflfer" action of the blood-
was decreased, not only for acids but for bases as
586
WALTZ: ACIDOSIS.
[New York
Medical Journal.
well. The method of determining the "buffer"
value of the blood is so complicated that it can
only be used in experimental work.
Carbon dioxide is constantly being transferred
from areas of high tension to areas of low tension;
from the tissues where carbon dioxide is formed
it is transferred to the blood, from there to the
alveolar air, finally to the external air where the
tension is the lowest. In this process the bicar-
bonate of the plasma plays an important part, since
the carbon dioxide is replaced by an acid leaving a
neutral salt, e. g., NaHC03+HCl=NaCl+H20+
The kidneys perform an exceedingly important
part in the prevention of acidosis by excreting an
acid urine from the blood which is alkaline, in this
way freeing the body of acids and acid phosphates
while the bases are conserved. Thus a new func-
tion of the kidney is recognized, conservation of
bases.
The production of ammonia, is not always in-
creased in acidosis as it is not called into play until
the fixed bases have failed to neutralize the rush
of acids. Hence in certain types of acidosis this
mechanism is not called upon. The lungs and
kidneys, however, always show some evidence of
acidosis.
The body fluids contain free carbonic acid in such
amounts that it converts into bicarbonate all bases
not bound by other acids. Hence the bicarbonate
of the body represents exactly the excess of base
left over after all the nonvolatile acids have been
neutralized and is available for immediate neutrali-
zation of further acids. The acid products of metab-
olism may be volatile, like carbonic acid, or non-
volatile, like sulphuric acid, or oxybutyric acid, etc.
The latter acids permanently unite with the reserve
alkali of the blood producing genuine acidosis.
Thus it is seen that the bicarbonate constitutes the
alkaline reserve of the body, acidosis being a con-
dition in which the bicarbonate concentration of
the blood is reduced below normal level.
There are three avenues by which we may de-
termine the existence of acidosis through laboratory
tests — the urine., the expired air, the blood. In
as much as there are no known methods of de-
termining tissue acidosis we must accept these
three intimate neighbors, and it can be assumed
without question that they reflect proportional, if
not minutely exact, tissue changes.
The urinary tests include — a determination of the
ammonia content, the quantity of acetone bodies
(acetone, diacetic, oxybutyric acid, etc.,) the alka-
line tolerance test. The ammonia may be increased
or decreased depending upon the type of acidosis.
In diabetes and eclampsia its determination is of
real import, an increase being present ; whereas in
nephritis it is of no significance. Urea is usually
decreased, while ammonia is increased in acidosis.
This finding, however, needs confirmation for it
may be due to a protein diet or the breaking down
of proteins. Urea may be easily determined by
the use of the Doremus ureometer. The deter-
mination of total nitrogen by the Kjeldahl method
is too complicated for ordinary routine work. The
detection of acetone is easy, as well as its immediate
precursor, diacetic acid. Oxybutyric acid is harder
to isolate and is of no more importance than ace-
tone of diacetic acid except that it is found in
severe and practically fatal conditions. The acetone
bodies have a significance of their own aside from
being associated with a depleted alkaline reserve.
The formation of acetone bodies indicates that fatty
acids, derived either from fats or amino acids are
being incompletely oxidized. Acetone is formed in
the liver and is normally almost entirely oxidized to
water and carbon dioxide. The alkali tolerance test
gives an approximate measure of acidosis, providing
the kidneys are functioning normally. It would
be unreasonable indeed to expect even a fair estima-
tion of acidosis by this test if the kidneys were
unable to excrete the acids that were causing the
trouble. A patient presenting an extremely acid
urine with acetone, but having an apparently good
excretion from the kidneys is given five grams of
baking soda by mouth. In two hours the urine is
examined and if still acid the dose is repeated. The
normal amount necessary to render healthy urine
alkaline is five to fifteen grams. A patient with
acidosis may require as high as ninety grams.
Williamson says that two drachms of baking soda
will render normal urine alkaline in twenty-four
hours. Personally I would hesitate giving a pa-
tient such an immense dose of bicarbonate merely
for diagnostic purposes when this test is held merely
as corroborative and not conclusive or valuable
alone. Cammidge (6) uses the excretion of the
five bases — sodium, potassium, calcium, magnesium,
ammonia — in the urine as a guide. Because of the
difficulty of estimating the first two he relies upon
the last three ; — calcium, magnesium, ammonia. He
noticed an increasing excretion of magnesium due
to nervous influences such as excitement, there also
being a relation between magnesium and calcium
excretion and oxybutyric acid.
The best that can be said regarding the findings
of urinary tests in acidosis is that they determine
only the amount of acid excreted by the kidneys and
not the amount actually present in the blood and
tissues.
An examination of respired air, however, gives
us quite definite information regarding acidosis. The
determination of the carbon monoxide tension of
alveolar air is an indirect, but very valuable method,
of determining acidosis, as it gives an approximate
estimate of the bicarbonate reserve of the blood.
The alveolar tension is decreased in acidosis. The
alveolar air is in equilibrium with arterial blood in
respect to its carbon dioxide content. Consequently
in accordance with the law of gas solubility the con-
centration of alveolar carbon dioxide is directly pro-
portional to the free carbon dioxide of the blood,
which in turn is kept proportional to the bicarbonate
of the blood with normal respiratory control as will
be shown later. Hence the alveolar carbon dioxide
through the medium of the blood carbonic acid is a
fairly accurate measure of the blood bicarbonate.
By way of illustration: If an acid is poured into
an aqueous solution of carbonic acid in an open
ves.sel exposed to the air, to which a certain amount
of bicarbonate has been previously added, the acid
will react with the bicarbonate forming its own salt
Cctobcr 5, 191S.]
WALTZ: ACIDOSIS.
587
and free carbonic acid which escapes into the air,
having split into carbon dioxide and water.
H2C03+NaHC03+HCl=H2C03+Naa+H2C03
HX03=H20+C02
This is just what happens in the body; only in
the body, the lungs instead of eliminating just this
newly formed carbonic acid eliminate some of the
original carbonic acid, thus lowering the carbon
dioxide tension of the blood and likewise of the
alveolar air. This decreased tension is nearly pro-
portional to the fall of bicarbonate. Hence there is
practically no change in the proportion of carbonic
acid to baking soda or sodium bicarbonate in the
blood in certain cases of acidosis. In other words
the hydrogen ion concentration is unchanged. That
there exists a constant definite proportion between
carbonic acid and sodium bicarbonate has been
amply proved. This was determined by an analysis
of the carbon dioxide gas in the blood. It was
found that blood plasma contains sixty per cent, of
its volume of carbon dioxide gas bound as bicarbon-
ate and three per cent, carbon dioxide bound as
carbonic acid (7), hence the ratio carbonic acid :
sodium bicarbonate :: one : twenty, i. e., for every
molecule of carbonic acid in normal blood plasma
there are twenty molecules of sodium bicarbonate.
As long as this ratio is maintained, the hydrogen
ion concentration is unchanged and if acidosis is
present it is compensated. But if this ratio be-
comes I :i5 or I :io there is an increased propor-
tion of carbonic acid to sodium bicarbonate and
consequently an increased hydrogen ion concentra-
tion.
The process of accelerated respiration and circu-
lation in acidosis is proportional to the fall of blood
bicarbonate, so that as already explained the i :20
ratio and hydrogen ion concentration are kept con-
stant. This can continue until the respiratory and
circulatory organs are no longer able to eliminate
carbon dioxide so rapidly as to keep the proportion
up to I :2o. Up to this stage the condition is called
a compensated acidosis. Rowntree estimates that
the equivalent of several hundred cubic centimetres
of a normal acid are excreted by the lungs in twen-
ty-four hours. The maintainance of this i :20 ratio
is arterial ; the carbonic acid of venous blood is in-
creased by the absorption of carbon dioxide from
the tissues ; hence venous blood is less alkaline than
arterial. The difference is so slight, however, that
normal venous blood taken at rest, and without
stasis, can be regarded as but slightly inferior to
arterial blood. Van Slyke found arterial hydrogen
ion concentration to be PH 7.44, and venous hydro-
gen ion concentration PH 7.41. Arterial sodium
bicarbonate and carbonic acid yields fifty cubic
centimetres carbon dioxide, while venous blood
yields fifty-five cubic centimetres.
In the examination of respired air, it is noted that
the bicarbonate concentration of the blood fixes the
level of the carbonic acid of the blood, which in
turn fixes the level of the alveolar carbon dioxide.
Consequently the determination of alveolar carbon
dioxide tension by the Haldane method is an in-
direct method of determining the bicarbonate con-
centration of the arterial blood. Under certain
pathological conditions, or under the influence of
drugs of decreased atmospheric tension, of anxiety
or excitement, the sensitiveness of the respiratory
centre may vary, so that the alveolar carbon dioxide
tension is not even an approximate measure of the
blood bicarbonate, under all conditions. It has also
been shown that simply changing the position from
erect to recumbent has altered carbon dioxide ten-
sion six millimetres. The air at the end of respira-
tion does not contain as much carbon dioxide as
does air taken at the middle of respiration ; evi-
dently the gas exchange varies in different parts of
the lung. All these sources of error, however, even
in pathological conditions, occur within such limits
that clinical use of alveolar carbon dioxide tension
as a measure of blood bicarbonate is thoroughly
established. However, there are so many other fac-
tors influencing the alveolar carbon dioxide tension,
besides the blood bicarbonate, that it makes the al-
veolar carbon dioxide far from an ideal measure
of alkali reserve. Alveolar air may be collected by
the Haldane or Plesch-Levy method. By the Hal-
dane method, the patient with a single quick ex-
piration fills a glass container. By the Plesch
method, the patient breathes in and out of a rubber
bag for thirty or forty seconds. The latter ap-
proaches venous blood, but has the advantage of re-
quiring less cooperation on the part of the patient.
In fact it has even been used successfully on
children.
Laboratory tests upon the blood for the detection
of acidosis are accurate but difficult for the ordinary
routine. The tests are : the hydrogen ion concen-
tration of the blood; the alkaline reserve of the
blood ; the carbon dioxide tension of the blood or
plasma. An increase in the hydrogen ion concen-
tration of the blood is only noted in cases of uncom-
pensated acidosis. I believe that most cases of
acidosis would show an unchanged hydrogen ion con-
centration. The normal hydrogen ion concentration
of the blood is PH 7.65. All cases with a hydrogen
ion concentration greater than 7.4 constitute a true
acidosis. All cases with a normal hydrogen ion
concentration, but a decreased alveolar tension and
a decreased alkali reserve, constitute compensated
acidosis. The alkaline reserve of the blood is low-
ered in every case of acidosis. The plasma bicar-
bonate is influenced by the free carbonic acid con-
tent. NaHC03+Protein=H2C03+Na Proteinate.
This is the reaction chiefly responsible for the varia-
tions in the plasma bicarbonate caused by varying
H2CO3 content. Another reaction which may take
place, of less importance, however, is 2NaHC03=:
Na2C03-(-H2C03. This reaction is of no real im-
portance because of the small amount of sodium
carbonate in the blood. These reactions are re-
versible so that an equilibrium is constantly main-
tained normally between sodium bicarbonate and
carbonic acid.
The alkaline reserve of the blood is estimated
from the amount of carbon dioxide bound as bi-
carbonate, using the Van Slyke method. Investi-
gations are being made with colorimetric methods
so that the actual bicarbonate concentration of the
blood can be measured instead of estimating it
from the carbon dioxide. Williamson (8) esti-
mates the reserve alkalinity of the blood by a
modification of Wright's method. Blood is drawn
58«
WALTZ: ACIDOSIS.
[New York
Mp.dical Journal.
from the arm anci allowed to coagulate. The
senun is then drawn off. Normal sulphuric acid
is diluted with distilled water in strengths of one
twentieth, one thirteith, one fortieth, etc., up to
I :too. One fourth of a c. c. of the serum is
mixed with one fourth of a c. c. of the acid solution
and the strength of the acid required to neutralize
the serum is recorded. The average is between
one thirtieth and one forty-fifth, the normal is ex-
N
pressed thus: — H2SO4. If acidosis is present and
35
the alkalinity is decreased it will take a weaker dilu-
tion of sulphuric acid to neutralize the serum.
N
Hence in acidosis the result would be, e. g. —
60
, N
or even — H2S04. His experimental results on
pregnant women were as follows : six normal
N N
women (thirty-fifth week) — to — ; nine toxemia
37 40
N N N
patients (eclampsia, kidney of preg- — to — , — .
nancy) 48 88 68
The fall in alkalinity bears no relation to the sever-
ity of the toxemia. In the case with the lowest fall
there were only two convulsions and a temperature
of 100.5°. The alkalinity was normal in ■ four
cases of chronic nephritis. This test is not accurate
but is valuable because of its simpHcity.
The carbon dioxide tension of the plasma is the
capacity of the plasma to unite with carbonic acid
under definite tension which determines the amount
of alkali in excess of acids, other than carbonic. In
. acidosis the carbon dioxide tension is markedly
lowered. It is noted that in acidosis the nonvolatile
acids increase at the expense of the carbonic acid.
These acids unite with the bicarbonate of the blood
leaving a diminished amount of bicarbonate shown
in making the determination of the carbon dioxide
tension, hence a decreased tension.
The best methods for the determination of
acidosis are: i, reserve alkalinity (Van Slyke) ; 2,
alveolar carbon dioxide tension (Plesch-Levy) ; 3,
hydrogen ion concentration (dialysis indicator of
Van Slyke). These tests determine whether
acidosis is present or not and whether it is compen-
sated or uncompensated. They are, however, quite
difficult for the ordinary laboratory. For the de-
termination of acidosis in ordinary routine work the'
following tests are suggested: i, acetone (nitro
prusside test) ; 2, diacetic acid (ferric chloride
test) ; 3, alkalinity of the serum (Williamson) ; 4,
alkali toleration. The clinical evidence must not be
forgotten in the reckoning, e. g., inability to hold
the breadth for twenty seconds, the normal being
thirty to forty seconds.
Clinical symptoms are due to the impoverishment
of bases. The dominant feature is an "acyanotic
hyperpnea" or rapid breathing without cyanosis, also
called air hunger. This rapid breathing is necessary
to eliminate the carbonic acid and is due to the in-
creased stimulation of the respiratory centres. An
acetone or sweetish odor to the breath may be
noticed showing that a ketonuria, and possibly an
acidosis, exists. There is restlessness, a rapid pulse,
and maybe some temperature. In children there is
aot to be nausea and vomiting. The clinical picture
in a child is very similar to pneumonia, with a
flushed face, rapid respiration, and quick pulse.
The laboratory findings need not be repeated. In
as much as the colon bacillus has a preference for
an acid medium, a colon infection of the urinary
tract should be watched for. Doctor Blodgett em-
phasizes a sore spot over the pancreas in cases of
acidosis. Rhamy finds that acetone bodies appear
in some lesions of the pancreas. Acidosis is found
more often in children than in adults but the sever-
est forms of acidosis are encountered in diabetes.
The reason for the increased susceptibility of chil-
dren to acidosis is the normally low carbon dioxide
tension, the somewhat lower alkaline reserve and
the fact that acetone bodies develop upon very
slight provocation. The so called cyclic vomiting
of children is due to acidosis. Lichty called atten-
tion to this periodical vomiting of children being
sometimes the precursor of a permanent tendency to
migraine, particularly if there is a history of mi-
graine in one or more parents. He believes that
the acetone found in children with cychc vomiting
is the result of the starvation incident to the vomit-
ing and not the cause of the condition. Cyclic
vomiting must not be confounded with meningitis,
intestinal obstruction, nervous or hysterical vomit-
ing. The laity term these attacks "bilious spells."
Acidosis is also found very frequently in the
toxemia of pregnancy, postanesthetic vomiting, and
starvation. It may also be found occasionally in
rickets, sepsis, cachexias, and severe anemias, renal
and cardiorenal diseases, infantile diarrheas. It is
also reported following burns, in drug addicts fol-
lowing the withdrawal of the drug, in cancer,
uremia, marasmus, etc. Gillespie, of London (10),
gives an interesting description of postoperative
acidosis. "In minor cases of acidosis it is noticed
that the patient vomits a little longer than usual.
In severer cases it is noticed that during the course
of the operation the patient goes under with sur-
prising ease, the breathing is shallow, even with
good air entry there is a tinge of cyanosis, the
patient requiring careful watching. It takes a long
time for the effect of the anesthetic to wear off ; if
conscious the patient becomes very restless and
tosses about ; the cyanosis becomes definite ; the
vomiting is frequent and of small amounts ; the
pulse rate increases rapidly but decreases as rapidly
in volume : the temperature shoots up even in a
cleim ca.se ; and visions of sepsis appear ; the patient
soon becomes unconscious. In children there are
shrill cries, in an adult maniacal delirium requiring
restraint ; coma supervenes, terminating in death in
the matter of thirty-six hours. If the urine be ex-
amined, acetone and diacetic acid will be found. If
the case is more prolonged these may be absent and
crystals of leucin and tyrosin may be found."
The predisposing factors of acidosis are nervous
and muscular activity, starvation, decreased oxida-
tion of diseased and injured tissues, direct injury to
October 5, 191S.]
WALTZ: ACIDOSIS.
589
the liver by the anesthetic. Starvation causes a
rapid decrease of the circulating glycogen in the
blood. Morphine helps to prevent an acidosis but
tends to increase it after it has once developed.
TREATMENT.
The first and most important thing is alk&li in
the form of sodium bicarbonate. It may be given
in anv way possible, depending upon the nature and
severity of the acidosis, by t'he mouth, by the rectum,
subcutaneously, or intravenously. The amount de-
pends upon how quickly the symptoms of acidosis
subside. At any rate the hydrogen ion concentra-
tion should return to normal, or if the urine is quite
acid, until the reaction is neutral or shghtly alkaline,
never strongly alkaline. A two per cent, solution
is used subcutaneously and may be combined with
potassium citrate or infusion of digitaHs. A four
per cent, solution is used intravenously. Transfu-
sion by the syringe method of prealkahnized serum
from a healthy donor has been used sucessfuUy
(II).
The clinical effects of the successful treatment of
acidosis with alkalies are relief of dyspnea and
diuresis, and occasionally mental improvement.
The use of carbohydrates in the treatment of
acidosis is of decided benefit, either in the diet or in
the form of glucose. A diet rich in fats may be
responsible for acidosis for with the increase of
fats in the intestines is the increased formation of
alkaline soaps derived from the splitting up of the
fats into fatty acids and glycerine. Thus the alkalies
are prevented from reaching the body. For the
complete utilization of two molecules of fat, one
molecule of glucose must oxidize ; thus two mole-
cules of fat yield six molecules of fatty acids and
two molecules of glycerole ; the two molecules of
glycerole yield one molecule of glucose. Now if
for any reason this complete process is interfered
with, you have the fatty acids remaining in the in-
testines unused. This is where the glucose treat-
ment can be of use, as well as a carbohydrate diet.
Carbohydrates contain a large proportion of
oxygen in their molecules in contrast to the small
amount of oxygen in fats. A part of this oxygen
is given up and assists in acidifying the fats into
simple harmless products. Glucose may be admin-
istered by mouth if there is no vomiting, one dram
to a glass of water several times daily. It may be
used in a five per cent, solution per rectum. If the
case be urgent a four or five per cent, solution sub-
cutaneously, or as high as a seven per cent, solution
intravenously, may be used. The glucose solution
must be freshly prepared, since, being a good culture
medium, it is easily contaminated. Glucose is utilized
very quickly and readily by tissue cells.
A very important part of the treatment, particu-
larly in children, is the regulation and control of the
diet. Van Slyke found that digestion increases
carbon dioxide tension. If a child is continually
being overfed the excess of energy supplied and
generated is normally cared for by storage of
glycogen or fats, or by such end products as car-
bonic acid, water, urea. This method involves com-
plete oxidation. If the body cannot aflFord to lose
oxygen, or has not the oxygen to lose, the oxidiza-
tion is incomplete and acids are left unoxidized.
These acids are neutralized by the body and if bases
are inadequate the drainage from the tissues takes
place — potassium and sodium from the red cells,
carbonate from the plasma, iron from the hemo-
globin, calcium from the bone, ammonia from the
proteins, etc. — and acidosis results. If energy is
derived from protein or fats without the presence of
carbohydrates, an increase of acids results. When
an individual fasts his cells naturally continue to
oxidize foods. The proportion of fats and carbo-
hydrates in the body is largely determined by the
previous diet. If the patient has but little fat then
the cells will live on protein. This type, however
(doubtful), does not produce acidosis because about
fifty per cent, of the protein is capable of conver-
sion into glucose and of the remaining fifty per
cent., only a small fraction consists of aminoacids
capable of yielding acidosis bodies. But if the
patient has a considerable glucose reserve and also
a normal amount of fat, there is no acidosis at first ;
but later, after the glucose decreases and the fats
are being used, there is a rising acidosis. If fast-
ing is pushed until fats are used up and the protein
is reached, then acidosis decreases. If the individ-
ual contams considerable fat in proportion to the
glycogen the result is a quicker and more severe
acidosis.
Reduce the amount of the diet, particularly fats ;
keep it simple ; creating demands for food, however,
is better than curtailing the supply. The ahmentary
tract should be emptied with castor oil or calomel,
although one author (Williamson) warns against
calomel for the bowels or mercurial douches because
mercurial poisoning causes the same lesions as are
present in acidosis. Glucose and bicarbonate are
administered. Barley water may be used. Water
is the best diuretic. In children when the periodic
vomiting has ceased give a low diet, low m fats,
proteins, and carbohydrate, but not fat free. Skim-
med milk, rice water, barley water, oatmeal water,
may be given for a limited time only. Juice of
oranges, pineapples, grapes, baked apples, prune
sauce, pear sauce, etc., are allowed. It takes fifty
pounds of apples to replace the protein of one
pound of beefsteak and yet two or three apples
contain enough alkaline base to correct the acidity
arising from the cereals normally consumed in a
day. Fruits are poor in protein but contain con-
siderable sugar, cane, dextrose, and levulose. Levu-
lose, or fruit sugar, is so delicate and unirritating
that it can usually be borne by the most sensitive
stomach. The final stage of fruit digestion is the
change of fruit acids and salts into alkaline salts,
chiefly carbonates. Vegetable foods contain con-
siderable alkaline base when raw, but when cooked
forty to fifty per cent of the mineral parts is lost.
Meat contains a large excess of acids and cereals
contain nearly one third as much as meat.
The prolonged use of alkali tends to produce
aciditv in the long run, either by stimulating acid
secretion or bv decreasing the alkaline output.
Massive doses should not be given day in and day
out, and even an excess of alkali should not be
pushed, as this tends to further disturb the acid
basic equilibrium. In some cases, after the use of
590
FISHER AND ELLIS: SARCOMA OF BRAIN.
[New York
Medical Journal.
alkali, small, well diluted doses of acids may stim-
ulate the body to produce its own alkali.
A few added suggestions for treatment might be
given regarding the acidosis of diabetes. Precau-
tion against acidosis should form a part of the
treatment in every case of glycosuria. A careful
diet is the best method. Drugs are palliative, and
even though the acidosis were corrected, shown by
a return of the hydrogen ion concentration to
normal, the original condition, diabetes, would still
be present. Even though diabetic 'coma is due to
acidosis, in some cases of diabetes in the terminal
stage of coma it is possible to correct the acidosis
and return the blood to normal alkalinity and still
have i^he patient die in coma, due to the inability to
correct acidosis in the tissues as well as in the blood.
The diet should have three objects: i, limitation of
the acid products of metabolism ; 2, conservation of
the store of alkaline bases in the tissues and blood ;
3, maintenance of the balance at normal level. The
acid production of metabolism may be limited by
the elimination of fats from the diet. To prevent
acidosis in the obese, a weight reduction is neces-
sary, thus eliminating a source of fat supply. The
tolerance for carbohydrates should be increased.
"In diabetes the maximum rate at which glucose
can be oxidized is lower than in the healthy body.
The limited amount of glucose the diabetic can
oxidize fixes the amount of fat that can be oxidized
without developing acidosis. And so a fatty acid
metabolism which would be normal in health be-
comes exceedingly high in severe diabetes with the
consequent development of acidosis" (12). Rest
and warmth help to inhibit the mobilization of fats
and assist the glucose to oxidize. The protein intake
should be restricted just enough so that there will
be no nitrogenous waste left to form acids. This is
best governed by the nitrogenous output in the
urine. In some cases of diabetes, withdrawal of
food increases or provokes an acidosis. Judicious
administration of carbohydrates may correct an
acidosis provoked by starvation. In severe cases of
diabetes the volume of urine must not be allowed to
decrease with the sugar.
SUMMARY.
Acidosis is not in itself a disease but like a fever,
an incident of disease. Alkali therapy for acidosis
is certainly beneficial, but, like the treatment of
fever with ice, it is merelv symptomatic (13).
Acidosis exists in numerous diseases but all tests
may not be present. Acetone ipay be found in
diabetes and in certain diseases of children but not
in chronic nephritis. All of these conditions may
show a decreased alveolar carbon dioxide tension,
or an increased soda tolerance, etc. Therefore
acidosis is not due to the same abnormal factor in
each case. Arterial blood must be kept neutral or
slightly alkahne. This is normally maintained by
the removal of surplus acid radicals by the kidneys,
and by the neutralization of the excess of acids, by
body bases, and by ammonia which, if not used,
would be excreted as urea. When for any reason
this balance mechanism breaks down, the alkali re-
serve of the body is lost, alkali starvation results, all
nutritive functions become disordered, and coma or
even death may follow.
REFERENCES.
I. Van Slyke and Cullen: Journal of Biological Chemistry,
June, 1917. 2. L. J. He.nderson: Transactions cf the Association of
American Physicians, May, 1916. 3. Pritchard: American Medi-
cine, June, igi6. 4. Rowntree: Transactions cf the Association of
American Physicians, May, 1916. 5. Ibid. 6. Cammidge: American
Medicine, June, loii). 7. Van Slyke and Cullen: Journal of
Biological Chemistry, June, 1917. 8. Williamson; American Medi-
cine, June. 1916. 9. Lichty: Archives of Diagnosis, July, 1916.
10. Gillespie: American Medicine, June, 1916. 11. Gettler and
Lindeman: Journal of the American Medical Association, February
24, igf'y. 12. Yandell Henderson: Transactions of the Association of
American Physicians, vol. xxxi, 12. 13. Woodyat: Transactions of
the Association of American Physicians, vol. xxxi, 64.
SARCOMA OF THE BRAIN.
By H. M. Fisher, M. D., and A. G. Ellis, M. D.,
Philadelphia.
(From the Ayer Clinical Laboratory of the Pennsylvania Hospital.)
CLINICAL notes — BY DOCTOR FISHER.
Mrs. C, fifty-two, a widow, born in Italy, was
married at the age of eighteen. T wo years later
she gave birth to one child, who lived only a week.
Following the birth of this child the patient suffered
from dysmenorrhea for many years, also from
symptoms of gastric and intestinal indigestion and
did not become pregnant again.
In 1897, Dr. George M. Boyd operated, removing
both ovaries and tubes and, following this opera-
tion, the patient's general health improved, although,
from time to time, I was sent for, owing to
repeated attacks of flatulent dyspepsia. Last win-
ter (1916) the patient had a bad attack of ear
ache and was very much depressed. The trouble
proved to be due to a furuncle in the external aud-
itory meatus, and no evidence of middle ear catarrh
was detected.
July 26, 1917, I was called to see the patient, and
was informed that for a week or more she had
been complaining of slight thickness of speech and
some weakness of the right arm. On August 20th,
she came to my office, still complaining of the same
symptoms, but was able still to walk with some
assi.stance, although complaining of some weakness
in the right leg. On September loth, I was sent for
and suggested a consultation with Dr. M. J. Lewis.
Since there was no evidence of arteriosclerosis,
systolic pressure 1 10-120, nor of heart or kidney
lesion, nor of any sudden loss of power. Dr. Lewis
decided that the symptoms pointed to an intra-
cranial growth or to cerebral syphilis.
Patient complained at this time of some pain
over the left orbit, but so far as I could ascertain
headache had at no time been a prominent symptom.
She was somewhat emotional, and the thickness of
speech from which she had previously suffered
had become much more marked. Any attempt to
speak more than a few words at a time seemed to
fatigue her very much. At this time there was
slight, but fairly well marked, paresis of the right
arm. A Wassermann blood examination proved
negative, and the urine was absolutely normal. From
this time her condition became rapidly worse and
on September 13th she was admitted to the Penn-
sylvania Hospital.
The following notes are from the history of the
case taken by Doctor Randall, resident physician
of the Hospital :
Patient is semicomatose. Respiration quiet and
October 5, 1918.]
FISHER AND ELLIS: SARCOMA OF BRAIN.^
59^
regular. Pupils unequal ; the right is the larger
and does not react to light. Left pupil reacts fairly
promptly. Breath very foul. Heart sounds very
weak and distant. Pulse weak and irregular. Pa-
tellar reflexes + No ankle clonus. Suggestive
Babinski on both sides. No distinct paralysis, as all
limbs move responsively to pin pricks. Systolic
pressure no. Diastolic fifty-five. Condition seems
critical.
September 14. — A lumbar puncture was made
and twenty-five c. c. of slightly cloudy fluid were
removed under increased pressure. The fluid con-
tained 165 cells, mostly mononuclear. Spinal fluid
Wassermann negative.
September 20. — Condition unchanged. The treat-
ment from the time she was admitted to the hos-
pital consisted in inunctions of one dram of mer-
curial ointment three times daily. Mercury succin-
imide, one-quarter grain hypodermically, twice daily,
and benzoate of sodium and caft'eine on account of
the M'eak heart action, and digalen hyperdermically
as required.
September 21. — Weaker. Medication stopped as
patient appeared moribund.
September 24. — Treatment started again, pa-
tient's condition having improved considerably since
a lumbar puncture made yesterday. The fluid
passed out under about normal pressure, was clear,
and contained only twenty-five cells. Wassermann
made on this fluid proved negative.
September 27. — Patient was seen by Doctor
Spiiler in consultation, who found both knee jerks
reduced, also that neither pupil reacted to light.
Suggested either cerebrospinal lues or uremic
poisoning.
Examination of the functional capacity of the
kidneys by phenolphthalein test showed elimina-
tion at end of first hour thirty, at end of second
twenty-five; total fifty-five. For the past two days
patient has voided urine normally, having had pre-
viously complete retention, and catheter had been
used regularly twice a day. Examination of eye
grounds by Dr. P. N. K. Schwenk made several
days ago showed no pathological changes in either
eye. Patient died in the evening of this day. Her
temperature had varied from 97.6° on the date of
admission to 101.2° three days later, the curve lying
for the most part between 990 and 1000.
PATHOLOGICAL FINDINGS.- — BY DOCTOR ELLIS.
The pathological diagnosis was as follows : Fatty
degeneration of the heart ; congestion of the left
lung; congestion and edema of the right lung:
chronic adhesive pleuritis, right side ; congestion of
the spleen ; congestion of the kidneys ; congestion
and parenchymatous degeneration of the liver ;
bilateral salpingooophorectomy ; abdominal scar ;
tumor of the brain.
Brain. — The brain weighed 1,220 grams. In the
left parietal region was a round elevated area two
or three cm. in extent, that was slightly roughened
and was grayish in color. At one border of this
area was a smooth, rather yellowish spot, two cm.
in diameter, that fluctuated when pressure was made
on the surrounding brain. The entire elevated area
was soft, as though fluid were contained beneath.
Incision of the yellowish area, in making inoculation
from it, allowed the escape of a thin reddish fluid,
apparently blood tinged serum. The remainder of
the brain had the usual consistency and appearance,
except that the small vessels of the pia mater were
somewhat injected.
A horizontal incision at about the midpoint of the
bulging area opened into a cavity five cm. in diame-
ter, at opposite poles of which were masses oi
fairly firm, gray, homogeneous tissue. The cavity
itself was filled partly by fluid, partly by softened
or necrotic tissue that hung in shreds from the
solid portions of the wall. The general appearance
was that of a soUd mass that had softened and be-
come partly fluid, with small hemorrhages occurring
into it. The solid portions of the mass were quite
sharply separated from the brain tissue, although
on close inspection there appeared no distinct cap-
sule or similar structure separating the two. The
mass had reached almost to the pia mater on the
outer surface, accounting for the fluctuation before
the cavity was opened. Internal to the softened
area the brain tissue for a zone three to four cm. in
width was tinged distinctly yellow by pigment, pre-
sumably due to deposition from the hemorrhagic
tissue in the cavity. The mass had apparently ex-
erted some pressure on the left lateral ventricle bu|
did not appear to have actually invaded it. In-
oculations on agar and in broth were made from
the content of the mass. The spinal cord and its
meninges showed no gross lesions.
MICROSCOPICAL EXAMINATION.
The microscopical findings of the tumor were:
Brain. — Sections of the tumor were very largely
cellular. These cells were round or oval and pos-
sessed palely stained nuclei. In areas they were
closely massed, in other portions they were sep-
arated by faintly staining, fibrillar substance. The
growth had no sharp line of demarcation from
cerebral substance ; the latter was gradually in-
filtrated bv the cells which extended for some dis-
tance into recognizable brain tissue before the latter
Avas completely replaced by the tumor.
The growth was, in general, quite vascular, the
vessels having fibrous walls. Quite extensive areas
were telangiectatic in structure, being composed of
closely placed vessels or channels separated by thin
bands of tumor tissue, and having no distinct wall
other than occasioned endothelial cells. In these
spaces were large bodies, apparently "shadow" red
cells, and fibrin. Small hemorrhages were near these
areas in one section and they bounded degenerative
and necrotic portions of the tumor that formed the
border of the cavity in the growth. In the necrotic
tissue were scattering leucocytes, chiefly polynu-
cle-ir in type.
Inoculations from the content of the cystic por-
tion of the tumor proved sterile. The cord and its
meninges had no noteworthy changes.
The structure of the tumor was very suggestive
of glioma, which was the diagnosis provisionally
made. Sections stained to demonstrate glia fibres,
however, failed to show their presence. The con-
clusion was that the tumor was a sarcoma contam-
ing some very vascular areas.
592
SAUTTER: PILOCARPINE IN CHRONIC DEAFNESS.
[New York
Medical Journal.
PILOCARPINE IN CHRONIC DEAFNESS.*
By C. M. Sautter, M. D.,
New York,
Assistant Aural Surgeon, New York Eve and Ear Infirmary and
St. Luke's Hospital.
The use of pilocarpine in the treatment of deaf-
ness has been advocated for many years, but in a
perusal of the literature I have been unable to fiind
any definite data concerning the part of the auditory
mechanism that is af+ected. The consensus of
opinion seemed to be that the drug was especially
efficacious in nerve deafness. I have used it fre-
quently in cases of nerve deafness, otosclerosis, and
in cases which I had been unable to attribute to a
nasal or pharyngeal disturbance. When the pilo-
carpine is inflated directly into the middle ear
through the eustachian catheter, the hearing and
tinnitus are in some instances improved ; but com-
paring the tests the changes in the tone limits have
always been in the lower vibrations. The question
arises : Does the pilocarpine influence the change or
is it induced by the routine inflation which is used to
assist the injection into the tympanum, and what
part of the auditory apparatus is influenced?
Occasionally I have administered the pilocarpine
solution by mouth, especially in the case of patients
who come from out of town and find it difficult to
return for extended treatments. In one of these
cases the result was so obvious and constant that it
seemed to be of sufficient importance to report.
Case. — Miss E., age thirty years, single. First came
under my observation at St. Luke's Hospital in Doctor
Bench's otological service on July 6, 1915. She was em-
ployed as a bookkeeper and stated that she was afraid of
losing her position because of her deafness. There was
no history of any other deafness in the family. She also
stated that she had been treated by a number of spec'alists
for a considerable length of time — the treatment consist-
ing principally of inflation — with no apparent change. She
gave a history of having had measles seven years ago,
when she was seriously ill. At that time her ears dis-
charged, and the right ear had been impaired ever since.
Five years ago she fell on tlie back of her head and be-
came completely deaf in the left ear. One year ago the
deafness and tinnitus -increased in the right ear. Both
tympanic membranes were intact, but were slightly re-
tracted and thickened. The nose and throat were ap-
parently norma!. In testing, the left ear was totally deaf
with the use of the noise apparatus, and the static labyr-nth
failed to react to turning or ice water irrigation. With
the right ear patient heard moderate voice at three inches,
but the watch was negative. Low limit at S.S d. v. ; high
limit, g,2go d. v. vibration. Bone conduction was greatei
than air conduction. The static labyrinth was nonreactivt
These limits remained the same after inflation. Both tubes
were very patent. A Wassermann reaction was negative.
Pilocarpine solution was given to the patient, with instruc-
tions to take it to the point of physiological reaction or
until a free perspiration was induced. L^pon returning the
following week, she stated that she had had a most pro-
fuse perspiration, with an immediate change of hearing
which was c|uite perceptible to herself as well as to her
family. In testing again in the same environment, the left
ear remained totally deaf and both static labyrinths in-
active. In the right ear. however, she was able to hear
the same watch at one inch and the moderate voice at
eight feet. The low limit was now 16 d. v.; high limit,
9,290 d. V. After an interval of more than two years, the
patient returned, upon invitation, June 2, 1917. The com-
parative tests showed the hearing to be identically the
same, and she stated that she had very little tinnitus.
*Read before the Otological Section of the Academy of Medicine,
November 14, 1917.
The change in this case was in the lower vibra-
tions, from 55 d. V. to 16 d. v., or normal low limit.
The hearing for the voice improved from three
inches to eight feet ; and for the watch from zero to
one inch. Since she had previously had considerable
inflation treatment with no apparent benefit, and the
only treatment administered in this instance was the
pilocarpine solution by mouth, it seems quite ob-
vious that the latter induced the improvement.
II East Forty-eighth Street.
ASPHYXIATION— RESPIRATION-
CIRCULATION.
By p. a. Kane, M. D.,
Chicago.
Asphyxiation is defined as suspended animation
from a deficiency of oxygen in the blood. To this
I do not fully agree and will state my reasons later
in this article.
The modern method of resuscitation, approved by
the medical profession, is to place the patient prone
on his face. The doctor kneels over the patient, one
leg on each side, and facing the head of his subject,
places both hands over the short ribs and presses
strongly and steadily and then releases pressure.
This process is repeated about eighteen times per
minute. This position, maintained for a short time,
is a good one for a patient who has been suffocated
in water. It removes the water from the lungs by
drainage and pumping. It also keeps the heavy
weight of the lungs and the water in the lungs from
impeding the venous circulation. For a man who
has been overcome by carbon dioxide or carbon
monoxide gas this position is not good. He should
be placed m a reclining position with the head
thrown back and chin slightly drawn in. The lungs
in these cases are usually empty and irritated, caus-
ing contraction. The prone attitude permits free
contraction of the lung, causing less expansion on
release of pressure, permits the heart to turn over
on itself, twists its arteries and veins, and thereby
iinpedes its proper functions. On the other hand,
in a reclining position, the gravity of the lungs would
help to overcome their contraction, and hold the
heart in proper position.
I would like to ask any doctor if he were on the
point of asphyxiation, or commonly speaking, short
of breath, would he lie on his stomach and face
and breathe only eighteen times a minute? Does
any animal when short of breath take but eighteen
respirations per minute ? Any person or animal in
such a condition will inhale and exhale very quickly
about six times and then give one long breath and
then start all over again. This one long breath en-
ables the blood to get back into the brain. Animals
in general lower the head and let the tongue protrude
from the mouth. Men throw the head back in
order to obtain the freest passage of air to the
lungs. Men never lie face downward, but prefer
to lie on the back with the body and shoulders raised.
Of course, if this method were used in asphyxia-
tion, an assistant would be needed to hold the pa-
tient's tongue from falling backward into the throat.
Eighteen respirations per minute is a good method
October 5, igiS.l
KANE: ASPHYXIATION.
593
for the doctor to use, but not for the patient. The
heart of the patient beats feebly, but very quickly,
about two hundred times per minute. His res-
pirations to correspond to this acceleration should
be about fifty, not eighteen, times per minute. To
get the blood circulating throughout the body is of
as much importance as getting oxygen into it. This
can only be done by working in unison with the
heart, at a ratio of one to four between respiration
and heart rate.
The heart is the pump which forces the blood
throughout the body. Normally it beats about
seventy-two times per minute. But in childhood,
sickness, old age, and exercise, it beats much faster.
It beats practically four times during each full res-
piration.
There arc two circulatory systems: the pulmonary
or smaller, and the systemic or larger. The right
•and left auricle, the right and left ventricle are of
practically the same size. The right ventricle
pumjis the same amount of blood into the pulmonary
system as the left ventricle does into the systemic
system. i\ny cause that disrupts this equilibrium is
sufficient to produce incipient asphyxiation, or so
called loss of breath. In looking upon the heart
as a pump, which undoubtedly it is, we overlook
that other pump, the lungs ; that other great pump
with a pressure of fifteen pounds to the square inch,
which forces oxygen into the blood and compresses
the inilmonary veins, forcing the aerated blood into
the left auricle. It also compresses all other veins
in the thoracic cavity and eventually pumps the
venous blood from the head and arms through the
innominate veins into the superior vena cava and
into the right auricle. By its action of compression
and release, it brings the chyle up through the
thoracic duct from the abdominal cavity. By the
lowering of the diaphragm during inspiration, it pro-
duces the following elTects : i. Compression of the
kidneys, forcing the venous blood into the portal
circulation and the urine from the pelvis into the
bladder ; 2. compression of the stomach, forcing the
blood into the hepatic veins and the food into the
intestines ; 3, compression of the spleen, adrenals
and pancreas, forcing the blood and secretions into
the circulation and on toward the liver, forcibly
contracting the liver, compressing the small veins
of that organ, and forcing the venous blood up
through the inferior vena cava and on into the right
auricle. Morris, in his book on anatomy says : "As
the inferior vena cava passes through the diajDhr.Tgm,
the walls are attached to the tendinous margins of
the caval opening and are then held apart when that
muscle contracts."
There are no valves in any of the veins of the
thoracic or abdominal cavities. As the veins are
so con.structed they would not or could not with-
stand the enormous pressure of fifteen pounds to
the square inch. Not speaking of the added strain
during coughing, emesis, defecation, urination, and
child birth. The blood in those veins, without doubt,
moves in two directions during respiration ; this ex-
cepts, of course, the arterial blood in the pulmonary
veins that moves toward the left auricle. The ven-
ous blood in the superior vena cava coming from the
head and upper extremities, moves in two directions
during the inspiration ; some of it is forced into the
right auricle, and some of it regurgitates, chiefly
into the internal jugular veins. These are the largest
and most direct, practically receiving the force of the
inspiring blow. '•The internal jugular vein,'' says
Morris, "has two enlargements ; one called the supe-
rior bulb, just external to the jugular foramen, and
an inferior bulb, about one inch from its termination.
One inch above its termination it contains a pair of
imperfect valves, below which a second dilation usu-
ally occurs." These, no doubt, in the fetus were per-
fect valves, but as soon as breathing occurred, the
force of the regurgitation expanded the vein and
they became imperfect, and later through disease,
became atrophied to some extent. Now, the force
of the blow occurred further up where it met the
weight of all the returning blood from the veins and
sinuses of the cerebral cavity, just external to that
cavitv. These two bulbous enlargements receive
the force of the regurgitated blood, in a similar
manner to the air chamber used by a plumber.
There are no bulbous conditions in the abdominal
veins. The regurgitation from the liver is practic-
ally infinitesimal compared to all its avenues of
escape. First, the whole of the liver is not thor-
oughly compressed on inspiration ; second, the mes-
enteric, renal, portal veins, etc., leave plenty of
room for regurgitation; third, if the systemic ven-
ous blood only eciuals the pulmonary circulation,
then the arterial blood from the left ventricle di-
vides into the head and upper extremities, the
azygos arteries, renal, mesenteric, hepatic, lower
extremities, etc., so that a much smaller amount
returns through the portal than through the
innominate and superior vena cava. The thoracic
duct has two perfect valves in its upper extremity ;
this, says Morris, "stops venous blood from enter-
ing therein."' The walls of this duct, like those of
the arteries, are built to withstand fifteen pounds
of pressure. The suction force exerted to pull the
chyle up from the receptaculum chyli comes from
the vein into which it flows.
If I breathe rapidly, say about sixty times a
minute, and keep up that rate sufficiently long, I
become dizzy. This proves that the blood is pumped
out of the brain faster than the heart refills. This
condition removes the natural pressure about the
brain, permits it to expand, thereby disarranging
its equilibrium, and vertigo is the result. y\nother
proof that the blood is taken from the head and
face faster than it is replaced by the heart is that
almost as soon as I resume regular breathing, a
warm feeling comes to my face, showing that blood
is quickly refilling the depleted arteries and veins
of the head. If I inflate my lungs to repletion and
hold them in that manner as long as possible, my
face becomes crimson and I become dizzy. This
proves that the heart is forcing blood into my head
without any return flow. The arteries and veins of
my face and brain become full and expand, the
brain cavity becomes congested, and causes an at-
tack of vertigo. Even the vessels of the eye be-
come congested and I see red. Now if I exhale
fully and hold my breath for a while, a dragging
down sensation is felt, at the root and bottom of
the lungs near the region of the heart. The lungs
594
KANE: ASPHYXIATION.
[New York
Medical Journal.
seem to have attained great weight, the dragging
down feeling becomes so strong that it fairly forces
me to open my month with a gasp, in order to in-
flate the lungs. This implies that the lungs are
contracted while the heart keeps regularly pump-
ing blood into the puhnonary arteries and veins and
arterioles. The surrounding pressure being re-
moved from these vessels, the blood not being forced
out of them by breathing, they naturally expand,
become full and heavy with blood. The specific
gravity of that weight forces me to take in breath
with a gasp. The sensitive nerve filaments in the
alveolar tissue act on the brain centre and force
me to gasp for breath.
The vessels in which the blood circulates, the
arteries, arterioles, veins, and sinuses, are always
filled with it. full at all times and under pressure,
heart beat pressure. But in the complete circula-
tion, there are two vacuums. There is always a
vacuum in the two auricles or ventricles. If these
cavities are filled at the same time, it is but momen-
tarily during the beginning of the systole. While
breathing normally, two heart beats occur during
inspiration ; one during expiration and one during
rest. V.Hiile 1 am inspiring and forcing the aerated
blood into the left auricle, the heart empties that
chamber twice into the systemic circulation. But
the heart at the same time is emptying the right
auricle the same number of times through the right
ventricle, into the pulmonary arteries. These arter-
ies are occluded at their termination to a great
extent during full inspiration. Men have been
trained to hold their breath for two to three minutes
at a time. I do not believe this could be kept up
continuously for an indefinite period. Their heart
beats would continue to beat at the normal rate of
seventy-two per minute or faster. The equilibrium
between the pulmonary and systemic circulation
would become disorganized and this in turn would
afifect the brain centre.
Pearl divers and sponge fishers have developed
this accomplishment to a marked degree. But these
men have the advantage of standing on their heads,
as it were, and externally are completely enveloped
in an area of very high water pressure which
without doubt is a great advantage to them. Some
years ago I saw a professional water nymph and
her assistant stay under water two or three minutes.
They did not exert themselves in any manner ; they
dived to the bottom of the tank of water as slowly
and easily as possible. If intense active energy had
been used to make the dive, this action would have
disturbed the brain centre of the heart, causing its
acceleration, disturbing its balance, and forcing the
divers to obtain oxygen sooner, which would have
spoiled their act. Men inhaling pure oxygen, after
some practice, have been able to retain their breath
for seven to nine minutes. Though I have never
seen this experiment, I am positive they could not
keep this up for twenty-four hours, nor could they
exert themselves violently by exercises or labor,
mental or physical. Dr. Ben Morgan who holds the
chair of anesthesia in the Chicago College of Medi-
cine and Surgery, assures me you cannot move or
think while holding pure oxygen in the lungs for ten
minutes. One must lie perfectly still and try to
sleep.
The heart pumps the blood into the arteries, and
by such action, creates a vacuum in the auricles.
The Imigs, by their expansion and contraction,
force the blood out of the veins into the auricles.
The newly born infant as soon as it inhales, exerts
this same air pressure, fifteen pounds to the square
inch. This pressure forces the arterial blood out of
the pulmonary venous capillaries into the left auricle.
At the same instant, it forces the venous blood out
of the superior and inferior vense cavse into the
right auricle. This equalizes the pressure on each
side of the septum of the auricles, and stops the
flow of blood from the right auricle into the left
auricle. This enables or forces the valve at this
opening to close ; and eventually one solid septum
is formed.
The human body is like a clock. All the parts
are there and coordinate but useless, until the pen-
dulum is started to swing, when everything works
in unison. So it is with the human body ; all the
organs are present, coordinate, but useless until that
great pendulum, the lungs, begins to work, when the
whole body starts and continues to function. The
ticking of the clock is caused by the swing of the
pendulum. The beating of the heart is a result of
breathing. The reverse in either case is nonsense.
The human body is like a locomotive, the breath-
ing of the cylinder heads with its accompanying ex-
haust, forces the piston rods — the heart — to per-
form their duty.
CONCLUSIONS.
These are summed up under three heads : As-
phyxiation, the pumping power of the lungs, and
the closure of the foramen ovale.
First : The asphyxiated patient should be in a re-
clining position, except while pumping liquid out of
the lungs and air passages. This overcomes the
irritated contraction of the lungs and holds the
heart in place. The head should be thrown back
and chin drawn in. This gives the freest passage
for air to enter the lungs. The doctor should give
five or six quick superficial pressures and releases
and one long, deep pressure and release ; this full
respiration should occur about twelve times per
minute.
Second : The pumping power of the lungs. Air
pressure in the lungs squeezes all the blood out of
the veins of the thorax and liver ; forces oxygen
into the blood ; squeezes the gall bladder and forces
the bile on into the intestines, helps to force the food
out of the stomach into the duodenum, down into
the intestines, and on into the colon, and finally
assists in its propulsion during defecation ; squeezes
the hilus of the kidney, forcing the urine into the
ureters and on into the bladder, and finally assists
in the last act, urination. All these acts except the
eliminating ones are performed involuntarily.
Third : The closure of the foramen ovale. This
equalization of pressure on each side is paralleled
in the triple valve of an air brake. This pressure is
understood by every experienced railroad employee.
1926 CoNGRFSs Street.
Medicine and Surgery in the Army and Navy
MEDICAL NOTES FROM THE FRONT.
By Chakles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat docent at the University of Geneva; Fellow of the Royal
Societv of Medicine, London, etc.
WOUNDS OF THE LOWER JAW IN WARFARE.
This paper sets forth some data on wounds of
the lower jaw in warfare, obtained from the surgi-
cal department of the Royal Reserve Hospital, No.
6, at Budapest, which is under the direction of Dr.
Johann von Ertl. How these notes came into my
possession it is not necessary to state. The Huns and
their Allies have jealously guarded the exit from
Germany or Austria of all medical and surgical
journals' and books pertaining to the surgery of
warfare, fearing lest they should be of value to the
Entente Allies in the treatment of their wounded.
I would add, however, that their fears are ground-
less, because their contributions to medicine and
surgery during this war have been astonishingly
meagre and mediocre, and they have adopted a large
amount of the teachings of the medical and surgical
corps of the French, English, and Italians, in most
instances giving the reader the impression that they
have originated with them. This, of course, is only
what might be expected from a race of Vandals.
Wounds of the lower jaw in warfare ofifer, like
other bone lesions, many varieties according to the
nature of the missile and its momentum. The
Austrian Army has sufifered greatly from wounds
of the lower jaw, from simple fracture to the total
removal of the bone and all intermediary lesions
between these extremes. The surgical treatment
varies according to the degree and nature of the
damage inflicted, and also in cases coming under
observation during an acute phase of the injury or
with cicatrices of the soft parts or chronic lesions of
the bone.
From the viewpoint of this special surgical work,
which has been greatly developed during the war,
wounds of the lower jaw may be divided into two
groups : I . Those which recover spontaneously by
a conservative buccal treatment ; and 2, cases in
which conservative treatment is useless and there-
fore requires a combined stomatological and surgi-
cal treatment.
In cases which show a tendency to spontaneous
cure, the principal factor in treatment is fixation.
Modern stomatology has numerous apparatus at its
disposal for obtaining absolutely irreproachable
functional results. In the special department of
Royal Reserve Hospital, No. 6, various fixation
systems of Surgeon Major Gadany and Doctor
Landgraf have been employed, partly in their orig-
inal forms, partly with variations. The recovery of
the patients, who of¥er a spontaneous tendency to
consolidation, can be readily explained. The bone
fragments which are found in the track of the
missile retain their vitality because they are still
tinited to the periosteum and soft structures and
these splinters become united and consolidated by
simple fixation of the jaw, just as in other cases of
fracture. The cure is to be aided by a palliative
treatment of the wound and in these cases the most
important therapeutic factor is fixation which, in
the case of the lower jaw, can be best attained with
the teeth still existing.
Stomatology comprises the use of apparatus of
fixation of the highest type, as well as orthodontic
FiC. I. — Exposure of track of missile.
procedures. Therefore, it is manifest that stoma-
tology, which in the cases under consideration gives
absolutely good results, is the branch of surgery to
which they should be confided.
In a large number of cases in which the bone
lesion is, it is true, of small importance, conservative
treatment may, however, not result in consolidation
on account of the special pathological condition and
the anatomical relations of the wound track. In
these cases spontaneous consolidation does not oc-
cur, because the missile has destroyed the perios-
teum, while the sequestra become interposed be-
tween the fractured ends, thus spreading them
apart. In these cases a cure can be obtained, ac-
cording to Doctor von Ertl. by resorting to his
osteoperiosteal plastic operation, because by this
technic healing is aided by removing the dead
sequestra, while the track of the missile is covered
by very vivacious periosteum taken from the bone
fragments or, still better, from the osseous lamellae,
so that the bone fragments can be brought and held
in contact. By the same procedure, the relations of
the bone fragments and living soft structures are
reestablished, and thus is created the possibility of
consolidation.
Let us now consider Doctor von Ertl's famous
technic of osteoperiosteal plastic work. Foremost
of all the case must be prepared for the operation
by stomatological work. An apparatus is first made
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
and applied to the existing teeth in order to retain
them in good articulation. The operation is carried
out under local anesthesia, by producing anesthesia
of the third branch of the trigeminus at the foramen
ovale ; next the cervical plexus and regional
branches of the facial nerve are anesthetized, while
Fig. 2. — Nonplastic vertical bone fragments brought in contact
to form hc-rizontal layers, thus supplying loss of bone.
the submaxillary plexus is in turn anesthetized
through the buccal cavity.
When the wound is located in the middle of the
jaw (chin) a vertical incision is carried down the
centre of the chin. When the track of the missile
is in the horizontal branch of the jaw the incision
is likewise horizontal. If there is a fistulous tract
in the field of operation it is comprised in the in-
cision. After incising the skin and fat they are
sufficiently dissected of¥, and then the trajectory of
the missile is laid open and the granulating perios-
teum exposed to view, and this is then dissected off
on each side to the end of the fracture. After this
dissection of the periosteum the track of the missile
is exposed (see Fig. i). In cleansing the track
Doctor von Ertl attaches great importance to the
removal of all small sequestra existing between the
soft structures, and if along the track of the missile
some bone splinters are still united to the perios-
teum or bone, an attempt is then made to preserve
them bv uniting them in the form of a mosaic,
and by this means the two bone fragments are
brought into contact. If, on the contrary, no viable
sequestra are discovered in the track of the missile
and if this track is more than one and a half or two
centimetres, or if the bone fragments are not of an
aplastic nature, von Ertl is inclined to bring the bone
fragments in contact by forming with the chisel
A'ertical bone lamellre which are brought over in two
or three horizontal layers which thus fill in the loss
of bone (see Fig. 2).
Next by way of the buccal cavity the track of the
missile is followed up by working with the curette.
enlarging the orifice of the track which opens into
the buccal cavity and removing the granulation tis-
sue. When the track has been cleaned out it is
plugged with iodoform gauze, at the same time tak-
ing care that the gauze can be easily withdrawn by
way of the mouth. Following this the bits of
periosteum are placed in their original position and
sutured together in the middle line, reinforcing them
above and below by catgut sutures (Fig. 3). By
this procedure the track of the missile is completely
closed below. Then the skin incision is closed with
interrupted sutures and, the operative work being
finished, the bone fragments are sphnted with the
apparatus made beforehand.
The success of this operative procedure depends
almost entirely on the aftertreatment. On the third
day the iodoform gauze is removed through the
mouth and renewed every day. During the pack-
ing one must especially pay attention that the cavity
is completely filled with the gauze by exercising a
slight pressure on the walls of the cavity. In this
way the process of hypergranuJation is avoided,
which would otherwise compromise the ultimate
success of the operative work. If the cavity is not
sufficiently packed the rapidly growing hyperplastic
granulations will soon choke up the cavity, and since
they do not contract in the form of connective
tissue they oflfer no framework for the periosteal
apposition over the bone. Following the ultimate
cicatrization of the granulation tissue the bone
fragments l)ecome separated by cicatricial tissue and
Fig. 3. — Replacing and siituri.ig bits of periosteum in originaT
position.
consequently, in spite of the operation, a pseudar-
throsis results.
For this reason great attention must be given to
the aftertreatment and particularly to tight packing
of the track of the missile, in order to prevent the
October s, 1918 ]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
597
process of hypergranulation from taking place. The
result is that the contraction of the connective tissue
of the granulations and the periosteal apposition of
the bone fragments proceed simultaneously. The
cavity fills in until by the end of the sixth week only
a small depression indicates the site of the track.
Complete bone union will also have taken place in
from six to eight weeks. Radiograms of these cases
show that the bone fragments are united by bone
callus, which is very distinctly seen on the plates
and which may be considered as a production of the
periosteum. Therefore, it must be admitted that
the debris of destroyed periosteum which still re-
main also regenerate by metaplasia of the surround-
ing congenerous tissue and that they can utilize
completely their osteoi)lastic energy.
Doctor von Ertl maintains that, by his osteoperi-
osteal plastic work, he has suc-
ceeded in curing cases of
osteomyelitis with fistulse
which had been present for
years and he resorts to this
operation in these cases and
"always with complete suc-
cess."
In wounds of warfare this
operation will be successful
only when the regenerated
periosteum is still sufficiently
vascularized and when ulti-
mately, after cicatrization has
taken place, it is not atrophied.
For this reason he resorts to
this technic only after the first
six to eight weeks following
the receipt of the wound and
when, during this time, the
cases offer no tendency to con-
solidation after conservative
treatment has been essayed.
If these considerations are
overlooked the operation will
fail and a permanent cure can
then only be obtained by
transplantation. In my next
letter I shall discuss in detail Doctor von Ertl's
views on this aspect of the question and his proce-
dures.
MAJOR GENERAL MERRITTE W. IRELAND,
Surgeon General, U. S. A.. Formerly Chief Surgeon
American Expeditionary Forces.
THE NEW SURGEON GENERAL OE THE
UNITED STATES ARMY.
Merritte W. Ireland, late chief surgeon of the
American Expeditionary Forces, has been nomi-
nated Surgeon General of the United States Army,
to succeed General Gorgas, who retires. He was
born at Columbia City, Indiana, May 31, 1867.
He was graduated from the Detroit College of
Medicine, March 20, 1890, and served as house
physician at St. Mary's Hospital, Detroit, from
December 20, 1889, to September 25, 1890. He
then entered Jefferson Medical College, Phila-
delphia, and was graduated April 15, 1891. He had
long had an ambition to enter the medical service of
the Army, and he passed the examination for the
service and was appointed assistant surgeon with
the rank of first lieutenant May 4, 1891. On the 27th
of the same month he was sent to Jefferson Bar-
racks, Missouri, continuing there until October 22d.
After serving at various posts, including Fort
Apache, Arizona territory, 1894, he reached the
grade of captain. May 4, 1896.
In the Spanii-h-American War he served with
the Fifth Army Corps, rendering important service
which won the commendation of his superiors,
especially in his capacity as executive officer of the
hospital at Siboney, Cuba. Returning to the United
States, he was stationed at Camp Wyckoff, New
York. He became a surgeon with the rank of
major, with the Forty-fifth United States Infantry,
August 17, 1899, going with his command to the
Philippines. He served in the Cavite campaign
and in the campaign in the
Camarines in 1900, participat-
ing in ten engagements and
being officially commended by
the chief surgeon. On April
20, 1900, he took charge of
the medical supply depot, Di-
vision of the Philippines, in
Manila. He was appointed
surgeon with the rank of
major (U. S. Volunteers)
June 30, 1900, and received
his honorable discharge from
the volunteer service June 30,
1901. Late in 1902 he was
attached to the office of Sur-
geon General Robert M.
O'Reilly, in Washington, and
served also under Surgeon
General George H. Torney.
While in the Surgeon Gen-
eral's Office Major Ireland
was in charge of the person-
nel division.
While at the Presidio, San
Francisco. California, Sep-
tember 29, 1906, he was
ordered to proceed to Cuba
in connection with the expedition to quiet the
unrest which was showing itself on the island at
that time. Being again attached to the Office of
the Surgeon General, he reached the grade of
lieutenant colonel, May i, 191 1. Leaving the
Office of the Surgeon General, April 29, 1912, he
again went to the Philippines, being stationed as
post surgeon at Fort William McKinley. Return-
ing to the United States he had charge of the base
hospital at Fort .Sam Houston in 1916. He left for
France with General Pershing.
Examinations will be held, commencing October
30th, of candidates for permanent appointment to
the Medical Corps of the Navy. The examination
will be open only to present temporary members of
the Medical Corps and members of the Medical
Corps of the Naval Reserve, between the ages of
twenty-one and thirty-two years inclusive. There
are about 325 vacancies to be filled.
598
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
HEALTH AND SANITATION WORK IN
THE SHIPYARDS.
Increased Efficiency, Decreased Labor Turnover,
and Contentment Among the Workers Seen as
the Direct Result of Improving Conditions
Around Shipbuilding Plants.
The Department of Health and Sanitation of the
Emergency Fleet Corporation, directed by Lieut.
Col. P. S. Doane, is bringing the condition of the
shipyards up to the highest point of health effi-
ciency. The health movement is comparatively new
in shipyards because until recently they have been
part of a backward industry sufficient only for the
needs of peace times. The results of the efiforts of
the department are increased efficiency, more con-
tions. Of course, some of the big shipyards of
the country had already made some advance in car-
ing for their employees' welfare, notably the De-
troit Shipbuilding Company and the McDowell-
Duluth plant. The latter has built a model vil-
lage, with an auditorium and an athletic club. But
the basis of the successful operation of any wel-
fare department is the elimination of sickness from
the ranks of the employees and the prevention of
accidents.
The health department is concerned not only
with the conditions in the yards, but conditions
surrounding them as well. Swamps, which are the
breeding places of mosquitoes that carry danger-
ous maladies, either must be filled or the breeding
of the mosquitoes in them in some way prevented.
Staff and employees &I Emergency Huspita!, llcg Island, Pa., Shipyard.
Surgeons, lower row, left to right; i, Dr. Asprey; 3, Dr. Rose; 4, Di. Holmes; s. Dr. Reiley;
6, Dr. McCleary: 7, Dr. Rappoport.
genial conditions, thousands of happier men and
families, and increased tonnage.
The principal task of the department is in over-
coming the difficulties that have arisen through the
expansion of old yards to meet the demands of
speed production, and the education of the work-
men to the values of more modern ideas and to
higher standards of health protection. The work
is largely educational, especially among the men in
the yards. Attractive posters displayed conspicu-
ously about the yards and plants are an essential
part of the program.
The big argument that the department has to
make to the yard management for its work is the
increased production that, results from having every
man on the job every day, feeling at his best, doing
more than he possibly could under the old condi-
A supply of pure drinking water has also to be
obtained. Civil authorities in the community are
encouraged to cooperate with the department to rid
the community of any factor that may be regarded
as a peril to health.
Within the yards the department is concerned
especially with adequate toilet facilities, and the
disposal of sewage and garbage. It is interested
in having provision made for first aid of the most
approved kind. In yards employing i,ooo or more
men a competent physician should be either in con-
stant attendance or subject to immediate call. Most
of the yards that are acquiescing in the depart-
ment's plans require physical examination of ap-
pHcants for positions.
At the Hog Island, Pa., Emergency Hospital,
since January ist, 20,875 employees have been
Oofober 5, 1918.I
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
599
treated. In March, of the men who reported to
the surgical department for treatment of injuries
only 7.7 per cent, lost time. Everything that mod-
ern science can suggest for relief and cure by surgi-
cal care is included in the equipment of the hos-
pital at this big plant. The operating room and
ward and the first aid rooms are equipped with the
latest surgical appliances used in the war hospitals
abroad.
The hospital has a dental department where the
employees can, at any hour of the day or night,
receive first aid treatment and thereby save the trip
to surrounding towns, with a consequent loss of
time.
The X ray department has the latest and most
modern type of machine — the type that is being sent
MEDICAL NEWS FROM WASHINGTON.
Promotions in Medical Corps of Navy. — Appointment of
Co»niiaiider Iloivard F. Strine, Medical Corps of Navy,
tj Important Duties at IVashington. — Proposed Bill
Granting Pay to Army and Navy Nurse Corps During
Captivity by Enemy. — Proposed Legislation Providing
.4dditional Hospital and Sanatorium Facilities in Con-
nection with Government War Risk Insurance.
Washington, D. C. September 30, igi8.
The Board of Medical Officers that convened on
September 3d to select members of the Medical
Corps of the Navy for permanent and temporary
promotion has made its report, and the list of
officers selected for promotion has been approved
by the President.
Medical Directors Albert M. D. McCormick and
— n'
V
Dressing and first aid room, Emergency Hospital, Hog Island, Pa., Sliipyard.
abroad to the battle fields. The first aid service
will be installed at the shipways, together with three
ambulances for both day and night service. Train-
ing school students, guards and firemen will be
trained in first aid. There will be submersion and
heat stations for the treatment of accidents along
the waterfront and the treatment of heat cases.
The hospital staff consists of three operating sur-
geons, three first aid surgeons, four nurses, two
first aid men, and three orderlies.
The names of the six surgeons are as follows :
Doctors Asprey, Rose, Holmes, Reiley, McCleary,
and Rappoport. Since the establishment of the
hospital the employees of the American Interna-
tional Shipbuilding Corporation have been practi-
cally free from contagious diseases, and the percent-
age of infected wounds has been reduced to one half
of one per cent.
Robert M. Kennedy were selected for temporary
promotion to the rank of rear admiral.
The following were selected for permanent pro-
motion to the rank of captain : Medical Directors
Charles E. Riggs and Ammen Farenholt, and Med-
ical Inspectors Middleton S. Elliott, Frank L. Plead-
well, Dudley N. Carpenter, James C. Pryor, and
Washington B. Grove.
The following were selected for temporary pro-
motion to the rank of raptain : Medical Inspectors
Raymond Spear, John B, Dennis, Eugene J. Grow,
Frank E. McCullough, Granville L. Angeny, Wil-
liam H. Bell, Holton C. Curl, Edward G. Parker,
Henry E. Odell, James S. Taylor, Joseph A. Mur-
phy, Charles N. Fiske, George F. Freeman, Charles
St. J. Butler, and John M. Brister.
The following were selected for permanent pro-
motion to the rank of commander: Medical In-
6oo
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
specters John T. Kennedy, Archibald M. Fauntle-
roy, Joseph P. Traynor, John L. Nielsen, Charles
C. Grieve, John D. Manchester, and James S. Wood-
ward, and Surgeons James A. Randall, Allen D.
McLean, Robert G. Heiner, Benjamin H. Dorsey,
Harry F. Hull, Lewis H. Wheeler, Owen J. Mink,
and Harold W. Smith.
The following were selected for temporary pro-
motion to the rank of commander : Surgeons Fred-
erick G. Abeken. Winheld S. Pugh, Jr., James E.
Gill, Isaac S. K. Reeves, Robert E. Stoops, William
J. Zalesky, Henry A. May, William A. Augwin,
Frederick E. Porter. Paul T. Dessez, Norman T.
McLean, Wray G. Farwell, David C. Gather, Ad-
dison B. Clifford, Richard A. Warner, Paul R.
Stalnaker, Curtis B. Munger, John B. Mears,
him for these important duties is a fitting recogni-
tion of his professional ability.
'fc ^ ifc 2^
The Secretary of the Treasury has sent to Con-
gress a tentative draft of proposed legislation call-
ing for an appropriation of $10,500,000 to provide
suitable additional hospital and sanatorium facilities
for the care and treatment of soldiers and sailors
and others entitled to treatment by the Public
Health Service. Such facilities are needed to take
care of men discharged from the military and naval
forces that are beneficiaries of the government war
risk insurance.
Under the provisions of the laws defining the
duties of the Bureau of War Risk Insurance, sick
Ward of Emergency Hospital, Hog Island, Pa., Shipyard.
George S. Hathaway, Frank E. Sellers, Edward H.
H. Old, Edward C. White, Thurlow W. Reed,
Edward U. Reed, Edgar L. Woods, Robert C.
Ransdell, Edwin L. Jones, Condie K. Winn, John
B. Kaufman, James P. Haynes, Thomas W. Raison,
James M. Minter, Rcnier J. Straeten, Reynolds
Hayden, Edward V. Valz, Montgomery A. Stuart,
Frank X. Koltes, Herbert L. Kelley, Juhan T.
Miller, George B. Trible, and Henry A. Garrison.
*****
Commander ?Ioward F. Strine, of the Medical
Corps of the Navy, has been appointed associate
profes.sor of the principles and practice of surgery
at the Medical School of Georgetown University,
Washington, and also as acting chief of the Depart-
ment of Surgery at the University Hospital.
Commander Strine has won a reputation, both in
the navy and in civil life, as an eminent surgeon, and
the action of the university authorities in appointing
and injured beneficiaries are to be furnished by the
United States such reasonable government medical,
surgical, and hospital services, and with such sup-
plies, including artificial limbs, trusses, and similar
appliances, as may be determined to be useful and
reasonably necessary.
The attention of the War Department has been
called to a pending bill granting to members of the
Army Nurse Corps (female) and the Navy Nurse
Corps (female) pay and allowances during any
period of captivity by the enemy. While as yet
there has been no report received that any members
of the Female Nurse Corps have been captured by
the enemy, such a condition might arise.
Legislation in regard to pay is necessary, in view
of the fact that the accounting officers of the treas-
ury have held that under the present laws the
women nurses would not be entitled to pay and
allowances during captivity.
( ictobcr 5, 191S. I
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
601
Officers of field hospital section. 11 -th Sanitary Train, Rainbow
(Nebraska); Lieutenant Claude A. Selby, i66;h (Nebraska); Lieu
166th (Nebraska); Lieutenant Eldred B. Waftlc, 167th (Oregon);
N. J.); Lieutenant Arthur L. Murray, 165th (District of Columbia
Lieutenant James D. Plamondon, i6,-th (Oregon); Captain Henry F.
i68th (Colorado); Lieutenant Joseph F. Snedec, i68th (Colorado)
tenant Carl O. Reed, i66th (Nebraska); Major John F. Spealman
commanding field hospital section (New York); Major Edwin W.
commander 165th (District of Columbia); Major James P. Graham
(Colorado); Mascot Jim, i66th (Lincoln, Neb.). (From the New
RAINBOW DIVISION COMMENDED.
Major General Commanding Recites History of Its
First Year — Commended in General Orders and
Complimented by the Corps Commander.
Major Genera) Charles T. Mencher, commanding
the Forty-second (Rainbow) Division, addressed a
general order to the officers and men of the division
on August 13, reciting its history for the past year
and congratulating them upon the admirable record
made. The division entered the trenches in Lor-
raine on February 21 st, being the first American
troops to hold a divisional sector. During the crit-
Division. r^ar rank, left to riglit : Lieutenant Earl B. Erskine. i66th
tenant Charles Frost, 167th (Oregon); Lieutenant Roy D. Bryson,
Lieutenant Jasper W. Coghlan, M. R. C., assistant director (Newark,
); Lieutenant Thomas H. Powick, 165th (District of Columbia);
Sawtelle, 165th (District of Columbia); Lieutenant G. W. Bancroft,
; Lieutenant "Jeffrey N. Elder, 167th (Oregon). Front rank: Lieu-
commanding i66th (Nebraska); Major Charles O. Boswell. director,
Lazell, commander i68th (Colorado); Major Herbert C. Bryson,
commander 167th (Oregon); Captain Alfred J. Campbell, i6Sth
York MsnicAL Journal for October 20, 1917-)
ical days from July 14th to i8th, this was the only
American division in General Gouraud's army on
the Champagne front It joined the battle front
before Chalons and captured great stores of arms
and munitions. It forced the crossing of the Ourcq,
took Hill 212, Sergy, Meurcy Ferme, and Seringes
by assault, driving the Imperial Guard Division for
a depth of fifteen kilometres. The division has been
formally commended by the corps and army com-
manders for its services in Lorraine, in Champagne,
and on the Ourcq. The accompanying photographs
were taken when the division sailed for France, and
Dublished in the New York Medical Journal.
Officers ambulance company section, 117th Sanitary Train, Rainbow Division. Rear rank: Second Lieutenant O. E. McKim, V. R. C.
(New York); Lieutenant M. J. Ferguson, 167th (Oklahoma); Lieutenant James D. Bick, i68th (Michigan); Lieutenant (Tarl
Hanna, i6?th (Michigan); Lieutenant Lindsay W. Newland. i66th (Tennessee); Lieutenant John R. Drake, i66th (Tennessee);
Lieutenant Arlington Lechlidey, i68th (Michigan); Lieutenant John R. Capps, 167th (Oklahoma); Lieutenant Henry A. Wall-
hauscr, T65th (New Jersey); Lieutenant Harry B. Chalfonte, 165th (New Jersey). Front rank: Captain Percy A. Perkins, commander
1 66th (Tennessee); Captain H. G. Larueau, commander 167th (Oklahoma); Captain Peter P. Rafferty, commander i6sth (New Jersey);
Captain Dunning S. Wilson, director, commanding ambulance section (Kentucky); Captain Robert T. Baskerville, commander 168th
(Michigan); Captain C. A. McAfee, i6Sth (Michigan); Lieutenant L. Bowne, 166th (Tennessee). (From the New York Medical
Journal for October 20, 1917.)
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc. D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are net responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, OCTOBER 5, 1918
AFTER THE WAR.
In an admirable and thoughtful address delivered
at the opening exercises of the College of Physicians
and Surgeons, Columbia University, which was pub-
lished in our Liberty Loan Number, Dr. Frederick
Tilney hails America as the Mecca of medical edu-
cation after the war. In surgery, America has long
since taken the lead. The diagnostic clinic or group
idea in diagnosis, under which it is possible to en-
list the services of a group of expert specialists in
diagnosis, is essentially an American conception
through which great progress is possible in the prac-
tice of medicine. The financial and commercial
exhaustion of the European nations caused by the
war will make it necessary for them to expend all
their energies in material rehabilitation, to the ne-
glect of the higher fields of education and scientific
study. America, therefore, will be called upon to
become the Mecca for medical students from all
over the world, and if our educators bring to the
task which will confront them the broad vision
which characterizes Doctor Tilney's address, Amer-
ica can discharge its obligations to the world in the
matter of medical education in such a manner as to
justify his claims to being the Mecca of medical
education.
In more material things, as well as in education,
America must also take the lead after the war.
During the last week of September the fourth an-
nual exposition of chemical industries, which was
held at the Grand Central Palace in New York city,
brought together groups of men and material which
gave convincing evidence that in the field of applied
chemistry the United States is rapidly becoming, if
it has not already become, independent of the re-
mainder of the world. While the exhibition itself
presented much that was interesting and instructive,
its most useful purpose was in ofifering the occasion
for a series of addresses which gave a most illumi-
nating insight into the problems which confronted
the chemists of America at the outbreak of the Eu-
ropean war and the rapidity and thoroughness with
which those problems have been met and overcome.
So manv of our modern therapeutic agents have
been made from the coal tar derivatives, that the
physician will be especially impressed by the won-
derful development which has occurred in the
United States in the chemistry of the coal tar deriv-
atives, including both dyestv.ffs and medicines.
While separate figures are not available to show the
precise measure of growth of the production and
export of medicinal chemicals, some idea of that
growth may be divined from the increase in the
exports of dyes, dyestuffs, etc. In the fiscal year
ending Jtily i, 1914, our export of these was valued
at $357,000. For the year ending July i, 1918, our
exports amounted to $17,000,000. With such a
startling record of growth before us, we may con-
fidently expect the United States to become a leader
in the field of applied chemistry after the war, just
as we look to its becoming a leader in the field of
medical instruction, taking the place of predomi-
nance in both these fields hitherto held by Germany.
GLOBULINS AND ANTIBODIES.
Is immunization dependent upon the serum
proteins, and is such dependence indicated by the
increase in globulins observed during the produc-
tion of immune bodies? Such are the questions
which form the subject of experiments reported
by Esther Skolfield Schmidt and Carl L. A.
Schmidt [On the Noninfluence of Injections of
October 5, 191 S.]
EDITORI.U. ARTICLES.
603
Pure Proteins upon the Proportions of Globulin
and Albumin in i^loocl Serum : Journal of Im-
munology, June, 1917]. The tendency has been
to associate the globulin fraction of the blood
serum with immune bodies because of its in-
crease when these bodies were being produced,
and because antibodies have generally been
found in the globulin fraction of immune serum
examined. The possible relation between these
two factors has been therefore submitted to a
series of tests.
The investigators chose pure proteins or pro-
tein derivatives for their work and those which
should represent respectively different factors
which might be at work. Thus it should be re-
vealed whether the production of immune bodies
was due to the increase of globulin or some other
agent. Therefore the substances selected repre-
sented all possible combinations which might be
responsible : antigenic and nontoxic ; nonanti-
genic and toxic; nonantigenic and nontoxic of a
complex composition; and nonantigenic and non-
toxic in very simple composition. Rabbits upon
which the tests were made were kept under con-
stant conditions, and error was carefully guarded
against.
The serum proteins in normal rabbits proved
to be decidedly variable, the quantity of globulin
being no exception. These fluctuations are prob-
ably metabolic in character, influenced by feed-
ing, amount of food eaten, surrounding tempera-
ture, etc. The normal leucocyte counts also vary
with different animals. The injection of anti-
genic and nonantigenic proteins apparently
makes no change in the serum protein of these
animals within the ordinary limits of variation.
This accords with the view to which previous
observations have led— that an increase in the
globulin fraction of blood serum is not necessary
for the production of immunity. The injection
of pure proteins was shown to effect a decided
change in the leucocyte count, but it was also
made apparent that there was no parallelism be-
tween the leucocyte count and the percentage of
serum globulins. By inducing an extreme leuco-
penia through the injection of benzol there was
a decrease in the percentage of blood serum pro-
teins, but no material change in the protein quo-
tient. The latter is altered after infection, but
the former percentage is not increased. The de-
crease in the protein, quotient further indicates
the nondependence of immunity upon globulin
increase. The injection of benzol produces a
condition very unfavorable for the production of
immune bodies, and yet the rabbits so treated re-
sponded to the infection by an increase in the
serum globulins.
The writers therefore summarize their results
by stating again that, while the quantity of scrum
proteins in normal rabbits shows a fair degree of
constancy, the protein ratio shows considerable
\ arial)ility. The injection of proteins did not pro-
duce any decided change in the protein quotient ;
the injection of benzol produced a decrease of
serum, but no change in the protein quotient. A
rise of globulins is not essential for immune body
production. A well regulated dosage of antigen in
rabbits produces immunity without giving rise to
an increase of globulins.
AFTER VACCINATION.
Recent thorough investigations establish the
fact that the unintended results following vac-
cination are due, not to the contamination of the
vaccine, but either to carelessness in its use or
want of care of the site of inoculation afterward.
Not only does this apply to the vaccination
done by the physician in private practice, but to
the wholesale vaccination carried on in public
schools, dispensaries, and armies. Vaccination
is usually carefully done in these institutions, but
there is no aftercare in most of them. Perhaps
it is because we feel that the poor will make little
public disturbance over any complications that
mav arise, or because we think that, as they have
paid nothing, they deserve to run any risks.
It is just such children as are vaccinated at
public expense that most need to be looked after,
lor they are likely to offer a good soil for all man-
ner of infections, and they have ample oppor-
tunity, from home conditions, to become the vic-
tims of such infection. Also it is the poor (or
those who get their vaccination done without ex-
pense to themselves) who make the greatest out-
cry over any untoward results with which it may
be accompanied.
The physician has discharged his duty in pri-
vate practice when he has warned the parents
that a vaccination wound should be carefully
looked after. If this is not done, he is not to
blame. It is incumbent on the department of
health, however, not only to vaccinate, but to
lake care of the vaccination wound ; and this it
must do through its nurses if it would fulfill its
whole duty. Such thoroughness will do much
to allay the fears of parents and to soothe the
antivaccinationists, who grasp at any incident
which will give them material for making a
clamor.
6o4
EDITORIAL ARTICLES.
[New York
Medical Journal.
VITAMINES OR ACCESSORY FACTORS
AND WAR DIETARY PROBLEMS.
The entrance of this country into the war has
not onl}' called for extraordinary efforts to sup-
ply men, war material, and so forth, but has also
demanded from the civil population an almost
radical rc<^ulation of their diet. The staple foods
in the United States have been meat and wheat.
However, war conditions insist that wheat and
meat in the largest possible quantities should be
exported for the use of our fighting forces in
Europe and for our allies, at an)^ rate, for our
British allies. This being so, it is incumbent
upon our civilian inhabitants that, as far as pos-
sible, they shall forego the consumption of wheat
and meat and use as their staple diet more per-
ishable foods, such as milk and fresh vegetables.
Moreover, in place of eating wheat bread they
should confine themselves to corn or oat bread,
or in any event to a bread whicli contains little
or no wheat.
Now it has been proved scientifically and con-
clusively that milk is not only an excellent sub-
stitute for meat, but that it is even more than
this, it is in almost all respects more nutritious
than meat, and that in combination with fresh
vegetables and corn bread, a most nourishing
diet can be procured.
Yet, and this is an impoitant point, a radical
change of diet, unless vigorously regulated, will
be accompanied by metabolic disturbances. The
vitamine content of a diet must be carefully con-
sidered. The new foods must possess a vitamine
content sufficient to balance the diet equal to the
original. In American Medicine, June, 19 18, Dr.
A. Bruce ]\Iacallum discusses the relative vita-
mine content of foods, showing those which are
rich in antineurotic properties and those rich in
antiscorbutic properties, and vice versa. Fresh
vegetables and fresh fruits are the chief antiscor-
butics, of which the potato is that principally
used bv the people of Europe. Incidentally
it may be said that Harriette Chick has suggest-
ed that the onion is the ideal antiscorbutic, espe-
cially for troops, as it stands the conditions of
transport better than other vegetables. The anti-
neuritic vitamine. contained in the germ and
aleuron granules of the pericarp of all cereal
grains and seeds, is the most resistant of all the
vitamines to variations in temperature, moisture,
and storage conditions. While its main source
is in the pericarp of grains and seeds, it is also
found in fresh meats, fresh and dried vegetables,
and in fresh milk and eggs.
Over and above the vitamines, there is an ac-
cessory^ present in butter, fats, and codliver oils
which Osborne and Mendel have shown is essen-
tial for the maintenance of health, and which, if
absent in the substitutes provided to take the
place of the fats and of course, especially of the
butter fats, must be supplied in one form or an-
other. The consumption of fat by human beings
cannot l)e entirely^ dispensed with, and this fat
should also contain the aforementioned fat solute
accessory.
The consequence of eating food not containing
a sufficiency of antiscorbutic and antineuritic
vitamines and fats deficient in the fat accessory
and of diminution in the quantity of fat ration
have evidenced themselves, since restricted ra-
tions have come into vogue, in the occurrence of
scurvy, beriberi, and xerophthalmia, as well as
by diminution in the growth of young children.
It is evident that in order to prosecute the war
successfully^ steps must be taken to supply the
Allies with all wheat and meat possible, and to
effect this object, the people at home must con-
sume the more perishable articles of food. A
diet as nutritious as that to which the population
has been accustomed can be obtained from these
more perishable foods, but at the same time such
a diet must be well balanced and in particular
must contain a sufficiency of vitamines and fats
and fat accessories.
The problem, so far as its ultimate solution is
concerned, resolves itself into a question of cost.
Foods abundant in or containing a sufficiency of
vitamine are, generally speaking, the most ex-
pensive. As the price of food rises, the poor nat-
urally buy the cheapest kind and suffer from avit-
aminoses accordingly. Therefore, it is neces-
sary for the well being of the community at large,
and for the successful conduct of the war, that
information be spread widecast and in a manner
calculated to reach all sorts and conditions of
men and women, as to the relative value of food-
stuffs. In addition, the really essential articles
of food must be retailed at a price within the
means of all. Otherwise information with re-
gard to food values would be of little use to a
large proportion of the people. If fat and pro-
teins must be decreased in amount and carbo-
hy'drates increased, the vitamine content must be
also increased, or deficiency diseases will be the
result. The vitamine content of food used in-
stead of wheat and meat must be well kept up,
instruction must be given on a wide scale with
respect to food values, and the cost of foodstuffs
must be restrained within reasonable bounds but the
vitrmiinc values must not be lost sight of.
October s, 1918.]
NEWS ITEMS.
605
THE INFLUENZA SITUATION.
The number of new cases of influenza reported
continues to grow in those sections of the United
States where it has made its appearance and it has
heen reported for the first time in many cities in
the eastern portion of the country. In the city of
New York 903 new cases were reported during the
twenty-four hours ending at ten o'clock on Wednes-
day morning. There were fifty-eight deaths from
influenza and fifty-eight from pneumonia reported
during that period. Up to Tuesday 88,000 cases
had been reported in the army camps, and 6,759
cases of pneumonia. Fourteen thousand new cases
were reported in the army on Monday, an increase
of 3.600 over the previous day. So far there has
been 492 deaths reported in Camp Dix. In manv
of the camps and cantonments in this vicinity both
soldiers and civilians are required to wear an anti-
septic gauze mask. In this city a number of arrests
have been made for spitting.
Dr. William H. Park. Chief of the Department
of Laboratories of the Health Department of the
City of New York, has prepared a vaccine from the
hacilli of influenza which, it is hoped, will safeguard
the person inoculated with it from attack. The
serum is being tried out on volunteers, but suffi-
cient time has not yet elapsed to arrive at any defi-
nite conclusion regarding its efficacy.
THE GREAT AMERICAN GUM.
Of all the varied means of masticatory stimula-
tion which have been resorted to by man in all climes
and ages, the great American gum seems least harm-
ful and most helpful. That there is a physiological
demand for some masticatory stimulant, is shown by
the universality of the practice of chewing, whether
it be the tobacco of the American Indian, the betel
nut of the East, the coca leaves of South America,
the slippery elm bark, the tamarack, and the spruce
gum of the down east Yankee, the sweet gum of
the Gulf States, the chicle of the Mexicans, which,
in its American adaptation, becomes the great Amer-
ican chewing gum, man has always felt the ne-
cessity of chewing something more than his meals.
That there is a practically useful side for this habit
is evidenced bv the orders placed by the Quartermas-
ter of the United States Army for 2,300,000
packages of this standard American dainty. We
learn from the War Department that the command-
ing officer of a field artillery regiment, about to
embark, stated that 250 pounds of chewing gum
would take the place of hundreds of gallons of
drinking water when water was most needed and
least readily obtainable. On long marches, the
chewing of gum would go far toward quenching the
thirst of the troops when water is not accessible. It
is true, as Mrs. Gertrude Atherton complains, that
the chewing of gum is not a particularly esthetic
practice, but there is no question that a supply of
chewing gum is a great comfort to the hot and tired
soldiers, famishing for water, either in the trenches
or on the march. The American Red Cross recently
cabled an order for chewing gum for use in the
reconquered territory where the wells had been
poisoned by the retreating Germans.
As Ellis Parker Butler has aptly said, "If our boys
over there to rip the hides otf the Germans, want
to chew gimi, let 'em chew. If they want ten tons
of gum, send them eleven tons." However much
the chewing of gum may be condemned from an
esthetic point of view, its practical utility is so
great as to quite counterbalance the esthetic objec-
tion. The gum chewing youths of our American
Army, may corrupt the good manners of the poilu
and make the French a nation of gum chewers, but
if thev do so they will probably improve the condi-
tion of the teeth of the people so greatly as to
quite counterbalance any esthetic objections which
may be raised.
News Items.
Asiatic Cholera in Vienna. — According to official re-
ports received in Madrid, Spain, several cases of Asiatic
cholera have been discovered in Vienna and deaths from
this disease have occurred there.
Personal — Major Jcseph B. Bissell, surgical director of
the Radium Sanatorium of New York (Radium Institute),
has been assigned to active duty in ^laryland. Dr. C. Ever-
ett Field, medical director of the institute, still remains in
charge of the routine v, crk.
Meetings of Medical Societies to Be Held in Phila-
delphia during the Coming Week. — Monday, October
7th, Bleckley Medical Society. Clinical Association: Tues-
day, October Sth, Pediatric Society ; Wednesday, October
0th, County Aledical Society. Aid Association of the County
Medical Soc'Cty: Friday, October nth, Atlantic County
Medical Societv, Xorthern Medical Association.
Venereal Disease Control in South Carolina. — At a
meeting of the Bar Association of South Carolina, held at
Spartanburg, on August 2d, resolutions were adopted re-
garding regulations of the State Board of Health of South
Carolina providing for the segregation and treatment of
persons having or suspected of having communicable
venereal d'sease, that is. synhilis. gonorrhea, and chancroid.
Major Perkins Quits Red Cross. — ^Major James H.
Perkins, commissioner general of tlie American Red Cross
for Europe, has resigned to accept a staff appointment in
the American E.xpeditionary Forces in France. The duties
of the commissioner general for Europe will henceforth
be assumed by a commission composed of commissioners
for France. Great Britain. Italy, and Switzerland, and
Major Ralph I. Prestm, deputy commissioner for Europe.
Medical Society of the State of Pennsylvania. — -At
the annual meeting of the society, held in Philadelphia dur-
ing the past week, the following officers were elected :
President, Dr. Cyrus L. Stevens, of Athens : first vice-
president. Dr. \\'ill-am Duffield Robinson, of Philadelphia :
secretary. Dr. W. F. Donaldson, of Pittsburgh ; assistant
secretary. Dr. C. B. Longenecker, of Philadelphia : treas-
urer, Dr. George Wagoner, of Johnstown. Next year's
meet'n.Q will be held in Harrisburg.
Additional War Hospitals. — Camp Snelling, Minn.,
Camp Sheridan. 111., and Camp Benjamin Harrison, Ind..
are to be converted into general hospitals for the reception
of wounded soldiers returned from abroad. Like all the
.genera! hospitals, thev will be reconstruction hospitals to
the extent of caring for the woimded so as to fit them for
vocational instpiction. Each of these hospitals will ac-
comniC:date i.ooo patients and extensions will be added as
required. Eacli hospital calls for a personnel of thirty-
five medical ofticers. 100 nurses, and ."^oo enlisted men.
American Hospital Association. — At the annual meet-
ing of the association, held in Atlantic City, Monday, Sep-
tember 3cth, the following officers were elected: Presi-
dent. Dr. A. R. Warner, of Cleveland : vice-presidents. Dr
Joseph S. Howland, of Boston ; A. B. Tipping, of New
Orleans: and Sister Frmentine, of St. Louis; executive
secretary, Harold Wright, of Cleveland ; treasurer, Asa
Bacon, of Chicago : and trustee. Dr. Robert J. Wilson, of
New York. Next year's meeting will be held in Cincinnati.
An important feature of the proceedings was the endorse-
ment of the plans of the government regarding hospitals.
6o6
NFWS ITEMS.
[New York
Medical Journal.
Volunteer Medical Service Corps in Pennsylvania. —
The Pennsylvania State Executive Committee of the Vol-
unteer Aledical Service Corps is composed of the following
members: Dr. I. J. Buchanan, of Pittsburgh, chairman;
Dr. Julius H. Comroe, of York; secretary. Dr. G. Franklin
Bell, of Williamsport ; Dr. Edward P. Davis, of Philadel-
phia ; Dr. W. S. Foster, of Pittsburgh ; Dr. Spencer M.
Free, of DuBois ; Dr. E. A. Krusen, of Norristown ; Dr.
Melvin J. Locke, of Bellefonte ; Dr. John B. McAllister,
of Harrisburg; Dr. Hiram McGowan, of Harrisburg ; Dr.
E. E. Montgomery, af Philadelphia ; Dr. W. A. Pearson,
of Philadclpiiia ; Dr. William Duffield Robinson, of Phila-
delphia, and Dr. Lewis H. Taylor, of W'ilkes-Barre.
Spanish Influenza in Canada. — Cases of Spanish in-
fluenza arc now being reported from many eastern
Canadian cities, but tho percentage of deaths remains low,
and it is said by medical authorities in Toronto that the
epidemic is not likely to assume such proportions as in the
United States. The situation in several military camps
in Ontario and Quebec, Tiowever, is causing some concern.
In St. Johns, Quebec, 580 cases and nine deaths have been
reported in the engineers' barracks, while eighty cases have
been reported among soldiers quartered in Montreal. Most
of the Ontario cases have been discovered in the Royal Air
Force camps at Toronto and at Hamilton. The Royal Air
Force has stopped all leave to the United States.
Captain Lucius P. Brown. — Lucius P. Brown, who
has been director of the Bureau of Food and Drugs of the
Health Department of the City of New York for the past
three years, has accepted a commission as captain in the
Sanitary Corps of the Medical Department of the Army
and has been given leave of absence, without salary, for
the period of the war. He will serve in the Division of
Food and Nutrition. Shortly after Dr. Royal S. Copeland
was appointed commissioner of health charges of ineffi-
ciency and improper conduct of his office were brought
against Mr. Brown by the chairman of the Civil Service
Commission. As a result of these charges he was suspend-
ed for several months, but when brought to trial he was ac-
quitted and reinstated in office. His salary in the health
department was $5,000 a year ; as a captain in the Sanitary
Corns his salary will be $2,400.
North Atlantic Tuberculosis Conference. — This con-
ference, which represents the States of Delaware, Mary-
land, New lersey. New York, Pennsylvania, Virg-nia,
West Virginia, and the District of Columbia, will be held
in Pittsburgh, Pa., October 17th and i8th, under the
auspices of the National Tuberculosis Association. The
general topic for discussion will be Tuberculosis and the
War. On Thursday the subjects discussed will be Health
Education of the Civilian Population in War Time, the
Need of Adequate Tuberculos's Programs in War Time,
and the Adequate Care of the Tuberculous Soldier. Fri-
day morning will be devoted to round table discussions of
public health nursing and the modern health crusade, and
in the afternoon Dr. Thomas McCrae, professor of medi-
cine in the Jefferson Medical College, Philadelphia, and
president of the National Tuberculosis Association, will
deliver an address on the Tuberculous Soldier, Asset or
Liability, and Dr. S. Adolphus Knopf, of New York, will
deliver an address on the Prevention of Relapses in Cases
of .\rrested Tuberculosis Among Soldiers.
Railway Surgeons to Meet in New York. — The
twenty-eighth annual meeting of the New York and New
England Association of Railway Surgeons will be held at
the Hotel McAlp-n, New York, Monday, October 21st,
under the presidency of Dr. J. S. Hill, of Bellows Falls,
Vt. The program for the morning session includes a sym-
posium on the modern treatment of infected wounds and
the annual address of the president. In the afternoon.
Dr. Joseph C. Bloodgood, of Johns Hopkins University,
will deliver the address in surgery, his subject being Hernia
as an Industrial or Military Problem. Other papers to be
read at the afternoon session are Unusual and Interesting
Fractures and Dislocations, by Dr. C. W. Hopkins, of
Chicago; Modern Treatment of Bums, by Dr. William
Senger, of Pueblo, Colo. ; Corneal Ulcer, a Surgical Dis-
ease, by Dr. F. Park Lewis, of Buffalo; Shock, by Dr. A.
H. Harriman, of Laconia, N. H. Dr. George Oiaft'ee, of
Little Meadows, Pa., is corresponding secretary of the as-
sociation, and will be glad to furnish programs and full
informat-on regarding the meeting, to all who are inter-
ested.
Clinical Congress of American College of Surgeons^
— The ninth annual session of the congress will be held in
New "\'ork, October 21st to 26th, under the presidency of
Dr. William J. Mayo, of Rochester, Minn. The programme
includes clinics in the principal hospitals of New York, on
general surgery, gynecology, orthopedic surgery, urol-
ogy, ophthalmology, laryngology, and otology, and
in Brooklyn there will be clinics on genera! sur-
gery, orthopedics, and urology, gynecology, and sur-
gery of the eye, ear, nose, and throat. Dr. Franklin
H. Martin, of Chicago, is secretary general of the con-
gress and Dr. J. Bentley Squier, 49 East Forty-ninth Street,
New "S'ork. is chairman of the committee on arrangements.
Coming Meetings of Medical Societies. — The follow-
ing medical societies will meet in New York during the
coming week :
Monday. October 7th. — Clinical SociVty of the New York Poly-
clinic Medic.il School and Hospital: Brooklyn Hospital Club.
Tuesday, October 8th. — New York Acarlemy of Medicine (Section
in Neiirologv and Psychiatry); Manhattan Dermatological Society;
New York Obstetrical Society.
U' rdnesiiay, October gth. — Medical Society of the Borough of the
Bronx; New York Pathological Society; New York Surgical Society;
Alumni .Society of the Norwegian Hospital.
ThiinJay. October roth. — New York Academy of Medicine (Sec-
tion in Pediatrics); West £nd Clinical Society; Brooklyn Patho-
logical Society.
Friday, October nth. — New York Academy of Medicine (Section
in (/tologv); Clinical Society of the Lenox Hill Hospital and Dispen-
sary; Easttrr. Medical Society of the City of New York; Flatbush
Aledical Society.
American Public Health Association, — The forty-
sixth annual meeting of the association will be held in
Chicago. October 14th to 17th, under the presidency of
Dr. Charles J. Hastings, of Toronto, Canada. The pro-
gram of the first general session, to be held Monday eve-
ning, October 14th, includes the presidential address of
Doctor Hastings and addresses by Dr. W. A. Pusey, presi-
dent of the Chicago Medical Society; Dr. Arthur Dean
Bevan, president of the American Medical Association, and '
Dr. E. W. Fiegenbaum, president of the Illinois Medical
Society, followed by a recept'on. Tuesday morning. Sur-
geon General Gorgas will deliver an address, and at the
afternoon session Colonel Victor C. Vaughan, Medical
Reserve Corps, will read a paper on The Health of the-
Civil Population in War Time; Major William H. Welch,.
Medical Reserve Corps, Public Health Problems and Op-
Dorttmities Created by the War ; Mahitenance of Balance
Between Civil and Military Health Protection, by Dr. W.
A. Evans, of Chicago. On Wednesday morning. Dr.
George E. Vincent, president of the Rockefeller Founda-
tion, will read a paper on Team Play for Public Health ;
Dr. Lee K. Frankel, of New York, will read a paper on
the Future of the Public Health Association. Thursday
afternoon's programme includes the following papers:
War Time Importance of Narcotic Drug Addiction, by Dr.
Ernest S. Bishop ; National Programme for Phvsical Edu-
cation, by Dr. W. S. Small, of Washington, D. C, and The
Need of a Section of School Hygiene of the American
Public Health Association, by Surgeon J. A. Nydegger,
U. S. P. H. S. There are the seven sections, as follows :
Public Health Administration, Dr. Oscar W. Dooling,
chairman; Laboratorv Section, Dr. G. W. McCoy, _ of
Washington. D. C, chairman; Sociological Section, Lieu-
tenant William F. Snow, M. R. C, chairman ; Section in
Industrial Hygiene, Dr. G. M. Price, of New York, chair-
man ; Section in Vital Statistics, Dr. John W. Trask, of
Washington. D. C, chairman ; Section in Food and Drugs,
Dr. Lucius P. Brown, of New York, chairman ; Section in
Sanitary Engineering, George S. Webster, of Philadelphia,
chairm;in. The United States Public Health Service is ask-
ing Congress for a ten million dollar deficiency appropria-
tion for war time health purposes. The efforts of the Ser-
vice are to be concentrated in communities congested by war
preparations such a; mdustrial centers, various surrounding
can'onments, shipyards, etc. The passage of Senate "Reso-
lution 63 is advocated. This proposes to establish a Sani-
tary Reserve Corps and the commissioning in the Public
Health Service of men of national repute in the various
nhases of health administration. Full-time health officers
for all states is urged and also for inunicipalit-'es. It con-
teinplates a thorough supervision of all war industries and
communities surrounding them; railway sanitation for the
benefit of both employees and the traveling public ; super-
vision of milk, water, and food supplies, etc.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
SOME NOTES ON DRUGS AND
TREATMENT.
A Review of Recent Progress in Therapeutics.
By Mark Sadler, M. D.,
Montreux, Switzerland.
V.
THE PHYSIOLOGICAL ACTION AND THERAPEUTIC
INDICATIONS OF DIGITALIN.
As Frangois Franck long since demonstrated,
digitalin acts on the myocardium, nervous system,
and the bloodvessels, but besides the cardiac and
circulatory action, which is the most important, the
alkaloid also influences the urinary secretion and the
gastrointestinal tract, its action on the digestive ap-
paratus being of a toxic order. Under the influence
of digitalin a reduction in the heart's action is
noted and is synchronous in both ventricles, the
consequence being an increase in the force of con-
traction. If a cardiac arrhythmia exists it will disap-
pear under the action of this drug, the beats becom-
ing regular, but if the therapeutic action is carried
too far or the exhibition too much prolonged, the un-
toward effects of accumulation are observed in the
form of a toxic acceleration occurring simultane-
ously in both ventricles. When intoxication is pro-
nounced, there are alternate phases of acceleration
and slowing of the pulsations, after which appears
the phase of digitalic arrhythmia, during which valvu-
lar anasynchronism is noted, this being characterized
by a simple pulsation to two cardiac beats. Digitalin
accumulates very easily in the organism, so that it
is not uncommon to meet with a bigeminous or tri-
geminous pulse which is symptomatic of drug satu-
ration if the doses given have been too large. If
the administration of the alkaloid is then stopped or
given within the limits of therapeutic doses, the ac-
cidents are avoided.
Another good effect of digitalin is the increase in
energy of the ventricular systole and this reinforce-
ment is so constant that if a toxic dose has been
reached, the cardiac beat ceases in a tonic spasm.
In his admirable researches Francois Franck brings
into relief this action and remarks that, in the rein-
forcement of the ventricular systole, the synchronism
is absolute but the synerg)' is only relative, and this
can be explained because the left ventricle has to
struggle against a much greater pressure than the
right ventricle, so that its effort in the resistance to
be overcome is proportionate. The cardiotonic
action of digitalin is manifest in both the normal and
pathological heart, but on the condition that in the
latter the organ is not functionally bankrupt. If
the discus is the seat of sclerosis or fatty degenera-
tion, digitalin has no effect, as the heart is refrac-
tory to the drug, and this takes place in the terminal
stages of the various cardiopathies.
There are even some cases in which digitalin is
not even a regulator, but may produce death. These
cases are instances of certain allorrhythmias which
digitalin itself can produce in arterial cardiopathies.
However, such accidents are exceptional and the
heart, being "a valiant organ," is susceptible to reac-
tion even when sclerosed. It is just in such cases that
the physician meets with real resurrections ; the pre-
cordial shock becomes more energetic and limited,
like a hammer beat, announcing a real awakening of
the organ. The cardiotonic action is otherwise
favored by the action of digitalin on the vascular
system. It causes an intense vascoconstriction from
its influence on the contractile elements of the
bloodvessels and also from its exciting action on the
vasomotor centre. The peripheral vascular action
plays a considerable part in the increase of
arterial tension and an increase of the energy of the
myocardium results. The increase of the arterial
tension partly explains the slowing of the cardiac
action (Marey) and brings about a diminution of
the rapidity of the flow of blood (Kaufmann).
Sphygmographic tracings taken in patients undergo-
ing treatment with digitalin show a more rounded
apex and a more oblique line of descent than in a
normial subject.
To Franqois Franck is due the honor of having
brought into relief the action of digitalin on the in-
sufficient heart by restoring to it its former energy.
The drug acts directly on the central organ of the
circulation by impressing the cardiac muscle* itself ,
and indirectly by exciting the cardiac nerves and
ganglia. By irritating the pneumogastric and rami-
fications of the sympatheticus the effects of digitalin
are reproduced with perfect exactitude. The drug
produces a slowing effect on the heart by its action
on the pneumogastric and its reinforcement by its
action'on the sympatheticus. The results of physio-
logical experiments are sustained by clinical obser-
vation. In a subject with cardiac degeneration there
is no response to the tonic action of digitalin on the
sympathetic nerve, but the drug will act on the
pneumogastric, resulting in slowing the cardiac ac-
tion but not reinforcing it. In another case in
which the tenth pair was paralyzed by pressure
from enlarged mediastinal lymph nodes, digitalin
reinforced the beats because there was integrity of
the sympathetic filaments, but it could not produce
a decrease in the beats. The physiological effects
of the alkaloid on the heart and circulation, namely,
regularization, increase of the energy of the myo-
cardium, and increase of the blood pressure, explain
the sure diuretic action of digitalin in cardiac
edema. The heart empties itself more thoroughly
during systole, whose energy is increased, while on
the contrary, it is more distended during diastole.
This results in the penetration of a greater quantity
of blood and an acceleration in the rapidity regard-
less of the high blood pressure. Now, it is a well
known fact that the acceleration of the rapidity of
a liquid in a porous tube increases the intensity of
the phenomena of endosmosis and this is what takes
place in digitahc diuresis. Therefore, digitalin
possesses an indirect diuretic action by causing the
6o8
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
liquid of edema and hydropsy to enter the general
circulation, after which it is eliminated by the renal
gland.
Sodium chloride, so essential to life, by the action
of its molecules which, in a healthy body, traverse
the living membranes and unceasingly assure the
osmotic equilibrium, becomes a cause of disturbance
in a cardiac patient. The salt is not elimi-
nated in normal amount, and accumulating in the
tissues, it attracts the water necessary for its solu-
tion, from which arises chloride rentention and
edema. It has been thoroughly proved that there is
a considerable increase in the elimination of the
chloride in digitalic diuresis ; there is in fact a
polychloruria, and it is not at all uncommon for the
chlorides to reach twenty, thirty, forty, or even fifty
grams in twenty-four hours after the exhibition of
digitalin and these chlorides can only be derived
from the liquid of the edema. The diuresis is often
considerable, reaching five to six litres in twenty-
four hours, but it is only temporary. When the
edema and the other fluid collections have been
eliminated, the daily quantity of urine returns to
normal and from this time on the digitalin has no
more influence on the elimination of the chlorides.
The action of the alkaloid as a diuretic is clearly nil
when the myocardiiuti is thoroughly degenerated or
when there are advanced pathological changes in
the kidney. Independently of its cardiotonic action
and diuretic action, digitalin influences the respira-
tion, and in therapeutic doses the number of respira-
tions is diminished. In toxic doses the respiration
is accelerated. The drug also decreases metabolism,
lowers the body temperature slightly, and has a
tetanic action on the muscular system.
The action of the drug on the central nervous
system is variable, according to the doses given. A
therapeutic dose is sedative, while on the contrary,
a toxic dose gives rise to phenomena of intoler-
ance, such as vertigo, headache, tinnitus aureum, ob-
scurity of vision, diplopia, and sometimes even to
digitalic delirium. When large doses are given at
once or the exhibition of the drug is too prolonged,
the gastrointestinal tract reacts in its turn. Digita-
lin has an emetocathartic action and gives rise to
nausea and vomiting with violent epigastric pain.
Anorexia, dryness of the throat, colic, and diar-
rhea have also been noted.
Most of the cases in which we have employed this
alkaloid have been hyposystolic myocarditics. The
treatment consisted of digitalin with caflFein and a
milk diet as succedaneums. In all the elderly sub-
jects the pulse became slower and regular. As to
the urine, I have been surprised that the diuresis
has never been so sudden or continuous as the text-
books would lead one to believe. In only one case
did the diuresis amount to three litres in twenty-
four hours, and two days later it decreased to one
litre and a half in twenty-four hours and then re-
mained stationary.
Sometimes it did not appear until the drug had
been given for four days and even then it was never
marked as the quantity of urine voided averaged
between 1,500 and 2,cxx) grams, soon falling to an
amount often inferior to the normal. All this goes
to show how greatly a drug varies in effect
according to the greater or less integrity of the
viscera. Perhaps the diuretic effect of digitalin
was interfered with in those cases presenting arterio-
sclerosis and evidently the possessors of an inter-
stitial nephritis. Or perhaps the heart was not
sufficiently toned up to give the blood wave the
rapidity and hypertension requisite for a proper
filtration. What is certain is that the diuresis was
not very accentuated. As to the polychloruria, it
was very remarkable in some instances, reaching
from twenty-one to thirty-six grams in twenty-
four hours, but as soon as the edema had disap-
peared the hyperchloruria ceased. In two cases the
elimination of NaCl fell to eight grams and in
another to twelve grams. In all the elimination
remained permanent as long as the heart and vessels
retained their tonicity, but as soon as cardiovascular
asthenia returned the chloride retention with its
edema and dyspnea reappeared. When the results
of the analyses of the urine made during various
paroxysms were examined, I noted that each time
there was a hypochloruria coinciding with the com-
mencement of the paroxysm. But under the treat-
ment with digitalin elimination of the chlorides took
place and the attacks disappeared. Between the
paroxysms the patient could absorb salt without
any inconvenience. In a cardiac subject, when the
cardiovascular asthenia has disappeared and the cir-
culation has resumed the normal, NaCl is no longer
attracted to the infiltrated fluid by a contrary osmo-
tic current.
In all my cases the relation between polyuria and
polychloruria produced by digitalin was constant.
An interesting point to mention is that in nearly all
the quantity of albumin was proportional to the chlo-
ride retention. The albumin diminished quickly
after the systemic elimination of NaCl and in one
instance it disappeared. Taking all things into con-
sideration the results of treatment with digitalin
were satisfactory and, in some cases, even most re-
markable. A male, seventy-five years old, who had
an old mitral insufficiency and an enormous liver re-
covered from three attacks of asystolia. Some of
the patients had sclerotic lesions of the aorta, but
we know that in the period of hyposystolia the ques-
tion of the orifi.ce involved is of very secondary im-
portance as far as the indication of the drug to be
employed is concerned. We have usually employed
the digitalin prepared by Nativelle, in the dose of
one half milligram twice daily.
Quick Type Determination of Meningococci. —
A. S. Gordon Bell and I. M. Harmer {Lancet, July
13, 1 91 8) state that under the most favorable cir-
cumstances from forty-eight to seventy-two hours
are required for a positive type diagnosis by the
agglutination method, and they have therefore
sought to make use of complement fixation on the
patient's serum for such determination. Using
either suspensions of stock cocci, or dissolved. an-
tigens prepared by Thomson's method, they deter-
mined the complement fixing power of the serum
for each type of organism, the serum having been
used in dilutions of 1-50, i-ioo and 1-200. While
the results were not clear cut, they agreed with the
results of agglutination in every case where this
could be carried out.
October 5, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
609
The Present Status of Immunization in Hay
Fever.— J. L. Goodale {Boston Medical and Surgi-
cal Journal, August 29, 1918) thinks it important
that sufficient account of the variation of the sea-
sons be taken in regard to the pollen produced, also
of the individual and temporary alterations in the
physical states of the patients, and presents a study
of a relatively small number of patients (330),
where the treatment has been carried out for not
less than two years. His remarks on the seasonal
variations appear to be of great importance, but can
hardly be abstracted. The diagnosis of the special
exciting cause is made by application of the pollen
suspected to a superficial scratch on the skin of the
arm in the usual manner. One grass pollen will suf-
fice for all grasses, one rose pollen for all members
of the rose family, and ragweed pollen for all of the
compositse. Pollen is obtained in the way described
by Wodehouse. One gram is soaked in a small
amount of normal salt solution for forty-eight hours
and fihered. The filtrate which contains albumin,
proteose, and other proteids is treated with sufficient
alcohol to bring the alcohol content up to twenty
per cent., by which albumin is thrown down as a
flocculent precipitate. To this fluid enough twenty
per cent, alcohol is added to make a volume of 500
c. c. Dilutions of this are made in the proportion
of 1-2,000, 1-5,000, and 1-50,000. When the in-
jections are started several weeks before the ex-
pected attacks, the treatment is called prophylactic t
when after symptoms have appeared, abortive. He
advises patients to report, if possible, ten weeks be-
fore the expected onset of their attacks, although a
shorter period is usually sufficient. The ordinary
course of procedure is to inject from one to three
minims of the 1-50,000 dilution. This causes in
nearlv all cases subcutaneous swelling ranging from
one to three centimetres in transverse diameter,
lasting from one to three days. This material as
above made with coagulated albumin produces a
different efifect than does the injection of material
of equal strength, where the albumin is in solution.
In the first instance the local reaction is not imme-
diately as marked, and requires a longer time for
its disappearance. Second, the coagulated material
has not caused any of the general anaphylactic dis-
turbances of which a few had been previously seen
in using the dissolved albumin. After the reaction
from the first injection has subsided, one may then
double the amount, and a few days later give twice
the amount of the second injection. The next
higher strength of 1-5,000 is taken, and three in-
jections of this are given, ranging from three to
seven or eight minims. Next a similar quantity in
three doses is given of the 1-2,000, and finally the
full strength of 1-500, in doses ranging from five
to ten minims. The number of injections required
during the first year has ranged from six to fifteen,
depending upon the rapidity with which the dose
can be increased. If the patient reports at the
beginning of his hay fever, he is given small daily
injections without awaiting the subsidence of the
reactions. So many patients have had their symp-
toms disappear in the course of a week that he con-
siders this the best method of affording relief. A
relatively high degree of resistance to p>ollen may
be assumed as present at the close of the season,
but with the omission of treatment this slowly re-
cedes, until at the beginning of the following season
skin tests show the same intensity as at first. The
following results were obtained in 123 of the 330
cases. They received desensitizing treatment for
two years or more. i. No improvement noted,
seven cases. 2. Improvement as compared vi^ith
previous years, but showing, nevertheless, trouble-
some symptoms for a short time, forty-six cases.
These patients in general may be considered as only
moderately well satisfied with results, and, in the
author's opinion, not materially better than most
cases treated in previous years by cauterization and
general hygienic measures. 3. Very definite im-
provement, apparently beyond criticism, was ob-
served in fifty-nine cases. These include patients
with a previous history of severe attacks, who,
under treatment, exhibited only slight symptoms,
causing not more than moderate annoyance. Here
are included patients with a previous history of hay
asthma, who were able to go through two or more
summers without asthmatic symptoms. 4. Five pa-
tients showed no hay fever for two or more years.
By this is meant complete absence of subjective or
objective vasomotor disturbance, in spite of full ex-
posure to pollen.
Treatment of Asthma by Peptone. — A. G. Auld
{British Medical Journal. July 20, 1918) cites the
experiments of Weil to show that the injection of
peptone exhausts the anaphylactic mechanism and
leads to desensitization irrespective of the nature of
the sensitizing antigen. Since the desensitization is
quite nonspecific, skin tests for the causative specific
antigen are not required. The desensitization can be
accomplished by a single large dose, but the effects
are relatively short lived and better results can be
secured by small and increasing doses extending over
a considerable period of time. In some cases the
large initial dose may be required, followed by
smaller and decreasing doses, but it is not the plan
to be recommended. The dose of peptone stops the
attacks for oeriods roughly proportional to their pre-
vious frequency; thus if the attacks occurred weekly
the remission should last from six weeks to two
months, while freedom for three or four months
should follow if the attacks occurred at intervals of
three weeks. The only peptones to be used are
Witte's or Armour's "ordinary" peptone, since these
are the ones which contain sufficient of the primary
proteoses. A two per cent, solution of Witte's or a
five per cent, solution of Armour's are the most con-
venient for use. The peptone should be dissolved as
far as possible in three quarters of the desired
volume of normal saline by agitation and warming
to 37° C. Then one mil of a two per cent, solution
of sodium carbonate should be added for each 0.33
gram of peptone to secure the requisite fineness of
the suspension. The whole is then brought up to the
desired volume with normal saline, adding phenol to
0.25 per cent. The initial dose should be about three
decimils which should be increased by about two
decimils every fifth day until six doses have been
given, when thfe dose then reached should be con-
tinued for three or four more injections. Injections
should not be given during attacks.
6io
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Duodenojejunostomy, Its Indications and
Technic. — James ^lacKenty (Canadian Medical
Association Journal, ]u\y, i(ji8) condndes: i. Duo-
denojejunostomy is not more difficult to perform
than posterior gastroenterostomy and its mortality
should not he greater. In chronic gastromesenteric
ileus it is the operation of choice, and in the acute
form, if any operation is advisable, it should be
given a trial. Gastroenterostomy has no place in
the treatment of this condition. 2. Cases of slight
dilatation of the duodenum due to partial obstruc-
tion by the root of the mesentery, in which the pull
of the prolapsed cecum can be demonstrated, should
have the cecum and colon suspended, as there is
ground for expecting that a fair proportion of them
will thereby be permanently relieved and avoid the
necessity of either a shortcircuiting operation or a
resection of the colon. 3. In the absence of patho-
logical changes in the cecum and colon demanding
their removal, their resection for the relief of chronic
gastromesenteric ileus is not necessary nor advisable,
as the same effect can be attained by less dangerous
means. 4. Chronic gastromesenteric ileus is prob-
ably a more common condition than has been sus-
pected. Stavely says, "a fair proportion of cases
now classed gastroneuroses" are due to "incomplete
obstruction by the root of the mesentery." In every
case of '"chronic dyspepsia" it should be kept in mind
as a possible cause, and in every exploration of the
upper abdomen the condition of the duodenum and
root of the mesentery should be examined. Inas-
much as the presence of partial obstruction here pre-
disposes to postoperative, acute dilatation of the
.■Ttomach, the knowledge gained will be valuable even
if no operation for the relief of the obstruction is
undertaken. By this means also, a question regard-
ing which there exists much difference of opinion,
may, by the records of a large number of observers,
be finally settled.
The Chemotherapy of Leprosy and Tuberculo-
sis.— T. Sugai {American Journal of the Medical
Sciences, July, 1918) employs a combination of two
parts potassium cyanide and one part of cuprous
cyanide, which he calls potassium cuprocyanide. It
is in the form of small, white, needle shaped crystals
which are soluble in water and alcohol. The lethal
dose for a rabbit is five mg. per kilogram of body
weight. The dose is an injection of a o.i to i per
cent, aqueous solution every ten days, the amount
injected being equivalent to 0.25 to 0.3 mg. per kilo-
gram of body weight. In leprosy he says'that after
one to three injections the nodes gradually become
soft or begin to bleed, after which they diminish in
size, in time disappearing completely. The leprous
ulcers heal and form scars, which lose their charac-
teristic color eventually. Sensory disturbances are
overcome when the swollen nerves have had time to
shrink to their normal size. Frequently the growth
of hair is stimulated in areas where it has fallen out.
In tuberculosis, animal experiments gave favorable
results. When used in tuberculous patients the re-
sults of treatment were : A few days after the injec-
tion the lung symptoms became aggravated, the
quantity of sputum raised was increased, a rise of
temperature of about one degree frequently occurred,
and in many cases the patient felt weak and tired for
a period of two to four days. Then conditions
usually showed marked improvement, the tempera-
ture falling gradually and the appetite being restored.
For three to six days after injection, hemorrhages
may be frequent. The sputum is greatly reduced in
quantity, even in severe cases, but frequently contains
larger numbers of bacilli for a long period. The
bacilli are apt not to wholly disappear from the spu-
tum until ten to twenty injections have been admin-
istered. Patients in the first and second stages of the
disease often feel well after five to ten injections.
The following is a summary of the paper: i. Potas-
sium cuprocyanide when injected intravenously has
an extremely beneficial effect in leprosy. It is prob-
able that a cure might be effected if the treatment
were continued for from six months to a year. 2.
A completely therapeutic effect in tuberculosis in
animals has been demonstrated. The animals which
received intravenous injections of potassium cupro-
cyanide lived longer than those which had no treat-
ment. After eight to ten injections the animals were
completely cured. 3. Potassium cuprocyanide had
a favorable effect on tuberculosis in man, including
the pulmonary form.
Restoration of Part or All of the Lovirer Jaw. — -
H. R. Allen (Journal of the Indiana State Medical
Association, June 15, 1918) suggests this rather for-
midable procedure: On one or both sides (according
to requirements of the case) an incision two or more
jnches below and about parallel with the clavicle is
made. It is sufficiently long to secure an appropriate
amount of skin and soft tissues to accompany the
superior and anterior section of the upper half of the
clavicle which is removed from the lower and pos-
terior remaining portion of the clavicle. It is not
necessary, except in unusual cases, to remove the
entire upper half of the clavicle. Ordinarily, the
articular ends and a considerable area near them
need not be touched. The lower skin incision mav
be carried directly across or pointed upward toward
the median line. At the ends of the horizontal in-
cision, vertical incisions free the flaps accompanying
appropriate lengths of the superior portions of the
clavicles on both sides, provided both sides require
restoration. This bone carrying flap, with its circu-
lation impaired though not cut off, is drawn upward
and sutured to the denuded face and raw tissues
above. The lower flap of skin and fascia may be
used to cover the raw surfaces of the portions of
clavicles accompanying them or extend across to
form a floor for the mouth, or serve both purposes.
The proximal ends of the clavicle segments may be
united now or subsequently. The clavicle segments
may be fractured at an appropriate time to form
angles for one or both sides of the jaw, making the
chin. After securing the flaps in place, the muscle
attachments released in removing the superior clav-
icular segments are now united above and below by
fascial flaps. The denuded area is closed by plastic
methods or by skin grafting, or bv both procedures.
A drainage may be employed. The head should be
well flexed forward and secured in this position.
By this method living bone may be transplanted — a
procedure having manv advantages over any system
of bone grafting in which the graft is cut off from
its blood supply. The function of the shoulder
girdle is unimpaired.
October 5, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
611
Value of Kidney Drainage with the Ureteral
Catheter, of Pelvic Lavage, and of Intraureteral
Manipulation. — H. G. Bugbee {American Journal
of Obstetrics, May, 1918) reports the case of a
woman of thirty-four, with a history of obstinate
constipation and with abnormal mobility of the right
kidney. During pregnancy pain in the right side of
the abdomen and back was experienced, and an ox-
alate calculus removed by operation from the right
ureter at the level of the pelvic brim. A ureteral
listula persisted, and a diverticulum formed at the
point where the ureter had been opened, because of
traumatism of the ureter. A second calculus, lower
down, had not been removed at the operation. A
bilateral kidney infection existed. Under continu-
ous kidney drainage with retained ureteral cathe-
ters, the ureteral fistula rapidly closed and the pa-
tient's condition improved. Calculi formed, how-
ever, in the ureteral diverticulum. The possibility of
removing these by intraureteral manipulations of the
catheter, even in the case of a calculus over three
centimetres long, was demonstrated. Upon twisting
the inserted catheter in the fingers it coiled about the
calculus ; traction brought on colic, the catheter was
loosened by uncoiling, and within an hour the cal-
culus was passed. Complete cure of the infection
and cessation of calculus formation was secured in
this case bv attention to the general condition, care
of the bowels, abdominal support, and local treat-
ment of the kidneys by lavage.
Clinical Experience with Koga's Cyanocuprol.
— T. I. Matsuda and T. K. Matsuda {American
Journal of the Medical Sciences, July, 1918) detail
their experience in the treatment of tuberculosis with
a compound salt of potassium cyanide with copper,
called cyanocuprol. (Possibly the same as that de-
scribed by Sugai in the same journal as potassium
cuprocyanide.) They say that cyanocuprol is very
effective in all cases of the first stage and in the ma-
jority of the second stage. With patients in the third
stage it may manifest its effect to a certain extent,
if favorable cases are selected and proper doses are
given. Its effect cannot be called strictly chemo-
therapeutic ; in some respects it shows a strong re-
semblance to tuberculin. The essentials of the treat-
ment lie in finding the proper dose for each pa-
tient. If the individualization, which is especially
important, is properly carried out its value is re-
markable, surpassing all other remedies ever tried.
The combination of calcium prevents violent reac-
tions and does not affect the efficacy of the drug.
The combination of immune therapy and sanatorium
treatment is necessary. The question of duration of
treatment is an important one. According to their
experience, if the patient is not improved after two
or three injections, or is weakened, the dose should
be reduced or the interval extended. If this brings
no improvement, the treatment must be given up.
Even in favorable cases, when the results are good
after each injection, the treatment is best interrupted
between the fifth and sixth, and eleventh and twelfth
injections, for at these times the condition is most
improved. If treatment is continued in such cases
there will be no benefit from it ; instead there may be
a return of previous symptoms and the patient's con-
*htion may bcome hopeless.
Intrarectal Administration of Arsphenamin. —
Augusto S. Boyd and Morris Joseph {Journal A.
M. A., August 17, 1918) recommend, on the basis
of their own experiences, the intrarectal administra-
tion of arsphenamin or neoarsphenamin in those
cases in which the intravenous method is not possible
or requires the exposure of a vein by incision. The
drug is prepared just as for intravenous injection,
hut only twenty-five to fifty mils of fluid are used
for neoarsphenamin and about 100 mils for arsphen-
amin. The patient is put to bed and the solution is
run into the rectum slowly, over a period of about
ten minutes. The patient is encouraged to retain the
injection, and the hips may be elevated or the foot
of the bed raised to facilitate retention, especially in
children. A cleansing enema may be given before
the injection, but it is not always necessary. The
injections can be given every three days, the full dose
of 0.9 gram of neoarsphenamin and 0.6 gram of
arsphenamin being used for adults and one of o.i
gram for each twenty-five pounds of body weight for
children. The method seems to have certain advan-
tages over intravenous injection, aside from those
mentioned before ; namely, it provides slower ab-
sorption, and hence more prolonged action of each
dose, and there is no risk of abscess formation from
the accidental escape into the tissues of some of the
solution, or of the systemic toxic effects seen after
the rapid intravenous injection of the drug.
Removal of Ureteral Calculi Without Opera-
tion.— A. J. Crowell and S. R. Thompson (Jour-
nal A. M. A., August 10, 1918) have employed their
niethod of nonoperative removal of ureteral calculi
in thirty-one cases during the past three years and
have been compelled to operate upon only two of
the patients. They express the belief that practi-
cally all recently impacted stones can be removed if
the treatment be carried out properly and persisted
in sufficiently long. If there has been complete
obstruction of the ureter without infection for as
long as three months, the secretory power of the
kidney will have been lost and the treatment cannot
be applied. If there be infection the condition is
surgical. The treatment as described consists in
first passing a No. 5 bismuth catheter into the
ureter until it meets resistance. A rontgenogram
then will show the location and size of the stone.
Then two mils of a two per cent, solution of cocaine
are inj'^cted slowly at the site of the impaction and
three or four minutes later the catheter is passed
beyond the stone and ten mils of sterile oil are in-
jected. If the catheter cannot be passed beyond the
stone the oil is injected with some force to dislodge
the stone and lubricate the way for its passage.
The patient is then kept well under the influence
of morphine, is put to bed and is given water to
drink freely to assist in expelling the stone, while
hexamethylenamine should be given in large
amounts to prevent infection. The urine is filtered
through gauze to catch the stone, or the stone may
be discovered in the bladder by cystoscopy. The
treatment is repeated every second or third day until
the stone is expelled, a larger catheter being used
each time to dilate the ureter. The number of treat-
ments required for expulsion varied from one to
eight.
Miscellany from Home and Foreign Journals
Pulmonary Compression Signs in Acute Fibri-
nous Pericarditis. — Henry A. Christian (Journal
A. M. A., August lo, 1 91 8) says that attention is
frequently called to dullness and bronchial breathing
over a portion of the left back, near and below the
angle of the scapula, as an accompaniment of peri-
cardial efifusion. The authors describing such signs
lay emphasis on the presence of a considerable
amount of fluid in the pericardium, but such signs
are often encountered in cases of acute fibrinous
pericarditis with to and fro friction and little evi-
dence of effusion. Of fifty-three patients with acute
pericarditis and friction rubs, observed by the au-
thor, thirty-nine, or 73.5 per cent., showed abnormal
signs in the left lower chest behind. In none of
these cases was there evidence of any considerable
amount of fluid in the pericardium, a fact confirmed
in many by aspiration or at necropsy. The signs
found included dullness of varying extent, bronchial
breathing, and bronchophony. From a study of
these cases the conclusion was reached that these
physical signs were probably due to compression
atelectasis of a portion of the left lower lobe. This
compression seemed to be due to the heart and peri-
cardium, to some pleural exudate, or to both. It
was also possible that there might have been some
intrapulmonary inflammatory changes, but this was
not proved. The pulmonary signs did not seem to
be of any significance with reference to the course
or the prognosis of the pericarditis.
Tinel's Sign in Peripheral Nerve Lesions. —
W. M. Macdonald {British Medical Journal, July
6, 1918) agrees with Deperine that the electrical
reattion of the muscles supplied by an injured
nerve are neither in themselves a guide. to the nature
and extent of the lesion, nor a measure of its sever-
ity. Much more satisfactory is Tinel's sign of
distal tingling on percussion, which depends upon
the fact that the percussion of young axis cylinders
leads to tingling in the skin areas corresponding to
their ultimate distribution. The formation of new
axis cylinders in the proximal end of a divided
nerve becomes evident by the above sign in from
four to six weeks. If these new axis cylinders are
arrested in their distal growth or are turned back to
form a neuroma, Tinel's sign can be elicited o^ver an
area not exceeding two to three centimetres, and lo-
cated at the site of the lesion. If the new axis
cylinders, however, grow down the trunk, or if the
nerve has merely been contused, the level at which
Tinel's sign can be elicited will descend and its de-
termination permits one to follow the progress of
regeneration. The growth of the axis cylinders
amounts to one or two millimetres daily and when
they have developed their functions completely the
sign disappears. This usually takes about 100 days
so that the cylinder will then have traveled about
ten centimetres down the trunk and the site of the
lesion will begin to lose its reaction to percussion.
In another 100 days the ten centimetres just below
the lesion will have ceased to respond to Tinel's test,
while the next ten centimetres will do so. Since
this sign always precedes by some considerable time
the return of muscle tonus, voluntary movement,
and normal electrical reactions, its discovery consti-
tutes an indication of great value after operation
for nerve restoration or in spontaneous regenera-
tion. The sign is also of great value in indicating
which of a number of wounds in an extremity is
responsible for the nerve injury. The sign is also
present in neuritic irritation, but it is then found
along the entire course of the nerve and the percus-
sion causes both tingling and pain at the point to
which it is applied. The sign is found somewhat
modified in form after concussion, compression, or
contusion sufficient to cause paralysis after the
elapse of about a month. In such cases its presence
for more than ten centimetres below the site of the
lesion by the end of the second month predicates
perfect recovery in a few months. In eliciting the
sign the percussion must always be begun distal to
the lesion and slowly carried upward until the
tingling is produced. Nerve operations should be
more largely restricted to cases requiring resection
and suture and should be delayed until after the end
of the third month following injury.
New Gonococcus Antigen. — David Thomson
{Lancet, July 13, 1918) discovered that weak alka-
lies rapidly dissolved the gonococcus and applied
this to the preparation of a new antigen. A con-
centrated emulsion of freshly grown gonococci is
prepared and one half is diluted to such strength
that there are 1,000 million organisms per mil.
To the other half in a test tube there are added a
few mils of decinormal sodium hydrate to dissolve
the organisms. The clear alkaline solution thus ob-
tained is made just neutral to litmus with decinor-
mal HCl, when physiological saline containing half
of one per cent, of phenol is added to bring the total
volume up to that of the first half. The antigen
thus represents 1,000 million organisms per mil.
This antigen keeps well on ice and constitutes the
stock. It is then employed in the complement fix-
ation test according to a new method. The serum
to be tested is inactivated before dilution by heat-
ing for ten minutes at 55° C. The complement is
standardized by titration against the stock antigen
diluted to one to ten with saline in the following
way: One tenth of a mil of the guineapig serum is
placed in each of twelve Wassermann tubes in serial
dilution as follows :
Tube 123 12
Dilution i/io 1/20 1/30 etc., to 1/120
To each there is then added one tenth mil of the
diluted antigen and an equal amount of saline. The
tubes are shaken and placed in the ice chest for an
hour and then in a water bath at 37° C. for half an
hour. Then one tenth mil of a three per cent, sus-
pension of sensitized sheep corpuscles is added to
each, the tray returned to the bath, and readings
made in fifteen minutes. One minimum hemolytic
dose of the complement is represented by the highest
dilution, which produces complete hemolysis. The
complement fixation test is then performed with
three tubes — A, B, and C. To A and B one tenth
mil of the inactivated serum diluted to one in twenty
October s, 1918.] MISCELLANY FROM HOME AND FOREIGN JOURNALS.
613
is added, to C one tenth mil of saline. To A one
tenth mil containing three minimum hemolytic doses
of complement is added, while two hemolytic doses
in a similar volume are added to B and C. The
tubes are then kept on ice over night, incubated for
fifteen minutes the following morning at 37° C, and
read. C should show total hemolysis ; hemolysis in
both A and B is a negative reaction ; no hemolysis
in either A or B is strongly positive ; and hemolysis
in A alone is weak positive. This antigen, when
made to represent a number of strains of gonococci,
gives better results than other forms of antigen,
having yielded nineteen positives out of twenty
cases, while it was always negative in normal sera.
Absence of Bacillus Influenzae in Present Epi-
demic—T. R. Little, C. J. Garofalo and P. A.
Williams {Lancet, July 13, 1918) have investigated
the epidemic disease which has recently been wide-
spread in Europe, studying both the clinical aspects
and especially the bacteriology of the exudate from
the upper respiratory tract. They came to the con-
clusion that the epidemic was not one of influenza
for several reasons. First, although its clinical
course resembled influenza the disease was of very
short duration, and relapses, recurrences, and com-
plications have been absent. Second, the disease
was not characterized by a sharp leucocytosis and
polynucleosis, but rather by a very slight leucocytosis
with a small mononuclear lymphocytosis. Finally,
the Bacillus influenzse was invariably absent frOm
the secretions and exudates from the upper respira-
tory passages, and in its place there was always a
Gram positive diplococcus.
DifTerentiation of Hemorrhagic Pulmonary
Spirochetosis. — F. Barbary (Bulletin de I'Aca-
deniie de medecine, Tune 25, 1918) alludes to the
view of A. Pettit, after examining a series of cases
of supposed icterohemorrhagic spirochetosis en-
countered at Lorient in July, 191 7, that the causa-
tive organism in these cases was dififerent from that
of the latter disease. The Lorient cases were char-
acterized by an abundance of spirochetes in the
urine, by immunity of guineapigs to inoculation, by
a rare incidence of jaundice, and by such unusual
manifestations — unknown in true icterohemorrhagic
spirochetosis — as rheumatism, erythema nodosum,
pleuropneumonia, etc. Trench fever and trench
nephritis have been ascribed to spirochetes. Re-
cently the author has had under observation two
cases of hemorrhagic pulmonary spirochetosis, both
in Lidochinese natives. The one presented harsh
breathing and friction sounds at the right apex,
harsh breathing and prolonged expiration at the left
apex, bloody sputum, slight evening rise of tem-
perature, and general asthenia. The other had
mucous sputum without trace of hemorrhage but
with evidences of a former congestion of the left
lung. Later both patients showed slight but con-
tinuous hemoptysis. The x rays revealed little else
than enlarged lymph nodes on both sides — a finding
unfavorable to the diagnosis of pulmonary tuber-
culosis. The sputum in both cases showed many
spirochetes, but none were found in the blood. The
Wassermann reaction was positive in one case,
negative in the other. There were no spirochetes in
the urine. Of three inoculated guineapigs, two suc-
cumbed with congestion and hemorrhage in internal
organs. Barbary concludes that in cases suspected
of pulmonary tuberculosis, clinical diagnostic pro-
cedures should henceforth include examinations of
the urine, blood, and sputum for spirochetes.
Bronchopulmonary spirochetosis must now be
clashed as a pseudotuberculosis, apt to lead to con-
fusion in the diagnosis of cases of closed tuber-
culosis. The examination of the sputum for spiro-
chetes is easily carried out with either methylene
blue or carbol thionin. The diagnosis having been
positively made, isolation is necessary, the disease
being extremely contagious. Apart from the direct
infection observed at Lorient among physicians,
orderlies, and laboratory workers, transmission
readily occurs from dried sputum. Sputum cups
should be used and the patient's mouth washed with
peroxide or chloral hydrate.
Site of the Murmur of Aortic Insufficiency. —
Tremolieres and Gaussade {Prcssc inedtcalc, July
II, 1918) find that the diastolic murmur of aortic
regurgitation is situated much oftener to the left
than to the right of the sternum. Combined etio-
logic, clinical, and x ray studies of these cases led
to a definite errouDiner into three classes, distinct not
only at the time but also with regard to prognosis.
First, in the recent aortic lesion, there is a murmur
at the left of the sternum, and the x rays show a
simple hypertrophy of the left ventricle with a ver-
tical aorta. Secondly, in more advanced aortic le-
sions, the diastolic murmur is mediosternal or
xyphoid in situation, and the x rays show notable
hypertrophy of the left ventricle with the aorta be-
ginning to incline to the right. Finally, in old aortic
lesions, the diastolic murmur is at the right of the
sternum and the x rays show not only hypertrophy
of the left ventricle, but also dilatation of the cham-
bers in the right half of the heart and deflection of
the aorta from above downward and from left to
right.
Alimentary Renal Glycosuria. — Kingo Goto
(Archives of Internal Medicine, July, 1918) asserts
that in renal glycosuria the elimination of sugar
occurs in spite of the fact that the blood sugar is
within the physiological limit of alimentary hyper-
glycemia, viz., 0.16 to 0.17 per cent. There is no
disturbance of carbohydrate metabolism and there
are no diabetic symptoms. The term "renal dia-
betes" is therefore a misnomer. The urinary glu-
cose in these cases may or may not have some rela-
tionship to the carbohydrate in the diet, according
to the permeability of the kidneys. In a mild case,
sugar disappears from the urine during a carbohy-
drate free diet. The morbid condition does not
progress ; thus, in a case Goto reports, the carbohy-
drate tolerance has remained the same for five years
and the subject is in good health. In dif¥erentiat-
ing renal glycosuria from diabetes, examination of
the blood sugar is required not only once after fast-
ing, but also .It least twice every hour after a cer-
tain carbohydrate diet with resultant glycosuria.
The renal threshold of the subject must simultane-
ously be studied. DiflFerentiation between disturb-
ance of carbohydrate metabolism and increased per-
meability of the kidneys for sugar is thus accom-
plished. The glucose test, consisting in study of
6i4
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
the blood and urine following ingestion of lOO
grams of glucose with 250 to 300 grams of water,
after an overnight fast, is also carried out, to ascer-
tain the condition of carbohydrate assimilation of
the individual. Possibly some of the cases of mild
diabetes in practice are actually cases of renal glyco-
suria, for most of them are diagnosed only by ex-
amination for sugar in the urine, or at most, by a
single determination of blood sugar without refer-
ence to the preceding meal. While it is now believed
useless to keep to a strict diet in renal glycosuria,
the harmlessness of giving carbohydrate in large
amounts to persons with lowered kidney thresholds
has not been established ; there is a chance that the
depression might thereby be increased.
Ear Disturbances in Military Aviators. — A.
Castex (Bulletin de I'Academie de medecine, June
25, 1918) notes that combats between aviators gen-
erally occur at altitudes between 4,000 and 5,000
metres, with the barometer at 47 to 41. The tem-
perature descends by 1° C. for every rise of no
metres at the lower altitudes and for every 200
metres at high altitudes. During an ascent general
lassitude may be experienced as a result of the re-
duction in atmospheric pressure. In full flight, at
about 5.000 metres, the aviator may experience pain
in the ears, heaviness of the head, somnolence, gen-
eral fatigue, and apathy. During the descent there
may be renewed pain in the ears and tinnitus. Upon
alighting there may be temporary deafness and at
times a staggering gait. Otoscopy then shows con-
gestion of the entire auditory apparatus. In a num-
ber of aviators one notes a progressive diminution
of labyrinthine perception. At times the men have
latent changes in the upper respiratory passages
which are adjuvant causes of their deafness. The
ear disturbances are due in particular to dififerences
in atmospheric pressure. Hence the relief secured
during ascent by Valsalva's method, and during de-
scent, by that of Toynbee.
Sanguineous Bronchitis. — H. Violle (Presse
medicalc, July ii, 1918) ^prefers this appellation to
that of bronchial spirochetosis, the bloody expector-
ation being the most prominent clinical feature of
the disease, and having been present in all cases he
has seen. The diagnosis of sanguineous bronchitis
should be made in all instances of mild pulmonary
involvement, especially at the apices, accompanied
by mucohemorrhagic expectoration, of the color of
currant juice, and with the general condition remain-
ing good, without fever or loss of weight or appe-
tite. A sputum smear stained with silver nitrate
will co!ifirm the diagnosis by revealing the spiro-
ch.-eta bronchialis in large numbers. Probably many
cases of closed tuberculosis have been wrongly diag-
nosed of late, being actually cases of sanguineous
bronchitis. This is a matter of considerable sig-
nificance in military practice; for in the French
army, patients clinically tuberculous are allowed to
leave the service even in the absence of bacterio-
logical confirmation, while if actually instances of
sanguineous bronchitis, many of them could be re-
tained. The duration of the latter disease, which
is relatively mild, has ranged, in Violle's experience,
from a few days to two months, with an average
of one month. Relapses seem to be very frequent,
occurring after cessation of all bloody, mucopuru-
lent, or even mucous sputum and after the spiro-
chetes have seemingly disappeared ; they may occur
even after intervals of several years. According to
Castellani the disease may be chronic, the local
symptoms being then more pronounced, and perma-
nent lesions of the lung parenchyma established.
Pneumonia, bronchopneumonia, and tuberculosis
are possible complications of the disease when acute.
On the other hand, the bronchitis may itself occur
as a complication in anemic or exhausted subjects,
and during attacks of typhoid fever, mumps, malaria,
or advanced lung tuberculosis. Isolation is indi-
cated for protection of both the patient himself and
those around him. Open air life, rest, and a gen-
erous diet, hasten recovery. Arsenicals may be used
as tonics, and later, drv cupping and tincture of
iodine used to ward off complications, opium for
painful cough, and calcium chloride and ice appli-
cations for the bloody expectoration.
The Need of Systematic Instruction for Hospi-
tal Interns. — Edward H. Bradford {Boston Med-
ical and Surgical Journal, August 15, 1918) thus
summarizes his paper: The government needs well
qualified young physicians and demands a year of
hospital service. This secures to the hospital a cer-
tain supply of young medical officers. In return, the
hospital should arrange that residents receive sys-
tematic instruction during their year of service. To
provide for this the following requisites must be se-
cured: I. Systematic instruction from the hospital
authorities and staf¥s. 2. Authorized conferences on
hospital cases. 3. Condensed and systematic case
records. 4. An arrangement of hours of work per-
mitting time for study. 5. Cooperation on the
part of hospital authorities with medical educators,
and supervision by state licensing boards of medical
education to secure proper hospital standardization.
The demands of the community for properly trained
medical practitioners require practical hospital train-
ing in addition to adequate medical school instruc-
tion. This throws upon hospitals an added responsi-
bility ; that is, the maximum of hospital educational
opportunity.
Nasopharyngeal Conditions in Meningococcus
Carriers. — F. J. Cleminson (British Medical Jour-
nal, July 20, 1918) sought the explanation of the
varying resistance to local treatment encountered in
meningococcus carriers in the conditions present in
the nasopharyngeal structures, and to this end ex-
amined forty-seven carriers. From this examina-
tion he suggests that the genesis of carriers may be
favored by the presence of adenoids and by firm
mucous contact between the middle turbinate of the
nose with the septum or the outer nasal wall. An
existing infection of the nasal accessory sinuses
seems to be unfavorable to the genesis of the carrier
state. Resistance to treatment seems to be favored
by the presence of pyorrhoea alveolaris, by firm
mucous contact of the middle turbinate, and by
existing infection of the accessory sinuses. Ap-
parently the accessory sinuses are the main sites of
infection in meningococcus carriers, and since it is
very difficult to disinfect them they can repeatedly
infect the other portions of the nasopharynx.
Proceedings of National and Local Societies
THE AMERICAN PEDIATRIC SOCIETY.
Thirtieth Annual Meeting, Held at the Curtis Hotel,
Lenox, Mass., May 2j, 28, and 2^, igi8.
{Continued from page 574.)
Appeal of the Medical Reserve Corps to the
American Pediatric Society. — !\Iajor Frothing-
HAM, of Boston, said that the government needed
medical men and the community needed medical
men and it was a question where the line was to
be drawn. If, a year ago, he had been asked
whether the Government wanted obstetricians and
pediatricians his answer would have been "No,"
but at that time Major Frothingham said he was
examining recruits. Since then he had had experi-
ence at Fort Benjamin Harrison and had found
that there was a great deal to do m the Medical
Department of the Army which had not the least
thing to do with the profession itself. He wished
to say that it was quite worth while to go into the
army to do things not professional in the strict
sense of the word. At the present time the Medical
Department of the Army was standing the strain of
a terrific expansion and was standing it well. There
were very few physicians in the army who did not
have specialties before entering the service, but a
man might do something for which he had not been
trained and might fill a very important position.
Major Frothingham described the duties of the
medical men from the time wounded men were
brought to the first dressing station until they had
reached a base hospital, showing that there were
many duties for the medical man aside from sur-
gery. All the transportation of the men had to be
done under the supervision of medical men. Even
on the firing line a few medical men were needed,
for there they had an outpatient department and if
a man became sick he was sent back. Big problems
of hygiene and the health of thousands of men de-
pended upon the men who ran the outpatient depart-
ment. Much of the work at the front the pediatri-
cian could do quite as well as any other medical man.
At the base hospital there were problems of acute
infection and empyema. The problems of acute in-
fection were those of the contagious diseases of
childhood and not those of chronic disease, and no
one was better fitted to handle them than the pedia-
trician. At the cantonments they had chest ex-
aminers and heart examiners and there the pedia-
trician would be perfectly capable. If the Govern-
ment did not need the pediatrician he should give
his name to the Red Cross. There was another side
to this matter which was worth while considering.
In the first place it was great fun to be in the game
and to be taking part in this big scheme of organiza-
tion and to be doing what every one thought was
the right thing to do. But if one did not go because
he felt it his duty to go, he should go because it was
a splendid way to improve his medical knowledge.
This was particularly true of the acute infectious
diseases, which were not seen in private practice to
anything like the extent that they were seen in the
army.
Hemorrhage after Scarlet Fever. — Dr. John
HciwLAND, I^altimore, presented the following case:
The child, five and one-half years of age, became
?11 on December i, 1917, and two days later a mem-
brane appeared on the tonsils. The child developed
no characteristic eruption. Cultures from the throat
were ^ent to the State Department of Health. Sub-
sequently albumin was found in the urine, and it
was thought that the child had a postdiphtheritic
nephritis. Twenty-three days after the onset the
child became very ill, the temperature rising to 99°
F. A necrosis of the right tonsil with a very foul
secretion was found and a perfectly characteristic
scarlet fever desquamation. There was a mass the
size of an egg in the right side of the neck, which
was opened and about two ounces of pus evacuated,
but no blood. In the middle of the night the child
was found exsanguinated and in a pool of blood.
The child was given 300 c. c. of salt solution sub-
cutaneously and transfused with the mother's blood,
250 c. c. being given intravenously. The hemor-
rhage stopped for a few hours and then began again
and the child again received a transfusion of the
same amount of the mother's blood. The child was
then given morphine and an attempt was made to
examine the abscess cavity, when there was a gush
of blood apparently from the external carotid or
the lingual. These vessels were ligated and the
hemorrhage controlled by pressure on the internal
jugular. Another transfusion was given and after
that the child improved and there was no further
hemorrhage until two weeks later, when another
hemorrhage occurred as the result of sloughing of
the suture on the external carotid. After this the
child improved quite rapidly though the convales-
cence was complicated by a psychosis. The anemia
cleared up rapidly and the child made a perfect re-
covery. While hemorrhage after scarlet fever was
found in about fifty cases on record, the most were
from the internal jugular and such cases ended
fatally.
Dr. FIowARD C. Carpenter, of Philadelphia, said
that in the hospital with which he was connected
they had a case of cervical adenitis that seemed to
be progressing satisfactorily. While the intern was
in one of the wards the child had a sudden hemor-
rhage, apparently from the carotid, and within two
minutes was dead.
A Case of Hirschsprung's Disease. — Dr. Wal-
ter Lester Carr, of New York, stated that his pa-
tient was six years of age, of Italian parentage, and
was brought to the City Hospital in an ambulance
without a history except that she had been consti-
pated for five years, and had vomited for twenty-
four hours. She was in a condition of shock, the
temperature was 97.5, pulse 120; the thirst was in-
tense. The abdomen was greatly distended and
there was constant involuntary discharge of feces.
Colonic irrigations of normal saline were given,
with stimulation, heat, etc. The child died eleven
hours after admission. A partial necropsy showed
a marked distention of the intestines ; this was par-
ticularly evident in the sigmoid colon, which was-
6i6
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
bent upon itself. The wall of the upper part of
the rectum and the lower part of the colon was
slightly calcified, and the lining mucous membrane
was very granular. There was hyperplasia of the
mesenteric lymph nodes. The anatomical diagnosis
was idiopathic dilatation of the sigmoid colon,
Hirschsprung's disease, with secondary calcification
of the upper part of the rectum and lower part of
the sigmoid. A microscopic examination of the tis-
sue from this specimen showed a complete loss of
mucous membrane, and in its place a vascularized
round cell proliferation of the submucosa. There
was a corresponding hypertrophy of the inner and
outer muscular coats.
Dr. Henry Koplik, of New York, said that some
of these patients died very early. He had had a case
in a child only a few weeks old who died of ob-
struction and the condition was confirmed as being
Hirschsprung's disease. On the other hand, in some
cases of obstruction supposed to be Hirschsprung's
disease it was found that the child only had a large
abdomen. Sometimes these obstructions were re-
lieved by nature, by diet, and by enemata, and some-
times they went on to complete obstruction, the pa-
tients were operated upon and died. The prognosis
was very bad if an artificial anus was made. Doctor
Koplik stated that one point he wished to make was
that some of these cases went on to adolescence with
the condition. He had published such a case. In this
instance the boy went on until he was fourteen years
of age and then died from obstruction. The condi-
tion might be rapidly fatal or it might go along
quite normally for a long time. Usually they did
not operate in these cases until they had tried med-
ical means and sometimes the patients would go on
to recovery.
Dr. F. B. Talbot, of Boston, emphasized the
point that when this condition was dignified by the
name of Hirschsprung's disease, it was later in the
disease, when the bowel had come to the point of
dilatation. The time to treat the condition was be-
fore the dilatation had occurred. There were many
patients with Hirschsprung's disease walking around
today ; some would reach the stage of dilatation
when the condition would be recognized.
Dr. Charles Gilmore Kerley, of New York,
called attention to a paper that he had presented be-
fore the American Medical Association two years
ago in which he reported and showed x ray plates
of about twenty cases of elongated sigmoid. He
said that these cases were fairly common, and that
the condition known as Hirschsprung's disease was
identical with these cases of elongated sigmoid that
folded upon themselves and became sacculated and
dilated and that were accompanied by constipation
and later constriction. The condition was very
common and it was only the severe cases that went
on to the formation of gross lesions.
Dr. Henry Heiman, of New York, stated that
the first stage of this condition was what was known
as megacolon and constipation and later it was
Hirschsprung's disease and obstruction.
Dr. Langley Porter, of San Francisco, took is-
sue with what had been said, stating that congenital
megacolon was found at birth and in the fetus
before birth. He had placed on record a number of
such cases.
Dr. Henry Koplik, of New York, said that
Hirschsprung thoroughly described this as a con-
genital condition or an anomaly, and he himself had
pictures of the new born baby in which both the
X ray and the autopsy showed most marked Hirsch-
sprung's disease.
Dr. Charles Hunter Dunn, of Boston, agreed
with Doctor Porter and Doctor Koplik that the con-
dition might be congenital. He stated that he had
seen two cases in the first week of life in which the
condition could not have been produced by pro-
longed constipation and must have been congenital.
Congenital Stricture of the Duodenum. — Dr.
H. M. McClanahan, of Omaha, stated that the pa-
tient was born on December 9, 191 7, and had a
history of vomiting from the third day after birth.
There was intermittent loss of weight and the stool
increased in frequency and became green at times.
X ray plates taken after the administration of
barium in milk revealed a large shadow over the
stomach and a distinct shadow down to the colon,
showing that the pylorus was pervious. At no time
was there any visible peristaltic wave, nor was a
mass palpable at any time. At operation, on Janu-
ary loth, an incision was made through the median
line through which the stomach crowded itself on
account of its great distention. The pylorus was
moderately constricted, by a distinct circular indur-
ation. The duodenum was greatly distended, and
following this down to the point where it passed
through the transverse colon, a very marked con-
striction was encountered. All the distention was
above the mesocolon. On examining the mesentery,
a constricting band was found compressing the duo-
denum about eight inches beyond the pylorus. This
band belonged to the mesentery and not to the in-
testine. The band was divided and the distention in
the duodenum was relieved at once. A posterior
gastroenterostomy was performed on account of the
distinct pyloric constriction. The child died sud-
denly in the night. The fact that at times the gain
in weight and the stools were normal indicated that
the band did not constrict all the time.
Dr. F. B. Talbot, of Boston, described a some-
Vvhat similar case under his observation that came to
autopsy. In this instance there was a constricting
band over the duodenum and there was obstructive
vomiting only a part of the time. After observing
the child for about a week it was found that most
of its time was spent in the knee-chest position.
When in that position it did not vomit. The con-
striction was reduced by that position so that the
food could pass through.
Dr. Langley Porter, of San Francisco, cited two
similar cases in which the symptoms presented re-
sembled those of pyloric stenosis.
Dr. L. E. La Fetra said he had seen two of these
cases, one at autopsy and the other during Hfe, and
the symptoms were very much like those of hyper-
trophic pyloric stenosis.
Cardiospasm Followed by Hypertrophy, Dila-
tation, and Stricture of the Esophagus. — Dr.
E. Graham, of Philadelphia, stated that the patient,
a boy, four years and ten months of age, had
vomited when first put to the breast and had vomited
ever since. He usually regurgitated or vomited im-
October 5, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
617
mediately after eating.. He sufifered from habitual
constipation. There was no abdominal distention.
The diagnosis of cardiospasm was made and the
presence of stricture of the esophagus was verified
by the x ray plates. A diagnosis of ulcerative
esophagitis was also made ; this was done by direct
inspection with the eye, the esophagoscope having
been passed by Dr. Chevalier Jackson, and the
ulcerative area being clearly seen. The patient was
treated by gastrostomy, feeding the child through
the tube for several weeks, nothing being allowed
by mouth except small quantities of water. Finally
the stricture of the esophagus was treated by dilata-
tion by sight, and not by touch, the esophagus being
passed with small bougies at first, and then gradu-
ally with larger and larger ones. A second child in
the Jefiferson Hospital with a stricture of the esopha-
gus caused by swallowing lye was being treated in
the same way.
A Case of Balantidium Coli.---Dr. Laurence
R. De Buys, New Orleans, said Balantidium infec-
tion was rare in man, less than 150 cases having
been reported, and very rare in childhood, there
being but three instances. The age of the patient
whose case was reported was five years, next to the
youngest case of Balantidium coli infection on
record. This patient was a boy who helped in
rounding up pigs and ate his food at times in the pig
pen. He gave a history of having been ill for nearly
a year with diarrhea. There were periods of im-
provement followed by recurring attacks, each at-
tack more pronounced than the preceding. The
stools resembled those of amebic dysentery, contain-
ing blood and mucus. The rectal tube was passed
and the organism identified. The patient was poorly
nourished, his skin dry. There was a catarrhal
stomatitis ; otherwise the physical examination was
negative, with the exception of some pain over the
lower abdomen. Doctor De Buys described and then
reviewed the history of the organism, referred to
the literature on the subject, and discussed the pa-
thology, symptomatology, diagnosis, prophylaxis,
and treatment of Balantidium coli infection. He
advised the use of emetine, since, because of the re-
semblance of the infection to that of amebic dysen-
tery, I, in the invasion and location of the organ-
ism in the tissues ; 2, in the histological pathology ;
and, 3, in its clinical manifestations, it was hardly
to be expected that local flushings would be of any
avail, after the infection was established.
Cribbing with Dilated Stomach and Spasm of
Diaphragm. — ^Dr. Perciv.al J. Eaton, of Pitts-
burgh, said that he was called to see a three weeks'
old baby that had lost considerably over a pound
since birth. The baby sucked its fists, tongue, and
a nipple and always vomited a good deal. The
stomach was dilated, the outline being easily made
out. The wave motion was quite visible, and some-
what exaggerated. There was much tympany of
the stomach and little of the intestine. By attention
to posture, prevention of unnatural sucking, mas-
sage, properly modified food, and absolute regularity
of feeding, the trouble was corrected. An oc-
casional dose of strontium bromide was given and
the child also had phosphorated oil in codliver oil,
and an abundance of fresh air and sunlight con-
stantly. The remarkable thing was that this child's
sister, now three years of age, was also a cribber.
Dr. Chakle.s Herrman, of New York, recom-
mended the use of atropine in cases of this kind.
His colleague had been using atropine and the re-
sults were sometimes very favorable.
Dr. D. N. CowiE, of Ann Arbor, said these cases
were sometimes very difficult to handle. He had
found that one way of breaking the habit was to tie
a spool in the mouth.
A Case of Kala Azar.— Dr. F. B. Talbot, of
Boston, reported this case. He stated that the child
was born in Greece and presumably became infected
before coming to this country. The onset of the
disease was insidious — a characteristic feature. The
symptoms were pallor, weakness, and enlargement
of the abdomen. The spleen was removed and the
diagnosis made from a smear of the splenic pulp.
The secretion was later obtained from the inguinal
glands and this also showed the presence of the
organism. Splenectomy apparently afifected the
course of the disease favorably. Later there was a
relapse and atoxyl was then used intravenously
without any effect. Tartar emetic was then used in
two per cent, solution, beginning with one c. c. and
working up to four c. c. This eventually caused
symptoms of salivation and was omitted. The
child improved rapidly, became normal, and has re-
mained so ever since.
A Case of Intussusception. — Dr. Frank X.
Walls, of Chicago, stated that the patient, a boy,
was taken with a sudden attack of pain in the abdo-
men, vomiting, restlessness, and drowsiness. A
normal saline enema was followed by the discharge
of blood stained mucus. Five hours after the onset
of the illness examination revealed a soft tumor
mass about two by three inches in the upper right
quadrant of the abdomen, with its long axis trans-
verse. Fluoroscopic examination after an enema
of barium buttermilk from a height of eighteen
inches showed the barium entering the bowel, filling
it from below upward until the mass reached the
middle of the transverse colon. Here the ascending
barium halted a moment and then a small stream
of barium trickled from the heavy column along the
periphery of the colon for a distance of about an
inch, and after this the column did not advance or
alter its position The arrested barium then looked
like a solid mass with a very decided concave,
U shaped termination. The boy was operated on
immediately and an ileocolic intussusception about
three inches long was found and reduced. A long
appendix which was engaged in the tumor mass was
removed. Recovery was prompt. The illustration
presented and the wet specimen which was exhib-
ited showed the loose approximation of the external
and middle layers of the intussusception. If barium
enemata had been observed under the screen in a
case of intussusception the mass would have been
observed filling up the bowel until arrested by the
intussusception, and a small amount would have
passed for a longer or shorter distance between the
intussusceptum and the intus.suscipiens. The
shadow made by the thin layer would have been
appreciably different from that made by the dense
mass and the end of the column would have been
S shaped.
6i8
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
Dr. Df.Witt H. Sherman, of Buffalo, stated that
he had shown x ray pictures at the annual meeting
of the Medical Society of New York State, one of
which was a subacute intussusception, and the same
state was shown as Doctor Wall had described. The
lumen through the intussusception was very narrow
and operation was advised. This the mother re-
fused, and the interesting feature in this case was
that the child passed part of the contents of the
bowel in a week or ten days after leaving the hos-
pital. The child had since progressed normally.
Dr. Langley Porter, of San Francisco, sug-
gested that it might be a good procedure to give a
child suspected of having an intussusception a ba-
rium enema and place it under the fliuoroscope and
then with hydrostatic pressure, with the hips well
raised, to attempt to reduce the intussusception by
the original Hirschsprung technic. So far as he
knew this had not been done and might be tried
before resorting to operation.
Congenital Cardiac Disease. — Dr. Charles
Hunter Dunn, of Boston, reported these cases.
He stated, that the first case occurred in a baby, two
months old, showing a symptom complex of systolic
murmur, thrill, and cyanosis. No enlargement of
the heart was revealed by percussion or by the x
ray. The x ray plate showed but one ventricular
cavity and one auricular, ventricular orifice. Tlj^
large vessels opened into this one ventricle. Search
was made for the aortic valve, which was found
above and in the wall of the ventricle. A rudi-
mentary ventricle was found in the wall of the large
ventricle.
The second patient was a baby three months of
age. In this instance there was a systolic murmur,
but no palpable thrill and no evidence of enlarge-
ment. The lips showed cyanosis but there was not
a proportionate cyanosis of the extremities. No ac-
curate diagnosis was made. At autopsy an anomaly
of the great vessels was found — a complete trans-
position. This was not an extremely uncommon
condition. In this instance the aorta divided into
two branches and the pulmonary artery into three
branches.
Dr. William P. Northrup, of New York, stated
that forty years ago he had presented a case of
transposition of the trunks of the great vessels and
he would now like to call attention to a case that
he had followed for many years. It was not often
that one had the opportunity of following a congeni-
tal heart condition until the patient was graduated
from high school. The case was a typical one with
a narrowed pulmonary orifice and incomplete ven-
tricular septum. Doctor Northrup said that he had
performed many autopsies and always found a nar-
rowed pulmonary orifice with this condition. The
girl died from a condition not connected with the
heart anomaly, and at autopsy, aside from the nar-
rowed pulmonary orifice and the incomplete ven-
tricular septum, there was no abnormal condition in
the heart.
Tuberculous Meningitis. — Dr. De Witt H.
Sherman, of Buffalo, reported a case of tubercu-
lous meningitis in a breast fed infant ten weeks of
age. He said that his patient had been normal un-
til its last illness. The child had never been on
the street and the family history was negative as to
tuberculosis. The child had never received any
food but breast milk and the little water it was given
was boiled. The illness began with mild convul-
sions, resembling hiccoughs, and lasting about a
half a minute. On the third day the child developed
ptosis of the right eye, which was not constant.
When the writer saw the child on the third day of
its illness, the pupil of the ptosed eye was larger
than that of the left eye and the pupillary reaction
of both was sluggish. There was some bulging of
the anterior fontanelle, slight rigidity of the neck,
doubtfully exaggerated patellar reflexes, and the
child could be aroused but made no further re-
sponse. All the other signs and symptoms of
meningitis were wanting. Lumbar puncture was
done and three guineapigs were inoculated. The
findings in the three animals were practically the
same, showing extensive tuberculous involvement
of all the visceral organs. The guineapigs all died
in from six to less than nine weeks after the inocu-
lation. From the extent of the tuberculous infec-
tion of these pigs the fluid must have contained
great numbers of bacilli.
Vaccination Case with Vascular, Joint, Muscle,
and Skin Disturbances. — Dr. Richard M. Smith,
of Boston, reported this case, which occurred in a
child four years and a half of age. The family and
personal history were negative. After vaccination
against smallpox the child had a very violent reac-
tion. A few days after the reaction subsided, the
face became swollen and red, and she complained
of stiffness when she bent her knees. These symp-
toms progressed until the joints in the body were
involved, including the spine. The muscles felt as
if they were in a clonic state of contraction. There
had been conjunctival hemorrhages and the mucous
membrane about the teeth was red, edematous, and
in spots hemorrhagic. The skin almost everywhere
on the body showed blotchy erythema, resembling
Raynaud's disease, and a brawny induration. In
some portions there was slight edema. The lesions
of every kind were absolutely symmetrical, even to
the erythematous blotches on the finger tips. The
hair was rather coarse and abundant even on the
upper portion of the back and arms. The child be-
fore the onset of symptoms was cheerful and
happy, but since the reaction had begun she had be-
come very tearful and quiet. The x ray had re-
vealed in the subcutaneous tissues a curious irreg-
ular striation unlike anything with which the writer
was familiar. The etiology of this condition was
extremely doubtful. The writer was inclined to
think that the vaccination had nothing to do with
it, and in this opinion the mother concurred, a fact
worthy of note. Possibly some toxic agent had
affected the glands of internal secretion. No focus
of infection had been found. The skin condition
might be primary and everything else secondary to
it. The most probable diagnosis seemed to be dif-
fuse scleroderma. No treatments had modified the
course of the disease in any way.
Dr. Henry Koplik, of New York, reported a
case, exactly similar to the one just reported by
Doctor Smith, that had occurred in his service at
the Mount Sinai Hospital. Some doctors who saw
October 5, igiS.]
LETTERS TO THE EDITORS.
619
the case thought it was a diffuse scleroderma, but
it was found to be a condition described by Doctor
Oppenheimer as a neurodermomyositis. The con-
dition was very rare. The general disease was not
a skin disease, but the skin was affected in common
with other structures. In this case there was gen-
eral atrophy of the muscles and a marked eosino-
philia.
Dr. A. H. Bf.ifeld, of Chicago, asked if these
patients had itching of the fingers, edema of the
distal phalanges of the fingers and toes with des-
quamation, alopecia or photophobia. He said he
haci seen six cases of a similar condition, but they
had been still more severe. Doctor Smith, in reply
to the questions, said that the child had no great
amount of itching and no desquamation except
under the arm and on the extreme finger tips and
the tips of the toes. There was no eosinophilia.
There must be some toxic agent at work, but it was
a question whether it acted directly or whether it
affected the various structures of the body by acting
through the glandular system. Glandular extracts,
esrecially pituitary, had been tried.
Preliminary Report on the Use of Vegetable
Milk. — Dr. Henry Dwight Chapin and Dr. Lud-
wiG Kast, of New York, presented a preliminary
study of a milk prepared from almonds which they
stated had certain advantages from both theoretical
and practical standpoints. Its theoretical advan-
tages were: i. It fermented much less readily than
ordinary cow's milk. 2. It had a higher fat ration
in the form of almond oil, which was sufficiently
emulsified to render it easily digestible. 3. The
proteins contained m this milk were much less apt
to undergo putrefaction than the casein of cow's
milk. 4. Almond milk contained a large amount
of phosphorus and a small quantity of sodium chlor-
ide, which would suggest its favorable employment
in such conditions as rickets and nephritis. From
its \o\\' carbohydrate content it could be readily seen
that it would be useful in various sugar fermenta-
tions. On the practical side it had been tried on
more than 1,000 adults by Doctor Kast, and while
some disliked it, actual disturbances had never been
caused by it. So far, no patient had shown an
idiosyncrasy to it. Patients kept on almond milk
alone maintained their equilibrium of metabolism
and usually gained in weight. It was particularly
well taken in the following conditions, and served
a good purpose : nephritis, typhoid fever, intestinal
putrefaction, malnutrition, and secondary anemia.
This preparation was rich in vitamines. While they
did not recommend its permanent use, it was desir-
able a? a temporary substitute.
A Child with Transposition of Viscera. — Dr.
Howard C. Carpenter reported this case, which
was that of a seven months, premature infant,
whose birth weight was estimated at three pounds.
He had had pertussis and measles, and an operation
for hypertrophied tonsils and adenoids. Since the
age of five years his nutrition had been subnormal.
He was at present eight and one half years of age
and weighed fifty-five and one half pounds. The
left side of t^je chest anteriorly was more prominent
than the right. The apex beat was visible in the
sixth interspace in the midclavicular line. Cardiac
•dullness extended 7.5 cm. to the right of the mid-
sternal line and four cm. to the ieft, and began
above in the second interspace. The muscular
quality of the first sound was good. A faint blow-
ing systolic murmur was heard all over the heart
area, but loudest at the apex. The pulse averaged
100 to 110, and after exercise, 140. The liver was
on the left side, the upper border being at the sixth
rib in the left midclavicular line, and the lower
border extending one cm. below the edge of the ribs
on the same side. The spleen was on the right side.
The X ray after a test meal showed the stomach
on the right side.
The Energy Metabolism in Amaurotic Family
Idiocy. — Dr. Fritz B. Talbot, of Boston, stated
that the diagnosis of amaurotic family idiocy was
made by finding the cherry red spot in the eye both
by the ophthalmoscope and at post mortem. The
child was two years and four months old. Its me-
tabolism was obtained in the apparatus of the nu-
tritional laboratory of the Carnegie Institution of
Washington in Boston, under the direction of Dr.
G. E. Benedict. The basal metaboHsm was found
to be very low in comparison with that of a much
younger, although normal, infant of the same
weight. The metabolism was also compared with
that of normal infants of the same age, and was
found extremely low.
(To be continued.)
<t>
Letters to the Editors.
PRODUCTION OF ANTIEMBRYONIC BODIES AS
A CURE FOR CANCER.
Cumberland Valley, Pa., August 19, igi8.
To the Editors:
I want to thank you for publication of my article on the
thyroid gland in the number appearing August 17, 1918.
I was also much interested in a review appearing under
Modern Treatment and Preventive Medicine entitled
Serum of the Normal Pregnant Woman in Treatment of
Pernicious Vomiting, recounting successful experiments
of Romulo Melgar (La Cronica Med., Lima, Peru, March,
I9r8).
These results absolutely confirm my theory of eclampsia.
In Medical Record, New York, February 24, 1917, p. 336,
under the caption, Is Eclampsia an Anaphylactic Phenom-
enon? I made the statement that "the mother's failure to
form antibodies for the toxic excretions of the fetus is
causative of the trouble." Where, I ask, could she get
these antibodies? From a normal pregnant woman, of
course.
To further quote from my article : "Abderhalden has
proved in his test for pregnancy that an antiembryonic re-
action is present. If this antiembryonic body fails to be
formed, we have an intoxication. In the metamorphoses
of the fetus there results a dissociation of embryonic cells
as well as their formation; these excretory products are
toxic, and the mother must be protected by alexins or
form an antibody to these products. When these anti-
bodies are not formed the result is eclampsia. Alexins will
take care of her perhaps for a time, but she must sooner or
later form antibodies."
With regard to this theory, J. Whitridge Williams, who
has done so much work upon eclampsia and, I believe,
first called attention to the ammonia coefficient and urea
content of the urine of eclamptics, wrote me:
"I was much interested in your theory and will bear same
in mind upon suitable occasions."
Doctor Melgar has now practically proved this theory
correct. Because undoubtedly many cases of pernicious
vomiting are but mild evidences of eclampsia. I have
seen the tugging of a Fallopian tube upon an adherent ap-
pendix (as the womb enlarged) caUse intractable vomit-
ing during pregnancy, and there may be many other causes ;
620 BOOK REVIEWS.— BIRTHS, MARRIAGES. AND DEATHS. [New York
Medical Joornal.
but true pernicious vomiting, according to my theory and
Doctor Melgar's work, are cases of anaphylaxis — lack of
protection against toxins of the fetus — embryotoxins.
Another theory of mine, the Endocrinopathic Em-
bryotoxic Anaphylactic Theory of Malignancy, read be-
fore the Medical and Chirurgical Faculty of Baltimore and
published in the Virginia Medical Semimonthly, September
24, 1914, embraces practically the same claim. "Waning
of internal secretions, or disturbance of their normal bal-
ance, lessens the power of holding in control embryonic
tissue. The lack of power to form antiembryonic bodies
permits intoxication (cachexia) and permits disordered cell
multiplication, these cells in many cases being atypical or
atavistic, and therefore abnormal and toxic."
The Abderhalden test proves that in cancer an antiem-
bryonic body is present (because cancer and pregnancy
are fallacies). This is certainly plain. But I contend
that this is only during the first or operative stage of ma-
lignancy. These antibodies help to complete the work of
the surgeon and radiographer. Later on no antibodies are
formed ; then we have anaphylaxis and hopeless, inoperable
malignancy. Cancer, eclampsia, and pernicious vomiting
of pregnancy, are all embryonic intoxications for which no
antitoxin is formed. Malignancy is a more gradual pro-
cess than eclampsia. The symptoms therefore are not as
acute.
In suggesting a cure for cancer {Medical Council, Jan-
uary, 1918, and Medical Council, March, 1918) I gave two
methods: i. By stimulation of antitoxic formation during
first stage. 2. By furnishing, during second stage, anti-
bodies from another host in whom antitoxin formation
had been stimulated. In the latter treatment for hopel,ess
malignancy two methods were mentioned: i. Using the
blood of a normal pregnant woman. 2. Injecting into the
person of some volunteer desiccated placental tissue; draw-
ing off the blood after the antibodies had formed and in-
jecting it into the cancer case.
Cary, of Chicago, was able to dry up the living ova in
the womb of animals by injecting placental tissue (desic-
cated). He also was looking for a treatment for pernicious
vomiting of pregnancy. His experiments proved that he
must use, as I suggested in the case of cancer, some other
person in whom to generate his antibodies. If he injects
desiccated placenta into one already overpowered by em-
bryotoxins he would simply increase the toxemia. The
fact that he dried up the living ova in the womb in normal
pregnancy shows that he simply stimulated overproduc-
tion of antiembryonic bodies to such a degree that no em-
bryonic tissue could survive.
Herein lies the secret of a cure for cancer.
L. J. SiMONTON, M. D.
$
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we revieiv those in which we think
our readers are likely to be interested.']
Invertebrate Zoology. By Oilman A. Drew, Ph. D., As-
sistant Director of the Marine Biological Laboratory,
Woods Hole, Mass. With the aid of former and present
members of the Zoological Staff of Instructors. Second
Edition, Revised. Philadelphia and London : W. B.
Saunders Company, 1918. Pp. x-214.
A second edition of this practical short manual
of invertebrate zoology has been demanded and there
are many reasons why this is so. It is short, it is
authoritative, it deals with the best known types of
lower animals and presents an excellent scheme for
their systematic study. It must be recalled that it
is a laboratory manual and not a text book, nor
yet an authoritative monographic presentation of
this branch of zoology, but a practical series of ex-
ercises and suggestions on how to study these groups
of animals.
The Hospital as a Social Agent in the Community. By
Lucy Cornf.i.ta Catlin, R. N., Director of Social Service
Work and Executive Director of the Out-Patient De-
partment, Youngstown Hospital, Ohio. Illustrated.
Philadelphia and London : W. B. Saunders Company,
1018. Pp. 113.
Apparently some are not fully convinced of the
efificacy and necessity of social service in the hos-
pital. To these Miss Catlin addresses her book.
Her material is well arranged and logically pre-
sented and her case histories are telling. The book
rings with the enthusiasm and faith that actual
experience and success give. She has successfully
and convincingly demonstrated the medical and so-
cial relation and the mtricacy and interdependence
of hospital work and charity, the law, industry,
public health, etc. Miss Catlin has a clear and in-
telligent conception of the place of social service
in the hospital and in general writes pleasingly. A
good feature is the multiplicity of examples to prove
almost every point she makes; this leaves doubting
Thomas without a leg to stand on. Who can refuse
the evidence of Rosie and Josie and Jackie and
Jakie, of their actual intimate histories with por-
traits on the facing page? The book is slightly
contaminated with piety and sentimentality ; we can
almost detect an evangelical selfsatisfaction. "Hu-
man interest" oozes a little from the pages. There
is no doubt that the author is a successful social
service worker ; at times we suspected that she was
more successful as a worker than as a writer.
^
Births, Marriages, and Deaths.
Died.
BucKLKY.— In South Boston, Mass., on Thursday, Sep-
tember 19th, Dr. Philip Townsend Buckley, aged sixty-five
years.
Cannon.— In Poultney, Vt., on Saturday, September
2ist, Dr Mott D. Cannon, of New York, aged sixty years.
Hendryx.— In Allentown, Pa., on Saturday, September
2ist, Dr. Will iam A. Hendryx, aged sixty-nine years.
HoERMANN.— In Milwaukee, Wis., on Sunday, Septem-
ber 15th, Dr. Ferdinand Bernard Hoermann, aged seventy-
four years.
Holmes.— In Allerton, Mass., on Thursday, Setember
19th, Dr. Edgar Miller Holmes, of Boston, aged fifty years.
Kaletsky.— At Fort Hamilton, New York, on Saturday,
September 28. 1918, Lieutenant C. Myron Kaletsky, M. R.
C, U. S. Army, aged twenty-seven years.
KiNNiER. — In Dubuque, la., on Monday, September 8th,
Dr. William H. Kinnier, aged seventy-four years.
Lewis. — In France, on Wednesday, August 28th, First
Lieutenant Sidney Pearson Lewis, Field Ambulance Corps,
U. S Army, of Jersev City, N. J.
Marvin.— In Washington, D. C, on Thursday, Septem-
ber 26th, Dr. Arthur Marvin, aged forty-five years.
Mathewson.— In Plainfield, N. J., on Sunday, Septem-
ber 22d, Dr. Charles B. Mathewson, aged sixty-five years.
ORnwAY.— In Everett, Mass., on Tuesday, September
24th, Dr. Charles A. Ordway, aged forty-four years.
Ryder. — In Newton, Mass., on Tuesday, September 24th,
Dr. Walter I. Ryder, aged twenty-nine years.
Stevens. — In Marlboro, Mass., on Wednesday, Septem-
ber i8th, Dr. Ralph Emerson Stevens, aged forty-eight
years.
Tuck. — In Roxbury, Mass., on Thursday, September
19th, Dr. Liicy W. Tuck, aged ninety years.
Ware.— In New York, N. Y., on Sunday, September 29th,
Dr. Edward J. Ware, aged sixty years.
Whtdden. — In Boston, Mass., on Wednesday, September
25th, Captain Rae W. Whidden, M. R. C, U. S. Army,
aged thirty-three years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1843.
Vol. CVIII, No. 15. NEW YORK, SATURDAY, OCTOBER 12, 1918. Whole No. 2080.
Original Communications
BACTERIOLOGY AND POSSIBILITY OF
ANTIINFLUENZA VACCINE AS A
PROPHYLACTIC.
By William H. Park, M. D., '
New York,
Director of Laboratories, Dtriiartnu-nt of Health of the City of
New Yoric.
At the first, when we realized the presence of the
so called Spanish influenza among us, the question
which arose in the minds of all investigators was
whether it was due to a new and virulent strain of
Pfeif¥er's bacillus, or whether some unknown organ-
ism, perhaps a filterable virus, was the infecting
agent which first started the disease and paved the
way by lowering resistance and by the changes it
produced in the mucous membrane for later com-
pHcating infections due to the influenza baciUi, vari-
ous strains of streptococci, and various types of
pneumococci.
As the investigations have proceeded in Boston,
New York, and elsewhere, it has become more and
more probable that the primary cause of the disease
is the influenza bacilli and that the complicating in-
fections, due to the streptococci and pneumococi, are
superimposed. It is fair to assume that the strain of
the influenza bacillus responsible for this epidemic is
an especially virulent one differing somewhat from
the strains previously in our midst. The streptococci
and pneumococci may be communicated from the
sick with the influenza bacilli or they may have been
present for some time before the attack.
With our present technic we have found the in-
fluenza bacilli in almost every case of clear cut infec-
tious influenza. In the complicating pneumonias,
we have found them associated x^'ith either the
streptococci or pneumococci. In one case the
bronchopneumonia was due entirely to the influenza
bacillus. Our results, in fact, have closely agreed
with those reported from the United States Naval
Hospital at Chelsea, Mass., by Dr. J. J. Keegan, in
the Journal of the American Medical Association,
September 28, 1918.
The cukural work in the Health Department Lab-
oratory has been carried out by Dr. Anna W. Wil-
liams and her assistants.
The fact that the disease seems to be primarily
due to the influenza bacillus, and that this is known
to develop antibodies in infected animals suggested
the use of a vaccine. In an epidemic only one strain
of the specific bacteria is usually met with. This
fact suggested the use of an influenza vaccine made
from a strain from the present cases. This is pre-
pared in the usual way from cultures by washing
the bacilli ofif in salt solution and subjecting the
fluid to la moderate heat so as to kill at the low-
est possible temperature. We are trying to test this
vaccine out in a large way by giving it to only a
limited number of persons in corporations employ-
ing many workers and among the troops in several
camps, so that we may soon be able to tell whether
protection is given or not. Undoubtedly, others
are also attempting to test similar vaccines in dif-
ferent parts of the country. We should, therefore,
in a very few weeks have on hand sufficient in-
formation to form some decision as to the protec-
tion afiforded by the vaccine.
At present, the dose is being given in three in-
jections at two day intervals in quantities of one
half billion, one billion and two billions. The local
and general reactions are usually very slight. The
Health Depaj^tment Laboratory is furnishing the
vaccine in New York city free to those physicians
who will promise to give information in writing as
to the number of persons injected and their later
history so far as this concerns influenza. As the
pneumonia seems to be only a complicating infec-
tion it seems best to test out a pure influenza
vaccine rather than one of a mixture of cocci and
bacilli. It is not probable that any appreciable im-
munity will develop in a period of less than five days
and probably not much before ten to fourteen days.
If cases of suspected influenza develop in those who
have taken the vaccine it would be very interesting
to have cultures made to discover whether influenza
bacilli are present. The cultures should be made
by swabbing the nasopharynx and tonsils.
A NOTE ON THE PATHOLOGY OR THE
PREVAILING PANDEMIC INFLUENZA.
By Douglas Symmers, M. D.,
Professor of Pathology in the University and Bellevue Hospital
Medical College, Director of Laboratories. Bellevue
and Allied Hospitals.
The naked eye and microscopic changes in the
several organs of persons dead of the so called
Spanish influenza combine to form a picture which
merits the attention of the pathologist as diifering
in certain particulars from that encountered in the
commoner acute infections of the respiratory tract
in this climate. Most strikingly is this true of the
lungs, in which the changes produced by the pre-
622
SYMMERS: PATHOLOGY OF PANDEMIC INFLUENZA.
[New York
Medical Journal.
vailing pandemic influenza are not only different
from those of the septic pneumonias as famiharly
revealed by postmortem examination, but tliey con-
stitute a composite which, in a certain group of
cases at least, is constant and characteristic.
Whether the same changes in the lungs are present
in all cases of influenzal pneumonia must be de-
termined by more extensive observations. The
pathological changes to be described in this note are
based on the naked eye and microscopic study of
fifteen cases investigated post mortem at the Will-
ard Parker and Bellevue Hospitals.
All of the fifteen subjects were well nourished
and the excellent muscular development invariably
occasioned astonishment that those so sturdily en-
dowed should succumb so rapidly to infection.
Moreover, all were between twelve and thirty
years of age. Two were negroes. Four of the seven
male subjects presented the bodily configuration of
status lymphaticus — narrow waisted with arching
thighs, beardless face, small axillary fat pads with
scanty hair upon them, pubic hairs sharply defined
in a transverse direction and skin of almost match-
less delicacy — together with which there were con-
firmatory signs of hyperplasia in the lymphoid de-
pots of the deeper parts, notably in the follicles of
the spleen. Six of the fifteen subjects were dis-
tinctly although not deeply jaundiced.
On opening the body one's attention was immedi-
ately fixed by the raspberry red color of the skeletal
muscles and their unusual dryness. In two cases
the rectus muscles were the seat of Zenker's
degeneration. In another case there was a large
nontraumatic extravasation of blood into the
intercostal muscles. With the exception of two
cases the pleural cavities were free *from patho-
logical accumulation of fluid and the pleural mem-
branes were devoid of all suggestion of exudate.
The lungs, as a rule, met or even overlapped in the
middle line in such fashion as partially or com-
pletely to obscure the precordial area. The naked
eye appearance of the lungs was distinctive, so
much so that, in one case investigated by Dr. Ben-
jamin Schwartz, of the medical examiner's office,
the diagnosis of confluent influenzal lobular pneu-
monia was made on the naked eye appearance alone,
and it was later ascertained that the clinical feat-
ures had been those of a typical attack of Spanish
influenza. In all of the fifteen cases both lungs
were involved, the lower lobe to a much greater ex-
tent than the upper. In fact, one can scarcelv evade
the conviction that in the pneumonia of so called
Spanish influenza the sequence of events is that the
infective microorganisms, acting first and practically
simultaneously upon the lower lobes of both lungs,
cause a rapidly confluent variety of lobular exuda-
tive pneumonia attended by changes in the vascular
structures marked by the escape into the alveoli of
variable numbers of red cells and quantities of blood
serum, either independently of one another or in
combination. For some reason fibrin is not de-
posited in the alveoli and only rarely, in my experi-
ence, on the pleural surfaces. The lower lobes are
a characteristic deep slate blue color and are almost
completely consolidated, the edges as a rule escap-
ing solidification only to undergo compensatory em-
physematous changes. Here and there hemorrhages
are visible, either in the pleura or in the substance
of the lung, and they lend contrast to the surround-
ing tissues. In the pleura the hemorrhages are usu-
ally small and petechial. In the pulmonary sub-
stance the hemorrhages vary from the size of one's
thumb nail to extravasations of considerable dimen-
sions. The surface of the lung is further mottled
by scattered numbers of slightly elevated pinkish
patches in which emphysematous air vesicles are
discernible as minute beadlike bodies. The cut sur-
face presents a deep bluish appearance and is re-
markably smooth, not a trace of fibrin revealing it-
self bv touch or sight to mar the velvety quality of
the solidified pulmonary tissues. Close inspection,
however, often reveals innumerable minute grayish
specks which, upon microscopic examination, are
found to correspond to alveoli filled by polynuclear
leucocytes. Occasionally are to be seen larger or
pinhead sized, grayish bodies corresponding, micro-
scopically, to miliary abscesses. The consolidated
tissues are easily lacerated, and pressure releases
huge quantities of blood tinged, frothy serum, or
even semipurulent fluid. The cut ends of the smaller
bronchi may be distinguished by the escape from
them of droplets of pus or of air bubbles suspended
in serum. The mucosa of the trachea and of the
larger bronchi is richly bathed in frothy serum, and
is swollen, deep bluish or bluish red in color, and
velvety in appearance. In some instances semide-
, tached flecks of grayish pseudomembrane are to be
seen lying on the bronchial mucosa. Microscopic ex-
amination of the larger bronchi shows marked con-
gestion of the wall and occasional collections of
polynuclear leucocytes, and desquamated epithelium,
with or without an admixture of red cells, lying on
the mucosal surface. The lymph nodes at the hilum
of the lung are grouped to form clumps of con-
siderable size. On section each node presents a
swollen, opaque, bluish red surface. Microscopic
examination of the lymph nodes shows intense hy-
peremia and edema.
The upper lobe of the lung presents a somewhat
different phase of the same process. The upper
half or third is made up of pinkish tissue showing a
surprising degree of emphysematous dilatation of
the air vesicles. For example, in one case emphysema
of the upper reaches of both upper lobes was so
marked that a crackling sensation was imparted to
the palpating finger through the skin covering both
supraclavicular spaces. I am told that this phenom-
enon is not uncommonly observed during life. The
lowermost portions of the upper lobe, on the other
hand, are occupied by large and small, bluish or
bluish red patches corresponding in every essential
to ihe consolidated lower lobes as already described.
These patches, however, lie in immediate proximity
to feathery areas of emphysema or to slightlv firmer,
pinkish, or reddish foci which correspond, micro-
scopically, to air vesicles containing coagulated
blood serum or a mixture of red cells, polynuclear
leucocytes and serum, or even pure blood. In other
words, the process of solidification can be followed
in the upper lobes step by .step, since it is here that
the pneumonic changes are least advanced.
From this description it has been made evident, I
October 12. 19.8.1 SVMMERS: PATHOLOGY OF PANDEMIC INFLUENZA. 623
think, that the pneumonic process in this group of
fatal cases of Spanish influenza is by no means
identical with the pneumonias of sepsis or with
croupous pneumonia. That variations of type will
be developed by further experience is to be expected.
The bilateral distribution of the lesion as thus far
observed, the early and almost complete involvement
of both lower lobes, the almost unfailing absence of
pleural exudate, the characteristic deep blue slate
color of the older areas of consolidation, the patches
of acute emphysema, the presence of numerous
hemorrhages, the smooth, almost velvety appearance
of the cut surface of the consolidated portions, and
the total absence of fibrin in the alveoli bespeak a
variety of pneumonia which is foreign to the com-
moner findings of the autopsy room. The difiference
is furthermore emphasized by the physical signs
which, I am told, in the pandemic influenza now
prevailing, are subject to exceedingly rapid muta-
tions, first manifesting themselves as scattered
patches of consolidation followed in a comparatively
few hours by signs of dif¥use involvement of the en-
tire lobe — clinical findings which are readily and
with complete satisfaction explained by the nature
and distribution of the anatomical changes in the
lungs.
The heart muscle is apparently well preserved,
except for congestion. In most cases, however, the
right side, more especially the auricle, is distended
by deep bluish black flui4 and clotted blood.
The kidneys are increased in size, reddish or
bluish in color, the capsule is tense and strips easily,
leaving a somewhat lustreless, injected surface, the
substance bulging noticeably beyond the cut edge of
the capsule. The renal parenchyma is easily lacer-
able. Cortex and medulla are well dififerentiated and
well proportioned, although the cortex appears to be
somewhat broadened. The cortical markings are
distinct, particularly the glomeruli, which stand out
as a profuse sprinkling of reddish, sandlike bodies.
Microscopic examination of the kidney shows the
presence of widespread cloudy swelling of the epi-
thelium, most noticeable in the convoluted tubules.
The cells are swollen and granular and their nuclei
obscured. The lumina of the larger tubules are in-
variably occupied by granular debris. The capilla-
ries are universally and deeply injected. The
glomeruli are enlarged and intensely hyperemic.
The cells lining Bowman's capsule show swelling and
granular disintegration with obscuration of the
nuclei and exfoliation of structureless debris into the
interval between capsule arjjd tuft.
Whether the degenerative changes in the kidney
precede or follow the pulmonary lesions is, of course,
impossible to determine on anatomical grounds.
However, in view of the urinary changes so com-
monly encountered in influenza patients who pass
through the disease without evincing pneumonic
signs, it would appear that the alterations in renal
structure are to be ascribed primarily to the toxemia
of the influenzal infection rather than to the efTect
of secondary factors as represented by the pneu-
monia. Since the changes in the kidney are those
with which every pathologist is familiar as revealing
degenerative processes consequent upon the elimina-
tion of toxic products, therapeutic measures should
be adopted, first, to facilitate the uninterrupted
passage of blood through the kidney, and, second, to
sweep the tubules free of debris resulting from the
destruction of the lining cells. In this connection
it may be remarked that, in the prevailing epidemic
of influenza, delirium is a frequent symptom and
that postmorten examination shows widespread
edema and congestion of the leptomeninges —
changes which are comparable to the autopsy find-
ings in certain other delirious states. I think it not
unreasonable to hope that any therapeutic measure
which would promote the excretion of toxic pro-
ducts through the kidneys would also tend favorably
to influence the meningeal changes and in this way
to combat delirimn. However fanciful this concep-
tion, certain it is that the renal changes in pandemic
influenza should not be ignored in the treatment.
In a small percentage of all cases of pneumo-
coccal lobar pneumonia a slight degree of icterus is
to be noted. In some cases the jaundice is so slight
as to be overlooked during life, becoming apparent
only upon inspection of the heart valves at the time
of autopsy, more especially in the pulmonary leaf-
lets. In other cases icterus is manifested by slight
greenish yellow discoloration of the conjunctivfe.
In still other cases the skin of the face, neck, and
upper portions of the chest are discolored. In the
present epidemic of influenza in New York city
jaundice was noted in six of the fifteen subjects
encountered post mortem at the Willard Parker and
Bellevue Hospitals. Investigation of this feature
has .shown that the mucous membrane of the du-
odenum is deeply congested and swollen and that
the exit of bile through the papilla of Vater is im-
peded to an extent sufficient, in part at least, to ac-
count for its retention in the bile capillaries and
liver cells. Moreover, microscopic examination has
shown that the liver cells are in such an advanced
state of cloudy swelling that the bile capillaries are
obstructed, the bile accumulating in the cells as
greenish particles.
In five of the fifteen cases of fatal influenza the
spleen was normal in size, in seven cases it was
slightly increased, and in the three remaining in-
stances it was distinctly enlarged, once to the extent
of 320 gm. In most of the cases the organ was deep
slate blue in color ; there was, in fact, a strong resem-
blance between the color of the spleen as viewed
through the capsule and that of the lung as seen
through the pleura. On section the substance of the
spleen was plentiful and deep bluish red in color,
friable rather than grumous — in which regard the
consistence differed markedly from the spleen of
sepsis as commonly observed — and the follicles were
unusually small but numerous. In two cases the
follicles were not only numerous but greatly en-
larged, some of them fusing to form bodies the size
of a split pea. Microscopically, the blood sinuses
were found to be universally engorged.
Finally, it may be noted that, in two of the fifteen
cases, tlie mucous membrane of the intestine was
intensely injected. Doubtless changes of this sort,
followed bv the diapedesis of red cells, are responsi-
ble for the blood which is occasionally to be found
in the feces during life.
338 East Twenty-sixth Street.
624
CLINICAL ASPFXTS OF INFLUENZA.
Clinical and Therapeutic Observations of Cases of
the Prevailing Epidemic at the Willard Parker
Hospital.
By Henry W. Berg, M. D.,
New York,
Attending Phvsician to the Willard Parker Hospital,
and Jesse G. M. Bullowa, M. D.,
New York,
Associate Attending Pliysician to the Willard Parker Hospital.
We have treated and had under our medical ob-
servation in the hospital over 500 cases of influenza,
known in this epidemic as Spanish influenza.
While the records at our disposal, owing to the lack
of a sufficient number of medical interns, have not
been ?s ample as is desirable, yet the cases have
been well observed by the attending and medical
resident staffs, and sufficient facts have been gath-
ered to enable us to formulate many of the essential
characteristics of the cases in this epidemic as dis-
tinguished from previous epidemic and endemic
cases of influenza which we have observed. Almost
all of our cases have been in young naval men,
mostly sailors under thirty years of age. They were
of exceptionally good physique and suffering from
no other maladies except influenza and its compli-
cations. Most of these patients entered the institu-
tion about three days after the onset of the disease
and some few were earlier, so that we were able to
mcke observations in the early stage.
It will facilitate the description of the bedside
symptoms to classifv the cases from a purely clinical
standpoint into three groups: i, the cases of pre-
dominating inflammatory disturbance of the upper
respiratory tract ; 2, those with predominating pre-
liminary symptoms : and, 3, those in which the con-
stitutional toxic symptoms are the predominating
factors.
Toxic manifestations were in fact present in the
first and second groups also to a greater or less
extent, but the third class is intended to include
those in which toxic manifestations out of. all pro-
portion to the throat or lung symptoms existed, so
that these toxic constitutional symptoms presented
the most obvious and serious clinical features.
There are. of course, in this pandemic disease,
symptoms that are present in all the cases to a
greater or lesser extent. These symotoms are chills
or chilly sensations, fever, prostration, pains
throughout the body and limbs, headache, rhinitis,
conjunctivitis, and cough. These symptoms are
present in many cases of influenza and have been
present in most cases in this epidemic.
In Spanish influenza, however, the patients have
described a peculiar "pain" or feeling of distress
below the lower sternum and above the diaphragm.
This pain is one that is not increased on external
pressure over the xiphoid and yet the maximum
severity point of its location is underneath the mid-
sternum. The pain is not sharp and cutting but
extremely distressing and burning. Deep inspira-
tion does not increase it ; the patient moans on ac-
count of it ; he never fails to mention it. It reminds
one of the deep, abdominal pain in Asiatic cholera.
[New York
Medical JoirRN.\L.
and one of the authors (Berg) has thought that
its pathogenesis is probably in the sympathetic
nervous system, while the other ( Bullowa) is of^the
opinion that it is due to the congestion of the
mucosa of the trachea and bronchi.
All three types of cases which we shall describe
have this pain, though with varying severity. The
headache is uniformly in the frontal region (fore-
head) and upper anterior part of the skull. It re-
sembles very much the headache of typhoid fever.
The headache and cough are responsible for most
of the sleeplessness. The headache is not accounted
for by the high temperature, for many patients with
only a slight rise of temperature have severe head-
ache. This headache is increased during the act of
forcibly flexing the head upon the sternum. The
headache is present even when there are few symp-
toms of catarrhal rhinitis and pharyngitis. The
headache may be associated with somnolence or in-
somnia. In this epidemic a great many patients have
very little rhinitis, conjunctivitis or pharyngitis, the
catarrhal symptom complex being absent or very
slight, and yet severe headache is present.
The fever curve in an uncomplicated case is fairly
constant in its general course. For example, in a mod-
erately severe, uncomplicated case of the first group,
with predominating inflammatory disturbances of
the upper respiratory tract, the temperature on the
first dav following the chill may attain 103° F.
After a slight fall during the night, the second day
will show a temperature of 104°, on the third day a
drop to 103°, and then resolution by rapid lysis, the
temp'^rature on the fifth day falling to the normal
figure. Rarely, there is a drop to normal on the
third day by crisis or partial crisis ; this occurs only
in verv mild cases.
The complicated cases of bronchopneumonia and
lobar with bronchopneumonia show the usual septic
curve of that condition. The pulse in adults is rela-
tively slower and fuller than the high temperature
wo'.fld warrant. There is no dicrotism. In cases
complicated by bronchopneumonia this is also true
except that in cases terminating in death the pulse
increases remarkably in frequency twenty-four
hours before death.
The catarrhal affections of the upper mucous
membranes, that is to say, rhinitis, pharyngitis, ton-
sillitis and laryngitis, are very much less marked
than in ordinary endemic influenza or grippe. The
tonsils are not affected at all except that the mucous
membrane co\'ering them is slightly reddened.
Diphtheria we have not observed. The Klebs-
Loeffler bacillus is rarely present. The gland-
ular tissue of the tonsil is not thickened or enlarged
as a symptom of Spanish influenza, nor have we seen
follicular tonsillitis in these patients. The tonsils
cannot be felt by external palpation under the angle
of the jaws. In cases in which the tonsils have been
enlarged and protuberant before the attack of the
influenza, there is no increase in the size of the ton-
sils nor are the usual tonsillar follicular signs pres-
ent. When the throat in one of these cases of in-
fluenza is examined, there is found only redness and
slight edema of the uvula and fauces and redness
of the surfaces of the soft palate and pharynx. The
tonsils will be found buried between the anterior
BERG AND BULLOWA: CLINICAL ASPECTS OF INFLUENZA.
%
October ,2, ,918.] BERG AND BULLOWA: CLINICAL ASPECTS OF INFLUENZA.
625
and posterior faucial pillars. So true is this in these
cases that we believe that signs of an active tonsilli-
tis preclude the diagnosis of influenza of the type of
the present epidemic. Nevertheless, many cases ot'
ordinary tonsillitis (not diphtheritic) during the
present epidemic will be wrongly diagnosed as cases
of influenza. The prognosis of ordinary tonsillitis is
very much <t)etter than that of Spanish influenza.
One of the authors (BuUowa) has observed a dew-
like appearance of the posterior part of the hard
palate and of the soft palate.
Owing to the mildness of the involvement of the
nasopharyngeal nnicous membrane, these cases in
the present epidemic have shown remarkably few
complications in the ears, eyes, and the tracts lead-
ing to these special organs. We have seen almost
no cases of ethmoidal, sphenoidal, frontal or mas-
toid sinusitis (suppurative), or acute, inflammatory
disease in these cases. This is so at variance with
the history of cases of other epidemics of influenza
or in endemic cases that it is worthy of emphatic
remark. The experiences, however, while ample in
a number of cases, cover only one month in length
of time. It may be that these cases may show com-
plications in the bon}^ sinuses as sequelfe later on.
Very few of these cases have a barking or hoarse
cough. All the patients cough, but the cough is
bronchial, bronchovesicular, or pleuritic. Very
rarely is it laryngeal. Of 250 cases in two pavilions
at the Willard Parker, but three cases of laryngeal
cougi'i v.'ith hoarseness were observed.
What we have thus far stated gives the essential
features of the first group. The second group of
cases, those with predominating pulmonary symp-
toms, constitute a very important group. From this
class comes practically the whole death rate. These
have the symptoms of the first class together with
those of pulmonary involvement.
It is hardly right to call these pulmonary com-
plications because in many cases the pulmonary in-
fection is present at the very incipiency of the dis-
ease. It would almost seem as though the infection
had occurred in the mucous membrane of the finer
bronchi and lining membrane of the air cells, and we
have thought that the infection in ordinary grippe lo-
cates itself chiefly upon the upper respiratory tract,
producing inflammatory disturbances with occa-
sional cases of extension of the inflammation to the
lower respiratory tract and organs (bronchopneumo-
nia). In this epidemic it afifects but slightly the up-
per respiratory tract but passes down and infects di-
rectly the lining membrane of the capillary bronchi
and air cells, producing a more or less disseminated
bronchopneumonia. This view of the pathogenesis
looks upon the toxic phenomena as secondary to the
disseminated inflammation, disturbances in the re-
spiratory tract and pulmonary tissue. The pulmo-
nary involvements are very extensive and corre-
spendingly toxic. There is a disseminated broncho-
pneumonia, sometimes in isolated patches, in other
cases afi:'ecting whole lobes. In these pneumonias
the pneumococcus, strains III and IV, the bacillus
of Pfeifi^er and various strains of streptococci are
prominent as bacteriopathogenic factors. Pleurisy
is very frequent, giving rise to excruciating pains in
breathing and aiding the diagnostician and patient
in localizing some of the sites of the pneumonic
areas. Wherever the pleura in involved the under-
lying lung is affected. The pleurisy is occasionjully
accompanied by eft'usion which becomes purulent
very early in the course of the effusion, as shown by
exploratory aspiration. Fortunately, pleural effu-
sions and emphysemas are exceptional. One of the
authors believes that there are some .cases in which
an acute emphysema occurs as a toxic manifesta-
tion and shows itself by pscudodyspnea and pro-
longed expiration. The diagnosis of the pneumonia
is principally made by percussion, secondarily aided
and confirmed by auscultation. The pulse respira-
tion rate is not of much aid since the pulse is not as
rapid as is usual in pneumonia, especially in chil-
dren. The characteristic periilission signs, however,
will rarely leave one in doubt as to the localization
of the consolidation. The value of the auscultatory
•signs is limited, owing to rales being present to- a
greater or less extent even in nonpneumonic cases.
The auscultatory signs are of value to confirm the
percussion results of dullness obtained by percus-
sion over the consolidated areas. In pleural effusion,
in addition to the flatness and distant or absent
respiratory murmur, the occurrence of broncho-
phony and amphoric breathing are a great aid in the
diagnosis of these eft'usions when considerable in
amoimt.
The location of these pneumonias is generally at
the bases of the lungs, rarely at the apices, occa-
sionally at the scapulovertebral space on either side.
The posterior surfaces of the lungs are more apt
to be involved than the anterior. Entire lobes and
even an entire lung may be the seat of consolida-
tion. The temperature curve of these pneumonias
is septic in character. The pulse rate is not as rapid
as in pneumonia of a similar kind in other con-
ditions. The respirations rarely reach above 30 in
the adult, and even in advanced pneumonias the re-
spira*'ions are seldom above 40 to 44. Only cases
that are about to terminate in death reach a very
high respiration count, due to the extension of the
pulmonary edema. There is constant distressing
cough, with moist rales. There are herpetic erup-
tions on both upper and lower lips in many of these
influenza pneumonia cases although these also occur
occasionally in cases uncomplicated by pneumonia.
Delirium is frequent, sometimes alternating with
semicoma. There is frequently sleeplessness in other
cases alternating with the delirium.
The third class of cases are those with predomi-
nating toxic constitutional symptoms and is intended
to include a class of foudroyant cases of which we
have seen only two. One of these died on the sec-
ond day after entering the hospital. It was an in-
tensely toxic case with extensive pneumonia. We
are disposed to think that most of these cases of
influenza are cases of influenza pneumonia at the
very onset of the disease. In these cases it is likely
to assume that the site of entry of the infectious
cause into the body is at the capillary bronchi and
the air cells. Cases of influenza in which vomiting
and diarrhea are prominent factors are also properly
to be classed in this toxic group. This disease, hav-
ing a predilection for young adults — the kind of
patients who do not consider themselves sick until
626*
BASTEDO: THE TREATMENT OF INFLUENZA.
[New York
Mkdical Journal.
severely stricken — it is natural that such are pro-
foundly infected by the time the physician is called,
and show signs of extensive pneumonia or general
toxemia leading to early death.
DIl-FERENTIAL DIAGNOSIS.
it is necessary to differentiate cases of the first
class from those of ordinary follicular tonsillitis and
sore throat. We have already spoken of the absence
of tonsillar involvement in Spanish influenza. The
presence of large acutely inflamed tonsils with
follicular patches excludes Spanish mfluenza.
Some of these cases, on account of the headaches,
fever, and low pulse rate, may be mistaken for
typhoid fever in the iri|^tial stage. All the more so be-
cause there is, in both these diseases, when uncom-
plicated, a low leucocytosis. In influenza the leu-
cocyte count may be from 7,000 to 10,000, with
eighty-five to ninety per cent, of polymorpho-
nuclear cells. In typhoid there is leucopenia with a
relative lymphocytosis. The spleen in typhoid fever
is, of course, large and palpable ; in Spanish influenza
it cannot be felt. We have seen two cases sent to
the hospital as Spanish influenza which, after a few
days, were diagnosed as epidemic cerebrospinal
meningitis and the latter diagnosis was proved
correct by the lumbar puncture yielding a charac-
teristic, cloudy, purulent spinal fluid. Cerebrospinal
meningitis may, however, be preceded by influenza
in our experience.
TREATMENT.
Doctor Park, in his article in this issue of the
JoijRNAL, discusses the bacteriology of this disease.
We may say that the relation of the streptococcus to
influenza is about that of this organism to scarlet
fever. While the streptococcus in both these dis-
eases is the most important bacterial cause of the
mixed infection complications, which cause the
death rate, it is not the essential and bacterial cause
of either of these diseases. An antiserum to the
streptococcus will therefore prove disappointing,
while an effective polyvalent antiserum to antagonize
all the organisms involved in the mixed infections,
including the pneumococcus, has not been produced.
The pneumococcus in these cases belongs to
strains III and IV. We believe, therefore, that
antibacterial therapy is still the hope of the future
and not the realization of the present. Doctor Park
will write of the prophylactic vaccine of which we
have as yet, only meagre experience. We still rely
'Upon symptomatic therapy.
For the fever, we have not used any of the coal
tar products, all of these being heart depressants.
Aspirin in moderate doses, we have used only in the
Ifirst to the third day. In some cases, instead of aspirin
we gave salicylate of soda in moderate doses,
with double the amount of bicarbonate of soda. In
using salicylate of soda the urine should be care-
fully watched for albumin. After the fourth day,
if the fever is an annoying factor, neither of these
drugs should be used. We have used hydrotherapy
in the form of sponge baths at eighty-five degrees
every time the temperature rises above 103.5 degrees,
such baths being preceded by a dose of quinine
sulphate or hydrochloride in five grain capsules
(Berg). Not more than ten grains of quinine
are to be given daily. As stimulants, we use
tincture of digitalis by mouth or digalen by veins as
indications require. The digitalis should be given
frequently in moderate doses. The pulse should be
the guide for its use. We are both using adrenaHn
in moderate doses, three to five minims of one to
1,000 solution by mouth, nostril or needle, as indi-
cations may require. On account of its effect on
the edematous, mucous membranes, and because of
its stimulant cardiac action, Doctor Bullowa con-
siders that it has a specific effect. Other indications
are met therapeutically as they arise.
The pneumonias in this disease being mostly
bronchopneumonias of the "moist" type with a
tendency to partial pulmonary edema, we have care-
fully avoided trie use of opiates and morphine.
Only in very severe cough are small, infrequent
doses of codeine given until the cough is relieved.
For the delirium with sleeplessness v/e rely upon
barbital in proper doses. The patient awakes from
sleep with a much clearer mentality.
This rather cursory account of the experience in
this epidemic includes no statistical inquiry because
of lack of time for the tabulation and classification
of histories. Our clinical observations here re-
counted, are not intended to do much more than call
attention to features in the clinical course of these
cases in this epidemic which have impressed us
most forcibly.
10 East Seventy-third Street.
62 West Eighty-seventh Street.
THE TREATMENT OF INFLUENZA.
By Walter A. Bastedo, M. D.,
New York,
Assistant Professor of Clinical Medicine, Columbia University;
Attending Physician, St. Luke's Hospital, etc.
From the standpoint of treatment, the influenza
cases fall into two groups : Those without pneu-
monia, and those with pneumonia.
cases without pneumonia.
In this group the dominating features are pains
and bronchitis, and these are treated symptomatic-
ally. For the general pains and heada'ches we use
salicylates, acetylsalicylic acid, acetphenetidin, acet-
anilid, or pyramidon, with or without codeine.
There is nothing gained by associating with these
antipyretics any drug for the protection of the heart,
such as caffeine or camphor, for if there is an idio-
syncrasy against one of these drugs of the acetanilid
group, there is no other drug known that will pro-
tect against it. Worth Hale has shown that caf-
feine actually increases their toxicity, and many of
the cases of collapse have occurred when the orug
was accompanied by cafi'eine.
For the bronchitis, local treatment is external in
the form of mustard plasters, turpentine liniment,
or hot poultices ; or internal, by inhalations of steam
containing the compound tincture of benzoin, or oil
of pine.
The systemic treatment for the bronchitis consists
October 12. .9.S.] IGLAUER: CONCOMITANT BRONCHOSCOPY AND ESOPHAGOSCOPY.
627
essentially of expectorants — one of the best known
being a mixture of ammonium chloride with ipecac.
The ordinary brown mixture has scarcely any ex-
pectorant value, and the popular Stokes's expector-
ant is more efifective in doping the patient with its
paregoric than in fluidifying the bronchial secre-
tions. The so called bronchial antiseptics, tar, creo-
sote, turpentine, terpin hydrate, cubebs. etc., are of
no value as antiseptics, though they may exert a mild
analgesic and antipyritic effect.
During the illness, sleep must be ensured, usually
by the milder hypnotics, such as barbital, trional, and
chloralamid, and the digestive tract must be kept
free from fermentation and putrefaction by a pri-
mary dose of castor oil or calomel and subsequent
mild laxative or a daily enema. The diet is neces-
sarily light in character and limited in quantity, and
water is freely given.
CASES WITH PNEUMONIA.
In the pneumonia type the problem is different.
From a therapeutic standpoint, the comfort of the
patient sinks into insignificance, and the main-
tenance of the vitality of the patient becomes the
need. In the lungs at post mortem we find very
extensive involvement, with abscess formation in the
alveoli and terminal bronchi, extensive hemorrhages,
and gangrene of the mucous membrane in the
larger bronchi. We are dealing with a broncho-
pneumonia and the patient is more or less septic.
If the pneumococcus is found in the sputum it
should be grouped, and if of Group i, the patient
should receive large doses intravenously of the
pneumococcus No. i .serum. If it is not of Group i.
the serum is useless.
The essential treatment is symptomatic. Al-
though the cold air treatment for pneumonia has
not proved an advantage from a mortality point of
view, it promotes the comfort of the patient and
favors sleep, and may lessen the cough. Therefore
have the patient out of doors or in a room with the
windows wide open. Because of the cardiac weak-
ness and the frequent development of auricular fi-
brillation, it is a wise plan to give all patients
digitalis in large doses for the first two or three
days.
Fear of tympanites demands the lightest kind of
diet, such as peptonized milk and broths, and also
adequate movements of the bowels, preferably
by a daily enema to avoid medication by mouth.
The presence of tympanites calls for vigorous treat-
ment by medicated enemas, hot stupes to the abdo-
men with a rectal tube in the rectum, and a brisk
catliartic by mouth, even castor oil. if that can be
taken by the patient ; or sometimes a hvpodermic of
one c. c. of pituitary liquid, repeated from time to
time. Plenty of water should be given to promote
excretion of toxins and to favor sweating.
For the cough, a throat spray or inhalation of
med-'cated steam or. if necessary, repeated doses of
codeine, may be employed.
For sleep, use the ordinary hypnotics mentioned
above, and if these do not suffice, use paraldehyde.
This may be given bv rectum in two dram doses
dissolved in saline. If there is delirium, or great
pleuritic pain not overcome by the ordinary seda-
tives, use morphine. It is a sine qua non that the
patient must have rest and sleep, yet I would avoid
the use of morphine as far as possible, because of
its tendency to favor the production of edema of
the lungs and tympanites.
If edema of the lungs supervenes, dry cup
the chest and administer, hypodcrmically, five
grains of cafi'eine and sodium benzoate, to stimulate
the respiration, repeating this in smaller doses if
required. If the edema of the lungs is in the serious
stage I would in addition do a venesection, with-
drawing ten to fifteen ounces of blood. If digitalis
has not been administered, but not otherwise, give
strophanthin, 0.5 mg., intravenously. If there is
cyanosis, use oxygen freely, preferably with steam
to obviate the drying effect of the oxygen.
The whole treatment is symptomatic and there
are many other conditions that may arise and de-
mand therapeutic consideration ; for example, acid-
osis, pleurisy, and empyema. I have not yet en-
countered any cases with empyema.
CONVALESCENCE.
In the convalescent stage the care of the patient
must be continued, for at this time the vitality per-
sists at a low point. Prolonged rest, fresh air, and
bitter appetizing tonics are indicated.
We have said nothing about abortive treatment,
though no harm, and possibly good, may come from
the usual attempt to cut the disease short, by a
brisk cathartic at the onset, a large dose of acetylsal-
icyhc acid, and measures to produce copious sweat-
ing.
57 West Fifty-eighth Street.
CONCOMITANT BRONCHOSCOPY AND
ESOPHAGOSCOPY.*
By Samuel Iglauer, B. S., M. D.,
Cincinnati.
Case. — November 26, 1917. F. W., a female, age twenty-
four, was admitted to the medical service of Dr. M. Brown,
at the Cincinnati General Hospital, suffering great distress
and agony from the effects of a rather concentrated solu-
tion of lye, which jhe had taken with suicidal intent. In
the receiving ward a stomach tube had been passed and
about a quart of diluted acetic acid had been used, as an
antidote. The patient's lips, mouth, tongue, and pharynx
were badly burned. At; acute nephritis soon developed.
After several days there was a profuse discharge of
bloody fluid from the mouth and throat, due to the "peel-
ing of the escharotic membranes, leaving a raw granu-
lating surface." The voice was thick and husky and there
was some occasional difficulty in breathing. At first deglu-
tition was pract'cally impossible, and three nutrient enemas
were given daily. These were continued for about four
weeks, although some tcod could be swallowed during the
latter half of the month, and by January 20, igi8, the pa-
tient could swallow cereals, bread and milk, and fruits.
February 2. iqi8. The patient was transferred to the
laryngological service. Examination showed a very smooth
tongue (papillffi destroyed), which could onlv be slightly
protruded, owing to the cicatrices in the floor of the
mouth. The pillars of the fauces and soft palate were
superficially scarred. At the root of the tongue dense
fibrous bands had formed, binding the tongue to the lateral
and posterior walls of the pharynx, forming a diaphragm
and leaving a roughly triangular opening with cordlike
edges wh'ch just about admitted the tip of the index
finger. The epiglottis was invisible, but a glimpse could
*Rpad at the First Annual Meeting of the Association of Amer-
ican Peroral Endoscopists, Philadelphia, May 31, 1918.
628
STERN: DAY PHANTASIES IN A CHILD.
[New York
Medical Journal.
be obtained of the arytenoids and the thickened vocal
cords. In addition to the faucial obstruction described
above, x ray plates (taken somewhat later) "show evidence
of incomplete stricture at the beginning of the esophagus
opposite the second dorsal vertebra. The length of the
stricture is not over an inch and the edges appear smooth."
(Doctor Doughty.)
Attempts at passing an esophagoscope all failed because
the introduction of the instrument through the cicatricial
diaphragm m the fauces completely occluded the aditus
laryngis and produced asphyxia.
March 21, 1918. Under local anesthesia some of the cica-
tricial bands in the fauces were partially severed by blunt
and scissor dissection, but in the course of about ten days
they formed again. Dilatation of the opening in the dia-
phragm was then begun by frequent introduction of a long
killian nasal speculum which was spread after its inser-
tion. In this manner slow progress was made. The pa-
tient was induced to swallow several yards of silk thread,
over which it was possible to pass Sippe's piano wire, but
neither Sippe's hollow sound nor Plummer's ohve tipped
bougies could be passed through the stricture. All manipu-
lations were rendered difficult because the patient was of
an exceedingly neurotic disposition and was prone to be-
come hysterical when treated or examined.
April 13, IQ18. In order to reach and dilate the esopha-
geal stricture, and at the same time prevent the asphyxia
which always threatened when an esophagoscope was in-
troduced, the following procedure was adopted : The
patient v/as anesthetized with chloroform (attended by
considerable cyanosis), and with some difficulty in enter-
ing the larynx, owing to the cicatrices, an 8..S mm. Kahler
bronchoscope was introduced into the trachea. The handle
of the instrument was then detached and the bronchoscope
was anchored to the patient's cheek with adhesive plaster.
A free airway was thus established and the anesthetic was
administered through the tube. A small Jackson esopha-
goscope was then introduced over the thread (which the
patient had previously swallowed). A very narrow cica-
tricial .stricture was found about eight cm. from the in-
cisor teeth. Sippe's piano wire was then threaded onto the
string and was passed through the esophagoscope into
the stomach. Jackson's flexible tipped esophageal bougies
— sizes 2, 4, and 6 — were then successivelv passed along-
side the piano wire and through the stricture. The
esophagoscope and bronchoscope were then removed.
A few days after this operation, no ill effects having en-
sued, it was found that small Plummer's olive tipped bougies
threaded over the string could be passed into the stomach.
Larger and larger tips have since been employed with
gradual dilatation of the stricture. At the same time the
opening in the pharyngeal diaphragm has been somewhat
stretched by repeated introductions of the Killian nasal
speculum. Deglutition has gradually improved.
COMMENT.
In order to insure an unobstructed airway in the
treatment of this case, several methods had to be
considered : First, a preliminary tracheotomy might
have been performed but was inadvisable, because
it would have meant another operation and burden
in a highly neurotic patient. Second, insufflation
anesthesia was considered but was not employed,
because the introduction of an esophagoscope
through the pharyngeal diaphragm would have shut
off the space for the return flow of air. A double
cathether providing for insufflation and exsufflation
might perhaps have been tried. Third, the stomach
might have been opened and retrograde catheteriza-
tion without end might have been undertaken ; but
this procedure would have been an additional
surgical risk.
Conclusions. — The concomitant introduction of a
bronchoscope and esophagoscope solved the difficul-
ties encountered and might be employed advan-
tageously in cases of a similar nature.
Seventh and Race Streets.
DAY PHANTASIES IN A CHILD.
By Adolph Stern, M. D.,
New York.
It is a matter of common knowledge that children
normally live in a world of make believe, as evi-
denced even in their games in which objects sym-
bolize living things, and we know that children revel
in fairy stories and things magical. That which I
am about to describe, however, is a distinctly patho-
logical phenomenon. For at least two reasons it is
pathological, the more important perhaps being that
these phantasies occupy the attention of the patient
to an extent excluding the possibility or even the
desire for a normal interest in his environment.
A patient of mine, a seven year old boy, was a
typical day dreamer, sitting at times, as the mother
told me, for hours, totally oblivious to his surround-
ings, immersed in his own thoughts. The second
reason for considering them pathological is the na-
ture of the phantasies which indicate repressed
wishes which the child could not realize in acttial
life. Unable or unwilling to give them up entirely,
the child resorts to his imagination to fulfill these
wishes. As we shall see, some of them are repro-
duced in the phantasies in an undisguised form,
while others are painted in a symbolic or disguised
state. Furthermore, these phantasies at times re-
mind one very much of tales, being in fact copies
of those the child had heard in school and adapted
to blend with his unconscious desires.
One can find a reason certainly why fairies stories
and tales of magic and great power find such a
fertile field in children's minds. Riklin has shown
that the same mechanisms at work in the phantasies,
dreams, and symptoms of the neurotic enter into
the construction of fairy tales and that the writers
of fairy tales give life to their own unconscious
wishes just as the individual does in his fancies and
dreams. Our patient was beset with the same emo-
tional conflicts between "I want" and "I must not
have" that confront every individual. Though their
real import was not quite clear to the child, yet the
tales of magic and power which he had heard gave
him just that which he sought. They provided for
him a world in which he could live as he wished,
and he incorporated into his own life those features
of the tales which he lacked on this hard, matter
of fact earth. This child, like so many adults also,
lived according to the pleasure principle, shutting
his eyes to reality as something too harsh ; and since
he refused to submit to reality, he resorted to his
phantasies to give him, without any effort, all that
which he vainly sought in his conscious state. ^
These phantasies emphasize several very interest-
ing and at the same time vital phenomena, which
are present in the fabric of all neurotic conditions,
or, rather, which lie at the base of every functional
neurosis. I refer to the parent complex with its
various manifestations.
Another illuminating phase of this study shows
'The distinction between conscious and unconscious in this in-
stance is that which Freud has pointed out. The unconscious em-
braces thought processes of emotional value, 'the real nature of
which for certain, so to speak, purposeful reasons are not known and
are not at the time fully recognized by the individual. The reasonj
for their not being recognized as such lie in the nature of the
thought processes, viz.. their incompatibility with morality or ethics.
The reader is referred to Freud's Interpretation of Dreams for an
elucidation of this phase of the subject.
October 12, 191 S.]
STERN: DAY PHANTASIES IN A CHILD.
629
how the individual's attitude to the outside world
is merely a reproduction of that which he manifests
at home ; the tendency to reproduce conditions ; to
feel "at home" only in conditions which are familiar
to the individual. This to some extent explains the
inability of the neurotic to adapt himself readily
to changes in environment.^
This marked tendency to live along certain lines
is established very early in life, and that is why
we say that an individual's future character is de-
termined very early in life, before the age of five
years, and therefore the urgent need of knowledge
of the deep psycholog}^ »f very young children. Let
us see what, in this direction we can get from a
study of the patient under consideration.
Case. — I. H., seven years of age, was brought to the
Mount Sinai Dispensary in May, 1917, because he stuttered
for the past three years, suffered from nocturnal enuresis
since birth, never having obtained full control of the
urinary sphincter; was obstinate, wilful, quarrelsome; did
not play much with other children ; was very irritable, and
easily became very angry. For two months before he
came under observation he sighed a great deal and sat for
hours absorbed in thought. While at the clinic, one of my
colleagues called my attention to the boy, who sat staring
ahead of him, entirely unconscious of what was going on
about. An examination revealed an intelligent, capable
looking little fellow, somewhat undersized and undernour-
ished", with a faraway, dreamy look, as if all that which
he sought lay in some distant place beyond his reach. At
the same time his expression showed dissatisfaction and in-
tense resentment.
The method of procedure in the psychanalysis of
children in nowise dififers from that employed in
the treatment of adults. Dreams, symbolic acts,
symptoms, and phantasies are the means whereby
the unconscious processes are made conscious.
Free association is employed just as in the case
of adults. In the patient under consideration,
little recourse was had for interpretation material
except to his day phantasies, which were very
numerous, in fact almost constantly present and
very readily reproduced, except now and then
when the patient manifested resistances to the
analyst, or because the phantasies or their associa-
-Freud has said that a neurotic lives in the past — on "reminis-
cences." While that is true of most people, especially is it true of
neurotics in their emotional life. In the case of the child under
analysis, 1 shall point out how his attitude tow.ird me, in the course
of ttie treatment, mirrored that which he maintained to his immediate
family — he invests me with all the powers, wealth, and qualities
with which he conceives his father to be endowed, and on that
account directs to me all the feelings of envy, hate, and jealousy
which he manifested toward his father; and just as he wished to
displace the latter, so too, he attempted to take my place, and
with it, everything he believed me to possess. This is, in brief,
what we mean by transference, a process that regularly takes place
in the course of an analysis. It is the difficult task of the analyst
to detect the various manifestations of the transference, bring
them to the conscious attention of the patient, changing thereby
the pathological nature of the transference. And since the physi-
cian symbolizes the (to the patient unconscious) familiar environ-
ment, a healthy attitude to the physician will of necessity bring
about a healthy attitude to the family, and incidentally to his
environment in general.
^In connection with the undernourished appearance, the mother
complained of the capriciousness of the child's appetite and that he
had to be forced to eat; he \vanted only those things which were
forbidden. That which his mother told him were healthful — milk,
bread and butter, cereals, and the like — he refused to take except
when compelled. The child would go for many hours without eating
unless reminded or ordered to eat. This condition was present only
for the past two or three years; before that the boy ate everything
that came his way and at the time was a chubby little fellow. I
explain this change purely from a psychic point of view. It is
one of the means of getting attention and at the same time showing
rebellion and antagonism. The study of the phantasies of the little
patient will show sufficient basis for this interpretation. Moreover
it is interesting to note that without any drugs whatsoever or any
efforts especially directed to that end, tha child's desire for food
increased during the course of the treatment, that he became less
capricious in his desires, and gained several pounds in weight.
tions led to more or less consciously repressed idea-
tions of a very painful nature.
The boy gave but one dream during the entire
treatment. This was narrated on his first visit at
my request that he tell me a dream he had had.
On his second visit, at my request for a dream, the
child said he had none, but that he had thoughts
in his mind. These I reproduce as his day dreams
or phantasies. On succeeding visits, to my requests
for dreams, he responded with, 'T have no dreams,
but I can make them up." He "made them up"
very fluently, hesitating only very little in their re-
cital. This gave the boy an outlet for his "make
believe" tendencies and an opportunity to put into
words his "make believes" in which he passed so
many hours all by himself. From the content of
these phantasies, as we shall see them, one need not
be surprised that the child kept them to himself and
that in the main he was quiet, morose, seclusive, and
resentful. At first he told these phantasies without
any affect of shame or embarrassment, but as
through the analysis the significance of their con-
tent dawned upon the child, there was manifested
more and more effort in telling thein, he colored
with shame or embarrassment or manifested fear,
etc., as determined by the nature of the disclosure
at the moment. The dream, given by the patient
on his first visit, is here partially reproduced :
"A robber came in and chopped my head off and my
hands and my body, and threw me in the river, and T sank
to the bottom ; and a cop took the robber to the judge and
the judge said: 'Take him where he put the boy and make
liim get the boy, and put the robber in prison, and put him
in the electric chair.' " Asked what came to his mind
with "robber," he said : "My big brother and a big boy I
know — they hit me — I don't like them. Sometimes I hit
them."
One can readily see the desire for revenge in this
child's mind, as symbolized in the dream. In very
young children, and 'also in neurotics, one can safely
translate "I don't like" into a positive "I hate," in-
dicated in this case by "put the robber in prison and
put him in the electric chair." The passive cruelty
is represented by "chopped my head off and my
hands, etc." Similar repressed emotions are present
in the day phantasies, one of which I shall now re-
produce in part :
"Robbers took me and knocked me in the water, and
the cop put the robbers in prison and put them on the elec-
tric chair and killed them, and the cop says to him, 'Where
is that little boy?', and he said, 'I'll get hold of you and
put you in prison.' He died in five hundred months, and
the cop said and the judge said, 'You must kill him in
prison and kill and try to find that boy every day; you
must go out and find him, and if you find him bring him
up to me and kill all the robbers.' And he put all the rob-
bers in the electric chair and put 'em in prison and killed
them. The cops surrounded the robbers and killed them
and brought them to the judge, and all the cops came and
then the whole crowd was dead,* and then they put him
*It was very instructive to watch the changes in the facial ex-
pression of the boy, as he unconsciously took the part now of one,
now of the other characters of his creations. What joy he expressed
as the robber was killed I The severity and the finality of the
judge's command to the "cops" to get the robbers and kill them
displayed a keen appreciation of a situation in which actual con-
ditions were reversed. How often the child was commanded by his
father to do something, and how often he was punished by beating,
for minor ofTenses! In his fancy conditions were reversed, and he
took full advantage of the situation against the "tyrant." For
many children regard their parents in this light, and justify this
attitude by calling to mind instances of apparent neglect or unjust
treatment on the part of the parent. These are what Freud calls
the "cover memories." The roots of the hostility lie deeper and
are unconscious.
630
STERN: DAY PHANTASIES IN A CHILD.
[New York
Medical Journal.
on the electric chair and chopped him up and then they
threw him away in prison, and he sank a thousand and a
thousand and a thousand leagues under the sea in the
water."
To this phantasy I asked for no associations,
since the boy consumed three quarters of an hour
in its narration. However, the similarity between
the dream and phantasy is quite apparent ; the re-
pressed emotions in both showing a marked resem-
blance in their nature. What follows is a partial
reproduction of a "make believe" upon my request
for a dream. The patient said he had no dreams,
but he could "make one up." We can call this an
"artificial" dream : note the close similarity be-
tween the natural dream, day phantasy and "arti-
ficial" dream.
"There is a robber ; he is so bad and he kills all the cops
and he kills his own robbers, and he saw all the cops and
all the robbers was dead, and he sees blood and he finds
out it's his own robbers, and then he says, 'That's my rob-
bers, I forgot,' and then he said, 'All right, I don't care.'
The robber gets knocked in the river, and he says, 'I don't
care for my robbers and cops.' " At this point patient's
phantasy ceased, and I asked him to tell me what came to
his mind with "I don't care for my robbers," and he said,
after some hesitation, "I want to kill myself. Sometimes
I feel so bad I want to stick a knife in my heart. Today
I was playing with a knife — about soldiers — I had a gun
in my back pocket and a knife in front, and I killed a sol-
dier." (Patient evidently has passed from association of
suicidal thoughts and is now again giving vent to his phan-
tasies.) "So the Mexican comes and says, 'Hands up' . . .
I know a scheme that I can kill you." Patient looks
straight at me, pointing his fingers, gun fashion, straight
at me, smiling the while. "I was a sailor, I had a sailor
suit on" — patient has a sailor's blouse on— "I said— I must
kill you and throw you in the river — then there were more
sailors, another had a fight with the Indians and all the
sailors were killed except two." Patient again stopped,
and I asked him to tell me what came to his mind with
"two sailors" — "One is myself; the other, Johnson — a
boy — Pete — my friend ; he likes a thousand and a thou-
sand and a thousand girls and fifty, girls was against him
and he knocked every one down — and we took the clothes
off the dead sailors" — evidently patient again has returned
to his phantasy — "I was there — I hide between the rocks
— I killed all the Indians and I take their clothes off — I
make out I die — and I shoot the Indian with a small gun.
It has a small thing in front" — At this point patient put
his right hand over his genitals and pressed his thighs
forcibly together. I called his attention to the act, and
with much embarrassment and blushing, he took his hand
away, disclosing the erect penis visible through his cloth-
ing. He then continued his phantasy. "They buried me — ■
I look up and I see I'm under the earth — I dig up — I run
away and I said, "Oh, I was under the earth — I make fun
.1 was dead — Oh, I was not dead"
The above "artificial" dream with its associations
toalains valuable information relative to the child's
repressed emctional life. Its theme is that which
vv^c saw before, viz., intense hostihty toward people
in authority. In addition thoughts of suicide ; a
strong sex desire — love — as manifested by "he can
like a thousand and a thousand girls" ; the "looking"
impulse — the desire to see the naked body, its
counterpart being exhibitionism, as indicated by "I
take their clothes off." Very interesting and graphi-
cally described is the birth phantasy,' symbolically
portrayed, t. r., "They buried me (in the mother's
womb') in the (mother) earth— I dig and I run
away." I took this to represent a birth phantasy
and explained to the child the process of conception,
pregnancy and birth. Another very instructive iri-
cident is the sex coloring of the cruelty and exhibi-
tion (looking) impttlse, as manifested by the erec-
tion of the penis as the patient described the kiUing
and tlie looking at the dead bodies with the clothes
off. Further value is attached to the looking im-
pulse, by the phantasy "I make out I am dead — I
look up and I see." In answer to a question the
child told that he often pretended to sleep and
watched his parents and his oldest sister in bed.
He frequently slept in the same room as they did.
An extract from a later "artificial" dream ex-
plains so called "hard luck," or as this patient put it
'"he always makes something happen to me." The
phantasy follows : •
"There was an old man — he was very poor and a soldier
was there, and he said, 'Hurry up, you must go or I'll
shoot you,' and he ran and he ran and he could not run
very fast — he ran slow and the soldier shot him." Asked
to tell what occurred to him with "old man," he gave the
following associations : "He is a good man — he cannot run
fast — he walks slow — my cousin — he died and went up to
heaven, to God — he is way, way up in heaven by God, and
when I play he makes something happen to me — I can't
find the ball — he makes it go away because I play — so I
hurt my leg, then I go in the street and play with every-
body, so something happens to me — every day — then I cry ;
then I go upstairs and play and something happens to me
— and I cry and never stop crying for a whole day."
These misfortunes following the narration of the
killing of the old man by the soldier, we can safely
say that they result as an (imconscious ?) selfpun-
ishment for the wicked impulse and unconscious
criminal acts as depicted in the fancies. I so ex-
plained it to the patient, who, we know by this
time, readily identifies himself with many of the
characters he creates. The following, a short ex-
tract from another phantasy, plainly reveals,
through a lapsus lingua?, the direct object of some
of his criminal impulses:
"A boy is burying a man." Asked to associate man,
said, "My cousin — I wish I could do that — a man comes
and takes it away to heaven — if I could do that — when
my f-f-f-cousin died" — at this point patient stopped; I
asked him to say what came to his mind with "f-f-f-" ; he
hesitated a long time, and then said — "my father — I want
to bury my father — I want to kill him — he is bad to me."
The sexual symbolism of "devil" and its symbol-
ism of wickedness are indicated by the following
extract from a phantasy:
"There was a man — he was so rich — he kills everybody ;
he is a devil." Asked to tell what came to his mind with
"devil," said, "I am afraid of the devil. I go to my moth-
er's bed and choke the devil ; he has horns — he looks wild
— he— the devil — is skinny — he goes through the keyhole
— like this." The patient indicated what he meant by in-
serting the extended index finger of his right hand into a
ring formed by approximating the tips of the left 'humb
and index finger. At the same time he caused his cheeks
to bulge by forcing his tongue against the inside of the
cheeks, and moving it about in a circle.^ I suggested to
the patient that he was sticking his finger into a hole, and,
blushing, said he had often inserted his finger into his
rectum with pleasurable effect. Freud has called atten-
tion to the sexual significance of this anal interest.
What we call the transference is indicated in the
following: By transference we mean the various
manifestations of the attitude of the patient to the
physician, resembling, rather reproducing, in essen-
tials that which the patient bears to his earliest and
'A stutterer, a boy of ten, whom I analyzed, and who had a habit
of rolling his tongue about in his mouth and sticking it into his
cheeks, informed me that boys whom he knew called this "having
intercourse" (he used the boys' slang word for the act), the cheek
representing the vagina and the tongue the penis.
October 12, 1918.]
STERN: DAY PHANTASIES IN A CHILD.
631
most intimate environment, i. e., his family. This
regularly takes place with all people in their social
intercourse with one another. It is necessary to
bring the various manifestations of this transfer-
ence to the consciousness of the patient before real
progress toward a cure is made. The attitude of
the patient toward his family is one of "overvalua-
tion" in many respects. The boy considers his
father very rich, very powerful, tyrannous, creating
in the child envy, hate, and rebellion. He shows
toward me the same feelings. Witness the follow-
ing :
"There was a man ; he was so rich — he had a thousand
million, dillion dollars and a big house and a thousand
automobiles." Asked to associate "man," said, "Yon," and
then added, "I own a mountain — bigger than the story
mountain." Patient is envious and wishes to make me
envious by telling me he is richer than I. He proceeded
after a short pause — "He is a poor man — he's a plain man
and he writes down everything like a confessor." Patient
sees me write down what he says, and unconsciously rec-
ognizing the nature of his thoughts considers me a con-
fessor. "I want to be the head of the confessors — you are
the real head one now — but I'm going to be higher than
you — I'm going to be a dillionaire and make them jealous
— I'm going to get a pistol and shoot the whole family,
except my big sister."
The following fragment of a fancy and free asso-
ciations to part of its contents show the connection
between sex desire and the act of micturition ; also
the sexual symbolism of knife, the feelings of envy
and rivalry and hostility to the rival, the exhibition
impulse, and the feeling of omnipotence. Like the
other artificial dream the patient related this one at
my request for a dream. He said :
"I had no dream, but I can make it up. There was a
poor man; he felt so bad and he wanted to stab himself
and he lived al! day and then stabbed himself and they
brought him to his mother and she cried." Asked to asso-
ciate "man," said, "That's my father, and I told him he
must die, and he stabbed himself — I killed him — I'm God —
I can take his knife — I had a real one." Told to tell what
comes to his mind with "knife," said : "My sister's boss has
a knife — I don't care for my sister's boss — I got his knife
— I held it in my hand — I took it out on the street. It's
his knife." Asked to associate "sister's boss," said, "He
likes my sister — I hate him." He then continued, in words
I do not wish to put into print, to inform me that his
sister's boss attempted intercourse with her, and also that
he, the patient, saw a boy in the park attempting inter-
course with a girl, but, "He can't, because there are people
around." All this contains so many evidences of sexual
interest, i. e., exhibition — "I took it out on the street" —
and masturbation — "I held it in my hand," that I ventured
to say to the child that he wants to masturbate, but is
afraid of detection, f. c. there are people around. To this
he replied that when he wishes to masturbate® he goes
under a table, and added that on several occasions he had
had intercourse with his oldest sister. I have no verifi-
cation for this. If the acts did not actually take place, the
telling of them by the child as a reality, indicates the in-
tensity of the wish, so that the wish and its fancied real-
ization are synchronous. He described the acts, and his
attempts at getting an erection — as he put it, "I try to make
mine hard." The child manifested envy of his father be-
cause the latter had "such a large one," indicating the size
by holding his two hands about a foot apart, palms facing.
"His is so big," the boy continued, "It tears his drawers
— he can't put it in." At this point the child expressed a
sudden and urgent desire to urinate and, after returning
from the toilet, said, "You got a knife, like that," indi-
cating paper knife on my desk, "and God said everybody
with a knife must die."
An interesting phenomenon manifested in the
"His words were, "When I play with my mickie."
above extract is the boy's hostility to men to whom
the boy has the same attitude as to his father, show-
ing the tendency to reproduce conditions. The feel-
ing of rivalry toward the father is reproduced in his
attitude to his sister's "boss" on account of the
fancied love of the "boss" for his sister. On one
occasion he expressed hostility toward me because
"you got a wife," referring to the female office at-
tendant. He gave evidence of this feeling in an ap-
parently playful manner by saying, "I have a gun to
shoot you and bullets," pointing a toy gun at me
and smiling. Upon my questioning him why he
wants to shoot me, he gave the response above
quoted.
I have selected from a mass of material what I
think most readily shows the nature of the malady
from which our little patient suffered. Immersed in
liis thought for hours at a stretch, dreaming dreams
which could never come true, weaving fancies of
whose real nature he was totally unconscious, it is
not at all stirprising that the boy was seclusive, in-
different, or hostile to his environment. Reality had
little to offer him, so he sought what consolation he
could, in his own imagination. The sullen and re-
sentful expression on his face, an expression that he
constantly bore, is fully explained by the nature of
the phantasies.
Though these phantasies are present in this child
to an extent rendering him, for the time being at
least, unfit to take his proper position in life, namely^
that of an emotionally healthy, active, interested
little boy, yet they but typically portray the strivings
and longings consciously or unconsciously present at
one time in all human beings. Therein lies the im-
portance of Freud's teachings. He has repeatedly
emphasized the fact that what we find in the neurotic
we find also in the normal, except that in the latter
an adjustment of these conflicts between "I want"
and "I must not desire" has resulted ; while in the
former psychic ill health is the result of the con-
flict.
Love'', hate, envy, and jealous}- are emotions
present in all beings. They are superabundant in our
little patient, and his inability to adjust himself to
these emotions causes the flight from reality to his
fancies, in which he gives full vent to all of them.
As in the adult neurotic, so in this boy also, we can
trace the source of these emotions to the attitude of
the individual to his immediate family. Envy and
jealousy of the parent on the part of the child be-
cause the former possesses so much in material
things, in power and privileges denied to the latter
are important sources of neuroses. To what an ex-
tent the child learns to forego much that he immod-
erately desires just so much more progress does he
make in the direction of cultural development, pro-
viding of course that he does not flee to his fancies
for the substitute, but finds it in every day childhood
activities.
As noted in the report of the case, in places where
the associations to selected parts of the fancies or to
the fancies themselves warranted it, interpretations
were given by me to the patient. It was very in-
'In the ease of this patient love consists essentially of the different
forms of sex curiosity and sex desire as such. He has given suffi-
cient evidence of this. In the text the word "love" is used in its
generally accepted sense.
6.3-
KAHN: SPONTANEOUS PNEUMOTHORAX IN TUBERCULOSIS. [New York
Medical Journal.
teresting and very satisfactory to watch the change
in the facial expression of the patient, when the
interpretation was correct. The child, then, gave
ready assent. More conclusive, however, on such
an occasion was the unconscious, the spontaneous
and instantaneous change in his expression — the
blushing, confused smile, hanging of the head, all
followed by a distinct change for the better in the
facial expression, a diminution in the intensity of the
generally suspicious and resentful facial expression.
Equally important is the fact that when the boy dis-
agreed with my interpretation, he said so, at the
same time giving his interpretation.
It was most gratifying to note the gradual im-
provement in the general demeanor of the boy as the
treatment proceeded. At first he kept his eyes
averted, very rarely looking me in the face. A smile
was in the beginning a very rare occurrence. Now,
some six months after I first saw him, he is a cheer-
ful little fellow, with a ready smile, an easy de-
meanor, and a frank expression.
40 West Forty-eighth Street.
SPONTANEOUS PNEUMOTHORAX IN
PULMONARY TUBERCULOSIS.
By Moses Kahn, M. D.,
Brooklyn, N. Y..
Attending Physician to St. Anthony's Tuberculosis Hospital,
Woodh.-iven, L. I.
Reports have frequently been made, showing the
beneficial results which occasionally follow spon-
taneous pneumothorax, occurring as a complication
in pulmonary tuberculosis. Arrest of the disease
sometimes resulted. This idea was seized upon by
Forlanini, and independently by John B. Murphy,
and was the origin of the modern treatment of
selected cases of hopeless pulmonary tuberculosis,
by inducing artificial pneumothorax. The method
consists in introducing nitrogen or air into the pleu-
ral cavity, following the indications of a water
manometer.
The following is the report of a case from my
practice of far advanced pulmonary tuberculosis,
followed by spontaneous pneumothorax. The con-
dition has resulted in an arrest of the disease. The
usual fatal outcome of spontaneous pneumothorax
is due to the rush of air into the pleural cavity,
followed by sudden displacement of the heart and
great blood vessels, and the rest of the mediastinum :
Case. — J. S., aged twenty-one years. The patient was
firs*^ seen on October 29, 1017. Illness began nine months
ago. Coughs very much, expectorates one half cup of
green pus daily. There is occasional bloody expectoration,
and fever, night sweats, weakness, great dyspnea. The pa-
tient has lost thirty pounds in weight. Pains and paralysis
are present in both legs. Physical examination shows
moist subcrepitant rales throughout the right lung, and
dullness over the same area. Heart and pulse average
130, and temperature averages 102.5° F. Patient is very
pale, dyspneic, and emaciated. The legs and feet are very
painful and patient is unable to move them. A diagnosis
of far advanced tuberculosis of right lung and multiple
neuritis was made. The prognosis was very unfavorable.
The treatment prescribed was absolute rest in the open
air. r was considering doing an artificial pneumothorax,
if the hygienic treatment failed. December 5: Left lung
shows a few subcrepitant rales in the left interscapular
region. December 26: Much cough. December 28: Much
cough. Bloody expectoration. Morphine was given. De-
cember 31 : Great pain in right chest and great dyspnea,
and shock Examination showed right chest distended,
tympanitic on percussion, with no breath sounds on aus-
cultation, and no rales. A diagnosis of spontaneous pneu-
mothorax was made. The prognosis was unfavorable, but
from then on the patient gradually improved in every way.
January 24, igi8 : Temperature averaged 99.6° F. No
breath sounds, and no rales. April 22, 1918: Patient feels
fine. No cough. No expectoration. Temperature aver-
ages 99.5° F. Left lung: no rales. Right lung: hyper-
resonance in upper half, dullness in lower quarter Auscul-
tation showed absence of breath sounds, and absence of
rales. May 10, 1918: Condition of legs has greatly im-
proved. When first seen the patient could not walk, but
he is now able to walk. May 14, 1918: Still no expec-
toration. No cough. Gaining weight, feels fine. June
4, 1918. Temperature averages 99.5° F., pulse 84. Legs
improving. Right apex, amphoric breathing. Right lung,
no breath sounds, no rales. Right lung flat, but no suc-
cussion sound. Patient feels well. No cough, no expec-
toration, and no other symptoms. All the symptoms gone,
and the patient is daily improving.
SUMMARY.
This was a case of complete tuberculous consoli-
dation of the right lung, accompanied by severe
symptoms. Spontaneous pneumothorax occurred
with rest of the lung and riddance of the pus, com-
pletely arresting the disease.
702A Halsey Street.
THE REAL VALUE OF FRESH AIR IN
TUBERCULOSIS AND MANY IN-
FECTIOUS DISEASES.
Why Fresh Air, in Itself, Is Not Sufficient as a
Preventive or Curative Agent for Tubercu-
lous and Many Other Infectious Diseases.
Its Relation to Preventive and Cura-
tive Medicine.
By Charles Gluck, M. D;,
New York.
As an instrument for the prevention and in part
the cure of innumerable common diseases, the
knowledge which is being rapidly gained in nose
and throat work will, no doubt, cause the entire
domain of prevention and cure of diseases to be
revised entirely in the near future. This will be
found true especially as regards the prevention of
tuberculous infections of whatever nature ; also as
regards numerous other infectious diseases.
There are certain selfevident facts of daily oc-
currence, namely, that in spite of our constant fight
for fresh air, cleanliness, and proper foods, we find
diseases, poor development, and malnutrition every-
where. There must undoubtedly be an excellent
explanation for this state of affairs.
The medical profession will regard the preven-
tion of the more common diseases and, to a great
extent, also their cure, from an entirely different
standpoint than does the nose and throat specialist,
whose view is more mechanical and hence more
efficient and far more practical. There is a greater
mechanical element involved in the production of
most of the common infectious diseases than has
heretofore been recognized. It is an old and well
recognized principle that many common species of
germs themselves cannot produce disease ; the pre-
October 12, 191 f.l
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633
disposing factors must be present. What are the
predisposing factors? The question arises, Are
there not two sets of such factors? The first, the
common factors, are those we all meet with, such
as the strain and stress of life, worry, exposure, etc.
The second, the nasopharyngeal factors, are the
actual means whereby the germs accomplish their
work, and they are to be found in the nose and
throat.
That we must have the germ to produce the dis-
ease is selfevident, but how the germ succeeds in
producing the disease is a question. Undoubtedly
it is brought about, as far as the writer can see, by
a chemicomechanical method, with great stress to
be laid on the side of the mechanical factor. This
mechanical factor is of paramount importance
when the ef¥ect these purely mechanical factors
have on inspired air is considered, resulting in such
changes or, more properly speaking, absence of
changes, in the inspired air, and facilitating growth
of germ life in all the nasopharyngeal structures,
so as to result in becoming the germ's main leverage
in producing disease. That is, these chemico-
mechanical factors bring about a state of the body
tissue wherein pathological processes may arise, a
condition aptly defined as suboxidation. By sub-
oxidation we understand that there is too little
oxygen in the body tissues to be compatible with per-
fect good health, or the highest degree of resis-
tance. Suboxidation is principally produced in a
purely mechanical manner by the inspired air being
drawn through abnormal nasal fossae or by mouth
breathing, resulting in improper moistening, warm-
ing, and filtering of the air as it passes through the
nasopharynx, thus making it impossible for lung
alveoli to absorb the oxygen in the proper propor-
tion. The question has been raised, why air passing
through the mouth in the case of mouth breathers
will result in suboxidation, facilitating the growth
of germ life in any of the body structures, espe-
cially the nose and throat, and resulting in disease,
either local or remote. Many physicians readily
understand why air passing through abnormal nasal
fossae will result in suboxidation, but the other
alternative seems to be a puzzle to them. It is self-
evident that air inspired through the mouth will not
be properly warmed, moistened, and filtered, since
the turbinate bodies of the nose, and not the struc-
tuies to be found in the mouth, were especially in-
tended to perform those functions.
Abnormalities of the nasopharynx are undoubt-
edly of vast import in the production or aggrava-
tion of many diseases, both local and constitutional.
These facts are true of an almost inexhaustible
list. As a common example syphilis may be men-
tioned. Clinicians will find that the difficult or in-
tractable cases are those afflicted with an abnormal
nasopharynx. This is true of both adult and child.
Interstitial keratitis in a child with a perforated or
deflected septum and enlarged tonsils and adenoids
is a difficult condition to cure ; whereas in children
with normal nasopharynges the condition clears up
under the simplest treatment.
To an important extent, then, many diseases
fundamentally owe their existence, and many
other again owe their intensified state, to chemico-
mechanical factors in the nasopharynx. These
facts are due largely to purely mechanical factors
found in the nasopharynx, preventing the normal
ingress of air. Because of this last mentioned
reason we may speak of such a thing as the "mech-
anism" of the production of disease ; i. e., in the
final alalysis, these pathological states are either
brought about or aggravated by purely mechanical
factors. These mechanical factors make it possible
for the chemical factors to accumulate, and pro-
duce actual disease. Should these facts be true,
then the nasopharyngeal factors should be given
their proper value in producing, aggravating,
preventing, or assisting materially in the cure of
many diseases. For simplicity sake, we will as-
sume there is such a thing as the "mechanism" of
the production of diseases. It is just this so called
mechanism of production of disease, so little un-
derstood, that will be found to be the explanation
for the existence of so much disease, malutrition,
and undevelopment.
In the "mechanism" of the production of many
diseases there are principally two simple, easily
understood factors ; a third factor may be involved.
Tuberculosis is not produced, or rather let us
say, permitted to grow in a healthy body. This is
selfevident. Its inception and growth require
something fundamentally wrong with the naso-
pharyngeal tract. These defects consist in young
subjects of hypertrophied or diseased tonsils, ade-
noids, and adhesion bands ; in older subjects we
find diseased tonsils, and adenoids or the remains
of adenoids, and adhesion bands, and in ad-
dition a third factor, a deflected septum. These
abnormalities produce a diseased nasopharyngeal
condition which is reflected on the whole body,
and this, in conjunction with the improperly treated
inhaled air, which is so poorly absorbable, gives
rise in turn to a condition of the body tissues in
which germ grOAvth or infection is allowed. These
abnormalities act to such an extent, in a purely
mechanical manner, producing disease by directly
interfering with the proper preparation of the air
as it is taken in, whether it pass through the mouth
as in the case of true mouth breathers, or through
an abnormal nasopharynx, that it is justifible to
refer to the process as the mechanism of the pro-
duction of disease. Thus the general condition is
brought about by a mechanical factor causing a
condition of suboxidation, or state of lowered re-
sistance. The infective or chemical factor is, of
course, of vast importance, but the degree of its
influence depends upon the extent of the mechani-
cal condition.
If sufficient oxygen is taken into the system, it
will keep the body well and burn up the dirt in-
haled, the germs and toxins absorbed, and any
other noxious material gaining access to the tis-
sues. This means not merely drawing sufficient
oxygen into the lungs, but its absorption in suffi-
cient (juantities by the lung alveoli from the inhaled
air. Thus the point of chief importance is the
percentage of oxygen the lung alveoli are capable
of absorbing from the inspired air. Are these ab-
sorptive powers normal or subnormal ? These
powers can only be normal, in the average alveoli.
634
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[New York
Medical Journal.
when the air is properly prepared, i. e., warmed,
filtered, and moistened, in its passage through the
nasopharynx ; this presupposes a normal naso-
pharynx, and the passage of the air through the
nasopharynx in a normal manner ; certainly not
as in mouth breathing. It is not so much the de-
gree of purity of the air that counts, within certain
limits, but the amount of air that will be absorbed
and pass into the system. The intimate connec-
tion between this and the state of the nasofossse-
tonsillar tissues will be explained. A deflected
septum with sinusitis and turbinal hypertrophy pre-
vents the air from reaching the lungs in proper
form for absorption in normal quantities. Mouth
breathing will do the same, as will hypertropied
tonsils and adenoids. Thus a state of lowered re-
sistance of the body tissues is produced which
permits growth of the tubercle bacilli and other
forms of bacterial life, absorbed most probably
from the tonsillar and nasal fossae tissues. In the
case of the lungs, direct implantation does ap-
parently take place. The importance of the gastro-
intestinal tract as a means of admission of the
tubercle bacillus and other germs to the body is less
than that of the nasopharyngeal.
Infection, leading to tuberculosis, presupposes a
peculiar state of the body, which can be quite
readily understood. There are various factors ab-
solutely necessary for its production. Tuber-
culosis is in every sense of the word a slow disease,
as regards onset, manifestation, and course. To
contract consumption a patient must first have his
tissues converted into a certain receptive state;
they must assume the nature of proper culture
material, wherein the growth of the tubercle
bacillus may go on undisturbed. This can be ac-
complished, ordinarily, in only one way — ^by a de-
ranged nose and throat.
7'his deranged nose and throat consists in all
cases of primarily three cardinal points. These are :
I. The presence of tonsils. The tonsils, whether
large or small, easily visible to the eye or invisible,
due to the fact that they are submerged or almost
completely covered by mucous membrane, and en-
tirely out of view behind the anterior tonsillar
I)illais, are diseased (chronic tonsillitis — Osier). 2.
Ti ssues found in the pharyngeal vault, consisting of
adenoids, or their remains, and adhesion bands. The
adhesion bands stretch between the Eustachian tube
and the pharyngeal vault, and the granulations
found among these bands are included under this
heading. 3. The presence of the deflected nasal sep-
tum, whether markedly deflected or only slightly so,
does not matter. This statement requires modifica-
tion in cases of most children less than six or seven
years of age. Though a deflected septum will not
frequently be found in their cases, nevertheless a
working condition equivalent to its presence will be
described.
That hyperthrophy of the turbinate bodies in-
cluding polvpoid degeneration and polypi is of im-
portance no one will gainsay ; this is equally true
of the various forms of sinusitis which are so fre-
fjuently met with in the accessory sinuses of the
nasal fossne. However, to any one doing much
nose and throat work along the lines suggested, it
must readily become apparent, that both turbinal
hypertrophy (including polypoid degeneration) and
sinusitis are merely pathological conditions result-
ing from the evil influences of the socalled three
cardinal points, and that almost invaribly if these
three factors receive proper attention the remainder
of the nasopharyngeal structures will take care of
themselves. Reducing the turbinates to about the
size they normally should possess is practically all
that is necessary (this includes attention to polypoid
turbinates and removal of polypi if present). Sel-
dom will it be found necessary to touch the si-
nuses. In children it will almost never be necessary
to touch these structures, since attention to the first
two cardinal points is usually sufficient ; the third
factor requires attention but infrequently.
The modus operandi of the production of tuber-
culosis varies with the age of the subject, though
in its final analysis is practically alike at all periods
of life, excepting the very old, or the very sick,
with completely broken resistance.
THK MECHANISM OF THE PRODUCTION OF CONSUMP-
TION IN THE YOUNG.
In the young it is produced by a mechanico-
chemical factor, producing a vicious cycle. The
child's tonsils become infected from sources due to
its environmental conditions : Kissing, speaking over
the child's face by its elders, and all forms of con-
tact with others, are probably the most prolific
sources of infection; food is another; likewise toys
and other articles the child puts into its mouth.
Germs of all varieties naturally enter the crypts of
the tonsils and the adjacent nasopharyngeal tissues
producing at first a slight cold (discharging rhini-
tis), light or severe coughs, or mild croupy attacks.
The tonsils swell up with each attack (hypertrophy) ;
the adenoids do likewise. The mucous membrane
of the nasal fossas undergoes a similar catarrhal
swelling; catarrhal ethmoidal sinusitis is present at
this stage. The swelling of the tonsils, adenoids,
and mucous membrane of the nasal fossae pro-
duces a mechanical obstruction of the nasal air
passages, interfering with proper nasal breathing,
causing mouth breathing, either constantly or in-
termittently. This is the "mechanism."
Two important chemical factors now enter, pro-
ducing the poisoning of the child, which is practi-
cally what it amounts to. i. The direct absorption
into the system of toxins or germs, or both, chiefly
from the tonsils, and also from the nasal fossae and
structures in the vault of the pharynx. Direct
pulmonary inhalation and direct gastrointestinal ab-
sorption would come next in importance in the
order named, but the efficacy of absorption from
these routes would depend entirely on the state of
normality or abnormality of the nasopliaryngeal
tract. Clinically, it is apparent that the tonsils play
the chief role, in the entrance of toxins or germs or
both to the body, causing the usual diseases found
in childhood. The tonsils seem to be the chief and
direct channel from the outside world into the sys-
tem, not excepting the method wliereby the tubercle
bacillus gains entrance to the body. It outranks the
nasal fossae, alimentary, genitourinary, and the
teeth (pyorrhea) since it is only necessary to recall
October 12, 1918.]
GLUCK: VALUE OF FRESH AIR IN TUBERCULOSIS.
63s
the fact that young children or infants have few or
no teeth.
2. This second factor is the production of
suboxidation, a condition where there exists too
Httle oxygen in the tissues and blood, insufficient
to burn up the toxins or germs circulating in the
blood or lodged in the tissues; i. e., insufficient to
permit the natural protective antibodies of the body
to work properly. This condition is brought about
by the mechanical obstruction of the air passages,
by the enlarged tonsils, or adenoids, and in all cases
also by the narrowed nasal passages, producing a
condition equivalent to the actual presence of the
deflected septum. The mucous membrane opposite
the anterior tips of both middle turbinates presents
a pyramidal swelling, simulating a deflected septum.
The child breathes entirely or almost entirely
through its mouth. In a certain percentage of cases,
an actual septal deflection will be found, but this is
.seen as a rule in children past the age of six.
Suboxidation is recognized ordinarily in the child
by the common symptoms of anemia, flabbiness,
malnutrition, lack of development, poor resisting
power to diseases, the ability to contract diseases
easily, the presence of the eczematous types of dis-
ease, which may be aural, nasal, or ocular ; and the
tissues of the child are more easily attacked by
germs. Naturally a low hemoglobin reading and
small red cell count is to be expected. Hence we
have slight colds (rhinitis), with its commonly
seen nasal discharge ; bronchitis with its well known
cough ; laryngitis with its familiar croup ; almost
the entire range of ear inflammatory diseases ; in-
numerable forms of eye disease, especially the
eczematous di.sease ; the entire gamut of the once
famous scrofulous disease; swollen cervical glands,
with or without discharging sinuses ; and as the
suboxidation becomes greater or the child is ex-
posed, perhaps a little more heavily than usual to
colds, stress, etc., the more serious conditions of
bronchopneumonia, pneumonia, pleurisy, pericardial
or endocardial lesions, nephritic, tubercular in-
fections ; also the entire range of the socalled
rheumatic infections, etc.
In other words the tissues of the child are con-
verted into such a state, and the resistance so
destroyed, that germ Hfe may grow easily. It is
well known that almost all ordinary species of germ
life are nearly always present on the surface of
all mucous membranes. Hence the exciting cause
is ever present, and all that is necessary for the
production of disease is to allow this condition of
suboxidation to supervene.
The vicious cycle operates as follows. The
more the tonsils and adenoids are infected, the
greater they naturally swell, and the greater th,e
swelling, the greater the interference with the nor-
mal nasal breathing. The more the child breathes
with its mouth, the greater will be the degree of
suboxidation, and the more easily will germs live
and proliferate and be absorbed from the naso-
pharyngeal tract to the detriment of the child.
Hence we have the vicious cycle leading to the pro-
duction of the terminal diseases of pneumonia,
diphtheria, tuberculosis, etc.
.That these deductions are correct can be proved
by the complete removal of both of the faucial ton-
sils, and the thorough cleaning out of the vault of
the pharynx. The child continues to grow, free of
almost all ailments thereafter. The vicious cycle
has been completely and easily broken.
No physician has a right to attempt to cure
eczematous keratoconjunctivitis without completely
enucleating both the faucial tonsils and thoroughly
cleaning out of the pharyngeal vault, every vestige
of adenoid tissue and adhesion bands, and assuring
himself of the fact that the septum is ordinarily
straight. This statement is equally true of all in-
filtrative inflammatory disease of the cornea. In
eczematous children it is absolutely essential to
finger scrape the pharyngeal vault repeatedly, sub-
sequent to the initial removal of the tonsils and
adenoids ; this should be done at stated intervals of
three, six, and nine months after the primary
operation. Beneficial results will be observed, as
a result of this finger scraping within a week's time
with almost mathematical accuracy. This is equally
true of eczematous diseases of all types, as found
in childhood.
The fingersnare method for complete enuclea-
tion of the tonsils, under local anesthesia (novo-
caine) is the best for all ages of the child. The
vault of the pharynx should be scraped by the
index finger (finger scraping) following a careful
use of the adenoid curette. It is also necessary to
remember to treat the vault of the pharynx in this
same manner, in periods varying from three months
to two to four times that length of time, subsequent
to the removal of the tonsils. If a piece of the
tonsil has been left over or returns, it is to be com-
pletely removed at the earliest opportunity.
The majority of deaths of slum babies, or for
that matter also of the better classes, is originally
caused, or has its foundation laid by diseased ton-
sils and adenoids producing the condition of the
nasal fossae described, and subsequently of the body.
The deaths of most of these children are pre-
ventable, by the timely removal of the tonsils and
adenoids. Not only does this hold true, regarding
deaths due to cardiac, respiratory, vascular, and
nephritic diseases, but it is equally true for aliment-
ary diseases, since they are seldom in themselves
the cause of death, but bring about diseases of the
cardiac, respiratory, nephritic, and vascular organs,
which are the direct cause of death.
In derision, it has been said that some men re-
gard the removal of the faucial tonsils as the
panacea of all diseases of childhood. It may not
be the panacea, but when combined with a thorough
understanding of the other two important factors,
the continuous maintenance of a perfectly clean
vault and a .straight septum, it will be the nearest
approach that has been made to it, and can undoubt-
edly be considered the foundation of good health.
METHOD OF PRODUCTION OF CONSUMPTION IN THE
ADULT.
In the acjult a vicious cycle is likewise established
resulting in a condition of suboxidation. The
principal reason for this is that the adult does
not receive the oxygen into his lungs in the proper
form in which it should be, thus producing sub-
636
GLUCK: VALUE OF FRESH AIR IN TUBERCULOSIS.
[New Yokx
Medical Journai.
oxidation. This is produced to a great extent by
the mechanical disarrangement of his nasopharyn-
geal organs, leading to easy growth and fermenta-
tion of germs in the nasal passages and structures,
and also in the tonsillar tissue and the tissues found
in the vault of the pharynx ; systemic absorption of
toxins or germs or both from these areas results,
producing milder or severer diseases and ultimately,
in many cases, tuberculosis.
We have in adults three cardinal points to deal
with. I. The diseased tonsils. The fact that some
tonsils appear quite harmless, is not in their favor ;
neither should their size materially af¥ect our judg-
ment, nor the fact that we can obtain no history
of sore throat. The tonsils occupy an even more
prominent part in the case of adults than they do in
the child, as the organ which gathers up, under ordi-
nary circumstances, more germ life and permits
more to be absorbed into the general system than
any other organ of the body. That is because
in the child the purely mechanical factor of nasal
fossae obstruction to air circulation is almost equal
in importance to the absorptive factor from the
tonsils and other nasopharyngeal structures ;
whereas in the majority of adult, cases, if the
mechanical factor of obstruction is present, it is
rarely produced by the tonsils, but most frequently
by the third cardinal factor, the deflected septum,
aggravated by the enlargement of the turbinate
bodies, and by the inevitable chronic catarrhal con-
dition of the mucous membrane of the nasal fossae
and accessory sinuses.
2. The presence of adenoids or their remains
acts by both the mechanical and chemical method
in assisting to produce this condition of suboxida-
tion. This process depends on the age of the
patient and the nature of the case. The adenoids
or their remains act as an absorptive area and assist
mechanically in obstructing the nasopharyngeal air
passages. In the younger adults we will still find
them present in large amounts. In older people they
will be found mostly atrophied, to a greater or less
extent, leaving bands of connective tissue (adhesion
bands), stretching between the vault of the pharynx
and the pharyngeal projecting ends of the Eu-
stachian tubes. The interspaces between these vari-
ous bands are the breeding and harboring spaces for
germs, which aid in infecting the tissues of the
tonsils and nasal fossae, and also act as direct absorb-
ing foci for the body.
The tonsils are the most important absorbing and
manufacturing organs for toxins, germs, or both,
that the body- has to contend with, and from them
more germs gain access to all the body tissues than
from any other source. The ability of the tonsils
to act in this serious capacity is only made possible,
in most cases, by the chemical and mechanical as-
sistance rendered it by the abnormal tissues found
in the vault, and the chemicomechanical pernicious
effect a deflected septum exerts on the organism.
The exceptions are those tonsils that are in them-
selves so viciously diseased that they themselves
can produce deleterious efifects on the organism ;
even these cases are invariably aggravated by
vault abnormalities and also frequently by a small,
high deflection of the septum. Patients afflicted in
the latter manner will, as a rule, never be found
as seriously affected as those in the former group.
The only abnormality of the nasal fossae which
is of prime importance is the deflected septum.
All other abnormalities of the nasal fossae are
secondary to it, and caused by it, or caused by the
deflection and the assistance rendered the deflec-
tion by the diseased tonsils and tissues in the
pharyngeal vaults. Practically all forms of sinusi-
tis, hypertrophy of the turbinates (including polypi
and polypoid degeneration of the turbinate), are
all secondary to the deflection, diseased tonsils, and
vault abnormalities, and owe their existence to the
presence of these latter conditions. The adenoids
or their remains and adhesion bands help to pro-
duce and aggravate these diseased conditions, in
proportion to their size.
In adults, as a rule, the most important factor is
the third cardinal point, the deflected nasal septum.
The importance of this as a factor is probably
greater than the absorptive part the diseased ton-
sils play, in allowing the infection to enter the
system.
We may claim that the presence of this third
cardinal factor is essential for the production of
tuberculosis, and therefore we may call the produc-
tion a purely mechanical matter, hence the use of
the term, the "Mechanism" of the Production of
Tuberculosis and other diseases. The importance
the deflection of the septum possesses as an in-
strument for the production of disease rests
fundamentally on the presence of the tonsils and
the abnormal tissues to be found in the vault of
the pharynx. Hence, in most cases, the presence of
the tonsils and abnormal tissues of the vault are
essential in enabling the deflected septum to pro-
duce diseased states.
For a properly performed submucous operation
to be a complete success, it is absolutely essential
that the tonsils be completely removed, preferably
preceding the submucous operation; a clean vault
is likewise essential. Where the tonsils remain
after a submucous operation the nasal discharge
(chronic catarrhal state) does not disappear, but
does so shortly after their complete removal.
Irrespective of the fact as to whether tuber-
culosis is produced by direct implantation of the
tubercle bacillus on the lung tissue itself, or is
conveyed there after absorption from the naso-
pharyngeal structures, or via the gastrointestinal
route, the tubercle bacilli could not possibly live
and grow, even allowing that they gain entrance by
various routes, unless the mechanical factors de-
scribed existed ; for if the oxygen were properly re-
ceived into the system, it would under ordinary
circumstances burn up (oxidize, by working
through the natural protective elements of the
body) the tubercle bacilli as fast as they gained
entrance. '
The importance of the third factor lies in the
fact that if the oxygen is to be assimilated by the
lung tissue in the normal percentage, it must be
properly prepared, that is correctly warmed, mois-
tened, and filtered; so that the lung alveoli can
absorb the proper proportion of oxygen, and give off
the normal amount of effete material, thereby en-
October 12, iqiS.l
GLUCK: VALUE OF FRESH AIR IN TUBERCULOSIS.
637
abling the body to take up the "sate margin" of
oxygen sufficient to burn up the toxins or bacteria
absorbed from mucous membrane surfaces. This
can only be accompHshed by the passage of the
air through normal nasal fossae.
. A person with a deflected nasal septum (in-
cluding the presence of ridges and spurs, which
are merely modifications of the deflection) can only
derive from one fifth to four fifths the benefit from
the air that a person with a straight septum does.
Or further, an individual with a straight nasal sep-
tum derives more benefit from a vitiated atmos-
phere than a person with a deflected septum derives
from a pure country atmosphere.
The condition of suboxidation in most adult
■ cases is produced by the state or states of the nasal
fossae described. These individuals are mouth
breathers, either constantly or intermittently, and
very frequently unknown to themselves. A normal
state of the nasal fossae is one wherein the nasal
septum is straight, making it possible for the two
nasal fossae to be equal in size, in all dimensions.
The air is then properly filtered, warmed, and moist-
ened, and can be absorbed by the lung alveoli, in
the normal amount. If the nasal septum is not
straight, thereby assisting in producing the other
abnormal conditions of the nasal fossae, the lungs
cannot absorb the proper amount of oxygen from
the air, which would be improperly prepared by
such nasal fossa;, suboxidation supervenes, germ
life, including the tubercle bacillus, may then easily
grow when implanted on the tissue just as the
seeds of the plant do when they fall on fertile
ground.
We have then this vicious cycle : The less oxygen
the lung alveoli can absorb from the inhaled air,
the greater the supervening state of suboxidation,
and the more pronounced the latter, the weaker
does the resistance grow ; with the constant absorp-
tion of bacteria, toxins, or both, taking place through
the tonsils and nasal fossae and with repeated colds
and other ailments the tissues finally become ripe
for the growth of the tubercle bacillus.
The longer the individual suffers from abnormal
nasopharyngeal conditions, the poorer will the re-
sisting qualities of his tissues become. The greater
the amount of absorption of bacteria and toxins
from the nasopharyngeal tract, the more pro-
nounced will the degree of intoxication of the in-
dividual's tissues be. TJie character of the environ-
ment to which the individual is subjected must be
taken into consideration ; the less perfect the less
time will it take to produce diseased conditions.
The strain and stress of the particular life the in-
dividual has to lead is naturally a highly important
factor. A careful person who is well protected by
kindly home influence will last longer than one not
quite so fortunate, although possessing the same
or perhaps not quite so abnormal a nasopharynx.
Dissipation in those, especially the young, afflicted
with an abnormal nasopharyngeal apparatus, leads
quickly to disease.
By deductive reasoning we must conclude that
we possess today a wounderful instrument for the
prevention of tuberculosis and innumerable other
ailments and for a more scientific handling of these
diseases when present.
By the employment of the above methods we
may, perhaps, achieve the eradication of tuber-
culosis in all its forms; but naturally this still re-
mains to be proved. It would appear that the body
can be considered in the light of a valuable machine.
The reason for breakdowns will thus be more easily
understood.
The similarity in the manner of production of the
common infectious diseases and tuberculosis must
readily become apparent to the clinician, when
looked at as above pitcured. The modus operandi
of their production is practically similar to the
production of tuberculosis. The diflference is due
to variety of infective agents, intensity of infec-
tion, difference in predisposing factors, such as ex-
posure and worry, wear an* tear, and stress and
strain of life, and difference in degree of abnor-
mality of the nasopharynx.
In practically all our cases of tuberculosis, we
can obtain on careful inquiry, a history of repeated
colds, poor health, and anemia ; frequently many
diseased conditions that may be referred to the
nasopharyngeal, and the respiratory system. These
histories usually cover quite a period of time. The
similarity of the histories will readily become ap-
parent on a close analysis, and undoubtedly greatest
stress must be laid on the nasopharyngeal factors
as the most important agents in bringing about
these pathological states. Pleuritic, pulmonary,
nasopharvngeal, laryngeal, and cardiac diseases owe
their existence primarily to the same causes, and
are only modified by the degree of intensity' of in-
fection, character of exposure, and diminished
local resistance {resistenti<r locus minoris), the mis-
fortune of being compelled to expose one part of
the anatomy more than another, and all the other
simple, ordinary, daily factors of this nature. Pri-
marily they hinge on a common origin, the abnormal
condition of the nasopharyx.
^^'e have, by the use of the above advised meth-
ods, a means of preventing a large percentage of
our childhood diseases, and if not completely, at
least we may make it possible that these appear in
a much milder form ; this is especially true of the
most serious diseases of childhood.
Here, too, is the key to the relief of most cases
of underdevelopment as found in children in all
walks of life: providing, that they were born nor-
mal and remained so until a few months subsequent
to birth.
We can also find here the explanation and cure
for the vast majority of cases of underweight,
malnutrition, and anemia, and the reason for the
inability to produce a cure in many diseases, such
as the eczematous type of disease in childhood
known in the older days by the general term of
scrofulous diseases, and including eczematous
keratoconjunctivitis, discharging ears, enlarged
cervical or submaxillary glands with or without
sinuses, etc. Chlorosis in young girls with its at-
tendant amenorrhea is another condition to be suc-
cessfully treated by this method.
The shock the general scapegoat "heredity" has
received up to the present from the medical pro-
638
CLUCK: VALUE OF FRESH AIR IN TUBERCULOSIS.
[New York
Medical Journal.
fession will be greatly intestified as the profession
in general realizes the tremendous importance the
above outlined work bears to the proper develop-
ment of the child, and that it most probably has an
all important influence in keeping the child free
from neurotic diseases.
It certainly is lamentable to feel that we possess
such inaccuarte methods, in attempting to prevent
tuberculosis or efjfect a cure in people afflicted with
it. The reason for this is that up to the present
the mechanism of production of the disease has not
been understood, but with a more thorough com-
prehension of this we will obtain more favorable
residts. We mistakenly attempt to eradicate the
disease with the body in the same state as when the
disease was contracted.
The object of the prevention of tuberculous and
many other diseases should be the destruction or re-
moval of the disease producing mechanism men-
tioned above, thus breaking the vicious circle estab-
lished and allowing the air to enter the lungs in the
proper form so that alveoli can absorb the oxygen
in the normal percentage ; likewise removing the
germ and toxin areas situated in the tonsils and
nasal fossae. This may be accomplished by, i, the
complete removal of the tonsils in all cases ; 2, re-
moval from the pharyngeal vault of all adenoid
tissue and adhesion bands (the last implies finger-
scraping the vault, at stated intervals), and 3, a
complete submucous operation to straighten the
nasal septum in those who require it.
If the above outlined work is a preventive of
consumption, it is logical to assume that it is also
the rational plan to be followed in attempting to
favorably influence the course of the disease. We
can say positively therefore that no tubercular
patient is properly treated unless his tonsils are
completely removed, and he is assured that in his
nasal fosss there exists a straight and thin nasal
septum, and that he possess a perfectly clean
pharyngeal vault, a fact to be repeatedly ascertained.
This practically means a complete submucous opera-
tion on the nasal septum in every tubercular adult,
provided the patient is able to undergo the opera-
tion. Naturally, the earlier all surgical work is
done, the greater will be the patient's resisting
power. Such a procedure can only be adopted,
under the most careful scientific handling, especially
as regards diet and prolonged rest in bed, or absence
from work. These rules the writer has found are
necessary only as regards tubercular cases ; all other
infectious diseases appear to be more benign and
amenable to surgical treatment and may be safely
handled in an ambulatory manner.
It will very seldom be found necessary to remove
much turbinate tissue; this refers to before, during,
or subsecjuent to the complete straightening of the
septum operation. A little trimming of the edges of
the middle turbinate on the concave side of the sep-
tum will be necessary, in order to reduce it to about
the normal size of a middle turbinate, but never to
less. This is equally true of the inferior turbinates.
Polypoid tissue of course, is to be removed, but al-
ways bearing in mind the necessity of sparing as
much of the turbinate tissue as possible.
Regarding the analogy of production, existing
between tuberculosis and innumerable diseases, we
may safely say they are produced in a manner ab-
solutely similar to tuberculosis and may be pre-
vented by steps similar to those used in preventing
tub&rculosis ; only more easily so, judging from the
difficulty of cure of tuberculosis.
The fight for sterilans magna which the body
is constantly struggling for, can easily be won with
a straight septum, absent tonsils, and clean vault,
but is more or less of a hopeless battle where these
conditions do not exist. The reason for the present
lamentable state of inaccuracy in the prognosis of
tuberculosis and innumerable other diseases can be
found in the patient's nasopharyngeal tract ; and
from the time when we regard the chances of re-
covery as proportional to the normality of the nose
and throat, this hazy state will disappear.
And finally, let us stop to consider the vast dif-
ference a normal nose and throat, so defined, would
mean to our boys in the trenches. The chances of
contracting tuberculosis would be ever so greatly re-
duced ; the chances of contracting innumerable other
ailments common to army and trench life, especially
pulmonary, meningeal, pleuritic, etc., would be
greatly minimized. Would it not mean healthier,
stronger, more resistant men, less likely to give way
under the necessary stress and strain of army life, to
tuberculous, nervous, cardiac, pulmonary, and oth^'r
diseases? It would mean more normal men in
general. In these men all that is necessary is the
removal of the tonsils and the production of a
thoroughly clean vault. Work on the septum
would be rather infrequently necessary.
During the writer's short stay at the Plattsburg
Training Camp recently, he was not at all sur-
prised to find that diseased tonsils and deflected
septi were as common as they are, even among
otherwise perfectly healthy men. And further,
when the examination of somewhat older men was
made, who had begun to show signs of deteriora-
tion, the invariable presence of diseased tonsils and
deflected septi, seemed to indicate a profund con-
nection between rather early degeneracy and an
abnormal nasopharynx. Proper attention to this
condition in early youth, might have avoided, or at
least ..greatly delayed this catastrophe and prevented
other diseased conditions.
There is one factor of vast importance — the com-
mon unhealthy practice of mouth breathing — to be
constantly kept in mind when discussing the im-
portance of the relationship of the nose and throat
to the production of disease. The majority of
patients with abnormal nose and throat are to a
greater or lesser extent mouth breathers although
they may be unconscious of the act ; during sleep
they are naturally unconscious of it. Proper nasal
breathing is an automatic act, which in a normal
nose and throat takes place spontaneously. After
a patient's nose and throat have been placed in a
normal condition he will naturally breathe through
his nose ; but as long as his nasopharynx is abnor-
mal he cannot breathe normally and will use his
mouth for breathing purposes a large part of the
time — a dangerous practice and one leading to
disease.
2626 Broadway.
Medicine and Surgery in the Army and Navy
IMPROVING THE SIGHT OF SOLDIERS
AND SAILORS AND RELIEVING PAIN.
A Suagestton to the Surgeon Generals of the Army
and Navy.
By W. H. Bates, M. D.,
New York.
Up to 1908 the United States required normal
vision in its army. In that year Bannister and Shaw
made some experiments from which they concluded
that a perfectly sharp image of the target was not
necessary for good shooting and that, therefore, a
visual acuity of 20/40, or even 20/ 70, was sufficient
for the soldier. This conclusion was not tmiversally
accepted ; but normal vision had become so rare that
it would, doubtless, have been useless to insist upon
it. The visual standard for admission to the army
was accordingly lowered to 20/40 for the better eye
and 20/ 100 for the poorer eye and it was further
provided that a recruit might be accepted when un-
able, with the better eye, to read all the letters on
the 20/40 line, provided he could read some of the
letters on the 20/30 line.
It is a matter of common knowledge that in the
enrollment of the present army these very low
standards have been liberally interpreted. It ap-
peared, no doubt, to those in authority that there
was nothing else to be done if an army was to be
raised at all, for even under these standards 21.68
per cent, of all rejections — thirteen per cent, more
than for any other single cause — were for eye de-
fects. To keep the enlisted eye defectives supplied
with glasses, an optical service has been organized
both for the training camps and the men at the
front, the overseas force consisting of a central
optical shop with eight auxiliary units.
^^^^ile the visual standards of the n?i.vy are higher
than those of the army, they are still below normal,
while, owing: to the extreme raritv of good eyesight
and the difficulty of securing the combination of
physical and mental qualities required for successful
flying, it is probable that the former high standards
of the aviation service are not being very strictly en-
forced. The British air service is very lenient in the
matter of visual tests, and it has been noted that (i)
some of the most famous of the British fliers have
had verv poor eyesight. On the currently accepted
theory that the only remedv for errors of refraction
is the placing of correcting lenses before the affected
eyes, this is truly an appalling state of affairs. No
aid to vision, however carefully adjusted, can com-
pensate for the loss of the natural powers of the
eye. No optical service, however excellent, can in-
sure that the lenses will not break, or become
clouded, at the moment when they are most needed.
For thirty years I have been of the opinion that
the usefulness of correcting lenses has been greatly
overrated, and I have lately been able to present
evidence (2) which seems to me to show con-
clusivelv that the defects for which they are worn
are functional and curable. Since the beginning of
the war I have had the privilege of making it pos-
sible for many young men to gain admission to the
army, or to favorite branches of the service from
which their eyesight had previously excluded them.
I beheve that' these benefits need not be confined to
the few, but that all soldiers and sailors may obtain
normal vision without glasses, and I have supplied
the Surgeon General of the Army with a plan
whereby this end might be attained with far less
time, trouble, and expense than will be necessitated
by the optical service on which we are now depend-
ing. The same method could be used with equal
success in the navy.
The plan is similar to the one used successfully
for eight years in the public schools of Grand Forks.
North Dakota, and for a shorter time in Rochester,
New York, and other cities. A Snellen test card was
hung in each classroom, and the children were di-
rected to read it every day with both eyes, also
with each eye separately — the other being covered
with the palm of the hand in such a way as to avoid
pressure on the eyeball. This required but half a
minute a day, but many children, finding that it im-
proved their sight, or relieved their discomfort, re-
peated the exercise at frequent intervals during the
day and were encouraged to do so. As the card
hung in the classroom all the time, the children
memorized it. It became a familiar distant object,
and they learned to look at it without the strain
always caused by unfamiliar distant objects.
At the front, or on the parade grounds of the
training camps, a Snellen test card might be imprac-
ticable ; btit there are other letters, or small objects,
on the uniforms, on the guns, on the wagons, or
elsewhere, which would serve the purpose equally
well. An officer has buttons on his coat with letters
on them. A noncommissioned officer has a belt with
cartridges. The letters, the cartridges, or the
spaces between the cartridges, could be used as
points of fixation.
Letters, or objects, which require a vision of
20/20 should be selected by some one who has been
taught what 20/20 means, and the men should be
required to regard these letters, or objects, twice a
day. After reading the letters they should be di-
rected to cover their closed eyes with the palms of
their hands to shut out all the light, and remember
some color, preferably black, as well as they are
able to see it, for half a minute. Then they should
read the letters again and note any improvement in
vision. The whole procedure will take not more
than a minute. It should be made part of the regu-
lar drill, night and morning, and men with imperfect
sight should be encouraged to repeat it as many
times a day as convenient. They will need no urg-
ing; most of Ihem are eager to adopt any means for
improving their sight, as imperfect vision is a bar
to advancement, and excludes them from the favor-
ite branch of the service, namelv, aviation.
In each regiment every ten men should be under
the supervision of one man who has been trained
in a manner to be described later. He should carry
a pocket test card, consisting of a few of the smaller
letters, and should test the vision of the men at th^
640
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
beginning of the training, and thereafter at intervals
of three months, reporting the results to the medical
officer in charge. Men wearing glasses should not
be required to take part in the drill, but when they
see the benefits of eye education they may wish to
practise it. They should then be permitted to do so,
but should be required to discard their glasses, as
the method will do them no good while these are
worn.
The method will not only correct defects of
vision that have become permanent, but will prevent
those deviations from the normal to which every
eye — no matter how good its sight may ordinarily
be — i.^ subject.
The normal eye is commonly supposed to have
Derfect sight all the time, but as I have pointed out
in a previous article (3), this is very far from being
the case It is unusual to find persons who can
maintain perfect sight continuously, even under the
most favorable conditions, and under the stress and
strain of army life it is not surprising that men
should frequently become more or less blind. Loss
of color perception is frequent among persons whose
sight is ordinarily normal. Night blindness of vari-
ous degrees is also common. Errors of refraction
of all kinds may be produced in normal eyes by
various kinds of mental and physical disturbances ;
many accidents in civil life and disasters in military
operations are doubtless due to this unrecognized
cause. Accidents to aviators, otherwise unaccount-
able, are easilv explained when one understands
how dependent the aviator is upon his eyesight and
how easily perfect vision may be lost amid the unac-
customed surroundings, the dangers and hardships
of the upper air. It was formerly supposed that
aviators maintained their equilibrium in the air by
aid of the internal ear, but it is now becoming evi-
dent from the testimony of aviators who have found
themselves emierging from a fog with one wing
down, or even with their machines turned com-
pletely upside down, that equilibrium is maintained
almost entirely, if not altogether, by the sense of
sight (4). If the aviator loses his sight, therefore,
he is lost, and we have one of those "unaccountable"
accidents that are so unhappily common in the air
service.
The cause both of continuous and of temporarily
imperfect sight is a strain or efifort to see, and eye
training is very successful in relieving and prevent-
ing this strain. All persons connected with the army
and navy, therefore, should make a daily practice of
reading small, familiar letters, or observing other
small, familiar objects, at a distance of ten feet or
more. In addition, aviators should have a few
small letters or a single letter on their machines, at
a distance of five, ten, or more feet from their eyes,
and should read them frequently when flying. This
will greatly lessen the danger of visual lapses, with
their accompanying loss of equilibrium and judg-
ment. Arrrmgements should be made for illuminat-
ing these letters for night flying or fogs.
Eye education is important, not only because it
improves the sight, but because the control of the
visual memorv obtained by palming, or the practice
of seeing black with the eyes closed and covered, is
extraordinarily efficacious in relieving pain and
fatigue and other physical discomforts.
Many years ago patients who had been cured of
imperfect sight by treatment without glasses quite
often told me that after their eyes were cured they
were always relieved of pain, not only in the eyes
and head, but in other parts of the body, even when
the pain was apparently caused by some organic
disease, or by an injury. The relief in many cases
was so striking that I investigated some thousands
of cases, and found it to be a fact that persons with
perfect sight, or the memory of perfect sight, do not
suf¥er pain in any part of the body, while pain can
always be produced in any part of the body by a
strain or effort to see.
Perfect sight does not necessarily mean the per-
fect visual perception of words, letters, or objects,
of a more or less complicated form. The color alone
is sufficient, and the color which it is easiest to see
perfectly is black. But perfect sight is never con-
tinuous. Careful scientific tests have shown that
persons whose sight is ordinarily perfect may lose
it temporarily for a few minutes, while most people
lose it even more frequently. For practical pur-
poses in relieving pain, therefore, the use of the
memory is more satisfactory. With eyes closed and
covered with the palms of the hands, shutting out
all light, a person with good eyesight who has had a
little training m the method is ordinarily able, in a
few minutes, or less, to remember or see a perfect
black. An untrained person may require the as-
sistance of some one who understands the method.
When the black is seen perfectly, a temporary, if
not a permanent, relief from pain always follows.
By this means surgical operations have been per-
formed and teeth extracted painlessly. The feeling
of heat, the feeling of cold, hunger, fatigue, and the
symptoms of disease, such as fever, weakness, and
shock, have also been relieved by it. If soldiers
understood this, not onlv much suffering, but many
deaths from pain, shock, hunger, thirst, or cold,
might be prevented.
A soldier in a trench full of water, if he can re-
member black perfectly, will know the temperature
of the water, but will not suffer from cold. He
may succumb from weakness on the march, but will
not feel fatigue. He may die of hemorrhage, but
lie will die painlessly. The method would also ob-
viate the necessity for using morphine to relieve
pain, and would thus prevent the soldier from be-
coming the victim of lifelong morphine habit.
The Germans use a bullet which breaks when it
strikes the bone and causes intense pain ; the men
often die of this pain before help arrives. When
they are rescued the surgeons at once give them
morphine. A few hours later the injection is prob-
ably repeated. Then the drug is given less fre-
quently, but in many cases it is not discontinued en-
tirely while the man is in the hospital. A Red Cross
surgeon at a recent meeting of the New York
County Medical Society stated that he had been
responsible for producing the morphine habit in
10.00c soldiers, and that every physician at the front
had done the same. By such a simple method as
palming all this might be prevented. If the black
can be remembered perfectly with the eyes open,
the same benefits will be obtained as by palming,
and since there are times, as with soldiers on the
march, when palming is not feasible, all soldiers
October 12, 1918.] MEDICINE AND SURGERY IN THE ARMY AND NAVY.
641
should be taught to remember black with their eyes
open.
Why the memory of black should have the effect
of relieving pain cannot be fully explained ; but it
is evident that the body must be less susceptible to
disturbances of all kinds when the mind is under
control, and only when the mind is under control
can black be remembered perfectly. That pain
can be produced in any part of the body by the
action of the mind is not a new observation, and if
the mind can produce pain, it is not surprising that
it should also be able to reHeve pain.
To provide a corps of instructors in eye educa-
tion and palming, ten men — either officers, physi-
cians, or privates — who have normal vision and do
not wear glasses, should first be trained by an ex-
pert. Each one should then train ten other men,
and each of the latter should train ten more. In
this way an endless chain will be started which will
soon provide competent instructors for every divi-
sion in the army and every vessel in the navy. All
nurses, all Red Cross or Y. M. C. A. workers, and
all members of the Medical Corps should qualify as
instructors, as they will have constant occasion to
use the method for the rehef of pain. If the
method is to be a success it must be practised by
those in authority as well as by those in humbler
positions. It is so simple that the rank and file
cannot be expected to take it seriously unless they
see that those of higher rank think well enough of
it to use it themselves.
REFERENCES.
I. PARSONS: U. S. Naval Med. Bull.. April, 1918. 2. BATES'
^EW \oRK Medical Journal, May S. 191 5, and May 18 1918
3. IBID: September 8, 1917. 4. ANDERSON: Lancet. March 16.
1918. p. 39S. HUCKS: Scientific American, October 6, 1917
p. 263.
40 East Fgrtv-first Street.
INFLUENZA AT THE PORT OF
EMBARKATION.
Sick Detached from Command Bound Overseas —
Hospitals Filling Up — Types of Infection
Segregated.
The movement of commands for overseas service
has not been materially afifected by influenza. All
save three of the camps in the United States have
reported the presence of the disease and every traui
load arriving at the Port of Embarkation brings its
varying quota of cases. No attempt is made to isolate
the contacts, as this would mean the complete cessa-
tion of the movement of troops, but all the men
affected are at once detached from their commands
and placed in hospitals. The Port of Embarka-
tion, which has its headquarters at Hoboken, em-
braces all the Atlantic ports from Baltimore north-
ward. Through this port as high as 300,000 troops
have taken ship for Europe in a single month. As
the incidence of the disease grows this means an
enormous concentration of influenza patients in the
niilitary hospitals in this district. Fortunately the
disease runs its course in a brief time, ordinarily in
a week or less, except where pneumonia develops.
On account of the rapid shifting of the military
population_ of the Port of Embarkation, and the
rapidity with which the influenza has increased, no
reliable statistics are available as to the total num-
ber of cases here nor as to the exact proix)rtion of
patients in whom pneumonia develops. The mor-
tality in the pneumonia cases varies from fifteen to
twenty per cent., the mortality in the different
camps and hospitals running quite uniformly in
each particular camp. The symptoms developed
are also fairly uniform for each camp. In some
of the camps vomiting is almost uniformly present,
in others it is absent. Nosebleed occurred in one
camp for a while, but eventually disappeared.
Since the disease is conveyed by direct, droplet, in-
fection, the utmost care is taken to isolate patients.
.\s soon as a soldier is reported on the sick list, he
IS required to put on a mask of gauze, or in the ab-
sence of gauze to tie his handkerchief over his nose
and mouth so as to prevent spreading infection
among his comrades. The patients are removed as
promptly as possible to hospitals where an effort is
made to segregate the different strains of infection.
As far as possible the patients are separated from
each other by curtains around the beds. Nurses
and surgeons are required to wear gauze masks
when on duty in the influenza wards. The treat-
ment is purely symptomatic and no general order
has been issued regarding it, each surgeon or each
medical service following its own ideas regarding
treatment. The administration of aspirin, salipyrin,
or other salicylic compounds, is the routine treat-
ment ; where cough or pneumonia develops they are
treated symptomatically.
When the disease made its appearance the Sur-
geon of the Port of Embarkation, Colonel J. M.
Kennedy, M. C, conferred with the commanding
officers of the various camps and hospitals vmder
his supervision, made ample provision for hospitals
and personnel and outlined the general policy to be
pursued in handling the situation. In view of the
wide variation of conditions existing in the several
camps no general order has been issued by the Of-
ficer of the Port, Brigadier General W. V. Judson,
but the commanding officer of each command has
issued general orders, of which the following is a
typical specimen :
Sl'FXIMEN OF GENERAL ORDERS ISSUED BY CAMP COM-
MANDERS.
Owing to the present dangerous epidemic of influenza.
Camp will be closed until further orders, com-
mencing at Retreat, this date. Official and purely business
activities not specifically mentioned will not be interrupted,
due care being taken by all concerned to observe effectively
both the letter and spirit of disease preventive measures
enjoined. The following is ordered:
(a) The issue of passes to enlisted men, other than those
required 'n the course of official business, will cease. Mar-
ried soldiers quartered outside of the reservation by
authority are excepted from this provision.
(b) Officers on duty with troops will remain with, or
in close contact with, their commands, and they will not
be permitted to leave camp for personal reasons other than
under exceptional circumstances, the responsibility of de-
termining which will lie with their commanding officers.
(c) Individual enlisted men of all organizations and
detachm.ents will be restricted to the area of their re-
spective camp section, which includes barracks, mess halls,
and latrines, the necessary exceptions required for the
transaction of official business being strictly interpreted.
This restriction does not apply to out of door formations
in charge of an officer or noncommissioned officer.
(d) Visiting days and the privilege of entrance to camp
connected with them are discontinued.
(e) All normal activities will be discontimied by the
642
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York .
Medical Journal.
Young Men s Christian Association, Knights of Columbus
and Jewish Welfare Board. Hostess House activities will
cease, except that they will be permitted to receive per-
sons who have been summoned by the commanding officer,
base hospital, on account of the dangerous illness of rela-
tives. The Liberty Theatre and entertainment halls will be
closed. Camp exchanj;es will be closed to individual busi-
ness, but goods may be sold to organizations through their
officers.
(f) The previous memorandum (concerning influenza)
is hereby rescinded, and the following will be exactly and,
scrupulously carried out.
(g) This order, together with Memorandum No. 25, will
be read at three successive formations to all permanent
organizations, to all transient organizations now in camp,
and to all incoming organizations after arrival.
MEMORANDUM NO. 25 — CONCERNING INFLUENZA.
With a view to limiting the spread of the present epi-
demic of influenza the following instructions are pub-
lished for the information and strict guidance of all con-
cerned, and to be observed in connection with General
Order No. 30.
"Influenza is a crowd disease. Epidemics are more ex-
tensive and complications more frequent and serious
according to degree of overcrowding."
(a) In barracks a minimum of fifty square feet of floor
space for each man is required. The type of barracks in
use at Camp , at the rate of sixty-six men per build-
ing, conform.s to these requirements. AH commanders will
check the number of men quartered in barracks under
their control. Where it is found that less than fifty square
feet of floor space per man exists, stens will be immedi-
ately taken to remedy this condition.
(b) Free ventilation of barracks is necessary — keep win-
dows open day and night. Arrange bunks so that no two
adjoining men have heads together (alternate head and
foot arrangement).
(c) Every effort v,'ill be m.ade to keep men in the open
to the greatest extent permitted by weather, by means of
drills, marches and games.
(d) Spitting on the floors must be absolutely prevented.
Men will be cautioned to cover their mouths and noses
with handkerchiefs when coughing and sneezing. Every
man shov/ing evidence of a cold or other ailment will be
immediately sent before a medical officer.
(e) Individual drinking and toilet articles must be in-
sisted upon.
ff) In mess halls men will be seated on one side of the
table only, all facing the same direction. This provision
will no doubt require doubling of service. All individual
mess equipment will be scalded after each meal.
(g) Floors of all occupied barracks will be freshly oiled.
(h) Daily inspection of all barracks will be made by an
officer of the organization, and by a medical officer. If
the command has no medical officer, inspection will be
made by the camp surgeon's office.
(i) The greatest reliance in combating this disease must
be placed upon careful and continued personal effort to
observe sanitary precautions, and to bring about com-
pliance with the above regulations. All persons connected
with Camp , of whatever grade or status, are cau-
tioned and directed to cooperate in their respective spheres,
in the effort to check the spread of this disease.
(j) This memorandum will be read at three successive
formations to all permanent organizations, to all transient
organizations now in camp, and to all incoming organiza-
tions after arrival.
In each camp the epidemiologist has drawn up a
set of instructions as to proper hygienic precautions
for the guidance of the troops. Copies of these
are given to the officers and these are read to all
of the men who are required to conform with the
instructions there laid down. These instructions
are along familiar lines as to personal hygiene. The
soldiers are required to arrange their cots so that
heads and feet alternate, and as far as possible
curtains are hung between the beds.
BACTERIOLOGICAL STUDIES OF THE DISEASE.
Laboratory investigations in the various stations
of the Port of Embarkation show that, since July,
ships returning from European ports have had
epidemics of influenza on the voyage. With the
permission of Colonel Kennedy, surgeon of the port,
Major E. H. Schorer, M. C, chief of the clinical
laboratory of the port, has supplied the following
information. From the first these were investigated,
but usually all the men had recovered by the time
New York was reached. Cultures were made from
the nasopharynx, tonsils, and sputum, and influenza-
like bacilli were found in about fifty per cent, of the
cases. In addition, streptococci, hemolytic and non-
hemolytic and Micrococcus catarrkalis were found
at tunes.
The investigations in the camps and hospitals in
the Port of Embarkation were begun as soon as
cases appeared. The methods and technic had first
to be developed, and the amount of material that
required examination was so large that some time
was required to evolve reliable and suitable methods
to get all the information desired. With a fairly
uniform technic in the various laboratories results
have still varied considerably, largely due to the
fact that the troops are only transient and come
from all the cantonments and camps of training.
Investigations have been concentrated on i, nose
and throat cultures of influenza patients so that
those patients with similar infection might be segre-
gated ; 2, study of the cultures from pneumonia
sputa ; 3, blood cultures ; 4, investigations at au-
topsy ; 5, white blood cell and differential counts.
1. Nose and throat cultures. — During the winter
and spring when many nasopharyngeal cultures
were made for the detection of meningococcus car-
riers, influenza bacilli were so frequently found that
surprise was often expressed that the disease, influ-
enza, did not exist. In this epidemic, however, in-
fluenza, bacilli have been less frequently found in
the nasopharyngeal cultures. In all over 5,000
cultures were examined.
The results vary markedly, influenza bacilli being
found in from four per cent, to ninety per cent, of
the cases, hemolytic streptococci in from one per
cent, to ninety per cent, of the cases and pneumo-
coccus in from 3.3 per Gent, to twenty-four per cent,
of the cultures taken at the various hospitals and
camps. This difference in results may, however, be
more apparent than real. Opportunity was pre-
sented at one hospital to get good data on naso-
pharyngeal and tonsil cultures, and out of ninety-
one patients from whom nasopharyngeal and tonsil
cultures were taken, influenza bacilli were found
only six times in the nasopharynx as compared to
seventy-eight times when the tonsil cultures were
taken. Hemolytic streptococci occur frequently and
so do pneumococci, but not so frequently as influ-
enza bacilli. The taking of throat cultures is advo-
cated so that cases can be segregated. In a series
of contacts studied hemolytic streptococci were
found in 7.8 per cent, of the cases as ccunpared with
Ten per cent in the influenza patients in the hospital.
2. Examination of sputa in pneumonia. — A large
number of snuta have been examined — about 1,000
October 12, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
643
to date. In these, influenza bacilli are found in a
large percentage, especially when mice or rats are
used to test with. Pneumococci are very frequently
found. The relative occurrence of the types at dif-
ferent hospitals is shown in the following tabula-
tion :
a bed
Type 1 3 7 69 I
Tyoe II 16 13 0 2
.A.typical Tvpe II o 8 0 o
Type III 5 29 o 2
Type IV 3.1 102 16 14
Hemolytic streptococci are being found in about
ten per cent, of the pneumonia sputa.
3. Blood cultures. — About 200 blood cultures have
been made. The blood is generally sterile and, so
far, influenza bacilli have not been found. Hemo-
lytic streptococci have been found on a few occa-
sions and pneumococci about ten times as fre-
quently.
4. Autopsies. — A considerable number of au-
topsies have been performed. Generally the trachea
is congested and red and frequently contains sero-
purulent and blood stained exudate. The lungs may
show either complete consolidation or bronchopneu-
monia, but always intense engorgement, and fre-
quently solution of the red blood cells. Adhesions
and empyema have seldom been found, probably be-
cause death has occurred too early for their devel-
opment. The bacteriological findings at autopsy
show that influenza bacilli occur in the tracheal
exudate and the consolidated areas but that hemo-
lytic streptococci and pneumococci occurred in the
lungs in at least one half of the pneumonic lungs.
5. White blood cell and differential counts. — The
white blood counts have shown generally but little
increase in the total number of white cells, even
when pneumonia existed. The differential counts
frequently have shown an increase in the percentage
of lymphocytes.
There can be no doubt that the epidemic is due to
the influenza bacillus, but the pneumococcus and
hemolytic .streptococcus are responsible for some of
the severe complications. The particular type of
the complicating organism is probably determined
by the type already prevailing at the camp or can-
tonment.
MEDICAL NEWS EROM WASHINGTON.
Surgeon General Ireland's Record. — Major General Noble
Becomes .■iss'stanf Surneon General for Overseas Serv-
ice.—Three Neiv Brlfiadiers. — Authority Asked to Requi-
sition Hospital Buildings and Sites. — Navy Staff Deaths
front In^uencn. — Promotion for Naz'y Officers. — For
Instruction of Physically Defective.
W.ASHiNGTON, D. C, October 5, 1918.
Perhaps no army appointment in recent years has
met with such universal approval in the regular
service as that of Major General Meritte W. Ireland
to be Surgeon General of the Armv, with the rank
of major general, to succeed Major General William
C. Gorgas, who reached the retiring age of sixty-
four ^ears on October 3d. General Ireland for
some time has been serving as chief surgeon on the
staff of General Pershing in France. Several months
ago. information came to Washington that the Army
Medical Service in France, including both perma-
nent and temporary officers, the Red Cross authori-
ties there, and others having to do directly and
indirectly with medical and surgical activities in
connection with the army in the war zones, were
practically unanimous in favor of the selection of
General Ireland for appointment as Surgeon Gen-
eral, and the same attitude was taken among the
permanent officers of the Medical Corps in this
country. This not only was on account of his pre-
eminent fitness for the place, but also because he
could bring to it the valuable experience gained with
the forces in France.
Service approval also attends the appointment of
Brigadier General Robert E. Noble, Medical Corps,
to be major general, for the period of the emerg-
ency, for service abroad, vice General Ireland.
Appointments also have been made of Colonel
James D. Glennan, of the Permanent Medical
Corps, and of Colonels James M. T. Finney and Wil-
liam S. Thayer, temporary officers of that corps, to
be brigadier generals in the Medical Corps, "during
the existence cf the present emergency."
The last army appropriation act authorized the
appointment of one assistant surgeon general, with
the rank of major general, for service abroad dur-
ing the present war (the place that has been held
by General Ireland and to which General Noble just
has been appointed), and two assistant surgeon
generals, who shall have the rank of brigadier gen-
eral, all of whom shall be appointed from the
Medical Corps of the Regular Army, and two major
generals and four brigadier generals to be appointed
from the Medical Reserve Corps. Most of these
latter places remain to be filled.
The Secretary of War has asked Congress to
enact legislation authorizing him to requisition
lands, buildings, etc., or to make temporary use
thereof, for hospital purposes. It is explained that
there is an urgent necessity for the enactment of this
legislation. Under existing law, unless the particu-
lar hospital it is proposed to acquire is so related to
a particular training camp that it may be considered
a part thereof, there is no authority under which it
can be acquired except by purchase or lease, or by
the slow process of condemnation under the general
laws on that subject. These laws do not meet the
requirements of the existing emergency according
to the armv medical authorities. The experience of
the War Department in attempting to lease a va-
cant hospital, the need for which was urgent, was
futile, as the owners of the property refused to sell
unless they could get what the authorities consid-
ered an exorbitant price, and they would not en-
tertain a proposition to lease it to the government.
The need for hosnital facilities . for sick and
wounded returning from the battlefields of Europe
becomes incrcasinglv great as more and more
American troops are getting into the combat, and
the permanent and temporary facilities alreadv pro-
vided hy the army are inadequate to cope with the
sitiwtion.
5{c ^ 5j: ^
Doctors and nurses are paying a heavy toll in the
fight against the epidemic of influenza, and this is
•644
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
particularly the case with the navy, where a number
of medical officers have given up their lives in de-
votion to duty, the latest reports indicating that at
least eight commissioned officers, one pharmacist,
and six members of the Women's Nurse Corps have
died as a result of contracting the disease. At ^he
Naval Training Station, Great Lakes, 111., no less
than twenty-four members of the Hospital Corps
(male) have died of pneumonia developing from in-
fluenza.
The navy medical officers whose .deaths have
been reported are Lieutenants G. M. Neuberger, at
Naval Hospital, League Island, Pa. ; Bronson E.
Summers, Marine Camp, Quantico, Va. ; John L.
Fisher, Battleship Kearsarge ; M. J. Carroll, Naval
Hospital, Newport, R. I. ; G. T. Courtney, U. S. S.
America; J. A. McCarthy, Naval Hospital, New
London, Conn. ; James L. King, Dental Corps, Naval
Base, Hamnton Roads, Va., and another at Philadel-
phia, whose death has not been reported officially.
Certain staff officers of the navy have become due
for promotion to the ranks of lieutenant commander,
lieutenant, and lieutenant (junior grade), by
seniority, as a result of proftiotion of their "running
mates" in the lines, as of September 21st. In the
Medical Corps, Lieutenants Ruskin M. Lhamon,
Robert A. Torrance, Clarence W. Ross, Carleton I.
Wood, Foster H. Bowman, Chalmer H. Weaver,
William A. Brams, William W. Wickersham, Cecil
S. O'Brien, Charles W. Depping, Henry McDonald,
William H. Michael, William A. Stoops, Talmadge
Wilson, Joel T. Boone, Walter W. Cross, Henry M.
Stenhouse, Joy A. Omer, Summerfield M. Taylor,
Frederic L. Conklin, John Harper, Richard H. Mil-
ler, Paul Richmond, Jr. ; Forrest M. Harrison, Law-
rence F. Drumm, George W. Taylor, Walter A. Vo-
gelsang, Elphege A. M. Gendreau, Grover C. Wil-
son, Russell J. Trout, and Virgil H. Carson are due
for temporary promotion to the rank of lieutenant
commander; and Lieutenants (junior grade),
James F. Finnegan to and including Boyce L. Bran-
non on the list for temporary promotion to the
rank of lieutenant.
Among the additional building projects just au-
thorized by the War Department to be carried out
under the construction division are the following :
Six two-story barrack buildings to be added to the
general hospital No. 14 at Fort Oglethorpe, Ga., to
cost about $123,000. Additions and improvements
to existing buildings at the base hospital at Camp
Stuart, Va., at a cost of about $449,000. The new
buildings will consist of additional officers' quarters,
laboratories, storehouses, and alterations to the ad-
ministration building, receiving ward, nurses' infir-
mary, and nurses' quarters.
*****
At the suggestion of the Public Health Service,
copies of a circular of instruction for draft regis-
trants rejected in the draft because of physical de-
fects have been sent to all the local draft boards
throughout the country. Surgeon General Rupert
Blue, of that service, has pointed out that in the
first draft about one-third of the men examined were
rejected for physical disabilities and that hundreds
of thousands will be added as a result of the ex-
aminations to be made of new registrants. It is
believed to be highly desirable that the men found
to be disqualified for military service by the ex-
aminmg physicians of the local draft boards should
receive instruction as to the meaning of their dis-
abilities and that a strong appeal be made to them
to correct these disabilities as far as possible. The
object not only is to reclaim men for the m.ilitary
service or for such service as they can perform, but
also to lessen the burden of illness and disability
among those engaged in essential industrial work.
It is hoped that the instructions in this circular,
which is really a primer of the physical defects of
the nation, will reach far beyond the draft boards
and be utilized by all agencies interested in improv-
ing the public health to instruct the people with
regard to their physical deficiencies and the ways
and means by which they can be remedied.
According to the Public Health Service, experi-
ence everywhere shows that the proportion of per-
sons with physical impairments is considerably
greater in persons between thirty and forty than in
those between twenty and thirty years of age. This
waning vitality at ages over thirty, so commonly
accepted as inevitable, can be postponed to a large
extent. In this connection it is pointed out that
sixty per cent, of the physical defects found in the
last draft were of a preventable or curable nature.
The circular now being distributed, which was pre-
pared by the Public Health Service, contains specific
information relating to the commoner causes of re-
jection or deferred classification, among them being
defective eyesight, teeth and feet, underweight,
overweight, hernia, hemorrhoids, varicocele, vari-
cose veins, bladder, kidney, and urinary disorders,
ear trouble, heart affections, high blood pressure,
lung trouble, rheumatism, venereal disease, alcohol,
nervous and mental disease, and miscellaneous
conditions.
*****
At present the only government hospital serv-
ices available for the care of beneficiaries of the
war risk insurance are the hospitals and relief sta-
tions of the Public Health Service, as the hospitals
of the army and navy cannot be used for the treat-
ment of discharged soldiers and sailors under the
law. An appropriation of $10,500,000 has been
asked to provide for this service.
Among the largest problems connected with tJiis
work is the caring for discharged soldiers and sailors
suffering from tulferculosis ; and, as 10,000 already
have been discharged and are eligible for compensa-
tion and sanatorium treatment, the government sana-
torium at Fort Stanton, N. Mex., has been filled to
its capacity, and difficulty is being found in securing
bed space in local hospitals, where the cost of main-
tenance is greater than in government institutions.
It is proposed to place hospital and sanatoria
additions at the following places : Boston. Chicago,
Cleveland, Detroit ; Evansville, Ind. ; Louisville,
Ky. ; Norfolk, Va. ; New Orleans, San Francisco,
Seattle, St. Louis ; Wilmington, N. C. ; Fort Stan-
ton, N. Mex. ; and Berkshire Hills, N. C.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. dh M. SAJOUS. M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Un3er Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, OCTOBER 12, 1918
THE PREVAILING INFLUENZA.
The very rapid spread throughout most of our
Army cantonments and through large sections of
the civil population of what has been called Spanish
influenza has quite naturally aroused the profound
interest of both the laity and the medical profes-
sion. This interest has led to the expression of
opinions by physicians which are more or less con-
tradictory and some of which are of a highly spec-
ulative nature. It is opportune, therefore, to pause
a moment to sift what seems to be the wheat from
what is obviously the chaff.
The very name, "influenza," calls to mind the
great pandemic and raises the question of the simi-
larity between this outbreak and the older one. Cer-
tain it is that the general features of the disease are
much the same now as they were in the influenza of
1890, but some differences are noticeable. In the
present outbreak there seems to be a small propor-
tion of cases of very brief duration — three days or
less ; the period of convalescence seems to be shorter
in a krge number of the brief cases ; complications
seem to be far less numerous and varietl now than
before and even of less frequent occurrence. In
fact they are almost limited to the development of
a bronchopneumonia, which, while comparatively in-
frequent, is extremely fatal in type. Finally the
intestinal form of the disease, so common in the
former outbreak and still often seen in the sporadic
disease, seems to be generally absent from the pres-
ent epidemic. It is difficult to interpret these clin-
ical differences, and others of less striking nature,
in the present state of our know-ledge, but they do
not seem sufficient to be used as arguments for the
lack of identity of the present epidemic and the spor-
adic influenza or the pandemic of 1890.
The causative organism of the disease still re-
mains a matter of dispute, and European authorities
particularly record the most divergent views as to
the specific organism. The studies reported by
Major E. H. Schorer (p. 642), by Lieutenant J. J.
Keegan {Journal A. M. A., September 28, 1918, and
the observations of Dr. William H. Park (p. 621),
all made in this country, seem to point to the Bacil-^
Ills influenz(.c of Pfeift'er as the causative organism,
or at least as one of the organisms, which in symbi-
osis, produce the disease. Keegan even goes so far as
to express the belief that the influenza bacillus is
the primary cause of the bronchopneumonia, strep-
tococci and pneumococci being merely secondary in-
vaders. It should be borne in mind, how-ever, that
the B. infliicnzcc has not been universally accepted
as the specific cause of endemic influenza, or of the
disease as it prevailed in 1890. From the point of
view of possible prophylactic immunization, the set-
tling of the question of the specificity or lack of it
of the B. iuflucnscc is a matter of the greatest im-
portance.
The pathology of the disease is quite unimpor-
tant save in the cases with bronchopneumonia. This
complication, or type of the disease, as the case may
be, varies from the rare instances of very severe in-
flammation of the capillary bronchioles and a few
small patches of lobular consolidation to the com-
mon type of widespread, confluent areas of bron-
chopneumonic consolidation. This subject is ad-
mirably covered in the paper by Dr. Douglas Sym-
mers on page 641 of this issue.
The treatment of this widespread affection seems
to fall naturally into three divisions. The first is
that of prophylaxis, both individual and communal.
The extraordinary infectivity of the organism and
the absence of absolutely characteristic early symp-
toms tend to make all ordinary prophylactic meas-
646
EDITORIAL ARTICLES.
[New York
Medical Journal.
ures less e/Tective than might be anticipated, but
there can be no question o£ the utility and necessity
of immediate isolation of the individual, the quar-
antine of cantonments or institutions, and the avoid-
ance of crowds in enclosed places. The universal
use of face masks by those ill with the disease and
by those in attendance upon it, scarcely requires
comment, and the same may be said in favor of al-
ways covering the mouth and nose with the hand-
kerchief in coughing or sneezing, its importance is
so great. The observance of good general hygiene,
an adequate diet, and living as much as possible in
the fresh air, should be urged upon all. Elsewhere
in our columns (p. 621) will be found some sugges-
tions as to the possible value of prophylactic immun-
ization with a killed influenza vaccine, and we must
leave the reader to the perusal of Doctor Park's
paper for more detailed discussion. The treatment
of the attack and of convalescence constitutes the
second division of the therapy of this disease, and
we would add little to the excellent suggestions made
by Dr. Walter A. Bastedo (p. 626). Special em-
phasis, however, ought to be laid upon the fact that
there is no specific treatment, and that one's thera-
peutic aims must be largely limited to the relief of
distressing symptoms and the avoidance of compli-
cations so far as possible. Time seems to have es-
tablished the salicylates as among the most effective
of the symptomatic remedies in influenza, and it has
even been suggested by some that they have more
or less definite specific action. However that may
be, if they are used they should be given in suffi-
ciently large doses to produce their eflfects and the
urine should be watched, although their potential
dangers to the kidneys have been decidedly exag-
gerated. There is certainly nothing to be gained by
the combination of caffeine with the coal tar antipy-
retics, and there is the possibility of danger. Atten-
tion should be directed to the fact, so often over-
looked, that if one or two average doses of acetan-
ilide or acetphenetidine, or other coal tar antipyretic,
do not relieve the symptoms, no further amount,
however large, will prove more effective. Their
exaggerated dangers neeci not be feared if this fact
is remembered.
Finf-.lly, the treatment of the complications, in
the present epidemic at least, largely resolves itself
into dealing with the very serious bronchopneu-
monia. Although suggested, it seems questionable
whether the use of Type I pneiunococcus serum in
cases showing this type of organism will prove of
any real value, because of the probability that other
organisms are as much concerned as the pneumococ-
cus, or more so. However, its use can do no harm,
and controllerl observations will soon settle the ques-
tion. The use of digitalis as a routine is to be com-
mended, but one should be quite certain of the ac-
tivity of his preparation and should also be on guard
to note the appearance of the first signs of toxic
action of the drug. Unless digitalis is pushed to
near the toxic stage its effects are much inferior to
what may be secured otherwise, and the best is none
too good in so fatal a pneumonia as this.
The prognosis seems to depend almost wholly
upon whether a bronchopneumonia develops or not.
If it does not develop, the outlook is extremely fa-
vorable, while if pneumonia supervenes the condi-
tion is entirely reversed, and a mortality of about
fifty per cent, or over can be expected. Statistics
are not yet available to indicate the morbidity rate
of the disease in the civil population, but in canton-
ments the rate is very high, and it would be fair to
anticipate that possibly as high as a quarter of the
population in invaded civil communities might be af-
fected. The rapid spread of the disease from Spain
over the European continent, to England, and thence
to our Atlantic seaboard, whence it has followed the
lines of travel inland, would lead to the anticipation
that the disease would continue its course across our
continent in epidemics of about a month's duration
in each of the communities to which it gains access.
RESPIRATORY DISEASES IN ARMY
CAMPS.
Anything that can throw light upon the trans-
mission and widespread occurrenc of respiratory
diseases is of utmost value to all civil communi-
ties. In army camps it is a matter of most essen-
tial importance. The study of these diseases
therefore in their incidence and prevalence has
both an immediate and a more lasting service to
perform. A detailed report of such a study by
two members of the medical staff of the army
lays emphasis upon a number of practically im-
portant features [Colonel V. C. Vaughan and Cap-
tain G. T. Palmer: Communicable Diseases in
the National Guard and the National Army of the
United States during the Six Months from Sep-
tember 29, 1917, to March 29, 1918, Journal of Lab-
oratory and Clinical Medicine, August, 1918].
This study would necessarily be somewhat in-
complete and indefinite. In the first place, it has
not been easy to obtain as full statistics from civil
life as desirable for comparison. Then it is also
impossible in the comparatively brief period for
observation afforded by the alterations in camp
life to watch closely the conditions of develop-
ment of disease, modes of transmission, and all
the factors which should enter into account. The
October 12, 1918.]
EDITORIAL ARTICLES.
647
writers have, however, brought many facts to at-
tention and suggested important lines for future
consideration and action.
It is undisputed that the prevalence of these
respiratory diseases is higher than in comparable
areas of civil life, and that both the morbidity and
the mortality rates exceed those of ordinary com-
munities. The study occupies itself chiefly with
respiratory diseases, under which practically all
the communicable diseases of our camps may be
included. Venereal diseases and the typhoids
are practically the only exceptions. The mention
made here of their incidence is brief, because of
the control secured at the present time over the
one group, and because the nature of the other
does not bring it under the same study of relation
to environment and mode of transmission as the
respiratory diseases.
Most numerous of the diseases incapacitating
the men for a shorter or longer period are colds,
influenza, bronchitis, and mumps. Pneumonia
and meningitis, on the other hand, have caused
the most serious loss of life, while measles alone
has been a very serious factor in incapacitation
of the men. Measles as well as the lesser ail-
ments also have a predisposing efifect toward
pneumonia. There has been a wide diflPerence in
the camps both in morbidity and mortality from
pneumonia, and the question is asked whether
the form of the disease has differed. Both lobar
and bronchopneumonia are reported. The latter
seems to have been usually the more fatal. It is
also more frequent as a secondary affection, par-
ticularly following measles. The pneumococcus
has been responsible for both forms of pneumo-
nia. The Streptococcus hcmoh'ticus has also
been reported as causing both these forms with
more frequent empyemic complication and
greater fatality than in the pneumonia caused by
the pneumococcus.
The wide survey of the appearance and results
of these diseases in all their variety in the vari-
ous camps, differently located as they are, and
drawing their men very often from the very lo-
cality in which the camps are found, offers many
suggestive fields for still further study. The
transference from one camp to another has been
an important factor, as this has introduced the
disease already incipient in many of the men
transferred, or lying latent in them as healthy
carriers. All these and many other features the
writers have passed in comparative review.
They conclude that the factor upon which most
emphasis must be laid is the natural susceptibil-
ity of the men. The other factors are variable
and of only secondary importance. Upon the
susceptibility of the men, however, they act as
upon ready soil, and it is this fundamental fact
which therefore best offers itself for protective
measures on the part of the medical control.
Susceptibility is due to lack of opportunity to
build up a resistance through an acquired im-
munity. This is particularly evident among
Southern men. Also weaker physiques are re-
sponsible, and it was found that the presence of
hookworm disease was a factor here. The igno-
rance of the men in regard to dissemination
through spitting and the like, the necessarily
close contact when coughing, sneezing, or even
in conversation — all these are participating fac-
tors. External conditions such as exposure, fa-
tigue, insufficient clothing, are then aggravating
elements which lessen resistance.
It is recommended that the induction into
camp should be more gradual and that there
should be more care in detecting incipient dis-
eases both before entering men and before trans-
ferring them from one camp to another.
INFLUENZA AND THE PUBLIC HEALTH
SERVICE.
That Congress should so promptly appropriate
$1,000,000 for work against the epidemic of
Spanish influenza, now raging in the United States,
reflects credit on our chosen representatives.
Within a few hours after the money was voted,
ofificers of the United States Public Health Service,
cooperating with the Red Cross and the Council of
National Defense, had organized several units of
doctors and nurses and hurried them to Massachu-
setts, where the epidemic has thus far raged most
intensely. In its extensive and rapid spread the
present epidemic reminds older practitioners of the
visitation of i8qo; certainly none of the outbreaks
of so called grippe of recent years have been so
widespread.
From foreign sources we learn that the epidemic
in Germany during June and July of this year occa-
sioned considerable controversy as to the nature of
the infection, much of it being carried on in the
newspapers. On the one hand, eminent authorities
expressed the view that it was caused by the in-
fluenza bacillus of Pfeiffer ; on the other, men
equally eminent insisted that the influenza bacillus
bore no causal relation to the disease. In this
coimtry opinion appears divided, and while it is ad-
mitted that the influenza bacillus is present in the
nasal or bronchial secretions in a large proportion
of cases (eighty per cent.), some of the best ob-
648
EDITORIAL ARTICLES.
[New York
Medical Journal..
servers are unwilling to regard this organism as the
sole etiological factor.
In this state of affairs, it is encouraging to know
that Surgeon General Blue has requested the Medi-
cal Division of the National Research Council to
initiate extensive laboratory investigations in dif-
ferent parts of the country, sending a specimen of
all pure cultures thus obtained to the United States
Hygienic Laboratory for comparative study. In
this connection, it may be well to recall the inter-
esting results obtained some time ago by Foster, in
his study of common colds. As our readers may
remember, considerable evidence was presented to
show that such colds were frequently caused by an
ultramicroscopic organism, a so called filterable
virus. The report of the United States Pubhc
Healih Service will undoubtedly be awaited with
interest.
A CANADIAN MINISTRY OF HEALTH.
To get the Canadian Government to give due
consideration to the formation of a Ministry of
Health with a view to prompt action, a strong
committee of those interested in such a Ministry
for Canada has been organized at Ottawa. Those
who have followed this question for the past
twenty years know that the Canadian Medical
Association has upon different occasions passed
numerous resolutions favorable thereto, has fre-
quently and fully debated the question, and has
on several occasions sent representative deputa-
tions to Ottawa to request the Federal Govern-
ment to act in this direction. The matter also
has been frequently debated in the House of
Commons, with the result, now becoming rather
monotonous, that it has always been shelved.
In public health matters Canada is in this po-
sition : At least six departments of the Govern-
ment have separate bureaus of public health ; and
the object is to consolidate all these under one
responsible Minister of the Crown. It is equally
well known that in all these years the main oppo-
sition to any scheme of a united public health
administration comes from the deputv heads of
departments who, it is understood, objected to
give up anything in the way of patronage in their
respective departments. Now, however, that
Canada is abolishing the patronage system — and
the evidence that business is meant in that direc-
tion commences to show itself — that objection
can no longer be tenable. The position in Can-
ada has been something like that prevailing in
England, where departmental heads have for
long blocked so desirable a system.
THE INFLUENZA SITUATION.
The influenza epidemic continues to spread and
has now made its appearance in every part of the
United States. Both in the number of cases and in
the number of deaths reported Boston still main-
tains its unenviable lead, but the latest reports show
a slight decline in the number of cases and of deaths
reported. The number of patients in the camps con-
tinues to grow, a total of 13,605 cases having been
reported on Wednesday. There were 2,930 new
cases of influenza and 212 of pneumonia reported'
on Wednesday in New York, a decrease of forty-
two in the number of new cases reported for the
preceding twenty-four hours. One hundred and
twenty-four deaths were reported from influenza
on Wednesday and 166 from pneumonia. A total
of 17,712 cases have been reported in the city up to
Wetlnesday night. The orders issued by the De-
partment of Health fixing the hours of opening and
closing business houses and places of amusement
with a view to diminishing the crowding on trans-
portation lines has had some effect, but it is charged
that this effect has been partially nullified by the
failure to provide an adequate number of cars.
One public school has been closed in the city.
Places of amusement have been notified that they
will be closed up if they are crowded or ill venti-
lated. The members of the senior classes in^the
medical schools have been assigned to duty to help
in nursing in the various hospitals. A clearing
house for influenza patients has been established
by the Commissioner of Health. An influenza clerk
has been assigned to duty at the Department of
Health and will answer telephone calls for informa-
tion as to hospital accommodations and medical
attendance.
A VOLUNTEER NOT AN ENFORCED
SERVICE.
The organization of the Volunteer Medical
Service Corps was hailed a wise move to coordinate
the reserve forces in the medical profession. It
had the express approval of the Surgeon General of
the Army, the Surgeon General of the Navy, and
the Surgeon General of the United States Pubhc
Health Service, all of whom took part or were
represented in the organization meeting of the corps
held r.t the Hotel Willard, Washington, on May 5th.
Since that time the President of the United States
has formally approved of the corps.
Unfortimately, however, in the zeal for enlisting
volunteers some of the literature sent out by the
organization smacked rather of a conscription than
of a volunteer organization. Some physicians have
construed the appeals as commands and vigorous
protests have been made against the too strenuous
campaign for membership in the corps. In order
that the entirely voluntary character of the organi-
zation may be made clear the following notice has
been issued by the officers of the corps:
No official or committeeman representing the Volunteer
Medical Service Corps or the General Medical Board of
the Council of National Defence is now authorized or has
October 12, 1918.]
OBITUARY.— NEWS ITEMS.
649
been authorized to favor any organized or unorganized
method of coercion in inducing members of the medical
profession to join the Medical Corps of the Army or Navy,
or the Volunteer Medical Service Corps. Our committee-
men are especially urged against favoring any movement
that v.'ould threaten to impair a medical man's standing in
his local, state, or national society because he refused to
enroll in the Army or Navy, or the Volunteer Medical
Service Corps.
It must be made clear that the Volunteer Medical Serv-
ice Corps is a volunteer organisation which has for its
object the enrollment and classification of the profession.
Its members are entitled to wear an insignia which will
clearly indicate that they have offered their services to the
government, when such services are needed. Patriotism
cannot be created by coercion. It also must be made clear
that the Volunteer Medical Sei'vice Corps has for its pri-
mary object furnishing its classification to the Army, the
Navy, the Public Health Service, the Red Cross, and Pro-
vost Marshal, as well as to civilian institutions and com-
munities, as a guide in providing for their needs to the best
advantage.
The object of the corps is not to disturb any medical
man in the performance of any duty to which he has been
assigned by any governmental agency either for service at
the front or at home.
This announcement is signed by Edward P. Davis,
president, Volunteer Medical Service Corps, and
Franklin Martin, chairman of the General Medical
Board, Council of National Defense.
CLIMATE AND HEALTH.
"It is your htiman environment that makes
climate."
This ■w'\se saying of Mark Twain's should be kept
in mind by the physician when considering the ad-
visability of sending a patient away from home.
Fortunately, this disposition of the sick is not so
frequent as formerly, but when it is made, it is too
often done thoughtlessly and with dire results.
The bodv lives by change — by stimulation, and
often a change of scene — in other words, a manifold
stimulation of the settse receptors by new surround-
ings does a great deal of good. But stimuli are of
two sorts : those which elevate and those which
depress the vital functions, and for the benefit of
health, a change of climate must not impose hard-
ship through loss of happy companionship and
homelike surroundings. A sensitive patient, lacking
the warmth of sunny friends, wotild pine in an
atmosphere otherwise surcharged with healing in-
fluences. An untold amount of pain from nostalgia
may be imposed, by change of climate, upon those
already sick.
On the other hand, where the human environment
at home is at fault — where nonappreciation and
nagging and family jars of all descriptions lay the
nerves bare and aggravate old weaknesses, the
change of climate is invaluable, though it does not
matter much where the patient goes. One should
not be deceived into thinking that it is ozone, or
altitude, or varied scenery, which brings about the
improvement. Could the human environment in the
home have been adjusted the results would have
been as remarkable. If the physician could only
remove the family skeletons and oil the machinery
which is responsible for family friction, he would
become a master hand at the making of what, for
medical purposes, we call good climate.
Obituary
CLARENCE FAHNESTOCK, M. D.
Major, Medical Corps, U. S. Army.
Dr Clarence Fahnestock, of New York, who en-
tered the army a year ago and was assigned to the
301st Infantry soon thereafter, died in France on
Saturday, October 5th, of pneumonia and was buried
with military honors near the front on Sunday.
Doctor Fahnestock entered the army as a line officer
but later took up his surgical work and was made
surgeon to his division. Major Fahnestock was a
son of the late Harris G. Fahnestock, vice-president
of the First National Bank of New York. He was
born in New York in 1873 and was educated at
Berkeley, Harvard, and the University of the State
of New York, obtaining his degree in 1900. He
was a member of the house staff of the Presbyterian
Hospital and later specialized in the New York Eye
and Ear Infirmary. He was widely known as a
hunter of big game. He made three trips to Africa
and Alaska in pursuit of that sport.
^
News Items.
Clinical Assistant Wanted. — There is a vacancy in-
the tJrological Clinic of tlie West Side Dispensary and
Hospital; three evenings weekly; splendid opportunity;
experience desirable but not essential. Communicate with
Dr. Abr. L. Wolbarst, 328 West Forty-second Street, New
York.
Public Health Meeting Postponed. — Owing to the
prevalence of influenza in all parts of the United States
the executive committee of the American Public Health
Association has postponed the annual meeting of the
association, which was to have been held in Chicago
next week.
New American Hospitals in France. — ^Thirty thou-
sand beds are ready for American wounded in a series
of new hospitals established in southern France under
the command of Major W. H. Browne, of Detroit. Hos-
pital units composed of American physicians and nurses
are being sent to Nice and other cities along the Ri-
viera, where the hospitals are located.
Deutscher Verein Now a Red Cross Hospital. — The
former German club on Central Park South, New York,
was turned over to the Red Cross on Wednesday even-
ing, October 9th, under whose direction it has been
transformed into a convalescent home for American
soldiers and sailors. The new name of the one time
Deutscher Verein is Lafayette House. It is the first
of several in the metropolitan area which will provide
50,000 beds for convalescents. Lafayette House is fur-
nished luxuriously. There are fifty-five rooms in all
and thirty-five bathrooms. Everything is ready for the
reception of patients.
The Morgan Disaster. — On Friday evening, October
4th. an explosion occurred in the shell loading plant of
T. A. Gillespie & Co., at Morgan, N. J., just south of South
Amboy. Following this explosion, which seems to have
been caused by an accident, a series of disastrous explo-
sions and fires occurred which lasted for nearly two days.
Nearly a hundred of the workmen in the plant were killed
and many others were injured. All the windows in the ,
buildings at South Amboy and surrounding villages were
shattered by the explosions and some of the buildings
wrecked by the exploding shells. A large number of physi-
cians, nurses, and ambulances were sent to the scene of the
disaster from New York and from the cities and canton-
ments of New Jersey. The entire plant, valued at some-
thing like $15,000,000, was wrecked, but will be rebuilt im-
mediately
650
NEWS ITEMS.
[New York
Medical Journal.
Influenza Increasing in Philadelphia. — For the twen-
ty-four hours ending at noon on Wednesday, October
9th, 4.013 new cases of influenza were reported, and in
the same period 304 deaths from influenza and 124 from
pneumonia were reported. ,
The Red Cross Reports. — The war council of the
American Red Cross has planned to issue a series of re-
ports to the American people concerning the use of the
first Red Cross war fund of $100,000,000. The first sec-
tion of these reports, issued September i, covers the work
of the Red Cross in caring for the families at home of
America's men on military service.
Camp Mills Quarantined. — Camp Mills, at Rlineola,
Long Island, was placed under quarantine on Wednes-
day, October 9th, by order of the military authorities.
No public statement accompanied the order further than
that the action taken was a precautionary rather than a
remedial measure. It is reported that a call had been
sent out for more nurses and doctors.
Medical Students Drafted as Nurses by the Health
Department. — At the request of Dr. Royal S. Copeland,
health commissioner of New York, the deans of the
various medical colleges in New York have given their
consent to fourtli year medical students dropping their
studies temporarily to aid in nursing influenza patients
in the city hospitals. As a result about 250 men were
added to the hospital nursing forces on Thursday morn-
ing, October loth. These medical students will work
under the direction of graduate nurses.
Coming Meetings of Medical Societies in New York.
— The following medical societies will meet in New York
during the coming week :
Monday, October 14th. — Society of Medical Jurisprudence; New
York Ophthalmologricai Society; Yorkville Medical Society; Asso-
ciation of .Mumni of St. Mary's Hospital, Brooklyn; Williamsburg
Medical Society.
Tuesday. October istli. — New York Academy of Medicine (Sec-
tion in Medicine); Federation of Medical Economic Leagues of
New York.
Wednesday, October i6th.^ — New York Academy of Medicine (Sec-
tion in Genitourinary Diseases); Geriatric Society; Medicolegal
Society; Northwestern Medical and Surgical Society of New York;
Wonien's Medical Association of New York City; Alumni Associa-
tion of City Hospital.
Thtirsday, October 17th. — New York Academy of Medicine (stated
meeting) ; New York C"eltic Medical Society.
Friday, October iSth. — New York Academy of Medicine (Section
in Orthopedic Surgery); Clinical Society of the New York Post-
graduate Medical School and Hospital; New York Microscopical
Society; Brooklyn Medical Society.
Resolutions on the Death of Dr. Morris Jacob Kar-
pas. — The New York Neurological Society, at an ex-
ecutive session following the regular meeting of October
I, 1918, unanimously passed the following resolutions:
Whereas, The New York Neurological Society has learned with
I)rofound regret of the untimely death in his thirty-ninth ytar, on
July 4, toi8, in France, of angina pectoris, of Dr. Morris Jacob
Karpas, major in the United States Army Medical Corps, by whose
death the society ha? been deprived of one of its most valued
members, a contributor to its scientific transactions of material of
exception.ll merit, and a man of pleasing personality and of broad
knowledge, particularly in his special field of medicine; and
Whereas. The New York Neurological Society feels that the
death of Dr. Morris Jacob Karpas is a great loss to modern medical
science, for not only was he possessed of imusual attainments, but
he unselfishly devoted his energies, time, and interest to the fur-
therance of t!ie amelioration of the sufferings of those wounded in
the present war, and to the application of all practical measures to
this end. At the time of his death he was engaged in the organiza-
tion of a large base hospital of the American army at Favanay,
France. He was born in Russio, was graduated '^rom Long Island
College in 1004, and war one of the leading physicians of New
York city, contributing untiring seviccs to the Neurological Insti-
tute, to Bellevue Hosjiital, and to the Montefiore Home and Hos-
pital; and
Whereas, The members of The New ^'ork Neurological Society
mourn the loss in the death of Dr. Morris Jacob Karpas of a deir
colleague, ever kind and courteous, and attached to many of them
by close ties of personal friendship; therefore be it
Resoh'ed. That The New York Neurological Society^ offer to the
family of Dr. Morris Jacob Karpas deep sympathy and condolence
in their sorrow, and express the hope that they will find comfort
in the consciousness of the nobility of his death and the strength of
his patriotism, and in the remembrance of his splendid usefulness
to his fellow men in the important activities which he so well and
thoroughly performed; and furthermore be it
Resolved, That these resobitions be spread upon the minutes and
that a copy be transmitted to the family of the deceased.
For Tie New York Neurological Society:
Frf.perick Tilney, President.
Charles E. Ataood, Secretary.
American Association of Clinical Research. — The
tenth annual meeting of the association will be held at the
Hotel McAlpin, New York, Saturday, October igth, under
the presidency of Dr. Rogej M. Griswold, of Kensington,
Conn. On account of so many members of the association
being in active service overseas, it was found necessary to
compress the proceedings into a one day session. Dr.
James Krauss, 419 Boylston Street, Boston, is permanent
secretary of the association and will be glad to furnish
information regarding the meeting to any one interested.
Meetings of Medical Societies to Be Held in Phila-
delphia during the Coming Week. — Monday, October
14th, County Medical Society (directors) ; Tuesday, Oc-
tober 15th, West Brar.ch of the County Medical Society ;
Wednesday, October i6th. County Medical Society (busi-
ness meeting). Section in Otology and Laryngology, Col-
lege of Physicians ; Thursday, October 17th, Academy of
Stomatology, Section ni Ophthalmology, College of Physi-
cians, Northeast Branch of the County Medical Society,
North Atlantic Tuberculosis Conference ; Friday, October
iSth, Logan Medical Association.
Assistant Physicians Wanted in State Institutions. —
Among the positions for which the New York State Civil
Service Commission will hold examinations on Novembc
9th is that of assistant physician in state hospitals and
TOther positions of a similar nature in various State and
county institutions. The salary in the state hospitals is
$1,200 a year, increasing $100 each year to $1,600, with
maintenance. The examination is open to men and women
who are licensed medical practitioners in New York State
who have had six months' experience on the resident staf?
of a general hospital, or who have been engaged in the
practice of medicine for one year. For application form
address the State Civil Service Commission, Albany, N. Y.
Volunteer Medical Service Corps Classification. — The
Committee on Classification of the Council of National
Defense announces the classification for the organization
of physicians who volunteer for service in the corps :
Class I. — Physicians who were first recommended by the Cen-
tral Governing Board to apply for commissions in the Medical
Reserve Corps of the Army, Reserve Force of the Navy, or for
appointment in the Public Health Service. They include physi-
cians under fifty-five years of age. who are without an obvious
physical disability which is disqualifying, and who have not more
than one dependent in addition to self; or who have an income
or whose dependents have an income sufficient for the support of
dependents other than that derived from the practice of their
profession.
Class II. — Physicians under fifty-five years of age who are without
an obvious physical disability which is disqualifying, and who have
not more than three dependents in addition to self. These will be
recommended by the Central Governing Board, when the need
exists, to apply for commissions.
F.rcepticns in Classes I and II. — There are several exceptions
provided for because of evident essential needs. Whether a physi-
cian's services are essential to his community will be established
by the C'^ntral Governing Board on recommendation of represen-
tatives of the board appointed by it to make a survey of local con-
ditions. Whether a physician is essential to an institution with
which he may be connected will be established after conference
between representatives of the Central Governing Board and repre-
sentatives appointed by governing bodies of the institutions con-
cerned. Similarly, the question of whether a doctor is essential to
a health department will be established by conference between the
Central Governing Board and the head of that health department.
The question whether a teacher in a medical school is essential to
that position will be established by the Central Governing Board
and representatives of the institution. Conference between the board
and accredited representatives of industries concerned will deter-
mine v/hether doctors employed as industrial physicians are essential
in those positions. A physician essential on his local or medical
advison.' board will not be requested to assume conflicting duties.
Class TIL — Physicians under fifty-five years of age who are with-
out an ob'"ious phvsical disability which is disqualifying, but who
have more than three dependents in addition to self; and they are
the physicians included among the exceptions from Classes I and
II, namely, those essential to communities, institutions, health
departments, medical schools, or industries. They will be recom-
mended by the Central Governing Board to apply for commissions
when the emergency is so great as to demand their ser\'ices.
Class IV. — Physicians who are ineligible for commissions in the
Medical Reserve Corps of the Army, or Reserve Force of the
Navy, but who are available for all other services. The physicians
in this class include those over fifty-five, those having an obvious
physical disability which is disqualifying, and those rejected for all
governmont services because of physical disability.
Physicians not professionally eligible for the Medical Reserve
Corps of the Army or for the Reserve Force of the Navy, or for
appointment in the Public Health Service, will be recorded but
not admitted to the Volunteer Medical Service Corps.
The editorial note which appears in another column
makes it quite clear that the corps is a volunteer corps
and that no one is under compulsion to join it.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
STROPHANTHUS AND ITS ACTIVE PRIN-
CIPLES VERSUS DIGITALIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
Until recently the chief features differentiating
strophanthus from digitalis as regards clinical use
comprised merely the more rapid action of the
former ; a presumably less pronounced constricting
action on the blood vessels in the case of strophan-
thus ; a looser union of its active principle with the
heart ; and a much less marked proclivity to "cumu-
lative action." Strophanthus was also believed more
prone to cause diarrhea than digitalis, and was
known to possess local anesthetic and mydriatic prop-
erties— which could not, however, be clinically
availed of, owing to its marked toxicity. It was
held less likely than digitalis to constrict the coro-
nary vessels in full doses and, according to Cushny,
strophanthin failed to raise the pressure in the pul-
monary artery, whereas digitalis sometimes did raise
it. Altogether, definite knowledge of the compara-
tive action of the two drugs, while somewhat greater
than that in respect to the other members of the
digitalis series, was quite insufficient, and the main
indications for strophanthus in preference to digi-
talis were practically confined to cases in which a
rapid effect on the circulation was desired and cases
in which digitalis had failed or caused untoward
side efifects, and other measures had, therefore, to be
tried. The former preferential use was itself inter-
fered with, moreover, by reason of the fact that
strophanthus was considered uncertain in action
when taken by month, and even more irritating than
digitahs when administered hypodermically.
Of late a beginning, at least, seems to have been
made on the task of more precisely defining the
pharmacodynamic and clinical relationships of the
two drugs. In this the increasingly widespread use
of the active principles from different species of
strophanthus has no doubt played an important part,
accuracy of observation with such principles being
more readily secured than in the case of the less
readily absorbed preparations of the whole drug. At
the same time it is well known that the various stro-
phanthins commercially available may differ mark-
edly in composition and strength. The official defini-
tion of strophanthin as "a glucoside or mixture of
glncosides obtained from Strophanthus komhc" it-
self suggests an indefinite composition, incompatible
with a constant degree of activity. For this reason
the most reliable studies of strophanthin action are,
in general, those conducted with ouabain, or gratus
strophanthin, which, while unofficial, occurs in a
definitely crystalline form of constant pharmaco-
dynamic activity. Ouabain prepared by the Thorns
method appears to be more toxic than that prepared
bv the method of Arnaud (Pratt, 1918), but when
either of these products is used, identical results
from that product even in the hands of different
observers are to be expected.
From the clinical viewpoint, the most positive
stand in differentiating the action of strophanthin
from that of digitalis has been taken by Vaquez
and Lutenibacher, 1918, of Paris. These observers
have been led to ascribe the former occasionally
fatal results from intravenous strophanthin therapy
to the multiplicity of products labeled "strophan-
thin" on the market, and believe that in the ex-
clusive use of Arnaud's ouabain, given intra-
venously, but in a dose not exceeding half a milli-
gram, no undue risk is entailed.
Vaquez establishes a sharp contrast between oua-
bain and digitalis as regards their actions on the
contractility, tone, and conductivity of the heart.
He lays stress on the following sequence of events
frequently met with in mitral valvular disease: For
a considerable time digitalis proves effectual in re-
moving all symptoms, without the assistance of any
other remedy. Then, from one day to the next, in
the absence of any noticeable change in the morbid
condition, of any excessive pleural or peripheral
fluid accumiulation, or of any intercurrent infection,
digitalis becomes inefl:"ective, no matter in what form
or dose it is given. This Vaquez and his associates
ascribe to loss of myocardial tone — a function of
the heart upon which, from his viewpoint, digitalis
has no hold under clinical conditions, in spite of
prevailing opinion to the contrary. They agree with
the conclusion of Merklen that when digitalis is
given to patients with pronounced cardiac dilatation,
edema often persists and cardiac insufficiency be-
comes worse even though the drug has slowed the
heart rate. This is accounted for by what Merklen
terms the dissociated action of digitalis. By increas-
ing the duration of diastole and causing the ventricle
to distend more completely during this period, the
strain upon the ventricle, it is asserted, will exhaust
it if the myocardium no longer possesses sufficient
tonicity. Under such conditions, according to Va-
fiuez, the active principles derived from strophan-
thus yield unexpectedly good results. Ouabain ad-
ministered by mouth induces, in his experience, un-
pleasant side effects — presumably manifestations of
gastrointestinal irritation — before its action on the
heart has begun. Intravenous injection, with due
care to introduce all of the solution into the vessel,
lest a sharp local reaction ensue, is therefore the
route to be preferred. Usually half a milligram of
ouabain in one mil of water is given. A quarter
of a milligram is hardly effectual, but may be tried
where the case is not urgent or for the purpose of
testing the patient's sensitiveness to the drug and
o1)viating all chance of overaction from a subse-
•luent dose of half a milligram. Doses exceeding
lialf a milligram expose the patient to malaise,
nausea, and even vomiting.
Apart from certain special circumstances, Vaquez
;>dministers the second injection of ouabain twenty-
four hours after the first, and follows it by a third
and a fourth injection at like intervals. Giving
more than four injections is seldom indicated and is
652
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
possibly harmful. The main indication for ouabain
in preference to digitalis is a combination of cardiac
insufrtciency, as shown by the usual symptoms and
signs, with loss of tonicity of the myocardium. This
indication exists chiefly in two conditions — acute di-
latation of the heart and progressive dilatation defi-
nitely rebellious to other remedies. Vaquez even
asserts that ouabain, while acting selectively on the
contractility and tonicity of the heart, exerts on the
conductivity only a negligible action from the clin-
ical standpoint.
Quite recent studies by Pratt seem to support Va-
cjuez's view of a qualitative difference between the
clinical effects of strophanthin and those of digitalis,
at least in so far as their action on the contractility
of the heart is concerned. Further reference to
these observations will be made in the succeeding
issue.
{To he continued.')
The Relation of Food Idiosyncrasies to the
Diseases of Childhood. — Fritz B. Talbot {Boston
Medical and Surgical Journal, August 29, 1918) says
that it was formerly the custom to determine gross
errors in diet by the microscopic examination of the
stools, to see if there was too much fat, starch, or
meat passing through the digestive canal undigested.
It is now possible, by means of the "skin test," to
find out which particular food is at fault. The
"skin test" is the linear incision, which breaks the
skin of the forearm just enough to draw serum but
not blood. To this scarification is applied the food
protein to be tested. If the patient is sensitive a
characteristic urticarial wheal, surrounded by a red
roseola, appears, the reaction coming in from two
to ten minutes, and fades in one half to two hours.
A careful study of anaphylactic cases has shown
that many individuals have a hereditary predisposi-
tion to sensitization. In twenty-eight cases of
asthma studied by the writer, sixty-two per cent,
gave a family history of anaphylaxis. In cases,
therefore, that give a pronounced history of hay
fever, asthma, or eczema in the direct ancestors,
special care should be taken when introducing a new
foreign protein into the diet. It should be given in
such a manner that it will cause immunity and not
sensitization. For example, if a nursing infant, with
a family predisposition to sensitization, is given cow's
milk at intervals of ten days or longer, instead of
daily, it might become sensitized to cow's milk, in
the same manner that animals are experimentally
sensitized.
During infancy and childhood practically all cases
of sensitization are due to foods, since food is the
commonest foreign protein with which they come in
contact. During growth, however, a child adapts its
body and habits to surrounding conditions, and by
the time he has reached puberty, he has either
learned the particular foods he cannot take without
feeling ill or has taken small amounts of that food
at frequent intervals and has gradually become
"used to it," that is to say, become immunized. By
the time puberty is reached, therefore, the idiosyn-
crasies to food are relatively uncommon.
In infancy and childhood, asthma, recurrent bron-
chitis, eczema, and gastrointestinal indigestion are
the diseases which are most commonly due to foods.
It is wise, however, to bear in mind that although
the cau.se of these diseases in the cases herewith re-
l)orted has been proved to be anaphylaxis, this ex-
planation cannot be given as the cause for all cases
of these diseases. It must also be remembered that
although at first sight the problem may seem a simple
one, it is, on the contrary, most complicated. The
commonest example of anaphylaxis, which has no
doubt come within the experience of every one, is
idiosyncrasy to eggs. This is characterized by vio-
lent vomiting, and sometimes diarrhea, whenever the
patient takes eggs, especially when raw.
Abdominal Surgery as a Factor in the Treat-
ment of Pulmonary Tuberculosis. — Norman H.
Deal {Canadian Medical Association Journal, July
1 91 8) says that in undertaking surgery in these cases
every detail should receive careful consideration, as
the result may finally depend on apparently minor
factors. Among these are the following: i. Place
of Operation. It is advisable when possible to oper-
ate upon these patients in the sanatorium where they
are being treated for the lung condition, rather than
in a general hospital. Dr. Craig is having a small
operating plant installed in the new Reception Hos-
pital of the Queen Alexandra Sanatorium, and we
believe this might be imitated elsewhere with advan-
tage to the institutional case where surgical treat-
ment is indicated. 2. Time to Operate. This is an
important question. In acute cases no choice is
given. In chronic cases, however, where a tend-
ency is shown to improve and relapse, the tide of im-
provement should be taken at the flood, and before
relapse sets in the operation should be performed.
3. Preparation of Patient. Most surgeons are against
purging and starvation in any operation, but in these
cases there can be no room for discussion. The diet
should not be restricted except the meal previous to
operation, when clear broth should take the place
of this meal. The bowels should be opened only
with a laxative. In some cases an enema alone is
preferable. 4. All details of the operation should be
carefully planned so that no time is lost, which is an
important element in these cases. The patient should
be carefully guarded from exposure during the op-
eration and in the corridors to and from the operat-
ing theatre if recovery rooms are not close at hand.
Iodine preparation of the field of operation is pref-
erable to chilling the patient's body with various
solutions. 5. Anesthesia. Ether is certainly not the
anesthetic for these cases. Nitrous oxide is the best
general anesthetic, and if it is not available, chloro-
form carefully administered. The anesthetist should
protect his hands by wearing rubber gloves in these
cases. This is very important, as the expectoration
during anesthesia from open pulmonary cases is a
source of danger which should be guarded against.
6. In the aftertreatment the psysician should share
in the direction of the case. Nourishment should be
commenced at the earliest moment possible, and
]~mshed vigorously. Fresh air and sunlight should
be withheld only until the patient recovers from the
narcosis. Hence the advantage of the facilities for
operating in sanatoria rather than caring for these
patients in general surgical wards.
October .2, .0.8.] MODERN TREATMENT AND PREVENTIVE MEDICINE.
653
The Newer Treatment of Burns. — Oscar M.
Shere {Colorado Medicine, June, 1918) found that
the resuhs from the use of Colonel Hull's paraffin
formula were very satisfactory, but that the healing
was slow and epithelialization was delayed. The
formula was also quite painful for some time after
application. To overcome these defects modifica-
tions were tried, and it was found best to vary the
formula of the paraffin mixture accofding to the
stage of the burn. The basic formula employed
was :
Wliitc vaseline, oz. xv ;
Liquid petrolatum, oz. ii;
Oil of eucalyptus oz. i;
Parafiin (m. p. 42.7' C), oz. xvi ;
White wax I y^^
Fix burgundica, )
For the first few days of treatment one dram
each of menthol and thymol iodide are added to
counteract the pain of the application and to combat
infection. During the next stage of treatment the
essential consideration is promotion of epithelializa-
tion, and for this purpose scarlet red is incorporated
in the basic formula to the amount of half of one
per cent. When the epithelialization is nearly com-
plete the scarlet red is replaced by bismuth subgallate
in the proportion of one to ten, for its drying and
astringent action. Blisters should not be interfered
with, the burn being simply irrigated with warm
Dakin's solution and dried with plain, sterile gauze
or warmed air. Then the first formula should be ap-
plied with a brush at a temperature of about 110° F.
and covered with two or three layers of plain gauze,
to which further coats of the paraffin are applied.
This is then covered with flufifed, dry gauze and a
bandage. Redressing is done daily. The other
formulas are applied similarly when the proper
stages are reached.
Glucose Intravenously as a Therapeutic Meas-
ure.— Lawrence Litchfield {Journal A. M. A.,
August 17, 1918), points out that in combating seri-
ous diseases we have to deal with the effects of de-
hydration, intoxication from retention of waste
products, and with nitrogen starvation, beside the
specific efi^ects of the invading organisms. A number
of factors interfere with the maintenance of an ade-
quate supply of water or promote its excessive loss.
"While the intoxication and loss of nitrogen are of
importance, the role of dehydration seems to be the
least generally appreciated. The picture produced
by these three conditions includes : Rapid respira-
tion ; rapid, small, thready pulse ; low systolic blood
pressure ; dry tongue and skin ; sunken eyeballs ;
pinched features ; reduced intraocular tension ; cold
bodily surface ; apathy ; oliguria ; constipation ; rest-
lessness and irritability : hallucinations, deliruin, and
coma ; and very rapid loss of weight. Such a pic-
ture may be encountered in empyema, meningitis,
typhoid fever, Shiga dysentery, peritonitis, brain
ahscess, pneumonia, etc. The problem is to supply
an adequate amount of fluid to make up for all that
has been lost, and at the same time to supply energy
and spare the body nitrogen. This can best be ac-
complished by the intravenous administration of hy-
pertonic glucose solution. Ordinarily from 200 to
300 mils of a twenty-five per cent, glucose solution
should be given intravenously per hour. A litre or
more can be given to an adult at this rate. The so-
lution should be freshly prepared and made with
freshly distilled, sterile water. The temperature of
the solution should be about 100° F. and can be con-
veniently maintained by keeping a length of the tube
lying in a waterbath. The efifects of this form of
treatment have been excellent in a series of very
severe cases of pneumonia and other infections,
marked improvement in the patient's condition usu-
ally coming on even during the injection.
Broken Sleep. — Guthrie Rankin {British Medi-
cal Journal, July 27, 1918) calls attention to the
importance of this condition in these strenuous
times, especially among those of middle age, and
urges the desirability of aiding them to secure their
needed rest by hygienic and drug treatment. In
addition to the general hygiene of the bedroom and
the use of light, but warm covering, including bed
socks where necessary, the person should be en-
couraged to engage in no serious work after his even-
ing meal, but to play some game or read some enter-
taining, light book before going to bed. He should
also secure some out door exercise daily. If there
is some constipation this should be relieved by ab-
dominal massage in the morning warm bath, by the
daily use of a tablespoonful of liquid petrolatum
before breakfast, and the use once or twice weekly
of the following pill :
Hydrargyri chloridi mitis, 0.o6s ;
Extract! colchici, 0.02;
Extracti rhei, or ) ^
Extracti colocynthidis, j
This pill is designed to promote the efficiency of
the liver. Gastrointestinal fermentation should be
prevented by periodical courses of the following
capsule, taken morning and afternoon for about two
weeks :
Carbonis, ") •
Retanaphtholis,! -- ^ -^^-^
Fellis bovis, f
Guaiaci, J
The evening meal should be light and consist of
a cup of clear consomme, fish, chicken, or eggs,
green vegetables as a puree, omelet, custard, or
junket. A glass of light claret. Moselle, or Chablis
often promotes digestion. A useful nightcap after
getting into bed is one of the following: An ounce
of brandy or whisky in hot milk, Benger's food, or
arrowroot. If it is not possible to do without hyp-
notics under such a regimen, they should be em-
ployed, and whatever one is chosen, it should be
given for three or four nights in succession to break
the sleepless habit. The bromides are the simplest
and should be given in doses of two grams (thirty
grains) ; if that is not enough 0.6 gram (ten grains)
of chloral hydrate may be added. This dose should
be given half an hour before bed time and can be
repeated safely in two hours if necessary. Other
useful hypnotics with their suitable doses include :
Chloralamide, two grams (thirty grains) ; chlora-
lose, 0.4 gram (six grains) ; medinal, 0.5 gram
(seven grains) ; adalin or bromural, 0.6 gram (ten
grains) ; trional or chloretone, one gram (fifteen
grains) ; and sulphonal, 1.3 gram (thirty grains).
Paraldehyde is of value, but its disagreeable odor
and taste make it less suitable than the others. At
times it may be necessary to give a few doses of
654
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
morphine, fifteen milligrams (one quarter grain),
with atropine. A combination of two of the hyp-
notics is often more efficacious than one singly and
the following are specially suitable : trional, one
gram (fifteen grains), with codeine, 0.03 gram
(one half grain) ; chloralamide, 1.5 gram (twenty
grains), with potassium bromide, two grams (thirty
grains) ; aspirin, 0.6 gram (ten grains), with
Dover's powder, 0.5 gram (seven grains) ; bromu-
ral, 0.6 gram, with morphine, ten mgm. (one sixth
grain) ; and zinc valerate, 0.3 gram (five grains),
with heroin, eight mgm. (one eighth grain).
Treatment of Tuberculous Arthritis of the Hip
Joint. — H. W. Meyerding {Minnesota Medicine,
August, 1918) describes the treatment of hip dis-
ease at the Mayo clinic. The acute stage in chil-
dren is treated by the Jones abduction frame, where-
as in adults this stage may be treated by Buck's ex-
tension in bed, with a sandbag support for the leg.
In the subacute stage, in cases without drainage, a
cast of the Lorenz type may be applied with the use
of crutches and the elevation of the sound limb by
means of a patten. Finally a Thomas splint is used
for. three or four months, at the end of which
period, when weight carrying is permitted and
causes no pain, crutches are allowed with the grad-
ual application of more and more weight to the af-
fected leg. Ninety per cent, of his cases showed
deformity, the flexion abduction type being practi-
cally always present ; nineteen per cent, had anky-
losis, and the average shortening was two and one
fourth inches. In sixty per cent, the right hip was
the seat of deformity, ten per cent, required aspira-
tion, and fourteen per cent, required curettage or
sequestrotomy. Patients with deformity and those
in the subacute stages were treated by brisement
force, plaster of Paris, and crutches. Osteotomy
of the Grant type was done in the cases with anky-
losed deformity.
Intravenous Treatment of Cerebrospinal Men-
ingitis.— W. W. Herrick {Journal A. M. A., August
24, 1 91 8) says that one of the most important fac-
tors in the treatment of this disease has been the
recognition that it is primarily a meningococcic
sepsis with secondary localization in the meninges.
Of 265 cases studied by the author the diagnosis
was made before the meningitis developed in over
forty-five per cent., that is, during the initial sepsis.
The characteristics of the stage of sepsis should be
recognized that treatment may be begun as early as
possible. Briefly there is a prodromal period of a
few hours or days marked by languor, malaise, and
infection of the upper respiratory tract such as
tonsillitis, pharyngitis, or laryngitis. Then the weak-
ness increases and apathy develops. There is tonsil-
litis, diarrhea, or conjunctivitis, and the tempera-
ture rises to 100 to 102°. A bursting frontal head-
ache is usually present. The tongue is coated, the
oral secretions are very viscid, and the pharynx and
tonsils are red. The dull apathy with capacity to be
roused temporarily, unmodulated voice, and the ab-
sence of the use of the facial muscles of expression
are very typical. A petechial rash appears in about
half of the cases and an ill balanced condition of
the deep reflexes is also characteristic. With such
symptoms himbar puncture should be performed at
once. The fluid will be found nearly normal upon
examination, but it should be centrifuged and the
last mil of the sediment should be evaporated on a
slide and searched for the organisms. If none is
found a second puncture a few hours later will gen-
erally show them. Treatment should be begun at
once and should aim at sterilizing the blood stream
as promptly as possible. To desensitize the patient one
mil of horse serum, or the serum to be used, should
be injected subcutaneously, and one hour later the
first dose of serum should be given intravenously.
The dose should be from 80 to 150 mils, the first
fifteen mils being given at the rate of one mil
per minute. Then, depending on the severity of the
case, the dose should be repeated at intervals from
eight to twenty-four hours, from four to twelve
doses being required. As soon as meningeal symp-
toms appear lumbar puncture should be made about
half an hour after each intraveneous injection and
enough fluid withdrawn to reduce the pressure to
normal and a dose of not over thirty mils of serum
given intraspinally. Under this treatment meningo-
cocci disappear from the blood stream in twenty-
four hours and from the spinal fluid in forty-eight
hours. The intraspinal treatments should never be
continued beyond eight or ten, when, if meningo-
cocci still persist, drainage alone with intravenous
treatment should be continued. Relapses should be
treated as are primary attacks. This plan of treat-
ment very greatly diminishes the frequency of com-
plications and has reduced the mortality in severe
cases from sixty-five to seventeen per cent, when
treated early, and from forty-two to nineteen per
cent, when treatment was begun late.
Intradural Vaccination against Smallpox. —
Louis T. Wright {Journal A. M. A., August 24,
1918) discusses the several methods of vaccination
and points out their various disadvantages, includ-
ing specially the moderately high proportion of fail-
ures and infections. In the hope of securing a
larger proportion of "takes" the intradermal method
was tried along with the incision method on 227
soldiers who had recently been unsuccessfully vac-
cinated by the incision method. In this group the
intradermal method gave good "takes" in seventy
per cent, as compared with eight per cent, for the
incision method. Of the sixty-seven men who failed
to .show "takes" by the intradermal method all but
four showed the immunity reaction or vaccinoid.
The method used employed a virus treated with a
mixture of one part of phenol with forty-nine parts
of glycerin and fifty parts of water. This virus
was diluted with an equal volume of sterile, distilled
water just before using. With a sterile tuberculin
syringe and a fine needle one tenth mil of this di-
luted virus was injected intradermally over the in-
sertion of the deltoid. Usually two injections were
made about an inch apart. The only difiference in
the reaction produced was the constant appearance
of a circle of vesicles about the site of the insertion,
measuring about a centimetre in diameter. The
method was found to be easy, rapid, much more
certain than any other, less likely to lead to infec-
tion, and the only one in which a definite, known
amount of virus was used. Its use also gave a fair
indcjt of the relative immunity already present.
October 12, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
655
Extraction of a Bullet from the Inferior Vena
Cava. — P. Duval and H. Barnsby {Presse medi-
cale, July ii, 1918) report the case of a man hit by
a bullet in the left anterior axillary line at the level
of the seventh rib. Slight hemoptysis was the only
symptom at first, but on subsequent days pains in
the cardiac region, made worse by motion, were ex-
perienced. X ray examination revealed, at the right
•of the sternum, a bullet dancing up and down
through a distance of twelve centimetres like an egg
shell on a jet of water. A median sternoepigastric
incision was made from the fourth rib to a point
midway to the umbilicus, the sternum divided, and
two lateral flaps turned back. The pericardium was
opened, and after several x ray examinations the
bullet seized when half way in the auricle from the
vena cava. A nonperforating purse string suture
was then passed around the base of the missile, the
vein incised at this point, the bullet quickly seized
and withdrawn with forceps, and the purse string
promptly drawn tight. A lateral suture completed
the hemostasis, and the pericardium, diaphragm,
peritoneum, and sternum were sutured. Recovery
followed uninterruptedly. The bullet is believed to
have entered through the left lung and passed
through the left ventricle, the interventricular sepn
tum, and the tricuspid orifice into the right auricle
and inferior vena cava.
Antianaphylactic Treatment in Asthma, Skin
Disorders, and Gastrointestinal Disturbances. —
J. Danysz {Presse medicale, July 18, 1918) has con-
cluded, from the study of much literature, that all
the phenomena termed skepto- or tachyphylaxis, ana-
phylaxis, anaphylatoxic crises, antianaphylaxis, vac-
cine-, bacterio-, proteose-, and serotherapy, and even
modern chemotherapy, are dependent upon reactions
of like nature, and that all therapeutic methods de-
rived from them should be grouped together as an-
tianaphylactic procedures. Whatever be the an-
tigen, the organism remains in a state of latent
anaphylactic hypersensitiveness just as long as it
produces and contains antibodies in excess. The
hypersensitiveness is always specific in that there
will always be a reaction to the antigen which in-
duced it, but it is not exclusively specific, as the re-
action may likewise be awakened by other antigens
or by sensory or psychic excitants. Thus, a tuber-
culous subject is hypersentitive not only to tuber-
culin but also to mallein, to a number of other an-
tigens of microbic or alimentary^ origin, to changes
of temperature, etc. In the last analysis it may be
conceived that idiosyncrasies, diatheses, and pre-
dispositions of all sorts are due to antigens and a
state of anaphylactic hypersensitiveness which may
be inherited or individual and more or less lasting
or evanescent. Undoubtedly in the great majority
of cases the alimentary tract is the focus of forma-
tion of the antigens : hence it is in the intestinal
flora that the antigens required for antianaphylactic
treatment of gastrointestinal, pulmonary, or cutane-
ous disorders should be sought. In a man of forty-
seven who had sufiFered five years from asthma
everv night, marked improvement followed two
series of ten injections of a bacterial preparation
isolated from the intestinal flora and sterilized by
heat. The improvement began with the first injec-
tion. In a patient who had had a phlyctenular
eruption for fourteen years, similar treatment
caused the eruption and attendant itching to disap-
pear. A ca.se of perianal eczema and three out of
four cases of psoriasis were similarly cured, the ex-
ception being a case in which the preparation was
ingested instead of injected. A salient feature in all
these cases was that virtually three fourths of the
total benefit accrued within twenty-four hours after
the first injection. The treatment is conceived of
as removing the excess of antibodies which is the
immediate cause of the attacks of dyspnea or skin
lesions. Similar results were obtained in numerous
cases of dyspepsia with epigastric pain and of pain-
ful enteritis or enterocolitis with constipation or
diarrhea. The treatment is much facihtated by the
fact that it is not necessary to employ precisely the
specific material for injection. In most cases studied
it was found sufficient to grow on ordinary agar, in
separate colonies, all the aerobic organisms that
would develop under these conditions, mix them in
their approximate proportions in the feces, sterilize
the emulsion by heat, and administer it by injection
or ingestion.
Etiology and Treatment of Enuresis. — Joseph
I. Grover {Journal A. M. A., August 24, 1918)
bases his conclusions upon a study of about 200
cases in children between four and twelve years of
age. He believes that the condition is never a dis-
ease entity, but is merely a symptom of an under-
lying, general neuromuscular fatigue. The fatigue
is chronic and the patients are all of the overactive,
nervous type. There is often an element of marked
mental strain from too prolonged school work. The
treatment is exclusively dietetic and hygienic. All
food between meals is forbidden, even bread and
butter and milk, and the following foods are ex-
cluded from the diet : Soups, coflfee, tea, cocoa ;
sweet, salty, and highly seasoned food ; ice cream,
candy, cakes, and pastry ; jelHes, jams, etc. ; condi-
ments, bananas, and raw apples. To simplify the di-
gestive work at night meat, eggs, and vegetables are
forbidden at supper. The diet consists of milk, butter,
eggs, meat, fish, breadstuflfs, cooked cereals, maca-
roni, vegetables, orange, stewed fruits, and simple,
unsweetened desserts. No fluids are given after 4
p. m. ; the child must be in bed by 7 p. m., and no
active play is allowed after 4 p. m. If very nerv-
ous, school is temporarily prohibited and a nap re-
quired every afternoon. Moving pictures, music les-
sons, and evening study are prohibited. Absolutely
regular hours are established for urination at night,
name'y, 7 and 10 p. m. and 6 a. m. ; and in some
cases with small bladders, 2 a. m. for a while. The
day wetters are made to urinate at regular times by
the clock, the intervals being lengthened to increase
the capacity of the bladder until a satisfactory
regime is established. Rewards are oflPered for fol-
lowing the directions. The results of such treat-
ment are surprisingly good as shown by the fact
that nineteen per cent, of the patients did not wet
again after their first visit, twenty-three per cent,
did not wet once after the first few weeks or
months, thirty-one per cent, were reduced to a maxi-
mum of wetting once a week, and only twelve per
cent, were not benefited at all.
Miscellany from Home and Foreign Journals
Significance of Heart Murmurs that May Be
Found on Examination of Candidates for Mili-
tary Service. — Lewellys F. Barker {Canadian
Medical Association journal, July, 1918) says that
experience at a medical advisory board, where the
hearts of 2,500 drafted men between the ages of
twenty-one and thirty-one, indicates: i. That many
organic murmurs (diastoHc murmur of aortic in-
sufficiency, presystolic murmur, and snapping first
sound of mitral stenosis) are often entirely over-
looked by examiners in local boards, for they are
not infrequently detected in men referred to the
advisory board for defects other than those of the
cardiovascular system. 2. That many extracardiac
(cardiorespiratory) murmurs and accidental intra-
cardiac murmurs are suspected by medical examiners
to be murmurs of serious import. 3. That the hearts
of some of the men presenting organic murmurs are
better prepared to stand exertion than are the hearts
of some men presenting no murmurs. 4. That good
response to the exercise test by no means rules out
the existence of organic disease of the valves of the
heart. S- That many men with organic disease of
the valves of the heart need not be unconditionally
rejected, though according to present regulations
they must be, for many of them are entirely capable
of undertaking special service not involving severe
exertion, and some of them could, without harm,
even be given duties requiring considerable bodily
exertion. Experience in the armies in Europe
would indicate that mild stenotic lesions stand strain
better than lesions causing valvular insufficiency.
The lesions of barrage are less serious than the
lesions of fuite. 6. That, on the whole, while the
study of cardiac murmurs is of great importance in
estimating the fitness of a candidate for military
service, still greater importance attaches to the study
of the condition of the cardiac muscle and to the
estimation of its ability to bear strain.
Albumin Content of Cerebrospinal Fluid. — L.
Boyer {Paris medical, June 15, 1918) recommends,
for quick and accurate results, the diaphanoscopic
method. The spinal fluid is treated with a solution
precipitating albumins and then compared with a
scale of standard solutions of albumin treated with
equal amounts of the precipitant. The precipitant
preferred is made by mixing thirteen grams of
crystalline salicylic acid with fifteen mils of pure
sulphuric acid in the cold in a porcelain dish. The
mixture liquefies, then crystallizes. It is fused
again with gentle heat, allowed to cool, enough dis-
tilled water is added to make 100 mils, and the re-
sulting solution is filtered. The standard albumin
preparations are made preferably with a mixture of
blood serum from several persons. To one mil of
serum are added seventy-four mils of normal saline
solution, thus forming a i in 1,000 albumin solu-
tion from which greater dilutions, viz., 0.2, 0.3, 0.4
in 1,000, up to I in 1,000, are made by adding
suitable amounts of normal saline. In each of ten
small tubes of equal size, preferably discarded surg-
ical gut tubes, are placed two mils of one of these
dilutions of the albumin solution and one mil of the
precipitant solution ; the tubes are then sealed and
labeled, constituting permanent albumin standards.
For receiving the spinal fluid another tube of ex-
actly the same size is used, with 2, 3, and 6 mil
marks filed on it. Spinal fluid is introduced up to
the first mark, precipitant solution up to the second,
and the tube stoppered, shaken a few times, and
compared with the standard albumin tubes, likewise
previously shaken. The comparison may be made
either by looking through the tubes toward the
source of light or by reflection, the tubes being well
illuminated and looked at against a dark back-
ground. Where the opacity of a specimen is greater
than that of the standard i in 1,000 solution, saline
solution is added up to the 6 mil mark and the
figure resulting from the comparison multiplied by
two.
Acute Mastoiditis as a Complication of Infec-
tious Disease. — George H. Lathrope {Journal A,
M. A., August 10, 1918) reports from Camp Shelby
a striking variation from the general experiences of
the other southern camps in reference to the occur^
rence of streptococcus infection. While penumonia
and empyema were very prevalent and fatal in
other camps and were due very largely to infection
with the Streptococcus hemolyticus, at Camp Shelby
the streptococcus of this type was uncommon and
relatively few cases of pneumonia or empyema oc-
curred. On the other hand acute mastoiditis was
quite prevalent and was generally due to infection
with the Streptococcus viridans. In 123 cases of
this condition studied in the base hospital there was
invariably a preceding involvement of the middle
ear, but often the mastoiditis came on so rapidly as
to make it seem almost synchronous with the otitis.
Measles directly preceded the mastoiditis in forty-
four of the cases, respiratory diseases in twenty-
eight, purulent otitis media in forty-three, mumps,
in six, and scarlet fever and erysipelas in one each.
The importance of measles and the respiratory dis-
eases, including mumps and scarlet fever in this
category from their involvement of the upper res-
piratory tract, was very evident. In seventy-three
per cent, of the mastoid cases cultured directly at
the time of operation the organism was a streptococ-
cus and this was in pure culture in over half of the
cases. There were only five instances of infection
by the hemolytic type, the remainder having been
due to the Streptococcus viridans. The Staphylo-
coccus aureus was found in pure culture in thirteen
cases. In seventeen of the streptococcus cases
there was a mixed infection with the staphylococ-
cus. In every one of the deaths, numbering twelve,
the streptococcus was present, once with the staphy-
lococcus, once with miscellaneous other organisms,
seven times pure Streptococcus viridans, and three
times pure Streptococcus hemolyticus. The occur-
rence of streptococcic infection was far more fre-
quent among the measles cases than among these
following other diseases, indicating the greater
dangers associated with the complications of
measles than of the other diseases considered.
October 12, lyiS.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
657
Diaphragmatic Movements in Acute Abdom-
inal Inflammation. — Llewellyn Sale {Journal A.
M. A., August 17, 1918) presents his conclusions
from a careful study of twenty-five soldiers ad-
mitted under the suspicion of having some acute ab-
dominal inflammation, the majority having been
clear cut cases of appendicitis. Control examina-
tions were also made in normal subjects. It was
found that in the majority of cases of proved acute
appendicitis the movement of the right half of the
diaphragm was decidedly limited, as shown by
fluoroscopy. This limitation was found to occur in
cases in which the peritoneal surface of the dia-
phragm was not inflamed, as well as in those in
which it was involved. This limitation of move-
ment was found to be confined to the side corre-
sponding to the abdominal inflammation. The oc-
currence of the limitation in the absence of involve-
ment of the diaphragmatic peritoneum could not
easily be explained, since the phrenic nerve was
known to have no inhibitory fibres. It was sug-
gested that the inhibition might have been in part
voluntary. With the limitation of movement there
was also often a diminution in the breath sounds at
the base of the lung, or even their total absence.
The degree of limitation of movement was not
found to run parallel to the severity of the acute in-
flammatory process in the abdomen, though its oc-
currence appeared to be a very valuable confirma-
tory sign of such inflammation.
Neurocirculatory Asthenia. — William H. Ro-
bey and Ernst P. Boas (Journal A. M. A., August
17, 1Q18) studied this condition, which has also been
called, "soldier's heart" and "the effort syndrome,"
in an American camp, and found that in the ma-
jority of the cases the patients gave a history of
similar attacks having occurred in civil life before
coming into military service. A family history of
nervous disorders was also very commonly elicited
and was a factor of importance in the diagnosis. It
was found that some of the cases became evident
immediately, while others were manifest only after
a few weeks of intensive training. From a very
careful study of the cases it was found that the con-
dition was essentially of neurotic origin and oc-
curred in persons with fundamentally unstable
nervous systems. The instabihty of the nervous
system resulted in a similar instability of the vaso-
motor system. A considerable number of the worst
cases were found by the psychiatrist to have consti-
tutional psychopathies, to be mentally inferior, or to
have psychoneuroses. In all of the patients the
systolic blood pressure was usually found to be ele-
vated and to show a marked tendency to rise
rapidly after exercise. The diastolic pressure was
usually normal, but often dropped almost to zero
after exercise, or quite so when the fourth phase
was taken as the reading. The application of Bar-
ringer's tests of the heart's functional capacity
showed the hearts to be practicallv normal in that
respect. Treatment of the cases according to the
methods of graduated exercise and training, as ad-
vocated by Lewis, utterly failed to bring about any
improvement in the constitutional cases, which con-
stituted the great majority. Time and money could
be saved by the prompt recognition of these cases.
Recurring Hemoptysis after Wounds of the
Thorax. — Courtois-Suflit (Bulletin de I'Academie
de medecine, July 23, 1918) notes that while in the
majority of instances hemoptysis after penetrating
war wounds of the thorax continues only a few
days, not rarely it persists two weeks, a month, or
even longer. Petit de la Villeon and Giroux have
reported cases in which it continued for six months
to a \ear. Especially noteworthy is the recurrence
of the bleeding at long intervals and without ap-
parent cause. Among thirty-seven cases of pene-
trating chest wounds under the author's observation,
four exhibited this recurrent form of hemoptysis.
In one instance recurrence of bleeding took place
nearly thirty months after the injury. The attend-
ing symptoms in such cases, viz., dyspnea at rest or
on exertion, at times pain in the chest, coupled with
occasional respiratory modifications, suggest the
possibility of tuberculosis as the cause of the recur-
rent hemoptysis. Careful investigation of the
author's patients showed, however, that- this is not
the case. There were no constitutional symptoms,
clinical and x ray examinations were negative, and
tubercle bacilli were lacking. Tuberculosis must be
an extremely rare complication of penetrating
wounds of the lung. The cause of the recurring
hemoptysis is not as yet definitely known. In two
cases a shell fragment and splinters of bone were
demonstrated in the lung tissue, but in the other
two there were no foreign inclusions. In the latter
the condition may perhaps be ascribed to a latent
inflammatory process. Loeper, Verpy, and Cosnier
have shown that the sputum of cases of thoracic
wound sometimes contains, over a year after the
injury, cells suggesting a silent inflammatory
process which cannot be detected by clinical or x ray
procedures.
Lead in the Kidney One Month after Cessation
of Exposure to Lead. — E. Lenoble and F. Daniel
( Bulletins et memoires de la Societe medicale des
hopitanx de Pans, March 21, 1918) report the case
of a painter, aged twenty-two, admitted to a hospital
with pains in the extremities and vomiting. Al-
buminuria had been present for six months. There
was herpes zoster of the left cervical plexus, with
headache. The blood pressure was high. Incessant
vomiting was followed by anuria and death. The
kidneys were found small and granular, with the
calyces and pelves filled with pus. Twenty grams
of the left kidney were treated repeatedly with nitric
acid and evaporated. The residue was mixed with
soda and ammonium nitrate, heated to dryness, and
then taken up with water acidulated with nitric
acid, and the resulting solution filtered. Passage of
hydrogen sulphite into it caused a precipitate subse-
quently indentified as lead sulphite. The patient had
not been at work for a month. The cerebrospinal
fluid at this time did not contain even a trace of
lead. In a previous research the authors had found
lead eliminated from the cerebrospinal fluid in ten
days, on an average. The case reported is held to be
of medicolegal significance in that, in the absence
of any symptom positively showing that death had
been diie to lead poisoning, chemical investigation
^revealed the poison. In some cases of mineral
poisoning the cause can be chemically discovered
long after cessation of exposure to the toxic agent.
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Dyspepsia among Prisoners in Germany. —
F. Ramond and A. Pettit (^Bulletins et meinoircs dc
la Societe medlcde dcs hopitaux de Paris, March
7, 1918), from examination of prisoners returned to
France from Germany as a result of a visit of the
Swiss medical commission to various German prison
camps, state that practically 100 per cent, of the
prisoners develop dyspeptic disturbances in these
camps owing to the unjustifiably scanty and inap-
propriate food distributed there. As soon as the
men reach these camps, whatever be their age or
previous condition of health, they are seized with
heaviness of the- stomach after meals and a tend-
ency to burning sensations after two or three hours.
Then apjjear colicky pains with abundant and often
fetid diarrhea — manifestations of an acute or sub-
acute gastroenteritis. Most of the prisoners later
return almost to a normal condition, experiencing
merely gastric disturbances of bearable degree and
at rather long intervals; this is accomplished,
however, only by exclusive feeding upon the con-
tents of a food parcel from home for two or three
days, thus giving the stomach a rest from the usual
harmful fare. Some of the prisoners, on the other
hand, develop more serious disturbances. Of these,
some show hypochlorhydria ; others, more numer-
ous, hyperchlorhydria. A few, afflicted with ob-
stinate constipation as a sequel to the initial en-
teritis, exhibit all the characteristics of dyspepsia due
to constipation. Most striking, however, is the con-
siderable proportion of confirmed gastric ulcers re-
sulting; one tenth of the patients under the observa-
tion of the authors had had repeated melena and
were admitted with a more or less advanced pyloric
stenosis. Four patients of this type required oper-
ative intervention.
Prophylactic Inoculation against Pneumococ-
cus in 12,519 Men — Russell L. Cecil and j. Har-
old Austin (Journal of Experimental Medicine,
July, IQ18) in order to determine the best dose and
interval of injection studied the agglutinins and
protective power of the serum of forty-two volun-
teers who were vaccinated against the pneumococ-
cus, types I, IT. and III. A definite immune re-
sponse was obtained to types I and II. The degree
of response seems to be dependent upon the total
dose of each type of pneumococcus given. Al-
though there is some response to two and one half
billion cocci of each type, a more constant and
greater reaction followed the administration of
thirteen billion, \\nien subcutaneous injection is
used the manner in which the dose is divided ap-
parently has little effect on the degree of immune
response, provided the total dose is the same, but it
was found that smaller doses frequently repeated
gave less general and local reaction than one mas-
sive dose. At Camp Upton 12,510 men were vac-
cinated against pneumococcus types I, II, and III.
Three or four doses, al intervals of from five to
seven days, were given, with a total dose of six to
nine billion of types I and II, and four and a half
to six billion of type III. It was possible to ob-
serve the men for only ten weeks at the camp, but
during that time no cases of pneumonia due to these»
throe types occurred among the men who had re-
ceived two or more injections of vaccine. On the
other hand, among the 20,000 men who were not
vaccinated there were twenty-six cases of pneu-
monia due to these three types. A point of interest
for which no explanation is offered is that the inci-
dence of pneumococcus type IV pneumonia and
streptococcus pneumonia was considerably less
among the vaccinated troops than among the unvac-
cinated. The reactions were generally milder than to
typhoid vaccination. In some instances small sterile
infiltrations which disappeared spontaneously fol-
lowed the injection of large doses of the vaccine.
This was interpreted as an expression of cutaneous
hypersusceptibility. The results of this work would
indicate that prophylactic vaccination against pneu-
mococcus types I, II, and III is practical, as it will
apparently protect against pneumonia caused by
these types. The duration of the immunity still
remains to be determined.
Typhoid in Immunized Soldiers. — Samuel
Bradbury (Journal A. M. A., August 17, 1918) en-
countered four cases of proved typhoid fever in a
companv of soldiers, all of whom had been immun-
ized only five months previous to this finding. Ow-
ing to the exigencies of active military operations
the source of the infection could not be traced with
absolute certainty, but ail the evidence pointed to
the mess sergeant who had had typhoid fever in
:91s. He was captured before his stools could be
obtained for examination, but all other sources of
infection were ruled out. It would seem, accord-
ing to the author, that the immunity in these four
men, out of a company of 175, had not lasted five
months. But their infection might also be explained
on the basis of their having had six weeks of very
hard work with long hours and irregular meals, and
also because thev may have been exposed to a very
large infecting dose of bacilli.
Value of Tests of Kidney Function, — L. F.
Frissell and K. M. Vogel (Archives of Internal
Medicine, July, 1918) report a series of 112 definite
cases of nephritis, in which over 1,400 test observa-
tions were made, covering more or less completely
the entire series of ordinary tests — phenolsulphone-
phthalein, nonprotein nitrogen, urea nitrogen, Mc-
Lean's index of urea excretion, etc. In general,
the results proved strikingly consistent, and the hi?h
percentage of fatal cases — sixty-one per cent. — was
in accord with the indications derived from the
tests. The curves for nonprotein nitrogen and urea
nitrogen showed a rapid rise during the three
months preceding death, though during earlier
months they tended to maintain a constant level.
The results seemed to prove that the delicacy of the
index of urea excretion is much greater than that
of a simple blood urea determination. The kidnev
functional tests are deemed to have a real prognostic
value, particularly if the results are constantl\- r-b-
normal on repeated examination. By plottin<r the
curve of a verv long series of cases, it should be
possible to arrive at an average expectation of life
as indicated by any individual determination. The
value of diet anrl drugs may also in future be shown
by these methods more clearly than in any other
way.
Proceedings of National and Local Societies
THE AMERICAN PEDIATRIC SOCIETY.
Thirtieth Annual Meeting, Held at the Curtis Hotel,
Lenox, Mass., May 27, 28, and 2^, ipiS.
(Concluded from page 6ip.)
Is the Present Frequency of Acute Otitis and
the Subsequent Mastoid Operation in Some
Measure a Reproach to the Pediatrist? — Dr.
Tpiomas S. Southworth, of New York, said that
the presence of middle ear trouble, often necessitat-
ing mastoid operation, would, when one considered
the growth of preventive measures in other direc-
tions, appear to be a reflection upon therapeutic and
medical research in general, and upon pediatrics in
particular, since these affections were so common in
childhood. There was here a territory partly oc-
cupied by the otologist and partly by the pediatrician.
Possibly because of this divided responsibility the
field had not been covered as thoroughly as it would
have been had it lain only at one door. The ma-
jority of these cases of otitis appeared in pediatric
practice and the pediatrician had the opportunity
to foresee and prevent them. During the past win-
ter the writer had twenty-five cases of acute otitis
media in a service averaging eighty infants under
fifteen months of age. These had been under the
close supervision of an otologist who had found in
five of them indications of mastoid involvement;
yet all had escaped mastoid operations, and dis-
charge had ceased in all of the infants save one,
which at the time of writing was nearly well. The
warning against blowing the nose in the recumbent
or supine position was one of such eminent and evi-
dent wisdom that the writer now irj,cluded it in rou-
tine directions in all cases of acute^hfectious disease
in which there was danger of middle ear in-
volvement through the Eustachian tube. The
pediatrician should consider the following ques-
tions: I. Are there any therapeutic measures which
tend definitely to prevent middle ear infections in
acute nasopharyngeal conditions? 2. Are there
any abortive measures which are reasonably effi-
cient in beginning otitis media? 3. Could not some
such measures be devised by well directed research?
4. Are we correct in assuming that immediate early
paracentesis is always indicated in all cases of effu-
sion into the middle ear? 5. To what degree and
under what circumstances after paracentesis is the
pediatrician justified in counselling delay, in the
presence of the classical indicatons for mastoid
operation? 6. Is the frequency of acute otitis and
of mastoidectomy inevitable, or is it due to a com-
placent neglect of further research in this field?
The m.embers of this society from their wide ex-
perience should contribute something toward the so-
lution of these problems.
Dr. Samuel S. Adams, of Washington, said it
had been his experience that the otologist advised
the general practitioner against putting various
remedies into the ear because he claimed that they
did -not allay inflammation and they obscured the
field of vision, thus making examination difficult;
yet he had known otologists to put those things in
the ear themselves. The preparations usually em-
ployed for this purpose were preparations of car-
bolic acid, adrenalin, and cocaine. The speaker had
used five or ten per cent, solution of carbolic acid
in glycerine, and felt that with it he had pretty cer-
tainly allayed earache, where there was inflamma-
tion of the middle ear, with the membrane led and
inflamed but not bulging. When the membrane
was bulging, he believed one should call in a skilled
otologist.
Dr. Godfrey R. Pisi£K, of New York, said he had
put these questions to the otologist and had found
that the otologist was not always certain in his own
mind as to the indications for operation. If he
found a sagging canal he was ready to operate.
Some otologists asserted that every discharging ear
was partly a mastoid infection, and that drainage
did little good unless the mastoid was opened. He
thought that otologists were incHned to lean to the
side of operation as being the safest procedure.
Dr. Fritz B. Talbot, of Boston, stated that the
problem of prevention of mastoid troubles lay in the
prevention of colds, which were the cause of most
ear troubles. He considered it important, as a
preventive measure, that babies' as well as older
children's noses should be wiped instead of blown.
Dr. Isaac Abt, of Chicago, said that as soon as
one got a nasopharyngeal inflammation he was
likelv to have a middle ear congestion, and the tym-
panic membrane became reddened. Some otolo-
gists immediately punctured the membrane. That
was a technical error. The membrane should only
be punctured when it bulged, or where there was
reasonable suspicion of pus in the middle ear. So
far as mastoiditis was concerned, pathological
studies showed that in the exanthemata and grippal
diseases there was more or less inflammation of the
mastoid and antrum. Many of these cases recov-
ered without operation.
Dr. Henry Heiman, of New York, said that
some years ago he used to have three or four mas-
toid operations a year, while now he had only about
one mastoid in ten years. Some children blew the
nose and that tended to cause infection of the middle
ear. Some snuffed salt water, which was a very
dangerous procedure. He was inclined to be con-
servative. It seemed to him that he had seen as
many mastoids follow incision of the drum as where
the drum was allowed to remain red for some time.
Dr. L. Emmett Holt, of New York, said that
from his experience in the Babies' Hospital, where
he believed they had had only one mastoid operation
in three years, he had come to take a very conserva-
tive stand in regard to mastoid operations. He felt
that many unnecessary operations were done on
ears, and that it was well for this society to enter
a protest against too many mastoid operations.
Dr. Roland G. Freeman, of New York, said
that he did not agree that operations were done too
fret|uently. He had never known an instance when
an ear was operated on when the drum was not red
and bulging.
66o
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
MfeoiCAL Journal.
Dr. HowAKD C. Carpenter/ of Philadelphia, in
speaking- of the prevention of otitis, warned against
digital examination of the nasopharynx for ade-
noids. By putting the fingers into the nasopharynx
one might stir into activity an inactive infection. In
reference to what had been said about blowing the
nose, he thought both sides of the nose should be
open while the nose was being blown. He also felt
a conservative position in regard to mastoid opera-
tions, should be taken.
Dr. Henry Dwight Chapin^ of New York,
stated that in young babies it was almost impossible
to see the ear drum, and when nothing was seen
it was assumed that nothing was present. He be-
lieved that many ]5atients were operated upon who
would get well without operation, but no one seemed
to be able to say which would get well without oper-
ation. It seemed to him that in blowing the nose
it was better to keep the mouth open than to try
to keep one or both nostrils open.
Doctor Kerley, of New York, stated that he had
seen many mastoids operated upon, but he had never
seen one operated upon where there was not pus
and inflammation of the mastoid cells. He could
not say that these patients would not get well with-
out operation, but he always felt better when the op-
eration was done. The mastoid operation was not a
serious operation, and the vast majority of patients
recovered. It was just as well to open the mastoid
and drain posteriorly as to run the chance of get-
ting adhesions and chronic deafness.
Dr. Langley Porter, of San Francisco, said that
one way to prevent infection of the nasopharynx
was to instruct mothers and nurses having colds to
wear respiration veils.
Dr. Alfred F. Hess, of New York, said that in
an institution with which he was connected where
there were 400 children under five years of age, in
the last five years thev had had four cases of mas-
toiditis, one being a case of pneumococcus menin-
gitis following ear trouble. They had had no case
of sums thrombosis. "The plan they had carried
out was to puncture red and bulging ear drums. In
regard to prophylaxis, one thing to be considered
was whether one was dealing with local or systemic
disease. This was true regarding diphtheria ; chil-
dren immunized with toxinantitoxin would not get
nasal diphtheria, and conseciuently this one source
of middle ear infection would be removed.
Dr. William P. Northrup, of New York,
called attention to the frequency of otitis media
following measles and said that the pediatrician
could be of help by watching out for otitis media
during measles. The point for which he should
look >,'sj)ecially was whether there was a rise in
temperature during measles or pneumonia.
Dr. Herhert B. Wilcox, of New York, called
attention to the possibility that frequent irrigations
of the ear might devitalize the superficial layer of
epithelium covering the drum, so that this was
elevated like a blister, and if this happened it might
be sufficient to merely incise this superficial layer
and not cut through the entire drum. He said that
the otologist had one complaint to make against
the pediatrician or general practitioner and that
was that he might open the drum and et'acuate the
pus and then neglect to make a culture. Later, if
an otologist were called in he would have difficulty
in interpreting the condition because he did not
know what organism was causing it.
The Relative Morbidity of Breast and Bottle
Fed Babies.— Dr. H. M. McClanahan, of
Omaha, stated that he had sent a questionnaire to
members of the American Pediatric Society and
other prominent pediatricians throughout the
United States inquiring as to their experience re-
garding the relative susceptibility of breast and
bottle fed infants, both in reference to contagious
and infectious diseases, and also in reference to
general infection and the relative rate of growth
and development of breast and bottle fed infants.
Seventy answers were received, among them being
very comprehensive data on 700 cases from Doctor
Sedgwick, of Minneapolis, and a table from Doctor
Pisek. An analysis and summary of the data ac-
cumulated showed: (a) That superiority of breast
milk might be due to chemical and biological differ-
ences which rendered it more readily usable by the
infant. As a result it had a more natural energy
which it could apply to the invading organism, (b)
Breast milk might contain natural antibodies or
protective ferments, both specific and nonspecific,
{c) Breast fed infants were less susceptible to in-
fection, with the exception of influenza and tuber-
culosis, (d) Breast fed infants resisted infection
more quickly and with less injury than bottle fed
infants, (e) Breast fed infants had less morbidity
than properly fed bottle infants ; badly fed infants
had a still greater disadvantage.
The Disadvantages of Low Fat Percentages. —
Dr. Alfred Hand, Jr., of Philadelphia, stated that
he looked upon anything less than two per cent, as
.1 low fat percentage, from two to three as moder-
ately low, from three to 3.5 as a fair percentage,
'ind from 3.5 to 3.8 or four as normal ; anything
above four he considered as a high percentage in
the feeding of infants. It seemed that for a while
past the advantages of low fat feeding, especially
in hospital work, had been overemphasized. While
a very easy way to upset a child's digestion was to
feed a food too rich in fats for his digestion, the
result of such feeding was scarcely ground for
branding that child as having fat intolerance for the
rest of his life. The writer had seen very few cases
of permanent or prolonged fat intolerance. If a
low fat percentage were fed for a long period, the
general nutrition of the infant was more or less
l")ermanently damaged. The main way in which
this was brought about might be summed up in the
term "rachitis." Children brought up on condensed
milk and other proprietary foods with low fat and
high carbohydrate content showed as a rule distinct
evidence of rickets. Constipation and failure to
gain in weight were the two conditions that might
be troublesome with the feeding of low fat per-
centages and low protein as well, unless the carbo-
hydrates were raised considerably above the amount
existing in either human or cow's milk. As a
temporary measure this might be of value but it was
of more lasting benefit to overcome the constipation
and increase the weight by raising the fat percent-
age as rapidly as possible. Two factors that seemed
October 12, 10 18.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
to influence the handling of fat in the dietary were
chmate and the breed of cows. A child that might
show intolerance to fat in the sunnner, when cooler
weather came would handle even a higher percent-
age of fat with ease. The milk of cows that had
five per cent, fat was not nearly as suitable for
infant feeding as that containing four per cent. The_
writer cited typical cases in which a low fat content
was given evidently to the detriment of the baby.
Ascending Infection of the Urinary Tract. —
Dr. Hexrv F. Helmiiolz, of Evanston, 111., re-
ported his work with a series of rabbits that were
infected by the injection of a pure culture of colon
bacillus isolated from a spontaneous case of pyelitis
in a rabbit. In a series of thirty-two intracystic
injections fifteen of the animals showed definite
pyelitis. Of this entire series of animals only one
showed abscesses in the kidney. The presence of
the pyelitis was controlled both pathologically and
histologically. The evidence obtained showed that
in all probability there were two routes by which
infection was accomplished : a, by way of tho
lymphatics, from the bladder to the ureter and to
the kidney ; b, by direct extension up the lumen
of the ureter.
The Acidotic State of the Newborn. — Dr. J. P.
Sedgwick and Dr. jNI. SEHA^[, of ^Minneapolis,
presented this paper, which was read by Doctor
Seham. He stated that 300 determinations of
alveolar carbon dioxide tension on seventy-five new-
born infants were studied with respect to the effect
of musciilar exercise, ingestion of food, and age.
Twenty-five phenolsuJphonephthalein tests were
made on the newborn, which showed from thirtv to
60.75 P^^ cent, excreted in three hours. The alkali
tolerance of newborns was also tested. These ob-
ser\'ations warranted the conclusion that there was
no definite evidence from these experiments that
the newborn was in a state of so called acidosis.
The carbon dioxide tension readings were about
normal. Fifty per cent, was the average phthalein
excretions in three hours, and it took less sodium
bicarbonate to change the urine acid to alkaline
than in the adult. A standard for the determina-
tion of alveolar carbon dioxide tension in newborns
was established.
Immunity Reactions in Hydrated and Concen-
trated Tissue.— Dr. Frederic W. Schultz, of
^Minneapolis, said that it was an old clinical ob-
servation that certain types of organisms succumbed
more readily to the invasion of disease than others.
This had gradually crystallized into the expression
that apparently the fat plethoric organism showed
on the whole a lesser degree of resistance than did
the lean fairly emaciated organism. That hydration
or concentration of tissues bore some definite rela-
tion to immune reactions unfavorable in the hy-
drated and favorable in the concentrated tissues was
the idea which had been repeatedly expressed in the
literature. To demonstrate the truth of this im-
pression parallel series of gxiineapigs were taken as
near as possible in age and weight. The animals
were kept under the best conditions possible. In
the fat series the attempt was made to cause in-
crease in weight as rapidly as possible through the
use of liberal carbohydrate feeding, particularly
maltose. The lean pigs were kept on a balanced
ration, just sufficient to sustain them. The weight
loss was brought about gradually before immuniza-
tion and generally amounted to twenty-five to
thirty-five per cent, of the original body weight.
The lysin reaction was compared in fifteen fat pigs
and eighteen lean pigs. The animals were im-
munized against blood cells by intraperitoneal inoc-
ulations. The precipitin reaction was carried out
on eleven fat and eleven lean animals. The agglu-
tinin reaction was carried out on seven fat and
seven lean animals. Tables presented showed that
the lysin reaction was negative or nearly so in prac-
tically all of the fat animals, but was positive, some-
times to a marked degree, in over sixty per cent,
of lean guineapigs. The precipitin reaction was uni-
formly negative in both the fat and lean series.
For some unaccountable reason the guineapig serum
did not give the precipitin reaction. This was
strange in view of the agglutinin reaction, which
while present in only eleven per cent, of the fat
animals, was present in over seventy per cent, of
the lean animals. While the drawing of definite
conclusions from a study of this kind was certainly
unwarranted it seemed that if immunity reactions
were a good criterion of tissue resistance the rather
striking behavior of both lysin, and agglutinin re-
actions would seem to indicate that there was a dif-
ference in favor of concentrated tissue and that the
theoretical considerations expressed by Czernv and
other observers were substantially correct.
A Comparison of the Carbon Dioxide Tension
of the Alveolar Air, the Bicarbonate of the Blood
Plasma, and the Hydrogen Ion Concentration of
the Urine in Infants with Acidosis. — Dr. Oscar
M. ScHi.oss, of New York, said that the cases ob-
served occurred as a complication of gastrointestinal
disorders and were of the type described bv How-
land and Marriott. In the present study an attempt
was made to compare the reaction of the urine, the
carbon dioxide tension of the alevolar air, and the
plasma bicarbonate, with special reference to the
diagnosis and treatment of acidosis. The results of
their observations seemed to show that the plasma
bicarbonate was probably the most accurate index
of the alkaline reserve of the blood and was used as
a standard by which other methods were compared.
The reaction of the urine in infants was definitely
influenced by diet and was more acid than that of
adults on a mixed diet. This was probablv due to
the fact that the diet of infants was poorer in bases.
Correspondingly the carbon dioxide of the alveolar
air and the plasma bicarbonate were correspond-
inglv lower. In acidosis the urine was always very
acid but in moderate degrees of acidosis the urine
was no more acid than in some normal infants on
an acid producing diet. Urine with a hydrogen ion
concentration of six or less excluded the possibility
of acidosis. The carbon dioxide of the alveolar air
corresponded very closely to the plasma bicarbonate
in normal infants and in cases of acidosis before
sodium bicarbonate was administered. In acidosis
after the plasma bicarbonate had been brought to
normal by sodium bicarbonate the carbon dioxide
of the alveolar air was often much too low. This
was probablv due to continued irritabilitv of the
respiratory centre.
662
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
Dr. W. McKiM Marriott, of St. Louis, said that
his experience had been the same as that of Doctor
Scliloss. The faihire of the alveolar carbon dioxide
to indicate the presence of acidosis after sodium bi-
carbonate had been given, had also been observed.
In regard to the reaction of the urine as a guide in
acidosis to the amount of sodium bicarbonate to be
given, care should be exercised in taking the alkaline
reaction to litmus or the mistake of giving too much
bicarbonate might be made. It was better to use an
indicator that would change somewhere near the
normal acidity of the blood. They had found cresol
purple to be such an indicator.
A Protective Therapy for Varicella, and a Con-
sideration of Its Pathogenesis. — Dr. Alfred F.
Hess and Dr. Lester Unger, New York, reported
that during the past year varicella was widespread
in New York and made its appearance in the admit-
ting pavilions of the Hebrew Infant Asylum. An
opportunity was thus aflforded to attempt immuni-
zation. In all about thirty-eight children three or
four years of age were vaccinated intravenously.
None of these patients developed any local or
general signs, nor any eruption suggestive of vari-
cella. They were all in the course of the epidemic,
unavoidably, in contact with one or more cases of
chickenpox, but in spite of this proximity only one
developed the disease ; this one thirty-six days after
the time of inoculation. Vaccinations of this kind
induce neither local nor general reaction. The ac-
quisition of immunity likewise indicates that the
specific virus is contained in the vesicles. A simpler
method of therapy, the application of the lymph to
the broken skin or mucous membranes, failed to
bring about satisfactory immunity, although it also
occasioned no disorder. These investigations have
a secondary bearing as to the natural portal of entry
of the varicella virus nito the body. As the skin
and mucous membranes in this connection can be
excluded, it would seem most probable that the
virus enters by way of the respiratory tract, and
that contagion comes about through the air. This
mode of infection would account for the almost
unexampled communicability of the disease.
Intrathecal Injections of Normal Horse Serum
in the Treatment of Chorea. — Dr. Langley Por-
ter, of San Francisco, read a paper on this subject.
Dr. Oscar M. Schloss related some of the re-
sults obtained in Doctor LaFetra's service at
}3ellevue Hospital where it had been attempted to
follow out Doctor Goodman's treatment for chorea.
They tried that treatment in twelve cases and those
twelve cases did no better than twelve control cases
that received no serum. Some choreics might have
become better after the first, second, or third dose,
but one frequently saw the same improvement in
other cases that had not received the serum treat-
ment.
Dr. Charles Herrman, of New York, asked
whether a certain amount of spinal fluid was re-
moved before the serum was employed. If the
spinal fluid was withdrawn and improvement fol-
lowed, it might possibly be due to relief of intra-
spinal pressure.
Dr. L. E. LaFetra, of New York, said in speak-
ing of Doctor Goodman's method of treatment, that
it was not altogether a simple matter to draw off the
blood, keep it sterile, and then inactivate it. For
some reason no success "tould be recorded in getting
the brilliant results that Doctor Goodman had ob-
tained, and he did not feel justified in continuing to
use the treatment. Doctor LaFetra would like to
see others try Doctor Porter's method, for he
thought there might be some advantages in using
other than an autogenous serum.
Doctor Porter, in closing, said that in reference
to what had been said of the psychological' element
in these cases of choreas he would like to quote
from his paper. "Never can the psychical disturb-
ances of chorea be overlooked and it might well be
that the results which followed the use of sera are
evidence of a successful, if unwitting, application
of suggestive therapy." He formerly beHeved that
chorea and rheumatism were an entity and that if
the tonsils were removed the root of chorea was
also removed. In connection with that belief he
had had an interesting experience. A little patient
was brought to him from a distance and he ex-
plained to the mother his belief that if the tonsils
were removed the child would be improved or
cured. The mother took the child home and had
the tonsils removed and a week later wrote him that
the child had shown no symptoms of chorea since
coming out of the anesthesia. On the basis of such
an experience one might think that anesthesia was
a cure for chorea. The case simply served to show
how fallacious are some of our conclusions in re-
gard to the effect of various remedies employed for
the relief of chorea. This report was only pre-
liminary, but he felt that the severe cases were
certainly benefited by the injections of horse serum.
He hoped that others would follow up the treat-
ment and find out what it was worth. He felt that
it was better to withdraw more of the spinal fluid
than the amount injected. All of these cases
showed high intraspinal pressure. There was
nothing to lead one to believe that there was an in-
fection as the cell count and the globulin of the
spinal fluid were normal.
Medical Prophylactic Work in the Army; Its
Application to the Civil Population. — Dr. Paul
Armand Delille, Mcdicin Major de I'Arnicc
Fraiicaisc, related the history of the development
of preventive work in tuberculosis and of child wel-
fare work in France, and told what remained to be
done in these directions at the present time. He
showed that it was in France that the modern
movement for the protection of infants and young
children originated. After describing the work of
the various agencies organized to protect the new-
born, he stated that they had two laws desi^^ned to
protect early childhood. The first law, the Loi
Roussel, aimed to protect children placed by their
parents in nursing homes. Every child confided to
a wet nurse, to an ordinary nurse, or to another
woman for its care, came automatically under gov-
ernment supervision. This surveillance was ac-
complished by the prefects in each department, who
corresponded to the governors of States in the
United States, and who were assisted by local com-
mittees. Every woman wishing to care for a child
must furnish a certificate testifying to her qualifi-
cations. The second law, that of Senator Paul
Strauss, was adopted shortly before the war, in
October .3, .9.8.] PROCEEDINGS OF NATIONAL AND LOCAi. SOCIETIES.
663
June, 1913, with the addition of certain amendments
in June, 1914. It had to do with the protection of
the mother during her pregnancy and of the mother
ond child for the first four weeks after birth. It
permitted the mother to have complete rest and to
begin the nursing of her child under the best possi-
ble conditions. Any woman worker, employee or
domestic, or even one insufficiently supplied with
funds, was authorized to leave her work without
giving any indemnity, and the government provided
a certain allocation during the four weeks preceding
and following confinement. There also existed a
law for the aid of large families. In addition to the
Consultations de Nourisson or Baby Clinics and the
Gouttes de Lait, there had been established since
the beginning of the war Chambres d'Allaitement or
"Rooms for Nursing" in the munition manufacto-
ries and other institutions producing war materials,
where women were employed. In each factory
there were set aside one or more rooms, well aired
and kept perfectly clean, where the working women
brought their children in the morning and returned
at regular intervals during the day to nurse them.
There was also added a room for the sterilization of
milk in case supplementary feeding were necessary.
There might also be added a restaurant where the
mother might receive well chosen and well cooked
meals at a low price. For the older children there
Avere established "garderies" with rest rooms and
play rooms, and a dining room where a diet was
provided suitable to the child's age. Since the be-
ginning of the war the problem of the protection of
infancy had been made much more difficult owing
to the fact that physicians from the age of twenty-
five to fifty-five years had been mobilized, that
monev formerly given to agencies working for the
reduction of infant mortality had been diverted to
the war requirements, and that the birth rate had
markedly fallen since the beginning of the war.
Since 1916, a large number of societies had been
formed to handle the problem of infant mortality.
There had been opened in Paris, Lyon, and other
large cities, asylums for pregnant women, day
nurseries, etc. In order to furnish an efficient per-
sonnel for these organizations, there had been
founded in Paris, under the auspices of the "Ligue
contra la Mortalite Infantile," a Central School of
Puericulture and lectures had been given on this
subject for several years in connection with other
organizations. The writer had himself given such
a course. In 1917 the American Red Cross had ar-
rived in France with its special department, the
Children's Bureau. This had had a most astonish-
ing success and had been able to group under its
standard the best elements of the city, refigious,
civil, and political.
In speaking of the problem of tuberculosis among
children Dr. Major Delille told of the various
institutions for the treatment of active tuberculosis
among children, mentioning more particularly the
Rollier method established at Leysin in the moun-
tains of Switzerland, by which children were ex-
posed entirely nude, by successive stages, to the
rays of the sun. He described the operation of the
Grancher system which aimed to prevent tubercu-
losis among children, by preventing the propagation
of tuberculosis, in giving to its children a good
moral education, and in bringing them back to the
life of the country. The organization took children
from three to fifteen years of age from families in
which there was tuberculosis and placed them in
healthy peasant families in the country. The chil-
dren were seen daily by a physician who made the
rounds of his special territory in a small motor car,
seeing them in their foster homes and in the schools.
Before the war the Grancher Society was caring for
810 children ; the number was now reduced to
about 400. The American Red Cross had been in-
teresting itself in this work.
Child Welfare Work in France. — Dr. William
Palmer Lucas, director of the Children's Bureau
of the American Red Cross in France, described the
work being done by the American Red Cross in
France. He stated that this work was divided into
groups, some working for the French army, some
working for our own army, and some working for
the civil population. This latter work was also
divided into several groups, such as the work for
the refugees who were continually coming into
France, the tuberculosis work which was being
carried on in cooperation with the Rockefeller
Foundation, and the child welfare work. Doctor
Lucas described his work in a hospital at Toul
which was later occupied by soldiers. They then
retired to a hospital farther back. When the ma-
ternity hospital at Nancy was bombed and then
taken over for military purposes, fifty of the ma-
ternity cases were transferred to their hospital, so
that they had a maternity as well as a children's
hospital. This hospital had in connection with its
work a number of traveling dispensaries that went
out on certain routes among the villages and towns,
making visits on stated days. With the present
scarcity of physicians in France these t;"aveling dis-
pensaries fulfilled a very important function. Doc-
tor Lucas described the work being done at Evian,
which he said was much more spectacular than that
just described. The refugees from Belgium and
occupied France were returned to their country by
a roundabout journey through Switzerland. These
repatriates were mostly old people and children,
since the Germans had taken all able bodied people
who could do any useful work. The hospital at
Evian accommodated 200 patients, and had in con-
nection with it a dispensary. Since they had been
at work there they had examined 38,000 patients.
It was the Ellis Island of France. They had there
a verv remarkable system for cleaning up and dis-
infecting the people who passed through this station.
There were about 500 persons arriving daily and as
the town was small these had to be handled very
expeditiously to avoid excessive congestion. Here
they weeded out all cases of contagious disease and
all cases of tuberculosis. There were similar groups
of Red Cross workers at Lyon, Bordeaux, and
Marseilles. Of special interest was the work in the
contagious hospital at Evian. They formed cubicles
by hanging sheets between the beds and bv this
method and careful nursing thev had had only 2^/2
per cent, of cross infections, and had it not been for
one case of measles in which a mistake was made
they would have had less than one per cent, of
(364
BOOK REVIEWS.— BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
cross infections. The Red Cross Bureau ot Child
Welfare started in May, 1917, with only eleven
members and had today 400. They started their
work in one room of ordinary size and today they
had for the Paris workers an entire floor of a large
business building. There were at the present time
fifty or sixty doctors, 150 nurses, and a number of
other hel])ers engaged in the work. Doctor Lucas
spoke at some length of the efifect of the work of
the Red Cross in strengthening the morale of the
French peoi)le and said that even if the actual work
that it accomplished was not valuable, although
they all knew tliat it was of the greatest value,
nevertheless it would be worth while, if only for its
stmnilating cflect on the French people.
The Massachusetts Child Conservation Com-
mittee.— Dr. R. M. Smith, of Boston, described
how, through the work of a central committee, an
educational campaign had been carried out in the
State of Massachusetts and subcQmrnittees formed
in towns throughout the state for carrying on child
welfare work.
^
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obliijation to reviriv them all. Nevertheless, so
far as space Permits, zvc revinv those in which we think
our readers are likely to he interested.]
Coinmosione Cerebro-Spinale. By Dott. F. Pedrazzini,
Studio Anatoinico, Clinico e Sperimentale. Dall' Institute
Anatomo-pathologico dell' Ospedale MaRsiore e dall' In-
stitiito di Fisiologia sperimentale di Milano. Milano :
Uliico Hoepli. 1918. Pp. xv-170.
This is a brief but very full treatise based upon
the principle of the conformation of the structure
of the organism to its functional necessities. In this
light the author has discussed the subject of cerebro-
spinal concussion and the injuries resulting there-
from, particularly those unaccompanied by any ana-
tomical evidence such as fracture. His discussion
is based upon clinical experience, his own and that
elsewhere recorded, as well as his own experimental
work. He calls attention to the provision in the struc-
ture of the cranium and the spine, along with the
anatomical prevision through the divisions and ap-
purtenances of the brain and spinal cord, to the adap-
tability on the part of these structures to the injuries
to which the central nervous system is subjected.
Of chief importance is the alteration in pressure of
the cerebrospinal fluid and the adjustability of the
cavity of the cerebral ventricles, and of the dural
sac through its compressibility and extensibility.
These anatomical factors are applied by the author
tc protectioii against injury actually sustained,
in which a disturbance of these anatomical and
physiological factors takes place. He relates them
also to serious diseases of the central nervous sys-
tem in which injury may have been sustained with-
out fracture. He makes special reference to in-
juries sustained during the present war and asserts
that in all these disorders this conception of injurv
should l)e taken into account. This necessitates a
medical therapy instead of the surgery indicated by
fractural injuries. And along with this, psycho-
therapy called for by psychic symptoms resulting
from these injuries must not be neglected. Various
fornife of such therapy are reviewed by the writer.
Twenty-seventh and Twenty-eighth Annual Reports of the
Eye, Ear, Nose, and Throat Hospital of New Orleans,
La. January i, 1916, to December 31, 1916. New Or-
leans, 1918.
The city of New Orleans may well be proud of
its eye, ear, nose, and throat hospital. To judge
by the reports before us the work done in it is fully
and favorably comparable to that performed in our
largest medical centres, such as New York, Phila-
delphia, and Chicago. The connection of its various
departments with such men as Souchon, Matas,
Dyer, and Lynch is. a sure guarantee of the high
scientifio standing of the institution, and the num-
bers of both clinical and hospital cases run into the
thousands embracing every variety of pathological
conditions of any importance in the domain of eye,
ear. nose, and throat. The statistical data would
furnish abundant food to the inquiring mind, for the
dead figures are full of vital importance to the med-
ical sociologist or ethnologist.
«>
Births, Marriages, and Deaths.
Married.
Lewis-Cragin. — In New York, N. Y., on Thursday, Oc-
tober 3d, Dr. Raymond W. Lewis, United States Navy,
and Miss Alice Gregory Cragin, daughter of Dr. Edwin
B. Cragin and Mrs. Cragin, of New York.
Died.
B.'VDGER. — At Skowhegan, Me., on Friday, September 27th,
Dr. Omar Badger.
Bennett. — In Philadelphia, Pa., on Wednesday, October
2d, Dr. John K. Bennett, aged forty-nine years.
Brown. — In Nahant, Mass., on Wednesday, October 2d,
Dr. William F. Brown, aged sixty-one years.
CoBLEiGH. — In Clinton, Mass., on Saturday, September
28th, Dr. H. R. C. Cobleigh. of Berlin, Mass., aged thirty-
two years.
Cohen. — In Boston, Mass., on Thursday, September 26th,
Dr. Hyman Cohen, aged thirty years.
Dewitt. — In Towanda, Pa., on Tuesday, October 1st,
Dr. William A. Dewitt, aged forty-one years.
Doerr. — At Camp Humphreys, Va., on Thursday, Octo-
ber, 3d, Lieutenant Colonel Charles E. Doerr, Medical
Corps, U. S. A., aged thirty-five years.
DucLos. — In Bridgeport, Conn., on Thursday, September
26th, Dr. William Durlos, aged forty-three vears.
Floden. — In New York, N. Y., on Monday, September
30th, Dr. Max M. Floden, aged thirty-two years.
Haight. — In Cedarhurst, Long Island, on Monday, Sep-
tember 30th, Dr. David L. Haight, aged seventy-nine years.
Harrington. — In Norwich, Conn., on Tuesday, Septem-
ber 24th, Dr. Robert E. Harrington.
Hartley. — In Philadelphia, Pa., on Saturday, October
5th,^ Dr. William K. Hartley.
Kaufman. — In Brooklyn, N. Y., on Tuesday, October
ift. Dr. Irving Harry Kaufman, aged thirty-two years.
KEND^irKSON. — In Boston, Mass., on Sunday, Septem-
iier 29th, Dr. Joseph T. Kendrickson.
Mara. — In Boston. Mass., on Thursday, October 3d, Dr.
Frank T. Mara, aged fifty-eight years.
Salvin. — In Boston, Mass., on Wednesday, September
25th, Dr. Louis W. Salvin, aged thirty-one years.
Schick. — In Philadelphia, Pa., on Thursday, October
3d, Dr. William B. Schick, aged fifty years.
Stark. — In Norwich, Conn., on Thursday, September
26th, Dr. Clinton E. Stark, aged sixty-five years.
Wells. — In .A.nnapolis, Md., on Sunday, September 29th.
Dr. George Wells, aged seventy-five years.
Wolfe.- — In Philadelphia, Pa., on Monday, September
3Cith, Dr. Thurston Wolfe, aged seventy-six years.
Yates. — In Pawtucket, R. I., on Monday, September
23d, Dr. Cora Geneva Yates, aged sixtj'-six years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal S Medical News
A Weekly Review of Medicine, Established 1 8 43
Vol. CVIII, No. 16.
NEW YORK, SATURDAY, OCTOBER 19, 1918.
Whole No. 2081.
Original Communications
ERRORS IN DIAGNOSIS OF PULMONARY
TUBERCULOSIS.*
By Abraham Trasoff, M. D.,
Philadelphia,
First Lieutenant, M. C, United States Army; Member Tubercu-
losis Board, Camp Meade, Maryland.
If I were to be asked: '"What is the most impor-
tant error one should avoid in the diagnosis of
pulmonary tuberculosis in the army?" my answer
would be; "The mistake of the overzealous in de-
claring a normal chest tuberculous." Such con-
fidence in one's ability and such proficiency in
diagnosis, undoubtedly imply a thorough knowl-
edge of the normal as well as of the pathological
lung — a comparatively rare combination in physi-
cians. Few men, unfortunately, fully realize the
importance of thoroughly knowing the normal chest
in its manifold variations, in order to diagnose
abnormalities, if present.
This lack of knowledge of the normal has its
foundation in the medical schools, where insufficient
training in the examination of the normal chest is
given. The student — spurred on by his instructors
— becomes more interested in the abnormal patho-
logical conditions, and attains some ability in detect-
ing these, without, unfortunately, acquiring similar
facility in diagnosing a normal state. As he leaves
the medical school to enter his service as hospital
intern, he again is confronted with abnormal con-
ditions only. And when, finally, he begins to practise
medicine, he certainly has little opportunity to see
many normal cases. As a result, he fails to acquire
a knowledge of the "normal abnormalities" — if I
may so express myself.
In civil life a mistake in diagnosis, whereby a
patient is declared tuberculous, may be pardoned, as
Colonel Bushnell truly remarks, since the treatment
prescribed — rest and good food — will benefit even
the nontuberculous, although many unnecessary and
undesirable hardships may follow in the wake of
such an error. In military life, however, mistakes
of this nature are of greater significance. When the
man power of the country is to be utilized for the
benefits each can contribute during its emergency,
it would be criminal to allow innumerable normal,
healthy young men to go about idle, or perhaps to
fill up sanatoria, merely because some few signsthey
presented were misinterpreted as evidence of tuber-
^'j^^'^'ished by permission of the Surgeon General, United States
Copyright, igi8, by A. R. Elliott
ciilosis. Such a condition of affairs occurred in
France during the first year of the war. About
3o,ooo soldiers were discharged as tuberculous — of
whom more than half were returned to full military
duty in a verv short time, with no abnormal findings,
or with a diagnosis of some minor bronchial ail-
ment. My personal experience as examiner for
tuberculosis for the last ten months has led to the
same conclusions. Often, especially in the begin-
ning of my career as examiner in the army, owing
to a rapid examination, I was inclined to declare a
man tuberculous, for one can' hardly afford to spend
much time on these examinations, whereas at a la-
ter date. I would be astonished at the absence of the
signs I formerly elicited, and mayhap wonder at my
own suspicions.
It is not my intention to discuss the diagnosis of
pulnionary tuberculosis in this short paper. That
subject has been fully treated in textbooks and dis-
cussed in the literature, and little can be added.
What I purport to do is to outline, as briefly as
possible, some of the physical signs frequently en-
countered in the normal chest — a knowledge of
which may obviate an incorrect diagnosis of pul-
monary tuberculosis.
For the sake of simplicity, I have listed these
signs under the four main methods of physical ex-
amination : Inspection, palpation, percussion, auscul-
tation.
I. Inspection. — (a) Diminished expansion. This
may be voluntarily simulated, if bilateral. (b)
Dyspnea, tachypnea, jerky respirations. These, too,
are often simulated. Especially is this encountered
in a certain number of men who try to impress the
examiner with their "illnesses" in order to evade
military service. In my experience with this type
of person, I found it a simple matter to demonstrate
their malingering by diverting their minds to some
ordinary topic of conversation — upon which their
breathing becomes absolutely normal, (c) Droop-
ing of a shoulder. This is very often occupational,
(d) Asymmetry of the chest. This is a very com-
mon condition, due to: i. Congenital malformation
of bony framework. 2. Absence of muscle or part
of it. 3. Atrophy of muscle. 4. Hypertrophy of
left chest — in left handed persons, (e) Multiple
scars on neck — evidence of a healed cervical ad-
enitis. Such a finding does not signify that the man
is sufifering from pulmonary tuberculosis. On the
contrary, it points rather to a greater resistance to
the infection, (f) Clubbing of fingers and curving
Publishing Company.
666
MAYER: ENDOBRONCHIAL TREATMENT OF BRONCHIECTASIS.
[New York
Medical Journau
of nails (pulmonary osteoarthropathy), though very
suggestive of chronic cardiopulmonary disease, does
not, per se, indicate pulmonary condition. I often
encountered it among negroes with normal heart
and lungs.
2. Palpation. — This method is least used in our
exammation — especially when it is rapidly made,
(a) Diminished expansion, and asymmetry of chest
may be ascertained by this method, (b) Muscular
rigidity, a condition frequently met with in pul-
monary tuberculosis, may sometimes be found due
to a transitory spasm of the muscles, (c) Tachy-
cardia, so common among recruits, is frequently
due to either vaccination or inoculation. Nervous-
ness often play^ great role.
3. Percussion. — (a) Position. It is very impor-
tant to have the recruit, or soldier, absolutely re-
laxed. Excessive muscular strain will result in an
abnormal note, (b) Technic. I am not going to
discuss technic in this short paper. Every examiner
should familiarize himself, thoroughly, with the
proper technic in standard textbooks on physical
diagnosis. I only wish to state that one can elicit
various abnormal notes in a normal chest, due to
faulty technic, (c) A note of the same resonance
throughout the entire chest is not to be expected.
In the interscapular regions, as well as over the
upper lobes posteriorly, there will be an impairment
of resonance, in comparison with the note ehcited
over the anterior aspect of the chest, and the bases
of the lungs. This difference is due to the greater
musculature over the regions named. For a similar
reason one must allow for diflference in the percus-
sion note between thin chested and muscular sub-
jects.
4. Auscidlation. — This method is, and should be
the most important part of the physical examina-
tion. Most errors of commission can be ascribed to
faulty interpretation of auscultory findings, (a)
Improper breathing. One can easily imitate: i,
bronchial breathing ; 2, harsh inspiration ; 3, pro-
longed expiration; 4, cogwheel breathing; 5, sib-
ilant and sonorous rales. Such errors can be obvi-
ated by having the patient breathe through his
mouth, somewhat more rapidly and more deeply
than normal, (b) Muscular development. Harsh
breathing is frequently met with among thin chested
persons — particularly if the subject has engaged in
athletic sports. Among negroes, too, harsh breath-
ing is quite common, (c) Extrapulmonary ad-
ventitious sounds: i. Muscle sounds. These often
resemble crepitant rales, are dull, rumbling, or
rhythmic in character and bear no relation to any
phase of respiration. 2. Atelectatic rales at the
apices. These usually disappear after a few force-
ful inspirations. 3. Marginal sounds. These are
best heard in the infraaxillary regions between the
anterior and posterior axillary lines — and occasion-
ally at the bases posteriorly. They are usually best
heard at the end of inspiration and are of a dry
crackling quality. 4. Clavicular and sternocostal
clicks, and stretching of the ligaments of the
shoulder joint, while raising the shoulders, will often
impress the inexperienced ear as rales. 5. Degluti-
tion, after coughing, often resembles rales. 6.
Creaks, heard in the interscapular and scapular
regions are, probably, fascial in origin. 7. Skin con-
ditions, viz., rough and scaly skin (ichthyosis) and
the presence of fine hair, may at times be mislead-
ing. 8. Presence of rales above of the clavicles with
no other associated signs, does not, as a rule signify
the presence of tuberculosis. 9. Harsh breathing at
the left base is not to be considered abnormal. 10.
The psychic state of the recruit must be considered
in order to account for some apparent abnormali-
ties.
Above all, and where mistakes are most fre-
quently made, is in the diagnosis of fibrosis of the
right upper lobe. This term is more misused than
any other in physical diagnosis. I must confess
that I, too, was guilty of this offense, during the
first few months of my career as examiner. The
normal, physiologic difference between the right and
left upper lobes should be constantly kept in mind.
To diagnose fibrosis of the right vipper lobe on the
slightest impairment of resonance, some increased
whisper, and prolonged expiration over an area ex-
tending down to the second or even third rib, would
mean to reject about forty per cent., or more, of our
healthy manhood.
One fact must be borne in mind : When a man is
diagnosed tuberculous, rejected, and returned to his
local board for reclassification, he is placed in Class
5. Thereafter no practical benefit can be expected
from him by the government, although he may be
in no worse physical condition than the men who
are serving in full military duty.
I lay claim to no originality in the material here
presented. I am greatly indebted to various men,
of national and international reputation — Colonel
P>ushnell, Pottenger, Riviere, Minor, Fishberg, and
many others, for information on the subject of
tuberculosis. I have endeavored to combine all
their observations, in so far as I found they applied
in my experience, and to present them in a small
article, so that other examiners in the army as well
as in civil life, might find the information at a
glance.
THE ENDOBRONCHIAL TREATMENT OF
BRONCHIECTASIS AND BRONCHIAL
ABSCESS.*
A Preliminary Report.
By Emil Mayer, M. D.,
New York.
In yielding to the request for a preliminary report
on the endobronchial treatment of hypersecretion in
the bronchi, I do so with much diffidence — as my
time of observation has been short, but with the
hope that, through the interchange and discussion
of experiences in the bronchoscopic treatment of
similar cases, it may lead to conclusions which will
result in benefit to these unfortunate sufferers
whose constant cough, expectoration, and malodors
render them doubly'unhappy.
About one and a half years ago my then asso-
ciate "^t the hospital, Dr. Sidney Yankauer, stated
that he believed it would be possible to clean out a
•Read at the First Annual Meeting of the Association of Amer-
ican Peroral Endoscopists, Philadelphia, May 31, 1918.
October .9, 19.8.] MAYER: ENDOBRONCHIAL TREATMENT OF BRONCHIECTASIS.
667
lung abscess by suction, wash it out, and apply
medication through the bronchoscopic tube. With
his masterly mechanical genius he made and per-
fected a double tube, the outer one to be attached to
the suction apparatus on the left, the inner one to
the irrigating apparatus on the right.
The method of treatment is as follows : A hypo-
dermic of half a grain of morphine with atropin
should be administered half an hour before treat-
ment is begun, followed by thorough cocainization,
with cotton applicators, of mouth, tongue, pharynx,
and larynx, from ten to twenty per cent. The pa-
tient should lie on his back with his head supported
by a trained assistant, the bronchoscopic tube in-
serted, and a spray of two per cent, cocaine and
adrenalin thrown into the bronchus to allay cough-
ing. The excessive secretion in the bronchi is then
withdrawn through the tube, by the suction ap-
paratus, and ten ounces of warm salt water slowly
introduced through the inner tube is at once with-
drawn through the outer one. This method is to
be used in the first or second bronchoscopy. The
patient, showing no intolerance to the introduction
of the fluids, finally receives a solution of iodine and
carbolic acid (iodine two drams, carbolic acid fif-
teen mm. to one pint of water) in place of the salt
water. This method of treatment was repeated
twice weekly in each case, and as far as I know,
with no serious results.
One of the patients is reported to have had a
pneumonia after he had been washed out many
times. The occurrence of that aflfection was not, in
my opinion, a result of the washing, for he has since
been washed repeatedly without creating the slight-
est disturbance.
In January of this year. Doctor Yankauer having
entered the service of the government, I assumed
charge of the laryngological department, by request
of the board of trustees of tbe hospital, and these
cases came under my care. I learned that those
then under observation showed signs of improve-
ment. In many instances the odor, which was
overpowering when treatment was first begun, had
practically disappeared ; the amount of secretion
was decidedly less in most of the cases ; and in all
the ease of expectoration was undoubtedly in-
creased.
As the treatment of these cases would in all
likelihood run over years before lasting results
might be noticed, I realized the danger of incurring
drug habits by the oft repeated use of morphine and
cocaine twice weekly for an indefinite time, and con-
sequently decided upon weekly treatments instead.
This course, though undoubtedly prolonging the
treatment, had with it the element of safety, by not
engendering a habit that might be more serious in
its results than the disease treated.
In each instance a record was made on the pa-
tient's chart each time he was treated in this man-
ner, and in order to ascertain the number of treat-
ments it became necessary to consult the records in
the hospital. As this had to be repeated in each
case, it meant a great deal of additional labor. I
therefore devised a chart on which was placed the
patient's name, the date, and the particular form of
treatment used. As this was noted at each treat-
ment we were able in a moment to note what had
been done for each patient, how many patients had
been treated each day, and how many had received
a given form of treatment. This table is herewith
presented :
B. M.
B. S. .
H. S.
J. .T.
K. H.
S. A.
G. J.
R. L..
F. H.
.F
.M
.M
.F
.M
.M
.M
,M.
.M
It, ti, tt,
. . 1=
. S S
. 12 V
. V 1-
. P V
B S S'
I'
X
TVs .
T'A
TV, T/i
TVs
S S
ry, T
s s
T T
I-
T
P
P V
B S
14 14 14 14 p
T T2 T2 .
T T2 . . V
T T2 T2 T2 r-
Bronchoscopic treatment; B, bronclioscopy ; S, saline; I. iodine
(figures indicate ounces); T tablrt; T'/o, one half tablet; T2, two
tablets.
A few of the cases were selected to receive
dichloramine-T, in the form of chlorazene tablets,
beginning at first with a solution of one tablet in ten
ounces of water. The bronchus in these cases was
first washed out with the salt water. A half ounce
of this solution was used in the beginning, increas-
ing to one, two, and finally to four ounces. No ill
effects were noticed after its use.
In the three months I have been able to observe
these cases, I have been ably assisted by Dr. L. G.
Kaempfer, who had cooperated with Doctor Yank-
auer throughout the entire previous time. I feel
greatly encouraged, in the first place, by the almost
complete cessation of odor, and this, from the treat-
ment thus far instituted, seems mostly to follow the
use of iodine. There is also a diminution in the
amount excreted ; at any rate expectoration is very
much easier. A very decided improvement in the
physical condition of these patients was observed.
As most of them have received treatment at various
clinics without any improvement they are quite
eager to accept this new form which gives them
some hope of being able to mingle with their fellow
men on terms of equaHty, and, perhaps, of ultimate
cure.
So my report here is one of distinct progress, and
is coupled with the belief that we have been able to
demonstrate the ability of the bronchi to withstand
the introduction of quantities of fluid without
harm.
It is with the hope that some other drug or
method may be suggested that would accomplish
more than we have thus far been able to, that I
present this report which otherwise would not have
been made — certainly not at this time.
40 East Forty-first Street.
Gastroenterostomy vi^ith and Without Suture.
— Doctor Estape (Revista de Cicncias Medicas de
Barcelona, May, 1918) in comparing the suture with
the button method describes excellent results with
the Jaboulay button, which is a modification of the
Murphy appliance. He has used this button in over
a hundred cases and he has come to look upon it as
the method of choice.
668
OBERNDORF: NEUROTIC SYMPTOMS REFERRED TO THE EYES.
[New York
Medical Journal.
NEUROTIC SYMPTOMS REFERRED TO
THE EYES *
By C. p. Oberndorf, M. D.,
New York,
Adjunct Neorologist, Bellevue Hospital.
"The eyes," quoted a patient, "are the windows
of the soul." If this is true, it should not be sur-
prising to find that neurotics, with their well known
tendency to shift responsibility when their souls
are in disorder, should complain of eye difficulties
instead of soul conflicts. The psychoanalyst is
struck by the large percentage of patients suflering
from neurosis who have worn or are wearing
glasses, or refer their symptoms to their eyes. They
describe their disability as weak eyes, blurring or
dazed vision, astigmatism, eye strain, etc., and
usually have been treated for such by physicians.
The eyes in such cases have been used for erotic
gratification to an extent which the patient considers
incriminating. It has become almost axiomatic in
psychoanalytic experience to find that no organ,
not specifically sexual, can be utilized intemperately
for erotic satisfaction without imparing to some
extent its ability to fulfill its normal duties. When
there has been excessive utilization of eyes, for pur-
poses which the patient believes incompatible with
their proper function, subjective ocular disability
is apt to result.
From the category of cases I wish to describe,
it is necessary to exclude those where there have
been scant complaints referable to the eyes, but
in which glasses have been prescribed without ade-
quate reasons, as a wild hazard that the neurotic
symptoms might be alleviated in this way. Such
a case is exemplified in a young man, a doctor's
son, whose father in his perplexity over the son's
nervous condition, consulted his colleagues, one
after another, until an ophthalmologist suggested
that the condition originated in eye strain which
glasses would rectify. Upon analysis it developed
that the "nervousness" euphemistically designated a
stubborn fear of insanity, which had followed upon
a fear of hypnotization, which, in turn, rested upon
a masturbation complex. Since childhood he had
been in the habit of stealing his mother's and the ser-
vant girl's shoes, against which he would mastur-
bate. Subsequently, he would look at the shoes of
women longingly for erotic gratification until he
became ashamed to look at them. Headache and
eye svmptoms developed, but the former was more
prominent in this ca.se. In many respects the men-
tal mechanisms paralleled those which will be de-
scribed more in detail in connection with another
case which follows. Needless to say, the fear of
insanity was not altered by the attempt to correct
the headache, merely one of its symptomatic by-
products. However, it became possible for the
patient permanently to discard the glasses as his
mental disturbance came under control.
Frequently, patients report that the opthalmolo-
gist. at the time of applying the glasses, had him-
self expressed doubt as to the physical validity
of the disability and even as to the wisdom of his
•Read before the Section in Neurology, New York Academy of
Medicine.
course, and had cautiously suggested that the glasses
be worn tentatively. In such cases, however, after
once adopting glasses, the patient seldom discon-
tinues their use, because of the psychic comfort he
derives from them.
Occasionally vague conceptions as to the sub-
jective psychic reaction to the avowed visual defect
crept into the consciousness of my patients. One
woman remarked, "I always see better when I feel
mentally better." Again, when eyeglasses were pre-
scribed for the sister of a doctor, in the vain hope
that her headaches, due to a neurotic condition,
might be alleviated, she felt that the "glasses formed
a veil which permitted her to see without being
seen ;" and another patient under similar circum-
stances accepted glasses because he thought they
"formed a shade" which would "obscure the dark
circles under his eyes" which he attributed to mas-
turbation. The facility with which these eyeglass
wearers are able to see clearly after their neurosis
has been cured seems corroborative of the nervous
origin of the eye disorder. Mental adjustment ap-
pears to render further adjustment of glasses super-
fluous. It has been said that there are none so
blind as those who won't see — and many a person
possesses, more or less consciously, extremely good
reasons for not wishing to see, and even more
particularly for not desiring to recognize that he
is, or may be seen. In this latter type, the glasses
sometimes afi'ord a psychic equivalent of blinding
the patient's appreciation of the dangers of reality.
Cask I. — A male, American, aged twenty-foi:r years, was
referred to me primarily because of a terrifying sensation
of presstire between the symphysis pubis and the umbilicus
which occurred about six o'clock every morning. For the
purpose of this presentation it is not necessary to trace the
origin of this manifestation, but he numbered among his
various neurotic symptoms also a blurring of vision and
aching eyes, for which he had worn glasses for several
years. It is the origin of the ocular disturbance, which
becatne apparent during the analysis, that is pertinent.
From the age of nine to twelve the patient had mastur-
bated nightly, but then discontinued because he had been
told that masturbation caused insanity. At eighteen he
resumed the habit, and for the two years prior to consult-
ing me he had been indulging frequently in masturbatio
frustrata, i. e., exciting himself to the point of orgasm but
never allowing orgasm to occur because of the belief that
the ejaculation itself was the specifically noxious feature
of masturbation which produced insanity. Later, through
a childish but nevertheless persistent misinterpretation of
a chatice r';mark, the patient gained the idea that the nerves
of the body were gathered together in the greatest num-
ber in the glans of the penis. The penisl^ecame for him the
nerve centre, and he inferred that during the phenomenon
of erection of the peni^ the nerves were stretched. He had
also learned that many nerves were in the eves. Natur-
ally this would be impossible without a complementary pull
at the distal attachment of the nerves, namely, at the eyes.
.So, according to his reasoning, it followed that with the
contraction of the penis after erection and consequent re-
lease of tension on the eyes, the latter would pop forward
and become bulg'ng.
For some years he had noticed a feeling of vertigo, most
pronounced after masturbatio frustrata. When the svmp-
tom became intolerable, he consulted several physicians,
who told him that the vertigo was merelv nervousness.
From other data he had determined that nervousness was
but an euphemistic svnonym for insan'tv. Insanity
(nervousness, i. e., a disease of the nerves), he had been
told, was a brain disease, and he therefore inferred that
the brain must be situated where the nerves were most
numerous, namelv in the penis.
On the other hand, he had been told that insanity showed
October .9, 1918.] OBERNDORF: NEUROTIC SYMPTOMS REFERRED TO THE EYES.
669
itself in bright eyes, aiKl he further reinforced his theories
by the behef that masturbation, in addition to producing in-
sanity, also caused bulging eyes. Thus in the patient's
psyche rested the consciousness that he had indulged in all
the factors necessary for the development of eye trouble.
From these corroborative and interlocking bits of misin-
formation, it is not strange that he should have become
convinced from frequent and prolonged examinations be-
fore the mirror that his own eyes were both bright and
bulging — in other words, the brightness revealing incipient
insanity (vertigo = nervousness, nervousness = insanity),
and the bulging indicating the masturbation (masturbation
produces bulging and vertigo, vertigo is nervousness).
He felt convinced that he justly deserved the affliction of
the eyes, for through the abuse of his penis, the nervous cen-
tre, due to repeated stretching, he had necessarily affected
the complementary nervous centre, the eyes, causing them
to be bright and promnient. Having concluded that his eyes
were revealing the results of his practice, before long he
experienced an indistinctness of vision, for which he sought
relief from an ophthalmologist. Glasses were applied,
which the patient was wearing when he came for analysis.
During analysis it became obvious that the patient
suffered from a deep seated fear of insanity which
he thought his eyes revealed, and unconsciously he
began to refer all his symptoms to his eyes. This
convenient displacement naturally proved much less
embarrassing to him in applying for medical treat-
ment than his sexual difficulties would have been.
At the same time the glasses guarded from the
world the knowledge of his impending insanity, as
through them the bulging and brightness were di-
minished and obscured to persons looking at him.
The visual difficulty was the first of his many symp-
toms to yield to analysis, as the displacement came
very close to being conscious, and for three years
he has been getting along perfectly well without
glasses.
It has been pointed out that displacements of this
type to the eye could not occur so readily, were
it not for the great libidinous value which is at-
tached to the eye. This circumstance is further
enhanced in the male by a number of physical re-
semblances between the eyes and the genitals, par-
ticularly the testicles, through their form, changeable
size, mobility, great value to the individual and
their sensitiveness.^
Misconceptions of a type similar to those in the
case jtist cited, based on erroneous childish misin
terpretations, are not so infrequent as those who
are conversant with physiology might be inclined to
believe. Thus a patient, a librarian, aged twenty-
four, also an eyeglass wearer, suffering from a se-
vere ocular locomotor disorder, had since girlhood
paid especial attention to the interpretation of char-
acter through the eyes. Her knowledge of eyes,
however, not only constituted a means of judging
others but became a boomerang of self reproach,
in that she felt that her own character, which she
believed unrighteous, was revealed through her eyes.
In this connection she significantly remarked :
"When I talk with people I'm always thinking of
their eyes to tell if their thoughts are pure, but I
am worrying more what they see in mine." Evi-
'An analoeous association between the eyes and the genitals on
the basis of both being sensitive organs which might conceivably
persist unmodified to adult life, was reported to me by a mother.
She had reprimanded her nine year old boy whom she found play-
ing with his genitals, with the warning that he should never touch
those parts except when necessary for urination as they were the
most delicate organs of the body. To her surprise he vigorously
defended himself by retorting, ''Mother, how can that be so? The
teacher told us the other day that the eyes were the most delicate
organs of the body."
dently what she thought they beheld was not en-
tirely in accord with what she would have desired
them to see. for she further commented : "It hurts
to look oneself in the eye. Particularly it hurt me,
because I knew what was there. I was so sick and
tired of myself."
So too, the sense of sexual guilt based on certain
early homosexual experience, is revealed in the fol-
lowing remark : "When I saw myself in a mirror
during my bath, I thought it was not right. It re-
minded me of Liza in Pygmalion, who was not
good ; and I thottght that I was not good." The
defensive action of the eyes in guarding against ag-
gression is expressed by the statement : "When
1 was a child and we played kissing games like post-
office, if I were chosen I went out of the room with
the boy and just stared at him. He wouldn't kiss
me."
On the other hand, she felt herself able to
determine a person's character by his shoes, but
only if the persons were actually wearing them.
When sitting in the subway she would study the
shoes of the people opposite her to inake character
analyses. It is not surprising, in view of the im-
portance she attached to shoes, that she spent a
hugely disproportionate amount of her meagre in-
come on expensive shoes. In analytic terms her fine
shoes compensated for her unsatisfactory morality.
The whole ocular locomotor complex reverts to an
idea of physical connection between the feet and the
eyes, analogous to the stretching concept in Case I.
When a child of perhaps six, she had broken open
the abdomen of her bisque doll and there had dis-
covered an elastic cord lying on the back of the
doll. On puUing the elastic, she found it attached
to both the legs and the eyes and concluded that
they must always move harmoniously in the human
being. In later years, when she found difficulty in
making her eyes behave in conformity to her ideals
of morality, she stumbled and staggered so that she
could barely cross a room -if she felt herself under
observation. -
Cask H. — A Russian Pole, aged twenty-four, referred by
Dr. I. Strauss, complained of uncontrollable and feverish
blushing and the feeling that he was an outcast whenever
he came into the society, even that of his own people
and friends. These symptoms had naturally greatly inter-
fered with his advancement in business and with his social
enjoyments. As the analytical basis for these complaints
ramifies interminably, I shall mention only that portion
of his history seeming to account for his eye symptoms,
for which he had long worn glasses.
From the age of five the patient has been an insatiable
voyeur — a condition, in this case, coupled with an immuta-
ble foot fetishism. Although this did not constitute one of
the specific reasons for the patient's seeking medical aid,
it nevertheless formed for him a very vital problem, as it
diverted much of his energy from work and normal pleas-
ures. He often spent hours walking the fashionable thor-
oughfares, following a pair of well fitting shoes on a
woman. His interest in shoes had arranged itself into
definite levels of satisfaction — thus a low heeled oxford
shoe would hold his attention only transiently, whereas a
high heeled low shoe aroused him more. The low heeled
boot excited him more than the high heeled oxford, but
in the high heeled boot rested an irresistible attraction.
When the fancy high boot, short skirt mode became fash-
ionable about TQi.S, he spent days in the torturing pleasure
of fcllov.'ing one pair of shoes after another up and down
the streets.
-The analysis of another ocular locomotor syndrome appears in
the New Yot.k Medical Journal, July 22, 1916.
6/0
OBERNDORF: NEUROTIC SYMPTOMS REFERRED TO THE EYES. „ [New York
Medical Journal.
His t'lrsi recollection of emotional interest in shoes
dates back to the age of five, when a youns woman,
who had come from the country to be married, stopped at
his home for a brief repose before the ceremony. Dressed
in her wedding gown, she lay down on a couch, where she
fell asleep. While she rested, the patient stealthily crept
to the couch and kissed her shoe, a high black shoe, which
she had left exposed. This original fixation may possibly
account for the peculiar levels of satisfaction in the form
of shoes. Even at so early an age a sense of guilt over-
whelmed him, implicating, of course, some previous analo-
gous though forgotten experience for v.'hich he must have
been censured.
This patient has never masturbated in any of the fa-
miliar forms, but apparently has secured very complete and
constant gratification from voyeur experiences. Thus, as
a boy from the ages of ten to seventeen, he slept in a room
adjoining that of his older sisters, whom he would stealth-
ily watch at their toilets. This would produce prolonged
erections without emissions. About his thirteenth year,
the odor of one particular sister's high shoe so aroused
him that he would kiss the shoe passionately. Shortly
after his emigation into America, at the age of seventeen,
he became an assiduous frequenter of the burlesque per-
formances, which seemed for a time to satisfy his desires.
In order to gratify his craving to see more fully, he pur-
chased opera glasses, which he used even when his seat
was near the stage. At this period, and subsequently, he
also used these glasses for spying on the neighbors, so that
complaint was lodged against him with the police.
Up to his nineteenth year, whenever he experienced ar-
dent sex desire, he found it possible to appease it by accost-
ing some street prostitute and asking her if she would dis-
robe for him. The usual affirmative reply sufficed to relieve
him temporarily. So, too, a visit to a house of prostitution,
where he would pay some woman to disrobe, proved ade-
quate for sex relief. When he indulged in intercourse for
the first time at nineteen he found himself compelled to
kiss the shoes of the woman before relationship, and sub-
sequently discovered that he was impotent unless the
woman kept on her shoes.
On the whole, normal sex relationship appealed to him
comparatively little, as his voyeur experiences were more
exciting and emotionally gratifying. They have led him
into all sorts of perilous climbing expeditions over fire-
■escapes in order to spy, and also to elude his pursuers who
at times gave chase after they had detected him at their
windows. Once, when watching a woman disrobe from a
neighboring fire escape, he became so excited that he sent
a brick crashing through her window and fled precipi-
tately. On another occasion he avoided arrest, after being
caught by a life guard under the bath houses at the beach,
by volunteering to accept summary punishment at the
hands of his captor.
Hand in hand with his spying proclivities are exhibition-
istic tendencies almost as pronounced, which likewise re-
vert to vivid childhood impressions. As a child he was con-
sidered an exceptionally good looking youngster and called
the red cheeked beauty by his teacher. He made every
effort to attract her attention, and at times would drop
articles on the floor of the classroom, so that she would
notice him and so that, at the same time, he might catch
a glimpse of her shoes as he stooped to pick up the ob-
jects. There are many other tangible evidences of the close
interrelationship between the voyeur and exhibitionistic
tendencies exemplified upon the same sexual object. For
example, when he follows a woman in the street, he ex-
periences a strong desire to have her glance around and
see him, notwithstanding his lack of personal physical at-
tractions. However, he has adopted many artifices which
he considers make him appear comely, or, correctly speak-
ing, more conspicuous.
While the exhibitionistic tendencies have not been quite
so dramatic as the voyeur, they have been extensive, and
have at times violated the criminal codes against indecent
exposure. A less obvious example of this tendency is
evinced in his habit of always arriving late at a party or
going away early, whether there was necessity for it or not,
so that all eyes may be upon him in noticing his entrance
■or departure. So, too, he dislikes being in a crowd because
lie feels that he is so obscured by the number of people
that his personality cannot be appreciated. When he once
attended a baseball game he could not enjoy it because of
the recurrent idea of thousands of people applauding the
players on the field, who were so conspicuous, while he
remained unnoticed in the grandstand. He has never gone
again.
Analysis. — It is not unnatural, perhaps, that one
whose main recreations in Hfe consisted in spying
and pathological exhibitionistic activities, which led
him into all varieties of unsavory encounters of
which he felt thoroughly ashamed and alarmed,
should be apt to refer symptoms to that organ
through which the effects of stich activities were
transferred to his psyche. The next step would be
to seek some means of protecting the eyes, and him-
self, against the results of such habits. About the
age of twenty, a date which closely corresponds to
some of his most disagreeable experiences, the pa-
tient began to notice difficulty with his vision. He
found that he could not distinguish objects suffi-
ciently well across the street, and therefore applied
to an ophthalmologist, who prescribed glasses.
The reaction of the patient to the glasses is en-
lightening in that it appears to reveal what were
probably the unconscious motives which led to their
.ipplication. When he put on the glasses he thotight
of them as forming a partition between himself and
the outside world. Thus he felt that they would
be a protection, inasmuch as people could not see
him so well while he was seeing them unchallenged,
and he would not have to blush when he looked the
world in the face. To his surprise he found that
he could see too well with the glasses but, notwith-
standing his annoyance at this, could not prevail
upon himself to discard them.
Moreover, he felt a certain amount of embarrass-
ment v/hile he was wearing glasses and developed
the habit of taking them off whenever he met any
one whom he knew intimately, because he felt that
sucli persons would think that it was not right for
him to wear them. This attitude of mind, it seems
to me, had its origin in the knowledge of his inti-
mate self. He felt more or less conscious of the
fact that the use of glasses was unwarranted by ac-
tual disability, and that this knowledge was pro-
jected on the intimates of his acquaintance. (They
would feel that way, if they knew the truth). More-
over, his very peculiar custom of wearing glasses
only on the street, due to the belief that people
would consider it suspicious if he wore them in the
hotise, seems likewise a projection to others of his
own feeline of guilt, at the employment of glasses
indoors — opera glasses — for forbidden purposes.
An interesting compensatory symptomatic habit
in the whole affair appears in the frequency with
which he broke his glasses, usually at least once a
week. In the light of the patient's conflict, this fre-
quent accident appears to me as symbolic, not only
of unmasking himself, but at the saine time of the
desire to rid hiinself of the necessity for wearing his
glasses, that is. breaking his glasses symbolically
overcomes his sexual abnormalities. The patient also
believed that the glasses enhanced his personal ap-
pearance and made him more conspicuous on the
street f fulfillment of exhibitionistic desires).
In this case, then, the glasses accomplished a triple
function, pandering to the patient's desire to see. to
be seen, and not to be seen. According to the in-
October .9, 1918-] OBERNDORF: NEUROTIC SYMPTOMS REFERRED TO THE EYES.
671
terpretation which seems most plausible, the feeling
that he is not seen also permits him to see better.
The glasses prevented passersby from noting that
he was eyeing them, and for just this reason he felt
free to gaze at them without restraint, with the re-
sult that his undisturbed gaze, in contrast to his
previous furtivity without glasses, led to the com-
plaint that he saw too well. The feeling that glasses
afford distinction, i. e., make one more apt to be
noticed, is not uncommon among wearers of glasses.
For some years now, subsequent to analysis, the pa-
tient has been able to perform his work, jewelry de-
signing, which demands close application of the
sight, without glasses, and he finds, that he can see
across the street sufficiently well for all legitimate
purposes ; and he has substituted more normal ac-
tivities for the illegitimate ones.
Case III. — A ticlike blinking of the eyes formed one
of the minor .sym[itoins of a male patient, aged twenty-six.
This man, a very vain, physically rather undersized per-
son, constantly wished to be admired and courted by
both men and women (unconscious adult homosexuality
with a number of actual homosexual experiences in boy-
hood). He had always considered his eyes his chief physi-
cal attraction, ever since his mother had first admired his
pretty brown eyes when he was still quite a young child.
He cannot recall any one else praising his eyes, though he
occasionally would solicit such approbation by appealing
to his mother for a compliment when she would comment
on the beauty of his younger sister's wonderful black eyes.
On such occasions she consoled him by saying that men's
eyes nee(l not be so attractive as women's, but that his were
exceptionally fine for a man. In the course of the analysis,
it was pointed out to the patient that his tic represented
an unconscious effort to attract attention to himself through
the eyes, and the symptom disappeared entirely.
Some time after the disappearance of the tic the patient
related the following incident to me. He had, in a sub-
way car, noticed a neatly dressed, middleaged woman
across the aisle. She had stared at him rather intently, and
he, inferring that her fixed gaze might be construed as an
invitation to a flirtation, winked at her several times. She
continued to stare, but with indignation and wrath in her
eyes, and finally, just before she left the car, walked over
to him and upbraided him for his insolence, saying, "How
dare you wink at me?" Whereupon the patient replied
suavely. "Why, madam, I did not wink at you at all. I
suffer from a nervous trouble with the eyes." His retort
apparently did not satisfy the irate woman, who struck him
sharply across the face with her glove and left the car.
This incident is pertinent in connection with the
patient's mental attitude at the time he made his re-
mark. The thought almost simultaneously flashed
through his mind that in case of arrest he could
have me, his physician, appear in court and testify
that he suffered from a nervous, invoUmtary vm-
controllable blinking of the eyes. In this instance
the patient consciously utilized the wink for the
purpose for which he had developed unconsciously
his blinking tic. When his conscious act had led
him into a critical situation, his mind immediateh
discovered an excuse in the pathological symptom,
unconsciously developed for the very purpose for
which he had employed the wink, namely, to at-
tract attention for flirting (sexual) purposes. Thus
his malady, unconsciously originating for flirtation,
but because of its unconsciousness releasing him of
responsibility, is called upon as a propitiation for
wilful oftense — a type of mental defense reaction
particularly frequent in neurotics.
In this presentation I have intentionally avoided
reference to the eye as itself a symbol of the geni-
talia, though such instances have not been lacking.
Thus, one patient, aged thirty, who had suffered
many sex traumata as a very young child — mclud-
ing assault at five, witnessing parents in intercourse
at six, and incest with her brother at ten — went to
a free clinic of her own accord to have glasses ad-
justed for aching eyes at the age fourteen. At
the time she went to the clinic she felt ashamed of
being seen, and very guilty, as the dispensary had
been endowed for the poor, and her family was
considered wealthy. One of the symptoms of which
she complained at the time of analysis was a twinge
in the left eye whenever she told a lie — a symptom
partially determined by the deception which she
perpetrated at the dispensary. Even before she
experienced the sensation of aching eyes, she had
formed the habit of covering her left eye with her
left hand. In addition to the almost universal con-
notation of wrong implied to left — left is not right
— to this patient left indicated that she resembled
her father, who was left handed. At the same time
the father represented to her the personification of
all that is gross, sensuous, and vulgar. Thus when
she made a new acquaintance, she would use her
right hand for shaking hands and her left for cover-
ing her eye.
The eye possessed a symbolization for this girl
of the female sexual organs analogous to that pre-
viously cited for the male. The origin of the asso-
ciation appears in the following riddle which she
thought very amusing as a child of twelve, and
with which she enjoyed shocking her girl friends :
"Round like an apple.
Shaped like a pear.
Split in the middle,
And all around hair."
What is it?
When they appeared abashed, she would remark, "Why,
that's the eye."
That this sex significance of the eye continued, is
revealed by her remark, "When I was introduced
to J. T. at sixteen, I covered my eye because I was
ashamed to show my sex, I mean my sex feeling,
you can see almost anything through the eye."
In another case, that of a young man of nineteen,
referred by Doctor Strauss, for a compulsive fear
of putting out his eyes, there was much to warrant
the opinion that the eyes themselves symbolically
represented the genitals and the fear indicated an
unconscious wish for castration. In this case,
there likewise existed a double determination, in that
this individual was also unusually exhibitionistic ;
and blindness in his mind was intimatelv associated
with the ideas of sympathy and attention lavished
upon blind persons, together with the notion that
blind people have splendid voices.
I have refrained from dwelling on the very
powerful and extensive influences which the eye
has exerted in superstition and legend from the
earliest age, as the Cyclops, the Evil Eye, etc. So far
as this brief presentation goes, I might recapitulate
as follows ; "The eyes," quoted a patient, "are the
windows of the soul." "The glasses," mused an-
other, "are shades for the eyes." Some people who
live with untidy souls unconsciously find it feasible
to put up shades.
249 West Seventy-fourth Street.
672
DIAMOND: X RAYS IN ABDOMINAL DISEASES.
[New York
Medical Journal.
INTESTINAL STASIS, ILEOCECAL VALVE
JNCOMPETENCY, AND CHRONIC
■-^ APPENDICITIS ROENTGENO-
LOGICALLY CONSIDERED.
By Joseph S. Diamond, M. D.,
New York,
Instructor in Rontgenology, New York- Post Graduate Medical School
and Hospital.
INTESTINAL STASIS.
It is due to the work of Lane that considerable
attention has been paid to the subject of intestinal
stasis, since it has caused many discussions and led
to numerous controversies.
The prevailing opinion today is that the immediate
factors which serve to bring about intestinal stasis
are mechanical in nature. The origin of these
factors, however, has been the subject of consider-
able dispute, the Lane (i) and Jordan (2) school
claiming that they are due to various impediments
along the intestinal tract. This is exemplified by
bands, kinks, adhesions, membranes, veils, etc., which
may take place anywhere along the intestinal tract,
but chiefly at places of predilection, such as the
duodenojejunal junction, ileocecal junction, cecum,
ascending colon, the flexures, and at the junction of
the iliac and pelvic colon. These bands form mechan-
ical obstacles and cause obstruction in the drainage
of the food and feces along the alimentary canal,
with resulting stasis. This is characterized by con-
stipation and an accompanying toxemia, and may
also give rise to secondary inflammatory conditions
involving the appendix, cecum, and colon. These
bands usually occur at weak points and are formed
in the lines of stress, to act as additional support,
occuiring more in some persons than in others —
chiefly in the status enteroptoticus of Stiller. These
bands may also be the result of local peritonitis as
sequelfe to various conditions such as a typhoid
ulcer, or a paratyphlitis resulting in adhesions,
often matting together loops of intestines or kinking
the lumen by bands, and thus giving rise to the con-
dition of stasis and its accompanying patholog}'
above mentioned.
The other school, with Case (3), Kellogg (4),
and others at its head, deny that stasis, with the
exception of a limited number of cases, is due to
these mechanical obstructions. They argue that in
many patients the bands and membranes are found
without causing the symptoms of stasis. Also that
some of these are congenital in origin, being often
found in infants. They attribute the etiology of
iliac and colonic stasis to a disturbance in the neuro-
muscular apparatus of these organs, being reflex in
origin, or, as some claim, due to endocrine changes.
The result is a disturbance in the physiological
function of the large intestine as well as the
terminal ileum and ileocecal valve.
In order to fully understand this disturbed func-
tion it is necessary to make a brief survey of the
morphology of the large intestine as well as the
physiology of the .peristaltic movements. The colon
is a tube of different calibres at various locations.
It assumes in the human body more of a rectangu-
lar position, beginning with the cecum in the right
iliac fossa, the caput cecum reaching, in the upright
posture, the iliopectineal line. At the inner portion
of the cecum, about two or three inches from its
lower border, the ileum enters into it. Three quar-
ters of an inch below the entrance of the ileum the
appendix takes its origin. The cecum usually has
an upward mobility of about two or three inches.
The capacity of the cecum and ascending colon is
far greater when compared with a similar length of
any other distal portion of the large intestine, ex-
ceeding it several times. The ascending colon
merges into the hepatic flexure which reaches as
high as the costal margin. Here the colon is folded,
as a rule, upon itself, varying with the type of in-
dividual, sometimes with the appearance of a double
barreled shot gun, and often pulling down the
proximal portion of the transverse colon as low as
the cecum. It is here that adhesions may take place
and assume the form of veils or Jackson's mem-
branes, which can be ascertained on rontgenoscopic
examination by testing the separability of the folded
flexure.
The transverse colon varies again with the type
of the subject. Its position is high in the status
Fig. I. — U shaped transverse colon; cecum prolapsed into the
pelvis. Note the prolonged retention. This picture was taken fifty-
five hours after the administering of the banum meal. The patient
suffered from reflex cardiospasm; it was always relieved by cleans-
ing of the bowels.
epilepticus, hugging the lower border of the
stomach, which is likewise situated high in this type
of subject, reaching sometimes several inches above
the interspinous line. In the tall, slender person,
or the status of Stiller, the transverse colon assumes
the V or U shape type (Fig. i), reaching a number
of inches below the interspinous line, sometimes
reaching as low as the os pubis. The transverse
colon has the greatest range of motion, upward and
downward, of any organ in the human body.
The splenic flexure is higher than the hepatic
flexure, and reaches as high as the lower border of
the spleen. The descending colon is narrower. It
has a capacity of less than one third when compared
with an equal length of the cecum and ascending
colon and about one half of that of the transverse
colon. As it descends to the iliac fossa it is called
the iliac colon. It joins the pelvic colon in the
October 19. 1918.I
DIAMOND: X RAYS IN ABDOMINAL DISEASES
673
pelvis. The mesocolon at this junction is short ;
hence there is a limitation of motion of the colon
in this region. The pelvic colon is very variable as
to length, and has a free range of motion.
Considering peristalsis, Cannon (5) observed in
his studies on the lower animals that the prevailing
peristaltic motion was in the opposite direction, i. e.,
antiperistalsis, also called anastalsis. He noticed
Fig. 2. — Mass movement. The mass of feces has just rounded the
splenic flexure and is being pushed into the descending colon; note
thr; sausage shaped form and disappearance of the haustral markings.
the formation of constriction rings which pulsated
and from which a series of waves started, always
going in the opposite direction from the transverse
colon toward the cecum. Since then observations
have been made in man, which corroborate to a
certain extent the findings of antiperistalsis. This
motion is usually confined in man to the right half
of the colon, the tonus or constriction ring being
noticed in the proximal portion of the transverse
colon close to the hepatic flexure, from which a
series of shallow waves pass downward and back-
ward along the ascending colon toward the cecum.
About four or five of these waves are seen per
minute, for a period of five or six minutes. Their
function is to cause a greater retention of semi-
fluid fecal contents in this region for the absorption
of water and also of any food that may have been
left unabsorbed in the lower ileum.
As further proof of the antiperistaltic movement
of the large bowel in man, it is worth while to men-
tion here that it takes place in all such plastic opera-
tions as ileosigmoidostomy, performed by Lane and
others for the relief of intestinal stasis. The feces
are carried back from the sigmoid stoma by anti-
peristalsis toward the cecum and may be retained
in the large bowel for days, thus forming a great
obstacle for the successful establishment of the new
route and defeating the essential scope of the opera-
tion. Aside from this, the movements in the colon
may be described as follows: i. The haustral mark-
ings described by Schwartz ; 2, the mass movements
described by Holzknecht in 1909; and 3, the pen-
dulus or oscillating movements described by Rieder.
The large intestine is mostly in the quiescent state
throughout the day, except for a few moments sev-
eral times a day, when movements take place which
deal chiefly with the onward propulsion of feces.
The time at which these movements take place is
usually associated with the introduction of food
into the stomach, respiratory movements, or, some-
times, emotional causes. When observed rontgeno-
logically the distal colon assumes the shape of a
segmented tube, the so called haustral markings
which are the result of the circular muscle fibres
contracting upon the longitudinal ; the longitudinal
bands, being shorter than the circular, cause a cer-
tain folding, or the formation of plicae or sacula-
tions. These sacuJations are continuously present
and are somewhat analogous to the segmentation
of the small intestine as regards function. A con-
stant churning takes place here, subdividing the
fecal mass in small separate scybala, exposing as
many surfaces as possible for the complete absorp-
tion of fluids. The consistency of the feces in these
regions is usually solid. When a mass movement
(Fig. 2) is to take place the bowels suddenly lose
these haustral markings and are formed into an
ovoid, cylindrical, or sausage shaped mass with
smooth edges. A firm contraction takes place in the
circular fibres, which is passed along, with the re-
FiG. 3. — Distended cecum and stasis beyond sixty hours.
suit that the contents are pushed steadily by an
even pressure from behind forward, thus advanc-
ing along the gut, and bending around the flexures
as it traverses them. This whole procedure takes
place in a few moments, traveling about twice as
fast as the peristaltic wave of the stomach. The
6/4
DIAMOND: X RAYS IN ABDOMINAL DISEASES.
[New York
Medical Journal.
distance of the shifting may be from eight to four-
teen inches or more. Immediately after this has
taken place a gradual readjustment of the haustral
markings is seen and the bowel returns to its previ-
ous condition. All this takes place without any
consciousness on the part of the subject, except in
Fig. 4. — Ileocecal incompetency. Note leakage of enema into
ileum, filling up practically the whole of small intestines; appendix
is also filled and seen curled up. This patient had marked symp-
toms of intestinal to.xemia.
pathological conditions, such as colitis, when he ex-
periences the griping pains of colic. The move-
ments of Rieder do not deal with the propulsion of
the mass, but are various oscillating motions recog-
nized as preparatory to mass movements. The total
time of emptying the large intestine is considered
to be about thirty-six hours, a stimulus for defeca-
tion onlv taking place when the mass has reached
the rectal ampula, thus causing the irritation of the
sensory nerves.
A disturbance in function manifests itself in-
variably at first in increased tonicity and spastic-
ity along the colon. The starting point is usually
at the constriction ring in the proximal portion of
the transverse colon, above mentioned. With in-
creased tonicity at this point a greater number of
antiperistaltic waves take place, both in frequency
and in depth ; they travel backward along the right
half of the colon toward the cecum. The result
is longer retention of the fecal contents, fermenta-
tion, putrefaction, gas formation, distention of the
cecum, leading gradually to a permanently distended
and atonic cecum (Fig. 3). The transverse colon
later, under the influence of the same disturbing
factors, assumes also a greater tonicity of its muscu-
lar walls and gives rise to the well known spastic
type of colon. This is characterized by a narrowing
of the haustral saculations, giving, instead of the
broad haustral markings, the appearance of a nar-
row strip which varies according to the intensity of
the spasticity. The result is a prolonged retention
of the hardened fecal scybala, which is a typical
finding in the spastic type of constipation, also called
hyperkinetic constipation. Usually these changes
are found throughout the entire distal colon. The
vicious circle is hereby established, the greater the
retention of the fecal contents the greater the spasm
of the tonus ring and the greater the frequency
of the antiperistaltic waves, continuously damming
back the contents in the right half of the colon.
ILEOCFC.\L VALVE INCOMPETENCY.
As a result of increased pressure and distention
of the cecum, another pathological factor is intro-
duced. The ileocecal valve becomes incompetent
and allows the fecal contents to escape from the
cecum back into the ileum. According to Cannon
(5) the ileocecal valve is proved to be competent.
With the exception of two cases, in hundreds of ex-
periments he made on the lower animals, he found
no incompetent valve.
Looked upon from an anatomical standpoint, the
ileocecal iuncticn becomes a sphincter, in virtue of
the inward obliquity of the insertion of the terminal
ileum into the cecum and the invagination of the
several inner layers of ileum. When the pressure
in the cecum is at a normal ebb this anatomical
position is preserved, but with greater distention of
the cecum with gas and fluid, the walls are actually
pulled apart in a lateral direction, thus causing
gapping, and thereby destroying the valvular efTect.
Fig. 5. — Infective colitis; diarihea associated with stasis in the
cecum and ascending colon; a fixed and tender appendix; relieved
by the removal of the appendix.
The terminal ileum tries at first to overcome this by
a hyperperistalsis and a hypertrophy of the muscu-
lar fibres. When this fails leakage takes place.
The function of this valve is twofold: a sphincter
action which opens on the contraction of the termi-
October 19. 191S.]
DIAMOND: X K.-IVS IN ABDOMINAL DISEASES.
675
nal ileum, and a valvular action which is purely
mechanical, guarding against a reflux of the cecal
contents back into the ileum. It derives its itmerva-
tion from the splanchnic and not the vagus fibres.
Case (6), and later Holzknecht, and others dem-
onstrated the filling of the ileum after a barium
Fio. 6. — Adhesions at the ileocecal junction; note the defective
filling at the ileocecal junction associated with the distended right
colon and chronic appendicitis. Corroborated by the operative findings.
enema (Fig. 4). In a large number of patients
suffering from gastric disturbances they were able
to establish, in this country as well as abroad, an
incompetency of the valve, occurring in one out of
every six cases that were presented for examination.
The proper technic is of course essential in giving
these enemas, both in using the proper quantity of
fluid as well as regulating the pressure by using a
height not exceeding two feet.
There has been considerable skepticism among
surgeons as to the variable symptoms ascribed to
ileocecal incompetency. Some observers have gone
so far as to ascribe epilepsy and insanity to it. Such
cases, however, have onlv been reported sporadi-
cally and are very few. One doubts, of course, if
such far reaching degenerative changes are due to
this condition, but the presence of toxemia in these
cases must not be minimized. When it is recognized
that the rich flora of the cecal contents, with an
abundance of putrefactive and toxic agents, are sud-
denlv gushed into the ileum — which under normal
conditions is practically sterile — -it is inevitable that
toxemia should result. The mucous membrane of
the .small intestine differs considerably from that of
the large intestine by being highly vascular, and
specially adapted, through the presence of villi, for
rapid absorption. The extent of the symptoms will,
of course, vary with each subject, depending upon
personal immunity, i. e., upon the intrinsic power of
detoxication or neutralization of these poisonous
agents, and also upon the sensitiveness of the pa-
tient to the various toxins. The symptoms will
also vary with the stage of the disease and the
amount of absorption. If one watches these cases
clinically, invariably there will be found disturb-
ances in nutrition. There is loss of weight; jiallor ;
cold and clammy extremities; discolorations of the
skin ; ner\'0us disturbances, such as headache, dizzi-
ness, slight tremor, sleeplessness, and giddiness ; and
dyspeptic symptoms, such as fullness and pressure
after meals, flatulence, occasional vomiting, and
sometimes hyperacidity, but later a subacidity. A
splashing sound over the cecum can invariably be
elicited on palpation.
The symptoms above enumerated are evidences of
a severe grade of toxemia, from the combined
factors of colonic and ileac stasis, but arising chiefly
from the regurgitation at the valve. In extreme
cases of patency the feces are dammed back high in
the ileimi, causing a condition that is often spoken
of as "being fed on one's own feces." It is not
unusual to find the fluid after a barium enema to
reach as high as the first portion of the duodenum.
Kellogg (4) devised an operation for the correc-
tion of the sphincter, by passing a few purse string
sutures around the orifice of the ileocecal junction.
It has since been successfullv practised by many
surgeons, especially m conjunction with appendi-
citis, in the chronic cases, and in all forms of plastic
surgery in this region.
In the discussion of the etiology of spastic con-
stipation several direct and reflex factors must be
considered. A distended ampnla recti, such as results
from the frequently unheeded call for defecation,
the so called dyschezia, will invariably give rise to
secondary reflex manifestations along the large in-
testine for an increased spasticity. In hyperthyroid-
ism a similar increase in the tone of the bowel takes
place. Cathartics have a similar effect.
In colitis due to stasis resulting from infections
traveling by extension upward along the cecum and
giving rise to irritation and low grades of infection,
the same condition of spasm is found (Fig. 5).
Fig. y. — Appendix filled beyond sixty hours; adherent in the pelvis.
When the irritative process becomes intensifixed,
diarrhea may take place with discharge of mucus
containing leucocytes. In the later stages we have
the atonic form of constipation spoken of as the
dyskinetic type, when relaxation and atony of the
bowel wall take place (Fig. i).
676
DIAMOND: X RAYS IN ABDOMINAL DISEASES
[New York
Medical Journal.
CHRONIC APPENDICITIS.
In considering the subject of intestinal stasis we
must include the condition known as chronic ap-
pendicitis, for the appendix takes part in the same
general changes mentioned above. Since the advent
of the study of the appendix by the aid of the
rontgenoscopic method, much has been learned in
explanation of many diverse abdominal symptoms
previously grouped with the neuroses and often
Fig. 8. — Retained feces in the appendix; the right colon and
transverse colon are empty.
mistaken for gastric ulcer. The first rontgenoscopic
examination of the appendix was made in France
by Beclere, followed in England by Jordan, and then
taken up in this country, and later by Groedel in
Germany. The real credit, however, for the proper
study and interpretation of the normal and abnor-
mal conditions belongs to Americans.
Case (7), in 1912, and later George (8), and
Quimby (9), were the first to take up the work in
this country. These observers succeeded with
greater ease in the visualization of the appendix.
This was accomplished by the different opaque
meal used. Instead of using the thick farinaceous
bismuth paste, of the European countries, the but-
termilk and barium suspension was employed for
the morphological studies of the gastrointestinal
tract. By possessing a greater liquidity it is better
able to fill the lumen of the appendix. The infre-
quency of observing a filled appendix abroad caused
Groedel to regard a filled appendix as diseased.
This was refuted in this country, especially by
George, by the greater frequency of filled ap-
pendices, which gave better opportunity to study
and differentiate the normal from the abnormal.
The appendix today is regarded as the remains of
a vestigial organ, devoid of function, and, as is well
known, is not indispensable to the human body.
There are, however, some observers who attribute
a specialized function to the appendix in view of the
nature of its mucous membrane and its richness in
lymphoid tissue, this function being analogous to the
rich lymphoid tissue of the cecum which is phago-
cytic in action, in order to protect the body against
microorganisms in the ileocecal region.
Corner (10), perhaps, sums it up most satisfac-
torily. He draws attention to the fact that lymphoid
tissue is the characteristic finding at the cecum, and
that in the lower vertebrate kingdom the vermiform
appendix is represented by a mass of lymphoid
tissue situated at the cecal apex. As the vertebrate
scale is ascended this lymphoid tissue is collected
in an especially differentiated portion of the in-
testinal canal — the vermiform appendix. When for
any reason there is a disturbance in the mucous
membrane of the appendix, by disappearance of the
lymphatic tissue, there arise symptoms of disturbed
digestion which are of a reflex nature. It is a more
or less common experience in the profession today
to find persons suffering from a chain of symptoms
which can be traced to the appendix, even though
there are no histories of recognized clinical attacks
of acute inflammation. Moynihan speaks of these
symptoms as those of appendix dyspepsia.
The appendix has often been compared with the
tonsil, and is often spoken of as the abdominal
tonsil, for the reason that it may undergo fibrosis
without an acute attack. In like manner changes
may take place in the appendix ; first affecting the
mucous membrane, with a disappearance of the
lymphoid tissue ; later fibrotic changes reaching into
the muscular coats, thus interfering with the ef-
ficiency of the peristaltic action. The tube then
becomes incapable of emptying itself. The inspissa-
tion of the contents leads to the formation of con-
cretions which are pathological. The appendix be-
comes a breeding ground for bacteria. In time
subacute inflammation takes place, resulting in peri-
appendicular adhesions, which process later spreads
further up to the cecum and colon, giving rise to
typhlitis, paratyphlitis, and colitis.
From the various observations made up to the
present time, the chief points of information ob-
tained from rontgenoscopic examination are :
Fig. 9. — Reflex pylorospasm and large retention in the stomach
beyond six hours: taken from same case as Fig. 5.
I. Size, as to length and calibre. — Normally the
appendix appears narrow and ribbon shaped, lying
within the inner border of the cecum and directed
downward. It varies in length, the average size
observed being from three to five inches. It may
be anything from a stub to ten inches long.
October 19, 191S.]
DIAMOND: X RAYS IN ABDOMINAL DISEASES.
677
2. Appearance. — Normally it appears of uniform
diameter, perhaps slightly tapering toward the tip.
Under abnormal conditions it may show irregular
filling, being constricted in certain portions and ap-
pearing segmented (Fig. 6). Or it may appear
"vacuolated," i. e., the barium only filling certain
parts of the lumen, the rest being filled by fecaliths
or concretions. It may appear kinked or looped.
J. Direction. — Under pathological conditions it
may point anywhere, toward the liver, underneath
the cecum, then spoken of as retrocecal, toward the
umbilicus, or the left iliac fossa.
//. Fixity. — Under normal conditions it is freely
movable. When diseased it may become adherent
anywhere along its course. The tip however is
chiefly involved. It may become fixed to the gall
bladder, or sigmoid, or it may become matted to-
gether with the cecum or ileum. The fixity can l)e
easily determined by palpation with a gloved hand,
when instead of a free mobility only the shaft will
move, the tip remaining in one position (Fig. 7).
5. Tenderness. — This is elicited by direct palpa-
tion of the visualized organ. A positive symptom
is, of course, of considerable importance.
6. Emptying time. — Normally the appendix begins
to fill about six hours after a barium meal is taken.
It can, however, best be studied after ten hours
when the ileum is usually empty. A normal ap-
pendix should empty anywhere from twenty-four to
forty-eight hours. A delay after the second day is
called stasis and is distinctly pathological (Fig.
8). Some appendices do not fill, and cannot
therefore be studied rontgenologically. Some do
not fill on account of atresia of the lumen, due to
previous inflammatory conditions, or due to a block-
age of the lumen, which is filled with concretions.
These are distinctly pathological cases and one can
draw conclusions by inferences such as stasis in the
ileum beyond ten hours, cecal stasis beyond forty-
two hours, adhesions between the terminal loop of
the ileum and cecum, or an incompetent ileocecal
valve ; all of which invariably are accompanying
factors. Tenderness and lack of free mobility
found in the ceciuu will also help one to reach a
conclusion.
There are a certain number of appendices which
do not fill and still cannot be classed as pathological.
In these examinations, the right lower quadrant
bears no pathological sign, from a rontgenological
standpoint. Various theories have been advanced
for the lack of filling, such as physiological involu-
tion, which takes place mostly after middle life; or
a strong valve of Gerlach which guards the appen-
dicular orifice. In connection with this mechanism
at the orifice of the appendix it is interesting to note
that some observers are still of the opinion that a
normal appendix should not fill, that the valve and
the muscular tissue surrounding the appendicular
orifice is sufficient to cause, in the normal state, a
blockage of the entrance of cecal contents, only per-
mitting the escape of the normal secretions into the
cecum. When, however, distention and increase of
pressure in the cecum occur, then the mechanism
gives way, and we have a patulous appendix.
Squires (11) classifies a patulous appendix as
diseased, and outlines several stages. He main-
tains that an appendix will produce symptoms even
without stasis, that in the first stage there occurs
a hyperperistalsis of the appendix, which he has ob-
served by watching the appendix at several hour in-
tervals and has noticed various contortions and po-
sitions assumed by the appendix in the attempt to
empty itself, the feces acting as an irritant. In this
stage there is no stasis and no local symptoms, but
there may be found symptoms which are reflex and
will manifest themselves in disturbances of the
stomach and duodenum. Pylorospasm, hyperperis-
talsis, hypersecretion, and hyperacidity may be the
result, and the history of moderate dyspepsia can
be elicited. In the later stages there begins to be a
gradual failure of peristalsis in the appendix and.
not being able to evacuate its contents, stasis takes
place, the degree varying according to the stage of
the disease. It is at this stage that local as well as
general symptoms take place ; these are attacks of
colic, local tenderness, and the general reflex gastro-
intestinal disturbances before mentioned.
The importance of the reflex disturbances in the
stomach and duodenum, even in the early stages of
appendicitis, should not be overlooked. One is im-
pressed with the frequency with which one finds
duodenal irritation, pylorospasm, and often a fairly
sized residue in the stomach (Fig. 9). Frequently
one is led to the diagnosis of a peptic ulcer, only to
find on the operating table simply a diseased ap-
pendix.
In the diagnosis of diseased appendices by the
rontgenoscopic method, the observation of the
functional responses in the stomach, duodenum, and
intestines — the so-called indirect examination —
should not be neglected. One should not hesitate
to reach a conclusion even though the classical signs
of a diseased appendix — such as direct visualization
of a kinked, tender, and adherent appendix with
stasis — are lacking. Here the weight of evidence
should be taken into account, and when the second-
ary reflex disturbance before mentioned is present,
plus even slight evidence of disturbance in the right
iliac fossa, perhaps even an occasional attack of
colic with indefinite clinical history of fullness and
pressure after meals, etc., with cecal and iliac stasis,
one can with impunity make a diagnosis of chronic
appendicitis. All other conditions, however, such
as ulcer, gall bladder, and neurosis must first be
excluded.
REFERENCES.
I. SIR W. ARBUTHNOT LANE: Chronic Intestinal Stasis,
British Medical Journal. November, 1912. 2. A. C. JORDAN:
Radiogranhv in Intestinal Stasis, Proc. Roval Society of Medicine,
vol. 5. .i JAMES T. CASE: A Critical Study of Intestinal Stasis,
etc., SiDfjery, Gynecology, and Obstetrics, November, 191 4. 4.
J. H. KELLOGG: Incompetency of the Ileocecal Valve, etc.. Medi-
cal Record, June, 191 3; Surnery, Gynecology, and Obstetrics,
November, 1913- 5- W. B. CANNON: Mechanical Factors of
Digestion; The Movements of the Large Intestines, chap. xii. 6.
JAMES T. CASE: Rontgenological Observation of the Ileocecal
Valve, etc., Journal A. M. A., October 3, 1914; Further Studies
ot the Ileocecal Valve and the Appendix, American Journal
of Rontgenology, August, 1914. 7. JAMES T. CASE: Rontgen
Examination of the Appendix. New York Medical Journal, July
2S, !9i4. GEORGE AND GERBER: Value of the R6ntgen
Ray in the Study of Chronic Appendicitis and Inflammatory Con-
ditions Both Congenital and Acquired about the Cecum and Ter-
minal Ileum, Surgery, Gynecology and Obstetrics, October, 1913,
p. 418. 9. A. J. QUIMBY: Differential Diagnosis of Appendicitis
by Aid of the Rontgen Rays, New York Medical Journal, October
II, 1913. 10. E. N. CORNER: The Function of the Appendix and
Origin of Appendicitis, British Medical Journal, February 15, 1913.
II. J. W. SQIURES: The Significance of the Patulous Appendix,
Ant'c.ls of Surgery, 1917, vol. 65.
45 St. Mark's Place.
678
STIVELMAN AND RAY: FACET'S DISEASE.
[New York
Medical Journal.
FACET'S DISEASE OF THE BONES*
With a Report of Two Cases.
By B. Stivelman, M. D.,
New York,
and E. L. Ray, M. D.,
Louisville, Ky.
The term osteitis deformans had long been used
in the description of the large and very confusing
group of hypertrophic osteopathies, and although
Czerny first mentioned it in the description of a case
of osteomalacia, in 1873, it was not until 1877, when
Sir James Paget
called attention to
the distinct disease
now bearing his
name, that the term
osteitis deformans
designated a definite
clinical picture.
Malpighi, in 1697,
and much later Vir-
chow, described
cases of leontiasis
ossea, which most
observers, especially
Price (i), M. Koch
(2) , and Bartlett
(3) , are inclined to
consider, in view of
pathological find-
ings, in similar cases, as true instances of Paget's
disease. Wrany (4), in 1867, reported a case of
spongy hyperostosis with involvement of the skull,
pelvis, and left femur, which was undoubtedly one
of the earliest and most authentic cases of osteitis
deformans described in the literature. For a most
exhaustive study of the literature of the subject,
the reader is referred to excellent articles by
Packard, Steele, and Kirkbride (5), and Da Costa,
Funk, Bergheim, and Hawk (6).
Since 1882, when Sir James Paget (7) read his
second paper on this subject, there have been re-
ported cases which have been rather more than less
similar to the cases he described. But few cases
have been shown to present new symptoms, and,
although the pathology has been looked into more
deeply, and the radiographic findings are now avail-
able, the diagnosis in early cases is as frequently
overlooked as heretofore.
Osteitis deformans is a chronic disease usually
coming on late in life, and it is claimed that it does
not shorten life. The etiology is in dispute. In twelve
authentic cases, which constitute about five per cent,
of all the cases reported in the literature, has
heredity been shown to have exerted any influence.
Most of the French writers insist on associating
Paget's disease with syphilis. Some consider it a
paraluetic condition, others hold hereditary lues a
predisposing cause. Acquired syphilis has been men-
tioned as a possible etiological factor. Menetrier anil
Cauckler (8) reported two cases which came to
autopsy with findings of undoubtedly acquired
*From the Neurological Wards of tlie Central and Neurological
Hospital, Blackwell's Island, N. Y.
syphilis, and in cases where lues could not possibly
have participated in the causation of this affection,
Jaquet (9), Menetrier and Duval (10) find anti-
luetic treatment extremely beneficial in removing
distressing symptoms of this disease.
Pathological conditions exist chiefly in the long
and flat bones. These show an increased production
and deficient calcification of new bone which later
hardens progressively, especially on the surface, and
takes on a massive rugged appearance. This causes
an increase in size, and also gives rise to the various
deformities of the affected bones. Many observers
think that the deformity of the long bones is due to
gravity and muscle traction. Jewels Vincent (11)
emphasizes early nervous symptoms of the disease,
such as muscular cramps, fatigue, pain, exaggerated
retiexes, and occasional incontinence of urine and
local hyperesthesia, and is inclined to the hypothesis
of trophoneurosis, but in the few autopsies made, a
thorough study of possible pathological changes in
the nervous system has not been undertaken.
The disease is essentially a chronic inflammatory
])rocess affecting several bones. The order of fre-
fjuency of involvement is usually given as skull,
tibia, femora, pelvis, spine, clavicles, ribs, and radii.
The shape of the face becomes roughly triangular,
the chin forming the apex of the triangle, and the
enlarged head, the base. The superciliary ridges are
very prominent. There is a bowing of the legs, both
anteriorly and laterally. Stature is diminished.
Kyphosis is usually present due to changes in the
spine and pelvis. The clavicles are prominent. The
mind, according to most observers, is unaffected,
although Fits (12) reported a patient with marked
mental disturbance who was subsequently confined
to an asylum for the
insane.
There have come
under our observa-
tion two cases which
differed in some re-
spects from similar
cases reported. The
head in Case I was
sixty-six cm. in cir-
cumference and that
in Case II, sixty-four
cm., the heads being
similar in shape
and general charac-
teristics. The chin
in both cases formed
the apex of a tri-
angle having the en-
larged head as the
base. The supercil-
liary ridges were
markedly enlarged in
n^l 1 ¥10. 2. — Case I, siiowing triangular
both cases. 1 he neck ^ce and curved femora.
in both cases was
very short and there was a partial ankylosis of the
cervical vertebrn?, so that the head had very slight
range of movement in any direction. The sternal
ends of both clavicles were markedly enlarged and
prominent. There was no other involvement of the
u])per extremities in either case. Each had a marked
OctoiK-r .9, 1918.] ADAMS: TREATMENT FOR ACUTE ANTERIOR GONORRHEA.
679
kyphosis and there was marked anterior and lateral
bowing of the femora in both cases, but the tibia?
were not involved. Both patients stated that their
statures had been shortened at least five inches. The
onset in each case was between forty and forty-five
years of age. The mentality in both was aft'ected. but
more so in the first
patient, who is older,
and presents a later
stage of the disease,
(leneral depression
and confusion were
present in both pa-
tients without spe-
cial prominence of
any one set of men-
tal symptoms. Ar-
teriosclerosis w a s
marked in one and
absent in the other.
Case I presented a
systolic pressure of
235 mm. of mer-
cury ; Case II, 140
mm. of mercury.
Repeated examina-
tions of the blood
for the Wassermann
reaction were nega-
tive in both cases.
In each the spinal
fluid escaped under
moderate pressure,
and the Wasser-
mann reaction and
cytology of the spinal fluid were negative. In both
the u''ine showed changes suggesting the existence
Fig. 3. — Case I, showing kyphose
curved femora, and enlarged head.
Fig. 4. — Case II, showing Fig. 5. — Case II, showing
marked prominence of clavicles kyphoses and enlarged head,
and f upercilliary ridges and
curved femora.
of chronic interstitial nephritis, and the Bence-
Jones protein reaction was negative.
The blood picture in Case i showed an eighty
per cent, eosinophilia on numerous examinations,
while Case II presented a five per cent, eosino-
philia on several examinations. We could not de-
termine the causation of the eosinophilia in either
case, nor could we find eosinophilia mentioned in
cases of Paget's disease described in the literature.
The X ray findings in each case showed marked
evidence of rarifying osteitis in the femora and
markedly thickened skull.
SUMMARY.
The cases above described show the following
peculiarities: i. Persistent eosinophilia; 2. definite
mental symptoms ; 3. tibi?e not involved.
KEFERE.NCES.
I. Price: Transactions of the Association of American Physicians,
1902, xvii, 382. 2. Kocii: Verhandhinticn der Deutschen Pathologic
Gessclschaft, 1909. 3. Baktiett: Yale Medical Journal, 1909, p. 367.
4. Wrany: Prager Viertet jnhresschrift, 1867, 1-79. 5. Packard,
Steele, and Kirksbridk : American Journal of Medical Science. 1901,
ccii, 859, 6. Da Cosia, Funk. Bergheim, and Hawk: Repr. Pnh.
Jefferson Medical College. Philadelphia, 1916, vi. 7. Sir James
Paget: Medical and Chemical Transactions, London, 1882, Ixv, 225.
8. Menetrier and Gauckier: Bulletins et memoires de la society
medicale des hdpitaiix d.' Pari,?, IQ03, xx, 574. 9. Jacquet: La
pressc medicate, 190S, xii, 343. 10. Menetrier and Duval: La
presse medicale. 1908, xii, 343. ir. Jules Vincent: Maladie
osseuPe de Paget, Revi'e generale. Paris, 1904-1905. 12. FiT.<;: Trans-
actions of the Association of American Physicians, 1902, xvii, 398.
Note. — We wish tn express our indebtedness to Dr. Joseph
Byrne, from whose service the material was taken.
A TREATMENT FOR ACUTE ANTERIOR
GONORRHEA.
Bv Ch.^rles B. Ad.vms, M. D.,
New York,
Instructor, Genitourinary Diseases. New York Post Graduate Medical
Scliool and Hospital; .Assistant Surgeon, Second Genitouri-
nary Division, Out Patient Department, Bellevue Hospital.
There are such wide variations in the reported
results of treatment of acute anterior gonorrhea in
the male with the various silver preparations at our
disposal, that a study of the elements which com-
bine to give success, the causes of failure, and an
attempt to standardize a treatment ofifering the
strongest hope of good results seems pertinent.
THE P.VTIENT.
Success follows care of patients who report early
for treatment — either primary or second infection —
reporting from a few hours up to three days after
the first appearance of subjective symptoms — burn-
ing or discharge — provided there has been no treat-
ment prior to the first visit and especially if the so
called prophylaxis with two per cent, protargol in-
jection has not been employed. Patients receiving
the two per cent, protargol injection have damaged
mucous membranes which offer slight resistance to
the invasion and progress of gonococci. To sum up,
the ideal case is one in which the inflammatory pro-
cess has progressed only a moderate distance along
the urethra, and the mucous membrane has not been
impaired bv irritants.
THE CHOICE OF SILVER PREP.\RATION.
The silver selected should be the one which is the
least irritating to mucous membrane — argyroP in
freshly prepared solution is admittedly the prepara-
tion meeting this requirement. Supporters of its
use state that it is nonirritating in all strengths — a
claim not supported by clinical results, as can be de-
duced from an analysis of the action of argyrol so-
lution. This action, when the solution is properly
*Silver nucleinate is not identical with argyrol. Its use
stitution for argyrol will produce disappointing results.
sub-
68o
ADAMS: TREATMENT FOR ACUTE ANTERIOR GONORRHEA.
[New York
Medical Journal.
applied, is twofold. First and minor, germicidal —
directly killing gonococci on the surface of the
mucosa. Second and vastly more important, it
forms a definite silver deposit in the protoplasm of
the healthy hving lining cell which raises that cell's
resistance to bacterial invasion. In other words, a
protective wall is raised against progress along the
canal by the infection. If too much silver is de-
posited in the living cell either through employment
of too strong a solution, its too frequent application,
or its contact with the cell for too long a period, the
action is irritant. The cell dies, is desquamated, and
exposes a partially developed underlying cell to the
action of the gonococci — the resistance being i;ot
only lowered but practically destroyed.
With the outlined conditions in favorable cases
fulfilled, and the proper balance of strength of solu-
tion, duration of contact maintained, and frequency
of application, it is not unusual to find a patient
passing clear urine twenty-four hours after initial
treatment ; and it is to be confidently expected that
practically all patients will pass clear urine within a
week after the institution of treatment.
Opposed to these results we see men otherwise in
the pink of physical condition, after two or three
days of the routine army or navy treatment (two
per cent, protargol injections), presenting a rapidly
progressive infection involving the posterior urethra
and developing one or more of the complications —
prostatitis, seminal vesiculitis, epididymitis and gon-
orrheal rheumatism, with all the distress and dis-
ability that these involvements entail. At the end of
weeks or months of most careful management and
cooperation by the victim there is still discharge and
involvement of nearly the whole genital tract. Such
men would have made more rapid recovery had they
received no local treatment in the first two weeks of
their trouble.
MET310D OF TREATMENT.
Only freshly prepared solutions of argyrol made
directly from the crystals, employing a strength of
ten per cent, to fifteen per cent., should be used.
No injections sliould be entrusted to the patient for
personal use as long as discharge or cloudy urine
is present. All the prepared solution the anterior
canal will hold without distress should then be
slowly injected with a plunger or bulb urethral
syringe, as the patient is lying on his back, after he
has urinated and the glans has been cleansed —
care being taken that the urethral folds are fully
distended. Two drams to half an ounce is the
quantity required. Then the meatus should be
gently but firmly closed with the fingers, and the
injection retained in the canal for twelve to fifteen
minutes, afterward being allowed to flow into cot-
ton or other waste. The meatus should be covered
with dressing until the next urination, to protect the
clothes from being stained. Such injections should
be used once daily, the classic restrictions in diet
and activity ordered, giving internally only suf-
ficient favorite medication to render the urine
neutral or faintly alkaline. This routine should be
continued for two or three days after the disappear-
ance of discharge and free pus in the urine, as in-
dicated l)y the appearance of the first urine in the
two glass test.
It is well to consider the pathological condition
of the canal at this time. It is incontestable that
upon the appearance of pus at the meatus gonococci
are present in intercellular spaces — possibly in the
submucosa in .some portion of the canal. Injections
do not kill these bacteria. There is also a greater or
lesser area of desquamated mucosa — ulcerated area
— if that term is preferred — and possibly deep in-
fection of some of the mucous follicles or glands
of Littre. The plan for treatment of such a condi-
tion must be directed toward two aims: i. To pre-
vent reinfection of the canal from gonococci in the
tissues, and, 2, to assist in reforming the mucosa
destroyed. This is the time for mildly stimulant
medication and injections. Now may be used, with
cautious introduction, sandalwood oil or the balsams.
The patient may be entrusted with a mild injection
of protargol. one quarter per cent, (five grains of
protargol in foiu- ounces of solution), to be used one
to three times daily and retained for ten minutes.
The fact should be borne in mind that the margin
between mild stimulation and irritation is narrow :
and symptoms of overtreatment should be looked
for, i. e., first a return of cloudy urine, and later, dis-
charge. If no such symptoms appear, the protargol
mav be doubled in strength ; but that should be the
limit.
Then the more frankly astringent agents may be
employed in the reverse order of their irritating
qualities : zinc sulphate up to one grain to the ounce ;
lead oxide up to one grain to the ounce ; zinc and
lead combined to the same strength ; zinc perman-
ganate up to one grain in four ounces ; nitrate of
silver from one grain in two ounces up to two grains
in one ounce. In no case should nitrate of silver
be injected oftener than once in four days. The
other solutions may be used daily or every other day.
Should shreds and flakes persist in the third week
of treatment, in a patient responding promptly and
progressing without reinfection, it is almost posi-
tively an indication of deep involvement of some of
the mucous follicles. Here again injections and in-
ternal medication are valueless except for prophy-
laxis against reinfection, the anterior endoscope of-
fering the only efficient means of attack. This is a
chapter by itself and beyond the scope of the present
paper.
Patients should be under observation for a total
period of from five to six weeks and the urine free
from flakes and shreds before discharge. After
such a period it can be safely assumed that the viru-
lence of gonococci in the submucosa is spent and
that they are safely buried, except in the event of
most severe traumatism which is not of frequent
occurrence. So potent is the assistance given pa-
tients by the treatment outlined that a reinfection
caused by the thoughtless drinking of beer five days
after institution of treatment has subsided and clear
urine again been passed twenty-four hours after the
injection following the reinfection.
CONCLUSIONS.
Does it follow from the evil results quoted that
prophylaxis, as officially practised, is a failure or
even a detriment to the patient ? Undoubtedly ! But
it does not follow that all prophylaxis is a failure.
Octoiier 19, 1918.] INFLUENZA WARNING FROM THE ACADEMY OF MEDICINE
681
As originated and practised for the last fifteen years
by Dr. Winfield Ayres, prophylaxis is an unqualified
success. After thorough cleansing of the parts —
the meatus being held open with the fingers — Dr.
Ayres drops into the opened meatus one drop of a
five per cent, nitrate of silver solution from a drop-
per. The solution is gently rubbed into the fossa
navicularis by rolling the lips of the meatus together
between the fingers for a moment, and the excess
solution is then wiped off. The reaction is prompt,
destruction of all bacteria at the usual point of in-
vasion (fossa navicularis and meatus) is absolute,
together of course with the death of mucous mem-
brane superficial cells, upon which the silver solu-
tion has acted. The regeneration of cells at the
meatus, in the absence of bacteria, is prompt, and
no damage has been done to the remaining mucous
membrane in the anterior canal where the silver does
not reach. The treatment is logical and efficient.
After infection the favorable results of properly
applied argyrol treatment are rapid in direct ratio
to the quantity or area of healthy mucous membrane
in which the resistance to bacterial invasion can be
raised by deposit of silver in the cell. With a large
area of uninvolved mucous membrane (conversely
infection extending only a short distance down the
canal) there v/ill be an almost immediate check of
discharge and free pus. On the other hand, if there
is only a small area of uninvolved mucous mem-
brane near the triangular ligament, the treatment
will probably fail to prevent posterior invasion of
the canal — this being a direct result of too long ac-
tivity of infection before the institution of suitable
treatment.
There is a distinct shortening in the period of dis-
ability in the argyrol treatment of patients seen
early, a decided addition to resistance, and a protec-
tion of deep structures from involvement. That this
prevention of complications is worth while, no one
who has had experience in attempting to clear them
will deny.
There are many other valuable compounds of
silver on the market. Each has its peculiar range
of especially favorable action, and each finds its
use indicated at some stage in the progress of treat-
ment in the many cases which arrive too late for
the exclusive use of argyrol to be essential, or in
cases which, through injudicious treatment, have
been hurried to the stage of deep complications
which try the ingenuity of our most skilled opera-
tors.
No claim of discovery or pioneer work is ad-
vanced. The treatment outlined is one giving aston-
ishing results, logically explained. Absence of
gonococci in the original smear requires no change
in treatment, but aft'ords a shorter prognosis.
The general results of treatment of acute anterior
gonorrhea in the male — a disease to a certain degree
selflimited — shed no glory on the efforts of medi-
cal practice to control it. A large number of pa-
tients get well in spite of treatment rather than on
account of treatment. There is the need and the
means: for a revolution in this condition of affairs.
Let's have it !
47 Irving Place.
INFLUENZA WARNING FROM THE
ACADEMY OF MEDICINE.
Public Health Committee Issues IForJiiiig. — More
Vigorous Measures Needed. — Maximum
Morbidity Not Yet Reached. — Pre-
cautions Recommended.
The Public Health Committee of the New York
Academy of Medicine, after conferring with repre-
sentatives of the Department of Health of the City
of New York, hospital authorities, bacteriologists,
and others in close touch with the situation regard-
ing influenza, are of the opinion that, while there is
no . occasion for undue alarm on the part of the
public, further vigorous measures should be taken
by the Department of Health to prevent the spread
of the disease, and, in collaboration with every avail-
able public and private agency, to ameliorate the
condition of patients and of their dependents.
In the communities in which the disease has thus
far appeared in epidemic form the rate of sickness
has been high and the death rate not inconsiderable.
In this city the unusually heavy demands upon
private physicians, hospitals, dispensaries, and dis-
trict nursing organizations indicate of themselves
the presence of an epidemic which should be vigor-
ously combatted. Many individual physicians in
general practice report seeing from thirty to fifty
cases a day and declare that they are so busy as to
be unable to make prompt reports of influenza cases
to the Department of Health. The pressure upon
certain hospitals for the admission of influenza
cases has been so great as to necessitate the tempo-
rary conversion of wards ordinarily used for
surgical and other purposes to emergency wards
for influenza and its sequelae. A number of
the municipal hospitals have been overcrowded,
either by placing mattresses on the floor, or in the
case of one hospital by placing two or even three
children in one bed. Some physicians and district
nurses engaged in work among the poor report that
in numerous instances, upon visiting patients to
whom they have been called, they have learned of
other cases in the same houses which were unat-
tended and necessarily unreported. Reports are by
no means exceptional of whole families which have
come down with the disease ; where this has hap-
pened among the poor, there has been not only a
lack of medical care, but suffering from loss of in-
come and lack of food. A block census made on
October 9th of a typical upper east side tenement
block showed that among 340 families numbering
1,445 persons there were 160 cases diagnosed by
physicians as influenza, of which only nine had had
hospital treatment. This means that in this block,
up to October 9th, eleven per cent, of the population
has been affected. If anything approximating this
rate holds for the entire city. Greater New York
has already had several hundred thousand cases of
influenza ; and the epidemic is apparently still on
the increase.
Further evidence of widespread illness among the
population has been obtained by inquiries variously
directed. In a group of offices in one of the largest
buildings in the financial district, more than a third
of the office force was reported to be absent on ac-
682
INFLUENZA WARNING FROM THE ACADEMY OF MEDICINE.
[New York
Medical Journal.
count of illness on October 9th. Isolated factories
in the Borough of Manhattan report from twelve to
twenty per cent, of illness. The disease is prevalent
today in all or nearly all of the military and naval
centres in and around New York.
Returns from a group of more than fifteen large
public hospitals show that from twelve to forty per
cent, of the medical and lay workers in such insti-
tutions have been affected during the past two
weeks. One hospital in Brooklyn reports fifty-six
nurses down with influenza or pneumonia out of a
.stafi" of 120. Another, in Manhattan, reports fifty
cases out of 300: another forty out of 200. These
reports are similar to reports received from the
military hospitals. In one cantonment hospital 100
out of 200 nurses have been ill. There is no reason
for supposing that the epidemic will run a different
course in New York city from that which it has
pursued elsewhere.
The disease is of germ origin and probably is
spread most commonly through germ laden droplets
of mucus thrown into the air in unguarded cough-
ing, sneezing, and spitting. The Public Health
Committee therefore .strongly endorses the educa-
tional propaganda which has been carried on by the
Health Department of the City of New York and
other health authorities throughout the country,
warning the public against the dangers of over-
crowding and lack of sunlight and ventilation, as
well as those arising from ignorance or careless
habits.
Experience both abroad and in this country seems
to indicate that the epidemic runs its course in any
given community in from four to six weeks. Oc-
curring at this season, the epidemic in New York
city will probably begin to decline in from two to
four weeks. During this period the situation will
continue to be critical and should be dealt with as
effectively as possible.
RECOMMENDATIONS.
The following measures are recommended:
1. That the public should be sharply warned of
the danger of close contact with unrecognized cases
of influenza in crowded public places.
2. The community should stand squarely behind
the Department of Health in its efforts to minimize
overcrowding in public conveyances by conscien-
tiously observing the prescribed hours for opening
and closing of various classes of mercantile estab-
lishments.
3. The daily inspection of children on their arrival
at schools as practised by the Department of Health,
represents a principle which should find wider ap-
plication. There should be a daily inspection of
workers employed in all large establishments as
they report for work with a view to the prompt
exclusion and, so far as possible, the segregation of
all suspects.
4. During the epidemic employers should volun-
tarily report all employees who are absent on ac-
count of illness; such reports will help the Depart-
ment of Health to locate many neglected cases.
5. Gauze masks should be used by all physicians,
nurses and others in attendance upon or in close
contact with the patients suffering from influenza.
6. Measures should be taken to secure more com-
plete and uniform reports of cases of influenza.
The cooperation of physicians will be readier if it
is made clear that the reports are desired as a basis
for helpful action.
7. Nurses, social service workers, and others hav-
ing cognizance of neglected cases should report
them, and centres at which such reports can be
readily made in person should be established.
8. The city authorities should strengthen their
forces by arranging promptly for the close coopera-
tion and, if necessary, the financial support of the
United States Public Health Service, the Depart-
ment of Civilian Relief of the American Red Cross,
and of all agencies which are able to offer useful
service in the emergency. A specific talk should be
assigned to each cooperating agency and its sub-
divisions.
9. Every report of a case, especially in the poorer
districts, should be made the basis of action either
by the Department of Health or by a cooperating
agency, with the following objects in view:
a. Removal to hospital where necessary and
possible.
b. Medical care at home. In the block can-
vass referred to above it was ascertained that,
while a majority of the patients had been seen
by a physicians once, few had had subsequent
medical attention.
c. Nursing care at home. The nursing pro-
gram should include the use not only of gradu-
ate nurses, but of all women who have had
sufficient nursing experience to be of service.
d. The provision of food for the needy cases
and for the neglected children of sick mothers.
e. Temporary shelter for children whose
mothers are sick at home.
f. Inquiry into conditions among the close
neighbors of stricken families, with a view to
the prompt recognition of unreported cases.
10. Hospitals should be urged to obey the injunc-
tion of the Department of Health to discontinue all
nonurgent medical and surgical work in order to
afford partial segregation and medical and nursing
care for influenza and pneumonia patients.
11. The overcrowding of hospical wards with
cases of influenza and pneumonia should be dis-
couraged. Where hospitals command sufficient per-
sonnel to care for larger numbers of patients than
under normal conditions, such patients should not be
crowded into existing wards, but should be placed in
adjacent spaces, such as day rooms and corridors.
It is essential to hospitals caring for influenza pa-
tients to maintain a proper system of bed spacing
and screening.
12. Owners of apartment and tenement houses
should provide heat for such buildings during morn-
ing and evening hours. The proper ventilation of
apartments may thus be secured without undue ex-
posure to cold. The prevalent idea that the Fuel
Administration has forbidden the heating of apart-
ment houses before November ist is erroneous.
The committee is advised by the Fuel Administration
that reasonable discretion is all that is desired or
expected.
Medicine and Surgery in the Army and Navy
THE FUNCTIONAL REEDUCATION OF
THE WOUNDED*
By R. Tait McKenzie, M. D.,
Philadelphia, Pa.,
Major, Royal Army Medical Corps; Professor of Physical Thera-
peutics, University of Peiiiisylvaiiia.
During the spring of 191 5 it was my privilege to
visit the great camps scattered throughout England
and Scotland, in which Kitchener's armies were
Fig. I. — Protractors for measuring angles of movement in
the shoulder, elbows, wrist, knee, and ankle.
feverishly preparing for the fight in France and
Flanders.
In the course of these inspections for the observa-
tion of physical training we found large num-
bers of men who had broken down under the in-
tense strain they had had to undergo. The regi-
mental depots were choked by them and by
the men who were otherwise unfit and were
awaiting discharge from the terribly congested
hospitals. The latter were sending their
patients, as soon as they could be moved, to
the Red Cross Hospitals scattered throughout
the land. These were usually country houses
given for the purpose by their owners, the lady
of the house frequently taking charge, assisted
by her friends and neighbors. The already
overworked local doctor was supposed to treat these
patients, but too often hero worship and lax disci-
pline were followed by physical and moral degenera-
*Delivercd at the opening of the Clinic for Functional Reeduca-
tion of Soldiers, Sailors, and Civilians, at 5 Livingston Place, New
York, Monday, July 15, 1918.
tion, and recovery was retarded or prevented.
The solution of this grave state of affairs was
found in the establishment of command depots
under military discipline and medical direction, in
which men i-eported for treatment instead of drill.
During the winter of 1916 we had about 4,000
men under treatment at Hcaton Park, where I was
the medical officer in charge. Eight others were
soon established. There are now sixteen of these
dejiots, with a capacity of 5,000 each. Their char-
acter has been somewhat changed since they were
organized, by the founding of orthopedic centres and
special hospitals for heart, mental, and nervous
cases. The cases somewhat resembled those in the
hospital of a great industrial plant — fractures,
crushings, and lacerations are much the same
whether caused by the explosion of a shell in the
trenches or by an accident due to machinery. 1
TYPES OF CASES TREATED.
The types of cases which were found particularly
suited for this physical therapy treatment were :
First. — Cases of healed wounds, apparently small,
but with considerable scar tissue under the surface,
strangling the circulation and interfering with the
nerves, though the latter might not actually be in-
jured. The intense and wearing pain in such cases
was a serious bar to the recovery of the nervous
system.
Second. — Nerve wounds, ranging from mere
bruising of the nerve to its complete severance.
Where suture was necessary, healing was a long and
slow process, and much treatment was necessary to
overcome stiffness and atrophy.
Third. — (31d and gangrenous scar tissue where
sinuses were formed, followed by the extrusion of
pieces of dead bone, buttons, cloth, etc. Before the
war these cases were practically never treated by
massage, but now such objects are frequently locat-
ed and brought to the surface by this means.
Fourth. — Cases following operation on joints,
tendons, or nerves, followed by ankylosis where not
only medical but educative care is needed to prevent
slow degeneration, resulting in a stiffened limb.
Fifth. — Functional or so called hysterical cases
2. — Finger board for stretching abduction
fingers.
when there was no nerve lesion and where under an
anesthetic the muscles relax completely, only to be-
come stiff again when the patient regains conscious-
ness.
Sixth. — Cases of sheer exhaustion — men accus-
684
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
tonied to sedentary work, broken down after repeat-
ing, week after week, a twenty or thirty mile
forced march, carrying sixty pound packs on their
backs.
Seventh. — Cases constitutionally unable to stand
the nerve strain of modern warfare. Nervous
breakdown with marked neurasthenia. Shell shock
is a loose term much used in this connection and
Fig. 3. — Finger board for stretching contractions and finger flexions.
covering any form of nervous disability from the
concussion of an actual shell explosion close at hand
to the state of fear in Avhich a man can no longer
stand remaining at the front.
Eighth. — Functional heart cases. The pulse in
many cases ran up to 150 with extreme breathless-
ness on the slightest exertion or excitement. These
aitorded the most satisfactory cures, especially when
treated by progressive exercise and hydrotherapy.
At the command depot, Heaton Park, Manchester,
in one class of eighty men who were taking baths
and progressive exercises, about thirty per cent, of
those under treatment were able to return to the
fighting line.
Ninth. — Lastly, a large number of
cases of weakness, the patients need-
ing good food, rest, and progressive
exercises to overcome their disability,
made very satisfactory showing. Of
about 3,000 men of this type dis-
charged from Heaton Park in six
months, about forty per cent, were
able to go back to the front line, and
the same number to clerical or other
work connected with the armv, while
a comparatively small percentage were unable to do
any military service andwere classified as incurable.
THE MEANS EMPLOYED IN PHYSICAL THERAPY.
Application of heat. — The first object in phys-
ical therapy is to improve and heighten the circula-
tion. This is done by the application of the follow-
ing forms of heat :
1. Dry heat. The deep tissues and joints are
reached by diathermy and the processes of re-
pair hastened ; also by the electric lamp or
ether forms of dry heat, by means of which
a leg, or arm, or the whole body may be
heated. There are two main forms of baking
• — that in which the light rays predominate,
and that in which the heat rays are most
prominent and effective.
2. Circulating bath. The French introduced
a system of eaii conrante baths, whirlpools of
running water, into which the limb is plunged
tor twenty minutes in preparation for mas-
sage. The object of the circulating water is to
give the full efifect of the temperature. In still
water at 110° the limb soon becomes sur-
rounded by a layer of water at its own
temperature. The bath may be effervescing. This
is one of the most valuable forms of hydrotherapy.
Oftentimes a limb which is cold, blue, and intensely
painful to the touch, will come out of the bath crim-
son, comfortable, and easy to manipulate without
pain.
3. General douches. Rheumatism is a constant
complaint of the malingerer, and mii-aculous cures
have been brought about by a cold douche ruthlessly
and suddenly given. Sometimes only one or two
baths are necessary. In other and more genuine
severe cases the cure is not so rapid, but the relief
is great.
4. The continuous bath. This is very valuable
for functional heart cases. The patient is placed in
the bath at a temperature of 94° for one hour ; he is
then wrapped in blankets and made to rest for an-
other hour. It is very interesting to notice the daily
lowering of the pulse from 150 to normal. Shell
shock cases may also be treated in this way in a
temperature of about 94° with a most marked quiet-
ing efifect, and this treatment has long had an es-
tablished place in the treatment of mania. All these
forms of treatment are merely preparatory to the
second and greatest factor in the cure.
Fig. 4. — ^The arm table. A, Finger machines. B, Finger treadmill. C. Wrist circuindiictor. D, Wrist abductor and adductor.
E, Wrist mill for flexion and extensicn. F, Pronator and supinator. G, Creeping board for shoulder abduction.
October 19, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
685
Massage or passive movements. — If only one
means of treatment was possible, I would choose
massage before any other; in the hands of a skilled
masseur such a range of movement and of slow
stretching of joints and scar tissue are possible. But
though most other treatments lead up to massage,
F:g. 5. — Pulley weights for exercising fingers
hand doing exercise i, left hand with thunil)
n flexion and extension, right
attachment doing abduction.
and it is proving itself more and more invaluable, it
is, after all, a purely passive thing.
Active movements. — At some
time active movement on the
part of the patient is necessary,
and here is the weak and often
absent link in the chain of treat-
ment. When I first began this
work, in 191 5, I found the most
of the machinery available for
reeducation of weakened joints
was unsuitable, very expensive,
and frequently not to be had at
all. Makeshifts had to be con-
trived out of such things as
wood, wire, sewing machines,
etc., and yet two thirds of the
cases before us required this ac-
tive movement.
Three main principles evolved
themselves in the course of this
treatment. In the first place,
the contracted joints and tissues
must be stretched as far as
possible, but to stretch them
suddenly, ignorantly, or without
the patient's cooperation would
be dangerous. The doctor must
decide the extent of the opera-
tive treatment, but the patient may be trusted
not to wrench his own joints if the apparatus is left
under his own control. Secondly, all movements
should be made accurately. For example, prona-
tion and supination of the forearm in the case of an
.mkylosed eli)ow are of no use if the movement
comes from the shoulder instead of from the elbow.
Thirdly, the amount of exercise given to a limb must
be measured. Psychologically it is important for the
patiei^.t to understand on what he is working and
how he is progressing. This measure may
be done by means of a scale on the appli-
ance telling, in degrees, the amount of
movement and improvement, or the sense
of hearing may be used as an incentive if
the appliance can be made to click out, in
degrees the progress achieved.
The patient should have a definite task
set for each day to make him work a little
harder. Many of these men get discour-
aged, and like children, they must have
their progress proved to them. They
should be led on from simple to more
complicated tasks. The struggle for ex-
istence among his fellows must be pre-
pared for, not acquiescence in a state of
abject helplessness ; the latter state is
helped along by those sentimental people
who ruin a man by destroying his self-
confidence.
As more complicated movements are
needed, head work and calculation enter
into the treatment. Simple gymnas-
tics, games, rhythmical movements, ball
throwing, etc., lead to the teaching of a
definite trade, by which the man will be-
come self supporting. All movements
made useful as far as possible. For
a carpenter should be encouraged to
should be
example.
Wrist abduction in action, E, Beginning of wrist extension,
position of arm in pronation.
F, Correct
make the movements which he would use in work-
ing the saw or plane. There are now some fifty or
sixty appliances out of which from fifteen to twenty
have been adopted for the use of Canadian hospitals
686
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
and by the medical authorities at Washington.
These practically cover all the voluntary movements
of the main joints of the body.
To sum up, treatment begins with the preparation
of the limb or joint by electricity, radiant heat, or
hot baths, then massage or passive movements, fol-
lowed by active movement.
Measuring the range of
movement. — Before begin-
ning the reeducation of the
joint, the range of move-
ment should be carefully
measured. This is done by
means of protractors of
galvanized sheet iron, with
the scale marked in degrees.
Fisrure i shows the method
of measurmg movements ot
the shoulder forward and
backward, the protractor
being set with zero perpe'n-
dicular to the joint, as
checked by a plumb line.
The elbow, wrist, knee, and
ankle are measured by the
second protractor made of
galvanized iron strips,
hinged and with a scale
pasted on to a side place.
The appliances are used
for two purposes : stretch-
ing and improving the
strength. All the stretching movem.ents are kept
within the voluntary control of the patient ; the ap-
is used for stretching the contraction of the fingers
m flexion, and for stretching the abduction at the
metacarpo])halangeal joint. The exercises are un-
dertaken as indicated. Each movement is repeated
not more than five times.
Finger ])ulleys, such as are shown at A in Fig. 4
Fig. 8. — Amputated case leaniing control on the balance beam.
pliances for improving the strength can be loaded
with increasing weights as the power to use them
returns, and the patient can thus be kept interested
in his progress.
The finger board which is illustrated in Fig. 3
Fig. 7. — Amputated case practising walking through the ladder to exercise the stump and
teach control. Inversion and cversion treads also shown.
and in Fig. 5, are used for the flexion and extension
of the fingers. The wrist and arm are strapped at
the elbow, the fingers are inserted into
the glove stalls, and weight is added
until it can barely be lifted by the vol-
untary power of each finger. The
weights are increased as improvement
goes on, and the movements are re-
peated to the point of exhaustion.
Many other movements are under-
taken : thumb adduction and abduc-
tion ; circumduction of the wrist, by
turning the handle of a wheel ; adduc-
tion and abduction of the wrist by
means of a hand board ; flexion and
extension of the wrist with a roller and
weight ; supination, and pronation.
Wrist abduction, wrist extension,
and pronation are illustrated in
Fig. 6.
REEDUCATION IN AMPUTATION CASES.
Reeducation in amputation cases,
which form a very important class,
begins with the preparation of the
stump and the fitting of the artificial
limb for comfort, and for the cor-
rect bearing of the weight. The pa-
tient should first learn to balance
himself, which may be done by suspending him by a
belt under the arms, working from an overhead trol-
ley or by grasping a bar, as shown in Fig. 7. This
inspires confidence and prevents falling, especially in
amputation at the thigh, where the balance is a very
Octolicr 19, 1918.1
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
687
difficult matter. The patient then advances to the
use of sticks and progression on a smooth surface.
It is most important that he discard crutches from
the start. He then learns to walk on a smooth level
surface with one stick only to clear obstacles, like
the ladder rungs illustrated, and linally to walk
through soft sand, on uneven ground, up and down
inclines, and over obstructions. Further confidence
may also be gained by using the eversion and inver-
sion treads, and the balance beam, as shown in Fig.
8. From this he may go on to the playing of games
by means of special attachments for arm or leg, such
as have been designed at Hart House to allow the
playing of tennis, billiards, and even bowling.
CONCLUSION.
These are but brief outlines of the methods fol-
lowed in this work; methods which have been
evolved by many workers and based on the vast
experience of the war. They will serve to indicate
the lines pursued in the reeducation of the wounded,
a work which requires the constant exercise of in-
ventive ingenuity, in order to meet the varying
phases of the injuries received.
I sincerely congratulate the donors of the funds
which have made the opening of this clinic possible,
upon their wisdom in choosing a field in which their
generosity will be productive of such vast and far
reaching results. Through the work of this and
similar agencies, many thousands of our young rnen
will be won back to selfsustaining, self respecting
manhood who might, save for such aid, drift into
the class of aimless, helpless, and hopeless de-
pendents.
* * * *
CLINIC FOR FUNCTIONAL REEDUCATION.
The Clinic for Functional Reeducation of Dis-
abled Soldiers, Sailors, and Civilians was opened at
5 Livingston Place, New York, on Monday, July
15th. with an introductory address by the president
of the Clinic, Dr. W. Oilman Thompson. The Clinic
was estabhshed primarily to care for the mutilated
of the armv and navy, and to provide instruction for
medical officers in this special department of med-
ical work. It will be, however, a permanent insti-
tution for the care of those who become disabled
through accident, or in the processes of manufac-
ture or transportation, or through explosions.
There are about 200 major operations performed
annually in the city of New York; for the subse-
quent special treatment of such patients no system-
atic care has yet been provided, such as will be
alTorded through the Clinic.
Doctor Ihompson said: "The object of the Clinic
is to put the disabled individual into the best pos-
sible physical condition by means of our special ap-
paratus, so that he can eventually earn his own liv-
ing. However, we are not going to enter at the
present time, at any rate, the field of vocational
training. That side of the work is being under-
taken in the Red Cross Institute by Doctor Mc-
Murtrie. The Red Cross has undertaken the teach-
ing of various trades by which the men can after-
wards earn their own living. Our work is to put
these men into the best possible condition to earn
a trade. That is its limitation at the present time."
An affiliation has been created between the Clir
and Cornell Medical College. The staff of the
Clinic, while consisting in great part of the members
of the faculty of the College, is not exclusively so
composed, and officers experienced in the French
and Canadian work of functional reeducation have
been invited to give instruction.
Ihe buildings of tlic clinic have been leased for
a term of years from the New York Infirmary for
Women and Children, which institution has tempo-
rarily suspended operation. Funds for the equip-
ment of the clinic are ample, but those for its main-
tenance are available for a limited period only, and
the generosity of the public is relied upon to con-
tinue it after the war, since the work done by th'
clinic is a great necessity for the permanent wel-
fare of civilians injured in the performance of their
work.
The equipment of the therapeutic building com-
prises the following departments :
1. Complete hydrotherapy outfit, with apparatus
for pressure douches, needle baths, continuous
baths, whirlpool baths, local baths for the arm or
leg, with massage tables and electric light tables.
2. Mechanical apparatus designed by Professor
R. Tait McKenzie, of the University of Pennsyl-
vania, and Professor E. A. Bott, of Hart House,
Toronto. This apparatus has been standardized
for use in the medical department of the United
States Army.
3. An electrotherapeutic department furnished
with the electric apparatus for diagnosis and treat-
ment of nerve, muscle, and joint disorders, which
has been standardized for the United States and
Canadian military hospitals.
4. A department for special therapeutic exer-
cises and games, and for local massage. The mas-
sage tables are copied from the model of Professor
McKenzie.
5. Workshops.
t). X ray department.
7. Rest and reading rooms for the patients, an '
an extensive outdoor garden where many of the
exercises may be given.
In the main hospital building three wards are fur-
nished for patients who are unable to walk, and an
excellent operating room is provided where second-
ary operations may be performed."
All treatment is offered free to the poor, but hos-
pital patients referred by the city authorities or by
accident insurance companies, the War Risk Insur-
ance Bureau, or similar organizations, are charged
the rates for board, operation, or treatment which
these organizations are accustomed to pay other hos-
pitals and dispensaries of the city.
The chief speaker at the opening was Dr. R. Tait
McKenzie. who had come from Philadelphia to de-
scribe and demonstrate the uses of his special ap-
paratus. Following his address, which is given
above, Doctor McKenzie demonstrated the use of
the appliances, insisting upon the importance of the
inteUigent and logical order of the various treat-
ments and movements. For the illustrations used
we are indebted to the Macmillan Company, pub-
lishers of Doctor McKenzie's book. Reclaiming the
Maimed.
688
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
AN EMERGENCY HOSPITAL IN FRANCE.
A Six Hundred Bed Hospital Erected and in Operation
ivithin Twenty-five Days. — Reserve Hospital for Cha-
teau-Thierry.
When the United States Marines and the Rain-
bow Division attacked Chateau-Thierry, all the hos-
pitals available were quickly filled with wounded.
Every available building had been occupied by the
Medical Department and there was still need for
additional beds. The American Red Cross in Paris
received a telegram from the front reading, "We
must have a six hundred bed hospital in double quick
time." Fortunately, a deserted race track was found
which furnished the
necessary space. The
reserve store houses
of the American Red
Cross contained all
the material required
to set up the desired
hospital and to equip
it, complete in every
respect. Long motor
truck trains conveyed
the knock-down forms
to the grounds.
Framework, flooring,
canvas, windows, and
foundation supports,
all ready to be put to-
gether at a moment's
notice, were piled on
the trucks. Every
eighteenth truck car-
ried a complete oper-
aing room and equip-
ment and hauled a
would be difficult to duplicate, but which is char-
acteristic of the method of the American Red Cross
and of the Medical Department of the United States
Army. We present herewith illustrations showing
some aspects of this emergency hospital.
MEDICAL NEWS FROM WASHINGTON.
Surgeon General Ireland to Proceed to Washington.— Pro-
posed Appointments on Retired List.—Reconstruction
Work at Base Hospitals Progressing.
Washington, October 15, igi8.
Major General Merritte W. Ireland, the newly
appointed Surgeon General of the Army, has been
ordered detached
from duty, as chief
the staff
Pershing
and to
to
as-
trailer on which a sterilizing room was carried for
emergency needs. At the end of the twenty-fourth
day, the entire hospital, complete in every detail was
ready for occupancy.
The Army Medical Department arrived before
daylight with bed and equipment, and by noon the
hospital with six hundred beds was turned over to
surgeon of
of General
in France,
Washington
sume duty at the head
of the Medical De-
partment. Major
General William C.
Gorgas, who retired
as Surgeon General
on October 3rd, is still
in France, and no an-
nouncement of his
assignment to other
duty has been made as
yet.
General Ireland's
orders to proceed to
this country and the
appointment of
Brigadier General
Robert F. Noble, M.
C, as major general to succeed him in France, dis-
pose of the speculation that assigned General
Gorgas to duty as Acting Surgeon General and the
retention of General Ireland in France.
A bill, introduced by Senator Sheppard, of Texas,
is pending before the Senate Military Committee,
Coiirtrsv of the Americuii Red Cross.
IN THE EMERGENCY RED CROSS HOSPITAL.
Patitnts were received from the Chateau-Thierry Front within twenty-five
days after the erection of the hospital was requested.
Courtesy of the American Red Cross.
AN AMERICAN RED CROSS EMERGENCY HOSPITAE OF SIX HUNDRED BEDS.
This hospital was erected and equipped and in full operation with 160 patients in it, twenty-five days after the request for it was
received at Paris.
the surgeons, nurses, and hospital corps. By mid-
night of the twenty-fifth day after the order for the
hospital was received in Paris, 160 young Americans,
wounded, gassed, or sick, rested comfortably in
clean beds. This is a record of efficiency which
authorizing the President to appoint to the rank of
brigadier general on the retired list those officers of
the Medical Department of the Army who entered
the service of the United States over thirty-five
years ago, and who, at this time, though retired, are
October 19, 1 91 8.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
689
on active duty in war work, and who, under the
rule of seniority, would have been entitled to pro-
motion except for their automatic retirement for
age by operation of law. It has been suggested that
the bill be amended to include medical officers who
were retired on account of physical disability in-
curred in line of dut>', and who since have been
placed on active duty and are rendering valuable
service to the Government.
^ * * *
According to Lieutenant Colonel Charles W.
Richardson, M. C, acting director of reconstruction
work in army hospitals, about eighty per cent, of
the wounded will be
sent back to combat
duty after treatment
in the hospitals in
France, and the re-
mainder will be gath-
ered in base hospitals
there until they can
be brought back to
this country. It is
with this twenty per
cent, that the recon-
struction work is
chiefly concerned.
After arrival here,
they will be distrib-
uted to the base hos-
pitals throughout this
country, each man
being sent, when pos-
sible, to the station
nearest his home. At
present there are
twenty-six of these
hospitals, and more will be organized. Most of
them have about 1,000 beds each, but some are de-
signed to accommodate 3,000 patients. Reconstruc-
tion work is being: carried on at all of these in-
stitutions, and at two or three special hospitals, such
as the one in Baltimore, for the blind.
The patients are divided into three classes : Those
that will be able to return to military duty ; those
that can be trained to render limited military duty ;
and those to be discharged when they are capable of
self-support. The reconstruction division is co-
ordinating its work with all other branches and
forces for the good of the sick and wounded. The
men are being classified into groups and trained with
a view to their future usefulness, both in this war
and in the time to come after the war.
The officers in the reconstruction division of the
Surgeon General's
Office are Colonel
Frank Billings, i n
charge ; Lieutenant
Colonel Richardson,
acting chief of the di-
vision in the absence
of Colonel Billings ;
Lieutenant Colonel
James Bordley, Jr. ;
Majors M. W. Mur-
ray, A. C. JMonahan,
Frank B. Granger,
Arthur Dean, M. E.
Haggerty, and H. B.
Price ; Captain A. H.
Samuels and First
Lieutenant C. Will-
Tl,
Courtesy of the American Red Cros.
ERECTIiNX, FRAME WORK F(JR PORTABLE HOSPITAL,
s hospital with beds for 600 patients was erected and equipped
twenty-five days.
The spread of in-
fluenza in the city has
seriously impaired the
efficiency of many governmental departments. The
United States Public Health Service has mobilized
for an active campaign against influenza. Experi-
mental work is now beins: conducted.
Courtesy cf the American Red Cross.
UNLOADING THE EMERGENCY HOSPITAL ON THE RACE TRACK GROUNDS.
A complete 600 bed hospital furnished by the American Red Cross and erected back of Chateau-Thierry within twenty-five days.
Oijo
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New T«iK
Medical Journal.
PHYSICAL TESTS FOR AIRMEN ARE
NOVEL AND EXCITING.
The following authoritative statement from the
War Department regarding the physical tests for
aviators, appears in the September 21, 1918, issue
of the Official Bulletin:
All men who have won their wings in the
United States air service are now required to
pass a new heart, lung, ear, and eye test to establish
their physical and mental fitness when high in the
air and particularly to indicate at what heights they
arc in a condition to fly. Cadets receive a test be-
fore they finish their schooling; flyers are given
these tests periodically to eliminate any whose
physical or mental efficiency has become in any way
impaired.
These tests are the result of study and investiga-
tion by the Medical Research Laboratory at Hazel-
hurst field, Mineola, N. Y., whose
staff has devised apparatus and de-
termined upon a standard examina-
tion for classifying pilots. To stay
in the rarefied air at an elevation of
20,000 feet for any length of time
has been found to be a strain on
even the most physically perfect.
It has also been discovered that
many of the most seasoned fliers
cannot undergo the sudden quick
changes in altitude occasioned by
diving and climbing without physi-
cal deterioration. It was recog-
nized as too great a risk to subject
these men to actual flying tests. So
the medical laboratory at Hazel-
hurst field undertook to devise some
way of getting the same results by
means of a ground test.
In 'the early tests the pilot was
placed in a steel airtight cylinder
from which the air was gradually
exhausted and then replaced, to
simulate a flight into the rarefied
air of high altitudes and back to
earth, but today the pilot sits com-
fortably in the same room with his
examiners. His nose is clamped .so
that he can not breathe through it.
Over his mouth is placed the
breathing apparatus, which is con-
nected by tubes with a tank of
measured air, and with instruments that record
every breath he takes. The air is analyzed at vari-
ous stages of the run. As fast as he exhales the air
is taken into a reservoir where it is cleared of
carbon dioxide, and then returned to the tank.
Gracluallv he uses up the oxygen and thus air con-
ditions of high altitudes are duplicated. The higher
one goes up, the rarer the air becomes; just so with
the man under test.
The man under test is kept fairly busy, just as he
would be piloting a plane. Before him on a table
is a bank of small electric lights, one or another of
which flashes every five seconds. These he must
extinguish as fast as he observes them and before
they go out. He has but a few seconds. Below the
lamps is a corresponding set of buttons which,"
when touched with a pointer held in the right hand,
extinguishes the respective lights. Two observers
watch him constantly and check his errors or de-
layed actions.
Another instrument before him is an ammeter
which acts similar to a speed dial on a plane, and,
accordingly, in the test must be kept at a constant
point.
As time goes on (and the test lasts for about
thirty minutes) the pilot becomes a bit groggy or
sleepy from lack of oxygen, just as he would at the
corresponding altitude, and this condition becomes
manifest in changes in the action of his heart, eyes,
ears, and brain. A few minutes after his release
from the apparatus all signs of his recent fatigue
pass away and he becomes normal again.
MAJOR WILLI
M. c, r s.
A BROOKLYN SURGEON ON
THE WESTERN FRONT.
Major William Francis Camp-
bell, M. C, U. S. A., of Brooklyn,
professor of surgery in the Long
X'*AW - Island College Hospital, is now
:>^3yt: at work on the Western battle
front. When he first went over,
about the end of July, he wrote,
'T have been working with Dr.
Joseph Blake (in Paris), but am
transferred to more active service.
I am very happy in the work
because it is a man's job and
it satisfies both mind and heart. I
am glad I came. If you could only
see our brave and patient boys, and
know how much it means to them,
you would realize how much we are
needed here." From later letters to
a Brooklyn friend, we quote the
following: "(August) We have
operated on 2,000 patients in eight
days and we were then 200 behind
our schedule. I personally oper-
ated in forty-seven separate cases
in one day, with only two hours'
sleep in twenty-four hours, and
kept tins up for five days. But it
was all a great privilege to minister
to our boys. They are the finest and
the bravest bunch of kids I ever saw.
There isn't a single grouch among them. They lie on
their stretchers and wait patiently for the surgeon's
attentions. 'Take the other fellow. Doc, ; I can wait,'
is what you always hear as you go among the wound-
ed. They don't seem to think of themselves, it's their
])al comes first. Out here men lose all petty selfish-
ness in the glory of their supreme sacrifice. (Sep-
tember 3) We are now working in teams on eight
hour shifts — eight hours on and eight hours oflf so
we just work and sleep (when not interrupted by
sliel] fire). I have just enjoyed this big job and this
wonderful adventure and am glad to have had this
wonderful privilcre." INlnior Campbe'l was ren-
dered unconscious in Paris by a long range shell.
\M F. CA.MBELL,
A., of Brooklyn.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all comimiiiications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, OCTOBER 19, 1918
SCIENCE AND ART OF MEDICINE.
Science is supposed to be classified knowledge,
but what goes by the name of science in one age
may become the foolishness of another time ; the
knowledge may not have been rightly classified,
or the material carefully pigeonholed may prove
not to have been knowledge. This uncertainty
as to finality applies especially to the biological
sciences, and should make those who deal with
the human body cautious about being too dog-
matic. The scientist is apt to become as dog-
matic in his particular sphere as the theologian,
and with much more likelihood of hindering pro-
gress.
In a recent gathering of medical men an emi-
nent laboratory worker decried the use of vac-
cines in the treatment of hay fever, although the
clinical results presented seemed, in many in-
stances, to more than justify this means. He
argued that as hay fever was not primarily a bac-
terial disease, no vaccine could be of help. The
argument is, in a way, well taken, but, on the
other hand, we do not know the nature of the
anaphylactic condition present in hay fever, nor
are we thoroughly cognizant of bacterial pro-
ducts or their effects on the body. It is not im-
possible that the bacterial toxins may counteract
the substances in the blood (if they are there)
which produce the hay fever. If they do this
without injury to the patient may it not be better
to use them than to do nothing for the person
who seeks relief?
We knew a prominent professor of medicine
who became so scientific that he would not use a
drug which had, in other hands, proved of much
benefit in a certain disease, because it had never
been proved to his mind just how it could be of
benefit in the condition.
While he should be familiar with all the classi-
fied knowledge that is current, the physician
must, for the present, hold to the fact that he is
practising the art, rather than the science, of
medicine — an art guided by science but not to be
interfered with by the limitations of science nor
the scepticism of scientists. It is well to be con-
servative in medicine, but not to be a slave to
school laboratory findings, for the human body
is a laboratory with which the physician deals
daily.
ENDOCRINOUS ORIGIN OF GASTRIC
ULCER AND APPENDICITIS.
The obscurities of causation of these common
pathological conditions receive illumination in
the interesting conclusions reached by Friedman
and in the suggestive presentation of his recent
investigations [G. A. Friedman: Further Studies
of the Influence of Parathyroidectomy on the
Gastrointestinal Mucosa of Dogs and Rabbits,
Journal of Medical Research, March, iQtS]. In
about seventy per cent, of dogs and of rabbits in
which parathyroidectomy had been performed
gastric or duodenal lesions were found to have
developed, and in about twenty-eight per cent,
in dogs and twenty-one per cent, in rabbits there
were appendicular lesions. In both dogs and
rabbits autopsied as controls no such lesions
were found.
An ulcer, the investigator believes, develops
from an initial erosion, a lesion which would
seem to be induced by a disturbance in the thy-
roid secretion. A gastric ulcer in man shows a
tendency to spontaneous healing, as do also those
produced in animals by direct experimental meth-
ods. Experience in these experiments was di-
rectly contrary to this. It seems here that the
692
EDITORIAL ARTICLES.
[New York
Medical Journal..
disturbance in the constitution of tlie animals
occasioned by the permanent interference with
the thyroid secretion was the cause of preventing
this natural healing process, for these animals
were not autopsied in a number of instances until
several months after operation. The degree of
disturbance of the thyroid secretion was probably
far in excess of the milder degree which would
produce the initial lesion in the human being. In
the latter the ulcer becomes chronic, through the
irritation of food and perhaps the excessive se-
cretion of hydrochloric acid, if the constitutional
disturbance is not corrected. The initial lesion
in the appendix also, due to the thyroid disturb-
ance, is aggravated and rendered chronic by the
irritation of fecal matter and through the pres-
ence of bacteria.
The author attributes the origin of the lesion
to vasoconstriction induced by the diminished
amount of thyroid secretion in the blood. In
some individuals the effect of this may be pro-
duced upon the smallest gastric or duodenal
arterioles of the mucosa causing them to con-
tract. This spasm of the arterioles then causes
an ischemia of the mucosa, which is followed by
a superficial necrosis from which the ulcer arises.
A majority of the animals experimented upon
showed a hypotonic stomach, which corresponds
with the common clinical association of stasis
and hypotonicity of the stomach with chronic
ulcer or appendicitis. This is probably due to a
hypotonic condition of the vagus.
On the other hand, a peptic ulcer may be asso-
ciated with a hypertonic stomach, in which the
hypertonicity is probably due to an irritable con-
dition of the vagus. A spastic contraction of a
small area of stomach musculature, caused by an
irritable vagus, may produce the same conditions
favorable to a lesion as that due to the spasm of
the arterioles. This irritable condition of the
vagus may be caused by excessive secretion of
the thyroid. In either case, under such explana-
tion, the formation of the ulcer is dependent upon
a disturbance in the thyroid secretion. There
still remains the question whether other endo-
crinous glands are not also involved, tlirough the
vegetative nervous system, and whether, there-
fore, the initial lesion is not due to a pluriglandu-
lar disturbance. This point of view necessitates
the considering of peptic ulcers as due to sys-
temic disturbances. They cannot therefore be
cured by surgery alone, though this may remove
the mechanical complications and assist in the
healing process, which must be a spontaneous
one. The inherited constitutional tendency to
peptic ulcer is also explained in this way.
A GENERAL PRACTITIONER OF
CANADA.
Tucked away near the southwestern extremity
of the Niagara peninsula, in the Province of On-
tario, lies a little village of three or four hundred
inhabitants, by the name of Selkirk. It is out of
the way of ordinary routes of travel, though
easily accessible to Buffalo and Hamilton, in
which latter ambitious city they can hold record
breaking medical meetings when they have a free
hand, and no favors asked. There has just died
in that secluded hamlet a general practitioner of
ninety-one years who never allowed himself to
become moss grown, who did not believe in all
work and no play, and who would neither be shut
in the limited environment of his clientele nor
shut out of the larger professional life of the
meetings of national and provincial medical
bodies. Coming from a back township practice,
he attained to the highest honor of the Canadian
medical profession — the presidency of the Cana-
dian Medical Association.
To see Dr. Thomas Tipton S. Harrison enter a
medical meeting when in progress, either in
Montreal or Toronto, was to see a small, spare,
wiry man, of unknown age, but hale, hearty, and
beaming; for he enjoyed stealing in quietly to a
front seat, but his stealthy entrance never passed
unnoticed. It would seem as though his brethren
of the profession were always on the watch for
his appearance. Then there would be loud and
jirolonged applause and sometimes cheers. Quietly
he would slide into a chair, listen for a few
moments to the speaker, and then lapse into
peaceful slumber. His long journey had no doubt
wearied him.
His professional brethren could very compla-
cently await upon his repose ; for well they knew
that at either luncheon or banquet, Doctor Har-
rison would be called upon, when they could en-
joy his rural feast of reason and flow of soul. It
was not upon intricate problems of surgery or
obstetrics he spoke, though in his ripe experience
lie could break a lance with even the skilled pro-
fessor of the city and the college, but mostly
upon those humorous episodes of active country
practice, out of which he reaped a double enjoy-
ment, experiencing them, and then relating them
to liis more fortunate confreres of the towns and
cities. He was possessed of a rapierlike wit and
a bountiful humor.
Members of the medical profession are too^
prone to hibernate. It may be that their calling
forces it upon them. Perhaps the doctor cannot
have too many social friends. It is none too nice
either to be accused of "working" the church, the
Octoher 19, 1918.]
EDITORIAL ARTICLES.
695
club, tli£ fraternal lodge, or the ward political
room. They should, however, be free among
themselves, taking their best social enjoyments
from among members of their own vocation, and
tentatively sipping the sweets which lend the
most charm of happiness and contentment. They
should be the last to speak disrespectfully to
others of members of their own profession, al-
ways remembering that "to err is human, to for-
give divine." Far too often yet is heard the
slighting jibe at the attainments and ability of
some professional brother. Does it not enhance
the standing of our profession when men who
cannot speak well of a member, at least preserve
a golden silence ? Does it hurt any of us to hold
our lips even when the occasion might warrant a
sneer?
With no particular following — never having
been a professor — the life of Doctor Harrison,
and others of his kind, typifies the broad minded,
generous, sympathetic, kindly, jovial, general
practitioner who has his ups and downs in a
country practice. He battles with wind and
snow, rain and sleet, frost and cold; long stand-
ing bills and unpaid accounts; he faces complica-
tions when he must long for professional assist-
ance; and comes up to medical meetings in the
big centres bubbling over with life — and once or
twice in a century is honored with a presidency.
Then there is a void, an empty chair. But we are
the better for having had such as he.
PRIMARY MASTOIDITIS.
Primary mastoiditis is uncommon ; the most
interesting feature of the cases is the integrity of
the tympanum. It is quite curious to note that
an infection sufficiently intense to produce a de-
structive osteitis of almost the whole of the mas-
toid apophysis yet respects the thin barrier of-
fered by the tympanum.
During trepanation for acute primary mastoid-
itis, the antrum alone is involved or it may be
diseased with the rest of the apophysis. Isolated
cellulitides have been met with in the neighbor-
ing cells of the canal in the posterior groups and
in the cells of the apex, and in a subantral cell,
with integrity of the antrum itself. Communica-
tion between antrum and tympanic cavity is
easily suppressed, and what remains of the cavi-
ties is filled with a serous or mucous exudate.
If tumefaction is intense and if the osseous cells
?.re undeveloped, tlieir lumen disappears, so that
when they are surgically exposed they are found
fdled with a reddish pulpy mass. The lesions
soon extend beyond the mucosa and invade the
bone.
It has been shown histologically that after
ulceration of the mucosa of the cavities of the
ear, the superficial layers of the bone become ne-
crosed and exfoliate, while an infiltration of
round cells invades the necrosed parts and ex-
lends in depth along the perivascular tissues.
Around the vessels, young cell granulations in-
vade the bone laminte and set up the same
changes as in the superficial osseous layers. In
more advanced cases, extensive necrosis of the
osseous trabeculfe is seen and around these ne-
crosed areas granular tissue exists, in which can
be seen bacterial masses.
It should be recalled that the infection extends
from the mucosa to the bone by the perivascular
connective tissue sheaths or lymphatics, and also
that the bone infection manifests itself by necro-
sis of the adjoining lamellae. Now, if, instead of
the microscopic necrosis which constitutes caries,
one finds necrosis en masse of an osseous mass of
considerable size, the result will be the formation
of a sequestrum. Sequestra and necrosis are
consequently two slightly different evolutions of
the same process.
In the pus of a carious apophysis osseous dust
is found and nearly always the sequestrum is free
in a large cavity produced by caries of adjacent
parts.
The histological findings explain how the pro-
cess may become limited. The portion of ne-
crosed bone becomes separated from the healthy
bone, which itself is the seat of a reaction result-
ing usually in a partial or total hyperostosis, or
by eburnation. Hyperostosis of the petrous por-
tion of the temporal bone does not imply that it
is a defensive process of the organism against
invasion of the infection ; it is, in reality, a very
serious complication, because it is rarely limited.
By obstructing the antrum, mastoid cells, the
auditory canal, and condensing the external cor-
tex of the apophysis, it inevitably results in pre-
venting the pus from escaping, which is sooner
or later followed by serious cerebral complica-
tions.
The progress of the lesions may cease, regres-
sion may occur, and recovery take place, but if,
on the contrary, the process undergoes its evolu-
tion, the pus may find its way out through the
natural fissures of the petrous portion of the tem-
poral bone. Such an evolution is peculiar to
childhood. The petrosquamous suture not being
closed, the pus reaches the integuments through
it. The pus may likewise travel by way of the
vascular tract and come to the surface in the re-
694
NEWS ITEMS.
[New York
Medical Journ'.l.
tromeatic cribrose space, and this event is met
with both in children and adults, but in this case
it is practically certain that a diploic apophysis
is involved.
Finally, in the adult, the effraction of the pus
takes place at no matter what point of the ex-
ternal cortex. It may burrow downward toward
the neck, giving rise to one of the varieties of
Bezold's mastoiditis, according to the site of the
perforation. The pus may also find its way into
the external auditory canal by way of a minute
fistulous tract; or it may find its way to the roof
of the antrum ; or force itself through the upper
groups of cells, resulting in an extradural
abscess with or without an external pachymenin-
gitis or a meningitis.
Backward, the pus may attain the lateral sinus
and follow its walls, thus producing the destruc-
tive changes of perisinusitis, endophlebitis, and
thrombophlebitis. It is also by this route that
posterior meningitis develops on the under sur-
face of the cerebellum. Besides these complica-
tions, facial paralysis due to necrosis of the osse-
ous block of the facial or infection of the peri-
facial cells results. Pyemia, with or without
thrombophlebitis, cerebral or cerebellar abscess,
may be the ultimate result, while serious menin-
gitis is a less common complication.
THE INFLUENZA SITUATION.
The influenza has now been pronounced epidemic
in every state in the Union and up to Wednesday,
the daily reports showed an increasing number of
new cases reported in all the States except three.
There are indications of a subsidence of the incre-
ment of new cases in the military camps, though the
number of deaths is increasing. In Philadelphia
and in the District of Columbia, so large a propor-
tion of the public has been affected as to seriously
interfere with business. Public gatherings have
been forbidden in many of the larger cities. In
manv places, schools, churches, saloons, and the
moving picture houses have been closed, though
these steps have not been taken in New York city
up to Wednesday of this week. The disease has
materially affected the output of coal in the mining
districts of Pennsylvania. In many collieries, min-
ing has been brought to a standstill bv the illness of
the miners. Preventive vaccines, most of which
include cultures of the pneumococcus, are being tried
but so far no reliable reports are available as to
their efficacy. A sharp dift'erence of opinion has
arisen between Dr. Royal S. Copeland. commis-
sioner of health, and the Public Health Committee
of the New York x\cademy of Medicine regarding
the severity of the epidemic and the steps which
should be taken. The report of the Public Health
Committee appears on page 68r.
Th.ere is still a scarcity of nurses and physicians
and the third year medical students have volun-
teered to help out but have not yet been called on.
The fourth year students are now on duty. The
v'ity is being laid out into zones with the view to con-
serving the efforts of the physicians and nurses by
obviating the need for covering a large area. The
New York Telephone Company has issued a request
to the public to restrict the use of the telephone to
essential business only and has closed half the
booths in the public telephone stations. These steps
have been rendered necessary by the increase of the
number of operators suffering from influenza.
THE SURGEON AT THE FRONT.
In civilized warfare the surgeon and his staff
are recognized as noncombatants and free from
attack. In the present war the Germans have ig-
nored this precedent and have repeatedly attacked
hospitals far in the rear, killing and wounding
surgeons, nurses, and patients. A graphic account
of a night attack on an American hospital behind
Chateau-Thierry in the Saturday Evening Post for
October 19th shows the cold brutality of the Ger-
man airmen and the utter futility of such attacks.
The only possible end to be achieved, from a mili-
tary point of view, would be to terrorize the enemy,
and to prevent the erection of hospitals close be-
hind the lines. The material damage inflicted is
very slight, comparatively few are killed or
wounded, and in place of terrorizing the enemy
such brutal attacks have wrought the army to a white
heat of indignation which will tell heavily against
the Germans when the time for final settlement
comes. It will be remembered that the first Ameri-
can officer to be killed was a medical officer, Lieu-
tenant Fitzsimmons. of Kansas City, who was
killed by a German bomb in front of a base hospital
far in the rear. Fortunately, few such deaths have
been reported, but the danger is ever present and
the surgeons in the United States hosnitals have
made a record of coolness and self possession
under fire which entitles them to the highest praise
and which nullifies entirely any possible invidious
distinction which might have been made against
them as being noncombatants. Thev are noncom-
batants in that they do not attack the enemy, but
they are far from having any of the immunity
which was formerly accorded to the noncombatants.
News Items.
Buffalo Academy of Medicine Postpones All Meet-
ings.— Tn accordance with the request of the health de-
partment, the Buffalo Academy of Medicine has post-
poned all meetings until further notice.
Fort Sheridan Base Hospital. — The work of convert-
ing Fort Sheridan, 111., into a base hospital was begun
on October loth. The estimated cost of this work is
$3,434,000, and when completed the hospital will have
4,000 beds.
Academy of Medicine Section Meetings Postponed. —
Announcement is made that the Secti(Tn in Medicine
and the Sectiofi in Obstetrics and Gynecology of the
New York .\cademy of Medicine will hold no meetings
tliis moiUh.
Clinical Congress Postponed. — .Announcement is
made that on account of the influenza epidemic the
ninth annual Clinical Congress of the .American Col-
lege of Surgeons, which was to have been held in New
York next week, has been postponed.
October 19. igiS.l
NEIVS ITEMS.
695
Harvey Society Lectures. — The first lecture of the
series will be given on Saturday evening, October 19th,
by Dr. L. K. Dunham, of New York, his subject being
Certain Aspects of the Application of Antiseptics in
Military Practice.
Clinical Meeting of the Hospital for Deformities and
Joint Diseases. — Dr. Frederick Tilney, of New York,
will road a paper on Gail and the Reflexes in Cord Lesions
at a clinical meeting at the Dispensary and Hospital for
Deformities and Joint Diseases, 41-47 East 123d Street,
New '\'ork. Tuesday evening, October 22d.
Two Officers Die in Fire at Base Hospital No. 3. —
rvvo ^\rmy officers were burned to death, four others
were badly burned, and two others cut and burned in a
fire on Thursday, October lotli, which destroyed the
officers' quarters at Base Hospital No. 3, at Colonia,
N. J., near Rahway. The dead are Captain Warren T.
Walker, Medical Corps, and Captain Frederick Toole,
Quartermasters' Corps.
Public Health Service's Campaign against Influenza.
— The United Slates Public Health Service announces that
it has mobilized for a national campaign against the Span-
ish influenza epidemic. Headquarters will lie established
in cooperation with State and local authorities at Balti-
more, Md., Columbus, Ohio, Richmond, Va., and Colum-
bia, S. C. Dr. Adrnont Halsey Clark, associate professor
o£ pathology at Johns Hopkins University, died on Mon-
day, October 14th, from pneutnonia following influenza.
He was engaged ni experimental work on a cure for the
disease which had been suggested by the officers of the
Public Health Service.
Philadelphia Medical Societies Postpone Meetings. —
On account of the prevailing epidemic of influenza the fall
reception of the Medical Club of Philadelphia, which was
to have been held on Friday, October i8th, was postponed
to a later date. The West Branch of the County Medical
Society postponed Its October 15th meeting and the North-
east Branch will hold no meetings until further notice.
The section in Laryngology and Otology of the College
of Physicians has postponed its October meeting until
Noveinher, and the Logan Medical Association has post-
poned its meetings indefinitely.
Medical Society of the Missouri Valley. — .^t the
thirty-first annual meeting of the societv. held in
Omaha, Neb., September igth and 20th, Dr. Charles
Wood Fassett, of St. Joseph, Mo., for seventeen years
secretary of the society, was elected president by a
unanimous vote. Other officers were elected as fol-
lows: Doctor Watson, of Diagonal, Iowa, first vice-
president; Doctor Aikin, of Omaha, Neb., second vice-
president; Dr. S. Grover Burnett, of Kansas City, sec-
retary. Doctor Gebbart was leelected treasurer. He
is now in France and Doctor Burnett will act as treas-
urer untii Doctor Gebbart's return. An interesting fea-
ture of the program was the patriotic banquet on Thurs-
day evening, which was attended by one hundred and
fifty members and their friends. The guests of honor
were Colonel Franklin Martin, chairman of the General
Medical Board, Council of National Defense, and Colonel
J. M. Banister, of Omaha, U. S. Armv, retired.
Meetings of Medical Societies. — The following med-
ical societies will hold meetings in New York during
the coming week:
Monday. October 21st, — New York Academy of Medicine (,Section
in Ophth,ilniolcg~v) ; Jledical Association of the Greater City of New
York; Psychiatric Society of Ward's Ishmd; Yorkville Medicil
Society,
Tuesday, October 22d. — New York Academy of Medicine (S-c-
tion in Obstetrics and Gynecology) ; New York Dermatological So-
ciety; New York Medical l^nion; Metropolitan Medical Society of
New York city; New York Psychoanalytic Society; New York Riv-
erside Practitioners' Societv; Therapeutic Club; Valentine Mott Med-
ical Society; Washington Heights Medical Society; Woman's Hospital
Society,
Wednesday, October 23d, — New York Academy of Medicine (Sec-
tion in Laryngology and Rhinolr gyl ; New York Society of Inter-
na! Medicine; New York Surgical Society; Brooklyn Pediatric
Societv,
Thursday, October 24, — Hospital Graduates' Club; New York Phy-
sicians' Association; Ex-Interns' .Society of the Methodist Episcopal
Hospital (Brooklyn^,
Friday, October 25th, — Academy of Pathological Science; Audu-
bon Medical Society; New York Clinical Society; Society of New
York German Physicians; Society of Alumni of Sloane Hospi-
tal for Women; Brooklyn Society of Internal Medicine; Hospital
Graduates' Club,
Saturday. October 26th. — Harvard Medical Society; Lenox Medical
and Surgical Society; New York Medical and Surgical Society; West
End Medical Society. (
Meetings of Philadelphia Medical Societies. — The
following medical societies will meet in Philadeli)hia dur-
ing the coming week :
Monday, October 21st — Academy of Medicine and
.'\llied Sciences ; Bleckley Medical Society ; Clinical Asso-
ciation.; Medical Society of the Woman's Hospital.
Tuesday, October 22d — West Philadelphia Medical So-
ciety.
Wednesday, October 23d— County Medical Society;
Neurological Society.
Thnrsdav, October 24th — Northwest Branch of the
Countv Aledical Society ; Pathological Societv,
Friday. October 25lh — Medical Club (directors) ;
Northern Medical Association; South Branch of the
County Medical Society,
Model Field Hospital a Liberty Loan Exhibit. — An
interesting Liberty Loar. exhibit at Broadway and Fiftieth
Street, New York, is a model field hospital. In this hos-
pital is shown the niethods of using the Carrel-Dakin so-
lution in the treatment of septic wounds. One of the hos-
pital beds in the hospi;al is equipped with the special frame
invented by Dr. Joseph A, Blake, forinerly of New York,
and now in charge of the Arnerican Hospital in Paris.
This frame is equipped with pulleys by means of which
a wounded man is enabled to raise himself and change his
position, and there are appliances for keepin.g a wounded
leg in a firm position without inconveniencing the patient.
.A.nother new medical appliance included in the exhibit is
an artificial anestliesia apparatus, the object of which is
to enforce artificial respiration during an operation. It is
said that there are at present only four of these machines
in existence. There is also a complete sterilizing outfit
such as is used in the field hospitals abroad. Practical
demonstrations are given at this model hospital of the
treatment of wounded soldiers.
Special Influenza Programs at the Academy. — At a
stated meeting of the New York Academy of Medicine,
Thursday, October 17th. the evening was devoted to an
informal discussion of influenza. Dr. Royal S. Cope-
land, health commissioner of New York Citj', opened
the discussion, and other speakers were Major Dudley
Roberts, M. D., U. S. A., of Columbia Base Hospital;
Dr. William H. Park, director of laboratories of the
Department of Health of the city of New York; Dr.
Douglas Symmers, pathologist to Bellevue Hospital;
Dr, Henry W. Berg, and Dr, William R, Williams, A
general discussion followed.
Last week the Eastern Medical Societv presented a
special program on the influenza pandemic and its com-
plications, postponing the regular program, Dr, Mor-
ris Manges spoke on the symptomatology of the dis-
ease; Dr, I^ouis I. Harris, of the Bureau of Preventable
Diseases, New York Department of Health, spoke on
the epidemiology and administrative control; Dr.
Charles Krumwiede, of the Bureau of Laboratories,
Department of Health of the city of New York, dis-
cussed the treatment; Captain G, E, Lung, U. S, N,,
commanding officer of the Base Hospital at the Brook-
lyn Navy Yard, spoke on the military aspects of the
epidemic, and Dr, Royal S, Copeland, health commis-
sioner, presented a general survey of conditions in New
York,
Colorado State Medical Society.— The forty-eighth
animal nicetin.g of this society was held in Estes Park on
September 9th, loth, and nth, and notwithstanding war
conditions, an unqualified success. Next year's meet-
ing will be held in Denver. Major F. H, McNaught, Medi-
cal Corps, U. S. Army, was elected president to serve for
the ensuing vear, and Dr. J. J, Pattee, of Pueblo, first vice-
president. Major McNaught, the new president, was grad-
uated from the College of Physicians and Surgeons, New
York, in 1878, and practised in New York for a number
of years. Twenty-fivt years ago he went to Denver, He
was called to surgical service in the aviation branch of the
Un'ted States Army in December, 1917, reporting to Kelly
Field, Texas, After a month of service as assistant to the
surgeon in charge of that camp. Major McNaught was
ordered to the hospital at Camp Bowie, Fort Worth,
Tex,, as chief of the surgical service. After four months'
activity in this capacity, he was ordered to the hospital at
Plattsburg Barracks, New York, where he is chief of the
surgical staff.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
STROPHANTHUS AND ITS ACTIVE
PRINCIPLES VERSUS DIGITALIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Conlinucd from page 652.)
That recent comparative studies of digitalis and
strophanthin have suggested a more definite clinical
difference in the indications for these two agents
than has hitherto been thought to exist was pointed
out in the preceding issue. The conclusion reached
by Vaquez and Lutembacher, 1918, that strophan-
thin influences the tonicity and contractility of the
heart far more than digitalis, while the latter agent
acts more particularly on cardiac conductivity, was
emphasized.
Ouabain nrepared by the Arnaud method is em-
ployed by Vaquez in acute insufficiency of the left
side of the heart, manifested either in attacks of
angina pectoris — of the type occurring when the
subject is recumbent — or in acute pulmonary edema,
with bloody and albuminous expectoration and
marked development of rales in the chest. In these
conditions he first practises venesection to the extent
of 400 or 500 mils, then injects intravenously one
half a milligram of ouabain, later to be repeated two
or three times at twenty-four hour intervals. Very
often, decided improvement results within a few
hours after the first injection ; pain, dyspnea, and
angor diminish, and the patient is restored to a
condition of quiet and comfort, and is able to secure
much needed sleep. \Miere the expected benefit
from the first injection fails to materialize, Vaquez
does not hesitate to anticipate the time of the second
injection, giving one fourth to one third milligram
of the Arnaud ouabain only six hours after the
first dose.
An important observation made in these cases of
acute dilatation under ouabain treatment is that
the blood pressure is restored approximately to the
normal. Where, in subjects with originally high
blood pressure, the systolic pressure has receded to
eighty or ninety millimetres of mercury in the
period of acute heart weakness, it is progressively
raised to 120 or 140 millimetres by the treatment;
if this rise in pressure fails to occur, the prognosis
becomes much less favorable. Along with the
pressor effect the output of urine is augumented in
proportion to the extent of existing edema ; the
heart beats less frequently and more regularly ;
premature beats and gallop rhythm disappear, and
the relaxation murmurs previously present are no
longer audible. These favorable changes are asso-
ciated with and dependent upon a constant and very
appreciable reduction in the size of the heart ; that
this observation of Vaquez, based upon repeated x
ray examinations, may be definitely accredited seems
permissible, in view of his extensive special studies
in cardiac radiography, recently published in a large
volume devoted exclusively to this subject. In one
cnse of acute high pressure dilatation, of which he
publishes cardiac tracings, not only do these outlines
show a manifest reduction of the size of the organ
after four ouabain injections, but the blood pressure
is recorded as having risen from 180 systolic and
120 diastolic to 250 systolic and 130 diastolic —
Pachcn instrument. In some of these cases of acute
dilatation the symptoms disappeared after a single
short series of ouabain injections ; in others, another
series, beginning a week or ten days later, was re-
quired.
Similar results are reported in acute dilatation
involving especially the right heart, following pro-
longed or violent physical exertion and in subjects
with mitral lesions, notably in women in pregnancy
or labor. In such cases ouabain intravenously is
superior to digitalis by mouth because it acts with
sufficient promptness to meet the emergency ; digi-
talis here would be too slow in action, and besides,
its absorption would be interfered with by the
hepatic congestion usually existing in these patients.
In this connection Vaquez presents striking x ray
outline tracings from a case of mitral disease with
marked insufficiency of the right heart. One trac-
ing was taken after venesection and a single injec-
tion of one quarter milligram of ouabain, the sec-
ond after three subsequent injections each of one
half miliigram. A very marked reduction in the
size of the heart, afifecting chiefly its right side but
also to a considerable extent the left side, is shown
in these tracings, illustrating the pronounced effect
ouabam is capable of exerting on cardiac tonicity.
In chronic, progressive cases of insufficiency of
the heart following valvular disorders, subacute
myocarditis, and adhesive pericarditis, Vaquez post-
pones the use of ouabain until digitalis has definitely
become inadequate. Even then digitalis should not
be abandoned unless ample doses have been given
without result. Care must be taken, in order to
avoid acute cardiac intoxication, to wait five or six
daA'S after the termination of digitalis treatment
before beginning the administration of ouabain.
One fourth milligram of the latter is then given in-
travenously and followed, at twenty-four hour in-
tervals, by two or three injections of one half milli-
gram. Not itifrequently the benefits sought in vain
from digitalis now appear, venous stasis diminish-
ing, edema passing ofl". and diuresis being rees-
tablished. X rav examination reveals a diminished
size of the heart. Subsequent series of injections,
if indicated, mav be given at intervals of eight or ten
days, the patient being meanwhile kept at rest and
on a milk diet.
Another interesting observation made is that
where ouabain has not proved as efficient as had
been expected, a return to digitalis in large doses
after the ouabain treatment will show a restoration
of therapeutic action of the former drug which will
persist for months and even years. This species of
■'reactivation" of digitalis action occurs even where
ouabain has apparently been devoid of effect. It is
ascribcil by \'a(|uez to the restoration of cardiac
October 19, 191S.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
697
tonicity effected by the ouabain. Disorders unin-
fluenced by either of the drugs, if used alone, may
thus be successfully treated by their simultaneous
or successive employment. A considerable number
of cases of cardiac insufficiency such as would
hitherto have been thought irreducible, are amenable
to the combined use of these two remedies.
( To be continued.)
Large Doses of Salicin in Influenza. — E. B.
Turner (British Medical Journal, August 3, 1918)
recommends, in the highest terms, the immediate
administration of salicin in cases of influenza. One
and a third grams (twenty grains) should be given
hourly and the first three or four doses will remove
all discomfort and pain, while complete recovery
will take place within twenty-four hours. This
treatment also promptly renders the patient nonin-
fective and so checks the spread of the disease.
These statements are based upon an experience of
over 2,000 cases of influenza, treated in this way
without a complication or a single death. The treat-
ment has been used with equally satisfactory results
in the present epidemic of Spanish influenza.
Chloroform Analgesia by Self Inhalation.—
Torald Sollmann (Journal A. M. A., August 24,
ipi8) calls attention to the great need for some
simple and entirely safe method for the production
of brief analgesia for the purpose of changing
dressings and other short, painful surgical measures.
He advocates, from experimental and clinical
studies, the use of a measured five mils of chloro-
form, absorbed on a piece of cotton about the size
of a lemon, and held over the nose in the palm of
the patient's hand. This promptly produces a con-
fused state and a marked degree of analgesia, the
latter lasting about half an hour. The administra-
tion can be repeated if necessary, but it is not ad-
visable to do so on account of uncomfortable after-
effects. It is free from danger and does not require
the help of an assistant.
Treatment of Yavi^s w^ith Castellani's Mixture.
— Guerrero, Domingo, and Argiielles {Philippine
Journal of Science, July, 1918) assert that yaws is
widely distributed in the Philippines. They have
used Castellani's formula in forty-three cases, with
marked success. The formula calls for: Tartar
emetic, 0.065 gram ; sodium salicylate, 0.65 gram ;
potassium iodide, 4 grams; sodium bicarbonate, i
gram ; and water, 30 mils. This is given in one dose,
diluted in four ounces of water, thrice daily, to
adults and children over fourteen years of age ; half
doses to children of eight to fourteen ; less to
younger children, and not more than half doses to
Europeans. All but four of the forty-three cases
presented one or several of the following symptoms
during the treatment: Malaise, weakness, slight
fever, nausea, vomiting, gastralgia, diarrhea, phar-
yngitis, ptyalism, coryza, lacrymation, conjunctival
congestion, headache, and insomnia. The authors
gave on the first day one third of a dose three times ;
on the second, one dose twice, and on subsequent
days, one dose thre'e times. This system was
adopted in order to ascertain susceptibility and
€stabli.sh tolerance. The curative number of doses
varied from fifteen to eighty, and the time to com-
plete recovery from five to twenty-seven days. Of
one series of fourteen patients, ten showed complete
recovery and four, im.provement. Of a total of
thirty-six patients who continued the treatment,
twenty-four recovered completely, seven showed im-
provement, seven were unimproved, and five had re-
lapses in from two to five months after the lesions
had healed. Continuation of treatment after healing
— treatment for five to ten days with intermissions
of ten to fifteen days — would probably insure a
permanent cure. Emesis, gastralgia, and diarrhea, if
troublesome, can be prevented by increasing the
sodium bicarbonate or giving four mils of paregoric
or 0.0 1 gram of codeine fifteen minutes before each
dose. 'Vlasomotor symptoms are readily overcome
by epinephrine.
The Rapid Cure of Scarlatina. — Cesare Man-
gitta (Giornalc di Mcdicina Militare, January 31,
TQiS) describes his treatment of scarlet fever with
a combination of chlorophenol with quinine and
camphor. Two injections are sufficient in a case
of moderate severity, twelve to twenty-four hours
apart, given preferably intramuscularly in the gluteal
region. Every feature of the disease is ameliorated
and the course aborted. Mangitta considers that
this method changes the treatment of scarlet fever
from a passive to a markedly active one, and re-
ports in detail seven cases to support his assertions.
A marked feature of this method is the almost im-
mediate subjective feeling of wellbeing, with a rapid
drop in temperature.
Treatment of Bilious Hemoglobinuric Fever. —
E. Roux (Pres.se medicate, July 25, 1918) eni-
phasizes the uselessness of hemostatic agents in this
condition. Since it is due, not to a hemorrhagic
process, but to hemolysis, or rather, hemoglobino-
iysis, he was led to employ instead a remedy exert-
ing ?. conserving, reparative influence on the red
blood cells, viz., arsenic. Adequate dose by mouth
proved impraticable, most patients suffering from
repeated vomiting; intravenous injections of col-
loidal arsenic, however, gave excellent results. In the
first five patients treated — three already in a grave
condition — two injections cleared up the urine and
caused prompt convalescence. Subsequently the
following combination was used : Colloidal arsenic,
0.00034 gram; colloidal iron, 0.00012 gram, and
water, two grams. Twenty-three patients received
such injections, without any other treatment. The
combined series showed twenty-eight cases with one
death, or 3.57 per cent., as against the usual mor-
tality, of thirty-three per cent. The singe unfavor-
able case was that of a little girl of eight years in
whom no intravenous injection could be given, and
who received only intramuscular injections, which
are ineffectual. As soon as fever and hemoglo-
binuria appear in a malarial patient, an injection of
iron and arsenic collobiase should be given, followed
by another injection the next morning. The urine
now generally clears up, but for safety a third and
last injection is given. Beginning the fourth or
fifth day, adrenalin is administered for about a
week. During convalescence, malarial paroxysms
sometimes appear. These are satisfactorily over-
come by intravenous injections of quinine collobiase.
698
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[Nkw York
Medical Journal.
Spinal Tumors: Statistics in 330 Cases. — Carl
R. Steinkc {Journal of Nervous and Mental Dis-
ease, June, 1918; sums up his conclusions in these
words: i. Tumors must be operated on early to
obtain the best results. 2. Cord operations must
be delicately performed. 3. The post operative
treatment is important. 4. if few fibres are de-
stroyed marked recovery or cure follows within a
few' months to two years. 5. If the symptoms
have been shght, recovery may be expected. 6. If
marked spasticity remains, resection of the posterior
spinal roots is indicated.
Failure of Intraspinal Serum Injection to De-
sensitize.— Lewis Fox Prissell {Journal A. M. A.,
August 31, igiS") records a case of very severe ana-
phylactic shock from the rapid intravenous injection
of antimeningococcic serum, after several doses of
the same serum had been administered intraspinally.
It was to have been expected that the intraspinal
administration of the serum would have desensitized
the patient, just as its intramuscular injection is
known to do, but in this case it was evident that
such desensitization failed to occur. The failure
might be supposed to have been due to the failure
of absorption of the serum by the choroid plexus.
Treatment of Chancroidal Bubo. — W. Du-
breuilh and E£. JMallein [Presse mcdicale, July 11,
1918) recommend Fontan's procedure, which con-
sists in injecting a ten or fifteen per cent, preparation
of iodoform in petrolatum into the buboes. Distinct
fluctuation must be awaited before the injection is
made. The lesion is first opened by a narrow stab
with the point of a scalpel and the pus thoroughly
evacuated by pressure. The cavity is then filled to
complete distention with the iodoform preparation,
injected with an ordinary glass urethral syringe,
previously sterilized. The authors depart from Fon-
tan's original technic in injecting the iodoform pre-
paration cold ; this is to obviate its tendency, when
hot, to reissue through the stab opening. The syr-
inge is filled with the preparation hot, but then al-
lowed to cool, or immersed in cold water before the
injection. The affected area should previously have
been shaved and asepticized. After the injection
collodion and cotton are applied and followed by a
spica bandage. Two days later, unless the band-
age is still firm and there is no inflammation or
pain, the dressing is taken off, the iodoform prepa-
ration removed from the cavity, and a collodion,
cotton, and spica dressing reapplied. As a rule,
this completes the treatment and the patient can be
discharged in four to six days, as far as the bubo
is concerned ; generally, however, the original chan-
croidal lesion requires more prolonged treatment
than the bubo. Among 121 cases the treatment was
completely successful in 106; in four sinus forma-
tion occurred, in eight the bubo showed chancroidal
transformation, and in three such transformation in
the skin over the bubo had already taken place on
admission. The sinuses soon healed. Excluding
the last three cases referred to, the procedure failed
in only 9.3 per cent, of the whole series. Pain, in-
flammation, and discomfort pass off after the in-
jection ; pain may later recur, however, if the cav-
ity has not been completely filled.
Heliotherapy in Pott's Disease. — Maurice Ca-
zin {I-resse medicalc, July 23, 1918) calls attention
to the benefits of heliotherapy, as practised by Rol-
lier, in Pott's disease. The kyphosis can be elimi-
nated almost invariably without the use of a plaster
apparatus by this method. Heliotherapy, immobili-
zation, and compression by a cushion under the dis-
eased area, suffice to procure these results. The
weight of the body, acting on the spine through a
cushion of gradually increasing thickness', gradually
overcomes the kyphosis. When the pain has disap-
peared, after a few weeks of heliotherapy, the patient
is gradually trained to assume a ventral position
during a part of each treatment. This permits of
exposure to the sun's rays of both the diseased area
and the posterior aspect of the body. While this
is being done a hard cushion of increasing thickness
is placed beneath the chest to help correct the dorsal
and lumbar curvatures by accentuating the spinal
lordosis. The patients so easily become accustomed,
within a few days, to the ventral position that they
soon prefer it and pass most of the daytime in this
posture, meanwhile occupying themselves with writ-
ing, drawing, carving wood, etc. Even in cases
with marked kyphosis a cure is thus obtained in ten
to fifteen months — sometimes longer — where ab-
scesses and sinuses exist.
Arsenobenzol in Puerperal Bacteriemia. — H. A..
Miller and S. A. Chalfant (American Journal of
Obstetrics, September, 1918^ report eleven cases of
puerperal blood stream infection, usually verified
by blood cultures, in which arsenobenzol treatment
was followed by recovery of seven of the patients.
In such cases, presenting little or no local — uterine
— evidence of disease, the profession has hitherto
been practically helpless. Seven cases showed in
the blood various strains of streptococci, with two-
deaths, two a gram negative bacillus, and two, nega-
tive cultures but absence of local trouble with severe
constitutional symptoms. In every instance the
blood stream was rid of the invading organism by
the treatment, usually in twentv-fours. always in
forty-eight hours. After the injection there was
usually a decided improvement in the patient's gen-
eral condition. Five patients had but one injection,
three liad two, and two had four. The dose of
?rsenobenzol used is given as six milligrams. General
treatment consisted in giving water by the bowel and
stimulation when indicated. No local treatment was
employed except in two cases, in which the uterus
was irrigated with Dakin's solution every two hours.
The leucocyte count was usually low in comparison
with the temperature and pulse, but after the arseno-
benzol the leucocytes increased markedly. If, later,
the leucocytes decreased decidedly without a corre-
spondmg improvement of the patient, reinfection
was deemed probable and arsenobenzol given with-
out waiting for the confirmatory laboratory report.
In suspected blood stream infections, delay for the
report may similarly be avoided, arsenobenzol being^
given immediately after a culture has been taken.
The treatment is probably not applicable in throm-
bophlebitis, localized abscess, or pelvic cellulitis of
long standing, where there is repeated infection of
the blood stream, as the effect of the drug is not
long continued.
■October 19, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
Significance of Fats in the Diet. — Ernest H.
Starling {British Medical Journal, August 3, 1918)
calls attention to the fact that there are no scientific
studies as to the minimum requirements of the body
for fats, while the general food shortage due to the
war has brought into prominence the great practical
importance of the fat supply. From the material
available and a study of the proportionate fat con-
sumption by several classes of individuals under
normal conditions, the following conclusions seem
warranted. Since the alimentary canal of man has
been developed to deal with a diet in which a con-
siderable proportion of the energy is provided by
fats, a certain amount of this food material is ab-
solutely necessary. The diet of the infant yields
over half of its energy from the fat present, and
from the time of weaning to the age of six years
butter and milk supply the main sources of fat
which should represent about thirty-five per cent of
the total energv of the diet. From the age of six
years onward from twenty to twenty-five per cent,
of the total energy of the diet should be supplied by
fat, provided that there is no excessive demand upon
the bodv for energy output. Such a proportion can
be raised to thirty-five per cent, without any harm-
ful eflFects, but twentv per cent, should be considered
as the minimum. Where the energy demands are
excessive — 3.600 to 5,000 calories or more — these
increased demands should be met by an increase in
the proportion of fats up to forty per cent., on ac-
count of the limitations upon other foods bv reason
of the size and digestive capacity of the alimentary
tract. Such conditions are met in the food tables
adopted by the Tnter-AlHed Scientific Food Com-
mission.
Treatment in the Toxemias of Pregnancy. —
Gilbert I. Strachan (British Medical Journal.
August 3, 19x8) deals only with the immediate
treatment of the fullv developed condition, recog-
nizing, however, that this condition should be
largely avoided bv proper prophylactic care. The
treatment must always rest on the basis that the
woman is pregnant, and that the termination of
pregnancy removes the cause of the toxemia ; and
if the pregnancy is to be terminated it must be done
early and not postponed until the patient's life is
in danger. The treatment of various types of
toxemias must run on similar lines, the variations
being minor. In eclampsia sedatives are demanded,
and if properly used morphine is probably the best.
A routine which is both safe and satisfactory is to
give fifteen or thirty milligrams (one fourth or one
half grain) as the first dose, and if necessarv to re-
peat the smaller dose not over twice, at intervals of
two hours. If this does not prove satisfactory
operative measures will probably be required. The
drug decreases metabolism and so reduces intoxica-
tion, diminishes cerebral irritability and lessens the
fits, and lowers the blood pressure. If used w"ith
care and only for a hmited period it never produces
harmful results. Chloroform is very valuable but
must not be used over a prolonged period. Chloral
hydrate and potassium bromide are of value for the
restlessness between fits, but alone are of little seda-
tive aid in eclampsia. On the other hand, paralde-
hyde is of great sedative value and is absolutely
safe. Eight mils (two drams) can be given by
rectum, and half the dose repeated every two hours
when necessary. In such doses it is usually quite
equal to morphine and has none of its disadvan-
tages. Careful attention must be given to the pa-
tient's surroundings to exclude all sources of irrita-
tion and excitation and only a single, but a thorough,
examination sh.ould be made. The methods advo-
cated recently by StroganofF ai-e also highly satis-
factory. Circulatory sedatives, such as Vcratrum
viride and the nitrites have frequently been advo-
cated, but the former is too dangerous and the lat-
ter arc seldom efficient. In hyperemesis attention
must be given primarily to the gastrointestinal tract,
the stomach being first washed out and then the
bowel, which latter should be kept clear as it may
have to be used for feeding. Rectal feeding, espe-
cially with glucose, is usually ' well borne, but
nourishment may have to be withheld for a day or
two. Bismuth subcarbonate, tincture of opium and
dilute hydrocyanic acid are most variable in action
as gastric sedatives, but the most effective is dilute
hydrocyanic acid in doses .of 0.3 mil (five min.)
Purgatives may be used but can seldom be tolerated
by the stomach. Diaphoresis is of distinct value, as
is also venesection with saline infusion. If these
measures fail to give prompt relief the immediate
termination of pregnancy is demanded.
Hypophyseal Tumors Through Intradural Ap-
proach.— A. W. Adson (Journal A. M. A., August
31, 191S) anesthetizes the patient by the inhalation
drop method and places him on the table at an angle
of eighty degrees with the horizontal plane, the head
being held back so as to permit the natural gravita-
tion of the frontal lobe from the anterior cranial
fossa. An osteoplastic flap is made with its anterior
limb corresponding to the hair line, the posterior to
a point above the ear and the upper to the median
line, \vhere the incision is three and one half inches
long. Hem.orrhage from the flap is controlled by a
pedicle clam.p, that from the scalp by the application,
at half mch intervals, of forceps to the aponeurosis,
which is then turned outward to compress the edge.
The bone is cut with a bevel to aid in its retention.
A dural flap is next made at right angles with the
osteoplastic flap and this flap is allowed to remain
in position over the frontal lobe. The brain sur-
face and exposed dural surface are covered with
warm, moist cotton, and this by strips of rubber
tissue laid like shingles to make uniform pressure
when the cortex is raised by the retractor. The
retractor is lighed at one side of its tip. The hy-
pophysis and ODtic commissure are thus readily
exposed by gentle manipulation. When both optic
nerves have been exposed the hypophyseal tumor is
gently dissected free of the nerves and commissure
by means of blunt hooks. When the tumor is well
freed from its surrounding structures it is slowly
removed from its pedicle by means of a septal
snare. The pituitary bodv may then be removed
from the sella turcica. This operation gives an ap-
proach in a dry field which is free from infection.
The exposure permits complete dissection of the
tumor from other structures and the removal of
part or all of it and of the pituitary body. Trauma
of the commissure and optic nerves is avoided.
Miscellany from Home and Foreign Journals
The "Influenza" Epidemic of 1918.— Oliver H.
Gotch and Harold B. Whittingham {British Med-
ical Journal, July 27, 191 8) base their statements
on a careful study of the first fifty cases seen in an
Air Force Hospital. In all cases they grew a Gram
negative micrococcus, quite similar in most respects
to the Micrococcus catarrhalis, from the sputum or
from nasopharyngeal swabs. Pfeiffer's influenza
bacillus was present in only eight per cent, of the
cultures, though influenzalike bacilli were present
in direct smears in 62 per cent, of the cases. Other
organisms were also found in many of the cases,
but the only constant one was the micrococcus men-
tioned. This organism, when inoculated on the
nasopharyngeal mucosa of two normal persons, pro-
duced typical attacks of the disease and was recov-
ered from the throats and sputum during the dis-
ease in both of the cases. It was therefore regarded
as the probable causative organism, either alone or
in conjunction with the Bacillus inflnenzce. The in-
cubation period of the disease was usually one to
two days and the onset sudden with bodily pains,
headache, malaise, etc. The headache was generally
diffuse, the throat and nose felt tight and sore, and
there was a slight dry cough. The symptoms were
generally much worse by the second day and a pain-
ful photophobia developed. By the third day there
was usually some improvement, but some cases ran
a five day course. Convalescence averaged a week
to ten days. The physical signs were heavily coated
tongue; toxic appearance; marked conjunctival in-
jection ; acute inflammation of the whole mucosa of
the buccal cavity; rapid rise of temperature to 103
or over; defervescence by lysis on the third or fifth
day ; slow pulse ; slight bronchitis ; scanty, concen-
trated urine with albumin and casts ; initial leuco-
penia with relative polynucleosis followed by mod-
erate leucocytosis and a relative lymphocytosis.
Blood cultures proved negative.
Epidemic Three Day Fever on a French Hos-
pital Ship. — P. Joly and Baril {Bulletin de I'Aca-
demie dc medecine, July 30, 1918) describes an epi-
demic which broke out on a hospital ship in May,
1918, reproducing the epidemic that prevailed on all
Mediterranean shores at the time. The interval be-
tween the first and last case was eleven days. Over
forty per cent, of the previously healthy ship's crew
developed the disease, but very few of the patients
on board suffered. The onset was almost always
sudden, usually in the evening or at night, with
headache and backache. Other symptoms were ocu-
lar and periorbital pain, slight dysphagia, a tracheal
cough, myalgia, especially in the neck, back and
limbs, mental and physical prostration, anorexia, and
sometimes nausea. The temperature rose rapidly to
38 or 40° C., remained there as a plateau for two
days, and fell usually by crisis on the third day, oc-
casionally by lysis on the second or third days. Con-
valescence occupied but two to four days, and no
actual complications were witnessed, though there
was sometimes a considerable loss of weight. Quin-
ine proved ineffectual, but the following solution
gave relief : Sodium salicylate, two grams ; tincture
of aconite (French), ten to twenty drops; syrup of
belladonna (French), ten grams, and water, to make
150 grams. The authors argue against the condition
being grippe, on the ground that the cases presented
too uniform a clinical picture, that muscle pains
had been more marked than asthenia, that joint
pains, complications, and recurrences were wanting,
and that convalescence was so brief. The disease
much more closely resembled the so called Mediter-
ranean dengue or phlebotomus fever.
Epidemic Streptococcal Bronchopneumonia. —
W. G. MacCallum {Journal A. M. A., August 31,
1918) studied a series of cases of bronchopneumonia
caused by the Streptococcus hemolyticus and sum-
marizes his findings as follows. He concludes that
the Streptococcus hemolyticus is capable of giving
rise to extensive and fatal epidemics of a form of
bronchopneumonia which involves the framework
of the lung and the walls of the bronchi in such a
way as to be classed as an interstitial bronchopneu-
monia. This bronchopneumonia arises with or with-
out such predisposing causes as measles, but it seems
specially severe after that disease. There is often
also a diffuse, patchy, lobular pneumonia in which the
streptococcus is found finely scattered in the alveolar
exudate. Areas of such type may be confluent and
resemble lobar pneumonia. In the more acute cases
of such pneumonia there is frequently an ulceration
of the vocal cords and epiglottis. Empyema is an
extremely frequent complication, while other com-
plications are not common.
Epidemic of Streptococcus Pneumonia and
Empyema. — Joseph L. Miller and Frank B. Lusk
(Journal A. M. A., August 31, 1918) record their
experiences in Camp Dodge, Iowa, from September
20, T917 to May 10, 1918. From the beginning up
to March 20, 191 8, the ordinary clinical lobar pneu-
monia of pneumococcic origin prevailed, of mild
ivpe and giving a m.ortality of only eleven per cent,
in the 276 cases. In this series empyema occurred
in eleven per cent, of the cases, but showed a marked
tendency to multiple pus foci, and its mortality was
seventy per cent, in the colored troops and fifty-
seven per cent, in the white. Beginning between
March i8th and 20th, the epidemic of streptococcic
pneumonia broke out, and to May lOth there were
400 cases. In this pneumonia there was very early evi-
dence of severe intoxication, and empyema became
very frequent and was extremely early in its develop-
ment. The appearance of a pleural exudate was
often very hard to determine by physical examina-
tion, the X rays, and repeated aspirations. The fluid
was moderately turbid at first, slowly becoming
definitely purulent. The exudate showed pure strep-
tococci on culture in eighty-eight of ninety-five
cases, all being of the hemolytic type, while pneu-
mococci were also present in the remainder. The
mortality from this empyema was forty-four per
cent, in the colored and sixty-five per cent, in the
white soldiers, while the mortality from the uncom-
plicated streptococcus pneumonia was twenty per
cent, in the colored and eleven per cent, in the white.
October 10, 1918.] MISCELLANY FROM HOME AND FOREIGN JOURNALS. 701
Medium for Culture of Pfeiffer's Bacillus. —
John Matthews (Lancet, July 27, 1918) presents a
description of the preparation of this medium at
once, and without waiting for the preparation of a
more complete paper with the record of his experi-
ments, because of the prevalence of influenza at the
present time. The essence of the medium is the
use of blood digested by trypsin. This is prepared
as follows : One-quarter mil quantities of Allen and
Hanbury's trypsin compound are added to each of
a series of tubes containing 4.75 mils of sterile broth.
The tubes are th-en incubated for twenty-four hours
and contaminated tubes are discarded. To each of
the sterile tubes there is then added one mil of
blood, drawn by venipuncture, and the mixture is
incubated for three or four days, when it is ready
for use. Various other methods and other propor-
tions of blood may be employed in making the di-
gested blood, but the proportions here given are the
same as those used in making quantitative blood
cultures for diagnosis, so that such cultures thus ob-
tained as are sterile can be readily trypsinized and
employed. Douglas's trypagar, faintly alkaline to
litmus paper, should be prepared and the final cul-
ture medium is made by mixing five mils of the
trypsin blood with about thirty mils of the agar.
The advantages of this medium are: That it grows
the influenza bacillus freely from the first culture ;
that it is decidedly selective toward this organism,
inhibiting pneumococci entirely and streptococci and
other Gram positive organisms to a large extent ;
and that the colonies of the influenza bacilli are of
large size even in the initial cultures. With this
medium about a dozen recent cases grew the in-
fluenza bacillus, either from postnasal swabs or from
the sputum or nasal mucus.
Detection of Infective Syphilitic Lesions by
Staining by the Fontana-Tribondeau Method. —
Quioc (Paris medical, July 27, 1918) considers
staining of a smear for spirochetes the diagnostic
procedure of choice where early recognition of the
disease is required in the absence of positive clinical
signs. Ultramicroscopy is serviceable for this pur-
pose only where the specific spirochete is present in
considerable numbers and unassociated with other
spiral organisms. Staining by the Giemsa and Pro-
ca-Vasi!escu technic is of value only in very thin
smears with at least a fair number of spirochetes.
With the Fontana-Tribondeau method, on the other
hand, the specific treponema contrasts sharply with
the rest of the specimen. An entire smear may be
completely examined, and even sparse spirochetes
cannot be overlooked. The specific organisms can
be easily and at leisure differentiated from, other
forms of spirochetes. The author has conducted
seventy-eight examinations by this method, with
positive results in fifty-four instances. All lesions
clinically specific revealed spirochetes, and in some
instances the positive diagnosis promptly afforded
obviated all harmful delay in the institution of treat-
ment. The method is particularly recommended for
the diagnosis of chancre in the first two or three
days, before induration and lymphatic enlargement
have occurred ; for infected or mixed chancres, or
chancres artificially indurated with caustic agents ;
for gonorrheal chancriform ulcerations, and for
secondary lesions of the preputial mucosa altered by
concom.itant balanitis. Fontana's ammoniacal silver
nitrate solution is made by gradually adding am-
monia to the greater part of a solution of one gram
of silver nitrate crystals in twenty mils of water,
stirring constantly with a glass rod until disappear-
ance of the sepia colored precipitate occurs. The
remainder of the solution is then very gradually
added until a slight turbidity is seen which persists
on stirring. This reagent will keep for some time
in darkness. In staining a smear, the latter is first
carefully dried, then treated two or three times for
thirty seconds — according to its thickness — with
Ruge's solution, made by dissolving one mil of
glacial acetic acid in 100 mils of two per cent, for-
maldehyde solution. This dissolves the hemoglobin.
The preparation is then washed with alcohol and
the alcohol remaining on it ignited. Next it is cov-
ered with a solution of one gram of phenol and five
grams of tannic acid in 100 grams of water, and
heated to steaming for about one minute. Finally,
the tannin solution is carefully washed off with
water, the preparation dried, the silver nitrate solu-
tion applied, and the slide again washed and dried.
All spirochetes are stained, but the specific organism
exhibits its special morphological features, in par-
ticular its marked tenuity. It appears violet-black
on a transparent or light yellow background.
Immediate Bimanual Percussion in the Diag-
nosis of Pulmonary Tuberculosis. — O. Peyret
(Prcsse medicale, July 25, 1918) seeks to supple-
ment the findings of ordinary mediate finger per-
cussion by investigating with the palmar surfaces
of both hands the massive or total dullness of the
lung apices. Patient and observer should perferably
be standing. Anterior and posterior landmarks are
first determined, the former being on the anterior
border of the clavicle at the midpoint of a line join-
ing the sternal crotch and the outermost point of the
acromion, above the head of the humerus ; the pos-
terior landmark is the spine of the scapula. These
two points are joined by a line, as short as possible,
passing over the shoulder and prolonged vertically
behind for ten centimetres below the spine of the
scapula and interiorly for twenty centimetres below
the clavicle. These lines serve as axial guides to the
percussing hands ; the anterior hand is placed with
the tip of the middle finger half a centimetre below
the clavicle, and the posterior hand, with the meta-
carpophalangeal joints over the spine of the scapula.
The observer stands at the side of the patient, fac-
ing the nearest shoulder. The patient throws his
head back, allows his shoulder to hang loosely, takes
a deep breath, then lets all the air out and remains
motionless, with the mouth open. Percussion is con-
ducted alternately over one apex and then the other,
the observer merely leaning forward to attain the
more distant shoulder, without in the least disturbing
the relationship or position of his two arms. The
hands must be carefully adjusted so that the palms
and fingers are in complete contact with the parts
before beginning to percuss. All the force of per-
cussion should come from the arms, the wrist re-
maining passive and motionless, though not rigid.
The percussion should be relatively light, preferably
in the form of a series of rapidly repeated blows.
702
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Dullness noted by this method is almost pathogno-
monic of lung congestion, i. e., of an active lesion
rather than a fibrotic condition ; in this respect it is
of service where ordinaiy mediate percussion fails.
Where doubt remains, felt gloves may be used to
eliminate the slapping sound of the percussing
hands. Tactile sensations should, apart from the
percussion notes, be carefully noted during the pro-
cedure ; the diseased apex imparts very plainly an
impression of diminished elasticity as compared with
the normal or less affected side. Stethoscopic aus-
cultation may be combined with bimanual percus-
sion.
Gas Bubbles at the Sites of War Fractures. —
P. Duval and H. Beclere {Presse medicate, July ii,
1918) have encountered four cases in which x ray
examination clearly showed accumulations of gas
in war fractures. The gas was present in the form
of a more or less extensive bubble, located either in
the bony focus proper, between the ends of the frac-
tured bone ; in contact with the shaft, or extending
from the seat of fracture into adjancent muscle tis-
sue. The gas bubble persists six to ten days, then
wholly disappears. The question arises whether
such collections of gas are due to confinement of air
in the. empty space frequently existing between the
bone fragments or to an abnormal production of
gas at the point of fracture. The discovery of
anaetobic germs in the wounds suggested that these
may be responsible.
Essential Partial Tetanus. — G. Etienne {Paris
medical, August 3, 1918) lays stress on the fact that
partial tetanus by no means implies mild tetanus. In
two cases the incubation period was but three and
five days, respectively ; in another, fever was noted
very early, etc. These cases showed gradual inten-
sification of the tetanic manifestations, and the au-
thor believes they should be classed as instances of
incipient tetanus in process of extension from the
tissues primarily- affected. Incipient, and still par-
tial tetanus is, indeed, apt to be overlooked, until
sudden, rapid, aggravation, with extension to the
masseters and neck muscles, occurs. Extending
tetanus may be caused to remain partial by early, in-
tensive serum treatment. To secure this result,
however, early diagnosis is required. None of the
cases of incipient tetanus which came under the au-
thor's observation had been diagnosed as tetanus.
To detect incipient tetanus one must observe the first
spasmodic manifestations near the portal of entry
of the virus. The definite diagnosis is to be based
on fibrillary or fascicular contractions induced by
sudden, repeated movements of the suspected limb ;
on exaggeration of the reflexes and of muscle irrita-
bility ; on spastic attitudes of the limb, and on the
athletic appearance of the muscles and the sensation
of firmness they impart on palpation. One should
always bear in mind that while the tetanus toxin
formed at the point of injury may act in an over-
whelming manner through the blood stream, striking
from the outset the entire nervous system though
manifested first in the elective centres of the masse-
ters and neck muscles, extension may also take place
progressively through nervous channels, beginning
near the site of infection. In these cases extension
may be slow and steady or may suddenly pass into
general involvement. In progressive cases trismus
appears only when the disease has already been pres-
ent for a certain period, and is a sign of generaliia-
tion of the disease, unless the wound is in the dis-
trict of the facial nerve itself.
Brain Changes in Gas Poisoning (Carbon
Monoxide).— Emory Hill and C. B. Semerak
{Journal A. M. A., August 24, 1918) made careful
studies of the briins in thirty-two cases of this form
of poisoning and reviewed the literature of the
pathology of this intoxication. They found that
carbon monoxide produced a characteristic lesion of
the brain, namely, a bilateral ischemic necrosis of
the lenticular nucleus, especially of the globus pal-
lidus. This lesion was due to thrombosis and de-
generation of the vessel walls as a result of the
presence of the carbon monoxide in the circulating
blood, while anatomic peculiarities of the circula-
tion seemed to account for the characteristic local-
ization of the lesion. The extent of the necrosis,
as found post mortem, varied from slight perivascu-
lar lesions to grossly visible softening of the whole
lenticular nucleus and internal capsule, the varia-
tions depending on the amount of gas inhaled, the
duration of life after intoxication, and upon pre-
existing pathological changes in the vessels. Various
small hemorrhages in the leptomeninges and cerebral
white matter were also part of the characteristic
lesions of the poison. Edema and hyperemia of the
brain and internal hydrocephalus were frequently
found. These facts readily explain the subsequent
development of various nervous and mental condi-
tions, as well as the occurrence of death.
Determination of Quantity of Secreting Tissue
in Living Kidney. — C. K. Watanabe, Jean Oliver,
and Thomas Addis {Journal of Experimental Medi-
cine, September, 1918) report the results of investi-
gations made some years ago, when they attempted
to approximate, as closely as possible, the conditions
met with in disease, by a comparison of the degree
of anatomical defect resulting from the action of
uranium on the kidney and the degree to which tlie
function of urea excretion was disturbed, under
conditions involving strain on the kidney. An
anatomical classification of the kidney lesions based
on the extent of damage seen microscopically, ac-
cording to whether it was slight, moderate, or
severe, and a similar functional classification was
determined, depending on whether the function
after uranium was sixty-six per cent, or more of
the measurement made in the control experiments,
which was considered as slight functional damage ;
between thirty-three and sixty-six per cent, of the
original was listed as a moderate defect, and when
the function was less than thirty-three per cent, of
the control experiment, it was considered severe im-
pairment of function. Under the strain induced by
the administration of urea, the authors were able,
using the above classifications, to show the relation
between the amount of anatomical damage in the
kidney and the degree of defect in the urea excret-
ing capacity induced by uranium. In attempting to
do this, they also found that the closest correlation
between structure and function was obtained when
the ratio between the urea content of the urine and
of the blood was used as the measure of function.
Proceedings of National and Local Societies
MEDICAL ASSOCIATION OF THE
GREATER CITY OF NEW YORK.
Stated Meeting, Held January 21, jpi8.
Symposium : MediCal Problems of the Wak
Draft.
The President, Dr. Thomas S. Southworth, in the Chair.
Rehabilitation of the Rejected— Dr. William
Harris Sheldon read this paper, which embodied
an account of the work of the Volunteer Physical
Reclamation Committee to date. The object of the
formation of the committee was to make fit for
military service those men who had been rejected
by the army examiners for being underweight and
underdeveloped. In April, 1917, classes were
started at Cornell Medical Clinic for building up
these men, some of whom were referred by the
Navy Recruiting Office. Physical drill was taught
and instruction in l^giene given. In the fall of
1917 an evening class was opened and it has since
been held regularly three times a week. A record
was made of the history and physical condition of
each man and he was personally instructed as to his
habits, work, diet, and hygiene. Most men who
were underweight had poor muscles and were un-
derdeveloped. The object of these classes was to
build muscles, particularly of the chest and abdo-
men. This aided the circulation of the blood,
helped nutrition, and increased the power of diges-
tion and assimilation, thus enabhng the eating and
digesting of an amount of food otherwise impossi-
ble. Physical drill was conducted in squads of
twelve for twenty minute periods, and exercises
were selected to develop the chest, abdominal and
foot muscles, no apparatus being used. The men
were instructed to take the same exercises at home
on alternate days, but to avoid other exercise except
a moderate walk, with deep breathing. The drill
was followed by a warm and then a cold shower
and a brisk rub, and each man was given a pint of
milk and crackers ad libitum. On November i6th,
116 men had entered the classes, twenty-four had
gained the requisite weight and been accepted in the
army or navy, and several others had been regis-
tered for service. Apart from this, the men car-
ried themselves better, had acquired habits of per-
sonal cleanliness, and showed more selfrespect in
every way.
The types of men referred to these classes were
those with long chests, badly developed, and with
narrow subcostal angle, stooped shoulders, and wide
intercostal spaces with ribs slanting downward at
an acute angle. Low centrally placed hearts were
common, and not a few had functional murmurs
which cleared up after a short period of training.
The long enteroptotic type of abdomen was often
observed.
These men were earnest and eager to fit them-
selves for the service of their country. The experi-
ment hati been a success. The field for such work
was almost unlimited, not onlv in times of war but
of peace, for if it accomplished nothing else it
demonstrated its value in spreading through the
community the idea of a proper method of living.
Mr. Roger B. Wood, director of the draft in New
York city for the Adjutant General of the State,
stated that the fundamental principle of the selec-
tive draft act was that no man not liable to service
should be called to the colors. He expressed his
deep conviction that every exemption board, every
physician, and every lawyer associated with these
boards would make it his business to see that this
principle was carried into eflfect. That they were
successful in carrying out their purpose was dem-
onstrated by the fact that at Camp Upton the record
for rejections upon physical examination was only
four per cent. — better than that of any camp in the
United States.
Medical Advisory Boards. — Major Charles M.
DowD, M. R. C, said that on June 5, 1917,
9.586,508 registrants between the ages of twenty
and thirty-one were enrolled under the selective
servict law, and of this number 1,057,363 were
certified for military service, and a large proportion
of them were actually in that service. A new plan
had been adopted, purposed to utilize the resources
represented by the remainder of these tiine and a
half million registrants. They were to be divided
into five classes, numbered according to the different
degree of availability of each class, for the nation's
need. Ph3^sical examinations were to begin
promptly in Class i, so as to select those men best
qualified for the next army. For this the authorities
in Washington decided to create a new type of
medical examining board, to act mainly in the
capacity of consultants and to be called the Medical
Advisory Boards, the members of which were to be
nominated by the governors of the individual States
and appointed by the President of the United States.
A member of the Medical Reserve Corps should act
as aide to each governor in districting the state and
nominating the members of the boards, taking
council with representatives from the American
Medical Association and the Medical Section of the
Council for National Defense. The boards were to
represent ten different specialties : Surgery ; internal
medicine ; tuberculosis ; neurology ; ophthalmology ;
ear, nose, and throat ; urology ; laboratory ; rontgen-
ology; and dentistry. Since the boards had only
an advisory capacity the types of men who were
consultants were especially adapted for appointment
on them. Fifty-eight such boards had been ap-
pointed in New York State, thirty-three in Greater
New York and Long Island, and twenty-five in the
remainder of the state. There were 658 physicians
and sixty-three dentists upon the boards, and they
represented the best type of consulting talent in the
state. The authorities of each of the following hos-
pitals organized a medical advisory board : Columbia
University, St. Luke's Hospital, New York Hospital,
University and Bellevue Hospital Medical College,
Cornell University Medical College, Post Graduate
Hospital and Medical School, Flower Hospital, Lin-
coln Hospital, and Fordham Hospital. In Brooklyn,
I
704
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
boards were organized at the Methodist Episcopal
Hospital, Brooklyn Hospital, Trinity Hospital
St. Catherine's Hospital, Greenpoint Hospital,
and the Norwegian Hospital. A board was organ-
ized in Jamaica and one in Richmond. Many were
organized in triplicate so that the members could
work on stated days in the week and meet the con-
tingency of a great rush of work if necessary.
Throughout the state, boards were established at
White Plains, Newburgh, Poughkeepsie, Albany,
Troy, Saratoga Springs. Plattsburg, Saranac Lake,
Ogdensburg, Watertown, Utica, Syracuse, Roch-
ester, Buffalo, Jamestown, Elmira, Binghamton, and
Middletown. A diagrammatic statement of the plan
of procedure, made by Dr. Robert L. Dickenson,
was included in the official instructions. The mani-
fest function of the medical advisory boards was
the giving of expert opinion, thus conserving the
rights both of the government and of the individual
registrants, and placing the type of physical exami-
nation on so broad a basis that all might acknowl-
edge its justice. New regulations increased the
amount of examining to be done by the boards and
even took away their function as consulting boards,
but every effort was being made to equalize the
strain thus thrown upon the medical advisory
boards.
The cases examined by the medical advisory
boards were referred by the local boards, acting
either independently or at the request of a govern-
ment appeal agent or an examining physician. The
registrants themselves might, with certain restric-
tions, appeal to the medical advisory boards. Reg-
istrants who were at a distance from the local
boards of their home districts were referred to
medical advisory boards. Delinquents might be re-
ferred by the Adjutant General to medical advisory
boards.
Supplementary directions for the boards of this
state were issued from the office of the Adjutant
General, under date of December 29, 191 7. The
local boards were expected to designate in what re-
spect examination was desired and to refer the regis-
trants at such time and in such number as should
prevent undue crowding or undue retention. An
order of reference and three properly filled out
copies of Form loio should be received from the
local board through the mail. The registrants should
be identified, and substitution prevented by means
of signatures, fingerprints, photographs, or all three
if necessary. In the local regulations of this state it^
was directed that the orders of reference should be
kept and that the physicians who made examinations
should sign their names on the backs of these orders.
In addition to this, carbon copies of the entries of
the boards' official decisions were filed with the or-
ders of reference. The Federal Government had
also given directions for very simple records.
Need for Standardization of Local Board and
Army Examinations. — Dr. Richard \\'.a,rd West-
KROOK said that the jjrincipal defect of the medical
work of the draft lay in the lack of standardization.
Some examiners accepted a weak man on the theory
that army life would bring about a wonderful change
in him and would make of him an efficient soldier;
other examiners rejected the same man on the theory
that tlie strain of military life in modern warfare
would i)ull him down to the point of developing dis-
ease and cause him to become a drag upon the army.
In the first draft, the authorities urged the accept-
ance of a sufficiently large percentage of men ; also
that the Government be always given the benefit of
the doubt and the registrant sent to the army if
there was any question of his fitness. When the
registrants were finally sent to the cantonments, the
criticism of the army surgeons was summed up as
follows : That much of the medical work had been
badly done; that it showed both lack of care and
lack of conscience, and that the Government was
being put to great expense in caring for and return-
ing unfit men. At the same time word came from
the regular army lecruiting offices that good men
were presenting themselves for enlistment but could
not be accepted as volunteers under regulations, as
they had been rejected by local boards.
The work of the forthcoming draft, as arranged,
would be an improvement in several wavs, but it
was well to emphasize the need of standardization
of the local and advisory mec^ical boards in their
personnel, equipment, and methods, and also the fact
that the army examination standards should con-
fo'^m as exactly as possible to those of the civilian
boards. In New York city, a group of four exam-
iners— an eye specialist, a throat and ear specialist,
an internist, and a surgeon — could examine comfort-
ably and thoroughly one hundred men a day for a
local board and have part of the day left for private
practice. The employment of paid clerks would do
away with the interminable writing during examina-
tions. Medical examiners should be provided with
a standard examination equipment by the Govern-
ment, and should be provided, through reading mat-
ter and lectures and demonstrations by armv officers,
with first hand information as to the work of the
soldier in the different branches of the service. The
civilian medical work should be under inspection by
experienced men who might also direct and suggest.
The medical advisory boards might well supervise
the work of the local boards associated with them,
and also act as middlemen to keep in touch with both
local boards and the army. If the medical advisory
boards were to be swamped with numberless reex-
aminations of slackers, or unfit men. appealed by
Government agents, it would not serve its real pur-
pose. If used as a consulting board, with its special
experience and special facilities, it would be able
to clear up the questions in time of real doubt, re-
sulting in economy of men, money, and time to the
Government. Such advisory boards, too. should
by consultation and agreement with each other, for-
mulate such standards in ruling, especially in con-
ditions of the heart and lungs, as would make for
uniform fairness toward registrants, and would be
in conformity with the accepted practice of the army
surgeons in such conditions. It was possible that it
might be well to reject every man with an authentic
past history of tuberculosis, even if with no other
finding. The regular army recruiting regulations
should now be identical with those of the local
boards. The Government had appointed ;i board
which would revise "so much of the regulations is-
sued under the Selective Service Law and of the
Manual for Recruiting Officers as is related to phy- .
October 19, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
sical examination," tlie object being to harmonize
the, standards of the draft and of the army. The
speaker had been assured by the experienced sur-
geons of the regular army that they would cooper-
ate with the selective service boards in every way,
allowing them to observe their work and making it
possible for them to familiarize themselves, so far
as could be, with the soldier in his daily life. One
must concede the right to the army surgeon to be
more arbitrary in his judgment of the recruits than
the boards, because of his greater knowledge.
Some Abuses of the Medical Side of the Draft.
This paper was read by Dr. Victor C. Pedersen.
The Cardiovascular Problem of the Draft. —
Major Harlow Brooks, M. R. C, chief of
the Medical Service at Camp Upton, delivered this
address, in which he pointed out the matters of in-
terest in which the draft boards and the army ex-
aminers had failed to come together in cardiovas-
cular problems. It was not in regard to heart ex-
aminations that the local boards committed the
greatest number of errors ; in the main their work
in this regard had been exceptionally satisfactory.
Accepting the experience largely of the English,
Canadian, and Australian medical ofificers, from the
very outset, much less importance had been placed
on the existence or nonexistence of cardiac mur-
murs in the examination of recruits. One no longer
rejected a recruit simply because he had a heart
murmur ; this was particularly true as regards sys-
tolic murmurs at the apex, and especially those of
the cardiorespiratory type, even in many instances
of unquestioned mitral incompetency. Reexamina-
tion of many of these cases had shown that the
regulated life and systematically administered ex-
ercise of military training, though severe, was fol-
lowed by great symptomatic improvement and often
by the complete disappearance of the murmur. It
was not so much a question of the valve lesion as
of the heart muscle that was fundamental to the
prognosis. This was even more true of systolic
murmurs at the base ; only a very small percentage
was due to actual stenosis of the aortic valve or
ring. Most were hemic, functional, or not explain-
able on an organic basis. A very large number of
them disappeared in the course of the recruit's train-
ing-
The armv placed its final and most important
decision on the question of the ability or disability
of the heart to perform its duty. It was on this
ruling that the civilian examiners and those at the
camps had most difiered. The army examiners bad
a great advantage. In testing the possibilities of a
heart they v/ere not obliged to be content with the
simple tests of the ofifice or clinic, but in questionable
cases could send a man to full duty, to work in the
trenches or at bayonet drill, where, even on the hike
or at games he was under observation — usually en-
tirely unknown to him, the regimental medical
officers carefully reporting his reaction to exercise.
This m.ethod had enabled the detection of n. -linger-
ers'^who, through the use of drugs or in other
ways, had succeeded in deceiving their medical
advisors and friends. The functional test was the
thing. It had been carefullv worked out by the
Royal Army Medical Corps' of the British, and
American physicians were profiting to a very en-
lightening degree from their experience. This field,
so largely inaccessible to the physician on the draft
board, was one in which those on active duty had
preeminent opportunity, and the one in which they
most disagreed with the conscientious work of the
patriotic draft boards, and it was in this field that
the speaker wished to emphasize the importance of
heart efficiency and the secondary importance of
cardiac peculiarities.
Captain J.xmes F. Rooney, M. D., of Albany, de-
clared that up the State the men who resorted to
various expedients to get into the service were
almost as numerous as those who tried to evade it.
All those in charge of the draft, especially the
Adjutant General of the State, and the Chief of the
Federal B ureau, felt that the success of the draft
was largely due to the self sacrificing devotion of the
medical profession. Every precaution was being
taken to reduce mistakes to a minimum, and those
that had been made would not be repeated. The
local boards would be relieved of some responsi-
bility by the appointment of advisory boards, but
the work of the latter was going to be difficult. The
gradual standardization of physical requirements,
however, would probably result to great advantage.
Whatever criticisms had been uttered elsewhere, the
y\lbany office greatly appreciated the efforts of the
men engaged in this work in building a new army
for the United States.
iDr. James S. Waterman, of the district board,
said he had been very much interested to hear of
the work of the Volunteer Physical Reclamation
Committee, and would be very glad to refer these
young men who knew so little of how to walk,
breathe, or even talk properly, where they could be
helped. Two changes had been made in reference
to the new draft which were very important. One
was the addition of a lawyer as an advisor and
councilor. Many of the appeals had been absolutelv
futile and obviouslv useless ; this addition would
prevent a great deal of needless work and be of in-
valuable assistance to the drafted men. Another
change had resulted from the need for interpreters.
In regard to the advisory boards, the speaker be-
lieved that even if nothing more was accomplished
by them, the moral effect created by their existence
would stimulate the local boards to their best efforts
and have its strong influence over the men. Doctor
Brooks was to be congratulated on the absolutely
intelligent, common sense attitude of his position
toward the heart cases. Aside from this point, it
would be interesting to know if Doctor Brooks had
noticed any relief from rheumatism in th^men who
were immunized against typhoid. In the navy it
had been reported that many men had been much
relieved.
_ Major Brooks said that they encountered three
kinds of rheumatic conditions in the camp, one of
them being what was believed to be real rheumatic
cases. These were apparently improved, in some
instances, bv the vaccine. Another kind was com-
posed of those who said they had suffered in-
tensely before they came to camp, but, once there and
becom.ing interested and fond of soldier life, they
improved marvelously and became anxious for pro-
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES. ,
706
motion from the ranks. It was questionable, how-
ever, if this could be attributed entirely to the triple
vaccine. There was still another type, and this was
entirely unaffected by the vaccine — in fact was
seemingly made worse by it — and in which the only
desired treatment appeared to be exemption.
Doctor Sheldon said that though the work they
had been doing in building up men had so far been
carried on solely in connection with the Naval and
Marine Corps, they now had increased facilities and
would be very glad to include men referred by the
boards, as they could handle several hundred
men in the classes. Tliey had only had three
drafted men who had been rejected because of
cardiac murmurs and hypertrophied hearts, but
after several weeks' training they gave absolutely
normal cardiographs. They were very anxious to
be included in the next draft and had been doing
everything to fit themselves to pass the physical
tests', or to get into the Regular Army.
Stated Meeting, Held February 18, ipi8.
The President, Dr. Edward E. Cornw.all, of Brooklyn,
in the Chair.
Address of Retiring President. — Dr. Thomas
S. SouTiiwoRTH. of New York, expressed his ap-
preciation of the honor, twice conferred upon him.
of presiding over the meetings of the Medical As-
sociation of the Greater City of New York. He
paid high tribute to his fellow ofBcers and the mem-
bers of the coimcil who, by their wholehearted and
unselfish cooperation, had proved their devotion to
the interests of the association, and to the many men
of prominence in this and other cities who had pre-
sented papers and joined in the discussion at the
meetings. Owing to these two groups the duties of
president, instead of being onerous, had been a
pleasure. In selecting Dr. Edward E. Cornwall, as
president for the ensuing year, the association had
chosen a distinguished internist and writer on medi-
cal subjects, as well as an earnest worker in this
society ; he surrendered to him the gavel, the symbol
of office, with the full assurance that the future of
the association under his guidance was bright and
full of promise.
President's Address: Some Aspects of Symp-
tomatic Treatment. — Dr. Edward E. Cornwall,
of Brooklyn, said that in that not very remote
period of medicine before vaccines and serums and
internal secretions and metabolism became thera-
peutic catch words, a period which was sometimes
alluded to as the prescientific period, treatment was
generally one or more of three kinds, specific, ex-
pectant, and symptomatic. The specifics in those
days were very few ; expectant treatment was un-
popular, and symptomatic treatment occupied most
of the field. Even now, when true specifics, mostly
biological, were constantly being discovered, symp-
tomatic treatment constituted a very large part of
medical practice. But increase in scientific knowl-
edge, particularlv of physiology, brought up certain
questions regarding symptomatic treatment. The
first question was the definition of a symptom, and
to what extent symptomatic treatment was rational
or permissible. A symptom couJd be defined as an
unusual functioning of the body, more or less regu-
larly associated with disease conditions, sometimes
occurring without demonstrable pathological basis.
Svmptomatic treatment, as a universal dogma,
rested on the assumption that these unusual func-
tionlngs were themselves morbid manifestations, or
a part of the disease, and as such deserved to be
suppressed or abated. Careful observation, how-
ever, had shown that many symptoms, such as fever,
diarrhea, constipation, pain, and high or low blood
pressure, were evidences of Nature's work in com-
bating disease,if not part of the combative process it-
self. With this understanding, what became of symp-
tomatic treatment? Was there any warrant at all
for treating symptoms ? The answer to this question
was qualified, for certain symptoms should be
treated under certain conditions. Sometimes liyper-
functionings, or hypofunctionings, or abnormal
functionings kept on to such an extent- as to disturb
seriously the organism, or even to threaten it with
new trouble. When this was the case, legitimate in-
dications for symptomatic treatment might appear.
Also, an unusual functioning might be kept up so
long as to threaten to become a habit or a truly
functional disorder, and for that reason be a legiti-
mate object of symptomatic treatment. Some of
the hypofunctionings might involve actual morbidity
and require treatment to stimulate the functions to
meet vital necessities of the body; as when cardiac
contractions were too weak and vasomotor tone too
lax to insure an adequate circulation. Pain was a
svniplom which frequently called for treatment.
High blood pressure did not often require direct
treatment ; occasionally, however, it did, as when its
continuance at an exaggerated height threatened
acute injury to the cardiovascular apparatus, or in-
crease of damage which had already taken place ;
when cerebral hemorrhage had occurred in the
presence of very high blood pressure, arteriodilators
might be indicated ; and in certain conditions of
aortic disease, and in somie cases of angina pectoris
temporary lowering of the blood pressure might be
rational treatment. Fever, being regularly curative,
should be let alone in most cases, but hyperpyrexia,
when its continuance threatened harm, distinctly
called for antipyretic treatment. Constipation was
often a disease and a cause of disease, as well as a
symptom. Overcatharsis, however, seemed to pre-
vail widely. The routine use of cathartics, for the
sake of catharsis, was without justification. In
some diseases, notably pneumonia and typhoid fever,
constipation of moderate degree, provided certain
precautions were taken in respect to the diet, seemed
to be beneficial rather than otherwise. While symp-
tomatic treatment had a large and important place in
therapeutics, in order to be rational it must avoid
interfering with Nature when properly performing
her functions ; it was not a universal dogma, but re-
quired a distinct warrant for each particular case.
Acute Infectious Jaundice (Spirochetosis Icte-
rohaemorrhagica). — Dr. Charles Herrman, of
New York, said that the history of acute infections
jaundice was exceedingly interesting. It was
ably recognized by Hippocrates for the character-
istic changes of eyes, urine,- and feces could not
easily have escaped his attention. The disease was
mentioned by writers in the seventeenth century ;
October 19, 191S.]
LETTERS TO THE EDITORS.— BOOK REVIEWS.
but the first detailed description of epidemics was to
be found in the writings of the end of the eighteenth
and the ' beginning of the nineteenth century.
Among- the Federal troops in the Civil War 22,569
cases of acute infectious jaundice were reported,
Avith 161 deaths. In discussing the etiology, the
factors of defective drainage and putrefaction had
been mentioned, even by recent writers, very little
being said of the possibility of contact infection. It
was not at all surprising that this disease should
occur in camps, because of crowding and the pres-
ence of a certain number of susceptible persons.
This was not essentially, however, a disease of
adults or of camps. Only a small percentage of
persons exposed to infectious jaundice contracted
the disease. In urban centres, infectious and so
called catarrhal jaundice agreed, in that they were
prevalent during the late fall and winter months
and in that they affected primarily children under
ten years of age. In large cities, the disease oc-
curred sporadically as well as epidemically.
Doctor Ilerrman's observations led him to con-
clude that so called catarrhal jaundice, epidemic
jaundice, and infectious jaundice. Weil's disease or
Spirochetosis icterohsemorrhagica, probably repre-
sented a group of closely related diseases and that
clinically these diseases were similar; the infectious
material probably entered the body through the
nasopharynx, was then taken up in the circulating
blood, and had a selective affinity for the bile ducts
of the liver ; the disease was not due to indiscretions
in diet, and the infectious material was not con-
veyed by food or water; Weil's disease or Spiro-
chetosis icterohaemorrhagica was due to a specific
spirochete, and sporadic and epidemic catarrhal
jaundice were probably due to a related organism ;
the infection usually took place by direct contact,
might occur indirectly through infected urine or
fecal matter ; the disease was only slightly communi-
cable, there was a large degree of natural immunity
to it, and one attack rendered the patient immune ;
and in civil hfe, sporadic and epidemic jaundice
were somewhat more common in children, and in
camps the disease was most common among recruits
coming from rural districts.
Dr. HiDEVo NoGUCHi, of the Rockefeller Insti-
tute, stated that he had studied about a dozen of
the cases of icterus in children to which Doctor
Herrnian referred. Some years ago Doctor Herr-
man called attention to the possibility of the infec-
tiousness of this form of jaundice, but it was only
recently that it occurred to the speaker that it might
be due to the organism discovered by Inada and Ido
in Japan. The Spirochajte icterohremorrhagica of
these authors had also been found in Europe and
in America. It produced an acute febrile disease
yvith jaundice and hemorrhages. In Japan the
jaundice had been almost constantly present, but in
European cases, as reported by "certain French,
Italian, and British authors, among the soldiers, this
S5^mptom is not always constant. The spirochete
had been found in the urine in the convalescent
stage of the disease as well as at the height of fever.
No spirochetes were found either in stained prepa-
rations or by examination under the dark field mi-
croscope in the urine from the cases reported by
Doctor Herrman at the height of fever and also in
the convalescent stage. Inoculations were made
into a number of guineapigs, but the results were
uniformly negative. At the present time it was not
possible, to say whether or not the jaundice among
children as described by Doctor Herrman was due
to an organism similar to that found in forms of
spirochetal jaundice. In. order to ascertain whether
there was anv immune substance in the blood sera
or urine of these patients, they were studied with
the strains of the Spirochete ichterohaemorrhagica
from Japan, Europe, and America. In one case
there was some indication of the presence of specific
immune substance, but in the remainder no evidence
of it could be demonstrated. The study was still
incomplete, the question still undecided.
(To be continued.)
Letters to the Editors.
BETTER CARE IN ARMY THAN IN PRIVATE
/ LIFE.
New York, October 3. 1918.
To the Editors:
The news item in this week's issue of j'oiir journal,.
"Better Care in the Army Than in Private Life," also
appeared in an enlarged form in the New York Times as
an Associated Press dispatch from France.
In this article General Gorgas is reported as citing, in
addition to what you have published, "the example of a
man whose leg had been crushed in a logging camp or a
farmer's son shot accidentally," and pointed out, accord-
ing to this report, "that they would have had country prac-
tioners attending them at irregular intervals." This he-
contrasted with "the services to the troops of the most
skilled surgeons and the foremost physicians, as well as
trained nurses and all the modern appliances."
Admitting all this, it may be said in extenuation, if not
in palliation, that the private practitioners in civil life
are debarred the use of the Associated Press in promul-
gating the character of their services, remarkable as they
may be at times. This is not the case with those in the
public employ. With them the exigencies of the times re-
require that the public be informed with more and more
emphasis and under the most favorable aspects of the
nature of their accomplishments.
It should not be forgotten, however, that civil life fur-
nishes to the army today, as it has in the past, the highest
medical and surgical skill it possesses, and at a sacrifice of
personal and professional interest willingly answers the-
call of duty for the period of the war.
John P. Davin, M. D.
Book Reviews.
{We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so-
far as space permits, we revieiv those in which we think
our readers are likely to be interested.]
Etudes sur Ic fonctiunnement renal dans les nephrites
chroniques. By Pasteur Vallery-Radot, ancien interne
des Hopitaux de Paris. Paris: Masson et Cie. Ed'teurs,
1918. Pp. 256.
The author presents an exhaustive studv of the-
subject of renal function in chronic nephritis, in-
cluding an extensive review of the literature and a
large number of original studies. He is firmly of
the belief that the examination of every nephritic
should include a systematic study of the renal func-
tion and that for this purpose the three most sat-
isfactory methods are the determination of the-
blood urea, the use of Ambard's coefficient, and the
study of either the chloride excretion or of that of
7o8
BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Journal.
phenolsulphonephlhalein, l)oth of which give parallel
results. He finds that the evolution of nitrogen re-
tention, and the course or prognosis of the disease,
cannot be followed by the blood urea determinations
until the disease has already reached an alarming
stage. Where the blood urea, however, rises to
more than one gram per litre and remains at such a
level the prognosis of a fatal outcome within two
years can be made. For the earlier cases, in which
there is little nitrogen retention as shown by low
blood urea, the stage and progress of the renal
secretory disorder can be determined and followed
by the use of Ambard's coefficient. If a high Am-
bard is found constantly present it indicates a
permanent damage to the renal secretory function
and marks the prelude to a nitrogen retention, but
cannoi be used as a prognostic indication of the
probable duration of life. Chloride retention does
not occur by chance, but follows very definite grada-
tions according to the severity of the renal disturb-
ance and its determmation gives valuable informa-
tion. The limits of space forbid our entering fur-
ther into a discussion of the author's conclusions,
but, whether or not one agrees with them, his
studies and arguments deserve careful considera-
tion, both by the investigator, and especially by the
clinician who studies his cases with care and pre-
cision.
L'EIcctricitc uifdicah: cu clientele riudispensablc en elcc-
trothcrapie. Par J. Laborderie (De Sarlat), correspon-
dant national de la Societe de Therapeutique de Paris ;
correspondant du Journal dcs Practiciens. Comment
Guerir. Bibliothoque des Practiciens, public sous la
direction du Dr. Ch. Fiessinger. Avec 94 figures dans
le lexte. Paris: A. Maloine et Fils, Editeurs, 1918. Pp.
iii-376. (Price, 5 francs.)
This handy volume presents in a clear and concise
manner the essential facts as to the apparatus and
technic required for treatment by galvanic, faradic,
sinusoidal and high frequency currents and by static
electricity. A special feature is the description of
simple and inexpensive appliances, possibly home
made, which produce the same results as expensive
factory made apparatus. Electrodiagnosis is com-
pletely covered in every practical detail including
even its application to the special subject of otology.
Electrotherapy is systematically presented from a
practical standpoint, and the completeness of the
book is shown by the fact that a careful examination
shows only one detail omitted : viz., iontophoresis
as a means of sterilizing the root canals of the teeth
and curing chronic apical abscess and granuloma.
The book can be highlv recommended as a guide to
the general practitioner in his occasional use of
electricity and will abundantly repay perusal by the
specialist in electrotherapy.
One interesting observation is that '"without doubt
static electricity is the most powerful of emmena-
gogues" and that it regulates the perfbds and pre-
vents the violent pains. The static bath is employed,
the patient sitting for twenty minutes upon an insu-
lated platform which is connected with the negative
pole of the machine. This is followed by a five
minute application of sparks to the lumbar region.
Rhinophyma forming bulbous red masses on the
nose is treated by electrolysis. Three needles pene-
trate the mass parallel to the surface and about one
■eighth inch superficial to the level to be desired after
healing. The middle needle is positive and the two
outer negative and a galvanic current is gradually
increased to forty ma. if possible. When the tissue
turns gray the current is gradually turned of¥. A
dry scab comes oft in about fifteen days. The
Apostoli method of very heavy intrauterine gal-
vanization is not reconmiended for fibroids ; radio-
therapy is advised.
«>
Births, Marriages, and Deaths.
Died.
AuzAL. — In New York, N. Y., on Friday, October nth.
Dr. Ernest William Auzal, aged fifty-eight years.
Braislin. — In Saranac, N. Y., on Sunday, October 6th,
Dr. W. Donald Braislin, son of Dr. William C. Braislin,
of Brookh'n.
Black. — In Williamstown, Mass., on Saturday, October
Sth, Dr. M. S. Black, aged forty years.
Cannon. — In Poultney, Vt., on Saturday, September
2ist, Dr. Mott Dwight Cannon, of Greenwich, Conn.,
aged sixty years.
Chipman. — In Chelsea, Mass„ on Monday, October 2d.
Dr. William Reginald Chipman, aged sixty-nine years.
Collins. — In New York, N. Y., on Monday, October
14th, Dr. Frank Horan Collins.
Crowley. — In Westerly, R. I., on Wednesday, October
Qth. Dr. James M. F. Crowley, aged thirty-three years.
Cutter. — In Lawrence, Mass., on Friday, October 4th,
Dr. Arthur Hardy Cutter, aged forty-six years.
Davey. — In Keene, N. H., on Saturday, October 5th, Dr.
Harry E. Davey, aged thirty-four years.
DoRWARTH. — In Philadelphia, Pa., on Tuesday, October
Sth, Dr. Charles Votteler Dorwarth, aged thirty-one years.
Elemendorf. — In Bufifalo, N. Y., on Saturday, Septem-
ber 26th, Dr. William F. Elemendorf, aged sixty-four years.
Gross. — In. Metuchen, N. J., on Sunday, October 6th,
Dr. Herman Gross, aged thirty-eight years.
Grossman. — In Brooklyn, N. Y., on Sunday, October
13th, Dr. I. Jacques Grossman, aged twenty-seven years.
^ Hale. — In Providence, R. I., on Monday, September
30th, Dr. Robert Carleton Hale, aged thirty-nine years.
HoBRS. — At Meuil le Tour, France, on Thursday, Sep-
tember 26th, Lieutenant Austin L. Hobbs, of East Orange,
N. J., Medical Corps, U. S. Army, aged thirty-six years.
JuNGE. — In New York, N. Y., on Saturday, October 12th,
Dr. Bernhard W. Junge. aged fifty years.
KoRN. — In New York, N. Y., on Saturday, October 12th,
Dr. Abraham Korn, aged fifty-five years.
Lowell. — In Brooklyn, N. Y., on Thursday, October
lOth, Dr. Walter William Lowell, aged twenty-eight years.
Morgenstern. — In New York, N. Y., on Monday, Octo-
ber 7th, Dr. Adolph Morgenstern, aged thirty-five years.
Perkins.— In New York, N. Y., on Thursday, October
loth. Dr. John Richard Perkins, aged twenty-six years.
Rice. — In Babylon, L. I., on Saturday, October 12th, Dr.
Albert Carl Rice, aged thirty-two years .
Rothenberg. — In Brookljm, N. Y., on Saturday, October
5th, Dr. David M. Rothenberg, .Assistant Surgeon, U. S.
Navy, aged twenty-five years.
Smith. — In Philadelphia, Pa., on Tuesday, October Sth,
Dr. Edward M. Smith, of Valdosta, Ga., aged twenty-three
years.
Stein HOFF. — In New York, N. Y., on Friday, October
nth, Dr. Karl L. Steinhoff, aged twenty-five years.
Thompson. — In Bridgeport, Conn., on Sunday, October
6th, Dr. John E. W. Thompson, aged fifty-seven years.
Thompson. — In Standish, Me., on Tuesday, October 1st,
Dr. .William S. Thompson, aged sixty-four years.
Topping. — In Newark, N. J., on Saturday, October 12th,
Dr. Robert Samuel Topping, of Rutherford, N. J., aged
thirty-four years.
Van Derver. — At Norfolk, Va., on Monday, October
7th, Lieutenant Warren Abbey Van Derver, Medical Corps,
LT. S. Navy, aged thirty-one years.
Wells. — In Westford, Mass., on Sunday, October 6th,
Dr. Orion V. Wells, aged thirty-eight years.
Wiswall. — In Wellesley, Mass., on Monday, October 7th,
Dr. Edward Hastings Wiswall, aged fifty-six years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journahhe Medical News
A Weekly Review of Medicine, Estabhshed 1843
Vol. CVIII, No. 17. NEW YORK, SATURDAY, OCTOBER 26, 1918. W hole No. 2082.
Original Communications
iPuhlishcd by permission of the Sv.ryccn GciicrdI cf the Army.)
SPANISH INFLUENZA IN THE ARMY.
bT Charles L. Mix, M. D.,
Camp Mills, N. Y.,
Major, W. C., United Stiites Anny; Medical Chief. Base Hospital.
The first cases of so called Spanish influenza re-
ceived at this hospital were admitted on September
i8th, four patients coming in. On the 19th we had
five, on the 20th seven, and from that time on the
epidemic increased with tremendous rapidity, so that
in a few days we were receiving two or three hun-
dred cases daily. At the present time — October i ith
— we have under treatment approximately 2,000
cases.
PERIOD OF INCUBATION.
In some instances we have had opportunity to
find out the period of incubation. For example, two
of the earlier cases were admitted to a medical ward
and remained in this ward over night. I saw them
the following morning and recognized them as cases
of influenza, whereupon they were promptly taken
to the isolation ward. The wardman who superin-
tended their removal to the isolation ward came
down with influenza two days later, and on the same
day one patient occupying an adjacent bed also be-
came a victim of the disease. No more cases origi-
nated in that medical ward. The incubation stage
clearly then may be as brief as two days. In some
instances it is probably delayed a few days beyond
this, but in the vast majority of cases the incubation
period is extremely short.
ETIOLOGY.
The disease is always conveyed by contact with
existing cases. In this respect it is entirely analo-
gous to measles, and it bears a great resemblance to
measles in its stage of invasion. The contact in-
fection has been proved also in this base hospital.
For example, in this previously mentioned medical
ward there has been no epidemic of influenza, where-
as in a surgical ward about forty cases broke out
in a period of three days' time. The prompt recogni-
tion of the disease in the medical ward and the re-
moval of the patient ill with the disease accounts
for the lack of spread in that ward ; and the delayed
recognition of the disease for two days in the surgi-
cal ward undoubtedly led to the outbreak there.
There is another important conclusion to be drawn
from the above facts, and that is that the contagion
is not air borne. For example, the medical and sur-
gical wards just mentioned are not more than 200
feet apart, and the fact that many cases appeared
in one and not in the other proves that the germs
are not carried by the air. The conclusion is inevi-
table that the infection is passed by contact from
one person to another exactly as in measles. *
An important corollary in this connection is that
all epidemics theoretically may be stamped out by
the isolation of the persons affected. To be sure,
such isolation may sometimes be extremely difficult,
because of the large number of cases in a given lo-
cality, but in army work and in institutions such
isolation is absolutely feasible and should inevitably
be carried out. Theoretically, it could have been
kept out of the United States.
SYMPTOMS.
The symptoms of the disease are chiefly respira-
tory, gastrointestinal, and nervous. In the stage of
invasion there is usually a feeling of chilliness,
sometimes an actual rigor, and invariably there is
fever. The fever may last only a few hours or it
may extend over several days. There is great vari-
ability in the degree of temperature in the state of
'"vasion. In one instance the patient entered with a
temperature of 107.4° within a very Tew hours of
the time of onset. Another entered«with a tempera-
ture of 106°. Several patients have entered with a
temperature of 105° or 106°. Usually the patient
with very high initial temperature develops pneu-
monia. Ordinarily the average temperature^of the
stage of invasion is between 102° and 103°. Very
few run an initial temperature as low as between
99° and 100°.
The subjective complaints on the part of the per-
sons affected are, first and foremost, headache and
pains and aches all through the body. The backache
is sometimes as severe as in cases of smallpox or
meningitis. Complaint is also made that all the
muscles of the body are sore and painful, and when
attempts are made to move the patient in bed there
is usually marked objection on his part because of
the muscular soreness. ^
The respiratory symptoms are manifested by mild
degrees of laryngitis and pharyngitis, so that when
the mucous membrane of the mouth is inspected it
is found to be reddened and somewhat turgid. There
is no rash in the mouth as in the acute exanthemata, -
but there is, in the more acute cases, a redness of
the fauces which reminds one of the color of the
mucous membrane of the mouth in measles. Many
Copyright, 1918, by A. R. Elliott Publishinc Company.
.]]1X: SPANISH INFLUENZA IN THE ARMY.
[New York
Medicai, Journal.
of the patients show a moderate degree of laryngitis,
and in some instances are very hoarse because of the
excessive degree of irritation of the mucous mem-
brane of the vocal cords. In some instances there is
an undoubted congestion of the fossa of Rosen-
mueller with closure of the Eustachian tubes and a
consequent deafness and earache. Though at the
present time we have not found many complications
on the part of the middle ear and mastoid cells, a
few cases have already developed and we confidently
expect that otitis media and acute mastoiditis will
be more or less prominent sequelae. In some cases,
during the acute stage, there is considerable conges-
tion of the mucous membrane of the middle ear, so
that there is a bulging of the drum to such an extent
that it sometimes reaches close to the end of the
aural speculum when the instrument is introduced.
Paracentesis merely liberates a little blood, but it
seems to give the patient some relief.
The gastrointestinal nicinifestations are confined
chiefly to nausea and vomiting. Without preparing
statistics, it is my judgment that half the cases show
nausea, and perhaps one third actually vomit one
or more times during the stage of invasion. Fre-
quently the patient will not vomit until water is
given to him or until he tries to take a dose of medi-
cine. There have been no severe cases of intestinal
irritation, although one or two persons out of the
2.000 were troubled with diarrhea at the time they
entered the hospital. In the great majority of cases
there is, on the contrary, more or less constipation,
so that it is almost invariably necessary at entrance
to administer a laxative or a cathartic.
The nervous manifestations are much more pro-
nounced in this epidemic than the gastrointestinal.
There is usually evidence of quite a degree of in-
toxication of the brain and cord with, in some in-
stances, the actual production of a symptomatology
resembling meningitis. We have had six instances
during this epidemic of patients presenting the symp-
tomatology of meningitis. In each case we did a
spinal puncftire, of course, and found that three
were straight iiifluenza cases with negative fluid,
whereas the other three were cases of epidemic
cerebrospinal meningitis. The symptoms in the actual
cases of meningitis were not more pronounced than
the symptoms of meningismus in the cases of in-
fluenza. In these influenza cases there seems to be
at least an increase in the pressure of the cerebro-
spinal fluid though there is no exfoliation of cells
and no increase in the count. Thus, in one case, I
withdrew forty-five c. c. of cerebrospinal fluid very
rapidly, the fluid being under some slieht pressure.
The nervous manifestations resembling those of
the stage of invasion of epidemic meningitis are
headache, nausea, and vomiting, and muscular rigid-
ity. This muscular rigiditv is, in rare instances,
sufficiently pronounced to give rise to the Kernig's
sign and to tjgidity of the neck.
Chronologically the symptoms might be arranged
as follows :
I. Fever, in all instances ushered in by chilly
sensations, or by one or more chills separated
by short intervals — perhaps an hour or two.
The temperature ranges from 102° to 104° and
the fever is continuous.
2. The pulse at first is rather rapid, ranging
from 82 to 110. After the stage of invasion
and with the fall of temperature there is apt to
be a temporary bradycardia, the pulse dropping
to 70 or even to 60 and 50.
3. Headache, rather severe, even suggestive
of meningitis.
4. Backache and pains and aches in the ex-
tremities.
5. General prostration, quite marked ; well
described by the old word "grippy."
6. Marked irritability on the part of the
stomach, manifested in the majority of in-
stances by nausea and in perhaps one third of
the cases by vomiting, particularly on the inges-
tion of liquids or solids.
7. Rather pronounced nasopharyngeal ca-
tarrh with redness of the throat.
8. Laryngitis and bronchitis, Extending as
far as the second or third bronchus, so that in
the uncomplicated cases no rales are heard in
the chest during the stage of invasion. Later,
there is a marked tendency toward the develop-
ment of a bronchitis affecting the small bronchi
and bronchioles, so that some patients may show
almost a capillary bronchitis. All the patients
• cough.
9. The sputum is thick and very tenacious
and resembles the sputum of pneumonia in its
tenacity. Later on, expectoration is more pro-
fuse ; and the ordinary, thick, mucopurulent
sputum of acute bronchitis is encountered. If
pneumonia develops the sputum is bloody.
10. There may be, in the early stages, some
hypertonicity, so that the patient shows symp-
toms somewhat resembling those of meningitis.
The marked feature of the disease is the respira-
tory symptomatology. All patients are troubled by
a cold in the head, by a feeling of clogging in the
head, and by cough. The cough is sometimes very
distressing and is frequently much worse at night.
On going into a ward filled with influenza patients,
one is immediately struck by the large amount ol
coughing going on. As a rule, the bronchitis which
occasions the cough is more or less transitory, but
in many cases it takes several days before the res-
piratory mucous membrane returns to normal.
The thing which makes this present epidemic a
matter of such grave consequence is the fact that it
is not the result of an invasion by the influenza
bacillus alone, but, instead, an invasion by both the
influenza bacillus and the pneumococcus. It seems
almost as though Pfeififer's bacillus and the pneu-
mococcus lived together in a state of symbiosis. The
initial invasion is invariably by Pfeift'er's bacillus ;
this hits as abruptly and as vigorously as a sledge
hammer. The blow is almost a knockout. Within
two days, to five or six days' time, however, a cer-
tain degree of immunity seems to be acquired by the
patient, the temperature rapidly falling and the pa-
tient beginning to recover. But in from ten to fif-
teen per cent, of the cases the pneumococcus takes
up the work at this point and, without a chill and
somewhat insidiously, pneumonia begins.
The pneumonia does not seem to have any great
predilection for the right or the left lower l&be.ap-
October 26, 1918.]
MIX: SPANISH INFLUENZA IN THE ARMY.
711
pearing in each in about the same percentage of
cases. A large number of double lower lobar pneu-
monias have been found. A few cases of upper
lobe involvement were discovered, but not many.
One fatal case had involvement of the left upper and
the right lower lobes. In the majority of instances
the patients show the initial trouble along the verte-
bral border of the scapula, and usually at about the
level of the eighth spinous process. The disease
seems to start from the bifurcation of the large
bronchi and to spread from this point down through
the lobe, reaching the surface, sometimes only after
three or four days of symptomatic pneumonia. In
some instances the onset is at the base of the lower
lobe, but in the great majority of instances it is in
the upper part of the lower lobe, from which point
it .spreads downward.
The spread is sometimes extremely rapid. The*e
may, for instance, be a patch only the size of a half
dollar in the forenoon and an area as large as the
palm of one's hand in the afternoon, and by the fol-
lowing morning the whole lobe may be involved.
The rapidity of the process was exemplified in the
case of one patient who entered at 7 130 p. m. on
October 5th and died on the morning of October
7th, and of another who entered at noon on October
9th and died at 9:30 p. m. on October loth. Each
was ill altogether about thirty-six hours, entering
and dying with pneumonia combined with influenza.
Some of the boys of his company said that on the
morning of October 5th the first mentioned patient
was as well as any of them ; by afternoon he was
ill, and at 7 :30 p. m. he was brought to the hos-
pital on a stretcher.
In a few instances the influenza bacillus associates
itself with the Streptococcus hemolyticiis. This was
shown in one of our patients, W. C. H., who,
stricken on September 30th, with influenza, died on
October 4th. This patient had involvement of both
right and left lower lobes, and from his sputum the
Streptococcus hemolyticus was isolated. No pneu-
mococci were found.
The strains of pneumococci which have been
found have been of all four types, the majority be-
longing to Types II and IV. Not many cases of
Type I have appeared, and fortunately not very
many of Type III, the Pncitmococcus mucosus. The
Type IV cases, which ordinarily have an excellent
prognosis, in this epidemic are almost as virulent as
cases of Type II. We have lost several cases of
Tvpe IV pneumonia. The old rules of prognosis as
regards Types I, II, III, and IV do not hold in the
presence of influenza. In some instances the in-
fluenza bacillus is itself capable of causing a pneu-
monia, as we have found in cases in which pneu-
monia has existed and in which we have been able
to isolate nothing but Pfeififer's bacillus from the
sputum. Of all of our cases, 88 per cent, show the
influenza bacillus.
The physical signs of pneumonia are not like those
of the ordinary cases of uncomplicated lobar pneu-
monia which we were accustomed to see in the past.
For example, on percussion dullness is often not
marked until the patients are well on toward death.
It would seem as though the invasion of the hmg
was so rapid that it was patchy in distribution; in
other words, instead of spreading slov. ly through the
lung and involving every portion of it as it goes along,
it jumps by leap? and boumls t'irough the ])ulmonary
tissue, causing areas of consolidation here and there,
with spaces in between at first free from trouble.
The effect of this upon the percussion note is the
same as in bronchopneumonia ; the spaces between
the involved areas being in a state of elastic equili-
brium give to the areas of consolidation a part of
their resonance, so that the dullness is frequently
not much more evident than the ordinary relative
dullness found at the cardiac or hepatic border in
normal persons. As time goes on, of course, this
percussion note becomes deeper, so that in time
there may be marked dullness.
The most important findings are those obtained
with a stethoscope. For purposes of examination,
do not have the patient sit up. Have him lie face
down flat on his belly, with his arms hanging over
the sides of the bed. The latter maneuver spreads
the scapulse apart, and uncovers more of the chest.
He can He in this position as long as you want him
to without being inconvenienced or fatigued, and you
can make a thorough examination of his chest at
your leisure. Moreover, the right and left sides will
be in a relatively symmetrical position' so that you
can tell absolutely what your findings are. On ap-
plying the stethoscope one will find usually, on in-
spiration, a shower of fine crepitant and subcrepitant
rales. The expiratory portion of the respiratory
sounds will be prolonged and will be accompanied
by clicking rales. The consonant rales of early
pneumonia reach their finest exemplification in these
cases of influenzal pneumonia. Bronchovesicular
breathing is far more common than bronchial
breathing. If one makes a diagnosis of pneumonia
only in those cases in which there is pronounced
bronchial breathing, one will fail to diagnose a large
number of cases. If, however, one pays attention
to bronchovesicular breathing and to consonant rales
located in only one spot and asymmetrical in dis-
tribution, one will more often discover the cases of
pneumonia much earlier than if these signs are not
regarded.
Another error which is apt to be made is failure
to take into account the vicarious overaction of the
sound lung. Listening to a chest in the early stages,
one sometimes encounters an apparently suppressed
respiration on one side with exaggerated respiration
on the other. Some of the inexperienced and
younger medical officers have made the mistake of
finding the pneumonia in that side of the chest
which showed exaggerated breathing with a large
ninnber of rales due to the associated bronchitis, in-
stead of recognizing that the pneumonia really ex-
isted in the opposite side where breathing was sup-
pressed, but where it was distinctly bronchovesicular
or even bronchial in type.
In the old classical lobar pneumonia, increased
tactile fremitus and vocal resonance were always
mentioned as very characteristic. In these cases,
however, voice conductivity is only occasionally
found exquisitely manifested. In the majority of
cases there is a comparatively slight increase in vocal
lesonance. Bronchophony and egophony are not
nearly so common in these cases as in the well
MIX: Sl'AMSH INFLUENZA IN THE ARMY.
[New York
Medical Journal.
known uncomplicated lobar pneumonia. The ex-
planation for the relatively slight increase of vocal
resonance is the same as the explanation for the
relatively slight increase in the dullness. In some
instances the pneumonia seems to be almost "mas-
sive," the bronchi themselves being apparently filled
with the exudate as well as the air cells.
A very important part of the back to be examined
is that which lies along the vertebral border of the
scapula opposite the spines of the fifth to the eighth
vertebras. On one side or the other one will find, in
the cases showing pneumonia, a shower of sharp
crepitant or subcrepitant rales apparently very close
to the ear. The rales are not bilaterally symmetrical,
and therein lies their diagnostic value. If one finds
. rales of equal intensity and distribution on both
sides of the chest the probabilities are that one is
dealing merely with a bronchopneumonia, but not
with a lobar pneumonia. If, on the other hand, one
finds a definite patch of rales, crepitant or subcrepi-
tant, close to the ear, or consonant rales in one small
irea and not in its corresponding area on the op-
posite side of the chest, then one may conclude that
the case is one of beginning pneumonia.
No examination is complete without watching the
patient breathe. In many cases in which one base
shows diminished or absent breath sounds and a
dullness which is just dimly apparent, that base will
be seen to fail to expand equally with the opposite
base on inspiration. By placing one's hands on the
sides of the pulmonary bases of the patient, and ask-
ing him to breathe in deeply, one can frequently ap-
preciate the failure to expand better than with the
sight alone.
The cases of association of the pneumococcus with
the influenza bacillus are manifested very frequently
bv herpes labialis, a number of patients showing
very intense herpes.
We have made two observations in these cases
which are interesting. Many of the patients have
epistaxis during the stage of invasion or when they
are running fever and, perhaps, the majority of
these patients subsequently develop pneumonia.
One cannot help feeling that there is early in these
pneumonic cases some interference with the pas-
sage of the blood from the right side of the heart
through the lung with sufficient damming back of
venous blood to make possible nasal hemorrhaee on
the slightest occasion. This tendency to nosebleed
is to be correlated with the early cyanosis which so
many of these patients show. One of the striking
features of this epidemic is the blueness of the pa-
tient's face. All of them have red faces with a slight
amount of conjunctivitis so that they resemble an
earlv case of measles, and a great many subseauentlv
change from a red to a cyanotic shade. Indeed,
some of them are so red all over the body as super-
ficially to resemble cases of scarlet fever. If pneu-
monia is developing, the cyanosis is apt to become
very extreme. I have seen cyanosis quite as great
as that which occurs in miliary pulmonary tuber-
culosis or capillary bronchitis.
I feel somewhat uncertain about mentioning a
point, which has appeared in a number of in-
stances— namely, a series of red dots or spots
coming out on the trunk of patients very ill with
influenza. These red spots are frequently noted
upon the backs of the patients while they are being
examined. They look as if they might be the begin-
ning of an acne vulgaris, but they do not suppurate
antl they quickly disappear. In appearance they are
of the size and color of the rose spots of typhoid.
They are more apt to appear on the backs of those
having pneumonia. J am not altogether certain,
liowevcr, as to this point because the patients whom
I have examined were in all instances those in whom
there was a question of the existence of pneumonia.
There may have been numerous mild cases without
such spots, but I cannot speak with certainty on this
point because I have not paid much attention to the
mild cases. Nevertheless, it would not surprise me
to learn that extensive observation will disclose the
fact that these combined cases of influenza and pneu-
qjonia may show a characteristic cutaneous manifes-
tation somewhat akin to the rose spots of typhoid
fever.
SEQUELS.
In regard to sequelae, it is too early at the present
time to say what those of this present epidemic may
be. I am rather inclined to believe that there will
be some cases of otitis media following the epidemic
and some cases of delayed pulmonary resolution. I
do not believe we are going to be troubled with any
great number of empyemas ; thus far there has been
no evidence of empyema or of pleurisy with effusion
in any of our cases. Indeed, it is my belief that the
invasion is from the bronchi always to the parenchy-
ma ; hence pleuritic involvement would be the last
pulmonary sequel to appear. Surely pleuritic pain
is unusual.
IMany of the patients with pneumonia have the
ordinary crisis, but in perhaps one half the cases the
temperature gradually falls to normal. In some in-
stances the crisis is as spectacular as in uncompli-
cated pneumonia. On the morning of this writing I
saw a patient who in four hours' time showed a
drop of temperature from 103° to 97°.
PROPHYLAXIS AND TREATMENT.
Taking up the question of treatment, perhaps the
most important topic at the present time is prophy-
laxis. It is not a simple task to take care of the
situation when it has developed, but it may perhaps
be a simple matter to prevent its development.
Among large bodies of troops, the following three
factors aid in breaking down the natural resistance
to infection, and these three factors should be thor-
oughly borne in mind by all commanding officers :
I. It has become increasingly evident of late
years that anything which increases acidosis,
or, better, anything which decreases the amount
of normal alkalinity in a person's blood, in-
creases the tendency toward infection. There
are three great factors which contribute to the
production of acidosis — or more accurately to
the diminution of this alkalinity — and these are
starvation, fatigue, and exposure. We have for
a long time known that starvation acidosis is a
very definite thing. It has been met with in a
large number of cases following gastrojejunos-
tomy ; not infrequently the cause of the very
intense vomiting and death which follow is
October 26, 191S.]
MIX: SPANISH INFLUENZA IN THE ARMY.
713
starvation acidosis, relief of which, by intra-
venous injections of glucose, brings the patient
back to life and stops the vomiting. If troops
are allowed to travel long distances on trains,
improperly fed or fed at long intervals, or if
they are permitted to go without two meals out
of three in a day, their resistance to infection is
very remarkably lowered by a slight, and per-
haps immeasurable, but none the less actual
acidosis.
2. Another factor contributing toward acido-
sis is fatigue. If soldiers are very much
fatigued by long trips, excessive traveling, or
overwork of any sort, they are apt to show an
increased tendency toward acidosis.
3. The third factor is exposure to cold and
wet. Long immersion in cold water, as swim-
mers know, brings about a condition not well
recognized by those who do not think, but per-
fectly evident to those who have some under-
standing of what acidosis may do. The cause
of death in many of these cases of immersion
in very cold water is really the acidosis which
is thereby produced.
The application of these points is obvious. Young,
healthy soldiers usually can withstand strain along
one of the three lines mentioned with impunity, but
they cannot ordinarily withstand strain along any
two or three of these lines without subjecting them-
selves to the danger of infection. To put it briefly,
it may be possible for a soldier to go hungry for a
day without harming him, but on that day in which
he goes hungry he should not at the same time be
subjected to a great deal of drilling or labor in cold,
wet weather, for the combination of cold, fatigue,
and hunger is going to prove too much for him. No
soldier should ever be subjected to more than two of
these three conditions at a time ; he may be cold and
hungry if he is not tired ; cold and tired if he is not
hungry ; and hungry and tired if he is not cold. But
he should not be tired, cold, and hungry all at the
same time. If he is to be drilled hard he must be
fed well ; if he is to be exposed to inclement weather,
wet or dampness, he must be fed well and not over-
worked. Starvation, fatigue, and exposure all tend
toward acidosis which predisposes to infection.
Another possibility which presents itself from the
point of view of prophylaxis is the question of vac-
cination against infiuenza. To my mind, it it going
tQ be perfectly feasible to produce a vaccine which
will be potent. When one contemplates these great
epidemics of influenza from the historical aspect, one
is struck by the fact that they appear in periods of
time separated by about one generation. We had
our last great epidemic of influenza in 1889 and
1890. Another great epidemic preceded that one
by a generation. It seems as though there was a
certain amount of pabulum which these germs feed
upon which comes into being during a generation
and which they seize upon with avidity from time
to time, and thus a great outbreak takes place. But
the invasion of the hosts by this great outbreak im-
munizes them against subsequent attacks and the
result is that the disease apparently disappears,_not
to return again until sufficient fodder for its sus-
tenance has been gotten ready for it by the passage
of time.
The conclusion of the matter is then that the dis-
ease is one which produces widespread immunity,
and that it exhausts itself by this very trait which it
possesses. In the individual case, as well as in great
groups of persons, immunity seems usually to be
produced within a comparatively short period of
time. In typhoid fever immunity is very gradually
acquired by the host over a period of three to six
weeks. In influenza a state of immunity is ap-
proximately obtained in a period of from two to
three days in some instances, and in the majority
of cases in less than one week. Moreover, after one
has had the disease, one is immune from it. We
have no data at the present time which tells us how
long such immunity may last, except the broad ob-
servation that these epidemics occur at about one
generation of time apart. It is likely, however, that
immunity lasts indefinitely. The writer had a very
severe attack of influenza in December, 1889; dur-
ing the present epidemic he has not spared himself
in any particular and has not had the slightest sign
of any disturbance, whereas the younger members of
the staff have in many instances been temporary
victims of the malady. Whether age confers an im-
munity or not, it is difficult to say, but I am rather
of the opinion that the reason those older in years
escape the infection is that they have previously had
it or acquired an immunity against it. \\'e have ob-
served, however, that about two thirds of the young
soldiers have a natural immunity, the epidemic in-
volving as a rule about one third of the units af-
fected.
These remarks concerning immunity were made
chiefly because of their bearing upon the question
of vaccination. If there is such a thing as natural
and acquired immunity it ought to be possible to
bring about an artificial immunity in those who do
not possess it. It is not unlikely, therefore, that a
potent vaccine will be discovered which will lead to
the production of artificial immunity. Thus, it is
not too much to hope that in the future influenza
will be forced to disappear from armies in precisely
the same way that typhoici* fever has been forced to
disappear.
In the management of the active cases it is im-
perative that the patients immediately take to their
beds. Every ounce of strength must be safeguarded
and all exposure avoided. This is best done by
keeping the patient in bed. He should be kept
warm, but not too warm. Above all he should be
keptjquiet.
At present there is no serum treatment and I very
much question whether there ever will be. The dis-
ease is one which is over so quickly that serum
treatment for the influenza per se is hardly neces-
sary* It is the complication of pneumonia which
makes the disease dangerous.
The treatment of the influenza by drugs is very
simple. The only remedies which are of much value
are aspirin and salicylate of soda. The aspirin is
given in doses of ten grains every four hours, or
as much as sixty grains per diem. Ordinarily it is
not necessary to give the aspirin more than one or
two days. Salicylate of soda is perhaps slightly
7M
MIX: SPANISH INFLUENZA IN THE ARMY.
[New York
Medical Journal.
more effective, but not so agreeable a drug from the
point of view of the patient. The dose is approxi-
mately the same as that of aspirin — ten to fifteen
grains every four hours. As soon as the tempera-
ture has fallen to normal these drugs may be
omitted. As to a choice between acetyl salicylic
acid and sodium salicylate, personally I should
choose the sodium salt every time. I cannot help
feeling that the aspirin increases the cardiac weak-
ness, as shown by the cyanosis, and that sodium
salicylate does not depress the circulation at all.
This is merely a personal observation, to be taken
for what it is worth.
For the verv severe headache capsules containing
four grains of acetanilide and one grain of citrate of
caffeine are useful. Phenacetin (acetphenetidin)
would be very satisfactory if it could be obtained ;
in the old epidemic of 1890 it was very extensively
used.
We find it convenient, when the patient enters the
hospital, to see to it that his gastrointestinal canal is
put into a good hygienic state and that his nose and
throat are properly sprayed. We have done this as
a routine in certain wards, and not in others, and
have concluded that fewer cases of pneumonia de-
velop in the wards in which the nose and throat are
taken care of than in the wards in which no such
measures are taken.
In the treatment of pneumonia, the important
measure is to keep the patient alive until the crisis
is reached, and this can be done, to use a Hiberni-
cism, by keeping his heart beating. The great
danger in these cases, as in all cases of pneumonia,
is heart failure. The virulence of the toxins is very
great, and the hearts early show signs of giving out.
Tincture of digitalis — ten minims every four hours
— or infusion of digitalis — two drams every four
hours — or digitalin, i/ioo grain hypodermically
every four hours as soon as the heart shows the
slightest signs of trouble is very effective. Very
many patients show a tendency toward pulmonary
edema which may be thwarted temporarily or
permanently by the use of atropine sulphate in a
dose of 1/120 grain. For cases showing marked
cvanosi? aromatic spirits of ammonia, one drop per
minute, or twenty minims every twenty minutes in
a teaspoonful of water may tide over a desperate
place. Camphorated oil is to be used only in ex-
treme cases. We do not use it interchangeably with
digitalis during the whole course of the disease,
though some have advocated this procedure. Citrate
of caffeine in doses of one to three grains every
three or four hours has also proved of value in
many instances^^kiring emergencies.
The cases comoined with pneumonia have been
helped in some instances by venesection and by the
introduction of normal salt solution per rectum. I
have not received reports from the laboratory's yet
on acetone and diacetic acid in the urine of those
most desperately ill, who do not eat at all and who
drink but little, who are pouring out alkalies and re-
taining acids, but I am confident that a great deal
of the very intense intoxication is fundamentally an
acidosis. Here is a chance for some research work.
I am furthermore so convinced of this, that I am
giving some of these patients sodium bicarbonate by
rectum and injections of glucose intravenously. I
cannot as yet say whether this is a foolish and un-
necessary thing to do but from a priori considera-
tions it is a verv sensible thing to do. Surely about
the third or fourth day of delirium or stupor brings
with it a greatly diminished alkalinity of the blood.
Experiments with respired air should be made, but
at a base hospital with cases running literally into the
thousands there is no time for research work. The
sick must first be cared for.
The cough is a most distressing thing. Codeine is
useful, or perhaps it would be better to say is used ;
yet the cough keeps up until the toxicity so pro-
foundly lessens irritability that the cough ceases
spontaneously. During this stage of influenza
ammonium chloride is useful, but if pneumonia de-
velops it should far better be omitted. One does not
care to try to drown the patient in the secretions of
his ovv^n lungs, or to tempt the onset of pulmonic
edema. Since, however, about eighty-five in every
100 patients do not have pneumonia, and do have the
cough a good cough mixture of ammonium chloride
with codeine and paregoric is very well worth while.
Cases in which pneumonia is going to develop are
fairly easily recognized by the temperature, pulse,
and respiration charts. If the temperature, pulse
and respiration — the TPR — do not fall in three or
four days, pneumonia is to be sought for ; if the
temperature rises after it once falls, pneumonia is to
be suspected. All cases in which the temperature is
high — 103° or more — on the third day are pneu-
monia suspects and cardiac stimulation should be
started before the pneumonia is demonstrable. All
cases in which the temperature remains above 100°,
all cases in which the pulse persists above eighty-
eight, or the respiratory rate above twenty-four are
suspects. I found pneumonia today clearly dem-
onstrable in a patient with a temperature of 100°, a
pulse rate of seventy-two and a respiratory rate of
twenty. This is most unusual, but many similar in-
stances in lesser degrees have multiplied themselves.
I cannot refrain, in speaking of the convalescence
from influenza, from insisting that patients be kept
in bed five days with a normal temperature. I have
learned by mistakes. In the haste for men which
military officers show I permitted a man to be dis-
charged on the morning of the sixth day of normal
temperature ; on the evening of the seventh day we
sent an ambulance for him and found him desper-
ately ill with pneumonia, from which he subse-
fjuently died. We had one fatal case of pneumonia
(ieveloping in a boy who had three days of normal
temperature following influenza. On the evening of
the fourth day his temperature was 100.2°, on the
morning of the sixth day it was 106°. We have
reached the conclusion that ,it is wholly unsafe to
send out a patient before he has had at least seven
days of normal temperature ; and I think that as my
experience increases I shall arbitrarily raise my date
of discharge to ten days of normal temperature.
In treating large numbers of men it is highly im-
portant to separate the pneumonia patients from the
pure influenza cases. I am fully convinced that this
measure is as important as quarantine in measles.
This we diligently do by searching out the pneu-
monias and transferring them. I am not of the
October 26, 19 1 8.] COPELAND: GENERAL SURVEY OF INFLUENZA
NZA.
opinion that the patients should wear masks ; they
need to have unhampered respiration. If I had
pneumonia and were not delirious I would not con-
sent to wear a mask. Attendants may wear masks
and are asked to do so by government officials, but
I would personally caution all those wearing them
to put a new one on every time a patient coughs
towaul them ; for it is easily conceivable that a good
dose of influenza bacilli and pneumococci lodging
on the maks will, by the industrious breathing of
the wearer of the mask, be ultimately drawn into
his own system. Better far than masks is resistance
to infection built up by plenty of food, enough rest
and hours of sleep, and freedom from exposure.
In camps, these two considerations, so large and so
fundamental, are lost sight of in the minutiae of
formulated schemes of action and conduct.
The same broad considerations should control in
the wards. Screening of the patient is advisable,
but is wholly contraindicated when it interferes with
the far greater necessity of free exchange of pure
air. Cubicles may be all right in themselves in cer-
tain types of hospital construction, but not in all
types; and uniform adherence to directions as to
cubicles, without due consideration being paid to
the getting of the maximum amount of pure air by
the patient, is to say the least, inadvisable.
There is no rule of thumb for the treatment of
influenza, either pure or complicated by pneumonia.
If the cases are pure they almost cure themselves.
If they are complicated by pneumonia, the problem
is really the treatment of pneumonia and will have
to be met in the usual routine manner.
As regards serum therapy for the pneumonia fol-
lowing influenza, only cases of Type I are at present
very much helped, and we are using in cases of this
type the Type I serum. One of the great difficulties
in an epidemic of this extent, however, is the vast
amount of work suddenly thrust upon the labora-
tory. The course of the disease is so rapid that by
the time the patients are "typed" they are either
convalescent or dead. We have used the serum in
the Type I cases faithfully, but the results which
were obtained were no better than in the untreated
cases. This is probably due to the fact that the
pneumonia in all cases is compHcated by influenza ;
just as in Type IV the prognosis is made very bad
by the associated influenza, so in Type I the same
thing is true.
PROGNOSIS.
The prognosis in all of the uncomplicated cases
of influenza is uniformly good ; it is grave only in
the cases of those having pneumonia. In evaluating
the percentage of deaths from pneumonia, one
should take into consideration only the total num-
ber of influenza cases and the total deaths from
pneumonia. If one attempts to base statistics upon
the number of deaths in the number of cases of
pneumonia discovered, one may be somewhat in
error, owing to the fact that in many of these pa-
tients a diagnosis of pneumonia might be made by
one physician and not concurred in by another. In
this base hospital where every single case of pneu-
monia is seen by the writer, our mortaHty is running
approximately one third of all the pneumonia
complications. On the other hand our proportion
of deaths among the total cases of influenza is run-
ning at approximately two per cent. The pneu-
monia usually appears on the third or fourth day ;
death, when it comes, usually occurs before the
sixtli or seventh day. If the patient survives a
week he is very apt to get well. Cases of double
pneumonia have been numerous and almost uni-
formly fatal. Patients with early cyanosis, those with
nosebleed, those with delirium and with great pros-
tration, and those who are somnolent or stujxjrous,
all are very prone to die.
GENERAL SURVEY OF THE INFLUENZA
EPIDEMIC*
By Royal S. Copel.a.nd, M. D.,
New York,
Commissioner of Health of the City of New York.
It is meet and proper that at a time as critical as
the present, and one fraught with tragic con-
sequences to the lives of so many of the people of
this city, the commissioner of health should ap-
pear before the medical profession to submit to the
judgment of its members a report of the activities
of the health department and a statement of the
reasons which have guided him in determining upon
certain procedures and in omitting certain others
which have been suggested from time to time. I
gladly avail myself of this opportunity accorded me
iDecause I have consistently attempted to keep the
public, lay and professional, fully informed of con-
ditions.
To begin with, it should be borne in mind that we
have been living in abnormal times. It is quite
likely that when the history of this epidemic comes
to be written, it will be found that it originated in
the Orient, and that it was carried through the chan-
nels of military and commercial communication into
Europe, and after spreading far and wide to every
country of the latter continent, it was brought to
these shores by vessels bringing traders, passengers,
and troops who had left countries in which the epi-
demic was actively waging. The urgent necessities
of the war probably determined the federal author-
ities who guard our ports of entry, in the decision
to admit ships bringing persons affected with influ-
enza as well as those who were carriers.
We should bear in mind the fact that the large
cities of this country were powerless to put into
effect any official prohibition against the admission
into this country of influenza cases and influenza
carriers. The machinery of the health department
has through the course of many years been designed
and shaped to prepare to meet emergency situations.
We have been handicapped, unfortunately, by the
enlistment in the military service of a large number
of doctors and nurses of the health department
staflF. It should be stated in justice to those who
compose the health department's personnel, as well
as those who have exercised an influence in the past
in directing the organization and the building up of
the machinery of the department, that notwithstand-
•Address delivered at the meeting of the Eastsm Medical Society
on October iith, and at the regular meeting of the Academy of
Medicine on October 17, 1918.
7i6
MIX: SPAN'. GENERAL SURVEY OF INFLUENZA EPIDEMIC.
[New York
Medical Journal.
ing the haiulicnjxs produced by the depletion of its
nursing and medical forces, the health department
promptly and energetically met the situation. It is
but just to pay tribute to the devotion, zeal, and tire-
less efforts which have marked the conduct of all
of the employees of the health department in meet-
ing the critical situation which we are at present
facing. Doctors and nurses of the health depart-
ment have rendered most excellent service in the
nursing and care of patients in the home and in the
medical treatment of many afflicted persons, who
would otherwise have been without such care in
their severe illness.
Methods of prevention have been acknowledged
by the foremost authorities in the world to be the
most effective in protecting a community against
epidemic diseases. In so far as the prevention of
the entrance of the epidemic diseases in this country
is concerned, dependence must be placed first and
foremost upon the rigid guard which is maintained
at the ports of entry to this countrj'. These guards,
for reasons which have already been indicated,
could not, in the judgment of those who were re-
sponsible for their operation, be maintained during
these abnormal times.. Our first line of defense
was, therefore, weakened. From various ports and
various cities, there converged upon New York as
upon other communities, a number of influenza car-
riers, and these, unrecognized in most instances,
were the sparks which lighted the conflagration.
Secondly, the production of a vaccine which
would effectively protect persons against influenza,
has not yet passed the experimental stage, and its
use on a large scale has been decried by some as
tending to produce a special susceptibility to the dis-
ease during the negative phase which it produces.
At all events, while those most competent to decide
are not yet in accord with its value, it offers as yet
only a measure of promise as an agent in the
prevention of the spread of the disease.
For the tim.e being, every function of the health
department which does not contribute to the pre-
vention of the disease or to the care of the suffer-
ers, has been suspended or subordinated. The De-
partment of Health has reached out to hospital^ so
far as it could through persuasion, and through the
exercise of arbitrary power has taxed every avail-
able resource and has combed this city, as well as
neighboring cities, for the skilled and unskilled
workers who are necessary for the operation of
places which have been established as emergency
hospitals. Every day the department is supplying
nurses, nurses' aids, orderlies, and the other helpers
who are essential for the proper operation of an in-
stitution for the care of the sick.
I ;im grateful for the support which the Academy
of Medicine, through its members individually, and
through its Committee on Public Health, has ac-
corded me in these trying days. I desire to take this
occasion to acknowledge my thankfulness for the
heartening and generous expression of commenda-
tion given by the Public Health Committee of the
Academy of Medicine in its communication of Oc-
tober Toth, in which it stated that it approved all
the measures adopted by the health department and
extended an offer of cooperation.
The public press of this city has been most gen-
erous in serving as the medium for the education of
the people. Public health education has been de-
pended upon through placards, through circulars,
and through verbal instruction in the public schools,
to apprise the public of the danger of close contact
with unrecognized cases of influenza, especially in
crowded public places. The success of public
health education is, at best, limited. Its power to
prevent crowding and to secure the observance of
those fundamental laws which are essential for the
safeguarding of personal and community pubHc
health has well defined limitations. While avail-
ing ourselves to the utmost of its services, let us
not overrate its value. The sanitary police of the
Department of Health, and the police department
as well, have been active daily in arresting
those who are guilty of spitting, and large fines,
which should have a deterrent effect upon the con-
tinuance of this practice, have not sensibly dimin-
ished it even though placards conspicuously placed
in subways, stores, and elsewhere, have informed
persons of the menace which this practice offers to
health. We have, so far as human power, fore-
thought, and earnestness make it possible, bent every
energy to the adoption of every procedure which
has been commended by authoritative opinion.
In the citv of Washington, to all practical intents
and purposes, the government is the one large em-
ployer of labor, and the establishment of a relay
system of traveling to and from work is a matter
of relative simplicity. We have in the city of New
York taken radical action to prevent crowding in
the subways, and in the elevated and surface cars.
Thousands of business men have assisted in a spirit
of sacrifice that is perhaps unprecedented.
It is not mv disposition to complain of the co-
operation which private physicians are giving at a
tinne when each of them is bearing a strain such as
they have possibly never borne before, but I desire
to bring home to every practising physician the real-
ization that their reports, valuable as they are for
statistical purposes, serve an even greater purpose,
namely, to give us a better picture of conditions in
the citv than is possible from the fragmentary, dis-
jointed, and sometimes highly colored statements
vv^hich are made by individual observers who have
limited or personal sources of information, and who
reflect an experience which may be peculiar.
The Department of Health has bent every effort
to make the reporting of cases of private physicians
complete, so that it might be in possession of all the
facts which would enable it to concentrate the com-
bin^^d attack of its own staff and that of the social
agencies in those districts in which the disease is
most prevalent. It should be realized by all prac-
tising physicians in the city of New York that they
have not discharged their full duty to the patients,
if they have merely prescribed medication and other
forms of treatment. Those officially responsible
must not be held accountable for failure to make
adequate hospital, nursing, and medical provision
for the needs of the commimitv, if doctors who are
in direct touch with the entire situation fail to report
to the health department, so that the commissioner
may know how widely prevalent the disease in real-
I
October 26, iQiS.] COPELAND: GENERAL SURVEY OF INFLUlLUENZA. ,]C.
717
ity is and the localities in which it may be more
markedly concentrated. The department does not
wish to acquire these reports for other purposes than
for cooperative action and to enable it to serve the
pressing needs of the community.
The nurses' settlements, the Salvation Army, the
health department clinics, and other agencies have
been established as centres to which cases in urgent
need of medical and nursing care can be reported.
These cases are given immediate attention so far
as the resources of the department and these social
agencies permit. An Emergency Advisory Com-
mittee has been appointed, and its members, though
only recently called together, have already contrib-
uted valuable aid in their respective fields. This
advisory committee has representatives from the
American Red Cross, the United States Public
Health Service, the Academy of Medicine, Mer-
chants' Association, private hospitals, nursing serv-
ice of the city, and similar agencies. Through the
coooeration of the multiplicity of social agencies al-
ready organized in this city, there have been estab-
lished numerous centres whose purpose it is to co-
ordinate and harmonize the efforts which all these
agencies are making to secure nurses and doctors
and unskilled aid, to furnish food to the sick, and
to furnish motor cars and motor trucks, the former
to be used to take nurses and doctors from place
to place with the greatest dispatch. A clearing
house has been established in the Department of
Health to ascertain daily which of the hospitals have
vacancies, and to refer all cases in need of hospital
care to the nearest hospital offering such accommo-
dation.
It seems to me of the utmost importance that the
influence of every member of the medical profes-
sion should be brought to bear upon every private
hospital or other institution which may be adapted
for the hospital care of j>ersons suftering from in-
fluenza and pneumonia, so as to reduce to a mini-
mum the accommodation for surgical and medical
cases which are of an emergency character. It
would seem to me also most essential that every
vacant bed in any of the private or public hospitals
of this city should be under the control of a central
agency, such as the health department, so that the
distribution of patients to the various institutions
may be equitable and in accordance with the needs
of the various sections of the community.
Furthermore, it seems to me that the time has
come when every other consideration must give way
before the paramount needs of the situation created
by the epidemic, and every specialist, who in the
normal course of his daily life devotes considerable
time to laboratory, dispensary, or other work which
is not of an emergencv character, should come for-
ward and volunteer to respond to the calls for medi-
cal assistance which come from any quarter of the
city, where the physicians of the district are hard
driven and unable to care for all those who are sick.
Such specialists should be roused to the pressing
needs of the moment and should enroll under the
direction of the central agency, namely, the health
department, so that they may be placed where they
can best serve those who are sick. Such service
is as finely patriotic and humanitarian as any that
they could possibly perform.
In almost every important essential, the recom-
mendations, which the Public Health Committee
of the Academy of Medicine was good enough to
submit on October loth, were already in efifect or
were being put into operation at the time when the
suggestions were received.
Time does not permit of an extended review of
the manifold activities which the department has
entered upon in connection with its effort to con-
trol the epidemic and to alleviate the condition of
those who are suffering. While it would offer very
little consolation to those who have been bereaved
by the loss of a dear one through this disease, it is
nevertheless well to bear in mind that New York
city with its 5,750,000 of jwpulation has had a much
lower mortality rate from influenza and pneumonia
during the last four weeks than is reported by any
other American city at the same stage of the epi-
demic. From September i8th to date, we have had
a total of 5,725 deaths from pneumonia and influ-
enza combined. This total includes a number of
deaths which would in normal times be present in
this community from these respective causes.
However uncertain we are as to the actual prev-
alence of this disease in the community, because of
the insufficiency of reports from private physicians,
we have in the recorded number of deaths a valu-
able index. A comparison with the number of
deaths reported at the same stage of the epidemic
in other cities will demonstrate that the city of New
York has thus far, tragic and serious as the conse-
quences ofjhe epidemic have been, fared very much
better than other municipalities. We have taken
counsel in our administrative procedures, as already
mentioned, with some of the foremost authorities
in public health work in this country.
It is well that it be emphatically recorded that the
attitude of the health department with respect to
the closing of schools, theatres, and other places of
public assembly is the result of study and delibera-
tion which were conducted with an anxious regard
to do that which was best for the city as a whole.
Such eminent authorities as Charles V. Chapin,
William H. Welch, Milton J. Rosenau, Victor C.
Vaughan, as well as several of the prominent mem-
bers of this society, have emphatically endorsed the
attitude of the department with respect to its de-
cision as to schools and theatres. It requires cour-
age to assume such an attitude in the face of opinion
which is not based upon authority or study. It is
worthy of note that the citie^ which enforced the
most rigid closing orders for theatres, schools,
churches, and other public assembles failed to ex-
perience any marked reduction in the prevalence of
this disease, except in one or two instances where
the closing order went into effect at or about the
time when the decrease was unrelated to any
activity of the health departments of those cities.
It is amazing to find that the mortality among chil-
dren from five to fifteen years of age is almost half
that of children under five years of age. Our con-
trol of such children who go to school secures them
a degree of safety impossible if they were allowed
on the streets. Our rigid school medical inspection
7i8
• EPIDEMIOLOGY OP INFLUENZA.
[New York
Medical Journal.
of the children who dail}' attend and of those who
return after absence; our prevention of assembHng
of children in the playgrounds ; the opportunity that
we have to educate these children through the
school teachers and to educate their parents in turn-
all tl'.ese are advantages which are of overwhelming
importance and justify the stand which the health
department has taken. As to closing the theatres,
moving picture shows and the like, a discriminating
attitude has been adopted, those places being shut
dov,"n which were found upon inspection to violate
the sanitary law^s and to be favorable to the breeding
of disease. Had we adopted a universal order with
respect to the closing of theatres and moving
picture shows, we should then logically have closed
every department store, every office and factory,
every restaurant, and cabaret show, and every club.
The disease is one which is spread to a large degree
by contact in the home, and even if we went through
some Utopian method of policing to confine every
person to his or her home, it is doubtful whether
the epidemic could be measurably diminished.
Those in private practice see the disease'spread
from one member to all other members in the same
family in a way which would seem clearly to indi-
cate contact in the home as the distinct cause. Our
record of 5,725 deaths with a population of
5,750,000, as opposed to the record of 10,741 deaths
in the various army camps of this country which
total a strength of about a million, makes an en-
couraging showing and gives warrant for the belief
that our steadfast adherence to our views with
respect to the closing of places of public assembly
is justified.
In conclusion I may say that the Department of
Health stands ready to help the medical profession
in every possible way. We welcome all helpful sug-
gestions, all information that will contribute toward
the solution of this problem, all constructive criti-
cism ; but in return we want the assistance of the
profession, principally in reporting the cases. The
situation has taxed the resources of us all and we
are all doing our best to bring it to a conclusion. I
sincerely hope that another ten days may see jis
past the worst phase of the epidemic.
EPIDEMIOLOGY AND ADMINISTRATIVE
CONTROL OF INFLUENZA.*
By l-ouis I. Harris, M. D., Dr. P. H.,
New York,
Director, Bureau of Preventable Disease?, Department of Health.
Aside from such information as came to us
through the medical journals, we had no intimation
of the type of influenza which has since become epi-
demic, until August II, 191 8, when we were in-
formed by the quarantine officer that a Norwegian
steamer had arrived in this port, giving a rather in-
teresting history. We found, upon investigation,
that during the voyage two hundred passengers had
become ill. A fairly large number of them had
complained of abdominal pains, headache, general
prostration, and fever ; in addition to these symp-
\oms they suffered from diarrhea and vomiting. On
•Address delivered at a meeting of the Eastern Medical Society,
October n, 1918.
the Other hand, in a fairly large group of these there
was a history of fever, prostration, and symptoms
of acute respiratory inflammation. This history
taken together with the fact that the ship had fol-
lowed a zigzag course in its voyage across the At-
lantic— alternating between the torrid zone and re-
gions in which icebergs were encountered — caused
some of the observers to believe that these symp-
toms were purely a reaction to marked atmospheric
changes. Eleven patients arriving on this steamer
were seriously ill, suffering from pneumonia, and
these were removed to a hospital, and constant
supervision was exercised over these patients to
prevent the transmission of infection, for it was
suspected that they were cases of influenza.^ Those
passengers who were convalescent or who had
come in close contact with the sick were followed
up by nurses of the Bureau of Preventable Dis-
eases, with a view of discovering any new cases that
might develop, and to restrict the activities of such
persons until an adequate period of time had elapsed
to make it reasonably safe for them to go about.
Shortly thereafter, a French troopship and sev-
eral freight steamers arrived, each bringing a few
cases which were diagnosed as influenza and which
were promptly removed to the hospitals of the
health department, those who had been in contact
being kept under surveillance.
For the period of several months prior to Sep-
tember I2th, passenger steamers and freighters, as
well as troopships, were entering this port, each of
them discharging large numbers of patients, among
whom it is entirely reasonable to suppose there were
numerous carriers or missed cases of influenza. The
same story is true of the other ports of entry in
this country, and it would seem just to assume that
the epidemic was started by numbers of patients
who were admitted at the various ports of entry in
this country. The safeguards which have been
established to prevent the entrance of infectious dis-
eases to this and other ports have had to be relaxed,
apparently because of the great need of leaving un-
disturbed the channels of communication with the
seat of war.
The departments of health of this and of other
cities, which normally looked to the quarantine offi-
cers at the various ports to stand guard as a first
line of defence to prevent the entrance of persons
suffering from infectious diseases into this country,
were powerless to exercise their official powers to
prevent the entrance of infected persons who started
an epidemic which has exacted a large toll of lives
in this country. Before discussing the administra-
tive measures which have been adopted in this city
for the control of the epidemic, so far as its control
lies within the power of the health officials — after
thousands of foci had been distributed throughout
the country — it may be of interest to point out some
epidemiological facts with reference to the present
epidemic.
Shortlv after this disease was made reportable —
that is about September 2oth — the reported cases
seemed to show, upon analysis, that very few per-
sons other than those between the ases of twenty-
' A report of these cases was made by Dr. Edward E. Tornwall,
under whose care they came in the Norwegian Hospital, and pub-
lished in the New York Medical Journal for August 24. 1918.
October 26, 1918.!
H.4RRIS: EPIDEMIOLOGY OF INFLUENZA.
five and thirty-five years, were attacked by the dis-
ease. The preponderance of cases among those in
the latter age group continued to be very marked
until the first of October, approximately. From all
indications the epidemic seemed to have become
actively manifest about September 15th. There-
fore, for a period of about the first two weeks of
the epidemic, persons between twenty-five to
thirty-tive years of age seemed to bear the brunt
of the attack. P'rom October first up to the present
day, the epidemic has shown a distinct tendency to
expend a large part of its force, not only upon
those between twenty-five and thirty-five years of
age, but upon earlier age groups as well. Out of
a total of 25,082 cases of influenza reported to the
Department of Health by private physicians and
hospitals from September i8th up to and including
October nth, the ages of affected persons were
given in 21,211 cases. Of this number,,
2,140 cases were children under five years of age;
4,865 cases were children from five to fifteen years of age;
4,726 cases were persons from fifteen to twenty-five years
of age ;
4,833 cases from twenty-five to thirty-five years of age ;
1,957 cases from thirty-five to forty;
2,641 cases forty years or over.
At first, apparently, those most easily susceptible
to the disease, namely persons between twenty-five
and thirty-five years of age who were in contact
with carriers in the markets of the world, in offices,
factories, subway cars, and in other places of public
assembly, were afifected. One may reasonably as-
sume that these cases as they increased in num-
ber served as foci of infection in their respective
homes. Apparently the disease, which had first
been spread about through the avenues of commer-
cial and mercantile intercourse, was carried into the
homes, and domestic or family contact probably be-
came the chief source of transmission.
While in the pandemic of 1890, the disease af-
fected males chiefly, in the present epidemic it is
worthy of note that from the very outset the num-
ber of females afifected has been equal to the num-
ber of males. This change is perhaps accounted
for first by the fact that in the last decade women
have in increasing numbers entered industry, and
have during the period of the war, especially, taken
over thousands of places formerly filled by men,
and second, by the fact that a large number of men
belonging to the age group which is most susceptible
to this disease are now engaged in overseas military
service.
Extent of the epidemic. — The actual extent of
the epidemic in this city is difficult to measure. The
commissioner and those of us who are assisting him
m the control of the present epidemic fully reaHze
that only a fraction of the cases actually occurring
in this city are reported by private physicians. The
cases reported to us are of value, not because they
give an adequate notion of the extent of the dis-
ease, but rather because they represent the report
of a number of physicians in active practice who,
from the outset, have continued to report the
cases coming under their care, thus giving us a
daily cross section which fully depicts the varia-
tions in conditions as seen by a fairly large group
of practitioners. However, in the number of .deaths
reported daily to the heal.
from both pneumonia an
index which, in the ligh
perience in this disease,
eign countries, in various
communities, gives us a fa
of estimating the extent of
community. In the various
this country, the mortality amon^
has been about four per cent.
higher than reported in civil co.
suming the mortality in the city o.
have been quite low, so as to make t
the total number of persons affected
as liberal as possible, we have calcula
2,550 deaths from influenza and pneun
have been reported from September 18.
represent a mortality rate of two and
per cent. Therefore, the total number of
aft'ected up to the present time would be
T02,ooo. Unless reasons appear which woi
dicate the necessity of changing the method c
calculation, it would seem just to assume that a
stage of this epidemic, the most liberal estimatv
to the extent of its prevalence would be obtained
multiplying the total number of deaths by fort
on the assumption that the deaths represent bt
two and one-half per cent, of all persons affected.
Several times during this epidemic, the nurses of
the Bureau of Preventable Diseases have made a
block census, visiting each home in a given area to
ascertain the number of persons who were sick and
thus to secure data as to the probable prevalence
of the disease. This evening, October nth, a
census of six densely congested blocks in the
Borough of Manhattan was completed by nurses
of the Bureau of Preventable Diseases. The
Borough of Manhattan is divided into seven dis-
tricts. A congested block in each of these districts
was chosen for the purpose, with the following
results : 3,041 families, consisting of 10,594 persons,
were visited by the nurses. The total number of
cases of influenza which they found during this
census was 335. Of this number, however, 220
were under the care of private physicians who had
established a diagnosis, and 115 persons were not
under medical care, but had assumed to diagnose
their own condition. Indications, therefore, are that
at the present rate the disease is not nearly as wide-
ly prevalent as it has been estimated to be by a
number of unofficial observers.
The disease is causing grim and tragic conse-
quences which all must regard with great sorrow.
It is most important, however, to bear in mind that
terrible as the loss of human lives in this com-
munity will be found to have been, when the
epidemic is at an end, we will have much to be
grateful for if the mortality rate among those
affected will Jiot have risen a great deal higher be-
fore the disease has run its course. This point of
view is of the utmost importance if one wishes to
appraise justly and calmly the guiding principles
which have governed the conduct of those of us who
have been responsible for establishing a definite pro-
gram for control and prevention of the epidemic in
this city. The commissioner and his official advisers
HARRIS: EPIDEMIOLOGY OF INFLUENZA.
[New York
Medical Journal.
iSel of many who are ap-
.he tragic events through
dhered to an administrative
a painstaking and most earn-
jlcms created by the present
be discussed more in detail
ice. — The present pandemic, un-
of 1890, has traveled from coun-
Liring the summer months of the
eem that seasonal influences play no
ent situation.
/ the infection. — During the early
present epidemic in this city, a very
r of virulent infections were observed
al hundred cases treated in the hospitals
,partment of Health. Many cases were
Jminating type. During the first days of
ent month it was noted by the physicians
jre attending the cases in our hospitals that
jease had assumed a somewhat milder form,
-hat the severe intoxications, delirium, and
ily fatal terminations were not nearly as fre-
nt as during the early period of the epidemic,
iparently the previous state of health of persons
t'ected by this disease has had little relation to
leir susceptibility and to the course of the
disease. Robust and vigorous soldiers and sailors
were seriously attacked and seemed able tO' of¥er
little, if any, resistance to the infection. It would
seem that those persons about the age of thirty-
five, and particularly those who were over forty, and
who very likely survived attacks of influenza in pre-
vious years, enjoyed the largest degree of immunity.
It would seem that the exposure to inclement
weather, fatigue, and crowding in dormitories were
largely influential in causing robust and vigorous
men enlisted in our army and navy to be attacked
by the disease. It has been stated by some observers
that one attack of influenza does not protect against
subsequent infection by the influenza bacillus. If
there is any merit in the theory that there is a sur-
vival immunity among persons forty years of age
and over, it would seem to argue powerfully against
the view that one attack predisposes rather than
protects against a subsequent one.
An unusually large number of deaths have been
attributed to influenza. On many days the
number of cases which were reported to be due
directly to influenza was greater than the number
of deaths reported from secondary pneumonia or
bronchopneumonia. It is incredible that about
fifty per cent, of the deaths reported are due to
the effects of influenza itself. It would seem, in the
light of the best clinical experience, that many of
these patients die as the result of a bronchopneu-
inonia in which the physical signs are few or unrec-
ognized, and in which toxemia dominates the pic-
ture. It is important and of interest ^to note that
nearly seventy-five per cent, of the deaths reported
during the present epidemic have occurred in per-
sons between the ages of fifteen and forty-five:
slightly less than ten per cent, of these deaths have
occurred in children under five years of age ; and
remarkably enough children of school age — -namelv
those between five and fifteen years — although
equaling the number of cases reported between the
ages of twenty-five to thirty-five, have contributed
only 5.8 per cent, of the deaths thus far reported.
Administrative procedures. — In the main it will
be found upon comparison of the administrative
procedures for the control and prevention of the
epidemic that different communities have adopted
very much the same program, in so far as essentials
are concerned. In New York city both influenza
and pneumonia were made reportable by an amend-
ment to our Sanitary Code on September 17th, a
few days after the disease was recognized as having
gained entrance into this city. An educational cam-
paign, through placards placed in subway, surface,
and elevated cars was immediately begun ; circulars
of information for the prevention of the spread of
the disease, together with instructions for the care
of the sick, were promptly issued; and the news-
papers, which have generously and unstintingly
given aid -in the campaign, furthered every effort
of the health department to spread broadcast a
knowledge of the rules and instructions established
by the latter. This epidemic has been a dem-
onstration of the fact that public health education,
in the sense in which the term is ordinarily em-
ployed, has a very narrow limit of usefulness. If
one were to weigh all evidence dispassionately it
would probably be found that in spite of the well
organized educational campaign in which many
agencies have assisted, it has been impossible
through this means to check the indecent and dead-
ly habit of spitting in public places, and to educate
persons, many of them quite intelligent, to use a
handkerchief when coughing or sneezing. Many
arrests have been made in the city of New York
for spitting during the last few weeks and heavy
fines have been imposed by the judges before whom
these culprits were brought, but these punitive meas-
ures have little or no value in restricting the practice.
It should be recognized that preparedness is the
most essential principle in applying public health
education. It would seem to be of the utmost value
to impose a rigid discipline upon school children so
that they may grow up to appreciate the danger of
spitting, coughing, and sneezing without the proper
use of a handkerchief. We have adopted vigorous
efforts to supervise places in which food is
prepared and sold, and particularly in the super-
vision of soda water fountains to secure the proper
washing of glasses and spoons. There is, unfor-
tunately, a popular prejudice against the use of the
paper cup at soda water fountains which
prejudice has retarded the manufacture of
an adequate supply of this most important article
for the prevention of the spread of disease. This is
another subject which would seem to merit public
health education as a part of the school curriculum.
Quite early in the course of the epidemic, the
commissioner inaugurated an epoch making experi-
ment in instituting a relay system for the opening
and closing of business establishments, thinking in
this way to minimize the crowding which follows as
the result of having an opening and closing hour
almost identical for all trades and industries.
All nurses of the Bureau of Preventable Diseases
and a number of those employed in the milk stations
of the Bureau of Child Hy.giene have coordinated
with the other home visiting nursing agencies of this
October 26, 1918.]
HARRIS: EPIDEMIOLOGY OF INFLUENZA.
721
city and are now giving actual care to the poor who
are in need of such services. Several hundred pa-
tients are under the care of the Department of
Health nurses, to say nothing of those cared for by
other agencies which have previously given service
of this type to the community. The diagnosticians of
the Bureau of Preventable Diseases have been more
than doubled in number and have responded to the
call of persons in the community who could not af-
ford to pay for the services of a private physician.
They are working hard to meet the demands made
upon them. Unfortunately there was no system of
central control of all physicians in this city, such as
is contemplated in health insurance, which would
guarantee to every person in the community, however
poor,, the privilege of securing medical service, and
which would enable a central authority to distribute
the physicians where their need was greatest ; in this
way much of the waste, energ}', and time which fol-
lows from an individualistic system of medical
practice during a crisis such as the present would be
eliminated. Whatever the merits of health insur-
ance or any other system of central control of medi-
cal practice in the community may be, there is no
doubt that in such an emergency as the present —
and particularly because the ranks of the medical
profession in this city have been depleted by the call
to military service — a more equitable and just
method of distributing medical care would have
been possible. Under a system of central control,
many specialists who are now pursuing their normal
daily routine, could have been commandeered to
render emergency aid.
The public schools have been allowed to remain
open.'not as the result of laxity or because the com-
missioner and his official advisers have failed to
appreciate the solemn responsibility which devolves
upon them, but as the result of searching, painstak-
ing, and thorough study of the merits and demerits
of such a procedure, and also as the result of coun-
sel obtained from some of the foremost public
health experts in this country. As the result of our
deliberations and studies, we feel certain that the
commissioner has taken, not only a courageous, but
a sane and scientific view of the situation in keeping
the schools open and utilizing many special provisions
for safeguarding the health of the children which
have been devised to meet the present situation.
From present indications, it seems likely that when
the epidemic shall have passed, and when its results
will have been carefully recorded, that it will be
found that the city of New York has compared
more than favorably with other cities, in the sanity
and wisdom of its procedures, and in the results
achieved through such methods, especially when
contrasted with the illogical and arbitrary methods
employed in some communities where fear and
panic have prevailed. The children, under special
arrangements made in the city of New York, are
being more carefully guarded through medical
supervision and through the intelligent oversight of
teachers than ever before in the history of any com-
munity. This is a venturesome statement, but I be-
lieve will be found to be true. Thus far we have dem-
onstrated that with many hundreds of thousands of
children imder our supervision, the schools have
continued in operation without producing any au-
thentic evidence that our school population has been
thoughtlessly exposed to greater ''anger than they
would have encountered on the ; .reels of the city
of New York where they would be without rigid
and constant supervision and without the concen-
trated educational attack which is made upon them
each day as the most important part of the curric-
ulum during the period of the epidemic.
The commissioner of health has closed only
such moving picture theatres as were found to be
violating the sanitary laws or harboring conditions
conducive to disease. Unlike other communities,
the city of New York has not closed the theatres
and the moving picture theatres indiscriminately,
because we could not carry such a procedure to its
logical conclusion, without the paralysis of indus-
try and of social life which would have made con-
ditions in this, the greatest city in America, intoler-
able. Had we closed theatres and moving picture
theatres it should have followed logically that all
department stores, all restaurants, all clubs, all
offices in which workers were congregated, and all
factories in which they come together in large
groups, and every transportation line should have
come similarly under the ban. It will be interesting
to note when the epidemic has come to an end, if
an honest and accurate system of accounting has
been kept in each community, that the prevalence
of the disease will have been just as great, if not
greater, in those cities in which vigorous closing
measures were adopted as compared with the city
of New York. One may venture to predict with
confidence, realizing how dangerous prophecy is,
that the usual quota of from twenty-five to forty
per cent, of influenza cases in each community will
have been recorded, providing of course that a
careful system of records has been kept.
It will be realized in time no doubt, that contact
in the home was one of the most important, if nof
the most important, of all causes for the transmis-
sion of the disease throughout the community.
Possibly we will begin to realize when this epidemic
13 over, that in our reform of housing conditions,
vve must strive to insist upon a standard which
will give the poorest family in our community an
adequate number of rooms to make at least a small
measure of isolation of the sick possible when a
case of infectious disease occurs in a family. In
time it will come to pass, though this is perhaps
a Utopian conception, that the law will com.pel the
building of apartments and the maintenance of liv-
ing cotiditions within them to be of such a stand-
ard that it will be held illegal to have families
herded as they now are in various congested sec-
tions of the city, and it will come to be realized
that no member of the community, however rich
and sheltered, is safe from the visitation of an
infectious disease with its terrible consequences,
unless the poorest members of the comm_unity live
in such fashion that infectious disease may not
select their habitations as a breeding place for con-
tagion and pestilence which- radiate to all other
homes m the community. And public health edu-
cation in our elementary schools, night schools,
high schools, and colleges will perhaps be made in-
creasingly of a character to promote an understand-
ing of personal and public hygiene and sanitation.
722 MANGES: SYMPTOMATi
SYMPTOMATOLOGY OF THE PREVAIL-
ING EPIDEMIC INFLUENZA *
By Morris Manges, M. D.,
New York,
Visiting Physician, Mount Sinai Hospital. Professor of Clinical
Medicine, University and Bellevue Hospital Medical College.
Two days ago I was invited by your president to
open this discussion on the prevailing pandemic of
influenza. Naturally, on such short notice and
with very little spare time for its preparation, no
attempt at a complete paper was possible. I have
simply attempted to note the more striking features
of the disease as I have observed it.
One of the chief points of interest is its occur-
rence in young adults between the ages of eighteen
and thirty-six years of age, the decade between
twenty and thirty being the period of greatest fre-
quency. At the onset of the pandemic very few
children and adults beyond the age of forty were
attacked. As the disease became more prevalent
the number of children attacked increased, but the
severity of the disease in them was much less
marked than in young adults. The older adults
have remained relatively free. The oldest patients
I have seen who have been attacked were fifty-
three and fifty-four years old. It is true that many
cases have been reported among older persons, but
I am convinced that most of these cases are not true
influenza. There is a natural tendency to attribute
every case of acute pulmonary disease which occurs
at the present time to influenza ; but it must be re-
membered that we always have had respiratory dis-
eases at all seasons of the year.
This incidence of influenza among young adults
is strikingly unlike that of the pandemic of 1889
and 1890, when all ages were attacked alike. The
malignancy was most marked in older adults and
the aged. That the older persons should be spared
in the present pandemic is readily understood, for
they have acquired immunity either by having had
the disease in the pandemic of 1889 and 1890, or
through natural immunity ; but why the children
should be more immune this year and have the dis-
ease in a milder form, is very difficult to under-
stand.
Another point of great interest is the distinction
in social grades. In the better class of people are
_ seen only milder types of the disease, and even
those are relatively few in number, whereas nearly
all the severe cases which I have seen have been in
my hospital service or in consultation ; they have
occurred in the lower middle classes or in the poor
— people who have been living in crowded places or
have traveled in the subways and crowded street
cars. On account of this congestion they have been
brought into close contact with those suffering from
the disease or have acquired it while nursing sick
members of the family.
There are three distinct types of onset. The
first begins with a mild onset of muscular pains,
headache, coryza, and slightly elevated temperature.
This condition lasts two or three days, and the pa-
tient is well. With some this marks the termina-
*Address delivered at a meeting of the Eastern Medical Society,
New York Academy of Medicine, October ii, 1918, as part of a
Symposium on Influenza.
[Nev
LOGY OF INFLUENZA. „ [New York
Medical Journal.
tion of the disturbance. But there is a large num-
ber in this group who, after being apparently well
for four or five days, experience a sudden change ;
there is a feeling of chiUiness and marked prostra-
tion, and suddenly the patient becomes severely ill
with symptoms of typical bronchopneumonia. The
prognosis is serious in this type.
The second group begins with moderately severe
symptoms of influenza, prostration, moderate fever,
and slow pulse. These patients are sick for two or
three days ; then there is a sudden crisis and they
are well. Among a certain proportion of these
cases, however, after this lysis on the third day, the
temperature suddenly rises to 104°, and the patients
become acutely ill with the bronchopneumonic group
of symptoms. They are sick for eight or ten days,
when they have the usual lysis. They do very much
better than those who have a milder onset and de-
velop acute symptoms afterward.
The third group comprises the foudroyant or ful-
minating cases. These patients are taken acutely
and violently ill at once, with high fever of 106°
or more, great prostration, cyanosis, a rapid pulse
and respiration, followed by death inside of thirty-
six or forty-eight hours, with very few physical
signs in the chest.
In legard to the symptomatology, I shall confine
myself to the individual symptoms; the general pic-
ture is too well known to require any detailed de-
scription.
I would refer first to the asthenia which is such
a striking feature of this disease. Even in the
mild cases it is present to some degree. It is much
more pronounced in the severe types, and its in-
tensity is a good index of the severity of th5 tox-
emia. Indeed, I know of no sign which gives a
better index to the condition of the patient and the
prognosis than the asthenia. The first glarrce at
the patient will give one more information as to his
condition than the most detailed physical examina-
tion could insure. Any patient whose illness is
ushered in with severe asthenia will undoubtedly
have a stormy course.
The asthenia has two important therapeutic re-
lations : One is to avoid the free use of depressing
coal tar drugs, one of which is the much advertised
aspirin. Secondly, it is an indication for the free
use of alcohol. I consider whiskey or brandy in full
doses a most important part of the treatment. In
these days when prohibition has even invaded the
hospital wards and when the younger generation of
physicians is ignorant of the value of alcohol in
toxemias, it may not be amiss to lay stress on the
great benefit which may be obtained from it in the
treatment of these patients.
Chills are conspicuously absent. There is only
a chilliness which frequently ushers in the disease.
It also occurs during the course of the disease when
there is a recrudescence of the fever or an addi-
tional involvement of the lungs. The height of the
fever varies with the type of onset. It is a more
or less continuous fever around 104°, which usually
lasts eight or ten days in the moderately severe
cases. There is a curious drop in temperature on
the third day. In the milder cases this marks the
end of the disease, but in a large number of patients
October 26, 191 8.]
MANGES: SYMPTOMATOLOGY OF INFLUENZA.
723
the temperature suddenly rises to 104° or 105°, at
which height it remains with daily oscillations of a
degree until the eighth or tenth day, when lysis be-
gins ; in two days the temperature becomes
normal. At times the temperature assumes a dis-
tinctly remittent type, but these cases are not com-
mon. In the severe types there is a steplike rise of
the fever to 106° or higher. When this occurs the
prognosis is very poor.
The pulse is slow — about 80 to 90. No matter
what the temperature is, there will be a slow pulse
of rather large volume, often dicrotic, and remind-
ing one of a typical typhoid fever pulse. It is a
wonder to me that any physician should give digi-
talis in the early stages of this disease. The heart
is already under the influence of a powerful vagal
inhibitor and the use of digitalis in the early stages
is contraindicated. An increase of the pulse rate
to 120 with a tendency to go upward, accompanied
by a rise in temperature, is an ominous prognostic
sign.
The blood pressure remains good and constant,
the range being 110 to 120 systohc and 60 diastolic,
and one has nothing to complain of in the action of
the heart, in spite of the asthenia. But if there
is a low pressure at onset or if there is a sudden
drop, it is well to beware of trouble.
Sudden deaths from acute dilatation of the heart
are by no means uncommon. Pulmonary edema is
much less frequent in occurrence than one would
expect in a disease in which cyanosis is so marked
as in these severe cases. In the very toxic patients
who are comatose and profoundly asthenic, the myo-
cardial condition is what is ordinarily seen in such
conditions. It is worthy of note that I have not
observed a single instance of endocarditis or peri-
carditis. This was verified by the postmortem ex-
amination of the hearts which showed only the
acute myocardial changes.
The respiration is usually slow and around twenty
to twenty-four. It is to be noted that the respira-
tory rate may bear no exact relation to the pulmon-
ary condition. Thus there may be a rate of twenty-
four to thirty with extensive pneumonic changes in
the lungs. On the other hand the respirations may
be forty or more, with few physical signs in the
lungs. This discrepancy will be referred to later
on under the physical signs of the lungs. I wish
to emphasize the ominous significance of a respira-
tory rate of forty or more, whether there are phys-
ical signs in the lungs or not; it denotes a profound
toxemia.
The skin shows remarkably few manifestations.
I have seen only two cases of roseola. Another
point to be noted is the absence of herpes ; I have
observed it in but one case which had pulmonary
involvement, and I am sure there was a pneumococ-
cus admixture in this case. Febrile erythema is
quite uncommon.
Another significant feature is the absence of the
coal tar drug rashes seen so frequently in the pan-
demic of 1889-1890. This represents a great ad-
vance in the therapeutics of today.
Cyanosis is a common condition in the severe
cases of the present epidemic and, when progres-
sive, is an almost lethal manifestation. It is not
the cyanosis produced or augmented by the propri-
etary remedies which were so extensively used
twenty-nine years ago.
Epistaxis is a very frequent symptom ; I believe
it is present in thirty-five per cent, of the cases.
There is no bleeding from any other mucous mem-
brane than that of the nose. Epistaxis may be re-
garded as one of the cardinal symptoms of the dis-
ease.
The sputum is not very abundant. It is usually
mucopurulent and is often blood stained and frothy.
It is unlike the sticky, tenacious sputum of ordinary
lobar pneumonia.
Vomiting is a very common symptom at the on-
set and early stages of the disease, and is often very
distressing. Jaundice of a mild type is occasionally
observed ; it is probably due to a mild cholangitis.
Another symptom referable to the abdomen is pain.
At times, this may be so severe that acute abdo-
minal conditions may be suspected. In the case of
a child recently admitted to Mt. Sinai Hospital, the
abdominal pain was so severe and cramplike and
the rigidity of the abdomen was so great, that in
the presence of fever and the absence of other
symptoms and physical signs, a diagnosis of acute
appendicitis was made. As nothing was found at
the operation the true diagnosis of influenza be-
came apparent. I have seen a number of patients
in my own service in whom the main symptom was
intense abdominal pain which was especially re-
ferred to the epigastrium.
The ears and sinuses seem to be almost exempt
in this pandemic. I have seen no case with sinus
involvement or mastoid disease, and I have ob-
served only three patients with otitis. The otitis
was of a mild type, which yielded to a simple para-
centesis. And yet all these cases were fatal. In
army practice, I have been informed, ear complica-
tions have been more frequent. But the fact re-
mains that this pandemic has been singularly free
from these complications. This is in striking con-
trast to the pandemic of 1889- 1890, when these
complications were exceedingly common.
The spleen is rarely palpable. Phlebitis occurred
in one case ; it involved both saphenous veins during
convalescence, and was accompanied by a fever of
103°. It may be worth while to think of this pos-
sibility in obscure rises of temperature during con-
valescence.
The urine has the characteristic feature of any
acute infection. But this pandemic has a milder
type of nephritis than was observed in 1889-1890,
when the urinary changes were often very marked.
The blood picture is very characteristic ; there is
always, even in the severe cases, a leucopenia. The
average counts are from 4,000 to 6,000, with sixty
oer cent, polynuclears and thirty to thirty-five per
cent, lymphocytes. High counts usually denote the
existence of some complication.
The last topic to which I will refer in the symp-
tomatology is the lung signs. These are among
the most important of all, since pulmonary involve-
ment is always present to a greater or lesser degree.
Coughing is usually prominent and is either pharyn-
geal, laryngeal, tracheal, or pulmonary in origin.
One of the surprising features of the postmortem
724 MANGES: SYMPTOMATOLOGY OF INFLUENZA.
examinations is the more or less intense tracheitis ;
indeed, tracheal ulcers are surprisingly frequent.
Another manifestation of the trachea being a point
of selection is the fact that pure cultures of the
influenza bacilli are found most frequently in the
trachea, more frequently even than in the lungs.
In diagnosis and treatment it is well to bear in
mind that the influenza cough may have these
various points of origin. In the physical examina-
tion of the chest, the two areas to be especially
examined are the trachea and the bases of the
lungs. The apices are only exceptionally involved.
Over the trachea we may hear coarse rhonchi ;
over the bases one finds the characteristic sticky
crepitant rales. If one does not hear them it is
important to make the patient cough. The per-
cussion note over the involved areas has a peculiar
wooden tympany or flatness which is suggestive of
Skodaic resonance. Sometimes it has even crack
pot characteristics. In the early stages when the
lesions are still scattered bronchopneumonic patches
there may be little change in the auscultation
sounds even though the percussion note is already
duller. Later on, it becomes bronchovesicular, but
it does not become bronchial until the bronchopneu-
monic patches coalesce into larger areas. The vocal
fremitus is not increased and may be absent. All
these physical signs may be explained by the fact
that aeration of the involved bases is usually poor.
The pleura is almost never involved in the cases
which I have observed. I have seen no effusions
nor empyemata. Only one patient had physical
signs which suggested an effusion ; this was con-
firmed by the x ray examination ; however, repeated
punctures failed to reveal any fluid. In the much
larger number of cases observed in the army, pleural
effusions have been found in a small number of pa-
tients. It is important to remember that the physical
signs of them often fail to correspond with the
actual amount of involvement of the lungs, for ex-
tensive areas are found by x ray examinations, and
at postmortems, when the physical signs would lead
one to believe that the lungs were not extensively
involved.
As regards prognosis the ominous signs are: i,
cases which begin fulminatingly ; 2, secondary
pneumonias which come on after apparent recovery
from a mild attack; 3, a steplike rise in the fever
above 105'^ ; 4, rapid pulse ; 5, rapid inspirations ;
6, an initial low blood pressure or a sudden drop ;
7, profound asthenia ; 8. cyanosis. One should
always be very guarded when influenza occurs in a
pregnant woman or when the disease attacks per-
sons who have healed or latent tuberculosis. In
both these classes, the mortahty is unusually high.
Furthermore, the lighting up of latent tuberculosis
by an attack of influenza should always be remem-
bered as a strong possibility.
I would like to say a few words comparing this
epidemic with that of 1889-1890. Not all of you
had the chance of observing cases at that time. I
was in Vienna in 1889 when the epidemic began
and saw it in all its phases there, and when I re-
turned here in December, 1889, the pandemic broke
out and I had ample opportunity to observe it.
That epidemics should vary in their essential
[New York
Medical Journal.
features is by no means uncommon. Those of us
with hospital experience know that this is true of
all infectious diseases. Thus every year there is a
difference in the type of typhoid fever ; in one year
there is more hemorrhage ; in another year there are
more perforations ; in still another year roseola are
more abundant. It is an interesting fact that we
should have these variations in the same disease as
it shows itself at various times. In influenza, how-
ever, one symptom is always contant and prominent.
Pneumonia has always been associated with this dis-
ease, even in the earliest reports of epidemics. Thus
Bockel in 1580, Sydenham in 1675, Arbuthnot in
1732. and Huxham in 1737 referred to pneumonia
as being the leading feature. There are several
features Avhich deserve notice. There is the remark-
able sameness of the cases you see now ; the only
thing that varies is the severity of the symptoms, but
the picture is the same. In the pandemic of 1889
there was the utmost variety. The second point is
the age incidence. In 1889 all ages were involved ;
it was net limited so mvich, as at present, to early
adult life. Then differences were the ear involve-
ment of the past ; otitis, mastoiditis and sinus dis-
ease were extremely common as well as neuritic
manifestations ; also psychoses were quite common.
Influenza stands third in the etiology of psychoses as
a result of the epidemic of 1880. I have not seen
any, but the army reports some. It is too early to
say as yet if these sequelse will develop later on.
Nephritis was very common in 1889 ; the changes
in the urine do not correspond at all today ; and
routine examination shows only mild febrile changes
and much less albumin than was seen in 1889. At
that time too abscess of the lung and bronchi-
ectasis were common ; I have seen none in this epi-
demic, but in this respect also it is too early to say
that these may not be observed in the future.
Last of all, I would like to call attention to re-
markable statistics which I chanced to find some
time ago in Leichtenstern's monograph on influenza
in Nothnagel's Encyclopaedia, 1896, p. no, vol.
IV, part I. This, refers to the frequency of pneu-
monia in the Prussian army in the pandemic of
1889-90. There were only 534 cases of pneumonia
among 55,263 cases of influenza in the entire army
(one per cent.) and only 175 cases of pleurisy
(0.3 per cent.). Compare this with the present
epidemic in the United States army in camps in this
country with ten per cent, incidence of pneumonia
and a mortality of thirty per cent. No better ma-
terial could have been chosen to make comparison
of the two epidemics and no better evidence could
be produced to show how unlike the two epidemics
are in their clinical features and mortalitv rates.
In conclusion, I would say that I have tried to in-
clude the chief symptoms of this protean disease as
it has shown itself in this pandemic. There are
others, but the limited time at my disposal in this
symposium precludes discussion of them.
Nothing has been said about the sequelfe. as it is
as yet too early to predict what these will be. To
one probable sequel, tuberculosis, I would direct es-
pecial attention, as its incidence after the last pan-
demic was much increased. It is, therefore, impor-
tant for every physician to be on his guard.
October 26, .918.] JELLIFFE: NERVOUS AND MENTAL DISTURBANCES OF INFLUENZA.
NERVOUS AND MENTAL DISTURBANCES
OF INFLUENZA.
By Smith Ely Jelliffe, M. D.,
New York.
The historical background of influenza affords a
hazy territory for research, conjecture, and specu-
lation. From the days of Hippocrates epidemics
have been written of which bear certain re-
semblances to the present day influenza. Even
Homer has been said to have placed an early epi-
demic on record. Thomas Glass, of Exeter, in his
description of the epidemic plague of 1775 calls
attention to the plague of the Iliad as presenting
features which convinced him of its identity with
the influenza. Of the history of these early plagues
it is not my purpose to write ; this has been done
fully well by hosts of students better qualified than
myself, and scores of sources are at the beck and
call of the historically interested. Hirsch, Webster,
Zeviani, Conradi, Kusnekow and Herrman, and
and many others have traced theSe from the fifth
century to the present time. Throughout this record
one finds certain unmistakable indicia of implica-
tion of the nervous system, but it is apparently only
from about the fourteenth century on, that the de-
tails are sufficiently recorded to enable the student
of the history of nervous affections to take up the
scent and feel that he is on certain ground.
In these early accounts we read of headaches and
deliria as frequent accompaniments of this disease ;
notably in the accounts given by Kusnekow and
Herrmann. Sauvages in his celebrated Nosologic
adopted the classification of cephalitis epidemica for
certain of these epidemic descriptions which have
notably come to us, chiefly outlined in Mezeray's
description of the epidemic of 1510.
Of the many opportunities for uncertainties in
the differentiation of different contagious disorders
it is not my purpose to speak. It is certain that
many whooping cough cases v/ere intermingled in
these early epidemics. But apart from all of the
historical intricacies of interpretation, the point to
be emphasized is that nervous and mental complica-
tions or manifestations have been evident from the
earliest times and it is becoming increasingly ap-
parent that the influenza microorganism is one
fraught with certain specific activities upon the
nervous structures.
One of the features that I wish to bring out in
this rather hasty review is that many of the factors
which have contributed to the dangers of influenza
are based upon this predilection for certain specific
nerve structures. Before attempting a generaliza-
tion, however, with reference to a specific activity
upon certain nervous elements, a review of the more
general clinical manifestations of nervous disturb-
ances seems advisable.
A great number of these nervous manifestations
have come under personal observation in private,
hospital, and dispensary practice. Their detailed
anamnestic consideration would unduly extend this
summary. The extremely extensive literature,
which, beginning with the epidemic of 1783, has
been recorded with each epidemic in voluminous
proportions, contains an extremely rich and varied
collection of a vast number of syndromes attribut-
able to the influenza bacillus. The epidemic of
1889 gave rise to several thousand literary produc-
tions of all kinds, those bearing on the nervous
system alone numbering at the very least several
hundred.
I am aware of the fact that a number of ob-
servers (i) have claimed that the influence of in-
fluenza upon the nervous system has been greatly
exaggerated by those who have emphasized this
relationship. In fact we find it recorded, in 1837,
that Broussais wrote that ''influenza itself was a
creation of people without a sou, and of doctors
without clients, who having nothing better to do
are nmused to create this rigamarole." Thus for
Broussais, and many others — and we have heard
the same expression of opinion at the present time — ■
there was no such thing as influenza although its
malign influence and singular severity, especially
upon the nervous system, had been emphasized for
centuries. Such is the usual forgetfulness of the
present for the past.
There can be no exaggeration of the countless
number of facts that indubitably attest the enor-
mous significance of the causal relationship between
influenza and diseases of the nervous system.
Since 1889 — when more exact methods of diag-
nosis, neurological, bacteriological, and cytological
have been more widely employed — the actual pres-
ence of the influenza bacillus, either in pure or
mixed culture or in section, and by other methods
of definite identification have more and more
aided the diagnosis of nervous syndromes and have
helped to clear the way to a more valuable therapy.
Pfuhl, Pfliiger, Nauwerk, and scores of others
have isolated in organism in various neurological
syndromes.
In practically all of the conditions which shall be
here mentioned the etiological relationship has been
clearly established by different observers, either by
direct observance of the organism or by a rigid
logical analysis. Snap diagnoses have occurred and
will continue to occur, and during an epidemic of
influenza it will not infrequently happen that a
superficial study of a nervous disturbance may be
taken as due to influenza and thus permit a dif-
ferent serious etiological factor to pass by unde-
tected. This may happen, and is particularly un-
fortunate in the case of syphilis or a tumor for ex-
ample.
With these introductory remarks we may take up
the consideration of the more widely observed syn-
dromes.
Cranial nerves. — Olfactory: Disturbances of
smell are frequent and anosmia is a widespread
early symptom. Whether arising from the pressure
of the swollen mucous membrane or as a direct re-
sponse to toxic action, cannot always be determined.
In certain patients the loss of smell persists for a
long period after recovery from the acute effects
of the infection. A few instances of anosmia
under personal observation have set in in from four
to five days or as late as ten days, after the onset
jf the acute symptoms. These have not been iso-
lated happenings, as loss of taste was also present
in one and loss of hearing an accesory symptom
726
JELLIFFE: NERVOUS AND MENTAL DISTURBANCES OF INFLUENZA. [New York
Medical Journal.
in another patient. Zwaardemaker (2), Bossers,
Bardt, Dippe, and others have reported similar
cases Olfactory hallucinations, presumably of
peripheral origin are also known (Bardt).
Optic nerve. — Optic neuritis, while a compara-
tively rare afYection, is nevertheless frequent
enough to demand serious consideration. Dififerent
neurones are involved. Thus retinitis results from
involvement of the receptors, giving rise to partial
or complete blindness, or more frequently to
scotomata. Acute axial neuritis with its character-
istic central scotomata is met with. It usually
recovers. The most frequent types in my experi-
ence are the interstitial and diflfuse forms of optic
neuritis, the so called retrobulbar neuritis of most
textbooks. In interstitial neuritis there results a
limitation in the visual fields from peripheral
scotomata, but many patients are unaware of the
reduction in vision until definite tests are made.
Influenza plays a very important role in the pro-
duction of difTuse optic neuritis, here being almost
as important a producing cause for this type as
syphilis. There is a large literature bearing on this
extremely grave disorder. Willbrand and Saenger
have collected this in their great monograph. Post-
chiasmal involvement of the optic tract may be seen
in influenzal meningitis, and rare quadrant hemi-
anopsias may be observed in occipital lobe involve-
ments, as in serous meningitis and in abscess, which
latter may result from a pure or mixed infection.
Ocular palsies. — Third, fourth, and sixth nerve
involvements, belong to some of the commonest of
the many palsies which accompany the influenzal
toxemia. They may occur as isolated palsies or are
found in combination, and may be accompanied by
more widespread involvement of the bulbar nuclei
or peripheral neurones of the cranial nerves. The
peripheral types are the better understood and also
offer the better prognosis. Isolated external rectus
palsy as a result of this toxemia I have encountered
in a number of instances. It, as well as the more
complex or complete types, is frequently preceded
by a severe eyeball neuralgia. Accommodation
palsies have also been seen by a score of observers,
occurring as an isolated event or in combination
with external ocular palsies. From a strictly
neurological standpoint there is nothing pathogno-
monic in these ocular palsies by which they may be
separated from palsies of other etiology. The
prognosis is usually better than the syphilitic,
typhoid, diphtheritic, polioniyelitic, or metallir
ocular neuritides.
Combinations of ocular palsies, external and
internal, with paralyses of the pharyngeal pillars,
or of certain of the laryngeal muscles occur. I
have seen two or three such patients, in whom the
resemblance to a diphtheritic palsv was very strik-
ing. This latter cause was excluded bv laboratory
tests. Joachim. Tankau and Uhtboff, Hevmann,
Krakauer, Faye, Fukula, Valide, Pfliiger, Albrand,
Stower, Greef, Bergermeister, Landolt, Weichsel-
baum, Sattler, Frank, Guttmann, and others, have
reported cases.
Trigcininus. — Neuralgia of the fifth nerve is one
of the most frequent and painful disturbances in
influenza. In our dispensary work it is frequently
observed. I have seen it less often in private prac-
tice, as many of these patients go to their dentists
in the belief that the trouble is a dental one.
Trigeminal zoster I have also seen, and some pa-
tients have a very severe trigeminal zoster as a
symptom of an influenza. Motor palsies of the
fifth nerve I have never seen.
Facial nerve. — Palsy of the seventh nerve I have
frequently observed when the general symptoms of
influenza have been present. It may or may not
be associated with an otitis. As not infrequently
happens, the neuritis may be severe and yet the gen-
eral symptoms of the influenza be quite mild, that is
speaking from the the usual standpoint — that the
nasal and respiratory symptoms are taken as a gen-
eral criterion of the severity of the disease. I am
disposed to believe that this is a great mistake, for
many extremely severe cases of influenza go through
almost to death with very minor nasal or respiratory
indications. It has seemed to me that when the
toxin seems to localize its activities in one type of
tissue it has a t^dency to limit itself there. Thus
most of the neuritides that I have observed — and
this applies to the neuritides of spinal distribution
as well as of cranial localization, including also
zoster cases — have occurred in patients in whom
bronchial, intestinal, or nasal manifestations
have been extremely mild. Thus to deny the pres-
ence of an influenza in the absence of these symp-
toms in a severe type is not good sense. In the
epidemic of 1889 and 1890 I recall a particularly
striking incident in one family in which one patient
died of an influenzal pneumonia, another with a
slight bronchitis only, died with a severe zoster, and
a third with no influenzal symptoms in the ordinary
sense had an external and internal ophthalmo-
plegia. In two patients seen recently, the mother
had a severe old fashioned influenza and was not
under my care, but two daughters had a zoster and a
mild chorea, respectively, but with only slight indica-
tions of the influenza. Thus I have expected not to
find the severe neuritides in the severe bronchial
cases. It may be that the internist sees these cases
and I do not. When the influenza has been mild and
palsies have been present they are referred to the
neurologist as nervous cases. This experience as
that of others as well would seem to be indicated in
the reading of the full historical accounts of former
epidemics. Fven in those way back in the early
centuries, we note that dififerent observers have
spoken of, "this epidemic as being noted for the
large number of mental cases" ; "this epidemic has
been noted for the large number of pneumonia
cases" ; "this epidemic runs to intestinal types," etc.,
etc. Thus, in the epidemic of 1781, it is recorded
that there were great numbers of very severe head
symptoms, "cruel pains," and the term "cephalitis
epidemica" was coined and used as a standard of
classification by Sauvages, as has been referred to.
Thus there are direct indications at least that a cer-
tain specificity of tissue type involvement may be the
usual thing. Complete analyses, which are rarely
ever possible, may show this to be a faulty generali-
zation, for there are by no means few instances when
dififuse and severe neuritides are known to have oc-
curred with severe pneumonic types. Thus severe
October 26. 19.8.] JELLIFFE: NERVOUS AND MENTAL DISTURBANCES OF INFLUENZA.
727
facial cervical zoster type accompanied a severe and
fatal exudative edematous pneumonia.
Since the general problem of the determination of
localization of disease processes is still so obscure,
the generalization is left for subsequent modifica-
tion and criticism. When one patient with a mild
influenza develops a zoster, another a mild optic
neuritis, and still a third a tachycardia, dif¥use per-
spiration, tremor, and other symptoms of a vago-
tonic exophthalmic goitre with other adenopathies,
all three resulting from a similar toxic producing
agent, it becomes an interesting problem of individ-
ual constitutional variation in organ susceptibility —
a problem which has been but little touched upon but
is of paramount importance, not only in the reactiv-
ity to the influenza toxin, but to other types of in-
fectious disease, syphilis for instance. Among
others, Potzl, Bartels, Paltauf, and Adler in his
Inferiority of Organs and Their Psychical Com-
pensation, have broken ground in this fascinating
realm for investigation.
Eighth nerve. — The marked tinnitus which is an
almost invariable symptom of the early stages is a
mixed auditory nerve and physical exudative phe-
nomenon. When the involvement of the auditory
nerve is more persistent, deafness results. Vertigoes
and nystagmus of vestibular origin are also re-
ported.
Ninth nerve. — The glossopharyngeal palsies have
been less thoroughly studied, although the throat
complications of the grippe are very widespread.
Hoarseness with weakness in swallowing and in
phonation are very frequent mild accompaniments.
They are conditioned by disturbances which are in
part of neurological functioning and in part of
physical interference. The great laxness in the
tonus of these muscles is directly due to the dis-
turbance in the vegetative control which is so
marked a feature of the entire poisoning that it
will be made the subject of special discussion.
Tenth nerve. — As will be brought out later, this
vegetative nerve disturbance is a fundamental
underlying condition in influenza poisoning, and
for this reason the symptomatology more directly
connected with the pneumogastric will be merely
touched upon. These are masked, as it were,
beneath the more striking internist situation of an
edematous pneumonic flooding — which is so fre-
quently complicated by the ef¥ects of the activities
of other microorganisms, thus altering the purer
(?) picture of a true influenzal vasomotor paresis
of the pulmonic vessels with edema, bloody extra-
vasation, etc. I shall pass on to the more usually
thought of neurological phenomena, saying at this
time only that the peculiar character of the grippe
edematous flooding has been so strikingly different
as to have attracted attention and record for sev-
eral centuries and must be elucidated ultimately in
the light of the vegetative functions of the vagus
(autonomic) and sympathetic systems respectively.
Hypoglossal nerve. — Disturbances of muscular
control of the tongue are few, and unilateral atro-
phy of this structure, while recorded (Leyden), is
a rarity. Taste disturbances of a mixed nature are
a frequent finding and the universal disgust for
food, which is a mixed psychical and cranial nerve
disturbance, is too well known to demand special
attention (Frey-Laache) (3).
Spinal distribution. — Neuralgias, neuritides, with
palsies and zosters of every regional distribution —
central as. well as peripheral — have been seen,
either as isolated localizations or as widespread and
serious polyneuritides. Even the most severe
grades of multiple neuritis, grouped under the
symbol of Landry's paralysis, are known. Many
of these isolated neuritides with their consequent
palsies resemble poliomyelitis cases closely and a
clinical differentiation is at times extremely dif-
ficult. Poliomyelitis and influenza have often been
associated ; indeed there are not wanting those who
have claimed them as identical. There is a rich
Scandinavian literature upon this question, but with
our present 'knowledge this viewpoint seems un-
tenable.
I have seen comparatively few spinal neuritides
and a few zosters of influenzal causation, yet they
are among the best documented cases in the neu-
rological literature, and a passing word may be, said
concerning the more frequently observed types.
Neuralgias are extremely frequent. In some
epidemics nearly fifty per cent, of those afifected
have had severe neuralgias (4). Supraorbital and
infraorbital localizations are among the most fre-
quent, and seem associated with tlie near lying
sinus engorgements. Trigeminus neuralgia has
been mentioned. It is occasionally very intense
and chronic. Intercostal neuralgia is frequent
and is to be separated from the extremely fre-
quently felt sense of constriction of the chest. This
latter is usually a vagus sympathetic syndrome, as
has been noted by Kinnicutt (5), Edgren, Braken-
ridge, etc. Scapulohumeral and brachial neuralgic
types are the most frequent of the upper extremity
neuralgias (6). Sciatic neuralgias and neuritides
are extremely common. The entire distribution is
rarely involved in a neuritis sufficiently severe to
develop a palsy, although this sometimes happens,
and even bilateral sciatic palsies are known.
Polyneuritis. — A rare, but nevertheless, a most
important series of polyneuritis cases are on record.
Personally I have happened to see but two cases in
private practice when the causal relationship could
be carefully investigated. A number of suspicious
cases have been seen in my City Hospital service,
but the etiological factor had to be surmised rather
than proven. In one of my cases a complication
with ? possible rabies polyneuritis of the Landry
type obscured the picture. Theses have been writ-
ten concerning these polyneuritis cases (Diemer),
which have entered the literature as definite since
Dumenil called attention to them in 1866.
The multiple neuritis is apt to come on in the
period of convalescence, in from ten days to three
weeks, more or less like the postdiphtheritic palsies
to which they have often been compared, and, at
times attributed. Grippe polyneuritis is preemi-
nently a motor neuritis although even severe neu-
ralgic pains may precede its development. The
lower extremities are more severely involved as a
rule than the upper, and one side of the body is
apt to be more afifected. The muscles of the back
seem to be spared. The cranial nerves are involved
728
VOORHEES: INFLUENZA AND NOSE AND THROAT SPECIALIST. „ INew York
Medical Journal.
with the severe cases, even the pneumogastric (7).
The diaphragm has been paralyzed (Bonnet). The
distal muscles are more involved and the extensors
more than the flexors. Central vegetative disturb-
ances are not marked, though at times present, and
the stcretor\^ and trophic alterations minor. The
atrophy which follows seems to follow the per-
ipheral spinal type and the prognosis is usually
good. In marked contrast with polyneuritis of
alcoholic etiolog\% Korsakow's psychotic states are
rarely observed.
Some help in the differential diagnosis from a
palsy of central origin, poliomyelitis, may be gained
by a study of the sensory changes. In the poly-
neuritic types there are not infrequently changes in
bony sensibility (see Williamson), and epicritic heat
and cold tests reveal difterences ; light touch and
the sense of position also may be involved. These
signs are visually entirely absent in the poliomy-
elitides. unless the poliomyelitis virus has produced
a diffuse and severe transverse myelitis, or more
rarely a neuritis, but even here a careful sensory
examination will tend to show that the alterations
in sensibility follow out a peripheral or a segmental
metameric formulae (Head) respectively. In the
severe types which follow the so called Landry
picture it is doubtful if a differential diagnosis can
be established without laboratory aids.
{To he continued.)
THE TREATMENT OF INFLUENZA.
From the Standpoint of the Nose and Throat
Specialist.
By Irving Wilson Voorhees, M. S., M. D.,
New York,
Assistant Surgeon, Manhattan Eye, Ear, and Throat Hospital.
The management of a case of influenza is essen-
tially a nose and throat problem. As every one
knows, the very first signs of the disease, or the first
symptoms experienced by the patient, are referred
to the respiratory system. Chills, fever, aching in
the back, bones, and joints are constitutional effects
of bacteria and their toxins which have migrated
through the ineffective first line of defense in the
mucous membrane of the nose and throat, and have
been carried by the blood stream to all parts of the
body.
It may seem foolish to set down these facts for
the perusal of medical men ; but the right thinking
medical man will not object to being reminded of
certain well established principles. If a trouble-
some discharge from the nose is present, rhinitis
tablets are usually prescribed. Instead of drying
up the nasal secretion, we should aim to encourage
and increase nasal discharge, because activity of the
mucous glands carries away a large amount of in-
fection, especially from the depths of the glands
where bacteria live, thrive, and propagate in cases
which become chronic catarrh. One should, there-
fore, persist in irrigation of the nasal fossae with
warm normal salt solution every hour if necessary,
and follow this by the instillation of argyrol, twenty-
*ive per cent., five drops in each nostril. A nasal
\
irrigator or douche bag holding at least one pint
should be employed, and the entire amount should
be used at each sitting. There is less danger to the
ears from salt solution properly employed than from
leaving the bacteria free to be blown in by the pa-
tient in an unguarded moment, or to work their way
in by gravity. The most rigorous advice must be
given the patient not to blow the nose, but to draw
the nasal secretions back into the nasopharynx and
expel them by mouth. A close fitting nozzle to fit
the nostril snugly should be absolutely prohibited,
as it is sure to drive secretions and bacteria into the
ears. The best tip is an ordinary glass medicine
dropper or fountain pen filler. If the nose is so
obstructed that nothing will go through, adrenalin
inhalant should be dropped into the nasal vestibules
until it passes into the throat. Irrigation will then
be effective.
Nothing is quite so helpful in the oropharynx and
in the tonsillar crypts as silver nitrate solution
sprayed in as a two per cent, solution with a De Vil-
biss atomizer No. 16, or applied into each tonsillar
crypt upon a finely wound cotton applicator in forty
per cent, solution. The tonsils are favorite sites
for influenza bacilli. In taking cultures from the
nasopharynx and tonsils of ninety-one patients, in-
fluenza bacilli were found only six times in the naso-
phar) nx, and seventy-eight times in the tonsils !
V.'hen the infection extends to the bronchi, cough
medicines are mostly sedative, with the exception
that those cough medicines which produce excessive
secretion from the tracheal and bronchial mucous
membrane wash out great masses of bacteria which
are ejected mechanically by coughing. Cough rem-
edies are not bactericidal. On the contrary they
tend to constipate the patient if opium or any of its
derivatives are contained in them. The one thing
to do in all cases of bronchitis is to instill medica-
tion, antiseptic medication, directly into the trachea
through an intratracheal cannula. If this cannot
be done, it is permissible to inject through the thy-
rohyoid membrane with a fine hypodermic needle,
either dichloramine-T two per cent., one c. c, or
menthol in oil five per cent., one c. c. Some of this
medication will, of course, be coughed out, but
enough will remain to kill large numbers of bacteria
and in a few hours greatly relieve the previously
distressing cough.
Wc are now beginning to know a great deal about
the bacteriolog^f of the nose, throat, and lungs. It
is very important in the present epidemic to take
cultures from the nose, nasopharynx, and lungs
(sputum). The influenza bacilli are not found in
every case, but in many instances they are present.
Hemolytic streptococci occur frequently, also pneu-
mococci, while various strains of staphylococci and
the bacillus mucosus of Friedlander are often en-
countered. It should be borne in mind that the
streptococcus can cause symptoms of chills, fever,
malaise, etc., quite the same whether associated
with other organisms or not, and the streptococcus
is invariably present in the fatal cases, particularly
the fulminating type, giving all the signs and symp-
toms of a real streptococceniia.
In the light of new knowledge of bacteriology- in
the present serious epidemic, it seems strange that
October 26, 191S.]
KAHN: COMPLICATIONS OF INFLUENZA.
729
up to a few days ago so little attention has been paid
to vaccines. There are still a very large group of
unbelievers, a larger group who know nothing about
vaccines because they have never used them, and a
group who are unalterably opposed to their use on
the ground of prejudice alone. For the past five
years it has been my custom to culture the nose and
throat of every patient coming in for treatment.
This of course must be done before any antiseptics
are applied. There is a standing order with my
laboratory man to save the culture and prepare the
manufacture of an autogenous vaccine^ in case an
infection does not clear up promptly under local
treatment. Vaccines properly given do two very
helpful things ; namely, they increase the appetite,
and bring about a quiet, restful sleep. In most cases,
therefore, it is unnecessary to give a tonic or a sed-
ative. My rule is to have the vaccine made up and
counted as 500 million to one c. c. The first in-
jection is one half c. c, and the dose is increased
one half c. c, or doubled, every second day accord-
ing to the reaction. No attempt is made to isolate
one germ and make a univalent culture. All of my
experience has been with polyvalent vaccines.
In the presence of such a menace to life and
health as we are now facing, every precaution should
be taken to immunize as much of the population as
possible. This should be the rule in all hospitals,
and every medical man who values his life should
submit to inoculation. A number of our profes-
sion have already died, and many are now ill from
receiving massive doses of bacteria from great num-
bers of patients. We should offer our services to
all of our brothers first, so that they can go about
their work of mercy with a minimum of danger. A
number of Y. W. C. A. girls and other volunteer
workers are trying to help in the care of the sick.
None of these should be allowed to submit them-
selves to this great danger until immunized — which
at the most should demand not more than ten days
before they may report for duty. All medical stu-
dents who are now acting as volunteer nurses among
the poor should be vaccinated at once, for such
workers are a potent source of spreading the dis-
ease, to say nothing of the danger to themselves.
It is the duty of every practising physician to
acquaint himself with the principles of vaccine ther-
apy, and then to notify his patients that they may
come to him for inoculation with some hope, at
least, that if they do contract the disease, it will
prove to be only a slight attack and not fatal, as is
so frequently the case at present. The New York
Board of Health would do well to establish a chnic
for the instruction of physicians in the treatment of
influenza, for at the present time all is confusion,
and nearly all the drugs in the pharmacopoeia are
being called upon to allay this or that symptom with
a result that is unsatisfactory, to say the least.
14 Centkal Park West.
* Dr. T. S. Schlauch, who makes these vaccines for me, says it
is very important that no heat be used to destroy the bacteria as
some chemical or lipoid change is produced by heat which destroys
the usefulness of the vaccine or, at least, makes it less effective
than if a dilute solution of carbolic or cresol is used for this pur-
pose. A good reaction is always to be desired if successful immuni-
zation is to be secured.
COMPLICATIONS OF INFLUENZA.
Ears and Mind Affected With Symptoms of
Meningismus.
By Alfred Kahn, M. D.,
New York.
As a consideration of every phase of influenza,
with special reference to its bearing on the present
pandemic, is of paramount importance, the finding
of unusual symptoms, tts a complication, may be
of interest. It is with this fact in mind that the
following experience is here presented :
On the evening of September 25th I was called
to see a young woman, twenty-seven years of age.
The substance of my examination and consultation
was that she had a temperature of 105°, and that
she presented the usual train of influenza symptoms
— intense headache, pains in the back and limbs,
chilly sensations, abdominal pain, with passage per
rectum of abnormal quantities of gas. The influ-
enza v/as complicated by a double bronchial pneu-
monia, but the lungs were not deeply or consider-
ably involved. The pneumonia was in its earliest
stage ; difficulty in breathing was not marked. The
respirations were in proportion to the temperature ;
they were repeatedly observed to be between
twenty-four and thirtv a minute. The pneumonia,
taking into consideration the fact that the patient
had a double lung involvement, did not seem to be
giving much trouble. The pulse at this time was
about 103, and although soft, was not excessively
rapid.
The following unusual symptoms were noted at
the time of the first visit : The patient, normally
of a hysterica] temperament, was somewhat dull
and extremely hard of hearing on this occasion.
In order to make her understand, it was necessary
to raise my voice to quite a high pitch ; her hearing
was reduced and evidently impaired. I was inter-
ested to know the cause of this impairment and to
determine its importance as a factor in influenza.
On examining the ears, the drums showed no signs
of disease. My experience along this line makes
me certain in stating there was no middle ear in-
volvement in either ear. The patient was slightly
dizzy and showed a very slight nystagmus toward
the right. She could hear slightly better with the
right ear than with the left. Forty-eight hours
after the ear symptoms were noted, the patient
developed a mental condition of an insanity turn.
I did not consider it a delirious state nor did it ap-
pear to be of a hysterical nature. One might be
inclined to think it a meningismus. It did not pre-
sent, so far as I was able to determine, signs of a
meningitis — Kernig's sign, or stiffness of the back
of the neck, was negative. My explanation of it
was that it was a condition of toxemia, probably
especially associated with the activity of this germ,
whereby first the endolymph in the cochlear and
semicircular canals, together with the cerebro-
spinal fluid, and with the juices in the nerve fibres
themselves, were peculiarly affected.
Following this state of mental development, the
patient's temperature dropped to practically normal.
The lungs did not show an excess of involvement.
The patient's condition improved; but the mental
730
BELLOWS: PROPHYLACTIC TREATMENT OF INFLUENZA.
[New York
Medical Journal.
State never did clear. The patient died, after an
illness of about two weeks. I attribute her death
to a toxemia early and progressively affecting the
brain tissues and probably the fluids entering into
the substance of the brain tissues.
CONCLUSIONS.
While I have only seen one case of this type, and
do not know of any similar case having been re-
ported, it seems as though there was sufficient evi-
dence of an intense toxemia in this patient, whose
ears were normal before the onset of influenza,
followed by this peculiar train of ear symptoms and
mental state, to warrant an unfavorable prognosis.
50 East FoRTV-SECONn Street.
PROPHYLACTIC TREATMENT OF INFLU-
ENZA FOR THE PREVENTION OF
PNEUMONIA.
By Charles M. Bellows, M. D.,
Brooklyn, N. Y.,
Consulting Surgeon, New York State Hospital, Former Visiting
Surgeon, Busliwick Hospital-
The following article is based on recent observa-
tion and treatment of at least 400 cases of influenza
in the present epidemic, with fifteen cases of
bronchial pneumonia and two of lobar pneumonia,
without a death.
The infection enters the nostrils and throat firstj
is then absorbed in the blood, and following this
affects the bronchial tubes and glands. In the ma-
jority of cases the system lacks the ability to elim-
inate, and the resistance is low.
Cultures of the throat and nostrils and blood in
all cases have shown both streptococci and pneu-
mococci.
The plan of treatment pursued has been, first to
neutralize the blood extension of the infection ; and
second, to prevent the local proliferation of germs
and pulmonarv and nasal absorption. The author
has found that it is possible to prevent this absorp-
tion and the rapid formation of germs locally.
The bronchial tubes and throat are found filled
with mucus from the hypersecretion due to acute
infection. The mucus — both bronchial and throat
— contains the bacteria, but not in large numbers
at the onset ; however, in twenty-four hours the
number is greatly increased.
By promptly stopping glandular secretion, includ-
ing that of the throat, the nose, and the bronchial
tubes, the extension of the disease is immediately
checked, providing systemic elimination is attended
to and pulmonary edema is immediately relieved.
I will submit, without citing individual cases, the
treatment which has been used with most satisfac-
tory le suits. k
The internal treatment consists of the adminis-
tration of the following:
Quinin. sulph., gr. xx ;
Phenacetinse, gr. xl;
Sodii (or ammonii) salicylat., gr. xl;
Extract, belladon., pulv., gr. iV^ ;
Extract, opii., pulv., gr. iVi ',
Camphor, pulv gr. iii ;
Extract, eupatorii (boneset), gr. xl.
To he made into twelve dry capsules.
Sig. : One every three hours.
In consequence of this internal treatment the
temperature will be reduced, the skin will act, and
there will be an immediate arrest in the functions
of the mucous membrane of the nose and bron-
chial tubes.
The feeling of exhaustion and heart weakness,
due more specifically to the intense infection, will
be relieved by strychnine, in addition to the above
mentioned capsules.
The cough will be relieved by the use of code-
ine.
The local treatment consists of the following;
Iodine gr. ii ;
Oil of cinnamon, min. v;
Thymol, min. v;
Oil of eucalyptol, min. vi ;
Camphor, gr. ii;
Menthol, gr. ii;
Petrolatum, liquid .^i
Apply thoroughly every two hours to nose and throat
with swab or spray.
In addition to this, hot mustard and soda baths
will help to promote the action of the skin.
Hypodermically, preceding or accompanying the
pulmonary involvement, pneumonia phylacogen
should always be used — five minims immediately,
ten minims in six hours, ten minims in eight hours,
and every day following as long as necessary —
watching the resolution. Antistreptococcus and
antipneumococcus serums have also been given.
The serum is given within the first twenty-four
hours of the sickness, and even prior to the pul-
monary involvement, recognizing the importance of
increasing the number of leucocytes as a protection
to the system.
I most earnestly ask all doctors to carefully con-
sider the treatment here submitted. In my hands
its results have been most satisfactory, and I be-
lieve that a great many deaths can be prevented,
more specifically by the prophylactic measures, as
the majority of cases are serious from the begin-
ning and should be treated vigorously before the
recognition of any secondary and pulmonary in-
volvement.
433 NosTRAND Avenue.
(Translated from La Presse Medkale, October 3, 1918.)
THE MICROBIAN FLORA OF INFLUENZA.
By Surgeon Major Orticoni,
Assistant Surgeon Major Barbie,
j-nd Assistant Surgeon Major Leclerc,
French Army Bacteriological Laboratory.
Most of the writers who have observed the grippe
in 1 91 8 seem to agree in finding in it a return to the
grippal pandemic that in 1889 created a worldwide
sensation, having been preceded in 1833 and 1847
by analogous epidemic manifestations.
The affection that is at present raging shows the
same manifestations as the former epidemics, par-
ticularly the extraordinary rapidity of extension, the
suddenness of evolution, and the extreme conta-
giousness as well as the immunity of isolated com-
munities. The clinical symptoms offer numerous
common points.
October 26, 1918.] ORTICONI, BARBIE, AND LECLERC: MICROBIAN FLORA OF INFLUENZA. 731
Judging by the different reports made in France
and abroad, it seems that after having assumed a
mild form during the months of May and June last
the grippe may actually bring about serious compli-
cations, and the so called Spanish grippe, the Swiss
grippe, and the German grippe only seem to be
synonyms for one and the same affection corre-
sponding to the type of the grippal epidemic of
1889 and 1890.
We find, indeed, this year some features of dif-
ference from the former epidemics, and one of the
most striking of these consists in the possibility of
seeing, in the course of the year's hottest season,
the evolution of pneumonic or bronchopneumonic
complications of a serious, even very serious nature.
The epidemic of 1889, which raged chiefly through-
out the winter, had accustomed us to regard these
bronchopulmonary complications of the grippe as
chiefly due to the influence of the season.
But we must remember that two epidemics are
never seen evolving in an altogether analogous fash-
ion. It is with them as with the clinical aspects of
most affections. Very seldom, in fact, do we see the
same malady follow an absolutely identical progress
m two dift'erent persons.
From the microbian standpoint, it is well known
that many bacteria have been blamed as originating
the grippe. During the 1889 epidemic a part had
been ascribed to the pneumococcus and the strepto-
coccus, but none of these germs had seemed to show
specific features in the etiology of the grippe.
In 1892 Pfeiffer attributed a pathogenic power in
the grippe to the coccobacillus known by his name ;
but the work that followed his researches seemed to
have shown that this germ is not found exclusively
in grippe. Nobecourt and Paisseau have recognized
a role for it in the respiratory complications follow-
ing the eruptive fevers of childhood. Many authors
have established its presence in the sputum of the
tuberculous. It has been assigned by Meunier as
the only microbian agent in some cases of meningi-
tis. On the other hand, Pfeiffer had only found it
in the sputum of the diseased and had never been
able to isolate it in the blood. This isolation, de-
spite the numerous researches to which it has given
rise, seems to have always been very difficult to ac-
complish.
In short, the present state of our knowledge re-
garding Pfeiffer's bacillus seemed to warrant us,
with many authors, in considering it as a saprophytic
germ, which, while not a commonplace one, rarely
entails severe morbid manifestations.
Having had occasion quite recently to observe
some grippe cases, some of them with grave compli-
cations, we deem it interesting to make a report on
the bacteriological researches we have had an op-
portunity to make. We shall give here a succinct
recapitulation of them, to be later on amplified by an
article detailing our complementary findings.
MILD r.RIPPE.
When some cases of mild grippe were recognized
in May and June, we made a certain number of
hemocultures, blood examinations on plates, nasal
mucus and nasopharyngeal examinations, as well as
experimental inoculations on the animal.
AH our hemocultures, made by placing from five
to seven c. c. of blood in ordinary bouillon or glu-
cosed bouillon, remained sterile.
Blo< d examinations made on slides failed to ver-
ify cither globular variations or alterations, while
the examination of the bronchial mucus, or of the
nasal or nasopharyngeal mucus, failed to show the
presence of Pfeiffer's coccobacillus.
With certain patients we observed the presence
of the pneumococc but not in any particularly
predominating fashion.
Intraperitoneal guineapig inoculations of one and
a half c. c. or two c. c. of blood taken aseptically
from the vein of the elbow bend in patients under
full febrile onset, gave the animal an increase in
temperature that lasted for many days. The rise
in temperature commenced in the guineapig within
the twenty-four or forty-eight hours following the
inoculation and persisted morning and evening,
varying from eight to ten days. The verified in-
creases in temperature are from two to three de-
grees, as attested by the curves we registered.
The blood examination on slides and the blood
cultures from the examined animals failed to dem-
onstrate the presence of any germ.
On the other hand, if blood is obtained from the
heart of a febrile guineapig following inoculation,
and two c. c. of this inoculated into a fresh guinea-
pig, a rise in temperature is seen in the latter within
the twenty-four hours following inoculation that
persists for many days.
To resume, the mild grippe did not permit us to
detect the Pfeiffer bacillus, or even the germs that
are the habitual agents of respiratory affections.
GRIPPE WITH GRAVE COMPLICATIONS.
On the other hand, in a certain number of pa-
tients affected by grippe with serious pulmonary,
bronchopulmonary or pleuritic complications, we
have been able to isolate in many instances a
bacillus having the morphologic and cultural char-
acters of Pfeiffer's bacillus. See a report made by
one of us in the Bulletin de V Academic de Medecine,
for September, 1917.
I. In a first series of cases, on nineteen hemocul-
tures made, we have verified in' seven of our pa-
tients the presence of an immobile, gram negative
bacillus, strictly aerobic, not thriving on the ordi-
nary media, thriving scantily on glucosed agar, and
yielding in blood agar more copious colonies.
The colonies furnished by this microbe are rather
small, transparent, hardly visible under the magni-
fying glass and located with preference at the bot-
tom of the tube, in the vicinity of the condensation
fluid.
We have never been able to isolate this germ by
culturing the blood of patients in ordinary bouillon.
The hemocultures were only found positive when
the blood was cultured at the rate of about eight to
ten c. c. in glucosed bouillon, following the usual
technic in hemocultures.
The bacillus is very little visible in the fresh state
between slide and cover glass ; its presence is hardly
ever verified except after staining. There is an ad-
vantage in overcoloring the preparation with diluted
Ziehl's fuchsin in order to make the germ rriore
clearly evident. Then it appears in a bacillary or
ORTICONI, BARBIE, AND LECLERC: MICROBIAN FLORA OF INFLUENZA. , [New York
Medical Journau
coccobacillary shape with distinctly larger dimen-
sions than are attributed by classic writers to Pfeif-
fer's bacillus.
In a second series of ten hemocultures we have
been able, by following the same processes, to iso-
late Pfeiffer's bacillus in the blood of the patients
five times. In one of these cases, where hemocul-
ture was made a few hours before the patient's
death, we were able to obtain a pure culture of this
bacillus.
2. In a certain number of purulent pleurisy fluids,
we have verified the presence of the same germ, but
with a slightly different morphology. They occur
in rather slender and even filamentous bacillarj'^
forms, sometimes isolated, frequently grouped in
twins, and for the cases that came under our obser-
vation, always associated either with pneumococci
or with streptococci.
This bacillus has been found in ten different fluids
of purulent pleurisy, and the culture of each of these
samples of pus has furnished colonies with the char-
acters of those of the Pfeift'er bacillus associated
with colonies of streptococci or pneumococci.
The intraperitoneal inoculation of adult guinea-
pigs with one c. c. of these same pleural liquids
has caused the death of the animal in from twelve
to twenty hours. The autopsy has revealed in the
peritoneal liquid of the guineapig the presence of the
Pfeiffer bacillus without a passage into the several
organs, whereas the germs of associations (pneumo-
cocci or streptococci) were passing through the liver
and spleen of the animal. The injection of one half
of a c. c. of this peritoneal fluid into the peritoneum
of another guineapig has brought about the latter's
death within thirteen hours. The autopsy on the
second guineapig showed the same conditions as for
the first.
There is room for observing that the Pfeiffer
bacillus is found in great abundance in the peritoneal
exudate, but in a rather shorter coccobacillary form
and without elongated elements.
3. In almost all of our patients, the Pfeiffer bacil-
lus has shown itself to be associated with other
germs, particularly with diplococci either isolated or
in little chains, which we have recognized in the
hemocultures as well as in the fluids of purulent
pleurisy.
Certain diplococci had really all the morphologi-
cal, staining and cultural characteristics that obtain
in the pneumococcus ; they were cocci, grouped in
twins, lanceolated, capsulated, gram positive, uni-
formly clouding the bouillon in a few hours, yield-
ing on agar colonies in characteristic dew drops
and killing a mouse through septicemia in about
twenty-four hours, as shown by the presence of
capsulated diplococci in the heart blood.
In some hemocultures, as well as in some pleur-
isy pus, we have verified the presence of gram pos-
itive diplococci m little chains. These little chains
were particularly elongated in the bouillon cultures
and in the peritoneal fluid of inoculated animals.
After coloring through the gram, they appeared as
presenting some sort of a common capsule, and it
may be asked whether this streptococcus does not
correspond to a variety that has been described by
a certain number of authors, and particularly by
Howard and Perkin'^ under the name of Strepto-
coccus mucosus. The virulence of this strepto-
coccus has, at all events, been shown to be very
great for the guineapig, but less so for the mouse.
4. In the sputum, the pneumococcus has been
found to be the paramount germ, even in the white,
aerated and foamy expectorations that do not show
the pulmonary type. We have not discovered or
isolated the Pfeiffer bacillus in the sputum. How-
ever, in certain grave forms we have been able to
isolate from bronchial expectoration the Friedland-
er pneumobacillus which was found in the expec-
torations of certain patients in a condition of true,
pure culture.
To resume, outside of the usual microbic agents
of the acute respiratory affections (pneumococci,
streptococci, and pneumobacilli) and of their
pleural complications, the most important fact we
gather is that we have been able to detect and iso-
late the Pfeiffer bacillus in the blood and the pleural
fluid of a certain number of grippe patients.
It is rather at the terminal period of the disease,
and in the very serious cases, that we have verified
the presence of the Pfeiffer bacillus, and almost al-
ways in association with other germs.
Can it be concluded that this microbe, whose
speci^city has been so much discussed, is the real
causative agent of the 1918 grippe? It would be
a premature affirmation. Further research may
yet permit us to determine whether the Pfeiffer
bacillus does actually play the chief role in grippe,
or whether it is only a satellite of secondary asso-
ciation.
HEALTH DEPARTMENT SUPPLIES
PROPHYLACTIC VACCINE.
Measures for the Prevention of Influenza Adopted
by the Department of Health of the City of
Neiv York.
Owing to the demand made by the medical pro-
fession and the public of the Department of Health,
the Board of Health of the city of New York has
decided to adopt the use of a bacterial vaccine
manufactured by the Research Laboratory under
the direction of Dr. William H. Park. This vaccine
was described by Doctor Park in the New York
Medical Journal for October i6th. The vaccine
is made from the influenza bacillus isolated from
cultures of the present epidemic. The vaccine is in
containers furnishing sufiicient material for inject-
ing from one to eight patients. The material is
issued only to physicians on written request. Owing
to the labor conditions produced by the war, the de-
partment is unable to mail the vaccine to physicians,
who must apply by messenger or in person for it.
The dose is arranged in two schedules. No. i, for
the robust, consists of two injections, one of 1,000,-
000,000 bacteria and a second injection, forty-eight
hours later, of 1,500,000,000. For the less robust
three injections are given at intervals of two days,
the first injection containing 500,000,000, the sec-
ond, 1,000,000,000, and the third, 1,000,000,000
bacteria. For children, one half to two thirds of the
above amounts should be administered according to
the physical condition and age of the child.
October 26, 1918.I
INFLUENZA IN THE NAVY.
733
The department has also established clinics in the
several branch offices of the various boroughs for
the free administration of this vaccine to such
citizens as apply for it.
In Manhattan these are located at 331 Broome
Street, 439 East Fifty-seventh Street, 431 Pleasant
Ave.iue, 481 West 145th Street, 307 West Thirty-
third Street, and 130 Prince Street. These station?
are open from nme a. m. until nine p. m.
There are two offices in the Borough of the
Bronx, six in the Borough of Brooklyn, four in the
Borough of Queens, and one in the Borough of
Richmond. Applications may be made at the office
of the Department of Health in Manhattan, and at
the main borough offices for further information.
Owing to the demand made by various organiza-
tions for a mask that would be simple, efficient and
inexpensive, the department has had* made two sets
of masks, one of surgeon's gauze with a ribbon
sewed to act as a loop about each ear. A piece of
gauze which acts as a bafifle is four by six inches
and at each corner the ribbon is sewed, making a
loop which fits over the lobes of the ears. This
is easily removed, is inexpensive and can be quickly
made. The use of a moist gauze mask has not been
advised as under ordinary conditions the mask need
be worn only a short time. A similar mask may be
furnished in the form of crepe tissue paper. In-
stead of ribbon being formed into a loop over the
ears the ends are folded flat on themselves and a
piece of paper one half by two inches is snipped out,
leaving an opening which will permit the paper to
be placed around the face, baffling the nose and held
in situ by the openings through which the ears can
protrude. These tissue napkins can be easily re-
placed, the old ones being placed in a paper bag
which can be carried in the pocket of the doctor or
nurse and when the supply is exhausted the bag may
be burned without danger of infecting others.
INFLUENZA IN, THE NAVY.
Inflvienza apparently has run its course in the
shore stations of the navy, although there still re-
main manv cases of pneumonia. The number of
new cases last week was only about half that of the
week before, in which latter week there was a
marked decrease in the number of admissions for
the disease over the preceding week.
The navy still declines to give out any figures re-
garding the number of cases of influenza and re-
sulting pneumonia, or the number of deaths. Other
than the influenza epidemic, the health of the navy
is excellent. Among some 254,000 men ashore in
this country, there were only four cases of scarlet
fever last week, sixteen of cerebrospinal fever, eight
of diphtheria, six of malaria, eighteen of measles,
and 272 of mumps.
The vessels of the fleet also have suflfered con-
siderably from influenza. There also has been a
considerable number of cases among troops while
en route in the transports, although it is not beheved
that the epidemic has been as severe in that service
as was feared. However, on a recent trip of one
of the largest transports to France there were 100
deaths from influenza.
The Naval Medical Corps continues to pay heavy
toll from influenza. Since the previous report in
these columns, the following medical officers have
succumbed : Lieutenant Commander Chester C.
Wood, of the Battleship Alabama ; Lieutenant James
F. Feely, Dental Corps, at Pelham Bay Park, N. Y. ;
and Lieutenant W. I. Ryder, Naval Reserve Force,
at Naval Hospital, C^slsea, Mass. Lieutenant
Ryder was a brother of Commander Charles E.
Rydei, of the Medical Corps of the Permanent
Navy. In addition, Lieutenant Hadley H. Teter,
Medical Corps, was lost on the Ticonderoga.
ADVICE TO PERSONS WITH INFLUENZA.
At a stated meeting of the New York Academy
of Medicine, held Thursday evening, October 17th,
recommendations were submitted by the Advisory
Council of the Department of Health of the City
of New York as follows :
Obey all the orders of the health department.
If vfu feel sick all over, with chilliness or achiiia; of the
bones, and with feverishness and headache, perhaps with
a cold in the head or throat, you are probably getting in-
fluenza.
Go to bed and, until you get a doctor, do these things!
Take castor oil or a dose of salts to move the bowels.
Keep reasonably but not too well covered, and keep
fresh air in the room, best by opening a window at the top.
Take only simple, plain food, such as milk, soups, gruels,
or porridge, or any other cereals. Eat bread and butter
and any kind of broth or mashed potatoes. Eggs may be
ealen, but not more than two a day. Do not take any meat
or any wine, beer, or whiskey, or other spirits unless you
are ordered to by the doctor.
Do not get up unless absolutely necessary, and then do
not walk about and expose yourself to cold and do not go
about in bare feet. Tn this way you will avoid getting
pneum.onia or bronchitis.
Do not take any medicine unless ordered by a doctor.
Do not cough or sneeze in the face of other people.
\'ou should drink plenty of plain water all through the
sickness.
Stay in bed until you have no fever and are feeling
much better. Stay in the house two or three days longer.
If you are not much better, or practically well in two
or three davs, call a doctor, if you have not already done
so. or ask the nearest hospital for help, or call the nearest
nursing centre, or notify the nearest Board of Health
clinic.
The recommendations were signed by Dr. A.
Tacobi, Dr. W. Oilman Thompson, Dr. Antonio
Stella, Dr. Walter B. James, Dr. Frederick C. Hol-
den. Dr. Francis Huber, Dr. L. Emmet Holt, and
Dr. Henry W. Berg.
An Influenza Commission. — Governor Whitman
has appointed a commission to study and make a re-
port on the cause, prevention, and treatment of in-
fluenza, thus making available to health officials and
the medical profession generallv the scientific infor-
mation regarding the influenza epidemic now accu -
mulating. Among those who have been invited to
serve on this commission are the surgeon generals
of the Army, Navy, and Public Health Service, Dr.
Rufus Cole, of the Rockefeller Institute ; Dr. Walter
B. James, president of the New York Academy of
Medicine ; Dr. Hermann M. Biggs. State Commis-
sioner of Health, and Dr. William H. Park, director
of the research laboratories. Department of Health
of the City of New York.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.,
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
post office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are net responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, OCTOBER 26, 1918
OUR SECOND INFLUENZA NUMBER.
We are fortunate in being able to present to
our readers in our second special influenza num-
ber, a series of admirable and informing papers
and discussions of the epidemic. The subject is
treated from various viewpoints, and every
reader will find something to interest him. Major
Charles L. Mix, who sets forth his experience in
the observation of two thousand cases at Camp
Mills, covers the situation from a military point
of view in a most illuminating and helpful man-
ner. The belief that the disease is not air borne,
but is conveyed by direct contact, he again con-
firms. He warns against starvation, fatigue, and
cold, as avoidable predisposing factors, and cau-
tions the practitioner against the great danger of
relapse in patients dismissed too soon, advising
against dismissal under ten days after the normal
temperature has been established. In studying
the statistics furnished by Major Mix, the fact
must be borne in mind that his paper was writ-
ten on October nth, and consequently repre-
sented conditions as they existed then, before the
epidemic had reached the height of its wave.
Later figures will be quite different, of course, not
only in numbers but in the relation of the mor-
bidity to the mortality. The same facts should
be borne in mind in considering the statistics
given by other authors.
In the opening paragraph of his general survey
of the conditions in New York, Dr. Royal S.
Copeland, the Commissioner of Health of the
City of New York, says: "It is meet and proper
that in a time as critical as the present, and one
fraught with tragic consequences to the lives of
so many of the people of this city, that the com-
missioner of health should appear before the med-
ical profession to submit to the judgment of its
members a report of the activities of the health
department and a statement of the reasons which
have guided him in determining upon certain
procedures and in omitting certain others which
have been suggested from time to time." The
admirable spirit shown here appears throughout
the papers by the commissioner himself and those
written by members of his staff, one of which,
by Doctor Harris, appears in this issue, while
others appeared in our issue for October 12th.
Doctor Harris not only presents a record of the
administrative measures taken by the city gov-
ernment, but gives some informing data concern-
ing the statistical aspects of the epidemic. He
confirms the observations made by Major Mix as
to the effect of starvation, fatigue, and cold as
predisposing factors, and directs attention to the
diminution in the virulence of the infection
which has taken place.
Dr. Morris Manges finds that there are three
distinct types of onset and that the prognosis is
fairly imiform for each of these types. The de-
gree of asthenia, he says, is a reliable index to the
degree of toxemia and consequently to the
prognosis.
Doctor Jelliffe, in his broad and illuminating
study of the nervous and mental disturbances of
influenza, refers briefly to the history of previous
epidemics which have recurred at varying inter-
vals since the days of Homer, though the first
satisfactor}^ literature of the subject dates from
the epidemic of 1300. But his most interesting
remarks are based on his own clinical observa-
tions, which bring out clearly the wide variety
and serious character of the neurological mani-
festations of the disease, a point not accentuated
by the internists. These may appear in one or
more of the organs of sense, may closely simulate
the symptoms of poliomyelitis, or meningitis, or
EDITORIAL ARTICLES.
735
October 26, 191 S.]
may even develop 'into multiple neuritis. The
case reported by Doctor Kahn (page 729) comes
in the category covered by Doctor Jelliffe.
Another special phase of the epidemic is treated
of by Dr. Irving Wilson Voorhees, who speaks
from the standpoint of the nose and throat spe-
cialist and who offers hope of relief from early
local treatment.
The prophylactic treatment, with a view to the
prevention of pneumonia, is advocated by Doctor
Bellows, who reports excellent results from fol-
lowing the methods laid down on page 730.
A French view of the bacteriological aspects of
the epidemic is presented in an article by three
surgeons in the French Army who have made a
study of the microbian flora (p. 731). In our
issue for October 12th, we published the observa-
tions of one of our own army bacteriologists.
Major E. H. Schorer, chief of the clinical labor-
atories of the Port of Embarkation, and by Dr.
William H. Park, director of the research labora-
tories of the Department of Health of the City
of New York. Doctor Park's work has been
carried a step further and the Board of Health of
the City of New York has now undertaken to
provide a serum elaborated in the city labor-
atories for free administration. Clinics for this
purpose have been established in the various
branch ofiices of the Board of Health. Supplies
of the serum will also be furnished to physicians
who apply to the Board of Health for it by mes-
senger or in person.
In view of the gravity of the situation, we feel
justified in devoting almost this entire issue to
the subject of influenza, and feel sure that every
practitioner, whatever his special line of interest
may be, will find something of value in this
number.
INFLUENZA IN EASTERN CANADA.
Influenza is prevalent in eastern Canada — in
some parts very prevalent. As may be imagined,
the disease is extremely rife among soldiers. In
the camps and barracks in and about Montreal,
Toronto, Hamilton, and Ottawa, there are hun-
dreds of cases and a large percentage of deaths.
In Montreal and neighborhood there were, in the
week ending October twelfth, something like
nine hundred cases in the military camps and
barracks, and the death rate has been about
eight per cent. So serious is the situation in
Montreal that schools, libraries, theatres, and all
places of amusement, and even churches and syn-
agogues, have been closed. The Provincial
Board of Health of Quebec has been accorded ex-
traordinary powers in order to deal with the epi-
demic as effectively as possible. From one end
of eastern Canada to the other influenza is ram-
pant, sometimes of a virulent and sometimes of a
mild type.
In Canada, as in th^ United States, the present
pandemic is diagnosed as Spanish influenza, pre-
sumably for the reason that it is supposed to have
originated in Spain. The pandemic which afflicted
the civilized world in 1889 came from Russia —
mainly from Asiatic Russia, which is the home of
influenza and of most of the pests — and was
termed Russian influenza. An epidemic of the
disease which occurred in Italy some few years
ago was called German influenza, because it was
imported into Italy from Germany.
However, the majority of laymen and some
medical men appear to regard this pandemic of in-
fluenza as a malady siii generis, as a new disease.
Weight has been given to this view by the opin-
ions expressed by European physicians. For ex-
ample. Professor G. Sampietro, in the Annali
d'Hygiene, June 30, 1918, referred to by the Lancet,
September 14, 1918, has stated his belief that the
pandemic which began in May and went through
Europe, was, in reality, sandfly fever. Plausibil-
ity was given to this theory, owing to the fact
that Pfeiffer's bacillus was met with rarely, but
the presence of a gram negative diplococcus of
the type of Micrococcus catarrhalis was isolated
frequently. Moreover, sandfly fever usually
prevails from the middle of May to the end of ,
September, whereas influenza is not epidemic in
the summer. The spread of the malady to this
continent and to other parts of the world has
severely shaken, if it has not altogether upset this
theory. And again, the behavior of this pan-
demic is similar in almost all respects to that of
1889-1892. In some places the disease is of a
virulent and in other places of a mild type. It
presents itself in mystifying forms and it is as-
suredly true that there is much yet to be learned
concerning its etiology and other protean phases.
At any rate, authorities are agreed as to its
microbic origin, and to Pfeiffer is attributed the
honor of discovering the causative microbe. Or
perhaps it would be more discreet to say, one of
the causative microbes. Finkler in his Tzventieth
Century Practice of Medicine says that he is of the
opinion that there exists a pandemic influenza
caused by Pfeiffer's bacillus, and also an endemic
epidemic influenza of identical nature which devel-
ops after the pandemic infection has run its
course, being caused by germs left by the latter.
73^
Furthermore, various forms of catarrhal fever
occur, which are often called grippe or influenza
by physicians and laymen. Dr. A. Bernier, pro-
fessor of bacteriology at Laval University, Mon-
treal, and bacteriologist to the Supreme Board of
Health of the Province of Quebec, coincides with
these opinions. He has recently isolated the
Pfeiflfer bacillus in a number of cases at Victoria-
ville, Quebec, but on the other hand in several
cases failed to discover it. Dr. Bernier holds
that there is a true influenza characterized by
the presence of the Pfeiflfer bacillus, and a
pseudoinfluenza of a catarrhal nature, whose ori-
gin is unknown. The discovery of the character-
istic microbe alone proved that the infection is
true influenza. The complaints presenting
catarrhal features are very numerous in this pan-
demic, as in the pandemic of 1889-1892, and are
calculated to lead laymen and even physicians
astray as to the real nature of the malady.
In any event, whether the PfeifTer bacillus is
found or not, every measure possible should be
put into force to prevent the spread of the dis-
ease, and every care should be taken to safeguard
the infected.
ATTENTION TO SPINAL SURGERY.
Spinal surgery attains much more prominence in
war than in peace — nor has the present war alone
brought this about. Frazier [C. H. Frazier : MiH-
tary Aspects of the Surgery of the Spine and Spinal
Cord, Surgery, Gynecology, and Obstetrics, June,
1918] has presented some of the latest features of
spinal surgery and emphasized its importance in mili-
tary surgical practice, and he has also called atten-
tion to its recognition as a matter for consideration
at the time of the Civil War. He speaks also of the
devotion with which that need was met then, when
such men as Weir Mitchell, Moorehouse, and Keen
devoted themselves to its practice and to the arduous
task of recording their experiences.
An effort has been made in Philadelphia, under
the surgeon general's direction, to train men espe-
cially in surgery of the spinal cord, that the peculiar
dangers and ineffectiveness which have been appar-
ent in this field of surgery may be lessened or elimi-
nated. For a better understanding of the subject
Frazier has prepared this review of its principal
features. Every segment of the spinal cord has been
subjected to injury in this war, but the thoracic re-
gion suffers most frequently because of its special
exposure. The bone lesions show a variety of form,
depending upon the portion of the vertebra which
sustains the injury, but also upon the shape of the
projectile and its course and velocity. A ricochet-
TNew York
Medical Journal.
ing bullet may attack several arches and their pro-
cesses and also indirectly fracture arches and pro-
cesses immediately above and below those directly
injured. This same force with which it strikes may
carry forward into the canal spicules of bone, par-
ticles perhaps of the projectile itself, and bits of
clothing. There is usually considerable splintering
and Assuring of bone. Visceral wounds of the pelvis,
abdomen, or thorax may be associated with spinal
injuries if the missile has struck anteroposteriorly.
The bullet more often is driven through the entire
spinal column or it may rebound from the bone com-
pact and become lodged in the soft flesh at some
remote region. Sometimes it merely sinks to a lower
level than that at which it entered the spinal canal.
The cord is liable to a variety of injuries. It may
suffer severe laceration or be completely severed by
direct contact with the bullet or the fragment of
bone or it may be merely contused by these. Either
of these may serve to compress it, or a subdural
hemorrhage, adhesions, or serous exudates may have
the sr.me eff'ect. Grave structural changes may take
place in the cord as the result of concussion caused
by tlie striking of the bullet against the vertebral
column as it bounds back to be lodged elsewhere, or
merely from the sudden change in atmospheric
pressure caused by the exploding of shells. These
structural changes are chiefly edema, hemorrhage,
primary destruction, and secondary disintegration.
The structural changes in the case of spinal cord
injuries are a fairly constant feature. These effects
of concussion have been explained as due to the
pressure waves set up in the spinal canal and the
disturbances of the lymphatic circulation. The os-
cillation of the cord within the canal at the time of
impact would also cause direct injury in contact
with the walls of the canal.
Operation upon the spine demands, first, accurate
localization, and so calls for repeated and careful
examination ; neither should it be undertaken
hastily. Rest and quiet are so essential for con-
valescence that spinal operations should be under-
taken only in the base hospital. Besides, " it is
possible often to determine, after a certain period
has elapsed, whether the injury is simply a func-
tional one or has produced an actual lesion. If
doubt still remains an exploratory laminectomy is
justified and often affords relief ; and it may dis-
cover a hemorrhage or undetected injury. More-
over, the clinical signs of a total lesion are often
misleading and laminectomy may reveal a lesion by
no means irreparable. Even direct and evident les-
ions of a severe nature are still matters of conjec-
ture, and operation has, in such cases, saved lives
whicl: would otherwise have been lost. There is
nothing here to be risked and good may result.
EDITORIAL ARTICLES.
October 26, 191S.]
OBITUARY.
727
The dural sac must not be opened unless there is
evidence that the bullet is there. Suturing should
then be recommended, especially if there is septic
material in the wound. If however, there is no in-
fection and the cord should be so swollen and edem-
atous that closure of the incision would cause seri-
ous pressure, the incision should be left unsutured.
A FUNCTIONAL DISEASE.
Of all the misleading expressions in common
use, none more deserves to be dropped from med-
ical diction than the expression, "It is only a
functional disease." Either there is no such
thing as a functional disease, or every disease is
functional. There is no such thing as function
without structure ; there is no such thing as nor-
mal functioning without normal structure or ab-
normal working, unless the organism has gone
wrong in its inner makeup.
In saying this we mean that if any organ of the
body has gone wrong in its behavior, either it or
some other organ somewhere in the body has
undergone change ; and it is this larger view of
the body and mind as a whole that is most needed
in the practice of medicine. If, for instance, the
heart beats more rapidly than usual it may be that
structural changes have but begun in the thy-
roid, and certainly exophthalmic goitre is no
fimctional disease. Moreover, in time, the path-
ological changes in the heart are altogether indis-
putable, and, if so, they must have begun some
time, and why not from the very beginning. We
are altogether too prone to separate activity from
the thing acting.
In the realm of nervous and mental disease it
is still more difficult to get rid of old terminol-
ogy. The "nervousness" of hyperthyroidism may
not begin in the nerve structures, but must fol-
low at once the disturbance of the thyroid lab-
oratory. In insanities, because the changes in
the brain are not revealed by the none too deli-
cate eye of the microscope it seems to the mind,
which must struggle still to connect itself with
the body, that here at least are activities which are
"purely functional."
We need to substitute some expression for
"functional disease." "Beginning structural"
would be better, though awkward. "Dependent
disease" might express the condition where a
malworking appears (or seems to appear) sec-
ondarily to the misbehavior of some other part
of the body. At least we should have a term
which means something more serious than the
term "functional" has come to convey.
It is in this realm of the beginnings of disease
that attention is and should now be centred. A
full fledged malady, such as is described in med-
ical books, can be detected by any one as a dis-
ease, although the exact nature of the disease
may not be patent. It is the inception of disease
which is difficult to determine, and to know this
we must thoroughly understand the normal and
where the normal begins to approach the abnor-
mal. It is a most fascinating study for the fu-
ture, and the deeper it is gone into the earlier the
phrase "only functional" as related to disease will
be dropped. On this study, of course, depends,
to a large degree, the future of preventive medi-
cine.
HONORS FOR SURGEONS.
Of the six officers to whom the Distinguished
Service Cross was awarded on October 13th for
extraordinary heroism, three were naval surgeons,
attached to the United States Marine Corps. Two
of these. Assistant Surgeon O. D. King,* and
Passed Assistant Surgeon Joseph F. Boone, won
their crosses in the action at Bois de Bleau on
June 9th and loth, while the other, Passed As-
sistant Surgeon William T. Gill, was awarded the
Distinguished Service Cross for heroism displayed
in the treatment of the wounded on July 19th in the
action near Virzey. On October 14th, the Dis-
tinguished Service Cross was awarded to Lieuten-
ant Robert O. Blood, M. C, of the 103d Infantry
for his heroic action under fire near Bouresches, on
July 20th to 23d. Captain George E. McGinnis, of
the lioth Ambulance Company, 103rd Sanitary
Train, has also been awarded the distinguished
Service Cross for heroism shown in the night
of August 9th during the action of Fismette. These
are but a (ew of the many instances of heroism
displayed by the members of the Medical Corps of
the Army and Navy. The nature of their work is
such that they are not likely to be given credit for
the heroism displayed, which is usually less dra-
matic though none the less truly heroic than the
services rendered by the combatant officer.
Obituary
EDWIN BRADFORD CRAGIN, M. D.,
of New York,
Dr. Edwin Bradford Cragin, prominent in New
York for many years as an obstetrician and gyne-
cologist, died on Monday of pneumonia at his home.
10 West Fiftieth street, New York, in his fifty-
ninth 3'ear. He had been in ill health for more than
a year, but continued to carry on his practice until
a month ago.
Doctor Cragin was born at Colchester, Conn., the
son of Edwin Timothy and Ardelia Ellis Cragin ;
was graduated from Yale in 1882, and got his M. D.
from the College of Physicians and Surgeons, New
York, in 1886. He commenced the practice of med-
icine in this city the same year, after serving for a
738
NEIVS ITEMS.
[New York
Medical Journal.
time on the hospital staff of Roosevelt Hospital.
He was later appointed assistant gynecologist to the
hospital and assistant surgeon to the New York
Cancer Hospital, and in 1899 became attending sur-
geon to the Sloane Maternity Hospital.
Doctor Cragin became prominent as a gynecol-
ogist and obstetrician early in his career. He was
consulting surgeon to the City, Maternity, Italian,
and New York Nursery and Child's Hospitals and
consulting gynecologist to the Presbyterian, New
York, Roosevelt, Lincoln, and St. Luke's Hospitals,
and the New York Infirmary for Women and Chil-
dren.
As professor of obstetrics and gynecology at the
College of Physicians and Surgeons, as well as
chief of the Sloane Maternity Service, he came in
close intimate contact with thousands of the medi-
cal students of Columbia University. His great
personal charm, kindliness of spirit, accuracy of ob-
servation, and ever ready desire to help others, en-
deared him to all and aided him in building up a
large and lucrative practice. Doctor Cragin was
also vice-president of the New York Academy of
Medicine, member of the New York Medical and
Surgical Society, New York Obstetrical Society,
American Gynecological Society, American Medi-
cal Association, and many others. He was a mem-
ber of the Republican, University, and Yale clubs,
and of the board of elders of the Central Presby-
terian Church.
News Items.
General Gorgas on Active Duty. — Major General
Gorgas, M. €., who was retired for age on October 3d, has
been assigned to active duty abroad, where he will inspect
the service in England and France and will return to make
a report of that inspection.
Enlisted Dentists to Be Commissioned. — Orders have
been issued that all graduate dentists who are serving in
the army as enlisted men shall be examined for promotion.
All found fit will be given commissions as first lieutenants
in the dental corps. Pending the results of the examina-
tion no examinations of civilians for commissions will
be held.
Meetings of Medical Societies to Be Held in New
York during the Coming Week. — Friday, November
1st, New York Academy of Medicine (Section in Sur-
gery) ; New York Microscopical Society ; The Practition-
ers' Society of New York; Alumni Association of Roose-
velt Hospital; Gynecological Society, Brooklyn (annual).
Saturday, November 2d, Benjamin Rush Medical Society.
Influenza in Sing Sing Prison. — Authorities of Sing
Sing prison have fitted up an emergency hospital in the
prison school. As a step toward curbing the spread of
influenza, of which there are now over seventy cases, Dr.
Amos O. Squires, prison surgeon, administered vac-
cine to over 600 prisoners. The regular prison hos-
pital has fifty beds, and the prison school has twenty
patients quartered there. The rest of the 1,000 inmates
now in Sing Sing will receive prompt treatment to render
them immune.
Advertisements Barred. — Recent issues of French
inedical journals have reached us with blank spaces where
advertisements usually appeared. The publishers explain
that the military authorities have prohibited the transmis-
sion to foreign countries of journals containing adver-
tisements. We have read of the use of advertisements as
a means of conveying information by spies, but have
looked upon the statements as ingenious fabrications. The
action of the authorities in barring the transmission of ad-
vertisements indicates tliat there is some truth in the re-
ports. It is said that a code was used based on the use
of misplaced, inverted, or damaged letters.
Clinical Research Society Postpones Meeting. — An-
nouncement is made that, owing to the epidemic of in-
Huenza, the annual meeting of the American Association
of Clinical Research has been postponed.
Influenza in Argentina. — According to press de-
spatches from Buenos Aires, dated October 22d, the influ-
enza epidemic, which has seriously hampered business and
other activities, continues to spread. The government has
ordered all schools closed until further notice.
Red Cross Hospitals Taken Over by the Army. —
The American Red Cross hospitals No. 4 at Mossley Hall,
Liverpool ; No. 21 at Paignton, South Devon ; No. 22 for
ofiicers at Lancaster Gate, London, have been taken over
by the United States army. The navy has taken over
the Red Cross hospital at Aldford House, Park Lane,
London.
PersonaL — Dr. Arthur A. Landsman has moved from
17 East Thirty-eighth Street to 310 West Eighty-sixth
Street, New York.
Dr. George Chaffee, of Brooklyn, a member of the sur-
gical staff of the New York Polyclinic Hospital for
twenty-five years, has opened an office at 100 Hawley
Street, Binghamton.
Influenza Spreading in Canada. — According to press
dispatches, Spanish influenza has now spread throughout
the Dominion of Canada. Vancouver reports 149 new
cases with two deaths ; Hamilton, Ont., seventy-two cases
and six deaths ; Winnipeg, seventy-two cases with two
deaths. Ottawa had thirty-three deaths. Toronto has had
452 deaths. The epidemic is still raging in Montreal and
Quebec City. Many of the smaller cities of On-
tario report almost one third of the population stricken.
Kingston has 4,000 cases and Stratford more than 2,000.
Theatres are closed in so many of the Canadian cities that
the routes of touring companies have been abandoned.
Free Medical Treatment for Former Soldiers. — A bill
has been introduced in the U. S. Senate relating to free
medical treatment. It provides that any person having
served in any wars in which the United States has been
engaged as a belligerent, and who has been or may here-
after be honorably discharged from the army, navy,
marine corps, or coast guard by muster out, resignation, or
otherwise, and who may be suffering from the effects of
wounds, injuries, or sickness incurred in the line of duty
while in the service of the United States, shall be entitled
to receive surgical and medical treatment from the med-
ical officers of the army, navy, or public health service,
whenever practicable, free of charge, in the same manner
and under the same regulations as are or may hereafter
be authorized to officers and enlisted persons in the mili-
tary service. It also is provided that any medical officer
or surgeon of the army, navy, or public health service,
who shall unreasonably or capriciously refuse or neglect
to grant surgical or medical attendance to the persons au-
thorized to receive the same shall, in the discretion of the
President, be dismissed from the service of the United
States and shall be rendered incapable of holding any
office of honor or trust under the United States.
The American Women's Hospital. — This organiza-
tion has recently received from Mr. Gibson, special com-
missioner of the American Red Cross in France, a request
for six imits, each to consist of ten medical women, ten
nurses' aides, and a sufficient number of chauffeurs to take
care of three or four cars. The Red Cross will supply the
nurses. These units are to be known as American
Women's Hospital Units Nos. i to 6. Dr. Caroline M.
Purnell, special commissioner of the American Women's
Hospitals in France, reports that the organization, coop-
erating with the American Committee for Devastated
France and working with the Sixth French Army in the
advanced area, has established Hospital No. i in a Fif-
teenth Century chateau near the front. Dr. Barbara
Hunto, of Bangor, Me., is director of this unit. Her staff
includes the following doctors : Dr. Ethel M. Eraser, Dr.
Mary Getty, Dr. M. Louise Hurrell, Dr. Mary MacLachan,
Dr. Mary Evans, Dr. I. Jay Manwaring, Dr. Ruth Ingram,
Dr. Charlotte Fairbanks, and Dr. Inez C. Bentley. Beside
this hospital, the American Women's Hospitals have sev-
eral dispensaries which are doing very important work.
Doctor Purnell reports that typhoid fever and dysentery
are the two diseases most prevalent in the areas recently
evacuated by the Germans.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
The Frequency of Protozoic Enterocolitis in
the Middle West. — Frank Smithies {American
Jourval of the Medical Sciences, August, 1918)
analyzes ninety-three cases of protozoic enterocolitis
with regard to etiology, symptomatology, laboratory
findings, and treatment. Under general treatment he
says that it is important that all local infection foci in
the teeth, tonsils, and mouth, or throat ulcers, diseased
gallbladders or appendices, etc., should be removed
before attack is made upon the intestinal infection.
If such are not taken care of radically, reinfections
may occur or subsequent ailments of such parts may
lower general resistance sufficiently to again permit
of enteric infection by protozoa. Encysted protozoa
may lurk for years in the appendix or the gallblad-
der. When this is the case the host is to be con-
sidered a not altogether harmless carrier. To free
the intestine from protozoa he places his patients on
a liquid diet for two days, with a glass of citrate of
magnesia each morning, and then begins the admin-
istration of specific medicines. Entamebse are par-
ticularly susceptible to ipecac or emetine, while fla-
gellate or ciliated protozoa are slightly af¥ected by
these drugs, but are destroyed by calomel. Thymol
is effective against both. In the entamebae cases the
patient is put to bed on liquid diet, with hot pads
moistened in boracic alcohol mixture over the abdo-
men— to prevent colicky pains or abdominal dis-
comfort. He is then given by mouth a ten grain
tablet of the aluminum salicylate of ipecac (al-
cresta) every hour and one third grain of emetine
hydrochloride hypodermically every four hours for
two days. If the stools show diminution of the
parasites the dose of ipecac and emetine is then re-
duced by one third and this continued for another
two day period. No reduction is made if the para-
sites are still very abundant or are very active.
Usually by the end of the first week the patient is
taking one to two grains of emetine hypodermically
daily and ten grains of ipecac ("alcresta") four
times daily. The treatment is continued even when
no parasites are seen. Accompanying the medicines
given by mouth the colon is carefully lavaged with
four quarts of hot normal salt solution or a solution
of quinine, 1/3,000, and thymol, 1/5,000, in normal
salt solution night and morning. On the sixth day
the patient is put on fat free diet for twenty-four
hours — to render thymol administration safe. At
bedtime of the seventh day thirty grains of thymol
in honey are administered at eight p. m., and again
at ten p. m. At six o'clock the following morning the
patient gets two ounces of Epsom salt in hot water,
and all that morning frequent drinks of black cof¥ee,
fat free broth or malted milk. During the second
week the emetine, ipecac and bowel irrigations are
continued, and usually on the tenth day from the
beginning of the treatment two doses of fifteen
grains each of thymol — preceded by twenty- four
hours of fat free diet — are given in the evening.
Daily examinations of the warm stools usually indi-
cate no parasites by this time and the diet may be
increased according to the patient's desires, provided
it is low in protein and not very bulky. If parasites
persist at the end of two weeks, then after thor-
ough colon lavage with hot normal saline solution,
from 500 to 1,000 c. c. of filtered, commercial kero-
sene are given per rectum, slowly. The external
parts are greased with carbolated vaseline and effort
is made to have the patient retain the kerosene for
at least one hour. The author has never seen any
harmful effects follow the use of kerosene. It has
proved very efficacious in ridding the bowel of
persistent infection.
When the entamebfe are no longer demonstrable
in the freshly passed stool, then local treatment of
the enterocolitis by large doses (thirty grains) of
bismuth subnitrate or subcarbonate given five times
daily should be carried out. Emetine and ipecac
should be continued for at least five weeks, the
ipecac alone for three months. The bowel irriga-
tions are usually stopped at the end of the third
week. The general state of the patient is taken care
of according to indications; HCl after meals if the
gastric juice is lacking in acid; iron and arsenic if
anemia is present. When flagellate protozoa are the
infecting organism the treatment is substantially as
outlined above for entameb?e, except that emetine
and ipecac are not used unless there is a concomitant
amebiasis. The flagellates are readily destroyed by
the administration of evening doses of calomel, five
to fifteen grains, followed by two ounces of Epsom
salt the next day. These doses of calomel are re-
peated about every five days, according to the indi-
cations furnished by the stool examinations. The
flagellates are usually less persistent than are the
entamebte with the exception of lamblije.
A careful study of specimens of gallblad-
ders and appendices removed at laparotomy indi-
cates that in these parts of the gut cysts of protozoa
may lurk for years. Reinfection of the bowel is
thus possible. Consequently if these organs have
not been removed, he insists that patients should
have stool examinations at least three times a year
and that they go through an abbreviated course of
treatment similar to that outlined above. Only in
this Vi^ay does he believe that protozoa carriers can
be ehminated or reinfection of so called cured cases
prevented.
Treatment of "Essential" Facial Neuralgia by-
Local Alcoholization. — J. A. Sicard {Boston Med-
ical and Surgical Journal, September 19, 1918)
states that the only effectual treatment of this dis-
ease is the destruction of the branches of the nerve,
"local neurolysis," by chemical substances, particu-
larly alcohol. He uses alcohol, varying in strength
from seventy to ninety-five per cent., and injects
not over 1.5 c. c, under local anesthesia produced by
novocaine or stovocaine, into the nerve ift the
foramina where it can be reached. Some of these
foramina are superficial, the supraorbital and infra-
orbital ; the opening of the inferior dental canal at
the spine of Spix is medium ; the foramen ovale
740
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
and foramen rotundum are deep. He prefers to
make the deep injections four or five days after the
others, but sometimes makes all five injections at
the same sitting. Care must be taken not to inject
the alcohol into a bloodvessel, as this may cause a
gangrenous necrosis of the area supplied by the
blood. The results are said to be remarkable,
though relapses are apt to take place in from twelve
to eighteen months. Certain conditions are indis-
pensable to success. The first of these is that the
case be one of the so called essential variety, and
the following points are given in dif¥erentiation :
I. Whenever the pain in facial neuralgia persists
continuously with no distinct intervals of relief it is
not a case of essential neuralgia. 2. Cases of
facial neuralgia which, not having been already
treated surgically or by local injections, are accom-
panied by cutaneous or mucous anesthesia, are not
cases of essential neuralgia. 3. When facial
neuralgia, previous to any intervention, presents as-
sociated signs of stimulation or paralysis of other
cranial nerves, such, for instance, as trismus, di-
plopia, facial paralysis, lingual hemiatrophy, etc.,
it is not a case of so called essential facial neu-
ralgia. 4. A case of facial neuralgia which ab
initio, involves the three branches of the trifacial,
is not a case of essential facial neuralgia. In
these cases we are dealing with secondary facial
neuralgia of either exocranial or endocranial origin,
e. g., syphilis, tuberculosis, cancer, abscess, sinusitis,
etc. In these the injection of alcohol, far from
aflording relief, may, on the contrary, aggravate
matters. Nor is it of service in neuralgia following
herpes zoster of the trifacial, for this is not a peri-
pheral lesion. The second important condition is
that every efifort must be exerted to reach the nerve
branches responsible for the pain. Cutaneous or
mucous anesthesia of the area innervated by the in-
jected nerve is the only evidence that can be ob-
tained of a successful injection. This should super-
vene directly after the injection, and is accompanied
by a sensation of induration and swelling, in reality
nonexistent. These disturbances of sensation are
very varied and peculiar.
Gunshot Wounds of the Head. — T. O. Graham
{British Medical Journal, August 10, 1918) draws
upon a personal experience of nearly 500 cases of
this form of injury in ofifering his conclusions and
suggestions relative to their treatment. Wherever
possible operation should be performed under local
anesthesia, produced by injecting two per cent, pro-
caine (novocaine) with epinephrine into the scalp
in a complete circle about the site of the operation.
This should be done after the patient is on the
operating table and should be preceded by the ad-
ministration of forty miUigrams (two third grain)
of omnopon. This form of injection of the local
anesthetic, not only produces complete anesthesia,
but it also provides very efficient hemostasis, and
is not followed by postoperative ill efifects. In every
case the whole scalp wound must be excised freely
to av»)id sepsis, as far as possible. In cases of fis-
sured fractures without bony depression, no opera-
tion is done upon the bone unless there are definite
neurological symptoms of increased intracranial
pressure. In such cases the skull is trephined and
the extradural clot removed and hemorrhage con-
trolled, but, even in the presence of subdural hemor-
rhage, the dura is not opened on account of the
dangers of infection. Lumbar puncture is sub-
sequently performed to reduce intracranial pres-
sure. In some cases, however, where the sub-
dural hemorrhage is very large one may have
to incise the dura and remove the blood. In
depressed fractures the bone is not disturbed
unless there are signs of severe intracranial pres-
sure, when the depressed bone is elevated and
the dura, if lacerated, is sealed by a muscle
graft. Where fragments of bone have been driven
through the dura into the brain the track of the
wound is exposed and carefully cleared of clot, dis-
integrated brain tissue, and all bone fragments. The
dural opening is then covered with a pericranial
roof, and the scalp tightly sewn with a small glove
finger rubber drain running down to the dura, but
not into its opening. Penetrating wounds are treat-
ed much as are those of the last type, but if the
retained missile cannot be removed without further
damage to the brain tissue it is left in situ. Hemor-
rhage from the meningeal vessels or sinuses, wher-
ever found, should be controlled by muscle grafts,
as far as possible, gauze and Hgatures being avoided.
Herniation of the brain should be of infrequent oc-
currence, but when present it should be treated by
keeping the patient in a sitting position, the adminis-
tration of sedatives, and the repeated performance
of Itmibar puncture with the very slow withdrawal
of small amounts of fluid. In gunshot wounds of
the head the mortality is fT«ve times as great when
the dura is opened, either by the wound or in the
operation, than when it is not.
Tuberculosis as an Army Problem. — Major Jo-
seph H. Pratt, M. R. C, and Lawrason Brown,
{American Reviezv of Tuberculosis, August, 1918)
of¥er a few criticisms of methods of the tuberculosis
examinations in the service and suggestions for
future work. The authors bear testimony to the
efficiency of the authorities in charge of the tubercu-
losis examinations in the army, and commend, in
particular, Colonel Bushnell's rapid auscultatory
method. Questionnaires are valuable, chiefly because
they save time, as the man transferred from board
to board always has his record with him, and they
keep together all records and examinations made
of each man, and could be returned to the original
board. The authors gained their experience on the
examining board at Camp Devens, which examined
27,300 men of the first draft of the National Army.
There were nineteen physicians on the board, all but
two of whom gave their full time to the work.
.A.mong the entire command of 27,304 officers and
men, 184 cases of pulmonary tuberculosis were
brought to light. One hundred and thirty-five of
these were rejected or discharged from the army.
The percentage of tuberculosis found was 0.67 of
I per cent. It was apparent from the figures that
mote cases of ttiberculosis were passed by the exam-
iners in some cities and town than in others. As to
the reliability of the history given by those exam-
ined, it was the impression of the authors that most
of them told the truth. The volunteers were, on
the whole, healthier than the drafted men.
October 26, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
Otitic Meningitis. — Edward B. Dench {Laryn-
goscope, July, 1918) calls attention to the import-
ance of suppurative otitis media in relation to
involvement of the intracranial structures, and men-
tions the fact that from the reports of 19,000 cases
of middle ear suppuration, he found that one patient
in every eijjhty-eight suffered from some intra-
cranial lesion — either epidural abscess, sinus
thrombosis, brain abscess, or meningitis. Fortun-
ately meningitis is the rarest of these intracranial
complications of otitic orgin. Broadly speaking, it
is any inflammation of the coverings of the brain
due to a middle ear infection. One class of menin-
geal inflammation is a comparatively simple compli-
cation and offers no menace to life, while other
classes are always severe and invariably terminate
fatally. The simplest form presents no symptoms
aside from localized headache, local tenderness,
sleeplessness, and a slight elevation of temperature,
the liymptoms often being so slight that the condition
is frequently not definitely recognized until pus is
found at operation. The Spinal fluid in such cases
ordinarily shows an increase of globulins and a
moderate increase of cell count. In the more se-
vere cases of complication, which are usually of the
fulminating type, the symptoms are more pro-
nounced and a cause for alarm. Cerebral manifes-
tations are usually marked, the spinal fluid is found
to be under great increase in pressure, is turbid, the
eel! count is greatly increased, globulins are present,
and pathogenic organisms are invariably found. The
ideal operative interference seems to be the removal
of the primary focus of infection, the exposure of
a large area of dura with subdural drainage in cases
of the fulminating type, and repeated lumbar punc-
ture in all cases.
Constipation in the Army and Its Treatment.
— Marcel Labbe (Prcsse medicate, July 25, 1918)
considers constipation among the most serious, as
well as among the frequent affections to which the
soldier is subject under war conditions. The chief
reasons for it are the change in diet — less of fresh
vegetables and more meat — the danger of being
wounded during defecation in active sectors, and the
inabiifty, among those with a preexisting tendency to
constipation, to carry out their usual procedures for
combating it — laxatives, enemas, or suppositories.
Five groups of cases may be recognized. In the
first, that of simple constipation, the difficulty is due
to loss of the habit of regular defecation ; many
cases of dyspepsia among soldiers are due to it.
Purgation, and subsequently laxatives and dietary
precautions are curative. The second group is that
of spastic constipation, due to irritation by fecal
sta.sis. Pain, a sensation of weight, and palpation
reveal this condition. In the third group, atonic
constipation, palpation, and the x rays exclud?
spasticity. The colon is soft and flabby, rolls under
the fingers because of gaseous distention ; the patient
complains of puffiness after meals and vague abdo-
minal discomfort. The fourth group is that of con-
stipation with intoxication, with irregular or period-
ical attacks so marked as to cause pronounced loss
of weight and even unfit the subject for any sort of
military service. In these cases, at the close of the
period of constipation, the urine often shows an
excess of ammonia and a high coefficient of ureo-
genic imperfection, due to disturbance of the liver
by the enterogenous intoxication. X ray examina-
tion shows marked slowing of food passage through
the intestine. The fifth group is that of constipation
with colitis or pericolitis, due to irritation. In the
treatment, proper diet and regular defecation are
first in order. Agar, linseed, olive oil, and mineral
oil are of service in simple constipation. Besides,
each subject has his own favorite remedy ; one per-
son found ten grams of bismuth in the morning the
only effectual laxative. A teaspoonful of sodium
sulphate, sodium citrate, and sodium bicarbonate in
equal parts, taken in hot solution early in the morn-
ing for two or three weeks generally gives good re-
sults. For spasm, belladonna and valerian are
appropriate ; for atony, strychnine, glycerophos-
phates, and dried suprarenals. In toxic constipation,
a vegetarian, but plentiful, diet forms the basis of
treatment, and bowel disinfection should be sought
by alternate use of lactic and paralactic bacilli,
calomel, benzonaphthol, betol, and naphthol.
Hepatic and biliary extracts are useful to excite both
the liver and bowel functions. Castor oil and
salines in small doses are of value, with intestinal
lavage for mechanical cleansing. In inflammatory
constipation, during peritonitic attacks, the diet
should be limited to milk soups, vegetable bouillons,
starchy purees, and fruit marmalades. Castor oil
in moderate amounts, tepid enemas, and hot abdo-
minal applications are serviceable. In inveterate
inflammatory constipation with progressive malnu-
trition surgical treatment is indicated.
Intraspinal Treatment of Cerebrospinal Syphi-
lis. — Clyde L. Cummer and Richard Dexter
(Jo urnal A. M. A., September 7, 1918) take issue
with a recent critic of the results of this method of
treatment and contend- that the method is most valu-
able and not associated with any danger, if prop-
erly carried out. They base their conclusions upon
an analysis of the Hterature and their own personal
experiences for five years with the Swift-Ellis and
Ogilvie technics. It is fallacious either to adopt the
criteria of clinical improvement or those of serologi-
cal changes to the exclusion of the other. Though
both usually run parallel, it is certain in some cases
that the striking manifestations of chnical improve-
ment, such as the return of a previously hopelessly
incapacitated man to his occupation, must be ac-
cepted in spite of little change in serological reactions.
No comparison is made between the exclusive use of
intraspinal treatment and that of intravenous. The
latter method often gives as good results as can be
expected from any form of treatment, but in some
cases it falls very far short of such results, and in
these the resort to intraspinal treatment is usually
followed by good recovery. The need for intra-
spinal therapy is especially marked in those who
cannot endure intensive treatment with mercury or
with arsphenamine intravenously. The improve-
ment in favorable cases is so definitely consequent
upon intensive intraspinal treatment and is so well
maintained even for long periods without further
treatment, that such improvement cannot be ex-
plained on the basis of a remission.
742
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
The Intracranial Treatment of Paresis. —
Henry A. Cotton and W. W. Stevenson {Journal of
Nervous and Mental Disease, April, 1918) sum-
marize tiie results of four years' experience in the
treatment of cerebrospinal syphilis as follows : The
intracranial — either the intraventricular or sub-
dural— method is the most efficacious in the treat-
ment of paresis and should be the mode of prefer-
ence. It is also the mo.st efficient one for the
treatment of tabes and luetic meningitis. Salvarsan
is preferable to diarsenal and other substitutes for
the treatment of cerebrospinal syphilis. The mer-
curialized serum of Byrnes is of doubtful value, as
it is not of sufficient potency to destroy the spiro-
chete. The success of any method of treatment
depends upon the stage in which the disease is
treated ; the earlier the stage the better the outcome.
Every case of syphilis should have an examination
of the spinal fluid at frequent intervals after all
symptoms of the acute stage are lost, especially if
the blood Wassermann remains positive after suf-
ficient treatment has been given. All cases of
paresis can be arrested and possibly cured if treat-
ment is begun early enough.
Treatment of Vernal Conjunctivitis with Ra-
dium.— William Allen Pusey {Journal A. M. A.,
September 7, 1918) says that the results of the
treatment of this form of conjunctivitis are the same
with radium as with the x rays, but that the latter
is far more convenient and can be limited in its ap-
plication much more effectively. The technic of the
treatment consists in the eversion of the affected lid
and its grasp in a lid clamp which has a heavy under
plate and a widely fenestrated outer blade. The
metallic under plate protects the eye from the rays.
The radium is then applied on a varnished appli-
cator containing five milligrams of the element,
which is of sufficient strength to cause a bright
erythema on the normal skin after application for
ten minutes. The applicator is passed back and
forth over the lid just short of making contact with
the surface. The application is made in broken
doses, an exposure of five minutes being given to
the whole lid on each of six successive days. Then
an interval of several months is allowed and the
treatment is repeated, if required. No reaction is
caused by this dose and method of application and
the results are very gratifying.
Operation for Empyema. — Hugh McKenna
{Journal A. M. A., August 31, 1918) describes a
new m.ethod for the treatment of all forms of
empyema, which has many advantages over the
older methods and which gives a very much reduced
mortality. It consists, essentially, in the drainage
of the pleural cavity or the pus pocket, irrespective
of the character of the pus, through a No. 14 French
rubber catheter. A trocar and cannula just large
enough to permit the jijassage of the catheter are
introduced through an interspace, and the catheter
is threaded in. The cannula is withdrawn, leaving
the catheter in place. A 100 mil glass syringe is
connected to the catheter and the pus is carefully
aspirated. When the pus is too thick for aspiration
a small amount of Dakin's solution is injected to
quickly liquefy the pus. By repetition of this pro-
cess the cavity can soon be emptied. The amount
of pus aspirated is measured, and half as much of
the Dakin's solution is injected and allowed to re-
main in the pleural cavity. The aspiration and
reinjection are repeated three times during the day
and twice at night by a specially trained nurse.
This procedure is followed for each pocket of pus
when two or more are found upon examination.
Of nineteen consecutive cases treated by this
method, all have recovered. The advantages of the
method are : That it is decidedly a minor operation ;
that the danger of contamination of the cavity with
other organisms is reduced to a minimum ; that the
lung is less completely collapsed than after costec-
tomy or thoracotomy ; the condition of the discharge
can be followed accurately day by day ; distressing
sinuses are not likely to result ; pus from dependent
parts of the pleural cavity can be evacuated thor-
oughly; solidification of the pus cannot take place;
and, lastly, there is no danger of injury to the lung
from the rubber catheter.
An Improved Method of Cocainizing the Eye
for Iridectomy in Acute Glaucoma. — O. Haab
{Corrcspondcnshlatt fiir Schwcizer Aerste, May
Ti, 1918) injects two drops of a ten per cent, solu-
tion of cocaine beneath the conjunctiva at the place
where the iridectomy is to be performed — usually
at the upper margin of the cornea — and is ready to
operate in from seven to ten minutes. If the con-
junctiva is very hyperemic a small quantity of
adrenalin is added. The elevation of the con-
junctiva, produced by the injection, flattens out so
as to form no obstacle to the operation within this
time, particularly if the region is gently massaged
once or twice through the lid. He asserts that the
anesthesia produced in this way is perfect, so that
the operation is painless and the patient hes quiet.
The point in which this method differs from that
employed by others is that a stronger solution — ten
per cent. — is used instead of one only two per cent,
or four per cent.
Prolonged Bile Drainage in Pancreatitis. — Ed-
ward Archibald {Journal A. M. A., September 7,
1918) presents his observations on the influence of
prolonged bile drainage upon the swelling of the
pancreas, loosely called pancreatitis, and occurring
in cases of gallstones or infection of the bile tracts.
From an analysis of the ultimate results, as judged
by the relief of symptoms and freedom from recur-
rence, in a series of thirty-three cases, the conclusion
is reached that the shorter the period of bile drain-
age the greater the likelihood of recurrence of symp-
toms or their persistence after operation. All pa-
tients in whom drainage was continued for four
weeks or longer recovered without any persistence
of symptoms and without subsequent recurrence. It
is evident, therefore, that in such cases steps should
be taken to maintain drainage for such a period
whether the gallbladder is the seat of infection or of
stones. It has been shown recently, however, in the
Mayo Clinic that complete removal of the bladder
without subsequent drainage gives equally good re-
sults. The removal of the bladder or the practice
of long continued drainage cures the pancreatitis,
probably by preventing the possibility of a rise in
bile pressure sufficient to cause reflux of bile into
the pancreatic ducts.
October 26, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
743
Curative and Immunizing Treatment of Ma-
laria with Mercury. — Guido Cremonese (Ga^cetta
degli Ospcdali e delle Clinkhc. May 30, 1918) re-
ports rapid cure of malaria by the hypodermic use
of bichloride of mercury, the results being corrobo-
rated by the disappearance of the protozoa from the
blood. He gives one centigram of the bichloride in
twenty-five per cent, solution daily for ten days and
then ten more injections at intervals of ten to fifteen
days. By mouth he gives the bichloride in pill form.
As a prophylactic measure he has found this almost
infalHble.
The Medical Treatment of Graves's Disease,
with Special Reference to the Use of Corpus Lu-
teum Extract. — Herman H. Hoppe {Journal of
Nervous and Mental Disease. April, 1918) recom-
mends, in addition to ordinary routine treatment,
hygienic measures and partial rest, the administra-
tion of extract of corpus luteum, 0.12, with quinine
hydrobromide, 0.12, and extract of belladonna, 0.006,
per dose. Nearly all patients require the extract of
corpus luteum continuously — some once a day, oth-
ers two or three times a day. As long as this is
done he believes that the patient will be improved
and can be kept in a fairly normal state.
A New Treatment in Acute Rheumatism. —
Santiago L. Brian (La Semana Medica, June 6,
1918) has had remarkable success with hypodermic
injections, once daily, of a solution of seven grams
of sodium chloride and ten grams of sodium sul-
phate in a litre of water. The quantity used at each
injection is 150 c. c, and it is seldom necessary to
give more than three or four doses to obtain marked
improvement. No other treatment has given such
rapid results, and there has been an entire absence
of complications in the cases so treated.
Recent Developments in Intestinal Bacteriol-
ogy.— Arthur Isaac Kendall {American Journal of
the Medical Sciences, August, 1918) says that there
appears to be an intimate relationship between the
character of the diet and the nature of the intestinal
flora. This relationship, bacterially considered, is
manifested by an adaptive intestinal acclimatization
of fairly definite types of bacteria. Changes in the
diet, if prolonged, tend to change the types of
bacteria. A change in the products of metabolism
of intestinal bacteria is also induced, depending
upon the presence or absence of carbohydrate.
Positive implantation of adventitious microbes —
those not accommodative to intestinal conditions —
appears to be infrequent. Bacteria which are norm-
ally acclimatized do not produce metabolic pro-
ducts widely at variance with the wellbeing of the
host. Toxic or irritating metabolic products tend to
arouse the antagonism of the host. The results may
be disea.se, expulsion of the microbe, immunity, or
the carrier state. Products arising from the utili-
zation of food for energy by intestinal bacteria are
of paramount importance in determining the speci-
ficity of action of these microbes. * To a limited
degree a careful modification of the diet may ma-
terially alter the character of these metabolic
products, with benefit to the host. Bromatherapy
may be practised in acute or chronic disease. Bac-
terial implantation within the alimentary canal must
follow natural lines. liactcrial acclimatization and
adaptation is the resultant of complex reciprocal
activities between host and parasite. Intelligent
bacterial implantation presupposes an accurate
knowledge of the chemistry of the metabolic pro-
ducts of the bacteria under varying dietary condi-
tions. It is unwise to generalize from incomplete
data. The data of bromatology and bromatherapy
in relation to microbic activity in the alimentary
canal are conspicuously incomplete. Nevertheless,
the remarkable influence of diet upon the activities
of intestinal bacteria, in so far as it is known, would
warrant the assumption that a new chapter in the
broad field of bacteriology has just opened. The in-
dications are apparently favorable for a new avenue
of approach to bacteriotherapy.
Uje of a Strap Arovmd the Foot to Reduce
Fatigue in Marching. — Bonnette {Presse medi-
calc, July 22, 1918) calls attention to the value of a
strap fastened tightly about the foot to facilitate
locomotion when the extremities are tired from pro-
longed marching and countermarching. Under these
conditions the plantar tissues sag, the nerves are
pressed and dragged upon, and the ligaments be-
come tender. Immobilization of the tibiotarsal and
calcaneoastragaloid joints by means of the strap
brings relief and permits of making an additional
effort to complete the march. The strap is passed in
figure-of-eight fashion under the itistep, in front of
the foot, and behind the ankle — over the shoe. This
procedure has proven so effectual that some have
used the straps for preventive purposes, to defer
fatigue.
An Automatic Apparatus for Carrel Treatment.
— Daure (Bulletin de I' Academie de medecine, July
30, 1918) comments on the inefficacy of devices
for automatic Carrel instillation so far described.
His own procedure consists in connecting a re-
ceptacle containing antiseptic solution with the
wound through a second smaller flask attached to
the distal end of a counterweighted, oscillating
lever. The counterweight holds the flask in an
elevated position until the solution, dropped gradu-
ally into it from the main receptacle above, has ac-
cumulated sufficiently to force up the counter-
weight at the other end of the lever, when the solu-
tion runs out from the flask to the wound through
rubber tubing. The rate of dropping from the
main receptacle to the flask is regulated by a screw
cock upon rubber tubing connected with a glass
tube which dips into the solution in the receptacle
through the cork closing the latter. The air ad-
mitted through the tube governs the outflow of solu-
tion from the receptacle. Any desired time interval
between successive instillations can thus be secured.
The amount of solution passing into the wound at
each instillation — from ten to eighty mils — is regu-
lated through a device by which the centre of
gravity of the lever, counterweight, and flask can be
adjusted at will. The apparatus has already been
in successful use for several months, under varying
circumstances. The author found it highly satis-
factory in the Carrel treatment of mastoid operative
wounds.
Miscellany from Home and Foreign Journals
A Study of the Nerves and Ganglia of the Lung
in a Case of Pulmonary Tuberculosis. — William
Snow Miller {American Rcz'iczv of Tuberculosis,
May, igi8 ) describes the distribution of the nerves
and oranglia within the lung in a case of rapid
tuberculosis occurring in a teamster, forty-seven
years of age, the duration of the disease being about
seven months. The author found that distribution
of the nerves and ganglia — in a tuberculous lung —
differed in no respect from the normal. Tubercu-
losis does not occasion an increase in the number of
nerves or ganglia in the lung. The lungs receive
their nerve supply from the pneumogastric nerve
reinforced by branches from the second, third, and
sometimes the fourth thoracic ganglia of the sym-
pathetic. These follow the bronchi throughout their
course, diminishing in size with the diminishing
calibre of the bronchi. In many places not only
these nerves but also the main nerve trunks are
highly inflamed, being surrounded by and infiltrated
with a large number of lymphocytes. Ganglia
were found surrounded by and infiltrated with
lymphocytes, showing that they, as well as the
nerves, were involved in the general inflammatory
process. This study gave rise to several questions :
Might not the increased activity of the glands be due
to the irritation of the nerves and gangUa ; might
not the irritating and productive cough in some
cases of tuberculosis and the dry hacking cough in
other cases be due to nerve irritation ; might not the
nervous hyperesthetic condition accompanied by
very rhallow breathing which was a frequent result
of gas poisoning in the present war be due in some
measure to irritation of this nervous apparatus of
the lung?
Instinct Distortion or War Neurosis. — Donald
E. Core (Lancet, Augvist lo, 1918) says that these
cases resemble hysterias, in that environment plays
a dominant part in their development ; but they
differ from the hysterias, since in the latter the role
of environment is indirect and since the hysterical
phenomena are based on a physiological reaction.
In the war neuroses the phenomena are pathological
and serve no useful purpose in protecting the con-
sciousness from unpleasantness. The diagnosis of
war neurosis is generally comparatively simple,
since the symptoms conform to the various motor
manifestations of fright. These are divisible into
two groups. The fir.st are those associated with
flight, and include facial pallor, staring eyes, dilata-
tion of the pupils, rapid heart, and muscular excit-
ability, tremor or spasm. The second group
includes those fright manifestations associated with
the ''crouching instinct" such as the inability to
move the legs or walk, aphonia, whispering speech
or stammering. Careful study of the case will show
that, in addition to looking terrified, the patient is
really terrified and is specially the victim of terrify-
ing dreams, or even of fear, during the waking
hours. Often he cannot sleep at all at first on ac-
count of his fears ; later he is able to sleep, but his
sleep is only fragmentary and is broken by dreams
which awaken him in terror. As improvement
progresses he sleeps better but awakens in the
morning with memories of distressing dreams.
Gradually the element of fear and terror is lost, at
first for only part of the time, later almost or quite
completely. But when this stage has been reached
many of the somatic symptoms, such as stammering,
tremor, etc.. have become habitual and require cor-
rection. The diagnosis of war neurosis should
never be made in the presence of definite evidence
of actual organic lesions. The treatment of war
neurosis is neither very difficult nor very compli-
cated and depends upon whether the patient is ill
or is in the habit stage. When in the active or ill
stage sleep should be aided by giving 0.6 gram (ten
grains) of trional, with or without aspirin, and
diminishing the dose as sleep improves. The pa-
tient should be kept in bed for the most part, and
preferably in a ward with a few other patients. As
sleep improves and fear becomes less he should be
allowed to leave the ward at intervals and mix with
other patients. During all this time he should be
encouraged as to his ultimate recovery, and the
physician should talk with him frequently and gain
his confidence. In the treatment of the various
motor disorders during the active as well as the
habit stage encouragement, exercise of the parts and
painstaking reeducation are the most important
measures. Occupation in the experimental work-
shops is also of j:he greatest value.
Celiac Disease. — G. F. Still (Lancet, August 10,
]9i8) presents a detailed discussion of the symp-
tomatology of this uncommon disease, calling atten-
tion to the fact that it is about three time as preva-
lent in girls as in boys. The condition usually be-
gins in the latter part of infancy and in ten per
cent, of the cases is preceded by infantile scurvy.
The onset may be very ill defined, but in many of
those cases in which it is fairly definite a history of
an attack of diarrhea will be obtained. Diarrhea,
however, is not a necessary antecedent. The stools
are characteristic even quite early in the disease,
being bulky, pale, creamy, unformed, pultaceous,
and very evil smelling. They are of decidedly acid
reaction and float in water. Later the stools tend
to change to pale gray, soft fecal matter, or to
greenish or dark brown, and are often mixed with
blood and mucus. The abdomen is distended, this
being one of the most characteristic features of the
disease. The urine is normal and the liver is re-
duced in size rather than enlarged. The spleen is
also not palpable. There is more or less marked
pallor associated with a relative deficiency of hem-
oglobin. Among the most striking features of the
disease is the arrest of growth and physical develop-
ment, which may be extreme ; with this arrest there
is a marked smallness of the voice. The dentition
is not much retarded. Muscular feebleness is ex-
treme, and the child often cannot walk even when
several years old. The mental capacity of the
child is not much impaired, if at all, in most cases.
Various complications are prone to arise in the
course of the illness, some of which are so frequent
as almost to be regarded as symptoms of the dis-
October 26, 19 iS.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
745
ease. Among these more or less general edema is
the most pronomiced. Other common complications
include attacks of tetany, purpura, and chronic
glossitis. Scurvy is also a frequent complication,
but is probably due as much to the dietetic treat-
ment as to the disease itself. The development of
glossitis, the looseness of the bowels and character
of the movements, the abdominal distention, the
' ^,vasting, the absence of enlargement of the liver,
and the afebrile course of celiac disease make it re-
semble sprue very closely. The course of celiac
disease is always very slow, and complete recovery
does not occur in any case in less liian one year.
Gradually the digestive abilities return, but for a
long time the arrested growth is not compensated
for. The mortality is not high, only four out of
forty-one cases seen having died of the disease.
On the other hand, in a large proportion of cases
complete recovery can scarcely be regarded as
occurring.
War Commotion and Emotion. — Dupre and
Logre (Bulletin de I' Academic dc medicine, July 30,
1918) divide commotion or diffuse concussion of the
neuraxis, due to nearby explosion of a shell or other
forms of violent, vibratory impact, into three syn-
dromes— the immediate commotional, the recent
postcommotional, and the late postcommotional syn-
dromes. The first of these consists of prompt and
more or less protracted unconsciousness, a more or
less profound state of coma, of the apoplectic type.
The second syndrome follows the first, lasts a few
weeks or months, and comprises subjective disturb-
ances of a psychic order as well as objective disturb-
ances of a neurologic order. The subjective mani-
festations consist of headache, dizziness, insomnia,
asthenia, apathy, and a mental sensation of empti-
ness and nothingness, with amnesia. In more severe
cases, occurring especially in those already predis-
posed, there may appear anxiety ; maniacal, melan-
cholic, or confusional agitation ; hebephrenic or cata-
tonic syndromes, hallucinations, motor automatism,
etc. Hallucinations, however, are sufficiently un-
common to afford a sharp contrast between the post-
traumatic and an infectious or toxic mental con-
fusion. The neurologic symptoms constitute, in mild
cases, a triad, viz., impaired vascular equilibrium,
one side of the body often contrasting with the
other ; auricular disturbances, tinnitus, hyperesthe-
sia, and often tympanic rupture and secondary
otitis ; cerebrospinal stigmata, viz.. slight albumi-
nosis, appearing in two or three days and disappear-
ing after a few weeks, spinal hypertension, excess of
glucose, etc. In grave traumatism, various signs of
cerebral tissue injury may be superadded. The late
postcommotional syndrome is characterized by slight
asthenia or emotional instability, or, in the uncom-
mon, more severe cases, by a permanent psycho-
pathic state with neurasthenic symptoms and ab-
normal irritability, anxiety, pessimism, and an ex-
treme morbid fear of the particular form of violence
originally responsible, which renders the subject un-
fit for further service at the front. In the most
severe cases, dementia may ultimately supervene.
Emotion is often associated with commotion, but
may occur separately. It is due, not to an external
traumatic influence, but to a purely mental shock or
series of intense aft'ective impressions reacting upon
the sympathetic and cerebrospinal systems. It re-
sults in an extreme degree of psychic and motor
activity, associated with terror, flight — in brief, the
defensive reactions of the instinct of selfprescrva-
tion. There follow signs of acute anxious emotion-
alism, restlessness, tremor, crying out, then quietude,
with persisting irritability, fear, and a tendency to
seek seclusion. Only in occasional cases are there
added functional disturbances of abdominal organs,
due to disordered innervation. Through a process
of emotional anaphylaxis there may result continu-
ous anxiety, incapacity for exertion, loss of weight,
tachycardia, insomnia, and a grave general condi-
tion. Like commotion, emotion may ultimately
cause chronic dementia.
Studies of Urobihn Elimination in the Normal
and Anemic Dog. — Harry Dubin (Journal of Ex-
perimental Medicine, September, 1918) states that
the output of urobilin is increased in experimental
trypanosome anemia in dogs, presumably as a re-
sult of the increased blood destruction. If arseno-
benzol, given during the anemic period, brought
about the disappearance of the trypanosomes from
the blood, and an improvement in the blood picture,
the elimination of urobilin was diminished : but
when there was no beneficial effect demonstrable in
the blood, this was not the case. Splenectomy in
normal dogs brought about a varying degree of in-
crease in the urobilin elimination, which Dubin
thinks may bear some relation to the anemia gen-
erally seen after splenectomy. During the course
of the infection splenectomy had no influence on
the course of the anemia nor upon the elimination
of urobilin. The conclusion is reached that the
present work supports the theory that the elimina-
tion of urobilin may be considered as an index of
blood destruction, but it does not explain the de-
creased elimination occurring in man in certain
forms of hemolytic anemia following splenectomy.
The Etiology of Epidemic Poliomyelitis. — Ed-
gar T. H. Tsen (Journal of Experimental Medicine,
September, 1918) is unable to confirm the results
of Rosenow and others, as his attempts to transmit
poliomyelitis to monkeys, guineapigs, and rabbits,
by the injection of streptococci isolated from hu-
man cases of the disease were unsuccessful. He
isolated streptococci from the central nervous sys-
tem of monkeys who had died of poliomyelitis, as
well as from the brains of monkeys dying from
other causes, and from the brains of normal rabbits,
and showed that the streptococci isolated in the
first case were in no way different from those iso-
lated from monkeys and rabbits who had died of
causes other than poliomyelitis. From this work no
etiological relationship could be established between
streptococci and poliomyelitis. In working with the
globoid bodies of Flexner, Noguchi, and Smillie,
Tsen was able to find organisms similar to them
culturally, morphologically, and tinctorallv, but he
could not carry the culture for more than three gen-
erations, so that monkeys were not injected with
the organisms, and no condusions can be drawn
from the culture work. Tsen was not able to pro-
duce typical poliomyelitis lesions in rabbits bv the
injection of either the poliomyelitis virus or strepto-
coccus.
746
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journai,.
Influence of Temperature upon the Velocity of
the Complement Fixation Reaction in Syphilis. —
— Ilideyo Nogxichi {Journal of Experimental Medi-
cine, September, 1918), in order to find out whether
the complement fixation of syphilitic sera or spinal
fluid can occur at a temperature below 37° C, car-
ried out numerous experiments to determine the re-
lation between time, temperature, and reaction.
Such a study is a valuable one at this time, for it
proves that the reaction can take place satisfactorily
at a temperature which can be obtained without the
use of a special incubator, so that the performance
of the test may be much more widely adaptable.
The reaction was found to occur equally well at
37° C. when a water bath was used, and incubation
for thirty minutes was necessary ; at 30° C. in a
special thermostat room, where the reaction pro-
ceeds with moderate velocity, and is complete within
sixty minutes ; and at 23° C, the temperature of the
laboratory, which required two hours' incubation.
The experiments showed no disagreement in the
tests made at the difiPerent temperatures, so that,
provided sufficient time is allowed, an ordinary labo-
ratory, made as warm as possible, is suitable for the
examination of syphilitic sera and spinal fluid when
an incubator is not available. Guineapig comple-
ment gave a sharper reaction with the sera which
contained less than one unit of the fixing substance,
and fixation was complete at any of the three tem-
peratures in twenty minutes when more than two
units were present. A serum which contained one
unit of fixing substance required thirty minutes for
complete reaction at 37° C, sixty minutes at 30° C,
and two hours at 23° C, whether human or guinea
pig complement was used. Noguchi's conclusions
refer only to the systems in which the acetone-in-
soluble fraction of tissue lipoids is used as antigen.
The Findings on Autopsy in the Present Epi-
demic of Influenza. — A. Glaus and R. Fritzsche
(Correspondensblatt fiir Schiveiser Aerzte, Au-
gust 24, 1918) describe the findings, on autopsy,
in fifty-three fatal cases of influenza. The ages of
the subjects varied from one to fifty-nine years, but
forty-one were between nineteen and thirty. Almost
all were victims of pneumonia, which presented an
unusual appearance in the great majority. The most
common picture was one in which hemorrhagic,
pneumonic, necrotic, and suppurating parts alter-
nated, each often wedge shaped with their bases at
the pleura. Between these, smooth, transparent,
parti}' atelectatic, partly air containing portions of
lung tissue frequently remained. This combination
of infarctlike hemorrhages, abscesses, necroses, and
pneumonic foci with hyperemia and edema of the
lungs seems to them to be the characteristic condi-
tion of the present epidemic, although not always
present. The hem.orrhagic infarcts and . lobular
pneumonic foci were often the most marked, while
the necroses and abscesses were so slight that they
had to be sought for specially. In a few cases ordi-
nary pneumonia was present, and in one. a man
fifty-three years old suflfering from emphysema, the
only finding was that of a purulent bronchitis. All
of the cases had bronchitis ; in about one-fifth it was
purulent, in the rest catarrhal. The larynx and
trachea showed more or less similar changes. The
pleura was usually involved, at least showing punc-
tate or large subpleural hemorrhages. In about
half of the cases there was a more or less marked
serofibrinous or fibrinous pleurisy ; in six there was
empyema, bilateral in three. A fibrinopurulent
pericarditis and epicarditis was present in three. The
results of the bacteriological investigation may be
summed up briefly as follows: The fatal complica-
tions of influenza, especially the pneumonia, seem
to be caused by a mixed infection of pneumococci,
streptococci, and staphylococci. Concerning influ-
enza bacilli, their presence could not be demon-
strated, but it was demonstrated with certainty that
they were not to be found regularly in the bodies of
those who died of this disease.
An Experimental Test of Nuzum's Antipolio-
myelitic Serum. — Harold L. Amoss and Freder-
ick Eberson {Journal of Experimental Medicine,
September, 1918) were unable to confirm Nuzum's
claim that his serum is therapeutically active in poli-
omyelitis. His experiments were repeated, but it
was found that his serum does not possess any
more neutralizing power for poliomyelitic virus in
vitro than does normal horse serum. The serum
was then subjected to the same tests as were applied
to Rosenow's antipoliomyelitic serum, with results
similar to those reported previously for Rosenow's
serum. While immune monkey serum completely
neutralizes the virus as it passes through into the
meninges and so prevents infection, the serum of
Nuzum and Willy possesses no such power, but acts
in the same manner as normal horse serum, so that
it rather promotes than prevents experimental polio-
myelitic infection. Amoss and Eberson think that
many blood cultures should be made before resort-
ing to the intravenous injection of antistreptococcic
serum on a large scale in the treatment of polio-
myelitis, as they do not feel that sufficient proof has
been adduced to establish the fact the streptococcus
plays an essential part in the pathology of epidemic
poliomyelitis.
Experimental Study of Parotitis. — Martha
Wollstein {Journal A. M. A., August 24, 1918)
records the results of a large series of experiments
on the virus of parotitis in which cats were used as
the experimental animals because of their known
susceptibility to the disease. Attempts to infect
these animals were made by injecting the suspected
material into the parotid glands or the testicles. In
ever)- case the material injected was rendered bac-
terially sterile by passage through a Berkefeld
candle. It was found possible to transmit the dis-
ease to cats by the injection of such a filtrate of the
salivary secretion of children and adults in the active
stage of parotitis. In the cats there was an incu-
bation period of about eight days. The virus was
also successfully transmitted from cat to cat by
injection of a filtered emulsion of the infected gland
or b} the saliva. In such experiments the virus in-
creased in virulence for the animals for several pas-
sages and then fell ofif again. In no case was the
virus obtained in the saliva from human beings
after the ninth day of the disease, and it was most
uniformly secured during the first three days. The
virus was also detected in the blood serum of in-
fected persons with severe constitutional symptoms.
Proceedings of National and Local Societies
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held Thursday, October 17, 191S.
The President, Dr. \V.\lter B. J.xmes, in the Chair.
influenza: an infokm.vl discussion of the
uise.\se and the present situ.vtion.
Dr. Walter B. James, in opening the discussion,
recalled the fact that a year ago at a meeting of the
Academy there was an informal discussion on influ-
enza and the various phases of the disease. The
city was not at that time in the throes of an epi-
demic, but it was realized that at any time the dis-
ease might return as an epidemic, and today the
epidemic is here, one part of it appearing to be a
pandemic. This meeting had been called to discuss
the disease and the present situation and a number
of speakers had been asked to present their views
rather informally and briefly. There was no cause
for panic, but this was a disease which it had so far
been impossible to check. It was fairly well known
how long such epidemics lasted, but it was to the
interest of the entire medical profession to secure
the best possible information as to the care of the
people of the city while the epidemic was raging
and running its course, and it was with that end in
view that this meeting was called together.
General Survey of the Influenza Epidemic. —
Dr. RovAL S. COPELAND, Commissioner of Health
of the City of New York, read this paper which is
published in full in this issue of the New York
Medical Journal.
Influenza at Base Hospital No. i. — Major
Dudley Roberts, M. C, U. S. A., chief medi-
cal officer of General Base Hospital No. i (Col-
umbia Base Hospital), presented observations
made on cases of epidemic influenza at the base
hospital. He considered that whatever details,
characteristic of this disease that could be made
clear were important, not alone in view of the
present serious aspect of the situation, but because
the disease was likely to recur after it subsided this
time and also because it was likely to be endemic in
New York after this in far greater degree than
before. The present epidemic form of influenza
was characterized by sudden on,set with chill or a
feeling of chilliness, headache and backache with
congestion of the eyes, nose and throat and cough.
The patient was usually dull, apathetic and the
leucocyte count was low — from 2,000 to 6.000. It
was important to be able to distinguish between in-
fluenza and other inflammatory conditions of the
nose and throat. The course of simple uncompli-
cated influenza was usually very short and the
temperature came down from 100° or 103° to nor-
mal within forty-eight hours ; elevated temperature
after this time was cause for suspicion of bronchial
pneumonia.
There were four distinct groups of broncho-
pneumonia following influenza. The first graup
acted like simple influenza even to the subsidence
of the temperature in forty-eight hours, but the
radiograph showed areas of lung consolidation
which persisted for weeks. The second group acted
like the first except that after the temperature sub-
sided, it suddenly rose again and the cases fre-
f|uenlly went on to rapid and fatal termination.
The third group were severely ill from the onset ;
after a few days they sometimes appeared to im-
prove and then the process in the lung started in
violently. Cases that were cyanotic from the be-
ginning had a very bad prognosis. The fourth
group, from the hour of onset, were patently fatal.
It was beginning to be ajiparent that there would
be anoiuer group of cases in which empyema com-
plicated the condition.
The pneumonia following epidemic influenza was
not easily recognized at the beginning which was
the time to recognize it if results were to be ac-
complished. The disease could be recognized first
because of the persistence of fever after forty-
eight hours ; secondly by the appearance of the' pa-
tient, the cyanosis, etc. ; thirdly by the rusty
sputum ; and last ot all by the physical signs in the
lungs. The earliest physical sign was a peculiar,
prolonged, harsh, somewhat high pitched note on
expiration, usually over the affected lobe. Dullness
was an unsatisfactory sign and crepitant rales were
not hea-rd as early, or with the same uniformity as
in lobar pneumonia. Small areas of suggestive
bronchophony and of broncho vesicular breathing
were the first positive signs.
Regarding treatment, they made it a practice at
the base hospital to digitalize the pneumonia cases
almost from the first. They had also been using a
mixed vaccine, both therapeutically and as a pro-
phylaxis. It was too early as yet to say whether
the remarkably favorable results they had attained,
as shown by several charts giving mortality and in-
cident rate before and after this measure was in-
stituted, would continue, but the intravenous
injection of a mixed vaccine, had enabled them to
produce figures which not only showed a mortality
rate reduced twenty per cent., but the cases of in-
fluenza that were treated immediately showed clini-
cal signs of improvement. The number of cases
of influenza developing among those who had been
vaccinated against it was almost nil.
The vaccine was made by Major Carey, chief
of the laboratory service, and contained in one c. c.
100 million influenza bacilli, 100 million of the three
groups of pneumococci, 100 million mixed strepto-
cocci, and 100 million staphylococci. The treatment
by intravenous injection was the only method that
was found of value. A series of cases treated by
subcutaneous injection gave very unsatisfactory re-
sults. The first dose had been one half c. c, the
second one c c, the third two c. c, and the fourth
three c. c, at twenty-four hour intervals. With
the one c. c. dose there was usually a prompt re-
action, a chill or chilly sensation, followed by a rise
in temperature. It was planned to use one c. c. as
the initial dose especially in the severe cases. The
dose would then be doubled daily. Probably the
strength of the vaccine would be doubled to avoid
using too large an amount of the mixture to admin-
ister the proper number of organisms While this
-48
I'KOCEEDJXGS OF NATIONAL AND LOCAL SOCIETIES.
[Xew York
Medical Journal.
plan of treatment had apparently given striking re-
sults, it must be viewed conservatively, and certainly
must be used early in the course of pneumonia if
satisfactory results were to be achieved.
Major E. G. Carey, chief of the laboratory
service of General Base Hospital No. i, said that
the majority of the twenty-two cases that came
to autopsy had shown a rather extensive and con-
rtuent type of bronchopneumonia or lobular pneu-
monia. There was only one case of typical lobar
pneumonia in this series of autopsies. A striking
feature of the cases admitted had been the leuco-
penia ; in sixty admissions only eight showed more
than 7,000 white cells. Even smears direct from the
tissues at autopsv showed very few leucocytes. As
to the benefit derived from the vaccine, that had prob-
ably been through its effect upon the leucocytosis.
Gay and Claypole showed with typhoid vaccines that
the intravenous injection produced a distinct in-
crease in leucocytes in sensitized animals and pa-
tients. The organisms of the present pneumonias
when cultured were found to be those that usually
did not succeed in invading lung tissue — streptococci
of various types and even staphylococci. Because
of the failure of the usual leucocytic response and
walling of? of the invading organisms the lung pro-
cess had been very rapid and very extensive. A
leucocytic response might produce a limitation of the
disease and a favorable influence in its course. In
following the blood counts of th^ treated cases there
were indications that such a response was obtained.
This helped aside from any specific action that the
vaccine might have, and such specific action re-
mained to be determined.
Dr. Douglas Symrieks, of New York, gave a
resume of his pathological findings, both micro-
scopic and macroscopic, in the several organs of
persons dead of the prevailing form of influenza,
as set forth in his article published in the issue of
Octol.'er 12, 191S, of the New York Medical
Journal.
Dr. Henry W. Berg, of New York, briefly re-
viewed his clinical and therapeutic observations of
cases of the prevailing epidemic at the Willard
Parker Hospital, as published in the issue of Octo-
ber 1..', igi8, of the New York Medical Journal.
Dr. William R. Williams, of New York, said
that though he had not had the opportunity of see-
ing as many cases as Major Roberts and Doctor
Berg, he had been very much impressed by the
fact that this epidemic presented a real disease
entity, the same disease that was described in the
lectures of Francis Delafield. The striking point
about it was the way it attacked the circulatory
system ; the word most mentioned by the speakers
this evening was the word "congestion" and that
emphasized the symptoms and signs that were en-
countered. There was congestion in the nose —
epistaxis ; congestion in the throat — it looked red ;
congestion in the lungs — the most striking finding
at autopsy ; congestion of the gastrointestinal tract
— vomiting of blood and bloody feces; and tre-
mendous congestion of the skin from which alone
the gravity of the case could almost be guessed.
In the New York Hospital there had been more
than 100 cases ; these cases had come in, for the
most part, rather later than those at the Willard
Parker, and certainly later than cases should be in
hospital at camps. The first cases were two sol-
diers on leave in town from camps. They came
in about the middle of September. Most of the
patients had had signs over the chest or shadows in
the r:i(!iogram. or mucopurulent sputum containing
enough blood to convince one that they had consoli-
dation of the lung. The mortality rate had been
extremely depressing; of the 100 cases twenty-two
were fatal. Some of the pneumonias were rather
slight and twenty-two per cent, mortality of mixed
cases often with slight pneumonia seemed very
high. The cases where the organs were seen at
autopsy had borne out the evidence of tremendous
congestion, startling one into trying to think of
some adequate therapeutic remedy to control the
generalized paralysis of the whole vasomotor sys-
tem. Some biological means of doing this must be
looked for and it was to be hoped that in the
next few weeks it would be learned that this had
been found, and Major Roberts had pointed out the
way.
Ur. Hermann M. Biggs, New York State Com-
missioner of Health, regretted very much that he
was not present to hear Doctor Copeland's address.
He had not much to say as there was not much to
be said, for in a way not very much was kno^\■n
about the situation, except what every one knev/.
This was the most serious epidemic of disease that
had visited the civilized world in a century. He
considered it a serious indictment of the methods
of public health education that at this time it was
impossible to check the spread of such an epidemic
as this. The cause was evident enough ; the secre-
tions of the nose and throat contained myriads of
the causative organisms, and no measures had been
taken to enforce penalties against the careless dis-
charge of these secretions. Twenty years ago the
Board of Health of New York City adopted an
amendment to the sanitary code against spitting,
but that was not so dangerous as unguarded cough-
ing and sneezing. That seemed to be the explana-
tion of this pandemic. The epidemic could have
been checked, or at least to a large extent, if this
had been realized and proper precautionary meas-
ures put into effect. There was a hospital in
London where they treated cases of scarlet fever,
chicken pox, diphtheria, whooping cough, and other
infections in the same ward in adjoining beds,
cared for by the same nurses under the same con-
ditions, and there were no secondary infections
simpl> because of the exercise of great care in the
disposal of the discharges from the respiratory
tract. If this could be done with such diseases,
there was no reason why it should not be possible
with influenza which was also a disease of the
respiratory tract. With all the modern prop^ress in
public health there had been no progress made in
checking diseases which were scattered primarily
and solelv in this way, because there had been no
progress in enforcing simple measures of cleanli-
ness and decency. Ninety per cent, of the popula-
tion did not cover the mouth and nose in coughing.
This was the lesson which had come with this epi-
demic.
As to the conditions in the state outside of New
October 26, 191S.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
York City some districts had been heavily invaded
and some had thus far escaped ; in the last week's
report there was a summary of cases in those locali-
ties where the disease was epidemic which showed
about 40,000 in the state outside of New York City.
This of course did not represent the actual number,
but gave some idea of the extent of the outbreak in
the heavily invaded areas.
"Major Carev, chief of the laboratory service of
Ease Hospital No. i, said that the great majority of
the cases had shown a rather extensive and con-
fluent type of bronchopneumonia, or lobular pneu-
monia. There was only one case of lobar pneu-
monia in the series reported on by Major Roberts.
A striking feature of these cases was the leucopenia,
leucocytes being practically absent. Even smears
direct from the tissues rarely showed leucocytes.
The vaccine injections had a direct effect on the
leucocyte count and in that way limited the course
of the disease and influenced results.
Dr. Louis Faugkres Bishop, of New York, said
that he had a book entitled The Annals of Influ-
enza, published by the Sydenham Society in 1853
covering the epidemics for about 300 years and giv-
ing the opinions of the best men of those times as to
treatment, and they almost without exception en-
dorsed the antiphlogistic treatment of pneumonia
of the influenza type. They used the lancet freely.
During the eighteenth century epidemics occurred
every three to five years, and there was no doubt
that their treatment of pneumonia was founded upon
this type, and when the antiphlogistic plan was con-
demned it was for an entirely different disease. A
great many of the very best older practitioners to-
day endorsed the early antiphlogistic treatment of
pneumonia and believed that it saved many lives,
and they quoted such authorities as William H.
Thompson, Francis Delafield, etc., to support this
contention. It was the absolute duty of those physi-
cians, having the technical facilities, to test this
treatment promptly in this type of pneumonia just as
they had tested and reported on the use of digitalis
in ordinary lobar pneumonia. The crisis in patients
treated by aconite was indeed very alarming, but the
patients did not die. As a heart specialist the
speaker had been called in a number of cases to sup-
port the heart in the terminal stage of pneumonia
and he had not been successful ; he believed that if
these patients had been treated with aconite early in
the disease many of them would have responded to
the active stimulation that was often necessary to
tide them over the crisis.
Dr. E. LiBMAN, of New York, inquired of Major
Roberts whether the series of cases which were
treated without vaccination were under observation
at the same time as the series which were treated
with vaccine, or whether the two sets of cases over-
lapped. Major Roberts replied that they over-
lapped.
Doctor LiBMAN considered that this had an. im-
portant bearing on the results. There had been,
during the last week, a change for the better in the
severity of thfe cases of pneumonia. Apart from
the cases he had seen in hospital, he had observed
between 300 and 450 cases of pneumonia following
influenza since the epidemic began. During the first
two weeks the mortality was very high. There ■
one type of case, very frequent at that time, wl'
had not been so often encountered during the i-
week, a type characterized by the expectoration
thin bloody fluid which was not frothy and con-
tained no mucus. Nearly all such patients died. Dur-
ing the past week he had been able to make a
favorable prognosis in a very large number of cases.
Although the results of the vaccination at the base
hospital looked good, it was of great importance
that further studies should immediately be made,
running a series of cases without vaccine at the same
time that an e(|ual number of cases of the same
type were treated with vaccine. In one of the train-
ing schools for nurses connected with a large hos-
pital in New York City, it had been reported that
the results of prophylactic vaccination had been .so
poor that it had been discontinued. Doctor Libman
hoped that some one connected with that hospital
would give the facts regarding the method that was
used because the cause for this failure might lie in
technic. Intensive studies should be made with
various types of vaccines given in varying doses at
different intervals in the hope that a successful
method of prophylactic vaccination would be found.
While there were many points to discuss, there
were only two that occurred to the speaker at the
moment. The cyanosis of the disease sometimes oc-
curred early before there was any marked involve-
ment of the parenchyma of the lung and before
there was any evidence of the heart becoming mark-
edly insufficient. He suspected that the cyanosis in
at least some of these cases might be toxic in origin
especially as it had been found that the pneumococci
could produce methemoglobin from the red blood
cells and could interfere with their ability to take up
oxygen. Major Roberts spoke of the atypical em-
physemata and the difficulty of recognizing them.
As Fraenkel pointed out many years ago the em-
physema following the pneumonia of influenza epi-
demics was very apt to be interlobar in situation.
If one could prophesy through the experiences of
others, there would be found later in the epidemic
more abdominal symptoms and more cases would
have symptoms simulating appendicitis. It was im-
portant to be on the lookout for these cases and not
to operate too early because as a rule they should
not be operated upon. In 190T Doctor Libman saw
a number of cases of influenza with symptoms re-
sembling appendicitis which were not operated upon
and they had had no recurrence of the attack since
that time. Operatign was performed in one such
case, where the symptomatology was so indefinite
owing to the patient suffering from dementia precox
that exploration was decided upon, and the appendix
was found to be normal. It was probable that such
pains were due to the effects of the toxin of the
disease upon the sympathetic nervous system. At
the same time, one must not for this reason over-
look real cases of appendicitis occurring during an
epidemic of influenza.
Dr. Max Einhorn, of New York, added two
points in regard to the clinical picture of the pre-
vailing influenza. He had seen a type of case in
which no mention was made in the symptoms as ex-
pressed by the patient concerning his chest, and yet
P^: LETTERS TO
su
nil
sa' 1 examination one found distinct pulmonary in-
ement. The second point was that in a number
latients abdominal symptoms were found to be
fV.e marked; there was tympanites, dullness over
the flanks of the abdomen and slight fluctuation.
This seemed to be caused by a condition of paralysis
of the intestine. Sometimes vomiting was present.
In conjunction with the above there were to be
found toxic symptoms — slight somnolence, head-
ache, and at times slight delirium. This group was
of great importance as it offered a very bad prog-
nosis, usually giving about fifty per cent, mortality.
Regarding treatment, in the Lenox Hill Hospital
they had tried all kinds of methods, but it appeared
to the speaker that alcohol did more good than any-
thing else. In addition large amounts of fluid should
be administered. In this hospital there had been 150
cases since the epidemic began, with thirty deaths.
The laboratory reported recovering from the sputum
the influenza bacillus, streptococci and the pneumo-
coccus of Type IV. There were no Types I, II or
III. Many Pfeiffer's bacilli were recovered from
the lungs at autopsy. The pneumonia in these cases
was undoubtedly secondary to the influenza.
THE PUBLIC HEALTH COMMITTEE ACTS
ON INFLUENZA SITUATION.
At a meeting of the Public Health Committee of
the New York Academy *of Medicine held on Octo-
ber 2ist, the following resolutions were adopted:
SNEEZING AND COUGHING IN PUBLIC A MISDEMEANOR.
Whereas, It is the belief of most of those who have
made a study of the transmission of various diseases that
influenza, pneumonia, and other respiratory maladies are
generally conveyed through disease germs coughed or
sneezed into the air, therefore, be it
Resohcd, That this committee urges upon the Health
Department of this city that, in agreement with the Health
Department of New York State, it enact an amendment
to the Sanitary Code, making it a misdemeanor for any
person to cough or sneeze in any public place without first
adequately covering the mouth and nose.
THE SHORTAGE OF NURSES.
In view of the acute shortage of nurses that is being
felt at the present time when large numbers of people are
sick with influenza and pneumonia, the Public Health
Com-mittee of the New York Academy of Medicine urges
upon the physicians and the public in general that they
employ as few nurses as possible for the care of individual
patients and that they relieve the nurses as soon as the
family is able to care for the patient. It is also urged that
in milder cases the nurses be engaged on an hourly instead
of a whole time basis and in this way the services of one
nurse should be made available for a larger number of
patient?.
TO CONSERVE HOSPITAL FACILITIES.
In order that all available hospital facilities might be
devoted to the care of patients suffering from influenza
and pneumonia, the Public Health Committee of the New
York Academy of Medicine calls to the attention of the
surgeons of the city the desirability of postponing the
performance of nonurgent operations until the time when
the present influenza has run its course. Such a decision
on the part of the surgeons will not only furnish larger
hospital facilities for the victims of the nresent epidemic,
but will be in the interests of the surgical patients them-
selves, as it will not expose them to the danger of con-
tracting the disease when in a weakened condition.
THE EDITORS. [New York
Medical Journal.
Letters to the Editors.
FACE MASK IN INFLUENZA.
Rockefeller Institute,
New York, October 21, 1918.
To the Editors:
During the epidemic of poliomyelitis in the summer of
1916, I suggested to the New York Commissioner of
Health that attending physicians, nurses, and patients,
should wear gauze masks, since the exhalation through
mouth and nose is a factor in the spreading of the disease.
To my surprise I received a reply from the commissioner,
stating that the advisory board was against taking such a
measure, as it would be of no value. In the issue of the
Medical Record for August 12th, I published a letter in
which I gave my views and in which I embodied the corre-
spondence I had had with the commissioner. Last winter Doc-
tor Weaver, of Chicago, reported favorable results which
he obtained from the use of face masks in a hospital for
contagious diseases. His communication appeared at the
time when the epidemic of pneumonia broke out in the
various camps. The mask became quite popular, and its
use is now common knowledge. In the present epidemic
the spreading of influenza is certainly facilitated by the
coughing and sneezing of the patients. Under these cir-
cumstances the wearing of a gauze mask could be, to a
degree, an efficient factor in checking the spread of the
epidemic.
I do not know whether the wearing of a mask is obliga-
tory in the hospitals under the control of the United States
and city governments, but I would like to impress general
practitioners with the fact that masks should be worn in
all cases of actual or suspected influenza. Surely the at-
tending physicians, nurses, and other persons who have to
be in the room with the patient should wear masks.
Whether the patient should wear a light mask on the face
is a matter to be learned from experience ; also whether it
would be tolerated. The masks ought to be changed fre-
quently. After they have been in use an hour or two, they
should be put into an effective antiseptic; after being dried
and ironed they can be used again. There should be a
sterile mask in readiness for the use of the physician.
Thus he will not be the means of the transmission of the
disease from one family to another.
S. J. Meltzer, M. D.
MOISTENING THE MASK WITH ANTISEPTIC
SOLUTION.
Jefferson Medical College,
Philadelpia, Pa., October 17, 1918.
To the Editors:
In this present epidemic through which we are passing a
great amount of work has been done in the bacteriological
laboratory without being able to isolate a specific micro-
organism.
In my own studies upon sputum, cultures from the nose
and throat, as well as cultures from the sputum, the ordi-
nary bacterial flora of these membranes (nose, throat,
and mouth) were observed.
The most constant organism in the sputum was a dip-
lococcus, which in morphology and staining properties
could be stated positively as the pneumococcus. Then the
Micrococcus catarrhalis, streptococci, and staphylococci
were found ; and from the throat cultures besides staphy-
lococci. Micrococcus catarrhalis, and some few cultures
of strepococci, pseudodiphtheria bacilli were com.mon.
In two or three specimens of sputum, a small thin gram
negative bacillus resembling Bacillus influenzse was ob-
served, but this organism was never recovered in pure
culture, and was onlv noticed in three or four instances
in mixed culture. The bacillus of Friedlander was found
in a few cultures from the throat.
In all, one hundred and twenty-five or more studies
were made, counting sputum, cultures from same, and cul-
tures and snreads from the throats of those suflPering
from the infection.
In most all cases of patients dying of the infection,
edema of the lungs was very apparent, and when a body
arrived at the mortuary, cultures were made from the
fluid exuding from the mouth or ears or nose. In no case
was an organism isolated which resembled in any way the
Bacillus influenzae.
Appreciating the fact that masks would be a protection
in this disease, gauze from four to eight or more layers in
thickness was worn over the mouth and nose.
Having had some experiments performed with brilliant
green as an antiseptic, such a decided germicidal action
was exhibited by this aniline dye in high dilutions (i-i6,ooo)
that I decided to use this solution on the masks. Enough
brilliant green was added to distilled or tap water to make
the solution bluish in color and transparent, but not
enough to stain the hand. The mask was made damp with
this solution and worn for several hours, discarded, boiled
for at least thirty minutes, and dried.
Naturally, where more than eight layers of gauze are
used this is in itself a bulky affair, but where eight or four
layers of gauze are used this blue solution can be applied
and worn easily without much discomfort. I wore a mask
thus treated for three and one half hours ; an assistant
also wore one for the same length of time. A piece of the
mask about three quarters of an inch square was cut out
of the masks while still in situ, with sterile instruments,
and placed in bouillon. No growth was noticed up to ten
days. Several other masks were obtained from nurses who
had worn them for a variable length of time — from ten
minutes up to several hours — and while these were not
sterile, in no instance were streptococci found and the
pneumococci were very few.
I also had pieces of gauze saturated with the solution
placed over the telephone transmitter, and after forty-
ci.ght hours I removed a piece by means of sterile instru-
ments and immediately placed it in sterile bouillon. After
seven days a mould appeared, but no other organism de-
veloped. In one instance, a piece of a mask removed from
a nurse remained sterile for twenty-four hours.
I believe that moistening the mask with some antisep-
tic solution is better than wearing the mask dry, as parti-
cles of air and dust are inhaled through a dry mask and
not inhaled through the moistened one. It acts exactly as
in filtering air in large factories or department stores,
where a sheet of water or a moistened sheet is used to hold
back foreign dust particles.
Randle C. Rosenbergf.r, M. D.
MODERATION VERSUS INTENSIVE TRAINING.
SiDis Psychotherapeutic Institute,
Portsmouth, N. H., October i8, 1918.
To the Editors:
Dr. Brooks, Surgeon General of the Massachusetts State
Guard, gave to the press a statement about his experience
of the influenza epidemic. If I understand Dr. Brooks
correctly, he seems to ascribe the epidemic to the crowded
condition of the ships, vitiated air, and lack of sunshine.
Permit me to ask. through the columns of your journal, a
few questions which may possibly prove of some practical
interest :
Are we to regard the present epidemic as being mainly
the result of crowded ships? Should lack of fresh air and
absence of sunshine be alone considered as the principal
factors of the influenza and pneumonia plague which rages
all over the country? Are there not other factors equally
important? Is it not biologically true that when an organ-
ism is suddenly exposed to intense exertion, exhaustion,
overstrain, fatigue, cold, etc., it becomes reduced in vitality;
that the general resistance to infection is lowered and that
it is apt to fall an easy victim to invasions by pathogenic
microorganisms? May we not, in our present plight, take
such factors into consideration? May it not also be that
in the present epidemic we have also to deal with such im-
portant predisposing conditions as overstrain, exhaustion,
fatigue, exposure to cold, etc., due to the sudden, quick
hardening process of severe training and drilling of mil-
lions of young men, unused to hardships and exposures,
unable to react and be adapted to conditions of severe in-
tensive training, fit for vigorous constitutions of veterans
who have been sifted by the natural process of the sur-
vival of the fittest? Is it not quite possible that in ac-
counting for the widespread epidemic that has broken out
in the camps and among the civilian population we have to
reckon with the consequences of such a fundamental factor
as the intensive process of raising and training armies of
millions of young adults in the briefest possible time, in a
few months, in a few weeks? May we not expect that
nature will exact its full penalty for the feverish activity
of getting quick results?
Have not Spencer, Clouston, James, and others warned
this nation against its "breathless hurry," "painful tension,"
"convulsive eagerness," and, more specially, against its in-
tense "solicitude for quick results?" Have we ever paid
heed to the warnings of those great men?
In this supreme moment of national life may it not be
the sacred duty of the medical man to sound a warning
note of danger against any and all intensive processes of
work and training, against the methods of getting quick
results at any cost, against sudden hardening and exposure
of millions of our young generation? May it not be well
and practical to take a critical account of our methods of
procedure, methods which may possibly defeat the ulti-
mate purpose of a vigorous and healthy national life? May
it not be quite probable that in the hurry of obtaining quick
results on a large scale, by intensive training and harden-
ing, we really exhaust, waste, and impair the energies of
our people, drain the sources of our national man power,
and expose the nation to serious dangers of virulent
plagues ?
If Dr. Brooks finds it necessary to point out the dangers
of crowding in space, may not the medical profession find
it requisite to warn the nation against the still greater dan-
gers of crowding in time? Is it not probable that the medi-
cal profession may perform a great and lasting service to
the country, if, with the greatest thinker of humanity,
Aristotle, special stress is laid on the fundamental prin-
ciple of moderation? Boris Sidis, M. D.
^ ^
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevcrthclcs's, so
far as space Permits, ive review those in which zve think
our readers are likely to be interested.]
Radiographics de I' adult e normal. Par E. Bordet. Atlas
de vingt planches. Paris: A. Maloine et Fils, Editeurs,
iyi8. Pp. 21.
This work presents many valuable suggestions re-
garding radiography. The intention is that a stand-
ard position shall be adopted for each part of the
body so that the radiograph may be compared with
the life size illustration upon which every structural
detail is clearly marked and named. A single ex-
ample is the interosseous line on the fibula, whicli
might be mistaken for a splitting oblique fracture,
the result of a twisting force. The position adopted
for the anteroposterior view of the head, with the
central ray passing below the occiput, differs from
the standard m this country, which has the central
ray twenty degrees above the base line formed by
the root of the nose and the external auditory
meatus. The position in the book does not show the
frontal sinus as well as ours. The troublesome de-
tails of regulating the degree of vacuum in the gas
filled rontgen tube makes one wonder why the
Coolidge rontgen tube with its instant control
throughout the entire range of x ray quality is not
referred to. The size of the book, twelve by fifteen
inches, necessitated by the life size illustrations,
makes it inconvenient for the desk or book case, but
the book is of the greatest practical value.
75^
BIRTHS. MARRIAGES. aK ■ DEATHS.
[New York
Med.cal Journal.
The Indian Operation of Couehing for Cataract. Incor-
porating the Hunterian Lectures. By Robert Henry
Elliot, M. D., B. S. Lend., Sc. D., Edin., F. R. C. S.
Eng., Late Superintendent of Government Ophthalmic
Hospital, Madras. With Forty-five Illustrations.. New
York: Paul B. Hoeber, 1918. Pp. viii-95. Price, $3.50.)
This little book gives briefly the history of the
operation of couching from the time of Cclsus, and
the technic of the different methods employed.
Then follows a description of the Indian coucher
and of his habits, with a statistical account of the
results observed. The most interesting part of the
book is that devoted to the pathological anatoiny of
couched eyes, which is the Hunterian lectures deliv-
ered before the Royal College of Surgeons in 1917.
This forms nearly half of the work and is well
illustiated. The final chapters are on the diagnosis
of couched cataracts and contain points of clinical
interest with regard to such cases. The work is of
interest to the student of the curious, and of prac-
tical value to the eye surgeon where such operations
are still performed, but is of no great value to most
ophthalmologists in this country.
^
Births, Marriages, and Deaths.
Died.
Bi.AiR — In Roxborough, Pa., on Wednesday, October
Qth. Dr. ^amuel C. Blair, aged sixty-three years.
Chappell. — In New York, N. Y., o4: Saturday, October
igth. Dr. Walter F. Chappell, aged sixty-three years.
Clark. — In Baltimore, Md., on Tuesday, October isth.
Dr. Admont Halsey Clark, of Johns Hopkins University,
aged thirty years.
Caverlv.— In Rutland, Vt., on Wednesday, October i6th,
Dr. Charles S. Caverly, aged sixty-two years.
Corson. — In Collegeville, Pa., on Wednesday, October
Qth, Dr. William H. Corson, aged thirty-four years.
Couillard. — In Manchaug, Mass., on Saturday, October
I2th, Dr. Pierre L. Couillard, aged sixty-eight years.
Cragin. — In New York, N. Y., on ^Monday, October
2ist. Dr. Edwin Bradford Cragin, aged fifty-nine \ears.
CuNiFF.— In Philadelphia, Pa., on Monday, October 7th,
Dr. Robert J. Cuniff, aged thirty-seven years.
CcNXiNGHAM. — In New York, N. Y., on :Monday, Octo- '
ber 2ist, Dr. Bertram L. Cunningham, aged thirty years.
DonsoN. — In St. Michaels, Md., on Thursday, October
loth. Dr. Robert A. Dodson, aged eighty-two years.
DoLAN. — In Glens Falls, N. Y., on Friday, October 4th,
Dr. M. M. Dolan.
Edmunds. — In Boston, Mass., on Tuesday, Octo-
ber 1st, Dr. Charles S. Edmunds, aged twenty-five years.
Ellis.— In Port Chester, N. Y., on Wednesday, October
i6th, Dr. Charles H. Ellis, aged thirty-four years.
Fly. — In Baltimore, Md., on Saturday, October 12th,
Dr. Ernest Fly, of Johns Hopkins Hospital.
FoLZ. — In Philadelphia, Pa., on Thursday, October loth,
Dr. James F. Folz, aged forty-five years.
Franklin. — In Hightstown, N. J., on Wednesday, Oc-
tober Qth, Dr. Charles Montanye Franklin, aged thirty-
eight years.
French. — At Freeport, L. I., on Friday, October i8th.
Dr. Harold Milne French, aged thirty-five years.
Friedman. — In New York, N. Y., on Friday, October
i8th. Dr. Alfred Friedman, aged sixty-seven years.
Golden. — In Manchester, N. H., on Saturday, October
I2th, Dr. J. L. Golden, aged seventy-three years.
Gray. — In Baltimore, Md., on Sunday, October 13th, Dr.
Ernest George Gray, of Johns Hopkins University.
Hassett. — In Lee, Mass., on Frnday, October nth. Dr.
J. J. Hassett, aged fifty-nine years.
Heap. — In New Bedford, Mass., on Sunday, October 6th,
Dr. Richard D. Heap, aged thirty-six years.
Him:. — In Waterbury, Conn., on Sunday, October 6th,
Dr. Harry Kingsley Hine, aged thirty-one years.
Hoeckh.— In Buffalo, N. Y., on Saturday, October 12th,
Dr. John G. Hoeckh, aged thirty-three years.
HoRTON. — In Edgerton, Wis., on Saturday, October 5th,
Dr. Clyde S. Horton, aged thirty-nine years.
Keflv. — In Brooklyn, N. Y., on Sunday, October 20th,
Dr. William A. Kecly, aged fifty-one years.
Jackson.— At Fort Oglethorpe, Ga., on Saturday, Oc-
tober I2th, Dr. Howard B. Jackson, Captain, Medical
Corps, U. S. A., aged forty-five years.
James. — In Laurel, Del, on Sunday, October 13th, Dr.
Charles Emora James, aged thirty-four years.
Laliberte. — In New Bedford, Mass., on Thursday, Oc-
tober 3d, Dr. Edmund Laliberte, aged twenty-nine years.
Lambert. — In Riverside, N. J., on Tuesday, October 8th,
Dr. Chauncey B. Lambert.
Lebret. — In Montclair, N. J., on Thursday, October 17th,
Dr. Gerard H. Lebret, aged thirty-two years.
Little. — In Lawrenceville, N. J., on Saturday, October
I2th, Dr. John Fordyth Little, aged thirty-eight years.
Marks. — In New York, N. Y., on Tuesday, October
15th, Dr. David Marks.
McPhail. — In Brooklyn, N. Y., on Wednesday, Octo-
ber i6th, Dr. Leonard C. 2\IcPhail, aged sixty-three years.
Mell. — In Fredericksburg, Va., on Tuesday, October
15th, Dr. Patrick Hues Mell, aged sixty-eight years.
Nason. — In Winterport, Me., on Saturday, October 12th,
Dr. Charles J. Nason, aged forty-one years.
O'Connor. — In Princeton, N. J., on Saturday, October
19th, Dr. Joseph T. O'Connor, aged seventy-eight years.
O'Neill. — In Jersey City, N. J., on Monday, October
14th, Dr. Francis Joseph O'Neill, aged thirty-three years.
Ordway. — In Everett, Mass., on Tuesday, September
24th, Dr. Charles A. Ordway, aged forty-five years.
RiCE.^ — In Delavan, Wis., on Wednesday, October 2d,
Dr. Ray Howard Rice, aged forty-four years.
Ryttenberg. — In Port Chester, N. Y., on Thursday, Oc-
tober 17th, Dr. Charles Ryttenberg, aged thirty-four years.
ScoRDONE. — In New York, N. Y., on Friday, October
18th, Dr. Vittorio Sbordone, aged fifty-six years.
SiFF. — In Brooklyn, N. Y., on Sunday, October 20th, Dr.
Celeman S. SitT, lieutenant, Medical Corps, United States
Army, aged twenty-four years.
Simons. — In Canajoharie, 111., on Tuesday, October ist.
Dr. Frank E. Simons, aged sixty-seven years.
Smith. — In Germantown, Pa., on Thursday, October
loth, Df. George L. Smith, aged forty-seven years.
Smith. — In Norwich, Conn., on Friday, October 4th, Dr.
Newton P. Smith, aged sixty-six years.
Starr. — In Hartford, Conn., on Monday, September
30th, Dr. Thomas K. Starr.
Stevenson. — In Baltimore, Md., on Thursday, October
loth. Dr. H. Burton Stevenson.
Stoelper. — In Philadelphia, Pa., on Tuesday, October
8th, Dr. Carl Stoelper, aged thirty-six years.
Thfrrien. — In Marlboro, Mass., on Sunday, October
13th, Dr. Edward Therrien, aged sixty-two years.
Thompson. — In Flatbush, L. I., on Wednesday, October
i6th. Dr. Edward Middleton Thompson, aged forty-one
years.
Urich. — In Lebanon, Pa., on Monday, October 14th.
Dr. Isaac K. Urich, aged fifty-five years.
Watts. — In Pawtucket, R. I., on Monday, October 7th,
Dr. Walter A. Watts, aged thirty-eight years.
Wellington. — In Hartford, Conn., on Tuesday, Octo-
ber 8th, Dr. William Winthrop Wellington, a.ged fifty-nine
years.
West. — In Laurel, Del. on Sunday, October 13th, Dr.
Earl Clifton W^est, aged thirty-five years.
Woolley. — In Pelham Bay, on Sunday, October 6th, Dr.
Harold Townsend Woolley, aged twenty-three years.
Yeaton. — In Medway, R. I., on Friday, September 27th,
Dr. George W. Yeaton. aged fortv' years.
Young. — In Geneva, N. Y., on Tuesday, October ist. Dr.
Gardner B. Young, aged fifty-nine years.
Youngman. — In Ardmore, Pa., on Friday, October nth.
Dr. Monroe Dart Youngman. aged thirty-two years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal '"e Medical News
A Week/y Review of Medicine, Established 1 843.
Vol. CVIII. No. 18.
NEW YORK, SATURDAY, NOVEMBER 2, 1918.
Whole No. 2083.
Original Communications
NEW YORK STATE'S PROBLEM OF THE
CARE OF THE FEEBLEMINDED.*
By Walter B. James, M. D.,
New York,
President, New York Academy of Medicine.
When your president, Doctor Tilney, invited me
to open this discussion on tlie problem of the feeble-
minded I was glad to accept, because T realize that
the solution of this difficult problem is much more
apt to be found if we can have the ssnipathy and
cooperation of the members of this distinguished
society. The Neurological Society has always stood
for all that is best in its department of medicine,
both a? far as neurology is concerned and in its
relation to the public health and welfare.
Although T realize how active and interested a
part your society has always taken in public dis-
cussions of matters connected with neurology and
psychiatry, nevertheless, because I know how easy
it is tor busy physicians to fail to follow the many
things that are done in Albany, therefore I am
going to take the liberty of stating the present
situation of the question of the feebleminded as far
as itg relation to the State government is concerned.
Tl is almost two years since the legislature, im-
pressed with the overcrowded condition of the
State hospitals for the insane and by the general
incoordinated and more or less unsatisfactory rela-
tion of the institutions for the feebleminded to the
State government, 'created the State Hospital De-
velopment Commission, whose duty it became to
study and report upon all of these institutions and
the care of the insane and the feebleminded, with
recommendations for such measures as might h-
needed in the interest of both groups of unfortu-
nates. In the course of its investigations, the com-
mission became convinced that the institutions for
the feebleminded suffered in that they were not co-
ordinated under a single control commission, as in
the case with the hospitals for the insane. I had
the honor of being one of the governor's two ap-
pointees on the Development Commission, and I
was much impressed with this state of affairs.
Accordingly the commission recommended that
the legislature create a new and separate body to
care for the institutions for the feebleminded, and
this was done last April, when the State Commis-
sion for the Feebleminded was created by act of
•Address delivered at the Three Hundred and Sixtv-ninth Regular
Meeting of the New York Neurological Society, October i, 191?.
Copyright. 1918, by A. R.
legislature. There had been previously, many leg-
islative committees to study and report upon this
subject, and recommendations had been made and
certain voluminous reports had been published, but
until this time no concrete action had been taken,
looking to the actual remedying of these difficulties.
Realizing the inadvisability of creating any new
salaried positions that could possibly be dispensed
with, it was decided that the makeup of the new
commission shou|d consist of a chairman who
should be a physician who had had at least ten
vears of actual practice of his profession, and that
the other two members of the commission should
consist of the secretary of the State Board of Char-
ities and the fiscal supervisor, both of whom were
already receiving salaries in their respective posi-
tions, and both of whom were offfcially in close
relation with the four institutions for the care of
the feebleminded.
The commission was charged with the duty of
administering all laws that have to do with the
feebleminded, of planning a census, and of keeping
a record of all persons in the State who are feeble-
minded, of estimating the capacity of the institu-
tions for the feebleminded in the State, of inquir-
ing into and establishing colonies and clinics in con-
nection with the institutions, making rules for the
reception, treatment and training, discharge, and
transtcr of inmates, and of making recommenda-
tions for such new institutions as might be needed.
The commission was also commanded to draw up
and present to the legislature a commitment law
for the feebleminded. The commission is intended
to be a permanent one, and to coincide closely in its
duties and powers with the State Commission for
the Insane.
The commission came into existence on July i,
1918, and began at once to study all of the insti-
tutions and other State activities that are main-
tained for the benefit of the feebleminded.
As you all know, there are a good many agencies
throughout the State which have to do with these
patients. There are four asylums in which they are
maintained and which accommodate about 4,000,
not inchiding the city institution at Randall's Island.
Then there are the ungraded classes in the public
.schools and the clinics that are being held in various
parts of the State and connected sometimes with
universities or with ho.spitals, and in many cases
with the courts, and ali individually doing good
work. Then there are large numbers of mentally
Elliott Puljlishing Company.
754
JAMES: NEW YORK STATE'S CAKE OF THE FEEBLEMINDED [N'ew York
Medical Journal.
defeolive persons who are located in jails, peniten-
tiaries, reformatories, trainins^ schools, and county
almshouses, and one of the most important functions
of the commission will be to try to correlate these
various groups of persons and to bring their diag-
nosis, study, and management into close relation, in
order especially to avoid the expense of duplicating
agencies for doing the same kind of work. Then
there are training schools needed in the institutions
for the feeblemmded for the purpose of educating
attendants and especially teachers for the ungraded
classes in the public schools.
But there is a whole group of questions that arise,
for answers to which we must turn to the medical
profession. There is the great and burning ques-
tion of the differentiation between primary and
secondary mental defectiveness, which in the light
of Weismann's law — that acquired characters are
not transmitted — becomes so acutely important in
relation to the question of sterilization and the pre-
vention of child bearing. It is perfectly evident
that if the question of child bearing could be defi-
nitely disposed of, many of the most trying dif- ^
Acuities would drop away from the problem itself.
Newark, with its 800 or 900 women of child bear-
ing age, segregated there for the purpose of pre-
venting them from procreating, always gives one
food for very serious thought.
In addition there are many questions as to what
type and what degree of education or training can
be advantageously applied to these persons and at
what age it is best to begin.
There is also the great question of the delinquent
feebleminded, whom we find in such considerable
numbers in every reformatory and prison. The
very \aluable work of Dr. Bernard Gluck has
pointed this out very vividly in connection with
Sing Sing Prison.
The recent brilliant work by Doctors Fernald,
Southard, and Taft, of Boston — Waverlcy Re-
searches in the Pathology of the Feebleminded —
a memoir presented to the American Academy of
Arts and Sciences, in May of last year, throws
much light upon the brain conditions of mental
defectives and opens up a fascinating line of in-
quiry into the relation between primary and sec-
ondary amentia with all the questions that have to
do Avith procreation and eugenics.
The work of Doctor Bernstein, of the Rome
Custodial Asvhmi, in establishing colonies where
these unfortunates can live a life that seems to be
about midway between a normal happy home life
and the dreariness of a large institution, suggests
the possibility that ways might be found for utiliz-
ing, for the public good, the large human asset
which is shut up in our various institutions, a
detriment to the individuals themselves and a loss
in labor to the community. This of course applies
only to the moron group. This work is still in the
experimental stag^ but certainly justifies further
careful trial.
The Lockwood bill, a recent law which requires
that vv^henever in any school there are as many as
ten pupils who are as much as three years behind
in their studies, they shall be formed into a special
class with a special type of teacher, is one distinct
step in advance in the mental hygiene of our Em-
pire State.
The Prison Commission is inquiring into the
matter of the feebleminded delinquents, and various
private committees are doing helpful work by their
investigations, so that, altogether, the subject of the
feebleminded today is occupying quite a good deal
of public attention and offers a fascinating field of
inquiry ; and probably there are few others in which
there is so ij^uch to be done in the way of human
bettei-ment through careful study of conditions and
possibilities from the point of view of modern med-
ical science.
The field of research in mental defectiveness has
hardly been touched in our country. The work
above referred to from Waverley, gives promise of
stimulating further work that is sure to be pro-
ductive of good results.
This war, in which we are so intensively engaged,
and the imperative need of maintaining a maximum
of efficiency in our armies, has made it imperative
that all mentally affected be weeded out of them.
This mental defectiveness and mental disease have
become an acute army question, and an immense
organization had to be developed to seek out, un-
derstand, and treat these cases. Much useful
knowledge will doubtless be obtained in this way,
and it is to be hoped that more young medical men
will be stimulated to devote themselves to this fas-
cinating and modern branch of medicine. It is like-
ly also that at the conclusion of the war a large
number of able young men skilled in psychiatry
will be turned back into civil life to occupy their
time, attention, and energies with the many prob-
lems thus presented.
I am quite aware that I have succeeded in out-
lining, only very briefly, our problem and the steps
the State has taken to attempt 'a solution of it, steps
toward which a large number of social and other
agencies have looked with much eagerness for a
long time.
I have not attempted to show how we expect to
meet it, for necessarily our plans are still only in
the formative stage, our commission being in exist-
ence only three months as yet ; but we have an
office established here in New York city where
active work is already being done.
There are other and difficult questions constantly
arising, and on these we shall ask the advice of the
profession. For instance : What is to be the ulti-
mate fate of the feebleminded of New York city,
.Are they to continue to be cared for by the city, on
Randall's Island, or should they be brought mider
.State control as was done successfully with the
city's insane a good many years ag<j? There is no
doubt that conditions upon Randall's Island leave
much to be desired, but these are questions that can
be settled only after careful study and much serious
thought.
This then, gentlemen, is the situation and these
are the problems, and this is why the commission
is so glad to turn to the medical profession and to
ask for its earnest aid in its important and difficult
task.
7 E.AST Seventieth Street.
Xovcmber 2, 191 s.] JELLIFFE: NERVOUS AXD ME
•
NERVOUS AND MENTAL DISTURBANCES
OF INFLUENZA.
By Smith Ely Jelliffe, M. D.,
New York.
{Continued from page 728.)
The autopsied case of v. Leyden (1893) is one of
the first cases of influenzal Landry's polyneuritis on
record. Bernhardt, Eisenlehr, Buzzard, Havage, Ho!-
men, Westphalen, and others reported early cases
in the 1890 epidemic. Senator in the discussion of v.
Leyden's patient called attention to an important
point in the pathology of this affection which will be
taken up later — namely, not only the tendency to
edematous infiltration but to the minute hemorraghic
infiltration or extravasation in the nervous tissues.
This is not a massive hemorrhage and in certain
patients with influenza dying of pneumonia Foa has
described this type of infiltration and edematous
swelling in the cord structures.
Space does not permit entering into a discussion
of the respective parts played by peripheral and cen-
tral changes in this rare but very sinister type of dis-
turbance. V. Leyden, Bailey, Ewing, and others
have discussed the polyneuritic aspect, while Bing,
Van Gehuchten, Giovanni, Raymond, Striimpell,
Medin, and others have taken it up from the aspect
of poliomyelitis. ,
An interesting polyneuritic syndrome is that of
pseudotabes. These cases have been described as
acute ataxias by some observers ; I have seen a few
only. The absence of positive Wassermann signs
has aided in the diagnosis. Dejerine has discussed
them fully. Putnam, Sottas, Livierato, and others
have described them. Ataxia, Romberg's sign, sen-
sibility changes, and loss of knee jerks are the usual
symptoms. The majority of the influenza polyneuri-
tides are motor, at least we have Bosser's statement
to the effect that they are exclusively motor, but
there are many observations showing that the sen-
sory neurones may at times be deeply involved. Pres-
sure over the nerve trunks in these ataxic cases is
usually painful. The Lasegue sign is usually posi-
tive, whereas in the true tabetic, nerve tenderness
and the Lasegvie signs are usually absent. Epicritic
sensibility changes are more apt to be present in
these polyneuritic psuedotabes cases, and the distri-
bution of the sensory modifications is apt to be peri-
l)heral rather than radicular. A few cases of radicu-
litis from influenza are on record (Feinberg).
Spinal cord changes. — Myelitides : Not only are
extensive changes in the peripheral nerves possible
.symptoms of influenza, even in what appear to be
mild cases, but active and severe involvements of
the spinal pathways and of the spinal meninges take
place. The extremely severe types of ascending
myelitis — related to and, perhaps, indistinguishable
from the severe ascending neuritides— Landry's
type, have already been discussed. They are rare.
Dorsolumbar myelitis resulting in a flaccid or a
spastic paraplegic picture are more often encoun-
tered. It is, however, the most frequently observed
type of influenzal myelitis. I recall but one case
seen in private practice. The grippe myelitides are
apt to be mild, however, and often clear up very
satisfactorily. The onset is apt to be slow, the
TAL DJSTL R13ANCES OF INFLUENZA. 755
symptoms developing progressively. This is more
true of the sj'astic types. The flaccid types usually
have a more furibund aspect ; several hospital cases
seemed to show this variation. Varying grades of
involvement are to be expected.
In the more distinctly hemorrhagic cases the onset
is more acute and there is a tendency to the forma-
tion of disseminated foci. This develops, not only
in the observation of the spinal symptoms, but is
also seen in the occurrence of other focal involve-
ments in other parts of the cerebfospinal axis. Thus
optic neuritis and ophthalmoplegias have occurred
with the spinal myelitis syndromes. Two personally
seen patients with the disseminated type resembled,
what is often termed, acute multiple sclerosis. Bram-
well, Maixner, Marburg, Massalongo, Nolde, Oppen -
heim (six cases), Rendu, and others have reported
similar findings. Some of these patients go on to
recovery and others run a more chronic course and
are often viewed as true cases of multiple sclerosis
of the so called secondary type. The influenzal
myelitides usually have a good prognosis ; fatal
cases, however, are on record and would probably
be more often reported here in this country were it
not for the many obstructive conditions surround-
ing opportunities for postmortem observation.
Eulenberg and Determann have reported curiosi-
ties in the form of spinal foci which have caused the
Brown-Sequard syndrome. Capillary exudations
and minute bleedings occurred in small areas involv-
ing but one half of the spinal cord. In Determann's
case tetany also was present and recorded.
Before leaving the spinal cord syndromes, and
particularly the differentiation of Landry's paraly-
sis, poliomyelitis, etc. — questions which are of much
importance neurologically and which are still in need
of more complete clarification — a word may be said
concerning the attitude of which the Scandinavian,
Borgstrom, is the chief representative. He holds
that there is a great polymorphism in the group of
organisms which cause influenza and poliomyelitis.
He thinks they are interchangeable, and has entered
the polemic field chiefly against Wickmann in an at-
tempt to prove, on the basis of the personally ob-
served cases ii: Sweden, that influenza and poliomye-
litis are the same disease. Wickmann's so called
abortive cases, he maintains, are certainly to be in-
cluded in this conception. His analyses, however,
are filled with faulty presuppositions, his neurologi-
cal technic in examination, particularly of the vege-
tative nervous system and of the sensory nervous
system, is so faulty that it is evident that he over-
steps the mark. At the same time it has been con-
sidered worth while at this time to dwell for a mo-
ment on the fact that severe spinal cord disease,
while a particularly rare form in influenza involve-
ment, nevertheless is one of the things that does
happen, and that the poHomyelitic form is a possi-
bility. The pathological differentiation of the types
of lesion is still to be decisively pronounced upon.
A great deal is known of the pathology of poliomye-
litis ; very little of that of influenza. In certain cases
of influenza dying of pneumonic complications the
changes in the spinal cord have been observed.
Brain involvements. — From the very earliest times
the cerebral involvements in influenza have be.en
756
JELLIFFE: NERVOUS AXD MENTAL DISTURBANCES OF INFLUENZA.
[New York
Medical Journal.
noted. The almost universal headache, the fre-
quent occurrence of delirium, with or without high
fever, have seemed to accentuate the belief among
nearly all of those who have had experience with
influenza that the brain .structures are involved
early. For the most part it is true temporarily, for
the headache, to speak of the most prominent
conscious symptom, usuaUv passes with the severe
pains in other parts of the bodv within three or
four days, but in some epidemics the cerebral in-
volvements are very pronounced and extremely
severe. In all the epidemics certain cerebral symp-
toms are present.
While the headache of influenza resembles in
most respects that of a number of other infectious
diseases, still it is characteristic enough to have
earned a special title early in the science of nosol-
ogy. Epidemic headache, cruel and severe, was the
appellation given it by Sauvages. It is cruel; at
times it is fiendish, and three marked types are dis-
tinguishable. There is an early headache, which
is primarily due to vegetative functional altera-
tions in blood pressure, in the imtrition of the vege-
tative nervous structures of the trigeminus, ])artic-
nlarly of the nervi vasovasorum. This seems more
closely related to the reaction to the toxemia of the
grippe organism. It is a headache which is usually
all over the inside of the head, giving a sort of
sense of internal explosion, as if the head would
burst. The type is freqtiently spoken of as a con-
gestive headache. A number of other toxins seem
to induce a closely similar vegetative nerve reaction
as an indication of the attempt at vascular control.
At times this headache, still in the toxic anaphy-
lactic functional realm, may be more sharply local-
ized. This localization, frontal, may be associated
with more severe local infections signs, such as
nasal and frontal sinus predominance ; occipital and
lateral, when the mastoid sinus is predominantly
involved.
\Mien an invasion of the meninges occurs by thf
Pfeififer bacillus, the various localized or diffused
mild or severe t3'pes of influenzal meningitis occur.
The headache becomes usually more of a dull char-
acter, and following the type of meningitis, active
more rarely, comatose, lethargic more frequently,
the headache seems to run with the meningitis and
is mingled with the general mentngitic series of
symptoms.
A third type is particularly interesting and im-
portant. I have seen a large number of postinflu-
enzal headaches of a particularly severe and pro-
tracted type. So intense and so prolonged have
they been that they have come in consultation as
possible brain tumors. The postinfluenzal neuras-
thenoid syndrome is not now under discussion. I
am speaking of patients who have not been very
sick with the influenza, save perhaps they have all
shown an extremely intense reaction to the tox-
emia ; they have been sick for the most part not
over two or three days. There has been, with
these cases, a very severe general reaction with a
marked sense of great illness. The sthenic re-
action type has been characteristic. After recovery,
which has been uneventful, they have developed a
severe generalized or, more often, occipital head-
ache. This has been peculiar, in that if the patient*
does nothing he may be free from pain, but the
moment he attempts any labor, reading, writing,
concentration of eftort, the pain is so intense as to
force him to desist all efifort. Three such patients
could not even write a letter or read a paragraph
in a newspaper without the onset of the headache :
otherwise they were in excellent health. While I
am inclined to believe that behind this postinfluenzal
headache situation possibly certain definite psychical
components mav have been present, the fact re-
mains that the influenza brought the pain into the
foreground of active consciousness. Its function T
could not learn. These headaches have persisted .
from three to eight weeks and have all cleared up
almost as quicklv as they came.
Meningitis. — Spinal types as well as cerebral
types are known. The bacteriological evidence is
now beyond cavil, for the microorganism has fre-
quently been obtained by lumbar puncture, cerebral
puncture, blood culture, postmortem culture, and
by staining methods in postmortem examinations.
.\ great variability in grades of infection is known.
The simple vascular preinfection stages have al-
ready been spoken of; these are usually the more
benign types and recover soon. Possibly the severe
headaches which have just been mentioned may
represent serous meningeal types, without infec-
tion or with m.inimal locftlized infection. Serous
meningitis, then, may be a possibility. I know of
no definite proof of this for the only possible type
which could be proved, i. e., the focal infectious
type. One patient operated upon for possible brain
tumor showed a focalized serous meningitis. The
history of onset of the dif^^culty closely following a
severe influenza made this etiological factor a pos-
sibility, but culture experiments with the fluid were
negative and as the patient still lives, the etiological
factor is still uncertain.
Acute meningeal cases, found at all ages, more
frequent apparently in childhood, especially in the
milder type, may be of this congestive or hyper-
tensive type with minimal focalized infection. A
second degree of more serious involvement con-
stitutes the suppurative meningitides of pure
Pfeififer type, or mixed with other microorganisms,
notablv the pneumococcus and streptococcus. The
PfeifTer microorganisms have been isolated, closely,
following the discoverv bv Pfeiffer in i88g, by
Pffihl, 1892; by Slavyk. '1898: by Trouillet et
Esprit. Mao, 1903, and many others.
Influenzal meningitis differs little from other
:\pes of meningitis. It is usually an extremely se-
vere disease and the dift'erential diagnosis is difficult
without lumbar puncture or blood culture. Grasty
has called attention to a difference in the leucocyte
count of influenzal meningitis stating it to run
rarely above 15.000, while other purulent meningi-
tides are apt to run as high as 30.000 to 40,000.
Forbes and Snvder in a more recent study of
leucocytes in influenza in general find an absence
of hyperlevJcocytosis as a general feature of the
disease, with or without any meningitis.
To the neurologist the meningeal and encephalic
syndromes are still a very large grab bag, out of
which, by careful clinical and laboratory observa-
November 2, igis.] JELLIFFE: NERVOUS AND MENTAL D/STCRHAXCES OF INFLUENZA.
757
tion, much may be chosen with certain degrees of
definiteness. Still there are numberless patients,
viewed in the large, who develop meningeal or
encephalic syndromes of extremely perplexing char-
acters.
In the epidemic of 1890 I was a hospital interne
and my first perso;ial and professional baptism was
in the influenza epidemic of that year. Since then
from time to lime I have seen many of the syn-
dromes which have been spoken of here. Occa-
sionally there has been presented a type which has
received of late some special mention, in which it
has not been certain whether one has to do with
botulism (see English reports), poliomyelitis, or an
unknown infectious disorder involving the struc-
tures of the midbrain. The French have been
working at it as lethargic encephalitis and attention
has been already directed to it here, when speaking
of paralysis of the oculomotor nerves.
The type of disorder referred to has been present
in Austria, England, Italy, and France and Ivis
been given several names. It is characterized by
acute onset with chilliness, headache, and fever ;
nausea and vomiting are occasionally present. Then
a series of symptoms develops in which great
lethargy and cranial nerve palsies occur. The
lethargy, at times spoken of as narcolepsy, is very
profound. It may come on slowly with heavy eye-
lids— complicated by organic ptoses in the eyelids
— and an irresistible torpor. The patient may be
aroused, wake np, answer in responsive or irre-
sponsive monosyllables and sink again into deep
unconsciousness. Tiie patient may not be waked up
sufficiently to be fed, urination and defecation tak-
ing place in this deep stuporous state. Occasionally
this is broken by nightmares or at times a muttering
delirium. Death may ensue, the patient developing
Cheyne-Stokes respiration and going out. In the
patients who recover, which is the rule, the lethargy
slowly diminishes and the patient comes to himself
gradually .
The cranial nerve palsies are chiefly of the oculo-
motor group; either external, internal, or double
ophthalmoplegias are observed. This paralysis is a
nuclear palsy, solely motor, without the neuralgic
pains spoken of under the head of the neuritides and
oculomotor palsies. The cranial nerves afifected are
chiefly of the mesencephalic localization — third,
fourth, sixth. The paralyses are usually partial, dis-
sociated and incomplete. Ptosis is usual ; diplopia
not uncommon ; the pupillary disturbances rare, at
times very pronounced. Jacob and Hallez have noted
transitory Argyll-Robertson signs. Paralyses of ac-
commodation are frequent (Harris).
Double facial palsy may occur ; trigeminal, hypo-
glossal and glossopharyngeal palsies have been noted.
Sensory changes may also occur, and other variable
symptoms such as convulsive seizures, contractures,
hyperesthesia, anesthesia, catatonic or cataleptic
states. Sergent's white line is fairly constant. _ Al-
though too few cases are recorded to give reliable
statistics, the mortality seems to be fairly high. Sain-
ton quotes thirty-five per cent, in the French series
and twenty-five per cent, the English series. The
severe type seems to be marked by great thermo-
regulatory disturbance. The fever mounts rapidly
and does not fall. The signs of infection are very
profound. Death takes place in from eight to twelve
days. The subacute type shows a rapid rise in tem-
perature, then it falls, and has an up and down
course between 99° and 102° F. for some length of
time — four weeks to two months. Lumbar puncture
is usually negative, a fact of considerable import-
ance in separating this disturbance from epidemic
cerebrospinal meningitis. No signs of meningeal
irritation are present and the steplike mode of pro-
gression so frequent in the meningoencephalitis of
infectious origin is not present.
In the autopsied cases rei)orte(l on by Sainton,
Pierre Marie et Tretiakoff, and Caussade, attention
is called by the first observer to the incongruity that
exists between the severity of the symptoms and the
paucity of the findings. We are here reminded
again of Senator's suggestions respecting the minute
characteristics of the changes in the cord in the
myelitides, and certain cases of hemiplegia without
visible signs — ledemas probably — come to mind. Mi-
nute hemorrh.-jgic sufifusions or microscopical hemor-
rhages seem to mark the congested areas in the
mesencephalic structures. Histologically the hemor-
rhagic suffusion is most marked. In Marie's cases
degeneration of the cells of the locus niger was a
marked feature. The general character of the lesion
is that of a polioencephalitis histologically undiffer-
entiated from other types of polioencephalitis, not
including the syphilitic or tuberculous or malarial
types. Whether the influenza bacillus is able to
cause this type of lethargic meningoencephalitis is
still to be proven. The cases reported have all of
the features of an acute infectious disease. In the
early epidemics of 1889-1900 such case reports be-
gan to appear in the literature. Henry Young called
it grippe catalepsy. Later studies of Longuet
( 1892), \^^olf, Bozzali (1900) reported cases which
were attributed to influenza. Thus far in the re-
cent studies no definite organism has been reported.
Other types of encephalitis have been reported
since 1890 involving not only the cerebrum, but the
cerebellum as well. Guttermann (1900), Pfiihl,
(1892-1897), Nauwerk, and others have isolated the
organism from the infected foci. A great diversity
of clinical pictures has resulted from the many pos-
sibilities of such infectious foci. Abscess has been
the termination in some of the cases.
Influenza hemiplegia with or without aphasia has
been, personr.lly, the most frequently observed type
of symptom in this field. The otologists undoubt-
edly observe the abscess cases from ear or mastoid
extension, which are either purely influenzal or
mixed infections. Monoplegias, choreas, epilep-
sies, and abscesses are among the possibili-
ties which have been reported. Influenza, as
providing the necessary upset to precipitate a
cerebral .softening in an arteriosclerotic of sixty to
seventy years, has been not infrequent in my experi-
ence. These softenings have occurred in various
parts of the brain and have given rise to a very di-
verse syndrome \arying from the slightest types of
motor contractures or loss of sensibility to the ad-
vanced softening of a terminal dementia. Aphasias
and mental confusions have been not infrequent and
have for the most part had a good prognosis.
{To be concluded.)
758
COBB: PSYCHOPATHIC CONTROL OF PROSTITUTION.
[New York
Medical Journal.
PSYCHOPATHIC CONTROL OF
PROSTITUTION.
Bv J. O. Cobb, M. D.,
Qiicago,
Senior Surgeon, United States Public Health Service.
The mobilization of the great armies now at war,
with all the stupendous sanitary problems involved,
has enabled sanitarians to assemble and study cer-
tain mass data not before obtainable in reliable
figures. These data have been especially valuable in
the study of venereal diseases. The careful surveys
now in progress in our own country have already
uncovered an astounding and alarming condition of
society undreamed of by the general public, and
only partly comprehended by certain investigators
in civic welfare.
At the outbreak of war there seemed to be a wave
of sexual insanity spread over the land. In this
particular our country was probably neither better
nor worse than the other nations at war, though
knowing the experience of other countries, we might
have avoided their mistakes. It was generally be-
lieved that with the strict discipline, moral lectures,
and the enforcement of prophylaxis ii the canton-
ments, the venereal rate would be negligible. There
w"ere several factors not reckoned with, however,
and it was very quickly discovered that a vast ma-
jority of venereal infections were contracted just
prior to the call to the colors, before the men fell
within the routine and discipline of camp life. The
other venereal infections mostly occurred at week
end visits, or on furloughs to their own homes. The
percentage of infections among the men on short
liberty is surprisingly low. Of course, prophylaxis
is given most of the credit for these low figures, but
it must not be lost sight of that the man on short
leave is not so likely to be beset with the multitude
of temptations placed in his path, as is the man on
longer leave.
This exposure to infection just prior to entering
the camp makes the venereal curve very high for
the first few days after entering. In a few weeks
the curve for new cases drops far below what is
generally supposed to be the normal rate for a ci-
vilian population. In other words, the army data
on this point are convincing in that the percentage
of venereal infections of enlisted men is much less
than encountered among a civilian population in nor-
mal times, showing unmistakably that if the enlisted
man enters the camp free from venereal infect'on,
the likelihood that he will expose himself to infec-
tion is much less than if he remained under the con-
ditions of his home environment.
The man in uniform seems to excite all the latent
immorality of a community into violent activity. AH
kinds of pitfalls are placed in his pathway— drink
and women, mo.stU — and it is surprising that a
greater projiortion of these young men have not
succumbed to the insidious and subtle temptations
constantly thrown in their way. It is this condition
that has brought about the movement of the Govern-
ment to enforce the immediate suppression of vice,
as an urgent war measure, so that the enlisted man's
home environment can be made safe for him now.
and kept safe for him after he comes back from
abroad. The Government has made the enlisted
man's camp life safe for him; it certainly is but a
reasonable demand that fathers and mothers and all
those at home make his homecoming just as safe.
This menace of the prostitute is real. There are
no reliable figures at hand of the total number of
these women in America, but an estimate based on
conservative reports of several of the great cities
is alarming. In Chicago, alone, the vice commis-
sion reported (i) that in 191 1 there were five thou-
sand identified ijrostitutes in that city. The Atlantic
coast cities are said to be overrun with these women.
They are scattered in every town of the land, so
that sanitarians must visualize the picture of what
will take place when the troops come back from
Europe. Excusable emotional hysteria will grip the
nation. Old and young will tingle to their toe tips.
Nothing will be good enough to give our boys. To
move the picture along, one must not lose sight of
the temptations that will be placed at every hand for
these men. Vice will vie with victory. Hero
wofship, drink, women, are the steps to downfall.
The country must face an unpleasant fact and pre-
pare to meet it. The chronic prostitute must be
under safe keeping before that time arrives, and
the clandestine prostitute must be kept in hand by
forcible measures.
In the study of prevention of venereal diseases
one sooner or later comes to the conclusion that this
activity, to be at all worth while, involves the abso-
lute and continuous control of the prostitute. Aside
from its educational value and, of course, its neces-
sity as an urgent war measure, the present venereal
propaganda will have no real, or lasting effect on
the venereal situation imless the chronic prostitute
is permanently placed in custodial care. It must be
clear to every one who has given the matter due con-
sideration, that all previous reform efforts have met
with almost complete failure. Politicians have not
controlled prostitution. It has thrived and even pro-
gressed in the face of every moral and religious or-
ganization. It has made police and municipal court
cfliccrs sneerinsT unbelievers in its possible control.
Really, when this ariay of failures is honestly faced,
the pessimist has good ground for his contention
that very little is gained by arresting these women,
dragging them into the courts, curing them, perhaps,
and turning them loose again to take up their evil
wavs of living.
In searching for reliable data on these women,
one cfains the impression from the many careful
analytical reports upon the prostitute, that she is a
person apart, an entity wholly different from others.
This is but a natural assumption, for one cannot
think of a normal woman in terms of prostitution,
so the further one goes into the subject, the more
often arises tlie question, \Miat manner of person
is this woman ?
There was an attempt made to find ouj: who
would be the most likely to understand these puz-
zling women, and it was quickly discovered that it
was xiot the general practitioner, the sanitarian, the
moralist — so called — nor even the experienced police
officer. Whatever is known of the prostitute, that
is worth while, has been gained mostly in the mu-
nicipal courts, or in the psychopathic clinics and
laboratories, or in reform institutions — and largely
November 2, 191S.]
COBB: PSYCHOPATHIC CONTROL OF PROSTITUTION.
759
by women investigators, strange as it may seem.
In these various institutions most valuable research
has been reported, but these highly valuable sur-
veys have not reached the general reader, because
of their technical nature and because the public
does not care to deal with an unpleasant situation
until forced to do so.
When the facts that these investigators have to
present are carefully analyzed, one is compelled to
admit that the chronic prostitute is a person who
must be handled differently than she has been
handled heretofore. Laws and regulations must be
changed or enlarged. For the present, as an urgent
war measure, the venereal question is a sanitary
problem, but in the end the psychopathic investi-
gator, encouraged and aided by the sanitarian, the
moralist, and the municipal courts, is the one who
should have the final control of the prostitute.
A woman many times convicted of prostitution is
not normal mentally. Many of these women are
morons. The others fall into other psychopathic
classifications. The figures are too few to justify
definite conclusions, but the careful analysis of the
mental condition of groups of chronic prostitutes
shows that a large majority of these women should
be permanently confined in psychopathic institu-
tions.
The Massachusetts Commission for the Investiga-
tion of the White Slave Traffic reported that fifty-
one per cent, of prostitutes examined were feeble-
minded.
In a careful study of conditions in the Red Light
District of a large city of the State, the Virginia
Board of Charities and Corrections reported (2)
that ''All students of mental deficiency who have
investigated to any great extent the causes of pros-
titution are of the opinion that feeblemindedness is
a principal factor in the supply. Investigations
have been made from time to time in various parts
of the United States with the idea of ascertaining
the relation of feeblemindedness to prostitution,
v/ith varying results. The Chicago Morals Court
had 639 prostitutes examined, and found the pro-
portion of feebleminded to be sixty-two per cent.
At another time 126 prostitutes were examined by
the same investigators, and the proportion reacting
as feebleminded was 85.8 per cent. Of 104 sexually
immoral girls tested in the lUinois 'Praining School
for Girls, ninety-seven per cent, reacted as feeble-
minded. The Massachusetts Vice Commission ex-
amined 300 prostitutes in three groups of 100 each :
I, young girls just beginning prostitution; 2, women
plying their trade in the streets ; and 3, women who
were old offenders. The mental defect of fifty-one
per cent, was so pronounced as to warrant their
legal commitment to custodial institutions for the
feebleminded. The report of this commission states
that the women in this group came from shiftless,
immoral, and degenerate families ; they were indus-
triall}' inefficient, as shown by the low wages re-
ceived, and by their inability to retain a position,
even in imskilled callings ; they were very deficient
in judgment and good sense ; they lacked ordinary
general knowledge and practical information, as
well as ability to perform simple computations or to
read or write, except in the most elementary way."
"A study of 243 women made by the Massachu-
setts Reformatory for Women showed forty-nine
per cent, to be defective mentally, 16.5 per cent,
very dull, and forty-seven out of the remaining
eighty-four cases showed other defects, such as
epilepsy, hysteria, and psychopathic tendencies. Only
fifteen per cent, of the entire number appeared nor-
mal mentally and physically. In this group of cases
were included all women in the institution in whose
history there had been at any time a period of
commercialized promiscuous sex immorality."
In a study of 647 prostitutes made at the Bedford
State Reformatory, by Katherine B. Davis, 29.8
per cent, were feebleminded of the pronounced
type, and twenty others of this group were insane.
Basing her opinion on eighteen years' study of
prostitutes, Doctor Davis says that "Fully one third
were so mentally defective as to be in need of
permanent custodial care."
In a group of 647 girls, 107 were distinctly feeble-
minded, and 193 had some serious mental condition,
such as insanity, or insane tendencies (3).
In a group of 500 delinquent girls, studied by the
New York Probation and Protective Association,
thirty-seven per cent, were mentally defective. Of
III prostitutes who came under the same care,
thirty-five per cent, were mentally defective, twenty-
six per cent, of these being classed as feebleminded.
Edith R. Spaulding reported that over half of 205
.sexual offenders of one group treated at the Massa-
chusetts Reformatory for Women were mentally
defective. In speaking of another group of 243
prostitutes, Doctor Spaulding found only fifteen
per cent, normal mentally and physically. "Probably
forty per cent, could be considered segregable types,
and should be placed permanently, or at least dur-
ing the childbearing age, in custodial institutions.
If these cases who are apparently unable to care for
themselves could be removed from the community,
we believe the supply for prostitution would be
materially lessened and that such a movement would
be a help in attacking the problem."
Dr. Catherine Brannick, the present psychologist
of the above named reformatory, in a later report
says that "In the eleven months from September i,
1917, to August I, 1918, the period during which the
police have shown unusual activity in dealing with
the vice situation in general, 260 women have been
admitted to this institution. Of these, 178 were
committed for sex offences, and the histories of
practically all of the remaining number show that
they had been guilty of such offences but were com-
mitted on some other charge — as 'drunkenness' or
'larceny.' ... Of the 149 definitely committed
for prostitution, about forty-two per cent, are
readily graded as feebleminded. A large group still
remain classified as borderline cases, and more than
one half of this group will undoubtedly be graded
by further testing as definitely feebleminded. The
estimate is that decidedly over fifty per cent, of
these women are mentally defective."
The New York Probation and Protective Asso-
ciation found that one third of the girls who had
gone wrong were mentally defective.
A. F. Tredgold (4) says : "My experience is
that about half of the girls admitted into Magdalen
COBB: PSYCHOPATHIC CONTROL OF PROSTITUTION.
[New York
Medical Journal.
Homes on account of the 'first fall' are of this
feebleminded type."
George K. Hastings, secretary of the New York
Committee on Feeblemindedness, says that he con-
siders it a conservative estimate that fifty per cent,
cf these women are feebleminded.
In a recent group of sixty arrested prostitutes in
the city of Detroit, reported by Josephine S. Davis,
of the Social Service Department of the State Board
of Health of Michigan, twenty-one were feeble-
minded, thirteen subnormal, one feebleminded and
defective, one epileptic, three insane, eight deferred
and mild paranoid trend, two psychopathic person-
ality, and eleven showed no psychiatric condition.
Several careful investigators of prostitution have
been asked to estimate, from their experience, the
percentage of feebleminded among prostitutes, and
nearly all these results were conservatively placed at
thirty per cent. However, in trying to find the per-
centage of prostitutes that have actually been com-
mitted to institutional care for feeblemindedness,
there are not enough reliable figures to make even a
conservation estimate.
In fact, attacking prostitution along these lines
has not been generally considered or recognized as a
possible expedient, except by investigators working
in psychopathic clinics or by associations dealing
with delinquent girls and women. The process of
commitment to custodial care of the psychopathic
prostitute is entirely too rigid. There are borderline
cases that have certain criminal tendencies, and if
prostitution is one of these characteristics, then the
law should be so amended as to enable society more
easily and humanely to restrain the chronic, incor-
rigible prostitute in a vocational institution perma-
nently. It may be found, and I believe it will be,
that fully thirty per cent, of chronic prostitutes can
be convicted on the ground of feeblemindedness
alone and placed in institutions. Most clandestine
and occasional prostitutes fall under the classifica-
tion of psychic constitutional inferiority. These
borderline mental cases are much harder to deal
with, inasmuch as the courts would be inclined to
safeguard such persons on the ground of legislative
expediency, owing to the lack of definite, marked
psvchosis. As even many well pronounced morons
are exceedingly clever in memory, speech, and other
characteristics, it would be exceedingly hard to con-
vince a jury, or the court itself, that the psychic
inferior, or borderline cases were low enough in the
mental scale to justify such a summary proceeding
as permanent custodial care.
But it is just here that public opinion must be
aroused. The .state laws should be enlarged and
amended. It is hard to believe that a chronic
prostitute is a normal woman. It would seem pos-
sible to draft a law that would safeguard the people
individually and at the same time protect society
from these women. Surely our reformatory
schools, and like institutions, could b^ trusted to
handle the borderline case, for it is with this type of
prostitute alone, absolutely, that a worth while per-
centage may be reformed and restored to useful
lives. The feebleminded must be kept in institu-
tional lile and on training farms, at useful, healthful
occupations, where they will be well treated and
made cheerful by varied amusements.
Already in several states wonderful work along
this line is in operation. Inbreeding of the feeble-
minded must be prohibited. The feebleminded,
male and female, must be removed from the
ordinary walks of life. Especially is this necessary
for the feebleminded prostitute, as she is unmoral,
absolutely without a sense of responsibility. This
view_ is strongly supported by the summary of the
Virginia report, quoted above, which says, "Accord-
ing to the Binet scale, 71.6 per cent, of prostitutes
plying their trade in the segregated district of the
city reacted as feebleminded, and inquiries into their
family history substantiate the findings of the
psychological test. The logical conclusion is that
feeblemindedness is responsible in large degree for
the waywardness of these women, and that they
should not be punished for doing that which their
heredity made almost sure ; but society should segre-
gate them where they will be protected from licenti-
ous men and lewd, avaricious women; where they
cannot harm others and may, in a measure, redeem
themselves. Place them in a colony and they can
there earn their own support; put money into the
State treasury instead of being a constant loss, di-
rectly or indirectly, both on the pocketbook of the
taxpayer and the health and morals of the com-
munity ; for not less than a million dollars is worse
than thrown away in Virginia in prostitution every
year, and the prostitute, wherever she may be, is a
centre for the spread of venereal disease."
In fear that the trend of this paper may be mis-
understood, or be misquoted, it is necessary to state
that in the appeal to make the enlisted man's home
safe for him no apology for his possible yielding to
temptation is intended. It must not be assumed that
just because the male degenerate has been left out
of the discussion that he should be treated differently
from the female delinquent. Both are a terrible
menace to society, but there is just this hideous dif-
ference, however, that cannot be escaped, regardless
of one's ideas of fairness : a woman who is a pros-
titute is a psychologic factor that eats at the very
vitals of society. She is a commodity. She is the
victim of commercialized vice. She is the prime fac-
tor in the spread of venereal diseases. For these
reasons she is far more dangerous to society than
any male malefactor, be he burglar, crook, or
"cadet."
Hardly any one will question this position, as far
as it goes, but when it comes to applying remedies to
prevent immorality in all its phases, and, of course,
to the control of venereal diseases, illegitimacy, and
social delinquency — which are its potential results —
the public administrator is at once confronted with
the difficulty of adjusting conflicting views to a
workable basis. The moralists hold inflexibly to the
position that the question cannot be settled perma-
nently, except along the lines of educating the youth
of the land to a single standard of morals. Public
health officials would handle the matter purely as a
sanitary problem, with a faith that it can only be
settled in that way. Then there are men who believe
that prostitution is a safeguard for society, and that
the practice of selfrestraint would make molly-
November z, 1918.]
RODMAN: DISEASED TONSILS AND FOCAL INFECTION.
761
coddles of young men. Last of all is the veteran
police offifer, the worst pessimist of all, who merely
shrugs his shoulders and waves the matter aside
with his outstretched hands.
But surely there is a common ground on which
we all can stand for the betterment of this horrible
condition. At the very least it is worth while to
speculate upon the difficulties of the problem, and
upon some of the possible remedies. Suppose, for
the sake of illustration, that every house of prostitu-
tion were broken up and kept closed ; that all
prostitutes, undoubtedly feebleminded, were placed
in permanent custodial care ; that all other prosti-
tutes were prevented from interstate and intrastate
travel ; that every prostitute was held until cured of
venereal diseases ; that every male criminal, or sex
offender, was cured of venereal diseases, if infect-
ed ; and, finally, that all males, unquestionably
feebleminded, were unsexed !
Custodial control of the feebleminded prostitute
would, in a large measure, prevent profiteering in
prostitution, for it is from this group, mostly, that
houses of ill fame secure their supply of women. Be-
sides the undoubted influence this method of control
would have upon the incidence of venereal diseases,
it would have a still further beneficial result in pre-
venting a large percentage of illegitimacy of the very
worst type.
The causes of prostitution lie deep down in our
social structure, and its problem, though stupendous,
should be solved now. This is an era of action, the
day of big things, the time to say that this question,
as an urgent war measure, shall be promptly met ;
that red light districts shall not stand as permanent
tourist exhibits of great cities ; that houses of ill
fame shall not exist ; that feebleminded men and
women shall not beget their kind ; that a living wage
shall be given to women ; and lastly that the man-
hood of our land shall assert itself to save society
by its own selfcontrol.
RECOMMENDATIONS.
1. The employment of psychopathic investigators
for all venereal clinics for the purpose of carefully
surveying the mental capacity of all arrested prosti-
tutes, with the end in view of securing legislation in
all the States for the custodial care of all chronic
prostitutes that can be convicted of any of the men-
tal defects under present statutes.
2. A State wide movement for custodial and pro-
bationary control of all convicted prostitutes.
3. And a State wide movement to buy farms, and
to build reformatories, for custodial and probation-
ary control of all feebleminded and certain other
types of psychic inferiority.
REFERENCES.
I. The Social Evil in Chicago. 2. A Special Report of the State
Board of Charities and Corrections on Weakmindedness in the State
of Virginia. Knee: and: Commercial Prostitution in New York
City. 4. A. F. Tredcold: Mental Deficiency.
Treatment of Pneumococcic Peritonitis.^
Evan W. Meredith (Pennsylvania Medical Journal,
June, 1918) advises surgical measures in the lo-
calized form. In the diffuse type nonoperative
measures designed to cause subsidence and localiza-
tion should be used until the stormy symptoms
subside.
DISEASED TONSILS AND FOCAL
INFECTION.
With a Report of Cases.
By Harry Rodman, M. D.,
New York,
Adjunct .Surgeon, Bron.x Eye and Ear Hospital; Chief of Clinic,
Ear. Nose, and Throat Department, Hospital for
Deformities and Joint Diseases.
Although much has been written on this subject
in the last few years, it is of«such vital importance
and of such great interest both to the general prac-
titioner and to the specialist that I do not hesitate
to emphasize once more all that we have learned
pertaining to this subject.
The majority of us are now convinced of the close
relationship of various bodily ailments, both sys-
temic and local, to focal infection. We are con-
cerned here mainly with the tonsils as a factor of
focal infection, and the subject is discussed under
the following subheads: i, the normal tonsil; 2,
the pathological tonsil ; 3, relation of diseased ton-
sils to general and localized disease; 4, a report of
my cases with the practical results obtained after
tonsillectomy.
THE NORMAL TONSIL.
The faucial tonsils, two in number, are deeply
located between the anterior and posterior pillars
of the fauces on either side. They are largely com-
posed of lymphoid tissue supported by a framework
of connective tissue, and their inner surface pre-
sents many depressions or crypts. The exposed
surfaces, even of the crypts themselves, are covered
with mucous membrane ; these are most numerous
in the upper portion. Above the tonsil is a large
depression called the supratonsillar fossa. This
frequently serves as a pocket for the development
of suppurative inflammation. On its outer surface,
the tonsil is covered with a fibrous capsule from
which the connective tissue supporting the lym-
phatic structures is derived.
THE PATHOLOGICAL TONSIL.
An enlarged tonsil, per se, is not a pathological
one. Under certain circumstances the enlargement
becomes a pathological condition of great impor-
tance. The tonsils usually atrophy toward puberty.
If they do not spontaneously atrophy at that time,
they are liable to become the seat of pathogenic
changes of varying severity. Two distinct varieties
of enlargement of the tonsil are recognized : One
is a true hypertrophy of the gland, which is merely
a physiological process; the other, a hyperplasia, is
the result of repeated attacks of inflammation with
corresponding increase of the amount of connective
tissue in the glandular structure.
In children, simple hypertrophy is often the result
of overactivity of a physiological kind. After
puberty and in adult life there is no doubt that the
enlarged tonsil is hyperplastic and is the result of
repeated attacks of tonsillitis, which latter condition
may be the sole cause of the hyperplasia. On the
other hand, another pathological condition is their
presence, not as enlarged tonsils but as small cryptic
organi, the seat of repeated attacks of acute in-
flammation.
762
RODMAN: DISEASED TONSILS AND FOCAL INFECTION.
[New York
Medical Journal.
A surgical or pathological tonsil is one in which
not only the tonsillar tissue is diseased, but also the
tissue in association with the tonsil, thus involving
the surrounding structures. The tonsils may be
either large or small, bound down by adhesions, in
which have been formed pockets filled with caseous
material — the product of decomposed food and se-
cretions, the crypts being filled with pathogenic or-
ganisms as well as this same caseous material.
Such a tonsil is the source of constant systemic
absorption of poisonoiis material and, under certain
conditions — when the bodily resistance is lowered,
or from some unexplained cause — it becomes the
seat of focal infection. Incidentally, it interferes
with the physiological function of the pharynx,
nasopharynx, and the free drainage of the Eu-
stachian tube.
Some authorities consider that the tonsil in early
childhood serves to arrest the entrance of micro-
organisms to the body. Others believe that the ton-
sils assist in leucocytosis and so guard the subject
against disease. Still others, and they are in the
majority, believe not only that the tonsillar func-
tions, if any, are very limited but that, in addition,
the tonsils are a constant source of danger. In this
connection the absorption of enlarged cervical
glands after tonsillectomy may be considered, also
the great improvement in chorea, purpura hemor-
rhagica, and rheumatism after tonsil enucleation.
Children with enlarged and diseased tonsils, suffer-
ing with diphtheria, scarlet fever, measles, diseases
involving the nose and throat, are more likely to
develop otitis media, endocarditis, cervical abscess,
arthritis, and have a more protracted illness than
those who have had only small tonsils or who have
had the tonsils removed.
From the thousands of tonsillectomies performed,
we can easily disprove any theories of greater sus-
ceptibility of these children to diseases common to
early life. The majority of these diseases are
transmitted by secretions from the nose and throat.
The epidemic of anterior poliomyelitis two years
ago demonstrates this fact very clearly ; those chil-
dren whose tonsils had been removed and those who
had been free from attacks of tonsillitis suffered
least. When such children were stricken with this
disease it ran a much milder course. In a series of
verv severe cases, under the service of Doctor
Roper, where a fatal outcome appeared imminent
and where the conditions were most serious, tonsil
enucleation saved quite a few. This was considered
rather heroic treatment but was certainly justified
under the circumstances.
RELATION OF DISEASED TONSILS TO GENERAL AND
LOCALIZED DISEASE.
A great deal has been written recently on the im-
portance of the nose, throat accessory sinuses, oti-
tis, teeth, and gums in connection with systemic
infection, and particularly with joint diseases.
Many workers in this field — and among them some
very brilliant observers — have demonstrated beyond
possible doubt the very close relation of diseased
tonsils to various forms of arthritis an^ general
disease.
We are concerned here only with the tonsils, but
all the organs of the upper air passages have been
found to be the habitats of microorganisms which
cause infection. The actual demonstration of causa-
tive agents in the production of joint infections,
such as, for instance, the Streptococcus viridans,
whicl; has been studied by a most careful and bril-
liant observer. Doctor Rosenau, is particularly in-
teresting and instructive. Doctor Rosenau, among
other interesting experiments, inoculated animals
with the organisms formed in diseased tonsils and
produced promptly a streptococcic arthritis.
That persistently insidious attacks of bacteria in
the tonsil can cause painful joint conditions is a
well known fact. In 1877 Dr. Alfred Mantle con-
sidered and discussed the etiology of rheumatism
from a bacteriological point of view. In the last
few years the etiology of joint rheumatism has been
positively ascertained as being caused by patho-
genic bacteria. What led Doctor Mantle to associ-
ate the throat with rheumatic symptoms was the
frequency of such symptoms in children suffering
with scarlet fever. He observed that throat joints
and serous membranes became infected during bac-
terial invasion, and he suggested the possibility of
acute rheumatism having a like origin. By means
of a sterilized hypo syringe, he extracted, under
strict antiseptic precautions, a dram of serum from
the rheumatic knee joints of half a dozen patients.
He then made blood cultures, and in nearly every
case streptococci were found. Poynton and Pain,
in 1900, published the next work of importance in
this connection.
We now know that, in a great many instances,
the tonsils are the foci of this bacterial invasion.
We have learned beyond any possible doubt that in
the tonsils certain forms of bacteria will settle and
thrive, multiply and emigrate into the blood stream
to seek the region of the body where they can live
to the best advantage, the joints being mo.st sus-
ceptible, are attacked more often than any other
part of the body.
HISTORIES OF PATIENTS BENEFITED BY
TONSILLECTOMY.
P)efoie presenting these histories, I wish to state
that it is our custom and routine at the Hospital for
Deformities and Joint Diseases to examine all ton-
sils which we remove. Our pathologist has dem-
onstrated in most of such tonsils the presence of
pathogenic bacteria, particularly various strepto-
cocci groups, and in a number of these organs he
has found abscesses circumscribed and imbedded
deeply in the tonsillar tissue and near the capsule.
Only rarely do we find tubercle bacilli.
With regard to vaccines, our results thus far
have not been satisfactory before operation. In
some patients, after tonsil enucleation, the symp-
toms have become aggravated temporarily, and it is
in this class of cases that autogenous vaccines might
be helpful.
The following histories were taken of patients
upon whom I have operated at the above named
hospital. These histories are typical of the results
obtained in the majority of our patients suffering
with joint conditions as a result of tonsillar infec-
tion. I have selected a number of cases to illustrate
November 2, igi.s.i RODMAN: DISEASED TONSILS AND FOCAL INFECTION.
763
the type of joint conditions we meet with as result
of focal infection, due to diseased tonsils.
Case I. — J. G., age sixteen years.
Present history. — Patient has been sufferinR with pain
in his right shoulder for a year. Most severe pain when
moving, and particularly on raising his arm. Right shoul-
der and arm swollen and motion impaired.
Diagnosis. — Infectious arthritis.
Tonsillectomy was performed January 18, 1017. One
month after operation swelling and pain had subsided and
patient was very much improved. Three months after
that, patient was free from all symptoms.
Casi-; II. — Herman D., age twenty-six years ; occupation,
photographer.
Present history. — As far back as patient can remember
he had had pain in left knee ; slight swelling present. Had
been diagnosed as tuberculous knee. Was referred to an
ortliopedic hospital, where a brace was advised. Has worn
brace for the past six months. Pain was slightly relieved
for a time. X ray showed atrophy of joints.
Tonsillectomy was performed November 27, 1917. fol-
lowed in a week by marked improvement as to pain and
discomfort. One month after, swelling of joint was less
marked and pain had entirely disappeared. Never re-
turned for observation.
Diagnosis. — Infectious arthritis.
Case III. — Bertha R., age twenty-five years.
Family history. — Negative.
Present history. — Pain, stiffness, swelling of nearly
every joint in the body. Had been treated for rheumatism
by baking, massage, etc., which had reduced the swelling
somewhat, but pain persisted. Patient also suffered with
frequent attacks of tonsillitis. Tonsillectomy was per-
formed February 15, 1917. Within four weeks consid-
erable improvement was observed. Swelling of joints con-
siderably diminished; pain and stiffness of joints very
much improved, which improvements continued.
Diagnosis. — Infectious arthritis.
Case IV. — Louis S., age twenty-nine years. Admitted
into the hospital November 15, 1916.
Family history. — Negative.
Present history. — For one and a half years has had pain
in the right hip. No gonorrhea or syphilis. Wassermann,
negative.
Diagnosis. — Rheumatic sciatica.
Liniments and internal medication prescribed, which
failed to relieve pain. Tonsillectomy performed Novem-
ber 8, 1916. One month after operation sciatica cleared up
markedly and at the present time is free of all pain and
discomfort.
Case V. — Leonard L., age seven years.
Present history. — For past week patient had been com-
plaining of severe pain in both ankles and knees. At time
of admission to the hospital left knee and left arm were
infected. Had difficulty in walking. Gives history of fre-
quent attacks of tonsillitis. Wassermann, negative.
Tonsillectomy was performed May 20, 1917, followed
by immediate improvement, and within six weeks com-
pletely cured. No recurrence of symptoms at the present
date.
Diagnosis. — Infectious arthritis.
Case VI. — William L., age twenty-four years ; occupa-
tion, clothing cutter.
Present history. — For nine months pain and swelling in
left arm and left elbow, radiating to the fingers. For the
last two months also complained of pain in the left leg;
swelling appeared at the calf of leg.
Internal and externa! treatment, with no relief. Ton-
sillectomy February 2.3, 1917. Within six weeks pain and
swelling of joints and muscles disappeared. Patient did
not return to the clinic after that for future treatments.
Diagnosis. — Infectious arthritis.
Case VII. — Max M., age twenty-five years.
Present history. — For three years patient complained of
pain and Hmitation of motion of right shoulder and arm.
No swelling present, no discoloration. Symptoms more
severe at night, interfering with sleep. No relief from
internal medication. No syphilis. Wassermann, negative.
Tonsillectomy December 11, 1916, followed by marked
improvement, so that the patient could sleep and pain was
greatly alleviated. Limitation of motion still present
though less marked. Three months after the operation the
I'atient was practically free from pain, though a certain
amount of fixation of shoulder joint persisted.
Diagnosis. — Infectious arthritis.
Case VIII. — Alfonso J., age twenty-seven years.
Family history. — Negative.
Previous history. — Negative.
Present history. — Pain and swelling of the left shoulder
and knee joints. History of frequent tonsillitis.
Tonsillectomy performed May 28, 1917. One month
after the operation symptoms had entirely subsided, so
that at the present day we consider him cured, no recur-
rence of symptoms having occurred.
Case IX. — Natalie C, age twenty-six years.
Present history. — For the past three months patient
complained of snapping of bones in the right temporomax-
illiary region, especially when chewing. On opening the
mouth widely, would sufi'er a great deal of pain in that
joint. Also complained of interscapular pain.
Tonsillectomy performed September 13, 1916, followed
by relief of pain and discomfort shortly after.
Case X. — I\uby"S., age seventeen years.
Previous history. — Negative.
1 Present history. — Nine weeks before admitted, left wrist
and fingers of left hand swollen. Right middle finger
swollen.
Diagnosis. — Infectious arthritis.
Tonsillectomy December i, 1917, followed within two
weeks by almost immtdiate improvement in all symptoms,
and at the present day practically normal, and motion
good.
Case XL— Theresa G,
Present history. — Had been treated in the clinic since
July 31, 1916. Had betn complaining of pain and swelling
in both knees and elbows.
Diagnosis. — Infectious arthritis.
Tonsillectomy March 3, 1918. Two weeks after the
operation patient improved. Two months after, improve-
ment became miich marked ; pain and swelling reduced,
though movements of joints affected were limited.
Case XII — -Mafy H., age fifty-one years.
Previous history. — Negative.
Present history. — Pain in both knees and elbow joints,
with slight amount of swelling present. Finger joints also
painful and swollen. Frequently attacks of tonsillitis no-
ticed. No gonorrhea or syphilis. Wassermann, negative.
Tonsillectomy performed July 29, 1916, followed by
marked improvement in all the joints, particularly the
small joints. Patient has been observed several times since
the operation. Her irjiprovement has continued and at
the present day is free from all pain, although the fingers
are Jtill stiff and movement limited.
Diagnosis. — Infectious arthritis.
Case XIII. — Abraham G., age eighteen years.
Previous history. — Negative.
Present history. — Right shoulder joint painful and
swollen for some time.
Diagnosis. — Infectious arthritis.
Tonsillectomy performed April 19. 1918. Within a short
time symptoms were relieved and improvement noted at
the present day. One month after operation complained
of pain in his left shoulder, which, however, has disap-
peared.
CONCLUSIONS.
In view of the experience of others as well as
my own in this field, I feel justified in recommend-
ing removal of tonsils in all patients sufifering with
local and systemic infection and where the tonsils
are at all diseased. On the other hand, the condi-
tion of the accessory sinuses, the teeth, ears, etc.,
should be studied for possible forms of infection
and as connecting links in the chain of causative
agents in the production of painful joints and other
ailments, enumerated above.
Pyorrhea, sinusitis, gonorrhea, syphilis, colitis,
the entire genital tracts — all these conditions must
764
IVOLDERT: ALLEN-JOSLIN TREATMENT OF DIABETES MELLITUS. , [^'^^ yo""^
Medical Journal.
be thoroiit^hly investigated. Wassermann tests, x
ray examinations of the ethmoid frontal sinuses, the
antrum of Highmore, complement fixation tests,
etc., should be made before arriving at a definite
conclusion in regard to the seat of focal infection.
I am indebted to Dr. Henry W. Frauenthal and
members of our stafif, who have been kind enough
to help me in my work and who have furnished our
department with the proper materials and facilities
for pursuing this highly interesting line of work.
780 West End Avenue.
THE ALLEN-JOSLIN TREATMENT OF
DL^BETES MELLITUS.
By Albert Woldert, M. D.,
Tyler, Tex.
The modern method of treating diabetes mellitus
is based on certain facts established principally by,
von Noorden, Naunyn, and later by Allen, Joslin,
Hill, Eckman, and others. In this country Allen
was perhaps the first to emphasize the importance
of fasting and to introduce the starvation treatment
TO control the output of glucose in the urine. Joslin
has made certain methods more practical.
In the treatment of diabetes mellitus it is very
essential that the physician should at all times have
in mind the amount of food necessary to maintain
the normal nutrition of the body in health and
should also know the tolerance of the patient for
carbohydrate, protein, and fat, i. e., the amount of
carbohydrate, protein, and fat the patient can as-
similate or digest without the occurrence of glucose,
diacetic acid, B-oxybutyric acid, and acetone in the
urine. The following tables should practically be
memorized.
The data contained in this contribution are printed
in many instances verbatim from the publications of
Joslin (i), and of Hill and Eckman (2) on the
subject of diabetes, to which volumes all interested
are referred.
In determining the tolerance for various foods,
after the patient has fasted and the urine made
sugar free, the first question to be determined is the
tolerance for carbohydrates ; secondly, for protein ;
and lastly, for fat.
In addition to learning the data pertaining to the
diet, it is equally as important for the physician to
determine the actual percentage of glucose that oc-
curs in the urine, and such examinations should be
made at intervals of one day or two days, in order
to keep a check on the actual condition of the patient
at all times. It is essential that the patient should
be made to know that the treatment of his condition
through dieting is permanently necessary.
Joslin (3) has arranged the following schedule,
indicating the number of calories required by an
adult in proportion to his weight, weighing seventy
Icilograms, or 154 pounds:
TABLE I.
Calories per kilo-
gram body weight. Total calories.
At rest 25-30 1750-2100
Light work .15-40 2150-2800
Moderatf^ work 40-50 2800-3150
Hard work 45-60 .3150-4200
Therefore the diet of a person in health weighing
seventy kilograms, or 154 pounds, when at moderate
work, would be forty to fifty calories per kilogram
body weight, or a total of 2,800 to 3,150 calories per
day. For a person weighing sixty kilograms, or 132
pounds, 2,400 calories would be required.
Joslin agrees with Chittenden that the diet in
health should contain thirty calories per kilogram
body weight, and that there should be one gram of
protein in the food for each kilogram body weight.
He summarizes (4) the caloric needs of children
during the twenty-four hour period, in the follow-
ing manner :
TAT?-LF n.
Age in
years. Weight. Total calories.
■2 12 kilograms (26 pounds) 960
6 20 " (44 " ) 1400
12 36 " (80 " ) 1800
Hill and Eckman state that most adults do well
on about thirty calories per kilogram body weight;
children of four years need seventy-five calories per
kilogram, children of eight years need sixty calories,
and children of twelve years need fifty calories.
They further state that it is surprising to see how
well patients do on 1,500 or 2,000 calories per day.
Regarding the proportion of carbohydrates, pro-
tein, and fat in the normal diet of an adult, Joslin
gives the following (5) :
TABLE III. t
Quantity
Fond. in grams. Total calories.
Carbohydrate 400 1600
Protein 100 400
Fat 100 900
In the treatment of diabetes, food values are an
important consideration. Joslin (6) has summed
them up in this manner :
TAPLE IV.
30 grams (i ounce) contain approximately:
Carbohydrate. Protein. Fat.
Grams. Gram^. Grams. Calories.
Oatmeal, dry weight 20 S 2 120
Cream, 40% i i 12 120
Cream, 20% i i 6 60
Milk (sweet) 1.5 i i 20
Brazil nuts 2 5 20 210
Gvsters (six) 4 6 i 50
Meat (uncooked, lean) .0 6 3 50
Meat (cooked, lean) o 8 5 75
Bacon o 5 15 155
Eag (one) o 6 6 75
Vegetables, 5% group.. i 0.5 o 6
Vegetables, 10% group. 2 0.5 o 10
Potato (Irish) 6 i o 30
Bread 18 3 o go
Butter 0 0 25 225
Fish, cod, haddock
(cooked) o 6 o 25
Broth o 0.7 o 3
Small orange, or yi
grapefruit 10 O o 40
The same author has given this table (7), ar-
ranged approximately, according to the percentage
of carbohydrates :
Five per cent, carbohydrate vegetables (either fresh or
canned) : Lettuce, cucumbers, spinach, asparagus, rhubarb,
sauerkraut, beet greens, celery, cooked onions, tomatoes,
okra, cauliflower, eggplant, cabbage, radishes, leeks, string
beans.
Ten per cent, carbohydrate vegetables : Pumpkin, tur-
nip, squash, beets, carrots, fresh onions.
Fifteen per cent, carbohvdrate vegetables: Green peas,
artichokes, parsnips, canned lima beans.
November 2, 19.S.1 WOLDERT: ALLEN-JOSLIN TREATMENT OF DIABETES MELLITUS.
765
I'wenty per cent, carbohydrate vegetables: Potatoes,
shelled beans, baked beans, green corn, boiled rice, boiled
macaroni, ripe olives.
Fruits containing five per cent, carbohydrates : Grape-
fruit, lemons.
Fruits containing ten per cent, carbohydrates : Oranges,
cranberries, strawberries, blackberries, gooseberries,
peaches, pineapple, watermelon.
Fruits containing fifteen percent carbohydrates: Apples,
pears, apricots, cherries, raspberries, huckleberries.
Fruits containing twenty per cent, carbohydrates : Plums,
bananas, prunes.
Nuts containing five per cent, carbohydrates : Butternuts.
Nuts containing ten per cent, carbohydrates : Brazil nuts,
black walnuts, hickory nuts, pecans, filberts.
Nuts containing fifteen per cent, carbohydrates : Al-
monds, English walnuts.
Nuts containing twenty per cent, carbohydrates : Peanuts.
Nuts containing forty per cent, carbohydrates : Chestnuts.
METRIC SYSTEM AND SOME APPROXIMATE EQUIVALENTS, AVOIR-
DUPOIS WEIGHT, ETC.
A gram is 1.S.432 grains, or approximately speaking, 15^
grains.
IS grams is approximately 1/2 ounce or i tablespoonful.
30 grams is approximately i ounce or 2 tablepsoonfuls.
A kilogram is 2.2 pounds.
60 kilograms is 132 pounds, i. e., 60 times 2.2 pounds.
A level tablespoonful is approximately 25 grams of food,
such as cabbage, after being cooked.
A heaping tablespoonful of cooked food such as aspara-
gus (9 stalks 4 inches long) is equal to 100 grams.
A heaping tablespoonful of cooked turnips or spinach is
equal to 100 grams. One hundred grams is equal to 35^2
ounces.
One small serving of steak would, roughly, equal 100
grams.
Two slices of bacon about 6 inches long would approxi-
mately weigh 50 grams.
A level tablespoonful of butter will approximately
weigh 15 grams or Y2 ounce ; and a heaping tablespoonful
of butter will weigh 30 grams or i ounce.
In determining the carbohydrate tolerance Jos-
lin gives from 150 to 300 grams daily of five per
cent, vegetables, or about one third of the follow-
ing full diet :
TABLE V. — FIVE PER CENT. VEdtTABLES.
Protein 10 grams
Carbohydrate intake 15 grams
Fat 7 grams
Total calories produced 200
Breakfast. — String beans (canned), 120 grams, or 2^
heaping tablespoonfuls ; asparagus (canned), 150 grams,
or 3 heaping tablespoonfuls, or i3'/2 stalks 4 inches long;
tea or cofTee.
Dinner. — Celery, 100 grams, or 6 pieces; spinach
(cooked), 135 grams, or 3 heaping tablespoonfuls; tea or
coffee.
Supper. — Asparagus, 100 grams, or 2 heaping tablespoon-
fuls? or Q stalks 4 inches long; celery, 100 grams, or 6
pieces 4^^^ inches long ; tea or coffee.
It is best to boil these vegetables three times with
changes of water to reduce the amount of carbohy-
drate in them.
TABLE VI. — FIVE PER CENT. VEGETABLES.
Protein 7 grams
Carbohydrate intake 15 grams
Fat 6 grams
Total calories produced 150
Br<?a^/ajf.— Asparagus (canned), 75 grams, or 1^4
tablespoonfuls (chopped) ; cabbage, 65 grams, or i heaping
tablespoonful ; tea or coffee.
Dinner. — Onions (cooked), 100 grams, or 2 heaping
tablespoonfuls ; celery, 50 grams, or 3 pieces about 4V2
inches long; tea or coffee.
Supper — Spinach, 100 grams, or 2 heaping tablespoon-
fuls ; celery, 50 grams, or 3 pieces 4Y2 inches long.
In determining the carbohydrate tolerance the
patient is kept upon one third of the amount of
food mentioned in Tables V or VI for one day ; or
if the case is particularly severe, for two days and
the urine tested for glucose.
After the carbohydrate tolerance has been ob-
tained (see method below), the protein tolerance is
ascertained, and following that the fat tolerance is
determined. When the tolerance for carbohydrate,
protein and fat have been determined the diet can
be gradually increased and the patient put upon a
more or less permanent diet. The following are
Hill and Eckman's tables for gradually increasing
the diet after the urine has remained sugar free:
TABLE VII.
Protein 24 grams
Carbohydrate 8 grams
Fat 22 grams
Total calories produced 340
Brcal-fast. — String beans, 100 grams, or 2 heaping table-
spoonfuls ; one egg ; coffee.
Dinner. — One egg; 100 grams turnips, or 2 heaping
tablespoonfuls ; 100 grams cabbage, or 2 heaping table-
spoonfuls ; tea.
Supper. — One egg ; 100 grams turnips, or 2 heaping table-
spoonfuls ; ICQ grams spinach, or 2 heaping tablespoonfuls ;
tea.
TABLE viti.
Protein 3i grams
Carbohydrate I7 grams
Fat 14 grams
Total calories produced 327
Breakfast. — One egg ; asparagus, 100 grams, or 2 heaping
tablespoonfuls ; tomatoes, 100 grams, or 2 heaping table-
spoonfuls ; coffee.
Di)iner. — Chicken, 35 grams, or one small serving; string
beans, 200 grams, or 4 heaping tablespoonfuls ; cabbage,
100 grams, or 2 heaping tablespoonfuls ; tea or coffee.
Supper. — One egg; cauliflower, 240 grams, or s heaping
tablespoonfuls ; spinach, 100 grams, or 2 heaping table-
spoonfuls ; tea or coffee.
METHOD OF TREATING DIABETES.
Joslin divides diabetes mellitus into the following
three types : Mild ; moderately severe ; and severe.
In order to get rid of glucose, diacetic acid, and
acetone in the urine, the following patients should
fast only after a preparatory treatment: i, severe
cases ; 2, long standing cases ; 3, compHcated cases,
that is, cases complicated with diseases of thyroid,
heart, or kidneys, or with abscesses ; 4, obese cases ;
5, elderly patients ; 6, all patients showing
acidosis, or predisposed to acidosis who might suc-
cumb early if placed upon fats and proteids, fat ac-
cording to Joslin being the chief source of acidosis.
In all other cases, except those of mild type, fasting
should be begun at once. When a patient enters the
hospital Joslin's plan is to have him begin to fast,
by prescribing five per cent, vegetables, 150 grams
daily, and a small orange at each meal, if uncer-
tainty exists in regard to the character of the case.
MILD CASES.
In mild/ cases Joslin considers it unnecessary for
such patients to practise fasting, and finds that the
simple omission of fat and sugar will lead to a great
reduction in the amount of sugar excreted. There-
fore in mild cases he excludes fat, sugar, and bread,
and puts the patient on a diet of baked Irish pota-
toes, which contain twenty per cent, carbohydrate,
instead of a bread diet which contains sixty per cent,
carbohydrate, and limits the protein to 1.5 gram per
kilogram body weight. A kilogram equals 2.2
766
WOLDERT: ALLEN-JOSLIN TREATMENT OF DIABETES MELLITUS. „ [New York
Medical Journal.
pounds, and sixty kilograms would equal 132
pounds. Sixty times 1.5 grams (twenty-three
grains) would amount to 1,380 grains, or approxi-
mately three ounces of protein daily, for a person
weighing 132 pounds. The milder cases in a few
weeks attain a tolerance of more than 100 grams (or
three and one third ounces) of carbohydrates a day.
The carbohydrate should be held at about 125 to 150
grams a day, provided the patients have a tolerance
for that amount. After the urine remains sugar
free, fat is added to maintain the weight, but the
amount of carbohydrate taken is restricted for years,
even though no sugar reappears. In mild cases the
patient should be taught to take long vacations, se-
cure an abundance of sleep, keep the skin active by
frequent baths and massage, avoid constipation,
avoid excess in mental and physical labor, shun
obesity, and practise daily exercises.
SEVERE CASES.
In the treatment of severe cases, those of long
standing, complicated or obese cases, those of
elderly patients, and cases showing acidosis or pre-
disposed to acidosis, Joslin endeavors to make fast-
ing as safe as possible by adopting a routine plan
of preparatory treatment before fasting is begun.
This preparatory treatment consists in the omitting
of fats immediately, and the gradual reduction and
final omission of protein, followed by the continued
reduction of carbohydrate, with fasting eventually
if required. This preparatory treatment therefore is
as follows : Without otherwise changing the habits
or the diet, the fats are omitted from the beginning,
and after two days the protein is omitted and the
carbohydrates are halved daily until the patient is
taking only ten grams, 150 grains, of carbohydrate.
This preparatory treatment is instituted for the
purpose of preventing the development of acidosis
— a condition occurring in chronic diabetics who
might succumb if placed on a fat protein diet.
Fasting: — The patient should be advised to fast
for four days unless he is sugar free before the end
of that time. Water may be allowed freely, tea,
cofifee, and clear meat broths as desired.
Intennitfcnt fasting-. — If glycosuria persists at the
end of four days, one gram protein or 0.5 gram
carbohydrate per kilogram body weight for two days
may be given, and the patient advised to fast again
for three days unless he is sugar free before the end
of that time. If glycosuria remains, repeat this
treatment, and then advise fasting for one or two
days, as necessary. If there is still sugar, protein
should be given, as before, for four days, then a day
of fasting, and then gradually the periods of feed-
ing increased, one day each time, until fasting one
day each week. Joslin says that he has seen no un-
complicated case fail to get sugar free by this
method.
Determination of the carbohydrate tolerance.
— After the patient has undergone the fast and
when the twenty-four hours' urine is free from
sugar give five to ten grams carbohydrate (150 to
300 grams of five per cent, vegetables), that is to
say, one third of the amount of foods mentioned
in Table V, and continue to add five to ten grams
carbohydrate daily up to fifty grams or more
until sugar appears, or the approximate quantity is
reached which it appeals probable the patient will
tolerate. Following the trial with five per cent,
vegetables one can proceed to the ten per cent,
group, and these can be empirically reckoned as con-
taining six per cent, carbohydrate or approximately
twice that of the five per cent, group, or five grams
carbohydrate for seventy-five grams vegetables.
From this pomt onward the addition of carbohy-
drates can be made according to the desire of the
patient. It is often best to replace a large portion
of the five per cent, vegetables with ten per cent,
vegetables in order to get additional carbohydrates,
and if these are borne to add carbohydrates, as
cream, grapefruit, strawberries, orange, twice a day,
and then progress to peas, in the fifteen per cent,
group. After the carbohydrate tolerance has been
found, the tolerance for ptotein should then be de-
termined, and lastly the fat tolerance.
Determination of the tolerance for protein. — As
soon as the urine has been sugar free for two or
three days add about twenty grams of protein, and
thereafter fifteen grams protein daily in the form
of fish, lean meat, or eggs, or until the patient is re-
ceiving one gram protein per kilogram body weight,
or less if the carbohydrate tolerance is zero. Thirty
grams of fish (one ounce) or an egg of average size
contains approximately six grams of protein, and
thirty grams of lean meat contains approximately
eight grams. The white of an egg contains three
grains of protein. By this arrangement a patient
weighing sixty kilograms (132 pounds) would be
taking, within six days from the time he became
sugar free, one gram of protein per kilogram body
weight. This quantity, Joslin says, is quite satisfy-
ing to all except children, and he says he is aston-
ished to find how few patients care to take as much
as m grams protein per kilogram body weight.
Children need two or three grams protein per kilo-
gram body weight.
The advantage of giving and increasing protein
simultaneously with the determination of the car-
bohydrate tolerance is that one approaches nearly
normal conditions. The physician is attempting to
determine the carbohydrate tolerance while the pa-
tient is on a full diet and not the tolerance for car-
boiiydrate alone. There are few patients who will
not bear at the outset as much as one gram of
protein per kilogram body weight, and Joslin is very
loath to allow the protein to remain permanently be-
low this figure. The Chittenden standard is -one
gram protein per kilogram body weight, as stated
above.
Determination of the tolerance for fat. — Add no
fat to the diet until the protein reaches one gram
per kilogram body weight (unless the protein toler-
ance is below this figure), and the carbohydrate
tolerance has been determined ; then add five to
twenty-five grams fat daily, according to previous
acidosis ( some cases can only take five to ten grams
fat daily without causing acidosis) until the patient
ceases to lose weight or receives in the total diet
about thirty calories per kilogram body weight. So
long as the acidosis (diacetic acid, B-oxybutyric
acid, and acetone) and glycosuria occur the fat
must be kept low. The tolerance for fat is shown
by the reappearance of glucose and diacetic acid in
November 2, 19 18.]
MacNAlR: A FEW UNAVOIDABLE ERRORS.
767
the urine. While testing the protein tolerance of
course a small quantity of fat is included, which is
present in eggs, fish, and lean meat.
There are two important reasons why fat should
not be given a diabetic patient immediately upon his
becoming sugar free: i. By the omission of fat
partial fasting is continued, and thereby the patient
is gaining a tolerance for carbohydrate ; and 2, the
continued omission of fat is beneficial in counteract-
ing the last vestige of acid poisoning or preventing
the appearance of acid poisoning, which might easily
occur in a diabetic patient whose metabolism has not
become accustomed to so low a quantity of carbo-
hydrate. If the patient is one in whom acidosis has
been an essential factor, or if the patient is obese,
the fat should be increased slowly, and for such a
patient an increase of five to ten grams a day may
be all that can be taken without the recurrence of a
positive ferric chloride reaction in the urine.
The return of sugar demands fasting for twenty-
four hours, or until the patient is sugar free. This
rule should be inflexible in the case of children.
When the child learns that a reappearance of sugar
means a fast, there is little tendency to break the
dietetic regimen. If the sugar reappears after hav-
ing determined the tolerance for carbohydrate,
protein, and fat, the former diet should be resumed,
gradually adding fat last in order to maintain as
high a carbohydrate tolerance as possible, sacrificing
body weight for this purpose. Whenever the daily
tolerance is less than twenty grams carbohydrate,
fasting should be practised one day in seven. Great
care should be exercised not to break down the
tolerance a second time, since weeks or months may
be required to restore the powers of proper assim-
ilation of the food, lost by the patient. After he
has become sugar free, he can get along with a
smaller amount of food than an ordinary person.
Since a patient with diabetes mellitus may have to
be put upon a restricted diet for life, it is very im-
portant for him to learn the amount of food he may
take, and he should learn by heart the tables of
foods mentioned above. Joslin states that one day of
fasting may accomplish more than many days of
moderately low diet in ridding the urine of glucose.
SUBSTITUTES FOR BREAD.
Regarding bread Joslin (8) says: "Never give
bread substitutes early in the treatment of diabetes.
Teach patients to live without them." He seldom
advises breads, and says it is better for the patient
to forget the taste. In some instances bran bread
may be given. He adds that it is bulky and acts
favorably in constipation. The so called bran breads
and cookies may contain as much as sixty per cent,
carbohydrates. In purchasmg bran, Joslin advises
the patient to purchase it at a feed store, and to ask
for coarse bran for cattle, not bran for the table.
The starch may be washed out with water by tying
the bran in cheesecloth and fastening onto a faucet,
allowing the water to run through the bran to wash
out the starch.. It should be kneaded and thoroughly
mixed from time to time, and should be washed
until the water comes away clear — a process which
mav require an hour.
To make bran biscuits Dr. F. M. Allen advises the
following :
Bran, 60 grams, or q6o grains, or 2 ounces.
Salt, teaspoonful.
Agar-agar, powdered, 6 grams, or 90 grains.
Cold water, 100 c. c., or V2 glass.
Tic the bran in cheesecloth and wash under cold water
tap until water is clear. Bring agar-agar and water, 100
c. c, to the boiling point. Add to washed bran the salt arid
agar-agar solution (hot). Mold into two cakes. Place in
pan on oiled paper, and let stand half an hour : then, when
firm and cool, bake in moderate oven thirty to forty
minutes.
Joslin says gluten breads are made by removing
the sugar forming material from the flour, and that
it is surprising how thoroughly this can be done.
The large quantity of protein in small bulk which
they contain is obiectionable. Joslin also speaks of
casoid flour. Lister's diabetic flour, and Hepco
flour made from the soya bean, Barker's gluten
food, and other bread substitutes.
MILK.
Milk should be given to diabetics with caution,
on account of the large quantity of carbohydrate,
protein, and fat which it contains.
DRUGS.
In the treatment of constipation Joslin prefers to
administer one fifth grain aloin, or ten to thirty
drops fluidextract of cascara sagrada, or compound
rhubarb pill. Bran bread and coarse vegetables or
fruit for breakfast may prove efficient. For diar-
rhea he prefers to keep the patient in bed, and kept
warm, and at the saine time to administer hot water.
To overcome acidosis Joslin prefers not to use
alkalies but to get rid of diacetic acid and acetone by
fasting and dieting as advised.
REFERENCES.
I. Joslin: The Treatment of Diabetes Mellitus, Lea & Febiger,
Philadelphia. 2. Hill and Eckman: The Starvation Treatment
of Diabetes, W. M. Leonard, Boston. 3. Joslin: page 242. i.
Idem: page 243. 5. Idem: page 244. 6. Idem: page 250. 7.
Idem: page 260. 8. Idem: pages 505 and 519.
A FEW AVOIDABLE ERRORS.
By Robert H. MacNair, M. D.,
Springfield, Mass.
Lamentabl)^ unfortunate is that psychoentity that
is incapable of realizing that every individual soul is
prone to make mistakes. However, and again, it
is truly an unfortunate circumstance to be insuffi-
ciently trained for the life work one is to follow to
be armed against those blunders that must be
counted among the avoidable.
It is also lamentable that a certain proportion of
persons are either so highly endowed- with the ele-
ment the scientist calls exaggerated ego, that they
seem unmindful of their proneness to commit error,
or they seem to fail to profit, for the future, by the
mistakes of the past.
It is very distinctly recalled, from the student
days, in the halls of learning, how, along one im-
portant branch of professional work. Professor
Theophilus Parvin grew eloquent and exclaimed in
unmeasured indignation against the fearful neg-
ligence, in the face of a very sacred duty, of the
obstetrician who hurriedly applied the delivery
forceps before Dame Nature had indicated her in-
ability to complete a very natural function without
mechanical aid.
768
MacNAIR: A FEW UNAVOIDABLE ERRORS.
[New York
Medical Journal.
How interestingly the good professor's strong
teaching was recalled, but a few years after begin-
ning medical practice. It chanced that the acquaint-
ance was made of a physician, a genial man, of very
large, strong build, who enjoyed quite a large prac-
tice. But as this brother physician disliked the
practice of surgery (he enjoyed the theory very
much") I was very much favored by being called in
for most of the surgery that came to ray kind friend.
As he also had an extensive obstetrical clientele, it
happened, on many occasions, that there were
ruptured perinea? to repair. As may be imagined,
even though there was occasion for a great deal of
serious thought and reflection, it would have seemed
real presumption for a very young man in the pro-
fession to admonish one with such wide experience ;
besides it would have been exceedingly poor policy,
especially as the younger man would have accom-
plished nothing, save, most probably, the chance of
losing much good business, the same that was
needed to pay office rent, fuel, and feed bills, etc.
However, all of that caution of the distant past
cannot stand in the way of some present reflection.
On one occasion the good doctor hurried into my
modest ofifice to ask if I could go very soon to a
certain patient (a primipara) at whose delivery he
had used the forceps — and, of course, produced
rather an extensive rupture. With so much heft,
in live avoirdupois, at the distal end of the forceps
something had to give way, and the accoucher said
that, when the giving way came, he landed in one
corner of the room, all in a heap.
Another emergency that Professor Parvin dwelt
at length unon, connected with the same branch of
the profession, was postpartum hemorrhage. This
good, most conscientious teacher, whom I thought
exceedingly able — besides, he was truly inspired by
verv highest motives — would eloquently draw a
picture, deeply colored, with the real pathos of
human experience: That of the young mother,
whose soul had just been gladdened by the appar-
enlly safe delivery from long travail, whose heart
joyfully welcomed the reproduction in a sweet, in-
nocent little life, suddenly, to be snatched away
from such maternal happiness, by the onrush of a
postpartum hemorrhage.
During a vacation period from medical studies, it
becamic a very painful experience to see the attrac-
tive young wife of a dear friend die from post-
partum hemorrhage. What seemed to bring the sad
tragedy nearer to my own soul was the fact that
the young woman had been a great social favorite,
liad a host of friends, with whom I had the honor
of being classed. Be it said at the outset for the
accoucher v/ho attended this primipara. he seemed
to be too opinionated — a sort of old time country
nractitioner, one of the sort that depended rather
too much upon that same unfortunate ego exaggera-
tion. Hence he was not there in a severe crisis.
But later, and it is only charitable to assign the de-
feating cause, the doctor completely lost his head,
and consequently lost my good friend's young wife.
As the case was attended in a small town, and there
were no specialists in obstetrics to appeal to for as-
sistance, it ':ecmed quite. out of place to either ofTer
or accept any suggestions from a half baked medical
student. However, even then I knew "McClintock's
rule," and the patient's pulse rate just subsequent
to delivery — the latter not abnormal nor very tedious
— was a few beats over one hundred to the minute.
Yet the accoucher had turned the patient over to the
care of the nurse, received the usual pat upon the
back for good work, and gone on his rounds. It
became my painful privilege to know that hot
vinegar and styptic iron solution were used by the
gallon But strict aseptic precaution was not used, nor
were bimanual support and massage nor the empty-
ing of the relaxed uterus of clots practised. Gentle,
firm pressure upon the abdominal aorta, against the
lumbar spine, was, probably, not known then ; at all
events it v/as not tried. Absolutely nothing was
done to aid a relaxed uterus to get rid of the clot
obstruction, to get just a sHght breathing spell of
rest, in order to do more normal contraction and
close up the mouths of bleeding arteries. The good,
patient, old Dame Nature v/as then really up against
a very severe proposition, yet there was not a prac-
tically trained, competent servant, in the person of
an obstetrician, to lend the efficient hand. Conse-
quently, here was, indeed, another one of dear old
professor's pathetic pictures. '
Again, the good admonition of this able teacher
came home most vividly at the eighth year of private
practice. Having been engaged to attend a pri-
mipara in a labor that the little woman was looking
forward to with great anticipation of happiness, for
she was one of Nature's mothers — one of the normal
handmaidens — I was quite a little annoyed when
upon asking the messenger, who called for me in an
old sleigh, how long the patient had been sick, the
messenger replied, "All night." It was then after
breakfast on a snowy morning. When the patient
was asked why she had delayed until morning to
summon me, she replied that Mrs. , a neigh-
bor fa typical old Mrs. Butinski), had insisted upon
waiting until m.orning, while Airs. B pre-
vailed upon the patient to keep upon her feet and
in motion, throughout a good portion of the night.
The deliverv was absolutely normal, there was no
hitch anywhere, but just as soon as the placenta was
delivered the brave little woman indicated complete
weariness, muscular relaxation. The pulse rate
was counted at just 105 and, as good fortune seemed
to arrange it, an excellent trained nurse arrived.
The nurse had been expected the night before, but
the snow storm blocked the trolley line and she had
to wait until morning. Sustaining fluid diet had
been administered to the patient before the nurse
arrived. The old standby, brandy stimulant, was
not allowed, because I then suspected hemorrhage,
even though the uterus had made a fairlv good
effort at contraction. While the patient seemed to
be resting normally I took the nurse aside and ex-
plained my strong suspicion that there was a de-
cided likelihood of having to fight against hemor-
rhage— McClintock's symptom was there most
clearly. I then had an urgent call to make, but the
nurse was informed just where I could be reached
by telephone, and she was instructed to summon me
upon the first appearance of hemorrhage. While
fussing with a very high strung, restless driving
horse, to get the blanket oflp and get into the sleigh,
Novcmbc- 2, ,9.8.] ROSENHECK: REFLEX CONVULSIONS DURING DENTITION.
769
the gentleman at whose home I had just called ran
out to announce that the nurse had telephoned a
hurried summons for me to return to my confine-
ment patient. Fortunately the restless horse did not
waste any time on the way and, after applying the
usual, ordinary means to control a moderate degree
of postpartum bleeding, we were rewarded by a
complete, apparent return to the normal condition.
The pulse rate seemed to drop much nearer to a
firm, rhythmical beat. Hence after remaining with
the patient for an extra hour, she was again left to
the care of a very competent nurse.
Somewhere about the mid hour of a very cold,
dreary night the night gong rang furiously, to be
followed by the wailing voice of a poor heart
stricken man : "My poor little wife will die 1 know,
because she is now bleeding something awful."
Upon arriving at the bedside of my patient, I was
immensely encouraged to see, upon the pale sweet
face, a smile and the expression of true grit. The
nurse also was in the true fighting trim.
Lots of sterilizing fluid was hurriedly brought in,
while a hypodermic was being administered to the
patient. The obstetrical hands were most thor-
oughly sterilized, well lubricated and, with the right
hand gently introduced far enough up so that the
fingers could get into action within the womb, the
left hand went to a firm position on the outside,
just over the fundus. With the bimanual manipu-
lation, a combination of gentle massage and clearing
out of clots from the uterus was accomplished. At
the same time the nurse had been instructed to make
firm but gentle pressure upon the abdominal aorta,
which, owing to an exceedingly lax abdomen, could
be readily isolated and pushed against the lumbar
spine.
There were not many pleasanter impressions re-
called than that produced by the gradually increas-
ing contraction of the uterus upon the cramped,
tired fingers that were doing duty within. But, with
the recuperated muscular power given by nature,
the uterus did indicate its contraction by expelling
the fingers of the helping hand. Having remained
long enough to take early breakfast with the hus-
band, who had recovered his manly courage, I de-
parted with the firm belief that there would be no
further troxible. Subsequently, that patient was at-
tended in four other confinements, at none of which
was there a suspicion of postpartum hemorrhage.
The latter case has been described, not with the
slightest intention of taking credit for an accom-
plishment, but simply to illustrate how easily Dame
Nature's work may be thrown out of normal pro-
cess by the error of ignorant meddHng. It may also
be appropriate to suggest that, had a suggestion
been oflfered. by 9 "half baked medico," of any of
the means employed in the latter case to the doctor
who attended the southern friend's wife, doubtless
the ofter would have been considered little short of
effrontery.
What may be alluded to as another — a most
serious — error, can best be described in the words
of a very able New England surgeon, a friend who
is inclined to be somewhat of a pessimist: "The
medical profession is going to the bow wows, by
the air line of commercialism." We are forced to
admit that a very popular modern stunt is bluffing,
but, in order to get by with the bluff, it is always
essential to have a good, strong rearguard. No-
where is the necessity greater than in medical prac-
tice. For, as we are also forced to admit, the rank
and file of humanity is very much inclined to judge
a professional man by the external showing that he
can put up. Modern competition has become such
a sharply drawn process of a progressive era that a
good external showing must be used in the getting
by stunt. There is hardly any statement that more
clearly defines real merit than a certain declaration
of holy writ, viz., "The servant is worthy of his
hire." But, while no honest man may make the
claim of being above making serious, unavoidable
mistakes, in all efforts that are put forth in medical
practice, ^bove all he must be a thoroughly trained
servant, efficient in his special calling.
REFLEX CONVULSIONS DURING
DENTITION.
Their Treatment by Lumbar Puncture.
By Charles Rosenheck, M. D.,
New York,
Instructor in Neurology, Columbia University; Neurologist to the
Hospital for Deformities anc!«Jnint: Diseases.
Convulsions occurring during dentition have been
the subject of sharp division of opinion among
authorities. The relation of eclamptic seizures to
the eruption of teeth is given as an important fac-
tor by many, although equally competent observers
have denied the relationship. In a treatise by M.
Baumes written in 1783 the following observation
is made: "Thus convulsions, the most common and
often the most fatal of all the accidents of denti-
tion, present different important considerations.
They generally proceed from excessive mobility and
the pain of dentition is frequently the exciting
cause." That he recognized the fatal character of
some is evidenced by the following: "Convulsions
as well as the lethargy of dentition may terminate
fatally by apoplexy, generally of the serous or
lymphatic kind." ,His observations are confirmed
in the main by subsequent writers, notably Ash-
burner, Jacque, Savoye, Vanel, and Strumpell. In
sharp contrast, Jacobi in a series of lectures de-
livered in 1862 makes the following observations:
"The practice of explaining attacks of convulsions
occurring during dentition, in a period of life where
a large number of unwonted influences are brought
to bear upon the unresisting infantile organism, by
nothing but the irritation of the fifth pair of cere-
bral nerves, is entirely one sided and unjustfied."
Kassowitz after years of clinical observation con-
siders teething a physiological process unattended
by any untoward disturbances. Holt seems to adopt
this viewpoint, for he states that "dentition must
be regarded as an exceedingly rare cause of con-
vulsions."
I have purposely quoted the opinions of authorita-
tive clinicians and hold that in spite of the sharp
division of opinion, convulsions do occur during
dentition and at rare times become so formidable
as to seriously threaten life. The mechanism
that initiates the eclamptic seizure is not discussed
770
ROSENHECK: REFLEX CONVULSIONS DURING DENTITION.
[New York
Medical Journal.
here. The pathways by which peripheral sensory
stimuh are transformed into excessive motor mani-
festations are quite devious and intricate. It is
rather the persistence of the convulsive attacks that
is emphasized. An analysis of the causes under-
lying the continuance of the morbid process will
elucidate the problem and justify the use of the
therapeutic measures proposed.
It is assumed that at the height of the convulsive
attack there results an intense congestion of the
cerebral sinuses and veins. This state of afifairs
must affect the free flow of cerebrospinal fluid in
the ventricles, communicating channels, and suba-
rachnoid spaces of brain and cord. If the attack is
not repeated, the venous congestion subsides and
the flow of cerebrospinal fluid is reestablished.
However, if the convulsions are repeated, ihe initial
venous congestion and interference with the free
passage of the cerebrospinal fluid is increased im-
measurably. .A vicious circle is thus created, each
succeeding eclamptic seizure adding greater diffi-
culties to the overburdened ventricles and blood
spaces. Finally an acute hydrocephalus develops.
This increased intracephalic pressure is without
doubt responsible for the continuation of the con-
vulsions. Upon this point the observations of M.
Baumes made 135 years ago are worthy of note.
He states : "Acute hydrocephalus, whether we con-
sider it as a result of cerebral plethora, or whether
it be derived from a morbid affection of the serous
membrane of the brain, or whether it be caused by
the imperfect absorption of the humour which
lubricates the ventricles of the organ, has a close
connection with difficult dentition." It is this verv
"imperfect absorption of the humour which lubri-
cates the ventricles" that perpetuates the convul-
sions and menaces the infant's existence. Naturally
the use of lumbar puncture to relieve this pressure
at once suggests itself and has been used in three
cases under my observation with striking effect.
The convulsive attacks were coincident with the
eruption of teeth, the persistent spasms were clonic
and tonic in character, and had consistently defied
the usual remedial measures. Lumbar puncture
showed the cerebrospinal fluid to be under con-
siderable tension and the removal of an adequate
amount was followed by a cessation of the attacks.
One of the cases under the care of Dr. S. A.
Jahss is worthy of an extended note. This child was
wont to have a series of convulsions with the erup-
tion of every tooth. Its health was unimpared in
the interim. The number of attacks would increase
with each succeeding tooth and the intervals be-
tween the spasms were so shortened that the con-
vulsions were almost continuous. The last attack
lasted twenty-seven hours and Doctor Jahss noticed
that the child during this entire period was never
relaxed ; clonic convulsions were followed at once
by tonic spasms in the entire somatic musculature.
Heroic medication seemed to have no effect, and
the precarious condition of the child was quite evi-
dent. The coma was absolute and the signs of in-
creasing intraventricular pressure were quite mani-
fest. By lumbar puncture about forty-five c. c.
of fluid were withdrawn under a great deal of
tension. The convulsions stopped, the muscles
gradually relaxed, and the child fell into a
quiet slumber of several hours' duration. There
was moderate stupor and a state of muscular as-
thenia in the ensuing twenty-four hours, followed
by a complete and uninterrupted recovery.
Naturally so radical a method for treating the
reflex convulsions of dentition is hardly advocated
as a routine measure. Other well tried methods are
available and no doubt are just as efficacious. It is
only for those rare cases where the convulsions per-
sist and an acute hydrocephalus develops that lum-
bar puncture is recommended.
370 Central Park West.
Harmlessness of Serum Therapy in Massive
Doses. — A. Jousset (Presse medicale, August 5,
191 8) states that, among tuberculous patients, nor-
mal equine or bovine serums give rise to the same
kinds of untoward reactions and in the same pro-
portion of cases as do active antituberculous serums.
As to the relation of dose to reaction, the more
severe reactions are actually less frequent after
massive amounts given at short intervals than after
small doses. The author commonly injects 100 to
150 mils of antituberculous serum at one dose in
adults. Comparing the untoward reactions after
such amounts with those following the ordinary
doses of ten to forty mils, skin manifestations, local
or general, — urticaria, erythema, purpura, — proved
three times as frequent after the larger amounts,
and joint manifestations twice as frequent. These
disturbances are, however, amenable to calcium
chloride, adrenalin, belladonna, and sodium sali-
cylate, and deserve no greater consideration than the
toxic quinine or iodide eft'ects in malaria or syphilis.
The more severe general reactions, those often con-
sidered the result of anaphylaxis, were practically
no more frequent after large than after small doses
— five and four per cent., respectively. The author
strongly objects to considering these reactions as
anaphylactic manifestations, and reports over 1,500
subcutaneous serum injections without a single in-
stance of true anaphylactic reaction. The general
reactions resemble rather the nitritoid attacks which
sometimes follow arsenobenzol, or may appear only
after several hours or days. They often occur after
the first injection of serum, without any prepara-
tory inoculation. They arise merely from special
susceptibility of the subject to the material in-
jected, and their prognosis is no less favorable than
that of the skin or joint reactions already referred
to. The most serious reactions attending serum in-
jections are those constituting the Arthus phenom-
enon, in which after repeated injections there de-
velops locally what appears to be a -suppurative
hematoma. This may prove so painful that the pa-
tient will refuse further treatment. In this in-
stance, however, large, frequently repeated doses
proved less dangerous than small doses, awakening
the Arthus reaction in only two instead of ten per
cent, of all cases. On the whole the massive doses
prove both safer and more efficient. Intravenous
serum injections should not be used.
Medicine and Surgery in the Army and Navy
MEDICAL NOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-dncent at the T'niversity of Geneva; Fellow of the Royal
Society of Meilicine, London, etc.
BONE TRANSPLANTATION.
In the treatment of wounds of the lower jaw
experienced in warfare, Johann von Ertl, director
of the surgical department of the Royal Reserve
Hospital, No. 6, at Budapest, classifies the cases
suitable for transplantation in the following way :
Cases which do not consolidate under conserva-
tive treatment result in pseudarthrosis, and those
which result in severe and distinct destruction of
the lower jaw.
Cases which do not heal by conservative treat-
ment are those treated by splinting and which do
not respond to a fixation apparatus. They invaria-
bly end in a pseudarthrosis and, from the viewpoint
of conservative surgery, are today still an open
question.
Basing his theories upon the experiences of his
operative work, von Ertl looks upon these cases
in the same way as those where a little destruction
of bone has occurred. Bone injury from firearms,
just like those of the lower jaw, represent a total
interruption of continuity in the majority of in-
stances, and in this way the defect may be small or
considerable in extent. If such a fracture does not
unite spontaneously, callous cicatricial tissue will
develop between the fragments which, little by
little, Ijecome hyaline and then surround the bone
fragments and partially hold them in such a way
that the loss of bone assumes the nature of a
pseudarthrosis.
The majority of cases coming to von Ertl's
special clinic for treatment are jaw lesions of about
a year's standing, which during this time have been
treated by conservative methods but show no ten-
"dency toward consolidation. The changes which
have taken place in the bone fragments are such
that at this stage vmion of the parts can no longer
be hoped for, and on account of the cicatricial con-
traction, regressive changes of the bone ends will
shortly occur. Now, if these pseudarthroses of
the lower jaw are freely exposed and freed from
the cicatricial tissue, in most cases one will find a
distinct loss of bone tissue. In every case von Ertl
has found changes in the structure of the bone.
For example, the bone ends reveal an osteosclerotic
induration when the fracture is seated in the region
of the chin, while when seated at the angle of the
jaw softening from resorption is met with. These
regressive changes of the fractured ends involve
the bone to the extent of some one to two centi-
metres and, occasionally, considerably more.
These "aplastic" portions of the bone, as they
have been called by Verebely, cannot be utiljzed at
operation on account of their low vitality, and it is
for this reason that in order to transplant and ob-
tain a good consolidation, these bone ends must be
freshened until healthy bone tissue has been
reached. Therefore, the original defect is increased
considerably in extent and the primary pseudar-
throsis will have to be filled in with new bone, to
the extent of four to five centimetres of bone. It
is for this reason that von Ertl takes a similar view
in cases of small loss of bone and prefers to treat
them by transplantation. This conservative treat-
ment with a prothesis is preferred by many Ger-
man surgeons who patiently wait for consolidation
to take place. Yon Ertl does not go so far as to
deny the possibility of this taking place incom-
pletely, inasmuch as in some few cases the perios-
teum of the bone ends may undergo regeneration
under good conditions, with the ultimate union of
the fracture.
Calcification of the cicatrices may also occur, but
all these conditions are uncommon in practice.
Some surgeons do not consider bone transplant as
absolutely necessary, and are content with the func-
tional results that may be obtained by splinting and
other conservative treatment. At all events, there
is one merit that must be recognized in stomatol-
ogy, and that is, with its system of splinting and
protheses, the functions of the lower jaw may be
reestablished in quite a few cases when the splinting
can be accomplished on good, strong teeth, although
the functional activity may be only temporary. The
functional results are, however, exclusively de-
pendent upon the duration of the life of the teeth,
and tlie extra work thrown on them by a prothesis
unquestionably shortens it.
Some surgeons treat pseudarthrosis with injec-
tions of serum, tincture of iodine, chlorine, etc.,
and lately Schroder has essayed injections of an
emulsion of periosteum. The Vienna school is for
operating. For example, Pichler has successfully
employed a pedunculated bone pla.stic operation.
From one of the fractured ends he forms an osse-
ous flap with the chisel and brings it over the
defect. Esser has united the pseudarthrosis with
nails, with what success is a question. The Vienna
school has also advocated bone transplantation, par-
ticularly Weiser, Foramitti, Pichler, and Wunsch-
eim.
In von Ertl's service fresh wounds of the jaw
immediately treated never result in pseudarthrosis
because they are all operated on when, after a
trial of from six to eight weeks of prothetic splint-
ing, no consolidation has taken place. They are
dealt with by an osteoplastic operation asd union
always ensues. Von Ertl's working principle is to
reestablish as quickly and radically as possible the
lost function, and from this viewpoint he is of the
opinion that it is better to interfere surgically rather
than to wait for the uncertain results of conserva-
tive treatment.
Small and limited losses of bone of the lower
jaw, in the region of the chin, are common, like-
wise in the rami, but almost the entire lower jaw
may be missing in some instances. The small losses
of bone are usually due to a missile fired at a dis-
tance of over 500 metres, resulting in splintering
of the bone, both at the entrance and ex^jt apertures.
These splinters are in part carried away with the
772
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
missile and in part scattered about in the surround-
ing soft parts where they act as foreign bodies.
The exit aperture is apt to be the larger of the two
and offers a loss of substance to the extent of two
to three centimetres.
Cases are received in von Ertl's service either
directly after the receipt of the injury in an acute
state, or, on the other hand, they are long standing
chronic cases which have undergone a futile con-
servative treatment. In what he calls the acute
cases, von Ertl resorts to conservative treatment in
the first place, but if after the lapse of six weeks
there is no tendency toward consolidation, the pa-
tient is operated upon. In cases where the loss of
bone is not greater than two centimetres, it is
treated by an osteoperiosteal plastic procedure, but
if the resulting bone defect is more than this, ex-
perience has shown that it can only be cured by
bone transplantation. In those cases which he calls
chronic, with extensive cicatrices and suppurating
fistulse — if they have not already been treated by
some special orthodontic procedures — von Ertl says
that the bits of bone are usually held in their dis-
located position by cicatricial tissue.
The gap due to loss of bone is usually filled in
by dense cicatricial tissue, which only permits of a
very limited movement of the fractured ends, so
that the defect resembles a pseudarthrosis. How-
ever, by digital examination one can exactly locate
the defect and gently push the exploring finger be-
tween the fractured ends, which in most instances
are rounded. Radiographs in these cases usually
show a loss of substance varying from three to
four centimetres, generally in the form of a seg-
ment.
In cases where the process of repair of the soft
parts is yet in the acute phase and an exclusive in-
trabuccal treatment is being carried out, the result-
ing cicatrices will be elastic and superficial. A
pseudarthrosis does not exist, because the mobility
of the fracture is much freer, and during masti-
cation the teeth which have remained in the larger
branch of the fracture will be found to slide against
the defect. In these cases a diastasis of from one
to two centimetres will be found, and in defects of
the horizontal branch one may, with a diastasis of
thr-^.e to four centimetres, easily slide the larger
fragment toward the smaller one. A similar free
mobility is met with in pathological loss of sub-
stance, particularly following osteomyelitis, when
the sequestra have been removed by the intrabuccal
route.
In cases of larger defects in the acute stage, the
clinical picture is marked, besides the extensive
lesions of the bone and soft parts, by gaping of
the structures from actual loss of tissue. These
cases represent the most serious types of wounds
of the lower jaw, the patient's face being disfigured
to such an extent as to be unrecognizable. The
wounds result from a missile fired at short range.
This would produce the impression that it might
have been caused by a dumdum bullet, but such is
not the case, because if the lower jaw is hit in the
centre by the missile or pierced in two places, the
resulting wound is absolutely similar to that result-
ing from dumdum.
Bits of teeth and pulverized hone blown into the
wound along with the missile act as just so many
projectiles and produce really fearful destruction of
the soft parts. A missile producing such destruc-
tion in most instances involves a considerable por-
tion of the lower jaw. For example, the missile
enters obliquely at the angle of the jaw, goes
through the horizontal branch and may or may not
make its exit through the opposite side of the bone.
Such a wound may readily result in complete de-
struction of the cheeks and chin. Through the
gaping and lacerated borders of the wound the
root of the tongue, or what remains of the organ,
may be extensively damaged, while the pharyngeal
arch is freely exposed to view. The entire surface
of the wound is filled with bone splinters under-
going necrosis as well as sloughing, and purulent
bits of tissue, and a fetid, purulent saliva flows
away from the wound. On account of secondary
infection the discharge becomes larger in amount,
the soft structures become tumefied, so that the
patient can be fed only by means of a sound.
In other cases the damage to the soft parts is
really very small, although the destruction of the
jaw may be very extensive. Such conditions are
usually due 'to a missile which hits the horizontal
branch of the jaw at a very acute angle, shatters
the bone at the entrance aperture, continues its
course along the entire half of the lower jaw,
breaks the region of the chin, and makes its exit
through the opposite horizontal branch, which in
turn may be completely destroyed. In such cases
the soft structures may be only slightly injured and
still the jaw may be reduced to atoms, commencing
at the ascending branches and extending to the
frontal aspect. The minute bone splinters soon
undergo necrosis and are eliminated by an abundant
suppuration. If these cases can be treated early
and if the sequestra can be removed subperiosteally
by the intrabuccal route, the periosteum can be pre-
served and, later on, may become active in bone
reproduction.
In the cases of great defects the acute phase
will generally go smoothly because the entire field
of the wound is open and easily accessible to treat-
ment. The bone lesions, however, must be attended
to with great precaution, especially when the floor
of the mouth is also injured. The bone splinters,
acting as secondary missiles, will destroy the floor
of the mouth and wound the ligual artery and vein,
with the result that aneurysms or hematomata arise.
These vascular lesions in turn may ulcerate from
the suppuration and give rise to serious secondary
hemorrhage, to such an extent that, besides ligating
the vessels, intravenous transfusion must be done
to save the patient.
These very extensive wounds usually come to
von Ertl's clinic for treatment when they have
reached the chronic phase. Conservative treatment
being practically powerless, operation only is to be
considered. In a number of cases, von Ertl has ob-
served the poor results of previous attempts to re-
store the parts. At this phase there is great de-
formity and unsightly cicatrices, and what is very
striking is the tendency to exaggerated cicatricial
contraction of the soft parts, with the result that
the free bone fragments occupy the most varied
positions.
November 2, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
773
If, when treatment is first undertaken, no attempt
is made to fix the bone fragments in exact position,
or if this cannot be done on account of the great
extent of the destruction, these fragments will as-
sume certain typical positions due to retraction of
certain groups of muscles. For instance, when
there is total loss of the middle portion of the body
of the lower jaw both horizontal branches will draw
together and may unite in the form of a V, in which
circumstances the result will be that the lower jaw
takes the shape of a crow's beak, following cicatri-
cial contraction of the musculature of the floor of
the mouth.
In defects of the horizontal branch the bone
fragment at the angle of the jaw is usually retracted
inwardly and forward, this being due to the fibres
of the masseter and contraction of the temporal
muscle, while the larger distal fragment, when it
is not fixed by cicatricial tissue, may be freely
movable.
In defects of the angle of the jaw similar con-
ditions are met with. In these cases the ascending
branch is usually retracted inwardly and slightly
forward, this being due to retraction of the tem-
poral and pterygoid muscles. In defects of the
ascending branch the portion remaining is ordinar-
ily retracted inward and slightly forward. It is
interesting to note that this branch is usually firmly
fixed in this position, due, as von Ertl supposes, to
secondary changes in the joint. The temperomax-
illary ligaments being inactive, probably pull the
condyl strongly on the tuberosity, while the re-
tracted capsular ligament holds it fixed in this posi-
tion. In almost all cases of these defects of the
angle of the jaw the lateral facial and parotido-
masseter regions are depressed in the form of a
trough. This is due to atrophy of the muscles of
mastication and cicatricial contraction.
Another symptom useful for diagnosis for small
defects of the horizontal branch consists in the fact
that on the injured side the distance measured from
the middle of the body of the jaw to the angle is
shorter than on the normal side. Mayor, who rec-
ommends this procedure, has always found it exact
in cases of pseudarthrosis.
These patients, on account of the difficulties in
feeding, are generally very anemic, and gastric dis-
turbances in them are far from uncommon ; von
Ertl states that they become subjects of phthisis.
I should like to discuss the operative technic
employed by von Ertl, but this would extend this
article far beyond its intended limits. However, I
will say that as far as results and ingenuity go, the
work of von Ertl in no manner surpasses that of
American or Erench operators.
CRANIOCEREBRAL INJURIES IN WAR.
It has been the experience of some English sur-
geons that comparatively few cases of brain in-
jury reach the larger base hospitals, but it is now
generally admitted that all foreign bodies lodged
within the brain should be removed. When the
bullet has gone through the brain, the hydrostatic
pressure is transmitted in all directions and many
wounded die from arrest of the respiration, the
local lesion not in itself being the cause of death.
For this reason some surgeons have gone so far as
to advise performing artificial respiration directly
these patients are seen, but it is evident that this
practice cannot be carried out, given the circum-
stances of war surgery.
Craniocerebral injuries may be conveniently
classified as follows: i, Wounds of the scalp,
with or without denudation of the skull, without
fracture, but very frequently with cerebral con-
tusion ; 2, scalp wounds with cranial fissures ; 3,
scalp wounds with fracture of the skull of varying
types and degrees (in this variety the lesions are
usually more important in the internal than in the
external table) ; 4, comminuted fractures of the
skull with slight cerebral lesions ; 5, comminuted
fractures of the skull with extensive cerebral
lesions ; 6, craniocerebral perforation with missiles
lodged in the brain substance, artd 7, transfixing
wounds.
The best brain surgery can be accomplished at
the base hospitals, but a certain number of inter-
ferences must be undertaken at the first line ambu-
lances as has been made evident during the past
four years, particularly in the French and Italian
armies. Quite a number of symptoms ofifered by
these patients when first seen at the ambulance are
not the result of the cerebral lesion itself, but due
to shock, local edema or contusion of the brain.
They are merely temporary manifestations and do
not require surgical interference.
The fundamental principles of treatment of
craniocerebral injuries are: i, A careful cleans-
ing of the wound and surrounding scalp ; 2, an ex-
amination of the surrounding area after the wound
has been surgically enlarged; 3, hemostasis ; 4,
removal of bone splinters and, if possible, the re-
moval of the missile, and 5, establishment of free
drainage. In infected wounds a crucial incision is
preferable to the U shaped flap.
Decompression may be useful in certain cases of
war injuries during the first few days following
the receipt of the wound, on account of cerebral
contusion or edema or both, while later on it is
required in cases of meningitis or meningoenceph-
alitis. Decompression can be realized by resort
to lumbar puncture, which is unquestionably ex-
cellent in the serous form of meningitis. It may
also be obtained by craniectomy, but simple crani-
ectomy is useless on account of the inextensibility
of the dura. On account of the danger of infec-
tion from the primary wound, it is preferable to
carry out decompressive craniectomy on the op-
posite side to that of the wound. Meningitis
is the one great danger in cranial lesions of war-
fare, and all the measures resorted to up to date,
such as posterior bilateral trepanation or irrigation
of the spinal canal, have been ineflPectual. Cerebral
abscesses usually develop some time after the re-
ceipt of the injury, when adhesions have walled off
the subdural and subarachnoid spaces.
The lymphatic sheaths of numerous small blood
vessels distributed in the cortex are in direct com-
munication with the subarachnoid space, so that in-
fection of the white matter is easy. Now, while
the gray matter assumes an excellent offensive
against infection, reacting by throwing out a fibrous
tissue barrier against the infectious process which
r
774
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
limits the destructive process to a small area, the
white matter is far more fragile and it would ap-
pear that the farther away the white matter is from
the cortex, the easier it is destroyed by the in-
fectious process. A cerebral abscess may open
either into the ventricles or into the subarachnoid
space, thus resulting in a fatal meningitis. Drain-
age of these pus collections is a difiicult matter and
the drain should be left in situ until recovery of
the patient is complete.
Cerebral hernia is the result of infection of the
brain and underneath it, in the subjacent tissues,
will be found either a localized abscess, a septic
softening of the cerebral substance, or a foreign
body, either a bone splinter or a bit of missile. The
application of alcohol to the hernial surface and
compression are quite useless, while excision of
the hernial mass is dangerous, because it exposes
the patient to meningitis, not to say permanent
functional deficiency.
Intravenous injections of antiseptics have been
found useful and Ballance has used for this pur-
pose ten c. c. of a I iiooo mercuric bichloride, eusol
(hypochlorite and boric acid) solution, loo to 200
c. c. in a saline medium, as well as diiodosalicylic
acid in doses of five c. c. Various vaccines and
sera should likewise be essayed. The Italian sur-
geon, De Sarlo, has performed seventy-seven crani-
ectomies at the front ; he advises an exploratory
operation in all cases of cranial wounds, even if
the wound in the scalp is to all appearances slight
and although no serious cerebral disturbance is
manifested. If upon exploration bone or endocra-
nial lesions are discovered, the interference should
consist of an atypical craniectomy, whose essential
object is to obtain a careful and complete cleansing
of the parts involved with the aim of preventing the
ultimate development of meningoencephalic infec-
tion. Such procedures belong in the class of urgent
surgery at the front, and all cases should be given
the benefit of the operation as soon as possible,
because it is absolutely essential that the injured man
shall not be subjected to the dangers of transporta-
tion to a base hospital. The divergence of opinion
between English, French and Italian operatives is
still great ; the two latter surgeons with quite as
much experience in brain work as Ballance or
Gushing advise immediate operation at the front.
DEAFNESS FOLLOWING TRAUMA.
The causes of deafness following wounds of
warfare are of two sorts: t, A piece of bursting
shell or shrapnel shot or bullet hits the skull at some
spot more or less distant from the ear without
causing any direct lesion of the brain due to de-
pressed fracture. More or less generalized head-
ache ensues with tinnitus aurium, slight loss of
memory, decrease in audition and slight tremor of
the limbs, all being symptoms common to a more
or less violent blow on the skull. 2, A large
calibre shell explodes in the neighborhood where
the soldier is standing at a distance, say, of one to
four yards. No apparent wound can be dis-
covered, but the symptoms above- mentioned de-
velop and to a more marked degree. There is
loss of consciousness varying from a few hours to
several days, and violent frontal headache which
may persist for several months. Tinnitus aurium
is very marked but slowly subsides. There is also
a complete loss of memory and an absolute or al-
most absolute loss of hearing although occasion-
ally, the patient hears but does not understand.
Tremor is pronounced especially in the upper limbs,
while some patients often are deaf and mute. All
these are symptoms of severe cerebral commotion.
Lesions giving rise to deafness are of two kinds:
I, Lesions of the middle ear, with depression,
laceration and hemorrhage of the tympanum, often
with a resultant suppurating otitis media which
runs its course in about three weeks, or on the
other hand, continues for months, finally ending in
classic otorrhea. 2, In the second class, there are
no apparent lesions and these are the most serious
cases, because they offer severer symptoms and it is
assumed that they are due to labyrinthine or cere-
bral commotion.
The lesions of the auditive centres are the re-
sult either of direct blows on the skull or sudden
atmospheric displacement. They are visible if they
involve the middle ear and occult when they in-
volve the nervous centres, and in the latter case,
the curves of auditive acuity are the same as those
of deaf dumbness, a fact which gives a clue to the
probable cause of the latter process.
The question of treatment of these hypoacousias,
is outlined by Doctor Marage, in his excellent little
work entitled : Reeducation auditive des surdites
conscqutives a des hlessurcs de guerre (Paris:
Vigot Freres, 191 5.)
The selection and choice of patients in France
depend entirely on the surgeons of the military
hospitals, who send their deaf patients to the oto-
logical service of the region, which examines them
and then, in turn, refers them to Doctor Marage's
special service. Doctor Marage accepted all cases,
no matter what degree of deafness they offered,
eliminating only those patients who were unable to
follow the treatment on account of a bilateral sup-
purating otitis media. The patients are first ex-
amined both from the medical and otological stand-
points, that is to say after making the clinical diag-
nosis the degree of auditive acuity and the type
deafness is determined with a special instrument'
devised by Marage, called a sirene a voyclles. The
most careful account is taken of the cerebral con-
dition, tinnitus aurium, vertigo, headache, loss of
memory, tremor, disturbances of sleep and sight,
and these data once obtained are noted on a special
card, with the nature of the treatment, which not
only varies with each patient, but is also changed
from day to day according to the daily condition.
In point of fact, these subjects are very sensitive
to the slightest variation in temperature or humid-
ity. For example, an attack of influenza of mild
degree is quite enough to awaken an otitis media
from its latent state, resulting in renewed dis-
charges which must be treated immediately. Au-
ditive reeducation is an exclusively medical proposi-
tion and if not carried out directly under the super-
vision of the physician it will be unsuccessful.
There are three sorts of deafness: i. Patients
presenting only lesions of the middle ear, ten per
November 2, igiS.l
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
775
cent. ; 2, patients with cerebral commotion, without
apparent lesions, thirty-eight per cent., and 3,
patients presenting both lesions of the middle ear
and symptoms of cerebral commotion, fifty-two per
cent. Auditive reeducation has been carried on by
Doctor Marage with only his sirene d voyellcs. For
five minutes each day sound vibrations are made
to act on the tympanum. Atmospheric pressure in
the apparatus rarely attains five mm. of water,
but it should be remembered that even a very deaf
subject is frequently very sensitive to the weakest
sounds.
Since we are in a state of war, he considers that
a successful treatment is attained when a patient
hears well enough to be able to rejoin his regiment.
Sixty-eight per cent., i. e., more than two-thirds of
the subiects, were able to return to the front and
almost fifty per cent, of these subjects were very
deaf, some even being regarded as incurable. The
latter can be divided into two categories: some,
ten per cent., have remained absolutely deaf, the
others, twenty-two per cent., can hear when spoken
to directly into the ear and they can therefore be
employed in certain auxiliary services.
HOSPITAL ORGANIZATION IN FRANCE.
Elizabeth Frazer tells in a most interesting man-
ner of the hospital organization on the western
battle front in the Saturday Evening Post for Octo-
ber 5th. Her very sympathetic narrative includes
a description of the methods first followed and of
the modifications which were made necessary by the
more intimate intermingling of the troops of dif-
ferent nations after General Foch took supreme
comm.and :
One of the most distinctive features of the old
regime was the hospitalization system. Here as
elsewhere each nation carried on in its own fashion.
The British evolved one type of organization ; the
French another ; the Americans a third ; so that
there existed side by side three separate networks of
systems, each elaborate, ramified, complete, which
never touched each other. In the British sector, for
example, the seriously wounded are evacuated as
rapidly as possible back to England, where are
situated most of their big base hospitals. In the
French system the evacuation hospitals are dotted
all along the sector a few miles behind the firing
line, with their large base and convalescent hospitals
scattered throughout the interior, in the Midi or
down on the Riviera, far from the rude northern
v>^inds. And when the Americans were assigned
their sector in Lorraine they organized their system
along similar lines.
First come the evacuation hospitals, as close up
behind the Front as possible, in order to catch the
wounded man within two, three, or four hours of
the time he falls on the field. Here he is operated
upon without delay, rendered fit for transportation,
and then shipped to some big base farther back in
the rear. As the hospital formation recedes from
the advance zone of the army, and therefore from
acute danger and unstable tenure arising from like-
lihood of capture, shelling and bombing raids, the
bases grow in size and elaboration, until at some
points they are vast beehives, conmiunity centres
with a capacity of ten to twenty thousand beds. Be-
tween the two extremes of the formation, the evac-
uation hospitals just behind that invisible and most
uncertain quantity called the front line and the big
solid base situated some hundreds of kilometres
away — between these two types there exists the
greatest difference.
The base, as its name impHes, is solid, immobile,
permanent, steady as the Rock of Gilbraltar or the
skyscrapers of New York. The evacuation hos-
pital, on the contrary, creeping up as close as pos-
sible behind the fighting forces, is light, mobile, sup-
ple, easy to move, consisting largely of tents, stuff
that can be loaded swiftly on trucks and motor lor-
ries and carried away. If during a big push the
line begins to sway perilously, to strain, to crack,
with breaches showing here and there, and the order
comes to retire, the evacuation hospital can fold its
tents like the Arabs and silently steal away, not ,
on camels but their modern substitutes, camions,
with the orderlies on the rear truck, thumb to nose,
wagging derisive fingers at the oncoming boche,
who if he does break through will find — just noth-
ing at all.
That is one difference between evacuation and base
hospitals. And there are others. The bases do good
straight honest and honorable surgical and medical
work of the type that is known in America. They
have a fine regime, and this regime is rarely over-
turned. They are, therefore, prosaic. But an eva-
cuation hospital is dramatic, picturesque, full of
potentialities and surprises, with tragedy, comedy
and broad farce competing for first place every hour
in the day.
Here during a big offensive, when Allied and
enemv wounded are pouring in in a continuous
stream, surgeons, nurses, and personnel work like
fiends under a tremendous pressure, twelve, twenty-
four, even forty-eight hours at a stretch. Here are
to be witnessed in the operating room running fights
with death as tense and thrilling as anything upon
the battlefield. Sometimes the wounded m.an is ex-
actly upon the great divide, hovering between life
and death, an extra hair's weight capable of sending
him to either side ; shrapnel in his chest, his lungs
full of blood, breathing like a trumpeter, suffering
from shock, exhaustion, lack of food — and still able
to smile up into the surgeon's eyes and say faintly:
"I'm all right, sir. Take that other poor gviy. He's
worse off than me."
In cases like these, three minutes more or less in
the length of the operation spells all the difference
between time and eternity. The surgical team works
with the perfect union of a football eleven. In their
white aprons, caps, and masks they look like priests
performing a rite. The sweat stands out on their
foreheads. Their expert fingers move like light-
ning, yet precise, unhurried, sure.
In an operation of this kind, with life and death
in the saddle and both riding hard, I have seen the
assistant hold a watch on the operating team, as if
it were a horse race, and call aloud the minutes,
thus : ''Three ! Five ! Seven ! Ten !" Two min-
utes too long, and the patient may expire on the
776
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
table, or die of pneumonia from the added strain of
ether on the lungs. Here margins are short and
time more precious than the weight of irort in
rubies.
Here also is to be seen what is known as the new
war surgery. The wounded men are x rayed before
entering the operating room, and the exact position
of the foreign body indicated by an indelible cross
on the patient's skin. Consequently the surgeons
need not go delving and exploring and guessing all
over the landscape, but make a clean straight dive
for the intruder. As the greatest danger in all these
wounds is that of infection from the gas gangrene
germ, which infests the soil of France and therefore
every particle of the soldier's clothes, and as in addi-
tion the wounded are often forced to lie twelve,
twenty-four or even thirty-six hours on the field on
account of a violent enemy barrage, these wounds
are often badly infected by this germ before ever
they reach the evacuation hospital, near as that may
- be. In order, then, to prevent the further spread
of the poison throughout the body the wound is laid
wide open, the crushed and torn tissues shorn clean
away, and a big clean wound created. This is thor-
oughly cleansed, packed with gauze soaked in Carrel
solution, after which the entire area is wrapped in
compresses, solidly bandaged, strapped or splinted —
and the patient is ready to be shipped a hundred
miles.
From this it will be seen that it is at the outset
of the game, after the man is first wounded, that
the time element is most precious. Upon the speed
with wliich an ambulance can deliver a soldier to
the nearest evacuation hospital, divest him of his
dirty, infected clothes and lay him on the Hfe-saving
operating table depends largely the speed of his re-
covery and return to the lines. Delays there are
bound to be — violent shelling of trenches, back
areas or crossroads, which may block every form
of transportation for hours. And it is to counteract
these unavoidable delays that evacuation hospitals
are creeping closer and closer up to the Front, risk-
ing bombardment and air raids in order to save a
greater percentage of life and limb.
Behind these hospitals, then, stand the big solid
bases, imposing, safe, and sane. In front of them is
still another formation. Briefly, it is something like
this : A soldier is wounded on the field, in the
trenches, in a wood. If alone, he applies his own
first aid. If he has given it away to a comrade, he
uses his belt for a tourniquet, his bootlaces — any-
thing. If he cannot get at his wound or if he is
knocked unconscious, he lies until he is picked up
by friend or foe. If he is not picked up he "goes
West." joining the great host of immortal comrades,
and ail is well. That is the first step, where each in-
dividual attends to himself, is attended to by others,
or is lost.
The second step consists of getting him to a dress-
ing station, usually in some abri, where he is band-
aged, given a hot drink, an injection of antitetanus
serum., and an iodine cross is marked on his fore-
head to indicate that he has received the same. If
he is suffering acutely he is in addition given
a morphia tablet. After this he is transported by
ambulance to the divisional field hospital, where if
he is in good condition he is not even unloaded but
sent straight on to the evacuation hospital a few
miles farther back. Thus he receives personal, regi-
mental, and divisional first aid before ever he strikes
the evacuation hospital.
All of which, if he is lucky, he may get inside of
two or three hours, and be safely tucked away in
his cot coming out from under ether, raving not of
home and mother but of going over the top, shout-
ing in stentorian accents : "Shoot 'em to hell, boys !
The dirty skunks ! Shoot 'em to hell !" to the in-
finite delight of his comrades in the tent ward, who
cheer him on : "That's the stuf¥, buddy ! Atta-boy !
Eat 'em alive !"
Finally, after much batting of wobbly eyelids, he
opens his eyes feebly upon the white-capped nurse
at the foot of the bed and murmurs in weak flat
tones of pleasure : "Well, hello, chicken ! How'd
you ever git here ? Gosh ! That's a foul taste in my
mouth. Say, can a guy spit in this place?" And if
he has come through thus far alive the chances are
he will stick. He is the stuff that survives.
This sketches in the large the hospital formation
that the American Army built to care for its
wounded behind the Lorraine sector under the old
regime. All of the units, the string of evacuation
hospitals, base hospitals, and transportation facili-
ties were designed and constructed on the principle
of Am.erica's holding that particular sector.
MEDICAL NEWS FROM WASHINGTON.
Acquisition of Surgical Instruments. — Activities in Medi-
cal Department of Navy. — Addition to Naval Hospital
at Washington. — Progress of Reconstruction Work in
Army. — Appointment of Additional Dental Officers.
Washington, D. C, October 28, igi8.
In view of the fact that foreign sources have
been largely shut off, the army medical officers
who have to do v/ith the acquisition of surgical in-
struments have been obliged to overcome many
unexpected obstacles and to create sources of sup-
ply that have not existed hitherto.
In obtaining some instruments it was necessary
to go to the dropforging people and get them to
make dies, while the rough forgings were furnished
to all sorts of finishers. It became necessary, for
example, in obtaining bone drills, to develop a sup-
ply from the people that make drills for other pur-
poses. One of the sewing machine companies con-
verted its plant temporarily for the manufacture
of surgical needles, up to that time unobtainable in
this country.
Destruction and loss of surgical instruments
abroad, such as the individual instruments that
everv medical officer carries with him, is beyond
the estimate originally made. The wastage has
het-n enormous, nnd during the month of September
It was necessary 10 send to France no less than fifty-
five tons of instruments. This is partly due to the
demand made by a change in the hospitalization
svstem — instead of a small number of large cen-
tres, it was found necessary to establish smaller
hospitals, many of them in villages, resulting in a
dissipation of material and equipment.
MEDICINE AND SURGERY IN
November 2, iQiS.)
The forthcoming annual report of the Surgeon
General of the Navy will contain an interesting ac-
count of the various enterprises in which the medi-
cal department under him has been engaged in con-
nection with the war.
The subject of gas warfare, the use of masks,
the neutralization of poisonous gases, and the treat-
ment of the gassed have been fully mastered. The
ventilation of submarines and the food appropri-
ate to men serving in them, have been investigated
and improved. Antiflash clothing has been devised
to minimize the dangers from liquid fire, burning
gunpowder, and explosives.
Traveling laboratories have been organized at
the naval medical school, and on telegraphic request
their units, fully equipped, can proceed to the scene
of an epidemic where personnel is overworked or
facilities for bacteriological work are limited.
The medical departments of the vessels of the
fleet are fully prepared for the hazards of battle.
The battle dressing stations, located behind armor
and equipped with hot and cold water, electric
sterilizers, operating tables, and ample supplies of
surgical dressings, manned by skilled and devoted
physicians and attendants, are ready.
Careful study has been made Of all problems
connected with the food and clothing of the men.
Epidemic diseases have been investigated, both as
regards prevention and treatment, and elaborate
statistics have been tabulated. Instruction in all
these topics has been given, as required, to doctors
and nurses, and the personnel of the medical de-
partment has been kept fully abreast of scientific
advancement through quarterly and weekly publi-
cations, which embody our findings and all that can
be observed by our representatives abroad or
learned from current foreign literature.
*****
An addition to the naval hospital at Washington,
to furnish accommodations for 300 beds, which
was started about three weeks ago, is about com-
pleted. A heating plant is included in this plan.
The structure, which is of wood covered with
stucco, consists of three separate wings, contain-
ing six wards in all, two stories in height. It is
built to meet the growing demands for naval hos-
pital facilities at Washington. The permanent hos-
pital buildings had become inadequate, and with
the epidemic of influenza in Washington the hos-
pital situation had become very serious. The navy
had drawn upon the various civil hospitals for its
overflow of sick, but these institutions were badly
overcrowded in caring for the civil population.
if: ^ 5(!
The reconstruction division of the Office of the
Surgeon General of the Army has returned to
active duty abroad more than two hundred men
sent home from the American expeditionarv force
as hopeless cases. It has restored to limited mili-
tary service many hundreds of men supposed to be
of no military value when they were ordered back
from France or England. These men have been
formed into battalions singled out for special
duties for which they have been developed in their
hospital restoration. Thousands more are under
THE ARMY AND NAVY. 777
treatment for further usefulness in the war and in
civil employments after the war.
Medical officers at the base hospitals are laying
the foundation for the later rehabilitation of the
wounded, the sick, and those suffering from ner-
vous disturbances. In this way they are preparing
the patients that cannot be restored to active duty
for the care to come later by the War Risk Insur-
ance Bureau and the Federal Board for Vocational
Training, which will take up the training and make
it continuous after the reconstruction division de-
termines that the time has come when it is safe for
it to turn them over to the former for ultimate care
or to the latter to continue vocational training for
their economic support.
The results show that more than eighty per cent,
of those passing into the base hospitals sooner or
later filter back into the service either as full serv-
ice or limited service men, and of the others ten
to fifteen per cent, are discharged to the Federal
Board for Vocational Training, leaving only about
five per cent, ending fatally.
Upon the recommendation of Colonel William
H. G. Logan, Medical Corps, head of the dental
section of the Surgeon General's Office, a policy to
govern the appointment of additional dental officers
needed as a result of the recent increase in the
allowance of such officers and increase in the mili-
tary forces has been formulated.
By orders recently issued, the allowance of den-
tal officers in the army was increased in the United
States to one for every 500 men, three for each
camp hospital, and three per 1,000 for each general
hospital. The allowance for the forces overseas
was also increased, the new allowance amounting
approximately to one for every 500 of the total
strength of the army.
Under the new, schedule, a total of some ten thou-
sand dental officers will be needed by July i, 1919,
or about thirty-five hundred more than now are on
active duty or temporarily commissioned in the
Dental Corps and still in an inactive status.
The regulations that will govern the new ap-
pointments are based on the premises that those
dentists that are in. or will be taken, as a result of
the draft, into the enlisted grades of the military
service should first be given an opportunity to
qualify for commissions in the Dental Corps.
Therefore, opportunity for commissions will be
confined to those dentists who now are serving in
the enlisted grades and to those that may come in
through the draft later. If the vacancies are not
all filled from these classes, then dentists within the
draft ages and rated in Class lA and not then called
to service, and those between forty-six and fifty-five
years of age, will be given opportunity to take the
examination for appointment.
There are now about seventy vacancies in the
permanent Dental Corps of the Army. Candidates,
will be examined, commencing November 4th, by
boards that have been ordered to convene at Fort
Slocum, N. Y. ; Camp Meade, Md. ; Fort Ogle-
thorpe, Ga. ; Camp Lee, Va. ; Columbus Barracks,
Ohio; Fort Sam Houston, Tex.; Camp Funston,
Kans., and Letterman General Hospital, San Fran-
cisco.
Editorial Notes and Comments
NEW YORK. MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITHIELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT FUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
pest office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, NOVEMBER 2, 1918.
PUBLISHERS' ANNOUNCEMENT.
To our great regret our second Special 'Influenza
Ntimber, which should have appeared on October
26th, was delayed through a printers' strike. The
strike began with the press feeders and involved
practically all of the printing offices in Greater New
York. In view of the important character of the
information contained in that number bearing upon
the treatment of influenza, every efifort was made
to prevent any delay in its printing and distribution.
On advising the Surgeon General of the United
States Army of the circumstances, that cfificial sent
the following telegram to the feeders' union, which
had dictated the strike.
Washington, D. C, October 25, 1918.
"Am advised on account of printers' strike
New York Medical Journal cannot be pub-
lished. Contains important articles concerning
influenza epidemic. Request everything possi-
ble be done to ensure the publication on time."
As a result of this telegram, the union agreed to
make an exception in favor of the New York
Medical Journal and to allow its members to aid
m the printing of that particular issue. But for this
action on the part of the Surgeon General and of the
union in complying with his request there would
have been still further delay. The matter of the
strike was taken up by the War Trade Board, and
former President William H. Taft, accompanied by
other members of the board, came to New York and
at this time is engaged in a hearing concerning the
final settlement of the strike.
It is confidently anticipated that the matter will be
settled during the week, but even if it is definitely
settled the accumulation of publication work caused
by the idleness of the presses for more than a week
will probably entail some delay in the issuance of
the current number. W^e must beg the indulgence
of our readers for any such delay, which is unavoid-
able so far as the publishers are concerned.
A. R. Elliott Publishing Company.
INFLUENZA THERAPEUTICS IN
HISTORY.
Probably nothing serves so well to add emphasis
to the warning of the great fathers of medicine,
that the first duty of the physician is expressed in
the Latin phrase, non nocere — to be sure to do no
harm — as the history of therapeutics for influenza.
In the last epidemic in the early '90's, the coal tar
drugs were very largely used and undoubtedly did
an immense amount of harm. There is no doubt
that they reduced the fever, lessened the pain and
made the patient feel ever so much more comfort-
able, but their action is intensely depressing, and
one of the most serious effects of the disease it-
self is depression. The excessive use of depressants
added to the death rate of that epidemic. The
lessening of pain was undoubtedly a benefit to the
patient, but the reduction of the fever in this crude
chemical way was more than dubious. The ques-
tion is still open as to whether fever is not a con-
servative reaction on the part of nature to help in
the increased tissue metabolism that will add to
vital resistance and overcome bacterial invasion.
The preceding epidemics in the nineteenth cen-
tury Vv'ere treated by venesection and the free use
of whiskey or some other form of strong alcoholic
November 2, 1918.]
EDITORIAL ARTICLES.
779
stimulant. The venesection was undoubtedly weak-
ening and yet there always remained the possibility
that the removal of a considerable quantity of toxic
material in the blood, thus taken away, may have,
at least in vigorous persons, given nature a fresh
start on the road to the production of such reac-
tion as would eventually overcome the disease. Too
many good clinical observers for centuries saw al-
most immediate good effects from bleeding for us
to think that it was always a mistake. Too many
physicians in our time have seen tossing, restless,
strong pneumonia patients, at the height of their
fever, quieted by bleeding, to permit us to stamp
it is just an old fashioned error.
As for whiskey, its good effect is now well un-
derstood and it has been used with some very sat-
isfactory results, even in this epidemic. It is not,
as we used to think, a stimulant, but on the con-
trary, it is narcotic and perhaps slightly depres-
.-ant, but it is its narcotic effect that makes it valu-
able. We have heard so much about the fatality
of pneumonia in our time that most people, after
contracting the disease and realizing it, are very
seriously scared. y\s a rule they are thoroughly
conscious and they watch themselves breathe some
forty times a minute and note the solicitous looks
of friends and are likely to become miUch disturbed.
This may gravely interfere with their resistive vi-
tality and power to throw off the disease and some-
thing must be done to relieve their mental anxiety
and, above all, keep them from interfering with
their heart action by depression. A certain amount
of whiskey will do this easier and probably better,
and with less risk, than almost anything else, so
that it becomes easy to understand the popularity
of whiskey in the nineteenth century epidemics.
In the eighteenth century epidemics, calomel and
antimony were the favorite drugs, though in certain
of them tar water was looked upon as almost a
specific. Calomel and antimony were very largely
administered on the unfortunate general principle
that when a physician is summoned he must pre-
scribe something, though of course the elimination
of toxic materials through the intestines was
thought to be very desirable ; and undoulitedly the
removal of offending material of any kind from be-
low the diaphragm, so that there shall be no hamp-
ering of lung activity from there, must always be a
desideratum. Tar water was, howev'^er, entirely
another thing, popular much more among the "in-
tellectuals" who thought they knew everything, in-
cluding medicine, than men who were in any sense
scientific physicians. It was used very largely by
the profession generally, who thought that they savv^
some wonderfully good results from it. Of course,
it was practically water, with an odor of tar in it,
and therefore must have done very little harm. It
was made by stirring a gallon of water v/ith a quart
of tar, allowing it to stand forty-eight hours, and
pouring off the clear water. It was taken very
freely and Bishop Berkeley, the English philosopher,
particularly was its advocate and proclaimed it of
the greatest service. He went through an epidemic of
what was probably influenza and felt that it had
been a life saving remedy. He said, "I have had all
this confirmed by my own experience in the late
sickly season of the year 1741, having had twenty-
five fevers in my own family" (they had larger
families in those days and this num.ber includes
three generations) "cured by this medicinal water,
drunk copiously."
The good bishop had his experience, doubtless,
when the epidemic was waning, and when the great
majority of those attacked were improving, but he
was quite sure that the reason why his folk did not
die as did so many others of those attacked at the
beginning of the epidemic was because tar water
was used. The value of the whole story is in not
jumping to hasty conclusions in therapeutics and
being sure not to do any harm, for it would be in-
deed too bad if we were to have to go through this
epidemic without being able to gather from our ex-
perience with it something that will be of value for
the future. We cannot but commend the thor-
oughly conservative attitude of the United States
Public Health Service with regard to the various
remedies that have been recommended. There is
much more likelihood that jumping to conclusions in
the midst of an epidemic shall prove wrong rather
than right and much more than a possibility that
biological remedies of various kinds, except when
employed under the most rigid control, may do ever
so much more harm than good. History still re-
mains a precious resource, as a warning at least, in
such matters.
TREATMENT OF HYPERTROPHY OF
THE THYMUS.
The latent forms of hypertrophy of the thymus
gland which do not give rise to accidents of com-
pression and which are only recognized by ob-
jective signs (percussion, radioscopy) are most
frequently the result of tuberculosis and espe-
cially syphilis, as Marfan has pointed out. In
these instances medical treatment is alone indi-
cated.
Such, however, is not the case in the forms of
this morbid process which provoke accidents of
compression, such as cyanosis and suft'ocation.
They require energetic treatment, particularly
EDITORIAL ARTICLES.
[New York
Medical Journal.
with radiotherapy. Surgical interference is dan-
gerous and has been rejected by some of the best
French operators since Weill communicated his
results with radiotherapy in several cases of hy-
pertrophy of the gland.
In extremely urgent~cases intubation with a
long tube is to be done at once, and immediately
afterwards an intensive seance of radiotherapy
should be held. By these measures one may ex-
pect to see good ef¥ects follow within forty-eight
hours after their application. That these results
are no myth is evident from the consideraWe
number of radiologists who have had only suc-
cessful results to register.
The treatment of the early operators was man-
ifestly insufficient, and it was not until Regaud
and Cremieu had shown a better procedure that
the good results began to be recorded. The re-
sults of their researches led these two writers to
propose, in serious cases, to give a single dose of
X rays, giving the tint No. 3 to the skin, meas-
ured by Bardier's chromoradiometer, read by
daylight after interposition of an aluminium filter
four millimetres thick — in other words, a dose
corresponding to si.xteen H units ; and they rec-
ommended that twenty days later a second, but
weaker, irradiation was to be given, should indi-
cations require it. In milder cases of the process
they proposed a less severe dose, but they per-
sonally preferred the intensive method.
A less severe treatment has been recently pro-
posed by Weill, of Lyons, who states that the
dose of X rays should not exceed three to seven H
units, through an aluminium filter one to two
millimetres thick, and that this will suffice to
bring about a regressive process in the gland and
an ultimate cure. At present Weill employs four
millimetre aluminium filters in order to eliminate
all the ravs which may have a deleterious action
on the skin, but which after filtration do not ex-
ceed five to seven H units.
For these applications the anode is kept at
fifteen centimetres from the skin and the filter
at 7.5 centimetres. The rays should be directed
on the anterior and posterior areas corresponding
to the thymus. MuUer's or Chabaud's tubes are
used. The intensity of the Muller tube is 1.5
milliampere, that of the Chabaud from seven to
.8 milliamperes.
In order not to immobilize the children too
long, fractional dbses of the rays may be given,
and it is only in cases of thymic asthma with re-
peated subintrant paroxysms that very strong
doses, for example, sixteen H units, with a four
millimetre filter, should be employed.
WHY THE CHIROPODIST?
The chiropodist flourishes in the land, and
flourishes in numbers, for in some cities there are
as many as one to twenty-five hundred people.
Considering how few of the population can afford
to have corns treated, this is a large percentage
of specialists. For the same number of people
there will be, perhaps, two or three dermatolo-
gists and one or two orthopedic surgeons. The
chiropodist combines these two branches of med-
icine and besides limits his practice to the feet.
Every skin specialist knows something of ortho-
pedics and every orthopedist has studied skin dis-
eases more or less. Yet a dozen or more chiropo-
dists exist and flourish where there is one doctor of
medicine who devotes his time to diseases of the
skin and to deformities of the bones and joints.
Moreover, every doctor of medicine is presuma-
bly better trained in both these subjects than the
chiropodist, and yet the chiropodist gets the
practice in this line. The chiropodist is not more
or less a human than is the doctor of medicine,
and the latter is not one whit less anxious for the
almighty dollar. Why does the latter miss all
these good fees? They are often larger than the
general practitioner of medicine receives for his
services. It is certainly not because he does not
want the money ; neither is it because it is a
lowly and disagreeable task to treat the feet.
Compared with genitourinary work it is an ex-
alted and delightful practice.
Is it because the patient considers the physi-
cian a too exalted personage to doctor feet? We
are getting warmer in our search. There is some
clue here, but if so, it is the physician's fault if
the patient has such a notion. His highness, the
man of medicine, has too frequently handed the
owners of sore feet a prescription, and that was
the end of it. The patient w^as not cured by the
medicine, but went to a chiropodist who did cure
him. This has been so often the case that it is no
wonder people refuse to bring their feet to the
physician's attention, considering them as either
too busy or — whisper it — too incompetent. Then
there is the surgeon, and we know of one in-
stance, who, for the sake of a fee, secured a nurse,
anesthetized his patient, and removed a wart by
■'operation." The good chiropodist would have
removed it for one tenth the cost, with less risk
and distress.
There have been "corn cutters" from away
back, and since 1785 they have become chiropo-
dists. Until recently they have "picked up" their
accomplishment, but of late they are establishing
schools of their own. They have organized in
November 2, igiS.l
EDITORIAL ARTICLES.
781
local, state, and national societies. They have in
three states brought about legislation,, so that a
chiropodist must at least have a certain degree of
schooling and must pass an examination. The
corn cutters are coming along and the doctors of
medicine should take notice.
The graduate of a four or more years' cour.'^e
in medicine ought to be more skillful in caring
for the feet than a chiropodist, though practical
evidence seems to be against this statement.
There are two things which must be done to
make this theory true. In the first place, the med-
ical schools must pay more attention, both in
theoretical and in clinical teaching, to corns, cal-
losities, and deformities of the feet. They may
seem too common, but they are of almighty im-
portance to their possessor. In the second place,
the practitioner must give corns, callosities, and
deformities of the feet the care and attention they
deserve.
It will pay to study these things, for here is a
field of practice that is not likely to shrink. Ty-
phoid and malaria are passing, but corns we shall
have with us always, for the reason that ill fit-
ting shoes are likely to be worn, despite all
preaching of hygienists. The future of chiropody
is assured, for it has Dame Fashion always as a
helper.
THE INFLUENZA SITUATION.
From almost every section, there comes news of
a decline in the number of new cases of influenza
reported. The number of deaths has increased as
a result of the pneumonia following the disease, but
the falling off in the number of new cases indicates
that the apex of the epidemic has probably been
reached. If the decline continues, the city of New
York will have escaped with relatively much less
loss than most of the larger cities on the Atlantic
seaboard but it is too soon as yet to make any defi-
nite statement on this head. The situation in the
military camps is very much better and in most of
the camps the internal quarantine has been lifted
though the pubHc is still barred, except from .the
few camps that have suffered least. The nursing
situation everywhere still continues unsatisfactory,
the number of nurses available being inadequate.
The disease has taken terrible toll from the medical
profession. Ordinarily we have notices of about
twelve deaths in the medical profession and the
majority of these are of men of mature years. In
our last issue we recorded sixty deaths, and in this
fifty-one, a majority being physicians under forty.
Various preventive vaccines are being tried. In
Massachusetts and in New York, a vaccine made
from the influenza bacillus by Leary and Park, re-
spectively is being used. In Chicago a mixed vac-
cine of pneumococci, streptococci, staphylococci, and
influenza bacilli is being tried. Several commercial
mixed vaccines :>re also being used. The Surgeon
General of the United States Public Health Service
is watching the results but has not arrived at any
conclusion regarding their value.
GOOD NEWS FROM FRANCE.
The new Surgeon General of the United States
Army, Major General Merritte W. Ireland, brings
back the most encouraging news as to the medical
and surgical aspects of the work of the American
Expeditionary Forces of which he has been chief
surgeon. While there have been many cases of in-
fluenza, they have been mild and have rarely been
followed by pneumonia. The out-of-door life and
the vigorous condition of the troops seem to have
protected them from the disease, to a great extent.
The sick list runs about forty-three to a thousand
and about twenty, or a httle less than half, are sick,
the remainder being wounded. Since this includes the
influenza and pneumonia cases as well as those
suffering from other diseases, it will be easily seen
that there is relatively very little influenza and
pneumonia among the troops. The Surgeon Gen-
eral has only the highest praise for the surgeons,
the nurses, and the combatant forces of America.
"No army of any nation in the world has ever had
better doctors and surgeons in its personnel than
have the American Expeditionary Forces over-
seas," said General Ireland. In this connection, he
also said : "Too much cannot be said of the women
doctors and nurses doing their work of self sacri-
fice among the wounded. They are of the highest
standard and the people should understand that
they must be of high standard because of the sac-
rifices they must endure. One of the things which
most impressed me was the arrival of fresh con-
tingents of American soldiers from the United
States. These men, every one of them, the draft
men as well as the regulars, when they set their
feet on French soil seem to lose all thought of sel-
fishness. They all expressed themselves as having
come over there to win the war and lost all sight
of their individuality. The morale among these
men was fine. The wounded never complain, and
everybody is optimistic. We have the finest body
of men in France that ever lived anywhere."
Obituary
ROBERT COLEMAN KEMP, M. D.,
of New York.
Dr. Robert Coleman Kemp died of pneumonia
on October 23, 1918. He was born in 1865 and
was a graduate of Columbia University, receiving
his medical degree in 1889. After an internship
at Roosevelt Hospital, he was associated with Dr.
W. Hanna Thomson for a number of years and
carried on a series of physiological researches in
shock. Of late years, he has had a large practice
in his specialty of gastroenterology and had just
completed the second edition of his textbook.
782
NEWS ITEMS.
[New York
Medical Journal.
News Items.
General Kean Becomes Deputy Surgeon General. —
Brigadier General jet'terson R. Kean, M. C, U. S. Army,
was, before we entered the war, chief medical officer of
the American Red Cross. He went to France in that
capacity, and after General Pershing arrived in France,
WHS made assistant chief surgeon of the American Expe-
ditionary Forces. He returned to the United States with
General Ireland on October 28th, and has been appointed
deputy surgeon general.
Public Health Service Reserve. — A resolution has
been passed by tr.e Senate providing for the establishment
of a leserve for duty in the Public Health Service in times
ot national emergency, under rules and regulations pre-
scribed by the President, who alone will be authorized to
appoint and commission officers in the reserve. Officers
commissioned in this reserve shall have no rank above that
oi surgeon and shall be distributed in the several grades
in the same proportion as now obtains among the commis-
sioned medical otilicers of the United States Public Health
Service, and shall at all times be subject to call to active
duty by the surgeon general. When on active duty they
will receive the same pay and allowances as are now pro-
vided for commissioned medical officers.
The Surgeon General Returns from Europe. — Major
General Merritte W. Ireland, who has been acting as chief
surgeon of the American Expeditionary Forces and who
was appointed surgeon general to succeed General Gorgas,
who retired on October 3d, returned to the United States
on October 28th and assumed command of the Medical
Department. General Gorgas is still in France, where he
went some time before the date of his retirement, and has
been assigned to special duty in connection with the
American Expeditionary Forces. Brigadier General
Charles Richard, who has been acting surgeon general ever
since the departure of General Gorgas, retires for a^e on
November loth. In point of length cf service, he is the
ranking oflicer on the active list in the Medical Depart-
ment.
Loss to the Army from Venereal Disease. — From the
beginning of the war to September of this year venereal
disease lost for the United States Army 2,300,000 working
days. This statement is made by Lieutenant Colonel
William F. Snow, head of the Social Hygiene Division of
the War Department Commission on Training Camp Ac-
tivities. The loss, figured in another way, amounted to
the total incapacity of 6,300 soldiers for an entire year.
Army statistics indicate that each case of gonorrhea means
a loss to the army of a soldier's services for 9.53 days.
The total loss from this disease was 1,486,680 days. For
each case of syphilis a loss of one soldier's time for 20.75
Jays is figured — a total loss of 550,250 days having been
cliaiged against this disease. Each case of chancroid re-
sults in a loss of 11.69 days, and the total loss from this
cause was 258,230 days. It is estimated that five sixths of
this burden was brought into the army by men already in-
fected at the time they first arrived at camp.
Influenza in the Navy. — Reports from the naval dis-
tricts in the east indicate that the spread of influenza in
the naval personnel in that section has been checked, and
only the stations on the western coast continue to show
any increase in the number of cases. In many of the east-
ern stations the disease has receded to normal. In the
southern stations there has been far less virulence than in
the north and east. Conditions in the fleet are considered
satisfactory, and generally throughout the naval service
the epidem.ic is well under control. The cases of pneu-
monia continue, however, with about the same percentage
of fatalities. The epidemic apparently has run its course
in most units of the navy, but an outbreak may still occur
among the personnel that so far has not been exposed.
Other than influenza and its attendant diseases, the health
of the navy ashore continues to be satisfactory. Only
seventeen cases of spinal meningitis were reported last
week — part of these being presumably the result of the
epidemic of influenza, and four cases of scarlet fever and
one of diphtheria. The small number of other communi-
cable diseases is attributable to the precautions taken to
prevent the spread of influenza.
Drug Addicts Among Drafted Men. — Figures pub-
lished by the War Department show that of 990,592 men
examined in the draft up to January i, 1918, only 403 were
rejected on account of drug addiction and only seventy-
six were discharged for this reason.
American Association for the Study and Prevention
of Infant Mortality Postpones Meeting. — The ninth an-
nual meeting of the American Association for the Study
and Prevention of Infant Mortality, which was to have
been held in Asheville, N. C, November iith to 14th, co-
incidently with the Southern Medical Association, has been
postponed until further notice, on account of the prevalence
of influenza
Southern Surgical Association Cancels Annual Meet-
ing.— On account of the prevalence of influenza the
Southern Medical Association will hold no meeting this
year. The annual meeting was to have been held in Ashe-
ville, N. C, November nth to 14th, under the presi-
deiic\- of Dr. Lewellys F. Barker, of Baltimore.
Evacuation Hospital Commended. — By direction of
General Pershing, Evacuation Hospital No. 7, American
Expeditionary Force, commanded by Lieutenant Colcuiel
W. H. Tefft, M. C, U. S. Army, has been highly com-
mended for its admirable work in handling battle casual-
ties at Chateau Montanglaust, June 15th to August nth.
The letter of commendation was signed by Brigadier Gen-
eral Le Roy Eltinge, deputy chief of staff.
Personal. — Dr. William C. Woodward, health officer
of V\'ashington, D. C, since 1894, was appointed health
commissioner of Boston on August 1st, and assumed his
new duties immediately.
Dr. Charles H. Chetwood, former head of the depart-
ment of urology. New York Polyclinic School and Hos-
pital, has been appointed consulting surgeon to the French
Hospital, New York.
Dr. Allen J. Smith, of Philadelphia, has been appointed
dean of the medical department of the University of Penn-
sylvania, succeeding Dr. William Pepper.
Food Nutrition Officers for All Training Camps. —
Colonel John R. Murlin, chief of the division of food
nutrition, Surgeon General's Office, reports that by De-
cember 1st all the camps in the United States will be
supplied with food nutrition officers from the school at
Camp Greenleaf, Fort Oglethorpe, Ga., established by the
surgeon general to train experts in food values and nutri-
tion as applied to military camps and troop bodies. All
camps cf more than 10,000 men are entitled to one of these
officers, but thus far it has been impossible to train more
than about fifty, thirty of whom are on duty in France
and England, and the remaining twenty in the larger camps
in this country. At the school at Fort Oglethorpe two
months' instruction is given in camp sanitation, military
methods and organization, and the function of nutrition
officers in military camps.
Meetings of Medical Societies to Be Held in Phila-
delphia.— During the coming week medical societies
will meet in Philadelphia as follows :
Monday, November 4th. — Bloekley Medical Society; Clinical
Association.
Tuesday, November 5th. — Medical Examiners' Association.
Wednesday, November 6th. — College of Physicians,
Thursday, November 7th. — Academy of Surgery; Obstetrical
Society.
Friday, November 8th. — Atlantic County Medical Society; North-
ern Medical Association.
Meetings of Medical Societies to Be Held in New
York. — During the coming week medical societies will
meet in New York as follows :
Monday, November 4th. — Clinical Society of the New York Poly-
clinic School and Hospital; Brooklyn Hospital Club.
Tuesday, November 5th. — New York Academy of Medicine (Sec-
tion in Dermatology and Syphilis) ; Medical Society of Harlem
Hospital; New York Neurological Society; Society of Alumni of
Lebanon Hospital.
Wednesday, November 6th. — New York Academy of Medicine
(Section in Historical Medicine); The Bronx Medical Association;
Harlem Medical Association; Psychiatrical Society of New York;
Society of Alumni of Bellevue Hospital; Brooklyn Hospital Club;
Brooklyn Society for Neurology.
Thursday, November 7th. — New York Academy of Medicine
(Stated meeting) ; Brooklyn Surgical Society.
Friday, November 8th. — New York Academy of Medicine (Sec-
tion in Otology) ; Clinical Society of the German Hospital and
Dispensary; Eastern Medical Society of the City of New York;
Flatbush Medical Society; Society of Ex-Interns of the German
Hospital in Brooklyn.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
Treatment of Wounds. — John T. Morrison,
T. N. J. Hartley, and E. F. Bashford (Lancet,
August 24, 1918) believe that the most satisfactory
of all methods of treating infected war wounds is
the combination of thorough mechanical cleansing
with the application of the Carrel-Dakin treatment.
The results will vary, depending upon whether or
not there has been a preliminary surgical cleansing
of the wound, the results being decidedly better
where there has been such primary treatment. No
attempt should be made to excise the wound when
the infecting organisms have already invaded the
tissues, as this does not hasten recovery and ma-
terially increases the risk of septicemia. In such
cases operation should be limited to securing free
exposure of the entire surface and of all recesses.
In the preinflammatory stage, however, excision
should be radical. Partial closure of wounds at the
primary operation should not be practised as it
usually delays healing. Among the patients oper-
ated upon within twenty-four hours of being
wounded eighty-two per cent, reached suture stand-
ard in twelve days as compared with sixty-seven
per cent, in fifteen and one half days where the
operation was not performed within twenty-four
hours. When compared with other methods of
treatment the advantages of the Carrel-Dakin
method are striking, as indicated in the following-
table :
Carrel-Dakin with early operation, 77.5 per cent, dosed by
suture.
Carrel-Dakin without early operation, 53.5 per cent, closed
by suture.
Dichloramine-T in eucalyptol, 43 per cent, closed by suture.
Flavin", 22 per cent, closed by suture.
Hypertonic saline, 12 per cent, closed by suture.
Early excision with primary suture is the only
other method comparing favorably with the Carrel-
Dakin. Dichloramine-T in eucalyptol gives very
fair results, but it does not possess the advantages
which were anticipated for it, and epithelialization
is somewhat slow with irregular and imperfect
formation of scar tissue.
Restoration of Function in Penetrating Gun-
shot Wounds of the Knee. — John Everidge (Brit-
ish Medical Journal, August 24, 1918) believes that
many of the ultimate failures to secure wide or
complete range of motion in the knee joint after
favorable healing of penetrating gunshot wounds
can be avoided by beginning movements of the joint
early and continuing them until a range of at least
90° of flexion is secured before the patient is trans-
ferred to the home hospital. He has devised an
apparatus whereby this movement can be carried
out without danger to the patient and without any
pain and can be started on about the seventh day
after operation. It consists of the Thomas knee
splint made with extra heavy side bars and hinged
at the knee joint with a lock hinge. A wooden
frame is then constructed over the patient's bed
and the splint containing the injured extremity is
supported by counterweights. The splint is sup-
ported in its upper portion by cords running from
points immediately above the hinges, while the cords
from the lower segment are attached about fifteen
inches below the hinges. The cords from the upper
part are weighted with one counterpoise, those from
the lower with another, both, however, being sand
vats with openings at their lower ends to permit the
slow escape of sand. Above the upper counter-
poise is a sand reservoir while below the lower is a
container to collect the sand. The extremity is
perfectly balanced in this apparatus and when
mo-vement is to be started sand is allowed to escape
very slowly from the vat supporting the lower part
of the leg into that for the upper, thus gradually
causing angulation of the splint and flexion at the
knee. The range of movement is small at first and
is slowly increased until 90° is secured, when the
patient can begin to make active flexion in the
counterpoised splint. After this a course of mas-
sage, faradism, and active and passive movements
is given and the patient sent to a convalescent hos-
pital at home. By slight modification in the method
of fixing the extremity in the splint the knee flexion
can also be used in cases of fracture of the femur
as soon as acute sepsis has subsided and good align-
ment has been secured.
Local Effects of Hepatic Lipoids on Wounds
and Inflammatory Processes. — E. Savini (Paris
medical, August 17, 1918) prepares hepatic lipoids
by hashing up liver tissue, drying it well at 70° C,
reducing it to a powder, and placing it in a Soxhlet
apparatus for ether extraction. With the lipoids
thus obtained a five to ten per cent, emulsion in
sterilized olive oil is aseptically prepared. To keep
it aseptic a few mils of ether are added from time
to time. Before use the emulsion is slightly warm-
ed in hot water and well shaken up. The emulsion
is applied to wounds every other day, after cleans-
ing them with sterile saline solution and an aseptic
dressing is then employed. In sinuses and suppurat-
ing cavities the preparation is introduced with a
gauze wick or syringe. Small, uninfected wounds
heal in three to five days under this treatment. Pain
and burning in wounds are immediately allayed by
the emulsion. In broad, suppurating, sluggish
wounds, the hepatic lipoids soon arrest the suppura-
tion and lead to complete healing in eight or ten
days. Where Thiersch skin grafting is done the
preparation has a most useful action, powerfully
assisting fixation of the grafts and accelerating their
progress. Where possible, the wound should be
treated with the emulsion a few days before the
grafts are applied. Large, obstinate, varicose ulcers
of the leg may be cured by persistent use of the
hepatic lipoids. These also act rapidly and eflfectual-
ly against the inflammatory complications of hem-
orrhoids, suppuration, dermatitis, rhagades, ulcera-
tions, phlebitis, etc. In conjunction with their use
glycerin soap should alone be employed externally.
784
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Jourkal.
and by mouth sodium bicarbonate should be taken.
Preparation of the parts with the lipoids before ex-
cision of hemorrhoids leads to rapid healing and
prevents infection. In burns the emulsion im-
mediately allays the pain and promotes healing.
Intestinal lavage with an emulsion of the lipoids
^ave encouraging results in mucomembranous
colitis. In ulcerations of the uterine cervix good
results were likewise obtained. In the local treat-
ment of eczema and of syphilitic chancre or chan-
croid, however, no benefit was noted.
Autoplastic Bone Transplantation for Tibial
Pseudarthrosis. — Riche {Presse medicale, Au-
gust 5, 1 91 8) reports a case of war traumatism of
the tibia with extensive loss of bone tissue and com-
plete functional impotence of the limb. One year
after the injury, under spinal analgesia, two trans-
plants ten centimetres long were removed from the
lower end of the tibia and fastened with catgut
across the interval. Complete consolidation was
noted upon removal of the plaster apparatus on the
ninety-first day. After further use of a Delbet
walking apparatus for three months, the patient was
able to walk without the artificial support. Ten
months after the operation the results obtained
seemed permanent ; x ray plates showed the trans-
plants apparently fused with the shaft of the bone
and free from any tendency to reabsorption.
Continuous Extension in Fractures of the Pha-
langes and Metacarpals. — Lance {Presse medi-
cale, August 8, 1918) notes that in bullet or shfU
fragment injuries of the phalanges or metacarpals
the ends of the fractured bones are frequently
spared, the diaphysis, however, being comminuted.
In the absence of infection, healing is rapid but
there is much callus, deformity, shortening, pain
from pressure on nerves, and diminished motor
power. In infected cases free removal of bone
fragments is essential if prolonged osteitis and
elimination of sequestra are to be avoided, and this
free removal favors marked shortening of the bone.
For three years the authors have been instituting in
such cases continuous extension, to prevent shorten-
ing and deformity. Special palmar board splints,
differing in shape to correspond to the particular
finger injured and extending from the wrist to a
point some distance beyond the finger tip, are used.
The uninjured fingers are allowed free motion. The
extension is applied by means of a strip of adhesive
plaster passing, usually laterally, along two opposite
aspects of the finger, and secured more firmly by
two or three circular rings of adhesive plaster
at the base and toward the extremity of the finger.
The wrist is circled with eight or ten turns of
plaster bandage extending below the styloid pro-
cesses, over which they are molded to afford coun-
terpressure. The splint is then fastened to the
wrist by a second plaster bandage passed arounil
the first. When the plaster is dry, extension is in-
stituted by means of a piece of rubber tubing, five
or six millimetres in diameter, passed through the
loop of adhesive plaster beyond the finger tip,
through a hole in the splint, and then knotted at
the proper degree of tension. The latter should be
sufficient to reduce the deformity in twenty-four to
forty-eight hours, and continued until x ray ex-
amination shows an adequate degree of bony re-
constitution, viz., for about six weeks in the case of
phalanges and two months in the case of meta-
carpals. In the foot the method is applicable only
to the great toe and corresponding metatarsal.
Suggestions for Treatment of Septic Wounds.
— Frederick W. Robinson {British Medical Journal,
August 24, 1918) calls attention to the frequency
with which severe and disabling scars result from
septic wounds in the present war, and suggests that
this is largely the result of the invasion of the tis-
sues by infecting organisms which are not reached
by the usual methods of antiseptic treatment. To
overcome such deep tissue infection he suggests
a method of treatment and an apparatus for carry-
ing it out. The method consists in elevation of the
entire wound by means of the passage well beneath
the infected zone of several threaded bars over the
projecting ends of which wire splints are passed and
held by milled nuts. By approximating the splints
on the opposite sides of a linear wound, or by pass-
ing a stout ligature beneath all of the nuts in an
irregular wound, the entire wound is not only ele-
vated, relaxed, and perfectly immobilized, but its
surface is opened out for the better application of
antiseptics and the deeper tissues are caused to be
bathed in bactericidal lymph. The method of ap-
plication of the apparatus is shown in illustrationc.
Of equal importance is the prevention of all damage
to the healing surface by avoiding the use of gauze
or other dressings which require frequent changing
and by eliminating, so far as possible, the deleteri-
ous effects of antiseptics. To replace the gauze
dressings decalcified, perforated sheets of cancel-
lous bone are very useful, since they can be left
in place, are absorbent, permit the escape of the
secretions, and are readily absorbed by the tissues.
Treatment of Celiac Disease. — G. F. Still
{Lancet, August 24, 1918) says that since the dis-
ease cannot be traced to any one specific cause its
treatment must be largely symptomatic and empiri-
cal, but experience points to certain definite meas-
ures and shows the futility of others. The princi-
pal field of treatment is dietetic, and one of the
most marked and constant features of the disease
being failure of fat assimilation, the diet must be
regulated to exclude all fats or reduce them to a
minimum. The fat least well borne is that of cow's
milk and the most important of all steps in treat-
ment IS to eliminate milk and butter, or to curtail
their use most rigidly. Dried milk, containing a
small amount of fat only, asses' milk, or, in ex-
treme cases in early life, human milk may be tol-
erated as substitutes for plain cow's milk. The
various available fats other than those of milk are
also not well tolerated and must be largely elimi-
nated from the dietary. Although there is some
difficulty in dealing with carbohydrates there is
much less than with fats and these can be employed
in limited amounts and variety. The best tolerated
carbohydrates are prepared from lentils, small
amounts of wheat flour with dried milk, and rice
cooked to a jellylike state. Sugar can be taken in
small quantiti^;? only. To these articles may be
added veal or chicken broth, sweet jellies and eggs
if well borne. This diet is decidedly scorbutic, and
Noven.bcr 2. ly.s.] MODERN TREATMENT AND PREVENTIVE MEDICINE.
there is often difficulty in giving vegetables or fruit
Juices on account of the looseness of the bowels.
Grape juice seems the best tolerated. A so called
"fat free" diet can sometimes be taken with success,
and the potato which it contains is an efificient anti-
scorbutic. It is questionable whether fats can be
administered successfully by inunction, some cases
seeming to indicate that they can, while others show
tlie contrary. The use of the various digestive ex-
tracts does not seem to be of any value and the
same seems to be true of the organic extracts. The
only astringent which has proved of value is castor
oil and salol in the proportion of 0.3 mil of the
former with 0.15 gram of the latter thrice daily.
Other drugs seem relatively valueless.
Ipecac by Rectum in Amebic Dysentery. — ■
George B. Lawson {Journal A. M. A., September
28, 1918) reports excellent results, even in cases
which have proved refractory to the injection of
emetine, by the administration of an infusion of
ipecac by rectum. The infusion is prepared fresh
for the patient by adding from four to eight
grams (one to two drams) of powdered ipecac to
about 750 mils (twenty-four ounces) of hot water.
This is kept hot for an hour, but not allowed to
boil. The bowel is then washed out with warm
water and the v/hole of the infusion is injected
slowly and retained as long as possible. This treat-
ment is repeated daily and has the advantage of
being easy for the patient to carry out without hav-
ing to stop his work. Along with this local treat-
ment emetine should also be given »in the usual man-
ner, though it has been possible to cure cases of
obstinate amebic dysentery with the local treatment
alone.
New Principle in Surgical Treatment of Brain
fTumors.— A. C. Strachauer {Journal A. M. A.,
September 14. 1918) groups cases of brain tum.ors
into two general classes : Those in which the tumor
can be found readily by localizing signs or by the
usual methods employed after opening the cranium,
and those in which the tumor cannot be discovered
by any of the usual means after craniotomy. Cases
of the latter type have been considered hopeless and
it is among them that the new principle of treatment
finds its field. In a considerable proportion of such
cases, following craniotomy with the failure to dis-
cover the tumor, if the patient is allowed to wait for
some time after decompression a second operation
will reveal the tumor in an easily accessible position.
In such a case a single exploratory operation gives
the patient only half a chance, since with time and
adequate decompression an inaccessible lesion may
develop, come to or near the brain surface, and be-
come readily removable. In addition to this new
principle, the author points out that the two greatest
dangers in brain tumor surgery are shock and
hemorrhage and says that the dangers of both may
be much mitigated. Shock can be largely avoided if
the operator will work slowly and gently instead of
as rapidly as possible and will employ large decom-
pressions and make large exposures of the operative
field. Hemorrhage can be almost entirely controlled
by the proper use of Horsley's bone wax and wooden
pegs for bone hemorrhage and Cushing's cotton com-
presses and the Haidenhein hemostatic suture for
other bleeding.
Arteriorrhaphy and Neurorraphy. — Michael
Casper {International Journal of Surgery, August,
1918) reports a case of arteriorrhaphy, and gives
the technic of vasal anastomosis as follows: i. The
isolation of six to ten centimetres of the vessel ; 2,
the application of proper clamps ; 3, the severing of
the vessel transversely with resection if required;
4, the removal from the vessel ends of periad-
ventitial tissue, and also blood from between the
clamps; 5, the placing of traction threads to evert
the edges and insure contact of the endothelial sur-
faces ; 6, completion of the anastomosis by contin-
uous suture from within outward through entire
vessel wall ; 7, the removal of clamps. Hemorrhage
through stitch holes, as a rule, is controlled by com-
pression. In regard to neurorrhaphy Casper states ;
I. Primary neurorrhaphy is the most logical pro-
cedure in peripheral nerve injury and should be
applied in the absence of contraindications. 2.
Secondary neurorrhaphy may be successfully per-
formed where primary operation seems inadvisable,
and no instance of peripheral nerve injury should
be considered hopeless until after the aid of sur-
gery has been invoked. 3. Where the distal and
proximal nerve extremities have become widely
separated with formation of intervening fibrous
tissue, careful dissection with approximation by the
aid of mechanical devices may be successfully ac-
complished in a percentage of instances.
Treatment of Peripheral Nerve Lesions. — W.
L. Crosthwait {Texas Medical Journal, August,
1918) divides the treatment of peripheral nerve
lesions into two classes : operative and expectant.
The operative treatment is again divided into prim-
ary or immediate, and secondary or remote. Fac-
tors which determine success are : Early and care-
ful diagnosis, correct anatomical approximation,
and the maintenance of nutrition and relaxation of
parts supplied by the injured nerve. The treatment
of a divided nerve is suture, and primary suture
is the operation of choice. If the diagnosis is not
absolute, primary suture should not be performed.
It should be done by a wide or open exposure. One
of the essentials of success is asepsis ; and if there
is a reasonable chance that the wound is sterile,
primary suture is desirable. If infection is present
it is better to wait until it has subsided and then
perform secondary suture. The muscles which are
affected by the division of a nerve should be treat-
ed either manually or by electrical massage while
waiting to perform secondary suture. In the ex-
pectant treatment a limb in which a nerve has been
injured should be carefully protected against cold,
pressure, fixational positions unfavorable to re-
covery, etc. The tendency of the antangonistic
muscles to pull in the opposite direction must be
considered. The best method of union is end to
end suture through the nerve sheaths. The suture
material should be either fine, plain catgut, or silk.
Care must be taken to prevent adhesions. Fascia
taken from the thigh, with the smooth side turned
in, is the best material to enclose the nerve at the
point of union ; fat is sometimes used. To bridge
a gap in the nerve either gelatin tuBes, fascia, or fat
are employed. A gap of two inches may be bridged
under favorable conditions.
786
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Treatment of Prostatitis. — Frank Lydston
( Uroloyic and Cutaneous Review, September,
1918) in treating severe, acute prostatitis, recom-
mends: I. Putting the vesical neck at rest by per-
ineal section, stretcliing, and drainage ; 2, opening
the prostatic capsule on both sides and exploring
the gland with the finger. The objects accomplished
arc: Relief of tension with relief of pain;
drainage, and evacuation of pus, if present, or if
not present, prevention of its formation. If opera-
tion is performed as a routine in severe, acute pro-
statitis the unsatisfactory results following unde-
tected and unoperated prostatic abscesses will be
few, and the large, hard, chronically inflamed pro-
state will be a rare phenomenon. In chronic pro-
statitis operation is followed by good results if not
delayed too long. The operation should be limited
to opening the capsule and breaking up the lateral
lobes by finger exploration and pressure. This is
to be followed by perineal drainage.
Treatment of Syphilis with Galyl. — Paul Rich-
ard {Canadian Journal of Medicine and Surgery,
September, 1918) reports the results obtained in
twenty-eight cases of primary and secondary syph-
ilis, following the use of galyl instead of salvarsan
and neosalvarsan. It was used intravenously. A
series of injections of 0.2 gram were given, an
interval of four or five days being allowed to elapse
between the injections. After the fourth injection
the Wassermann reaction was usually negative and
continued so. After the Wassermann reaction be-
came negative the injections were given at five or
six day intervals, until two grams had been ad-
ministered. The reaction was of a slight nature,
no induration of the veins, diarrhea, albuminuria,
or nervous reaction having been noticed. Small
chancres healed in from four to eight days ; larger
ones in from ten to twelve days. The very large,
ulcerative, phagedenic chancres may take from
twenty-five to thirty days. In cases treated from
the outset no roseola or mticous patches developed.
Vaccine Treatment of Gonococcic Infection. — ■
G. Baril {Bulletin de 1' Academic de mcdecine, Au-
gust 13, 1918) reports good results in acute and
chronic gonococcal urethritis from the use of a
polyvalent vaccine made from a large number of
samples of the gonococcus, together with other
aerobic and anaerobic germs. The vaccine is in-
jected in the buttocks every other day, beginning
with 100 and increasing to 400 millions. The va..-
cine alone sometimes cures acute gonorrhea in fif-
teen to twenty-five days. After the first or second
injection the discharge and, at times, the pain are
increased, and there may be a slight constitutional
reaction. After the fourth or fifth injection, how-
ever, the discharge is generally reduced and be-
cnmcs more fluid. After the eighth injection the
discharge may completely cease. Gonococci dis-
appear after ten to twenty days. Where the vac-
cine fails to arrest the discharge completely, added
urethral irrigations suffice to produce the desired
result. The routine treatment is therefore to begin
urethral irrigations of mercury oxycyanide after the
fourth or fifth vaccine injection. By this method a
cure was ef¥ected in fifteen to twenty-five daj/s in
ninety-five per cent, of a series of about 300 cases.
In chronic urethritis of bacterial origin, vaccine in-
jections coupled with irrigations to the posterior
urethra yield a cure in the same average time as in
the acute cases. In chronic urethritis with stricture
of the deep urethra, vaccine injections reduce the
discharge and eliminate the gonococci with suffi-
cient rapidity to permit of prompt dilatation or
other surgical procedure necessary for complete
drying of the tissues. Among ten cases the vaccine
generally relieved the pain in four or five days, the
swelling simultaneously diminishing. Among ten
cases of cystitis, pain yielded in four or five days ;
pollakiuria and hematuria somewhat later. Among
six cases of gonorrheal rheumatism good results
were obtained in five and doubtful results in one.
Postoperative Treatment of Mastoiditis. — C.
H. Smith {American Medicine, August, 1918)
treats mastoid cavities in the following way : After
the operation is completed a small wick of narrow
gauze — about two or three inches long — is placed,
one end in the mastoid antrum and the other in the
lower angle of the wound. This is removed on the
fifth day and no other drainage is inserted. The
outer dressing is changed every second or third dav
thereafter. Two great benefits derived from this
method of treatment are : first, shortening of the
period of convalescence, the average period of heal-
ing being three weeks, as compared with six weeks
according to the older method ; second, the small
amount of depression in the mastoid region.
Radical Mastoid Operation Under Local Anes-
thesia.— Harold Hays {Annah of Otology, Rhinol-
ogy, and Laryngdloby, December, 191 7) noted, in
operating in a case of tuberculous mastoiditis, that
the radical mastoid operation could be done under
local anesthesia without pain. The superficial scalp
tissues and periosteum are sensitive, but bone has
absolutely no sensation, as evidenced by the use of
the chisel and the constant pounding in uncapping
the mastoid cavity. It was further observed that
the mucosa of the middle ear was extremely sensi-
tive and must be separately cocainized, and that any
irritation or destruction of the facial nerve was im-
mediately noticeable by the patient. Under local
anesthesia the making of the skin flap was facilitated
by the lack of bleeding due to blocking of? the ves-
sels by the cocaine solution. Doctor Hays found
that the end result of the operation was as good
as under general anesthesia.
Some Clinical Observations on the Lingual
Tonsil. — Greenfield Sluder (American Journal of
the Medical Sciences, August, 1918) says that the
treatment of lingual tonsillitis in the acute follicu-
lar stage is like that for the faucial tonsils under
like conditions. For the subacute or chronic state,
with or without enlargement, nothing has been so
satisfactory as applications of a small amount of
silver nitrate saturated in fifty per cent, glycerin.
Salicylic acid saturated in ninety-five per cent, alco-
hol is helpful and does not taste so unpleasant.
These may be made daily or as seldom as ten days.
For the enlargement, galvanocautery destruction
has seemed best. Myles's lingual tonsil guillotine
also serves well. Hemorrhage following surgery
of the lingual tonsil is more difficult to manage than
any in the upper air passages. It is fortunately
rare.
Miscellany from Home and Foreign Journals
Aviator's Heart. — Etienne and Lamy (Bulletin
de I'Acadhne de mcdecinc, August 6, 1918) found
a moderate degree of cardiac hypertrophy in all
aviators examined. The condition was already dis-
tinct after five months of aviation, and was still
present in a subject who had ceased flying for eight
months. The hy]-iertrophy was much more marked
in aviators customarily flying at altitudes exceeding
5,000 metres than among those whose duties re-
quited altitudes of only 1,000 to 3,000 metres. The
enlargement of the heart occurred in two stages,
taking place rapidly during the first few months,
then more slowly, until the apex beat reached the
nipple line. The hypertrophy affected in particular
the left ventricle, the right ventricle being only
rarely involved and late. For a long time the hy-
pertrophy causes no functional disturbance or
pecuHar subjective sensation. The condition is
plainly the result ot adaptation of the heart to the
varying atmospheric conditions encountered during
aviation. Above 2,500 metres there is a rise in the
systolic blood pressure, which is maintained
throughout the flight at high altitudes. During and
following descent there occurs also a rise of five to
ten millimetres of mercury in the diastolic pressure.
Again, during flight there is a stage of lowered dia-
stolic pressure, and after descent a diminution of as
much as twenty millimetres in the systolic pressure,
which may persist an hour. The cardiac hyper-
trophy may logically result from the stages of ele-
vation of the systolic and diastoHc pressures, but
lowered pressure might also be a cause, repeated
artificial hypotension in rabbits having been ob-
served to induce marked cardiac enlargement.
End Results of Ovarian Conservation. — J. O.
Polak {American Journal of Obstetrics, Augusr,
1918) states that in a series of 132 hysterectomies
with retention of one or both ovaries, the influence
of the ovarian secretion on the nervous molimina
of the operative menopause was found to depend
on the general health of the patient and on whether
the uterus was removed for fibroid or inflammatory
disease. The symptoms are less after extirpation
for pelvic inflammation than for fibromyomata.
Thev are more marked if the patient is operated
upon in comparatively good health, with a high pre-
operative blood pressure, than when the blood
picture shows anemia or toxemia. A conserved
ovary, if unhealthy, will leave the patient in a worse
state mentally, nervously, and physically, than if
total extirpation had been done. Case records of
over 300 patients followed for five years show that
the av-erage life of the ovarian function after the
uterus has been remoA-ed is not over two years, and
that within that time flushes, dizziness, and pre-
menstrual pain occur in the large majority of cases.
Ovulation without menstruation has little psychical
value. In inflammatory conditions requiring radi-
cal pelvic surgery the contiguous inflammation re-
sults in a cicatricial thickening of the tunica
albuginea, which promotes the formation of reten-
tion cysts, increased weight of the ovary, and pro-
lapse. In fibroid tumors circulatory stasis is a con-
stant concomitant, and likewise leads to thickening
of the tunica albuginea. Furthermore, removal of
the uterus itself causes disturbance of ovarian cir-
culation and innervation. Pathological studies after
reoperations in seventy-three cases in which one or
both ovaries had been conserved 'showed the fol-
lowing ovarian lesions : multiple cystic changes :
cirrhosis ; cystic formation ; infection, and thin
walled cyst with dense adhesions. Routine con-
servation of ovaries without due consideration of
the ovarian and contiguous pathological conditions
in the individual case is not good teaching. Re-
generation of the conserved ovary depends largely
on the type and duration of the existing infection
and the condition of the tunica of the individual
ovary. Even when the most delicate technic is ob-
served the ovarian circulation is impaired. The
retained ovary without the uterus is always a focus
for possible trouble.
Streptococcic Infection in Wounds. — Plisson,
L. Ramond, and J. Pernst (Pressc medicate, Au-
gust I, 1918) assert that streptococcic infection
may be suspected in all wounds that are not pro-
gressing favorably. Bacteriological examination,
however, is alone decisive. Examination of a
smear is insufficient, for the organisms are but
rarely disposed in chains in the wound secretions.
A liquid culture is therefore necessary — preferably
a mixture of four parts of ordinary bouillon with
one part of Sacquepee's soda albumin. In this
elective medium the streptococcus shows chains
within three hours in eighty per cent, of cases and
within six hours in ninety per cent, of cases. In-
oculations should also always be made on an agar
slant, in the water of condensation, and- in Veillon
agar, in order to ascertain the associated aerobic
and anaerobic flora as well as to confirm the pres-
ence of the streptococcus. Occasionally the wound
discharges fail to show streptococci. Here the
organisms are present only within the tissues them-
selves. Negative reports are thus not conclusive,
and must not be relied on as absolutely excluding
streptococcic infection unless repeatedly obtained.
In the treatment, the authors dissent from the view
of Gross and Tissier that, after primary suture of
a wound, discovery of streptococci in it indicates
immediate section of the sutures. In a number of
such cases they allowed most of the sutures to re-
main in spite of the intensity of the inflammatory
reaction, and no untoward results followed. In
most instances the tissues kept in apposition till the
tenth or twelfth day united by first intention. In
wounds left widely open, the object during the first
few weeks should be to favor elimination of dead
tissues and combat the streptococcic as well as sec-
ondary infections. All antiseptics, however, includ-
ing Dakin's solution, are powerless to overcome the
streptococcus. Repair by granulation is obtainable,
with silver nitrate cauterization of exuberant gran-
ulations, occasional dressing with ointments, and
heliotherapy. The period of recovery can be short-
788
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
ened, liowever, by a secondary surgical intervention.
In one large wound Thiersch grafts were success-
fully used. In eight cases, secondary suture of
wounds still infected with streptococci was at-
tempted, with complete success in six instances.
Before suture in these cases, forty per cent, for-
maldehyde solution was freely applied and a slice
of tissue extending two to three millimetres beyond
the wound margins removed, the base of the wound
being, however, spared. These secondary opera-
tions were always performed after the third week.
Preventive and curative antistreptococcic sero-
therapy being as yet unavailable, early and careful
removal of crushed tissue remains the best guaran-
tee against streptococcic wound infection.
Sarcoma of the Heart. — I. Perlstein (American
Journal of the Medical Sciences, August, 1918) de-
scribes a case of this nature with a summary of
other cases reported. Only thirty cases of sarcoma
of the heart were found after a careful search of the
literature. To these is added a case in which the
tumor originated apparently in the subepicardial
areola tissue. There is no characteristic clinical pic-
ture for the condition. The symptoms are mostly
those of seriously disturbed cardiac activity. Ex-
cessive and repeated hemothorax was the most strik-
ing clinical feature of the case reported. Sarcomas
of the heart occur at all ages, but are most common
in the vigorous years of life. Histologically all
types of sarcoma have been reported. The spindle
cell variety is the one most often found. They
occur more often in the auricles than in the ven-
tricles, and more frequently on the right than on the
left side. Among the postmortem findings, peri-
cardial and pleural efifusions and edema are common.
Blood Pressure Measurements. — Eugene S.
Kilgore (Lancet, August 24, 1918) reviews some of
the points with reference to the values and limita-
tions of blood pressure measurements and points
out many respects in which our knowledge is too
meagre to give any real value to such measure-
ments. In the first place the method of taking the
measurements should be the simplest which will
give concordant results, since the question of the
absolute accuracy of the readings is still unsettled
and of academic interest only. The most satis-
factory and probably the most trustworthy deter-
mination of the .systolic pressure is by the palpatory
method, while for the diastolic pressure either the
change of sound or the disappearance of all sound
should be taken as the criterion, depending upon
the accviracy of the determination in each individual
case. The point selected should be recorded and
always used in the future work with the same case.
The range of normal variation of the systolic pres-
sure should be given more latitude than that stated
in textbooks, and specially is the lower limit stated
too high. The range by the palpatory method
should extend from ninety to about 140 mm. of
mercury. The systolic pressure is imquestionably
of much more value than the diastolic and, con-
trary to general opinions, the relative range of
variation in the normal subject is wider in the
diastolic than the systolic. The pulse pressure de-
termination is subject to still greater variations than
either systolic or diastolic pressure determinations ;
and several factors beside the volume of blood
ejected from the heart influence this pressure, such
as vasoconstriction and dilatation, either general-
ized or local. The pulse pressure and various
quotients and formulas based upon it or upon the
relations of systolic, diastolic, and pulse pressures
seem of very questionable value and such formulas
should be regarded with considerable skepticism.
Blood pressure responses to work should also be
regarded as very questionable indices of the func-
tional capacity of the heart, and it is doubtful
if their results will even compare favorably in
value with a careful history and physical examina-
tion together with a consideration of the patient's
own sensations after exercise. The systolic pres-
sure is of unquestionable practical clinical value in
connection with arterial and renal diseases, cerebral
pressure, the toxemias of pregnancy, Addison's dis-
ease, and to a less extent with the diagnosis of
aortic insufficiency. A very valuable use to which
the sphygmomanometer can be put is the early dis-
covery of pulsus alternans, which can often be
brought out by careful adjustment of the cufif pres-
sure so as to cut out every alternate feeble beat,
even where the alteration is not otherwise appre-
ciable by the finger.
Detection and Estimation of Arsenic in the
Urine. — Paul Duret (Presse medicale, August i,
1918), for qualitative detection of arsenic, first de-
stroys the organic matter in the urine, then treats
the latter with nascent hydrogen in a flask over the
mouth of which rests a piece of filter paper pre-
viously impregnated with a one in ten alcoholic
solution of mercury bichloride and allowed to dry.
The arseniuretted hydrogen gas set free in the flask
produces on the paper a yellow or brown discolora-
tion, revealing the presence of arsenic. For quan-
titative estimation, the urine, after destruction of
organic matter, is placed in a Marsh apparatus.
The arseniuretted hydrogen produced is passed
into a Liebig tube containing an acid solution of
silver nitrate standardized with reference to a
known quantity of arsenic. The amount of silver
nitrate reduced, estimated by the cyanoargentimetric
method, shows the proportion of arsenic contained
in the original urine.
Pulse after a Marathon Race. — Paul D. White
(Journal A. M. A., September 28, 1918) studied
the pulses of twenty men just after they had run the
twenty-five miles of a marathon race. He made poly-
graphic tracing in all within five minutes of the time
that each completed the race. In one man who col-
lapsed during the race and was brought in in an
automobile the pulse was found to be thready and
eighty a minute. In the others the pulse rate after
the race averaged ninety-one with the extremes of
seventy-two to 107 beats a minute. In no instance
was there any evidence of an alternating pulse ;
marked sinus arrhythmia was found in two ; and
the only abnormal arrhythmia was a single pre-
mature ventricular contraction in the tracing of
one man. In many of the runners the pulse was
slower after than before the race. These studies
show that even the most violent physical strain
upon the healthy heart does not sufficiently ex-
haust that organ to produce pulsus alternans.
November 2, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
789
Distribution of Leucocytes in the Circulatory
System. — J. Jolly (Presse medicole, August i,
igi8) finds that the leucocytes are not equally dis-
tributed in different parts of the circulatory system.
They are always more numerous where there is
stagnation of blood. Accumulation of leucocytes in
the capillaries and veins where blood circulation is
poor temporarily deprives the general circulation of
?, portion of its leucocytes. When there is depres-
sion and stasis, the leucocytes accumulate in the
poorly irrigated districts. When, on the other
hand, the circulation becomes accelerated again, the
blood sweeps the vessels clear and causes leucocytes
to return into the general circulation.
Blood Pressure in War Traumatisms. — Edgar
F. Cyriax {British Medical Journal, August lo,
1918) calls attention to the fact that in a certain
proportion of cases with unilateral injuries the
blood pressures taken at the same time in the two
arms will be found to differ in level by as much
as even eighteen to twenty mm. of mercury. The
readings of one day may also be quite reversed a
day or two later. The differences involve both the
systolic and diastolic pressures, but not necessarily
in the same direction even at the same reading. In
most cases showing these differences in blood
pressures the phenomenon diminishes with improve-
ment and usually disappears some time prior to
complete recovery.
Endocarditis in Scarlet Fever. — P. Nobecourt
(Bulletin de I'Academie de medecine, August 13,
1918) deems true scarlatinal endocarditis, simple
and nonulcerative, more frequent than endocarditis
due to secondary infection, generally streptococcic.
True scarlatinal endocarditis was met with in chil-
dren aged six, twelve, and fourteen years, respec-
tively, as well as in seven out of 278 cases of scarlet
fever among soldiers. The cardiac complication at
times appears early, from the third to the seventh
day of scarlet fever, m other instances late, during
the third or the fourth week. Rather frequently it
appears in the presence of a mild or distinct scarla-
tinal rheumatism, either two or three or else ten to
fifteen days after the onset of the latter. When the
endocarditis sets in during the febrile period of
scarlatina, the temperature curve shows little or no
change ; if it occurs later there is often a temporary
febrile movement, rarely high and persistent fever.
No subjective or appreciable functional disturb-
ances supervene, auscultation alone revealing the
endocarditis. All the author's cases presented
mitral involvement, to which, in a few instances,
aortic endocarditis became superadded. The first
sign is a muffling of the valvular sound. This may
gradually disappear after a few days ; or there may
appear, often on the second or third day, a light
systolic murmur at the mitral orifice, or diastolic
at the aortic orifice. At times a presystolic roll or
murmur is superadded. Generally the patient has
recovered from the endocarditis and the signs have
disappeared upon discharge from the hospital. In
two out of seven soldiers and in two out of three
children, however, the endocarditis became chronic.
Dry or serofibrinous pericarditis, cardiac dilatation,
and late tachycardia were met with in some in-
stances.
Postdiphtheritic Paralysis. — F. M. R. Walshe
(Lancet, August 24, 1918) contends that one form
of postdiptheritic paralysis — the localized variety-r-
is due to the spread of the toxin directly along the
lymphatics of the nerves in the region in which the
diphtheritic infection is situated. Thus it is com-
monest and most frequent in the palate muscles
due to the proximity of the infection to the hypo-
glossal, vagus, and spinal accessory nerves and
their nuclei. It is also frequently encountered in
the regional nerves in cases of diptheritic lesions of
the skin on the extremities. This form of diph-
theritic paralysis is strictly analogous to tetanus in
its development and mode of spread. The second
form of paralysis may be regarded as of hemato-
genous origin and is more specific in the selection
of nerves involved, affecting those of the ocular
muscles and also causing a more or less generalized
polyneuritis. These statements and contentions
seem to be substantiated by the observations made
by the author in experimental animals and in a
series of cases of cutaneous diphtheria, and are
quite in harmony with the facts brought out for the
spread of the tetanus toxin by Orr and Rows and
by Meyer and Ramsom.
So Called Spanish Influenza in Switzerland. —
Jules Renault (Bulletin de rAcademe de medecine,
August 6, 1918) comments on the particularly
widespread prevalence of the epidemic disease in
Switzerland. The disorder has been characterized
there by a sudden onset with fever, headache,
diffuse pains, and irritation of the upper respira-
tory passages, throat, and trachea. The disease
runs its course in three or four days, and is fol-
lowed by marked asthenia. At times there occurs
a scarlatinoid rash, purpuric spots, or nasal or
uterine hemorrhage. Pulmonary complications are
not rare, appearing after three or four days, espe-
cially in the debilitated or improperly cared for.
Bronchial or lobular pneumonia often results fatally
on the fourth day, rather from intense toxemia and
cardiac collapse than from the extent of the pul-
monary lesions. Bacteriological examination of
the bronchial secretions in uncomplicated cases
showed the Pfeiffer bacillus in a few instances. In
the pulmonary complications it was never found,
but instead either the pneumococcus or a diplo-
coccus often disposed in chains. These organisms
were also obtained from blood cultures. The risk
of acquiring the disease is lessened by hygiene of
the nasal cavities and throat, and especially, by
avoiding visits to those affected and large aggrega-
tions of people.
Parameningococcic Meningitis and Septicemia.
— Brule (Presse medicale, June 13, 1918) calls at-
tention to the secondary septicemias sometimes ob-
served in parameningococcic infections. In any case
of meningococcic or parameningococcic cerebro-
spinal meningitis in which the blood culture is posi-
tive or in which a purpuric eruption indicates septi-
cemia, large doses of the corresponding serum
should at once be subcutaneously administered.
Practised in conjunction with the intraspinal serum
treatment, the subcutaneous treatment complements
the action of the former in antagonizing the general
infection that is often aggravating the meningitis.
Proceedings of National and Local Societies
NEW YORK NEUROLOGICAL SOCIETY
Three Hundred end Sixty-sixth Regular Meeting
Held at the Academy of Medicine
Tuesday, October i, igi8.
The President, Dr. Frederick Tilney, in the Chair.
Exhibition of Pathological Specimens. — Dr.
Irving J. Sands, of New York, exhibited the brain
of a man whose case had been diagnosed as paresis,
as he showed all the clinical evidence of the disease
and had been sent to the Manhattan State Hospital
as incurable, previously having received one in-
traventricular injection of arsenphenolamin. The
pathological evidence presented at autopsy spoke
eloquently against this form of therapy, for the
amount of inflammatory reaction, characteristic of
paresis, was far in excess of the normal quantity.
In the opinion of the speaker, the results of in-
traventricular injection of salvarsan did not warrant
treatment in this manner and he believed the patient
would have had a fairer chance of improvement
through intravenous injection of the drug.
Dr. Frederick Tilney recalled the fact that at
one of the meetings of this society last spring a
number of cases of paresis were presented by Dr.
Norman Sharpe, they then being under treatment
by intraventricular injection of arsenphenolamin,
and several opinions were expressed concerning
their improvement, or alleged improvement. There
was no pathological criterion in these cases by which
one could be gmded. As far as the speaker was
aware, this brain shown by Doctor Sands was the
first that had been exhibited after this form of
therapy had been employed, and it would be of
intere£.t in the light of such pathological evidence
to hear the subject discussed further.
Dr. B. S.^CHS, of New York, did not wish to
discuss the treatment of paresis by intraventricular
injection of salvarsan, but there was a question in
his mind regarding this brain and that w^as, could it
be regarded as typical of general paresis or had the
patient really suffered from meningoencephalitis
specinca. This excess of exudate did not seem
typical of true paresis, but it was just this type of
case which gave rise to paretic symptoms. As the
speaker understood Doctor Sands, the symptoms
appeared fairly early after the initial infection. If
this was so, the case was a very interesting one on
that account.
Doctor Sands replied that there was every rea-
son to believe the case one of general paresis, from
the clinical evidence the man presented. At autopsy
they found a lymphoid and plasma cell infiltration
about the vessels and within the pia ; also there was
cortical disorganization, and the granulation of the
ventricle was quite noticeable. This case was not
of the meningoencephalitis specifica type. Re-
garding Doctor Sachs's statement about the milky
exudate, one of the observations frequently made
at the Manhattan State Hospital was the milky ex-
udate usually found in the anterior two thirds of
the brain. It might not be a continuous process,
it might be only in patches, but it was always found.
Doctor Tilney said that doubtless many re-
membered when the Act of Mental Deficiency was
up before the House of Commons in 1913, how it
met with a good deal of opposition and required a
good deal of defense. The most telling argument
made in its behalf was a statement that a new
charter of liberty was being secured for a group of
persons heretofore deprived of their rights.
This country was very much behind England in
that respect and yet a movement in this direction
was growing every year. New York was perhaps
the leader in it and particularly of late, in conse-
quence of the appointment of a special commission
in this State to deal with the problems of the feeble-
minded, and to which Dr. Walter B. James had
been called as chairman. This was a long step in
advance, and Doctor Tilney felt the society was
very fortunate in having him there to explain hov/
the neurologists could be of assistance in furthering
this important movement.
The State's Problem of the Care of the Feeble-
minded.— Dr. Walter B. James, of New York,
delivered this address which is published in full in
this issue of the New York Medical Journal.
Dr. Charles L. Dana expressed his great con-
fidence in the work which Doctor James, as chair-
man of the new State Commission, was going to do
and hoped that the society would give him every
support. Naturally, the neurologists and other
medical men were very strongly in favor of the
view that the study and care of the feebleminded
was fundamentally a medical consideration to which
every possible allied science and art should con-
tribute help. Statistics showed that in clinics for
the feeblem.inded there was a very marked percent-
age of physical disease as well as actual mental dis-
ease. A survey of the history of the present
activities on behalf of the feebleminded showed that
there had been two somewhat antagonistic schools,
one which rather gave emphasis to the pedagogical
and psychological aspects, the other emphasizing the
importance of the medical side. Both schools had
among them strong and able advocates and both
had helped a great deal in the progress of the move-
ment, and it was encouraging to note that there was
a tendency now manifest for all workers in this
field to act in harmony toward a conmion goal. It
was a distinct achievement that the head of the
State Commission for the Feebleminded was a
medical man.
Dr. L. Pierce Clark said that as he understood
it the main purpose of the discussion was to make
clearer the application of social psychiatry to the
problem of feeblemindedness. In the first instance,
the isolated and aloof position of the State institu-
tions for the feebleminded as such must be aban-
doned. In the new order, the State institution could
well be made the centre of a division of the State in
which it could cooperate with agencies such as the
poor authorities, schools, prisons, and courts having
to do with the various aspects of the feebleminded.
The institutions should be the central bureau for ed-
ucating these agencies in diagnosticating feeble-
November 2, 191S.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
niindedness and advanced systems of hnmane care
and improving the condition of the fee1)lemin(lcd.
Thus tile medical staff of the State asyhims and
fanri colonies would have quite as many and per-
haps more important extramural activities to en-
gross their attention than merely training the
resident inmates consigned to asylum care. The
medical staffs should hold regular children's mental
clinics in the various localities of their districts ;
these clinics should not be dissimilar in character to
those planned and projected for the hospitals for the
insane. Indeed, a cooperative alliance between the
clinics in both fields of work should be encouraged
so that the whole field of psychopathies might
thereby be covered.
Inasmwch as it was doubtful whether sufificient
State provision for the feebleminded would ever be
provided, proper supervision and education of these
persons in their own home localities should be
undertaken. The excellent beginning the State had
made in providing ungraded classes everywhere
throughout the schools showed that the educational
;iuthorities were fully aware of their share in the
problem. State asylums and colonies should
heartily cooperate in this work, and place the ex-
perience of their teaching stafif at the disposal of
these ungraded classes and thus aid in the proper
founding of these schools. Further, the speaker
believed not only that more adequate medical and
teaching equipment of the State institutions for the
feebleminded should be provided, but in order that
this force might be thoroughly keen to solve its
various problems, a department of research into the
nature and treatment of feeblemindedness should be
established in every such asylum or farm colony.
Wise and well considered plans of pathological and
social research were real and indispensable func-
tions of the modern up to date State government.
The enormous number of feebleminded, epileptic
and various types of mental inferiors brought to
light in this present war showed that nothing less
than the most thoroughgoing and comprehensive
plan of research would enable the rooting out of
these sapping social defects in American life. New
York State should be congratulated upon its well
officered venture in taking up this great work.
The speaker wished to add his plea that the
neurologists do not allow this whole province of
feeblemindedness to pass from the field of social
neurology and psychiatry, into the hands of peda-
gogues and psychologists, by their attitude of in-
diiYerence to these issues. Simply because many of
the types of examination tests smacked of a scholas-
tic and educational approach, simply because certain
aspects of the feebleminded concerned reactions of
a psychological nature, these facts should not be
sufficient for neurologists to allow mental defects
to be the sole concern of others. They, and not
the public, should take the first step. They should
show themselves to be able, capable, and willing to
handle these defective disorders in spite of their
hopeless ultimate prognosis. Who knew but that
trained neurological science might in time even re-
move the stigma that all feeblemindedness was
rolely a hereditary and irremediable disorder.
Dr. B. Sachs said that the problem of the feeble-
ininded iiad been interesting every neurologist and
psychiatrist ratlv.'r intensively ; they had been face
to face with it for all the years they had been in
jiractice. He was glad that New York State had
been so fortunate as to secure Doctor James for the
head of a commission from which considerable pro-
gress could be expected. Many people realized
that great strides had been made in this city in the
last ten years about which time the Board of Edu-
cation, under the guidance of Miss Farrell, began
its special work, and a great deal had been done for
children of varying degrees of mental deficiency.
The problem was both a social and a medical
one. It would certainly be simpler if it could
be stated that feeblemindedness was a matter of
heredity only, but it was not merely a matter of
heredity. In many of the cases it was acquired,
and to prove th's one need only refer to that large
group due to disease in the first two or three years
of life. In patients who had a distinct heredity the
matter was not a simple one. Could anything be
suggested to diminish the number of cases of mental
defect? That could be done only if there was some
way to eliminate from the social system everything
that cnused it. There was a prospect of diminishing
the influence of alcohol, a potent factor in the de-
Aclo'pment of epilepsy, and mental defectives had
epileptic ancestors. With the elimination of alco-
holic poison from the social body there would be
a diminution in cases of mental defect. If there
v\'as any commission that could influence any legis-
lature, there was one law that should be passed with
reference to mental defect, and that was a law for-
bidding absolutely the marriage of close relatives.
The speaker had watched that matter with regard to
mental defectives and delinquents brought to him
in private practice and he had been so thoroughly
impressed with it that he had never failed to express
his opinion when relatives whom he knew had inter-
married. It was. true that Darwin had ridiculed
this belief expressed by observers of his time, but
Darwin himself was the offspring of a consanguine-
ous marriage. There had been advances in know-
ledge since Darwin's time, however, and those who
had studied the records could not fail to agree as
to the importance of this factor. If the stock was
absolutely pure on both sides there might be no
danger, but wherever there was the slightest taint
there was no doubt that it became intensified bv
intermarriage.
The question of feeblemindedness had been
driven home to the public in many ways, and anv
way in which success could be attained was legiti-
mate. There had been one claim brought forward,
however, which seemed unjustifiable and that was
that the feebleminded child was more or less a
potential criminal. Taking the entire number of
defects by and large, the number of criminals among
them was remarkably small, if one eliminated the
class, not defective but insane.
In many cases mental deficiency could be pre-
vented. The question was, could anything be done
for the relief of the already feebleminded, and the
answer was that much could be done through edu-
cation and vocational methods. Those were so im-
portant that another question arose from them and
792
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
that was whether enough was being done in creat-
ing the graded classes in the pubHc schools ; whether
there should not be for children of this class State
institutions which would take the child from the age
of three or four years and educate it all the way
up. There was a probable objection to that in that
the parents, who were willing to send their children
to ungraded classes, would not consent to send them
to ungraded schools, but that was a sentimental
objection that should be overcome, for these chil-
dren should be taken care of properly froin their
earliest years. That brought up again the question
of teachers for this class of pupils. The education
of such teachers was as pressing a need as any.
Any number of people had attempted the teaching
of defective children, but the average teacher who
had not been specially trained for this work was
unfit to carry it out.
MEDICAL ASSOCIATION OF THE
GREATER CITY OF NEW YORK.
Stated Meeting, Held February i8, ipi8.
The President, Dr. Edward E. Cornwall, of Brooklyn,
in the Chair.
(Continued from page 707.)
Syphilitic Joints. — Dr. Percy Willard Rob-
erts, of New York, said that modern pathologists
recognized that granulomatous masses were merely
tissue reactions which might be set up by any one of
several organisms, notably the Bacillus tuberculosis,
the treponema pallidum, and the Bacillus lepra, that
a differential diagnosis was at times impossible until
the invading microbe had been isolated. The trend
of events indicated the wisdom of correcting the
widely disseminated impression that every chronic
articular disability characterized by gradual onset,
the presence of spasm, atrophy, limitation of mo-
tion, limp, or alteration of attitude was due to
tuberculosis, for probably forty or fifty per cent., or
perhaps more, were sufifering from syphilitic infec-
tion. In this study of nearly two hundred cases it
had been revealed that the symptoms and radiologi-
cal characteristics of joint lesions due to inherited
syphilis were so nearly identical with those of tuber-
culosis that upon these factors alone dififerentiation
of the two conditions was impossible. The problem
of differentiation was reduced to the question of
either confirming or eliminating the presence of in-
herited syphilis. \A'hile the Wassermann reaction
was of considerable assistance, it was helpful only
when the test was done with sensitized antigens and
where full recognition was accorded the significance
of weak positive reactions. It was upon the dental
stigmata of syphilis that special emphasis should be
laid, for in every case thus far collected in this re-
search a clue to the diagnosis was obtained by ex-
amination of the dental structures. The therapeutic
test was more important than the Wassermann for
three reasons: first, a negative Wassermann did iiot
exclude syphilis ; second, a child might have_ in-
herited syphilis and consequently have a positive
Wassermann and yet his joint lesion might be due
to a superimposed tuberculosis : third, the judgment
of those able clinicians of earlier times whose
powers of observation were sharpened by the ab-
sence of present day laboratory refinements, could
not be ignored. The results of the therapeutic test
was striking, but it should not be assumed that every
patient enjoyed a prompt and rapid recovery. Re-
sults varied according to the type of tissue invaded,
the virulence of the organism and the cooperation
of the patient. Where there was no bone involve-
ment, joint symptoms of long standing usually dis-
appeared in a few weeks and sometimes with aston-
ishing rapidity. Bone lesions, on the other hand,
cleared up slowly, even when the accompanying
acute symptoms subsided quickly and where regen-
eration of bone did take place, approximately a )-ear
of continuous treatment was necessary.
Dr. Virgil P. Gibney, of New York, said that a
long association with cripples and with the fine class
of men studying their interests had shown a great
deal of progress in the relief of their sufferings and
much hope for the future. A great deal had been
accomplished in the amelioration of scrofulous and
tuberculous conditions. During the past year or two
very careful work had been done at the Hospital
for Ruptured and Crippled in the way of examining
and recording the dental conditions described by
Doctor Roberts. The moment these were found,
the patients were put under appropriate treatment,
and the results had been more than satisfactory.
The duration of treatment had been markedly
shortened, and many cases had cleared up which
had long resisted all the usual methods of treatment,
rest in bed, braces, climatic change, etc. The dis-
covery of this dental clue was a fresh inspiration
for courage in the treatment of these trying and
puzzling conditions.
Dr. Henry Ling Taylor, of New York, said that
the main point that emerged from these studies and
others that were being made was that the diagnosis
of tuberculous joint disease instead of being rather
simple, as was thought some years ago, was in fact
extremely difficult. The only way to make it posi-
tive was to recover the tubercle bacilli. Doctor
Roberts had pointed out that the routine diagnosis
of tuberculosis was not sufficient, since those in
clinical practice seldom had the opportunity of re-
covering the organism, and the pathological diagno-
sis remained uncertain in many cases ; therefore ex-
amination should also be made for other diseases.
For instance, syphilis of the lungs might be mistaken
for pulmonary tuberculosis. It was observed two
or three years ago that children suspected of syphi-
lis, but giving a negative Wassermann, often had
mothers with positive Wassermanns. In the last
year or so, a great deal of light had been thrown
on the frequency of unrecognized syphilis in chil-
"dren and adults. The evidence was now very strong
that children, apparently bright and healthy, might
have a latent syphilis and sometimes give a_ positive
Wassermann, "or might show characteristic teeth.
Besides the congenital type, children often had the
acquired form communicated by contact with
mother, nurse, or in other ways. A great advance
in this direction had been made by Doctor Roberts
and he had contributed very materially to the un-
derstanding of this subject, but there was a demand
for much more work along this line. The conclu-
November 2, 1918.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
793
sions, however, were not entirely new. Years ago,
various men claimed that syphilitic bone and joint
disease was extremely common in children, but they
did not furnish the proof and did not convince
many. Another observation had interested him a
great deal. He had recently gone over the annual
reports from the Hospital for Ruptured and
Crippled from the year 1893 to the present time and
tabulated the number of cases of chronic joint dis-
ease, usually put down under the title of osteitis,
which might he syphilis, or tuberculosis, or some
other infection, as it simply represented the type of
the disease, computing the number of cases in each
five year period and compared with the total attend-
ance of new patients in the corresponding periods.
There were more patients each year, yet the per-
centage of osteitis cases decreased to about one
fourth of the number in the first two periods. The
decrease was not steady, as shown by the annual
leports, but began about 191 1 and after that fell
rapidly. It might have been in part due to the
general decrease of tuberculous cases in the corn-
munity, and in part to better methods of diagnosis
adopted about that time which ruled out a certain
number of cases previously included.
Dr. George B.^rrte, of New York, said that m
many instances a given bone lesion might both
clinically and rontgenographically give a picture
impossible to dififerentiate from a tuberculous or a
syphilitic process. The dental diagnostic pomts
boctor Roberts had brought forward, furnished a
valuable aid in reaching a correct diagnosis.
Dr. CvKUS W. Field said that, as first understood,
a positive Wassermann reaction meant syphilis, a
negative reaction meant absence of syphilis. It was
now recognized that this was not true; that a
positive reaction meant syphilis in nearly 100 per
cent, but there were occasional cases which showed
a positive reaction in which neither history nor
pathological conditions pointed to the presence of
the disease. On the other hand, a negative Wasser-
mann did not rule out the presence of the disease
and these negative reactions were especially fre-
quent in the hereditary form of the disease. Doctor
Roberts was to be congratulated on havingVarried
on the study of malformation of the teeth beyond
the poitit at which Hutchinson had left it. It too
often happened that medical men, well knowing that
the disease occurred in the third and fourth genera-
tion, locked for syphilis only as an acquired dis-
ease, seldom remembering the fact that the patient
had a large number of ancestors. It seemed that
using both the complement fixation test for tuber-
culosis and the Wassermann reaction a more correct
idea could be obtained as to the etiological factor
in these cases of bone and joint lesions.
Dr. G. W. Vandegrift asked if Doctor Roberts
in studying the condition of the teeth had often ob-
served rhagades. In his own work he had often
observed the peg shaped teeth ; they were very com-
mon in congenital lues. He also asked if Doctor
Roberts had tried salvarsan in these cases. The
association of interstitial keratitis was also apropos,
for it was often met with in congenital syphilis, and
was also found associated with cases of hip joint
disease. He then cited two interesting cases ob-
served at Cornell, in sisters, twins, eighteen years
of age. One presented all the marks of congenital
syphilis, with a four plus Wassermann, Hutchin-
son's teeth, interstitial keratitis, etc. Her twin sister
was absolutely free from the disease, according to
every test that could be applied, a perfectly healthy
girl. A younger brother, aged six, had been treated
for years for tuberculosis of the hip. He was put
upon antisyphilitic treatment and improved very
mu."h.
Dr. W. B. Cornell, of New York, asked if Doc-
tor Roberts had published reports of the cases ex-
amined at Randall's Island. He had been deeply
interested, especially in that part of the paper re-
ferring to these cases, since at Randall's Island in
a large percentage of the cases the patients showed
evidence of dental deformity and abnormality
presumably due to syphilis. This work seemed ex-
tremely valuable and stimulating. He abso asked
what line of treatment Doctor Roberts found to be
most successful.
Doctor Roberts replied that as to rhagades, he had
seen them only a few times and had wondered that
they virere not rnore frequently present, but after all
this was only another instance of the absence of
those points popularly supposed to indicate con-
genital syphilis, and partly explained why tfi!s con-
dition was so often overlooked. As for salvarsan,
he had not yet liad an opportunity for trying it in
these cases, but hopeS to be able to do so. Theo-
retically, it ought to be beneficial in the joint cases
without bone lesions, and there were a number in
that category. As for treatment, he had relied
mainly on the old fashioned mixed method. He had
not made a definite record of the cases examined
at Randall's Island. While he appreciated the priv-
ilege at the time, he regretted now that he had made
this examination so early, for if it had been made
with a fuller knowledge of dental stigmata he
would have gleaned more valuable information
from it. He had not made any tabulation of the
cases, but had seen about sixty without joint symp-
toms but v/ith positive Wassermanns, and 700 or
800 others who were simply defective children.
Stated Meeting, Held March 18, ipi8.
The Picsident, Dr. Edv/ard E. Cornwall, Brooklyn, in the
Chair.
symposium: prevention of disease in the army.
The Control of Som€ of the More Important
Camp Diseases. — Dr. William H. Park, director
of the Bureau of Laboratories, Health Department,
New York city, delivered this address in which he
reviewed the results of treatment of such epidemic
and endemic forms of the important infectious dis-
eases as had occurred in the armv during the war.
Cerebrospinal Meningitis. — There had been
considerable interest manifested in the situation as
regards cerebrospinal meningitis. The disease had
been prevalent during the cool months in the camps
of all the fighting nations. A very significant fact
in this connection was that wherever cases of the
disease had developed and bacterial examinations
had been properly made, carriers of virulent types
of meningococci had been discovered. The carrier
rate had been carefully studied by the English in
r
794
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
the civil and military population in both the endemic
and epidemic forms. Two to five per cent, were
found infected where the disease was endemic, in
one garrison the carrier rate increasing as winter
approached until it reached an extraordinary height
in December, accompanying a somewhat propor-
tional increase in the number of cases. A rapid
succession of cases tended to increase the virulence
of the meningococci. The greatest number of car-
riers were found during the winter and early spring
months. The means for checking the spread of the
disease divided themselves into three lines. I. The
individual soldiers were protected as far as possible
from infection by suitable ventilation and floor
space, the elimination of carriers detected by cul-
tures, and cleanliness both in the individuals and
their surroundings. 2. Prophylactic injection of
meningococci killed by a low heat or suitable anti-
septic had been used experimentally both in animals
and man with apparently favorable results. Only
a serum known to be polyvalent should be used for
treatment. 3. Disinfection of carriers had been at-
tempted on a very large scale with considerable suc-
cess. The best results had been obtained where the
carriers entered rooms filled with a very fine spray.
Zinc sulphate in one per cent, solution and chlora-
mine-T in a one or two per cent, solution had given
the best results. Anterior and posterior nasal
sprays had also been used with some success. Men-
ingitis was one of the most important of the camp
infections.
Pneumonia. — Lobar and bronchopneumonia
due to exposure or as complication of measles and
other infections were common both in the camps
abroad and in the fighting area. In many cases in
France the temperature fell shortly after the use of
• serum. In two large camps all the men had been
vaccinated. In one camp, the cases became milder
and less frequent about ten days after the second
inoculation. In the other camp, the course of the
epidemic was unchanged. The train of pneumo-
cocci used came from a case in the first camp and it
is possible that the type of pneumococci in the sec-
ond camp was different. The results in South
Africa were very encouraging.
Typhoid Fever. — The greatest accomplish-
ment in the prevention of disease during the pres-
ent war had unquestionably been the limitation of
typhoid and paratyphoid fevers through vaccina-
tion. The military and «ivil authorities in all
countries were in accord as to this. The results in
the French Army were most striking. At the be-
ginning of the war less than half of the troops had
been vaccinated against typhoid fever and none
against paratyphoid fever. During the fall of 1914
and the early winter of 191 5, many cases developed,
but with improved conditions and the general use
of typhoid vaccines, the incidence gradually im-
proved. With the hot weather the number of cases
increased somewhat, but bacterial examinations re-
vealed that they were mostly paratyphoid fever.
During the winter and spring of 191 5 typhoid vac-
cination was pushed, but it was only in the fall that
the use of paratyphoid vaccines was undertaken.
Before summer in 1916, the troops had all been
vaccinated against both the typhoid and paratyphoid
[New York
Medical Journal.
A. and B bacilli. The sanitary conditions were also
better. T,he combined result of the vaccination
and the better care was that at the worst periods
less than one per cent, of the cases developed as
compared to 1914, and less than 10 per cent, of the
summer of 191 5. In 1917 results were even bet-
ter. The English from the start vaccinated all
their troops against typhoid fever, and after the
first year against the paratyphoid fevers. The san-
itation had always been good. The combined effect
had been to make typhoid and paratyphoid fever
cases very infrequent.
Tetanus. — During the early part of the war
there were twenty-four cases in each 1,000 of
English wounded and still more among the French.
Injections of antitetanus serums were first made
compulsory in all cases with infected wounds and
then in all the wounded. Less than one in 1,000
now developed tetanus in the English and French
armies, and these rare cases were usually those who
received no antitoxin. The serum in the developed
cases in France was mostly given subcutaneously or
intravenously ; the British advocated the intraspinal
method.
Trench Fever. — This was a form of relapsing
fever occurring especially among the English troops
in Flanders. The fever was accompanied by head-
ache and pains in the lower limbs. The blood con-
tained infectious organisms which did not pass the
stone filter. Microscopical examination revealed
no microorganisms. It was probably conveyed by
insects.
Dysentery. — The bacillary and amebic types of
dysentery h.ad been moderately prev^alent in both
the French and English armies. The amebic form
occurred during all seasons of the year, while the
bacillary form occurred only in hot weather. At
some portion of the front the Shiga infection was
most important, at others those due to the other
strains. A number of persons suffered simultane-
ously from both infections. There was no specific
treatment to prevent infection in dvsentery. The
ordinary precautions used against intestinal infec-
tions were employed as thoroughly as possible.
The vaccines so far prepared from the various
strains of dysentery bacilli had been too toxic to be
much used. The use of specific serum and bacillus
mixtures, sensitized vaccine, was still in the experi-
mental stage. There had been no vaccine devel-
oped which was effective in producing immunity
against infections due to the ameba. In the treat-
ment of severe cases, the polyvalent serum from
horses which had been injected with the various
types of bacilli, was administered simultaneously.
The earlier it was given the better. When one type
of bacilli was found to be the sole cause of the
local epidemic, a serum especially potent for this
type Avas employed if it was possible to obtain it.
The usual treatment of carriers with emetine hy-
drochloride was found in more than half of the
cases to fail to rid them of the infection. Lately,
emetine bismuth iodide had been substituted by the
English with better results. In order to prevent
diarrhea and vomiting the emetine could be given
in coated pills.
November 2, 19 iS.]
BOOK REVIEWS.
795
Venereal Diseases. — Major Sigmund Hollit-
ZEU, M. R. C, of the Surgeon General's Ad-
visory Board for Skin and Venereal Diseases, read
this paper. ^He deplored the belief that venereal
disease was of minor importance. The efifective
strength of an army was reduced by every man in
the hospital, and from this point of view it made no
difference Vv'hether the man was ineffective on ac-
count of pneumonia, meningitis, typhoid, or on ac-
count of orchitis, prostatitis, or gonorrheal arthritis.
This elementary fact, taken in conjunction with the
enormous preponderance of venereal diseases over
all other communicable diseases, made it evident
that the former were by no means less important
than the latter. The medical authorities of the
army were thoroughly alive to the importance of the
venereal peril. Their campaign against venereal
diseases included efforts directed toward the sol-
diers personally and toward the reduction of the
temptations to which they might be exposed. The
soldier was taught by pamphlets, lectures, moving
pictures, and other exhibitions that the venereal
diseases were really serious, oftentimes leading to
permanent disability and death ; that sexual rela-
tions not only were not a necessity but that the most
perfect physical condition, as in the training for an
athletic contest, demanded complete sexual conti-
nence. Every case of acute venereal disease was
hospitalized and a day's pay for every day in the
hospital was forfeited. If he failed to avoid ven-
ereal infection, he was required to make prompt
use of the prophylactic means provided, both at his
regimental infirmary and in the nearby city in which
he was exposed to infection. If he was found with
a fresh infection and could not show a record of
prophylactic treatment he was courtmartialed and
punished as for a violation of a regulation. To
help him maintain his morale, all sorts of measures
were employed wliich experience had shown to be
of use: athletic sports, entertainments of many
kinds, etc. No unchaperoned women were per-
mitted in the cantonments, and in a five mile zone
around each cantonment absolute police authority
, was vested in the Public Health Service. In addi-
tion, the civic authorities throughout the country
were urged to cooperate in these efforts to control
vice in the various communities, and many cities
had been cleaned up as never before in their history.
The eft'ect of all these measures, so far as could be
determined, had been excellent. The army today
was far more free from venereal disease than the
communities from which the men came. There
were many old cases that came in with the draft
men that were gradually being discovered and
treated, but the fresh infections were an insignifi-
cant proportion of the whole number. It might
safely be stated that the U. S. Army today was
made up of the cleanest lot of young men that were
ever gathered together. In conclusion, the speaker
emphasized the fact that venereal diseases did not
arise spontaneously ; that every case in the armv
micant a carrier in the civil community ; and that
there was urgent need for more thorough methods
of treatment and the active support on the part
of medical men of all intelligent measures tending
to diminish the venereal peril.
(To be continued.)
Book Reviews.
[We publish full lists of looks received, but we acknowl-
edge no oblir/atinn to review them all. Nevertheless, so
far as space permits, zve review those in zahich zve think
our readers are likely to he interested.]
Hcadaclics and Eye Disorders of Nasal Origin. By Grfen-
FiELD Sluder, M. D., Clinical Professor and Director of
the Department of Laryngology and RhinoloKy,_ Wash-
ington University Medical School, St. Louis. With One
Hundred and Fifteen Illustrations. St. Louis : C. V.
Mosby Company, 1918. Pp. 272.
Among the valuable acquisitions of modern medi-
cine there are few of greater importance than the
recognition of the intimate anatomical and physio-
logical relations between the orbit with its contents,
on the one hand, and the surrounding cavities in the
bones of the face, on the other. The mutual inter-
action of the pathological processes in these regions
has engaged the attention for the last twenty-five
or thirty years of some of the best eye, ear, nose,
and throat men both in Europe and in this country,
and thanks to their unremitting labors we are in a
fair way of establishing a definite pathology and
treatment of many hitherto unintelligible sinus and
eye conditions. The ophthalmologist is frequently
placed in a position where he can detect an early
sinus affection by the aid of distinct eye symptoms,
and in fact some authors (Snydeckers) go so far
as to claim that seven to ten per cent, of the patients
who consult the ophthalmologist for what is pre-
sumably ocular headache suffer from diseased
sinuses. On the other hand many affections of the
eye that are obstinate to any kind of treatment can
finall-y be traced to disease of a neighboring sinus or
sinuses, with the proper treatment of which the eye
condition will rapidly subside.
Among the pioneers in this line of work in the
United States is Dr. Greenfield Sluder whose book,
embodying as it does the results of painstaking inves-
tigations and studies extending over a period of al-
most a quarter of a century,, forms a distinct and
valuable contribution to the subject of the interrela-
tion between the eye and the adjacent sinuses. The
work presents a mass of accumulated clinical ex-
perience conducted with scientific accuracy and
mental acumen by one who has complete control of
the ground covered. It is unusually rich in an-
atomic data, which practically form its ground work
and which enhance its value so much the more. It
is introduced by a preface from the pen of the well
known medical scholar. Dr. Jonathan Wright, who
discusses certain points in the minute pathological
anatomy of the process, and is divided in three large
parts, followed by a series of clinical cases that serve
to elucidate the text in the body of the book. The
first chapter treats of vacutmi frontal (as well as
ethmoid and antrum) headaches with eye symptoms
only, and in the symptomatology we find particular
stress laid on Ewing's sign — tenderness of the tipper
inner angle of the orbit at the point of attachment
of the pulley of the superior orbit and internal and
posteiior to it. That this sign is uniformly present
not all the atithors agree (Brawley), and in view of
the fact that the headache is usually unilateral it is
recommended that pressure be made on correspond-
ing points in both orbits, when greater tenderness
796
BOOK REVIEWS.— BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Jourxai,.
will be elicited on the aftccted side. The exposition
of this class of cases is gone into with the author's
usual thoroughness anatomically and * pathologi-
cally, and diagnosis and treatment are given. Chap-
ter II is taken up with the syndrome of Nasal
(Sphenopalatine — IMeckel's) Ganglion Neurosis,
showing that clinical manifestations must of neces-
sity arise as a result of intimate anatomical relations
between the nasal ganglion and the surrounding and
neighboring tissues. The treatment of the subject
is carried out in accordance with anatomical and
physiological findings, into the discussion of which
we cannot possibly enter here: we will, however, say
that it may well repay reading, or shall we em-
phasize studying t\ii<. chapter very thoroughly, for
it contains valuable information for every rhinol-
ogist and eye man. The third chapter is devoted to
the subject of hyperplastic sphenoiditis in which the
author has done a great deal of original work, as
can be judged by his numerous investigations of
the anatomical interrelations between the sphenoid,
the immediate nerves, the cavernous sinus, the Eu-
stachian tube, as well as the adjacent foramina and
canals. The clinical manifestations of sphenoidal
disease are traced directly to anatomical causes. The
diagnosis, prognosis, and treatment of the condition
are gone into with the author's characteristic mi-
nuteness, especially the treatment, which the reader
win surely peruse with interest and profit. The
closing portion of the volume is given over to case
histories, the remarkable feature of which is the ex-
tensive variety of ocular afYections that can be
traced to sinus disease. They embrace such condi-
tions as intractable blepharospasm with great lacri-
mation, ophthalmic migraine, iritis, choroiditis, and
acute blindness. A useful reference list is appended.
The book presents an attractive appearance and will
form a valuable addition to the specialist's library.
<$)
Births, Marriages, and Deaths.
Died.
B.\KER.— In Philadelijhia, Pa., on Wednesday, October
23d, Dr. Jane R. Baker, aged fifty-one years.
Bedell.— In New York, N. Y., on Thursday. October
24th, Dr. William J. Bedell, aged forty-eight years.
Eekr.— At Fort Slocum, N. Y., on Tuesday, October 8th,
Dr. .A.lfred William Berr, aged thirty years.
BoGUE.— In Montclair, N. J., on Saturday, October 26th,
Dr. Frederick Lovell Bogue, aged forty-eight years.
BuFFUM. — In Liverpool, England, on Sunday, October
1.3th. Dr. William Henry Buffum, of Providence, R. I.,
aged forty-two years.
BuRic.^RTM.'ViER.— In Avondale, Pa., on Wednesday, Oc-
tober i6th, Dr. John H. Burkartmaier, aged thirty-five
years.
BuRNHAM.— In Essex, Mass., on Thursday, October loth,
Dr. E. Bennett Burnham, aged forty-four years.
BuTLEP. — In Fall River, Mass., on Friday, October nth.
Dr. William H. Butler, aged fifty-one years.
Collins.— In Albany, K. Y., on Monday, October 14th,
Dr. Charles E. Collins.
Cot.TTLLARP. — In Manchaug, Mass., on Friday, October
nth, Dr. Pierre L. Couillard. aged sixty-eight years.
CowLi-s — In West Brookfield, Mass., on Wednesday,
October i6th, Dr. Frederick Waterman Cowles, aged sixty-
two years.
Day. — In Newburyport, Mass., on Friday, October iSth,
Dr. Clarence C. Da v. aged fifty-three years.
Deems.— In Flushing, N. Y., on Sundav, October 27th,
Di . Francis AI. Deems, aged seventy-two years.
Di AIattf.o. — In Newark, N. J., on Monday, October
14th, Dr. Francis Robert Di Matteo, aged forty-one years.
Douglas. — In Newark, N. J., on Wednesday, October
i6th. Dr. William J. Douglas, aged thirty-four years.
Gardixer.— At Atlantic City, N. J., on Friday, October
i8th, Dr. William G. Gardiner, aged fifty years.
Gregory. — In Dansville, N. Y., on Saturday, October
26th, Dr. Walter E. Gregory.
Hammonu. — At Camp Lee, Va., on Thursday, October
loth. Dr. Ralph L. Hammond, of Ridgewood, N. J., aged
twenty-six years.
Kellogg. — In Seneca Falls, N. Y., on Wednesday, Octo-
ber Qth, Dr. Frank G. Kellogg.
Kemp. — In New York, N. Y., on Wednesday, October
23d, Dr. Robert Coleman Kemp, aged fifty-three years.
Koch. — In Paterson, N. J., on Saturday, October 19th,
Dr. George J. Koch, aged thirty-five years.
La Monte.— In Carmel, N. Y., on Wednesday, October
Qth, Dr. Austin La Monte, aged eighty-one years.
Le.witt. -In Brooklyn, N. Y., on Thursday, October
24th, Dr. Emanuel J. Leavitt.
Lincoln. — In Dodgeville, Wis., on Sunday, October 13th.
Dr. Walter Stephen Lincoln, aged fifty-four years.
Lockwood. — In Craig, Ohio, on Thursday, October loth.
Dr. Francis William Lockwood, aged forty years.
LtTBiN. — In New York, N. Y., on Sunday, October 27th,
Dr. Edward Kenneth Lubin, aged twenty-three years.
Merle.— In gatavia, N. Y., on Friday, October nth. Dr.
C. W. Merle, aged twenty-seven years.
Miller. — In Bound Brook, N. J., on Thursday, October
3d. Dr. John L. Miller, aged sixty-nine years.
Morris. — In Fall River, Mass., on Friday, October iith,
Lieutenant William S. Morris, Medical Corps, U. S. A.,
aged twenty-eight years.
O'Donxell. — In Los Angeles, Cal., on Friday, October
i8th, Dr. John J. O'Donnell, of Boston, Mass, aged thirty-
three years.
Osgood. — In Boston, Mass., on Friday, October 18th, Dr.
Gardner H. Osgood, aged forty years.
OuEii.ET. — In Orwell, Vt., on Saturday, October 12th,
Di. L. F. A. Ouellet, aged forty-eight years.
PfRHAM. — In Concord, N. H., on Saturday, October
19th. Dr Harry L. Perham, aged thirty-four vears.
Petersen. — In New York, N. Y., on Monday, October
2i5t, Dr. Leo S. Petersen, aged thirty-one years.
PiLON. — In Vergennes, Vt., on Monday, October 14th.
Dr. Edward Pilon, aged fifty-five years.
Pi..\GEMAN. — In Brooklyn. N. Y., on Thursday, October
17th, Dr. Rudolph B. Pla.geman, aged sixty-seven years.
P'ORTER. — In Caribou, Me., on Sunday, October 20th, Dr.
Joseph W. H. Porter, aged forty years.
Preston. — In Dansville, N. Y., on Wednesday, October
i6th. Dr. Ella Preston.
Reynolds. — In Clinton, Conn., on Wednesday, October
9th, Dr. Herbert H. Reynolds, aged fifty-eight years.
Rosenthal. — At Markleton, Pa., on Tuesday, October
22d. Lieutenant Joseph B. Rosenthal, Medical Corps,
U. S. Army, aged twenty-seven years.
Schall. — In Rochester, N. Y., on Wednesday. October
9th, Dr. Harry Mayer Schall, aged fiftv-five years.
SiMONTOiV. — In Centreville, ]Md., on Friday. October nth,
Dr. Lawrence J. Simonton, aged thirty-eight vears.
Smith. — In Orange, Alas?., on Thursday, October loth,
Dr. Hiram F. "SI. Smith, aged fifty-nine vears.
Stoil. — In Pottsville, Pa., on Tuesday, October 22d,
Dr Josenh Stoll, of New York city, aged thirty years.
Thi'RRIEn. — In Marlboro, Mass., on Monday, October
14th. Dr. Edward J. Therrien. aged sixty-two vears.
Turner.— At Camp Benjamin Harrison, Ind.. on Friday,
October nth. Captain William G. Turner, aged thirty-nine
years.
VoN Seutter. — In Jackson, Miss., on Friday, October
nth Dr. Edward R. Von Seutter.
Walsh.- -In Portland, Conn., on Sunday, October 20th,
Dr. Joseph W. Walsh, a.ged thirty-three years.
Wankell. — In Boston. Mass., on Tuesday, October 15th,
Dr. George Channing Wankell, aged thirty-six vears.
Westbrook. — In ^'ancou^er, B. C, on Sundav, October
20th, Dr. Frank Faircbild Westbrook, aged fifty years.
Young. — In Fort Plain, N. Y.. on Tuesday October i.;th,
Dr. \\'illiam H. Young, aged thirty-six years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 8 43
Vol. CVIII, No. 19.
NEW YORK, SATURDAY, NOVEMBER 9, 1918.
Whole No. 2084.
Original Communications
DESTRUCTION OF THE PHYSIOLOGICAL
FUNCTION AFTER OPERATIONS ON
THE NOSE AND THROAT*
By Wolff Freudenthal, M. D.,
New York.
It is not the aim of this paper to present a de-
scription of the untoward results of operations,
similar to one given several years ago by John Mac-
kenzie on the massacre of the tonsil. Its purpose,
rather, is to induce the rhinolaryngologist to con-
sider the physiology of the upper air tract more
thoroughly than has been done during the last
tw^enty years of successful nasal and pharyngeal
work, and to keep in mind the untoward results
following procedures that are considered nowadays
both legitimate and necessary.
PHYSIOLOGY OF THE NOSE
A great deal has been written on this subject, but
no universal agreement has yet been reached on
some of the most important questions to be con-
sidered here. The writer is pleased to note that
some of the fundamental principles laid down by
him are being gradually recognized. In order to
understand the complaints of patients — in other
words, the pathology — one must turn to the physio-
logical functions of the nose and investigate the re-
quirements of normal respiration through that
organ. The old theory that the nose has to filter,
warm, and moisten the air is still recognized today.
To accomplish this process nature has provided
many devices. The interior of the nose does not
represent a straight tunnel, but a complicated struc-
ture preventing the air from passing in a straight
line to the pharynx. A variety of bones and cartil-
ages covered with an important mucous membrane
has been set up in order that the air should strike
them, thus enabling the air to become physically
adapted for its work in the lower portions of the air
passages. Just as the food is prepared or rendered
digestible by the act of chewing, salivation, etc., in
the upper digestive tract, so the air is prepared in
the nose, in order to be assimilated, as I have called
the process.
Process of filtering. — The process of filtering the
•Read at the Thirteenth Annual Meeting of the American Acad-
emy of Ophthalmology and Oto-Laryngology, held at Denver, Colo..
August s and 6, 1918, and before the New York Physicians'
Association, September 24, 191 8.
Copyright, 1918, by A, R,
inspired air is probably the most important function..
In this respect the epithelial cells of the mucous
membrane are probably a primary and essential
factor of resistance against disease. Owen Paget
( I-) even believes that the epithelial cells of the tur-
binates and nasal sinuses have a special capacity to
form antibodies against tuberculosis. An intact
mucosa will therefore mean a great deal for the
filtering function of the nose. ^
Warming the air. — The second requirement, that
of warming the air, is so easily understood that it
need not be discussed at length. As Aschenbrandt
and R. Kayser have proven long ago, the air is
heated to 30° C. in the nose, regardless of what the
outer temperature may be. So here again it must
be repeated that the mucosa, and especially an in-
tact one, is essential for the work to be done.
Moistening the insfired air. — Much more difficult
is the third task — moistening the inspired air.
The value of this question, to which the writer has
given much thought and study for many years, is,
it seems, not universally appreciated by physicians.
The idea still exists in some quarters that this is
rather an unimportant factor, that it can be ac-
complished by the mucous membrane under almost
any circumstances and in nearly every kind of en-
vironment.
As early as 1895 I tried to establish the following
facts: that, i, a dry mucosa and, even more so, an
atrophic one, is never able to moisten the inhaled
ail satisfactorily; and 2, that the air, to be breathed
in, must contain a certain percentage of humidity in
order to be easily "assimilated." In proof of these
theories many points were brought out that year
and since that time. Suffice it so say that, as dis-
closed by many investigations, the fact was estab-
lished that the dwellings inhabited by us and in
which we often spend the entire day, do not
contain nearly enough humidity for physiological
respiration. When the air in our rooms is nearly
dry, as it frequently is, it desiccates the mucosa,
thus causing pathological changes, to be discussed
later on.
The normal mucosa of the nose is capable
of overcoming the lack of moisture in the air tc
a certain degree only ; beyond that it dries out and
can no longer be a factor in assimilating the inhaled
air. Thus a rhinitis sicca is produced with or with-
out a corresponding condition in the pharynx and
nasopharynx. A number of these cases finally re-
Elliott Publishing Company.
798
FREUDENTHAL: DESTRUCTION OF FUNCTION AFTER OPERATION. „ [N^w York
Medical Journal,
suit in atrophy.^ This process of desiccation that
has been observed in other parts of the organism as
well, has been named xerasia by the writer, while
Sticker, who independently came to similar con-
clusions, called it xerosis.
In distinct contradiction to these findings of mine
were certain studies of the effect of various atmos-
pheric conditions upon the upper respiratory tract,
a work to which the prize was awarded by a nation-
al society (3). The author's conclusions, as just
mentioned, differ greatly from mine. By analyzing
his paper, however, so much will be found that is
based on erroneous experiments and deductions that
his work cannot be considered conclusive or final.
Firstly, the exposure of any person, for a short
period of time, to the atmosphere of a room fol-
lowed by a change to another room with different
atmospheric conditions will give rise to only acute
symptoms, but never will it produce a rhinitis sicca,
which is brought about by many months, or prob-
ably years, of living in a vitiated atmosphere, i. e.,
vitiated as to the lack of humidity. Some of those ex-
amined by the author of these experiments showed
an enlarged turbinal, others showed redness or
the reverse, again others, increased moisture, etc.
But what does all this prove? Absohitely nothing.
These symptoms may or may not change when the
condition becomes chronic. Besides the individual
susceptibility to drafts, exposures, etc., had not
been tested beforehand, so that a good deal of the
value of these experiments is lost for this reason
alone. Furthermore, there is a great difference of
findings in different seasons •f the year, as pointed
out by the writer and M. Behr (4). During the
month of February, for example, there are many
more cases of rhinitis sicca than in August. Such
variations ought to have some effect on experiments.
Then the assertion that some cases showed in-
creased or decreased moisture brings up the ques-
tion : How was the moisture measured ; by the
Glatzel method? Certainly few physicists would
consider that conclusive. But the strongest point
against my deductions was made by this author on
the statement that laundry workers, who spent most
of their time in a moist atmosphere, "showed by far
the largest percentage of cases of atrophic rhinitis
of any of the groups." This puzzled me only until
I found an explanation for the mistake made in
the article referred to above. On page 166 one
finds the following: "Investigation of the laundiy
plants shows that the steam comes directly up into
the faces of the workers standing near the mangles,
washing machines, and other appliances much of
the time. In fact we feel certain that these steam
laundry workers are far more exposed to high de-
grees of humidity than the figures indicate." It
appears as if the last sentence was written in sup-
port of the author's theory, or supposed theory, that
a great amount of moisture in the air is rather con-
ducive to atrophic rhinitis, for among thirty-three
laundry workers examined he found twenty-one
'Regarding the development of atrophic rhinitis in the climate
of Colorado, the opinions of two prominent rhinologists seem to
differ. While Doctor Gallaher believes that this is rarely the case,
I5r. Robert Levy expresses a contrary view (2). But do these
gentlemen mean the same condition in speaking of atrophic rhini-
tis as I do? And do they agree with each other about thai
disease?
suffering from that disease, or sixty-three per cent.
But if one examines these statements more closely
one finds that "the steam comes directly up into the
faces of the workers . . ." and naturally up into
the nose. And what happens when steam at a high
temperature is brought in close contact with such a
delicate organ as the nasal mucosa will be easily un-
derstood. It simply destroys the membrane or
burns it. The skin of the face may or may not
withstand the insults of the hot steam — the author
does not mention anything about that point — but the
nasal mucosa gradually undergoes atrophy. Place
those laundry workers wherever you please, in ab-
solutely dry or absolutely moist air, the result will
always be the same — atrophy.
In the second table under this heading the author
shows the average atmospheric conditions in a large
number of boiler and engine rooms. Surprising
to say, according to his findings, the average rela-
tive humidity was only 26.5 per cent. In other
words it was only one half of what he himself had
designated as normal (fifty per cent.). We, there-
fore, have here a deficiency of humidity in the air
and not a surplus of it. How the author could give
this as a proof of his theory, it is difficult to under-
stand. On the other hand, this is exactly what I
tried to prove long ago, viz., that the lack of suffi-
cient moisture in the air is exactly what produces
a rhinitis sicca and finally a rhinitis atrophicans.
It is not a pleasant task to scrupulously analyze
somebody else's work. I hope, however, it will be
understood that this is not a personal matter, but
one of greatest importance, not only in regard to
heating and ventilation, but more so as to the pre-
vention of a number of nasal affections with all
their sequelae. It is my claim that during the winter
months people suffer from lack of indoor humidity,
and it is not a matter of indifference if that is
denied by others.
This question has commenced to attract the at-
tention of the medical and lay public. But even in
the minds of such a distinguished body of men as
the editorial writers of the Journal of the American
Medical Association there seems to be con-
fusion. In that journal (5) we find: "The question
as to whether the atmosphere can ever become too
dry for comfort or physiologic wellbeing has not
yet been satisfactorily answered." It seems to me
that I answered that question long ago in the same
journal (6). But in spite of the above sentence the
editorial continues : "In cold weather the moisture
may be largely precipitated from the air so that it
becomes extremely dry when it enters houses. This
led to the desire and the practice to moisten such
air." What a contrast between these two sentences.
Frederic S. Lee (7) has written an article along
the same lines, in which occurs the following : "The
harmfulness of living in confined air is found in
certain physical rather than chemical features — the
air is too warm, too moist and too still ; and if it
has not these physical features it is not harmful."
"Too warm" may be true, "too still" may also be
correct, but "too moist" is a grave mistake. I
should like to see any ordinary living or office room,
when the outside temperature is below the freezing
point, that shows by actual measurement the pres-
November 9. 1918.] FREUDENTHAL: DESTRUCTION OF FUNCTION AFTER OPERATION.
799
ence of too much moisture in the air. I wonder
how many dwellings Lee has examined to that effect.
In all my investigations the humidity was reduced
to such a low degree that its absence showed dis-
tinct pathological effects on the mucosa of the upper
air tract.
It should be mentioned here that, in 1916, Dr. S.
Josephine Baker (8) made investigations in coopera-
tion with the New York State Commission on
Ventilation as to the value of certain kinds of
ventilation, etc. As these studies have a bearing
on our theme, the conclusions arrived at by Doctor
Baker may be mentioned here :
"Children in classrooms with closed windows and
ventilated by mechanical methods were more sub-
ject to respiratory diseases, severe enough to keep
them from school attendance, than were children
who were in classrooms kept at the same or lower
temperature and ventilated wholly by open win-
dows." And then again :
"Children in classrooms with closed windows and
ventilated by mechanical methode were more sub-
ject to respiratory diseases not sufficiently severe to
keep them from school attendance than were chil-
dren who were in classrooms kept at the same or
lower temperature and ventilated wholly by open
windows. The relative humidity of classrooms,
whether ventilated by natural or mechanical means,
was not a causative factor in the occurrence of res-
piratory illness among school children."
It is especially the last sentence that deserves
our attention. Such a broad statement as this has
to be proven, but we looked in vain for any proof.
Later on the same author says : "It seems impossible
to show any relation between the percentage of ab-
sence and the relative humidity and saturation defi-
cit." Of course not ; such a thing could not be
demonstrated at once. One cannot say, that on ac-
count of a saturation deficit fifty or one hundred
pupils are absent today or will be absent tomorrow.
Such influences work slowly, as mentioned above,
and they may not be noticed until many months
have elapsed. Further on we find : "Where the
relative humidity was low, one class with twenty-
one had an absence percentage of 6.8 while another
with a relative humidity of twenty-eight had an ab-
sence percentage of 31.0." We hope the author
does not consider twenty-eight a high relative hu-
midity ; the lowest normal is forty per cent., and
it is only above forty that human beings feel com-
fortable (of course up to a certain point only). But
from these quotations it can be seen that no con-
clusions should be drawn from such findings. Ex-
periments have to be carried on differently when
the question of moisture is involved.
To overcome this deficiency of moisture many a
device has been recommended. P. W. Goldsbury
realized the importance of the problem of con-
structing buildings in such a way as to keep the in-
terior up to a fair degree of humidity. But he
thinks that so far engineers have made little practi-
cal progress toward its solution. Their ingenuity
has been taxed to improve the moisture in large
public buildings. The devices for this have so far
proved too expensive for private dwellings, hotels,
offices, or school houses (9). Bryce, of Ottawa,
who very likely had a similar experience, says that
seventy-five gallons of water must be evaporated
daily in an ordinary sized house to maintain reason-
able humidity "under the conditions of our northern
winter." It seems plausible that this stater- t
holds good for New York as well. But of the n.
devices recommended for such a purpose, we ca.
not recommend any. Even the four radiator de-
vices as tested by E. P. Lyon at the University of
Michigan are "practically worthless."
CLIMATIC CONDITIONS SIMULATING OPERATIVE
INTERFERENCE.
The question of humidity has been discussed here
at considerable length and you may justly ask, for
what reason? The reason is that our indoor life,
especially in winter, and the lack of sufficient in-
door humidity bring about certain symptoms that
frequently seem to be a strict indication for opera-
tive intervention, but in reality are not. Let us
illustrate this by a few examples :
Case I. — A. P. came into my clinic complaining that his
nose was stopped up. On examination the right side was
foimd to be wide, almost atrophic, and very dry. The
left side was clogged by the septum being deviated toward
the left, to such a degree that there was only a narrow
opening. The mucous membrane here was in quite a good
condition. When the patient was asked through which
side he could breathe the better, he promptly answered:
"The left one," i. e., the narrow side. The patient was
operated on and his septum straightened out with ex-
cellent immediate results. Soon afterwards he returned how-
ever, complaining bitterly that while formerly he could
breathe at least through the left side, now that side was
gone too. Crusts were found there and the mucosa did
not show the same healthy appearance as before the op-
eration.
Case II. — J. D. feels a dryness in the throat, especially
in winter. He has been operated on many times and (as
a result?) has lost his sense of smell. "Since my first
operation I feel no air. Plenty of room." This man's
nose is characteristic by the absence of both inferior and
middle turbinated bodies. The septum has been straight-
ened, and he asked, "What else is there to operate upon?"
The nasal air passages were large and the mucosa dry.
In Case I there was a tendency toward atro-
phy that was evident on the right side. No sooner
had we operated on the other side, than the same
process set in there, destroying the physiological
function of the mucosa on that side as well. In
the second case the nasal passages were made so
wide that the air reached the pharynx in a direct
line. There was no possibility of assimilating the
air to the needs of the organism, and the patient
felt a real hunger for air. A similar experience was
reported by Dr. A. T. Weil, of New Orleans :
Case III. — A colleague in his city had suffered from
nose trouble since childhood. Tonsils and adenoids were
removed in childhood. He became a physician, but still
suffered, and some turbinates were taken out by a spe-
cialist. Not feeling relieved, he consulted another laryn-
Rologist, who said: "Your turbinals were removed? Why,
they are immense." Again they were operated upon, and
a year later a third time. Thereafter he became hoarse
easily, and again was examined by three other laryngolo-
gists, each one declaring, independently of the others, that
the patient had a sigmoid shaped septum and that his voice
could never improve without the septum being straight-
ened. That was done, and now he is worse than ever be-
fore. His mucosa "swells" at the slightest provocation, so
that he is unable to breathe. He suffers from hoarseness
and, in short, feels miserable.
8oo
FREUDENTHAL: DESTRUCTION OF FUNCTION AFTER OPERATION. „ [N^w York
Medical Journal.
While writino: this another colleague consulted
me, regarding a similar case.
These cases, and many others observed later on,
n)ade me pause to consider in how far we are justi-
fied in performing certain operations. Tt was clear
to my mind that we had gone too far in these opera-
tions, and that the patient's complaints were due
to climatic conditions and not to an easily percept-
ible, faulty formation of the septum or the
turbinals. If simpler methods had been used the
patients would have experienced relief very soon,
which is impossible if a real, cartilaginous, bony
obstruction is the cause of the trouble. Besides, the
tendency toward atrophy should always be kept in
mind, especially where the initial stage is already
present.
We are now confronted with the following
question: Is an absolutely straight septum nor-
mal ? There was an era in rhinology when it was
thought that at least the aborigines had straight
septa. In 1904 the writer (10) examined more
than Soo crania of aborigines, and was surprised to
find that more than one third showed abnormal
conditions of the septum. Other observers reached
the same result, and it was pointed out that asym-
metry of the organs is probably the most normal
condition. Consequently many rhinologists have
learned the important lesson, that there are non-
obstructive deviations which do not necessitate an
operation.
In this connection an article by H. M. Goddard,
of Philadelphia (11), is very interesting and in-
structive. While he admits the many beneficial
results obtained by a submucous resection, he lays
great stress on the importance of an intact nasal
mucosa. "By destroying the mucosa we are very
apt to substitute a perverted respiratory function
for an obstructed one." Goddard then describes a
series of conditions that often sets in afterwards,
produced by the lack of epithelium, etc. — symptoms
which I ascribed to the impossibility of assimilation
of the inspired air. It is not my intention to men-
tion the absolute indications for submucous resec-
tion— an operation that the writer has to perform
quite frequently, but it may be opportune to warn
colleagues, as the result of my experience, that not
every deviated septum spells operation.
AGE OF THE PATIENT
Another point of importance that has to be taken
into consideration is the age of the patient. In
older or middle aged persons, i. e., beyond the age of
forty-five or fifty, the organism has adjusted itself
to a certain amount of pathological changes, to such
a degree that it does not require any operative in-
terference. Such people with a deviated septum or
a large spur often feel perfectly comfortable, as
they do not need as much air for breathing pur-
poses as in their younger and more active days.
They have unconsciously regulated their habits and
their daily work to fit into this altered condition,
and a change is not required for their wellbeing.
Let us illustrate this by an example taken from an-
other field of our work. As is well known, the
glottis in bilateral paralysis of the abductor muscles
is narrowed down to a very narrow slit. A minute
amount of air can pass through this, especially since
at each inhalation the glottis paradoxically closes
up more. Yet such patients may live for years in
relative comfort, if they learn how to get along with
little respiratory pabulum. I distinctly recollect one
patient, who was under my observation at the
Montefiore Hospital for more than eight years, who
had that condition of the abductor muscles due to
tabes ; besides, his lower extremities were paralyzed
and he was totally blind. He had to be rolled
around in his chair and had very httle occasion to
exert himself. He did not need much air for his
daily requirements. That was in the same pro-
portion as the intake of his food, which was much
less than in the days of his activity. Parenthetical-
ly, it may be mentioned, that another patient with
the same condition in his larynx, but without any
affection of his lower extremities and eyes, who
had been walking around, became intoxicated one
day and was found dead on the street. In making
routine examinations on several hundred patients
a number of cases were found (12) that were
similar to the one just narrated. Others have ob-
served the same conditions in patients of which
they obtained no history, as for example those re-
ported by W. S. Chamberlin, of Cleveland.
Similar obstructions, though not so exaggerated,
may prevail in the nose for many years with im-
punity. I have seen such people reach an old age,
experiencing not more discomfort than others who
had been operated upon. And these discomforts
were easier to bear than an atrophic rhinitis or a
rhinitis sicca.
THE TURBINALS IN SINGERS.
What has been said in general about the septum
narium holds good for the turbinals to a still greater
degree, that is among ordinary mortals ; but how
about singers ? Since nothing has been found in the
literature touching that subject, it may be timely to
give my experience with two well known singers.
Case IV. — Mr. X. complained of some difficulty in
breathing. Both inferior turbinals were removed by a
rhinologist of standing, whereupon the patient was unable
to sing for one and a half years.
Case V. — Mr. N. N. sang one night in one of the Euro-
pean capitals with remarkable success. The next day the
turbinals were removed, and from that moment on he was
lost vocally: he could not produce any high notes, and
never again appeared on the stage.
These cases reported are known to me personally.
Are they exceptions or have others observed similar
cfi:"ects ? On the other hand, some singers may and
do gradually learn how to place their voices and
accommodate them to the altered anatomical re-
lations. But, before operating, one should never
lose sight of the fact that the nose has a double
connection with the voice: as an air passage and as
a space for resonance. The air on passing by the
numerous projections, based on the principle of an
increased surface, is adapted for the requirements
of the system. The proper execution of these
hygienic function? of the nose is of special im-
portance for the voice producing apparatus, the
larynx. The importance of the nose as regards
resonance depends upon the pneumatic cavities and
upon the conchjc with their intact mucosae. It is
wise to keep that in mind before removing any of
the important tissues.
November 9. .9.S.] FREUDENTHAL: DESTRUCTION OF FUNCTION AFTER OPERATION.
801
THE ACCESSORY SINUSES.
As far as the ethmoids are concerned, the theory
"of Holmes — that in all probability the cellular
structure of the ethmoid labyrinth had for one of
its functions the protection from cold— should be
mentioned. This has been the writer's experience in
a few cases of ethmoid operation, but more so after
radical operation on the antrum.
As to these radical procedures on the accessory
sinuses. Dr. E. B. Gleason (13) says: "I cannot
help feeling that the status of radical operations on
the nasal accessory sinuses is worse than that of
the radical mastoid operation, which is, of course,
sometimes necessary to save life, but which, in its
final results, sometimes leaves a less satisfactory
condition than if no operation had been done and
sometimes requires much aftertreatment, from time
to time, to prevent recurrent suppuration. In other
words, one pathological condition has been sub-
stituted for another. . . ."
In presenting the data of other observers as well
as my own experience, it is not the aim to dis-
courage entirely operations on the nasal sinuses,
some of which are directly life saving, while many
others have afforded great relief to suffering pa-
tients. It is done rather with the idea of suggesting
that not too much confidence be placed in these
operations, thereby neglecting other means of re-
lief. A normal mucosa is apt to overcome many
difficulties, probably even an infection of the si-
nuses. To keep it normal or bring it back to the
normal, the deficiency of indoor moisture will have
to be combated first. Parenthetically it may be
added that one of the effective therapeutic measures
in chronic empyema of these sinuses is the use of
negative pressure (vacuum pump), as advocated by
Haskin, Coffin, Harmen Smith, W. A. Wells, Mac-
Whinnie, and lately by Gleason. It acts merely
by producing Beer's hyperemia, and hyperemia of
the mucosa means nothing more than increased in-
flux of serous exudation, or, in other words, in-
creased humidity.
OPERATIONS ON THE THROAT.
While in certain affections of the nose the
pathological process may be overcome by putting
the patient under normal hygienic conditions, as
outlined above, it is somewhat different in the
mouth and throat. I have proven elsewhere (14)
that the lips, the teeth, and tongue are affected by
the lack of indoor humidity, but so far I have not
been able to prove to my own satisfaction that dis-
eased tonsils and adenoids are the result of such
conditions also. Yet we have to operate on them
and do so frequently.
From the removal of adenoid vegetations no un-
toward results are known to me, unless they were
due to faulty technic. But how about the tonsils?
I.c it true that indications for the removal of tonsils
are not as simple as they appear to be? Does the
general practitioner or even the laryngologist al-
ways know when to operate and when not ? Some-
body has remarked, that it was easier to remove a
tonsil than to know whether or not it should be
done. What has happened since John N. Mac-
kenzie (15) wrote his article on the Massacre of
the Tonsil, in 1912, in which he speaks of "reck-
less, ruthless, and unnecessary" enucleation of the
tonsils in children? This article, on account of its
forcible language and the prominence of its author,
made an impression all over the country. Formerly
school children in the poorer districts of New York
city were driven by the hundreds to the clinics,
whether the parents gave permission or not, and
many of these children were operated on with or
without good reason. The nurses employed by the
New York Board of Health seemed to find satisfac-
tion in taking as many to the clinics as possible. On
some afternoons I was confronted with twenty to
thirty of such children and on many of them I re-
fused to operate, to the apparent disgust of the
nurse. That practice has markedly diminished.
Some people, however, still persist that since ton-
sils have no functions to perform, it is best to remove
them, and to do it radically. I hope not many think-
ing physicians will be found to subscribe to such
theories. For, firstly, it is absurd to advise remov-
ing an organ from the human body because the ex-
tent of its physiological function is as yet unknown ;
secondly, the tonsils have special functions to per-
form. They have to lubricate the food that is taken
in, thus performing the first and, perhaps, a very
important step in the digestion of food. Besides
they have to lubricate the throat during the
acts of speaking and singing and are of special im-
portance in this connection to speakers and singers.
Furthermore, the mechanical significance of the
tonsil has to be considered (Kenyon). This point
will be taken up shortly. Finally, the tonsils have
the same task as the nasal mucosa, only to a great-
er degree : they, like all the other lymphatic struc-
tures in the pharynx and elsewhere have to ward
off dangers by inhalation, infection, and especially
here, by contaminated fluids of the mouth and
pharynx. They do most important filtering work
for the organism, and with their phagocytes take up
the primary battle against the tubercle bacillus.
"Remember," says Henry L. Swain (16), in an ex-
ceedingly interesting article that just came to my
notice, "it is only when the phagocytes in the tonsils
fail in their work that the germ gets into the second
line trench, the lymph nodes of the neck. Many
times therefore they kill the tuberculous germs off,
?nd it is lucky for us that they do."
For these reasons there is a strong opinion
against the indiscriminate removal of tonsils, as
will be seen in the articles by C. W. Richardson (17)
and by Otto T. Freer (18), who speaks against the
"focal infectionists." On the other hand some are
emphatic — and the writer is one of them — against
radicalism in every case where an operation is
strictly indicated. When I read part of this paper
before the New York Medical Union on May 28th,
a practitioner of wide experience remarked, in the
discussion following, that a good deal of cod liver
oil and more of fresh air (taking the pupil out of
school) had saved many a little patient of his from
an operation. A pediatrist said he had used the
guillotine for more than twenty-five years and has
had no reason to regret it. I believe that both these
gentlemen are correct, but want to add that the sec-
ond one sDoke from his standpoint as oedifitrist.
802
FREUDENTHAL: DESTRUCTION OF FUNCTION AFTER OPERATION. CNew York
Medical Journal.
According to my opinion there are indications for
partial removal of the tonsil and radical tonsil-
lectomy, both of which I have practised for years,
and it is my experience that w^hatever is left of a
tonsil, if it is normal tissue, serves as a protection
to the organism. To prove this I may cite the fol-
lowing fact : After operations in the nose occasion-
ally an infection of the throat follows that may
spread to the cervical glands. Now it has been my
experience that this cervical adenitis is more fre-
quent after a perfect enucleation than in those cases
in which part or, naturally, the whole of the tonsil
had been left. This is also the experience of Dr.
Edgar M. Holmes, as expressed in a conversation
with the writer. On the other hand, one should re-
member that a cervical adenitis is sometimes kept
up by a purulent process in a part or the entire
tonsil. In such a case every particle of the tonsil
has to be removed. I do not speak against tonsil-
lotomy nor tonsillectomy ; each has its place in
medical practice ; but I am strongly against over-
operations on the tonsils, which are unnecessary and
not without danger. Yesterday I read in the news-
papers that someone cures insanity by removing
tonsils and teeth. That is insanity.
Physicians and laymen have begun to recognize
that neither tonsils nor, for that matter, teeth are
at the bottom of all evils in children, and that some
tonsils may be left where nature placed them. On
the other hand the removal of tonsils in grown per-
sons has always been considered from a different
viewpoint. It seems that after tonsillectomy the im-
paired throat of the adult has less capacity of re-
adjustment than that of the child. Yet tonsils that
suppurate at certain intervals will have to be re-
moved in toto, so long as better methods of getting
rid of the focus of suppuration are not known.
Likewise, the tonsils will have to be dealt with in
rheumatism, when there is positive evidence that
they are the etiological factors in the individual
ckse. There are other indications for tonsillectomy
which may coincide with those in children, but may
well be omitted here.
However, a tonsillitis, or a recurrent tonsillitis,
in the majority of instances is not a local affection,
but a manifestation of a systemic condition. To
remove the tonsils in such cases is like removing
one of the defenses nature has set up for protec-
tion. It will be best to illustrate this by one of many
examples that have come under my observation.
Case VI. — F. C, aged thirty-five, consulted me last
winter on account of an acute tonsillitis. His fever rose
to 102.5° but after about ten days he was well again.
A few months later he was operated on by somebody else,
the tonsils being removed radically. This winter his
troubles began very early and it was almost impossible to
free him of his sore throat. Tonsillectomy had been done
lege artis, but the cicatricial tissue that formed afterwards
was so abundant that a good deal of the mucous membrane
was destroyed. He suffered now from a stubborn phar-
yngitis that bothered him until warmer weather set in.
The power of resistance had been weakened in
this instance, and with the fall of the tonsils there
was lost one of the strongest fortifications — or as
Hudson-Makuen put it : "To remove the tonsil in
such a case is like killing the goose that lays the
golden egg." However that may be, tonsillectomy
leaves other dangers in its trail, as pointed out by
Hudson-Makuen, French, Kenyon and Kradwell,
Conner, Joyes, and many others. The.se dangers
are noticed mostly in alterations of the speaking
and singing voice.
The appearance of tonsillectomized throats has
attracted my attention for years past. Over and
again have patients consulted me showing such
masses of cicatricial tissue, adhesions, loss of mus-
cular tissue, to such an extent that one is astonished
at the destruction brought about by the opera-
tions now in vogue, and performed, not by hospital
internes, but by leading men in our specialty. Scars,
where mucous membrane is needed, work havoc, as
shown above as well as by many other examples
that everyone may see who is inclined to do so. As
to other defects following tonsillectomy the articles
by Kenyon and Kradwell (19) and lately by Ken-
yon (20) alone are so convincing that they are bound
to change our mode of operation in the future. The
work these authors have done "has failed to quiet
any feeling of unrest with respect to the operation
on either the speaking or the singing voice." The
physiological importance of the palatopharyngeus
and the palatoglossus muscles, the mechanical signi-
ficance of the tonsil, including its elaborate capsule,
the question of the intrapharyngeal aponeurosis and
the capsule, and many other factors have been ex-
plained so clearly by Kenyon that the damage done
to the voice by injuring these parts can be easily un-
derstood. His article is based on the examination
of 161 tonsillectomized throats, and on a study of
thirty cases of vocal or other disturbances re-
sulting from tonsillectomy — indeed, an appalling
number.
In analyzing mjr own records I am convinced
that the number of such disturbances seen by me is
still greater. This is also in accord with Makuen's
experience that deformities of serious significance
occurred in the hands of the most skillful operators.
Consequently one is not surprised at the remark of
Kenyon and Kradwell : "It seems conservative to
say, that following tonsillectomy, the palatoglossus
and palatopharyngeus muscles are never- wholly
normal in their action." "Never" is a dreadful
indictment against our present mode of operation.
In a similar way W. E. Conner (21) expresses his
opinion that the voices of singers have been prac-
tically destroyed in some instances, while the func-
tions of the tonsils, be they ever so few, have been
denied these patients forever.
However, it is the belief of some men that ton-
sillectomy serves to destroy, not merely a possible
function of the tonsil, but also to either disturb or
destroy an important physicomechanic function.
On the other hand, there are men who have ex-
pressed different opinions. Among the latter is
I. W. Voorhees (22) who went to the trouble of
sending out questionnaires to five hundred laryn-
gologists and five hundred singing teachers. While
Voorhees' paper deserves appreciation, its statis-
tics, like other statistics, have to be taken with a
certain amount of reserve. Nothing, to my mind,
is so misleading as statistics, no matter how truth-
ful the authors may be. From his statistics Voorhees
draws the conclusion that in singers — ^that was the
-The italics are mine.
November 9, 1918.]
KEARNEY: EYE GROUND APPEARANCES IN NEPHRITICS.
803
question he was interested in — there need be no
special fear of disastrous results after tonsillectomy,
when done by skilled operators. Yet an analysis of
some of his points does not quite seem to justify his
optimism, as, for example, the answer to question
No. 2: "Out of 341 cases only forty-six showed
cicatricial contractions, which is truly an excellent
operative record." This means that about twelve
per cent, had unsatisfactory results, which does
not impress me as an "excellent record" for pro-
fessional singers. Cicatricial tissue in the absence
of the lubricating function of the tonsil is a defect
that can be overcome by few singers only. In reply
to questions No. 5 and No. 6, ninety-five men re-
ported no ill effects, while thirty-eight men had
noted untoward sequelae in 172 cases. When one
considers that these efifects remain permanent in a
goodly number oT cases, one is struck by the rather
large number of men (thirty-eight out of 133 —
about one quarter) who experienced unsatisfactory
results. This is a surprisingly large percentage
against tonsillectomy. It is after studying such re-
ports that one recognizes the physiological necessity
of the tonsil and realizes that every effort should be
made to preserve at least a portion of this organ.
After a great deal of study and hard work in this
field for the past decades the question of tonsillec-
tomy and tonsillotomy will have to be taken up
once more, and investigated again from every point
of view. Not only will this question have to be
taken up, but many other operations on the upper
air tract will have to be scrutinized with the idea of
determining whether more conservative means will
not serve the purpose of preserving, as much as
possible, the physiological functions of the different
structures.
In conclusion permit me to say that it is time
we clean up our ranks as the gynecologists did some
fifteen or twenty years ago. They succeeded in
preventing the removal of almost every ovary that
came under observation. It is my hope that in the
near future similar results will also be achieved in
our field of work.
REFERENCES.
I. OWEN PAGET: Medical Record. October 20, 191 7. 2. Tran^-
actions American Laryngological, Rhinological, and Otological
Society, 1915, pp. 188 and 189. 3. Ibid, p. 138. 4. M. BEHR
and W. FREUDENTHAL: Beitraege zur Klinik der Tuberkuloie,
1904, p. 62. 5. Journal A. M. A., October 6, 1917, p. 1174. 6. W.
FREUDENTHAL: The Aetiology of the Postnasal Catarrh, Journal
A. M. A., November 9, 1895, P- 801. 7. FREDERIC S. LEE:
Recent Progress in Our Knowledge of the Physiological Action of
Atmospheric Conditions, Science, August 11, 1916, 44, p. 184.
8. S. JOSEPHINE BAKER: Classroom Ventilation and Respira-
tory Diseases among School Children, American Journal of Public
Health, January, 1918. 9. New York Medical Journal, Septem-
ber 23, 191 1, p. 647. 10. W. FREUDENTHAL: The Septum
Varium in Aborigines and the Cause of Deviations of the Septum
in General, Laryngoscope, March. 1904. 11. H. M. GODDARD:
Deviation of the Septum and Submucous Resection, New York
Medical Journal, September i, 1917, p. 398. 12. W. FREUDEN-
THAL: Laryngeal Manifestations in Locomotor Ataxia and Mul-
tiple Sclerosis, Journal A. M. A., June 13, 1908. 13. E. B. GLEA-
SON: The Laryngoscope, 1918, p. 2. 14. W. FREUDENTHAL:
Is Atrophic Rhinitis Always Autochthonous? Read by invitation
at the Fortieth International Medical Congress, Madrid, 1903;
Annals of Otology, June, 1903. 15. JOHN A. M.^CKENZIE: The
Massacre of the Tonsil, Maryland Medical Journal, June, 1012.
16. HENRY L. SWAIN: Medical Record, June 22, 1918. 17.
C. W. RICHARDSON: Transactions American Laryngological
Association, 1915. 18. OTTO T. FREER: Ibid. 10. ELMER L.
KENYON and \y. T. KRADWELL: A Study of the Physico-
mechanical Function of the Faucial Tonsil, Annals of Otology
1916, p. 862. 20. ELMER L. KENYON: The Foundations of
Voice Impairment Resulting from Tonsillectomy, Journal A. M. A.,
September i, 1917, p. 709. 21. W. E. CONNER: Texas State
Journal of Medicine. 1916, p. 545. 22. I. W, VOORHEES: The
Faucial Tonsils in Singers, New York Medical Journal, Decem-
ber 16, 1916, p. 1 183.
5g East Seventy-fifth Street.
DIAGNOSTIC VALUE OP EYE GROUND
APPEARANCES IN NEPHRITICS.*
By J. A. Kearney, M. D.,
New York,
Professor of Ophthalmology, New York Polyclinic Medical School
and Hospital.
The ophthalmoscopic picture of the fundi of the
eyes of nephritics, when changes are present, repre-
sents the results of alterations in the walls of the
retinal bloodvessels or of the toxines circulating in
the blood stream. One or other may be the pre-
dominant factor in producing clinical manifestations
in the fundi and often no definite division can be
made between them.
The so called retinitis albuminurica associated
with chronic nephritis presents the following char-
acteristic appearance in the eye grounds : Cloudiness
of the fundus details, most marked in the region of
the papilla where it masks its margins and the de-
tails on its surface ; lustrous white patches with ill
defined margins arranged around the papilla and
about a disc's width from its borders ; these patches
sometimes coalesce and form large, lustrous masses
producing the so called snow bank appearance ; hem-
orrhagic spots of various shapes and sizes occur in
the same zone ; there is a stellate arrangement of
white spots in the region of the macula ; the veins
are dark, distended, and tortuous, and the arteries
are not materially altered in size. The only sub-
jective symptom is blurred vision, which occurs late
in the disease, and both eyes are always affected.
The ophthalmologist is frequently consulted for this
and often is the first to discover by ophthalmoscopic
examination the fundus signs of an existing Bright's
disease, the patient up to then being unaware of any
serious organic malady.
The recorded proportion of retinitis in renal dis-
ease varies from nine to thirty-three per cent., and
it would be considerably higher if there were in-
cluded the minor lesions and blurrings of the disc
and retinal details, the result of slight alterations in
the walls of the retinal vessels and the reaction to
cytotoxic bodies in the circulating blood. Indeed
tine so called typical renal retinitis is not so fre-
quently encountered as the less elaborately produced
lesions of this affection. l?.enal retinitis occurs
usually between the ages of thirty and sixty years,
and especially from forty-five to fifty-five years, and
is found twice as often in men as in women.
The renal affection most frequently complicated
with retinitis albuminurica is the contracted kidney
in Bright's disease, although all forms of nephritis
may be thus complicated. Changes in the fundus in
cases associated with the chronic contracted kidney
are generally due to vascular sclerosis and the prog-
nosis as to life in those cases is usually bad, the
patient dying within two years of the onset of the
ocular symptoms.
Albuminuric retinitis occurs rarely in acute ne-
phritis associated with specific fevers and sometimes
is associated with the albuminuria of pregnancy. In
these instances the changes are largely due to toxic
ciiculating elements rather than to vascular sclerosis
•Read before the Clinical Society of the New York Polyclinic
Medical School and Hospital, October 7, 1918.
8o4
FISCHER: ACUTE ECZEMA DUE TO FAULTY METABOLISM. [New York
Medical Journal.
and the prognosis is not so serious, provided a
chronic nephritis does not develop. A wide spread
neuroretinitis with exudations and hemorrhages
characterizes the albuminuric retinitis of pregnancy.
It occurs usually in primipara and in the second half
of gestation. When retinitis is observed the prog-
nosis as to life and vision depends upon the duration
of gestation. Induction of premature labor is rec-
ommended at times, in the first six months of
pregnancy, as a therapeutic measure if sight is to be
saved. In few eclamptic cases are there signs of
retinitis.
At the time when classical symptoms of uremia
aie present, there is a visual disturbance, frequently
amounting to blindness (uremic amaurosis). Oph-
thalmoscopic examination at this time reveals no
abnormal changes in the fundi and this distinguishes
it from albuminuric retinitis. In uremic amaurosis
the loss of vision is sudden and complete while in
retinitis albuminurica the sight is gradually reduced
but seldom lost entirely. Normal vision is restored
when the patient recovers from the uremic attack
but the reduction of vision due to albuminuric
retinitis is usually permanent. The nature and ex-
tent of changes observed in the fundi of albuminuric
retinitis are no indication of the condition of the
diseased kidneys. At times, gross retinal changes
accompany minor kidney affections, and again minor
eye ground changes may be associated with gross
kidney disease.
Syphilis, sepsis, anemia, arteriosclerosis, poison-
ing from phosphorus and quinine, diseases of the
liver, carcinoma of the stomach, hydrocephalus
mternus, tumor of the brain, diabetes, and intra-
cranial disease, may excite changes in the fundus in
some subjects like those associated with chronic
nephritis (albuminuric retinitis). Albuminuria, on
the other hand, produces some extraordinary fundus
appearances. A patient once consulted me on ac-
count of intolerable headaches. The ophthalmo-
scopic examination of the fundi revealed choked
discs of six diopters elevation in both eyes that were
pink and juicy and without eschar or other
discoverable changes. The retina was unaffected
and the vision was normal. All necessary examina-
tions were ordered to be made to determine the
underlying cause, with the result of a report of only
one defect, medium amount of albuminuria with a
few granular casts. The patient was ordered to bed
and free catharsis, intensive sweating, and proper
dieting administered. The headaches disappeared
and the swollen discs were reduced to nearly normal
with no loss of vision.
Neuroretinitis from intracranial pressure may
simulate the early changes observed in renal retinitis,
and often only by a careful study of the urine and
general symptoms can the diagnosis be established.
Dr. Harvey Gushing believes that some of the cases
of albuminuric retinitis are due to increased intra-
cranial pressure and advocates cranial decompres-
sions as a remedy, but the results obtained have not
been considered entirely satisfactory.
The course of typical renal retinitis has been di-
vided into three stages, as follows: hyperemia of the
papilla, opacity of the retina, and hemorrhages, the
first stage ; the second stage, fatty degeneration ; and
the final stage, atrophy. The earliest fundus
changes to be noted in chronic nephritis are kinking
and increased tortuosity of the smaller vessels ac-
companied by a slight retinal haze, which forecast
the usual picture ot the degenerative process. Kink-
ing and increased tortuosity of the smaller vessels
of the retina are the earliest observable signs o!
arteriosclerosis anywhere in the body. Cloudiness ot
the disc details and its margins, without arterial
changes, usually forecasts the toxemic retinitis
which is generally of the inflammatory type. An
ophthalmoscopic examination with a complete
record is an important adjunct to the data in cases
of nephritis, and more particularly when it is possi-
ble to view the fundi in the early stages.
Except in the fundus of the eye there is no other
part of the normal body in which an exposed artery,
vein, and nerve can be seen. The retinal tissue they
supply with nourishment and sensation can also be
studiously observed. On account of the highly
organized and easily destructible protoplasm com-
posing retinal elements they react readily to toxic
substances in the circulating blood and degenerate
as readily when nourishment is withdrawn as in
arteriosclerosis. Hence the importance of an oph-
thalmoscopic examination of the eye grounds in all
general diseases in which toxemias or degenerations
are a factor, and records of the findings from time
to time should be included in all carefully studied
constitutional diseases.
127 West Fifty-eighth Street.
ACUTE ECZEMA DUE TO FAULTY ME-
TABOLISM OF FOOD ELEMENTS.
Notes on the Dietetic Treatment.
By Louis Fischer, M. D.,
New York.
The etiology of this disease is a mooted point.
While dermatologists maintain that extraneous
sources, such as local infections with pathogenic
bacteria and external irritations, are the chief causes
of this disease, other views, equally as strong, seem
to point to internal, physical, and toxic conditions-—
especially intestinal intoxication, as the cause of this
disease. This latter viewpoint I shall discuss as
based on my clinical experience.
That there is an association between gastric and
gastrointestinal derangements seems well borne out
when it is found that acute eczema follows over-
feeding of high fats or of excessive carbohydrates.
Eczematous manifestations are more frequently
noted in bottle or hand fed infants. One could
therefore assume that cows' milk per se is an
etiological factor. This, however, is not a fact.
Every pediatrist knows that infants, reared on the
human breast, suffer with eczema of the most dis-
tressing character when systemic conditions in the
mother introduce toxines through her milk. I have
records of many cases of eczema brought about hy
imprudent diet on the part of the mother, which
improved as soon as her diet was changed. So for
example, excessive eating of shellfish, cereals, alco-
holic beverages, and excessive quantities of sugar
November 9, 1918.] FISCHER: ACUTE ECZEMA DUE TO FAULTY METABOLISM.
805
add noxious substances to the milk which prove to
be an irritant to the infant.
Intestinal derangement, such as chronic constipa-
tion or coprostasis and the passage of hard, dry,
scybalous stools are usually forerunners of eczema-
tous manifestations. But I have also seen cases of
eczema in infants having mucous or jellylike foul
stools. If this is so — and I have seen many of these
cases — then it shows that intestinal decomposition
and intestinal intoxication must be considered in
their etiological relationship. Foul decomposed
stools, with marked indicanuria must load the blood
with toxines which exude and irritate the skin, giv-
ing rise to eczema. Eczema in the infant nursing at
the breast is a transmitted form of eczema — trans-
mitted by the mother through her milk to the infant.
The greatest ambition of a young mother is to see
her infant gain in weight. To accomplish this she
will frequently follow book and magazine advice,
and, without having her infant's digestion super-
vised, will feed cream mixtures or top milk formula
until a stomach breakdown occurs. This stomach
breakdown is due to the feeding of too much fat,
and when the peptic glands, the pancreas, the liver,
and the intestines do not properly functionate, then
intestinal indigestion and intestinal fermentation re-
sult. This usually induces either vomiting or
diarrheal conditions, such as fat diarrhea. As the
infant cannot assimilate the high fat mixtures such
formulas have an irritating effect and give rise to a
phenomenon akin to anaphylaxis.
Stagnant, undigested particles of food when not
properly assimilated give rise to fatty acids, and
these when absorbed cause intoxication which the
kidneys do not always eliminate. These toxic prod-
ucts give rise to skin irritation and result in excoria-
tion and eczematous manifestations. Cream and top
milk feeding give rise to fat indigestion in the
weakened or marasmic infant unable to digest and
assimilate the fat and heavy mixtures, resulting in
eczema. The overfeeding of sugar, whether su-
crose or lactose, is another common form of food
element which gives rise to eczema. Sugar excess
is more often the cause of eczema than any other
food ingredient, and one of the first signs of im-
provement in the itching, redness, and restlessness
will be seen when sugar has been withdrawn from
the diet.
Of the carbohydrates, cereals — oatmeal being one
of the most potent agents in developing eczema —
are factors in the etiology of eczema. Many patent
foods especially rich in sugar frequently give rise to
eczema. The absence of a live factor in food
caused by boiling or continued sterilization produces
a deadness in milk. Such devitalized food when fed
for some time is usually associated with, or followed
by, eczema. Condensed milk although rich in sugar,
low in fat and protein, if continued for a length of
time, frequently induces eczema. The absence of
vitamines from food is a factor which may influence
the development of eczema, as we frequently find
that when the vitsmines have been destroyed there
is a scorbutic tendency ; but this is also an element
which determines the absence or presence of eczema.
The following cases will serve as illustrations :
Case I. — Frank C, nine months old, a well nourished
and plump infant, had been breast fed since birth, about
four and one half months, when a severe form of
squamous eczema appeared. His appetite was good. The
stools contained mucus and undigested particles, was of a
greenish yellow color, and had a foul odor. The eczema
was most marked on the face, neck, back, and chest. The
skin felt hot. There was no rise in temperature. The in-
fant was extremely restless during the day, and had in-
somnia, and was given large doses of sedatives to induce
rest. He was weaned from the breast, as the attending
physician believed the mother's milk caused the eczema.
The child was given cows' milk and rusk, but the eczema
grew steadily worse and spread over a larger surface. ."Ks
the infant cri'ed continuously it was believed he was hun-
gry, so the physician ordered rice, farina. Zwieback, and
buttered toast. Under this new diet the eczema grew
steadily worse. Normal metabolism was disturbed. There
were symptoms of intestinal intoxication, and undigested
stools.
When seen by me he had been under the care of
several physicians for four months. The following
treatment was ordered : Discontinue all carbohy-
drates. All sugar to be excluded. Give milk from
which all cream has been skimmed. This treatment
was continued for two weeks. A slight improve-
ment was noted. The skin was not so hot nor red
on palpation. The stools were improved but the
itching, while not so intense, was still present. I
discontinued all milk and ordered eight ounces of
buttermilk every four hours. When it was possible
milk fermented with Bulgarian bacillus was given,
and when this was impractical, buttermilk or fer-
mented milk procured in the dairy was substituted.
Within one week after this treatment was installed
a decided change for the better took place. The
diet was then amplified with vegetables, fruit juices,
and later junket. After one month of this treat-
ment hardly any trace of the eczema could be seen.
Local treatment alone was unavailing. When I
ordered an ointment of two per cent, tar with zinc
salve, the mother stated that she had already used
this salve without effect. When, however, the
casein lactate feeding was given in conjunction with
the tar locally, a marked and rapid improvement
took place.
Case II. — Mary B., an infant, was seen when four
months old. She was a breast fed child. The mother
states the infant has had eczema since birth ; that she is
dissatisfied after nursing and puts her fingers in her
mouth ; that the child was constipated at times, at other
times had greenish and mucous stools three or four times
a day The mother has had three children, all sufTering
v;ith eczema.
As this infant was not gaining in weight, and had
had eczema since birth, I ordered twelve ounces of
skimmed milk, eighteen ounces of water, and one
half grain of saccharine, steamed five minutes and
divided into three bottles. These feedings were al-
ternated with the breast for a few days. Owing to
the fat deficiency the infant was constipated, and as
no improvement was noted I discontinued breast
feeding and gave twenty-one ounces of fermented
milk, twenty-four ounces of water, and four table-
spoonfuls of granum. The granum and water were
boiled ten minutes and mixed with the milk, which
was steamed two minutes snd the curd strained out.
This was divided into seven bottles, and boiled water
was added to make six and a half ounces in each.
Two ounces of spinach water was given once daily
between feedings, also two ounces of orange juice
each day. This feeding was continued two weeks.
8o6
FISCHER: ACUTE ECZEMA DUE TO FAULTY METABOLISM.
[New York
Medical Journal.
Slight improvement was noted both in the eczema
and in the weight. The formula was changed to
twenty-seven ounces of fermented milk, thirty
ounces of water, and five teaspoon fuls of granum ;
no sugar was added. A decided improvement was
noted. The eczema gradually disappeared. The
spinach was given for its antiscorbutic efifect, and
the orange juice for its vitamine content.
Case III. — Charlotte S., aged fifteen months, has had
eczema since she was three months old. Judging by the
the stool and the stationary weight, there is a faulty
metabolism cf food elements. *She is a poorly nourished,
backward infant with irregular dentition, and constipated
bowels. The child is troubled with insomnia. The ec-
zema is very distressing. The infant scratches continu-
ously, and is excoriated and bleeding. The skin is in-
flamed, red, scaly, and hot. Small furuncles are constantly
appearing, due to the infection of finger nails. The diet
is totally unsuited to the infant's needs. She has been
feeding with the adults at (the table, and has been re-
ceiving too much starchy food and solid food at irregular
intervals. The hygiene also is faulty. The infant is not
properly cared for and is kept up too late at night. Water
is seldom given.
It was necessary to impress the mother with
the danger of the disease, also with the structural
weakness existing, due to rickets. A strict diet was
ordered, which consisted of the following: Eight
ounces of buttermilk, warmed to feeding tempera-
ture, every four hours ; when the child suffered
hunger a saucer of chopped string beans, peas, or
spinach with every other feeding. Fruit juices
were given, also large quantities of water. A
saline purge — one half teaspoon of epsom salts —
was given twice a day.
Under the above diet, with which we persisted,
the eczema gradually improved, and in two months
had practicallv disappeared. Sugar, candy, and all
sweets were prohibited. Calamine and zinc oint-
ment was applied locally.
The above three cases will serve to illustrate the
persistent types of infantile eczema usually en-
countered.
In acute and subacute eczemas I have found that
the internal administration of the lactic acid
bacillus, or the Bulgarian bacillus in pure culture,
could be given after each milk feeding. When,
however, Bulgarian milk or buttermilk was given,
the improvement noted was more rapid and steady.
Meat, the protein of fish, and albumen in the form
of white of egg have a peculiar tendency to irritate.
Milk serves as a special article of diet, but it is not
equal to the beneficial efifects noted after the use
of sour milk. By using the Bulgarian bacillus the
casein is transformed into casein lactate, and it is
to this agent that the excellent effects noted in
eczema are due.
Vegetables in the form of spinach, peas, string
beans, sprouts, and even cabbage are well Taorne
and have a laxative effect. These green vegetables
aid in removing putrefactive bacteria, and their
earthy salts have a decided nutritive value. They
do not heat the body as do the carbohydrate foods,
and can be fed several times a day. These vege-
tables may be combined with milk either sweet or
sour, and may also be given with junket. Water
should be given frequently. To eliminate toxic
products through the kidneys thorough flushing
with water is indicated.
Many infants do not take kindly to the Bulgarian
milk, owing to the absence of sugar and to the
very acid taste ; however, by persisting we gradually
succeeded. The first improvement noticed was a
diminution in the redness and especially in the
itching. The infants rested better, and the skin
seemed cooler to the touch ; the stools became less
offensive and the food was better digested. The
starvation, incident to the refusal of the sour milk,
while it will deplete the body temporarily, will aid
in relieving the intense itching which is so distress-
ing to the infant.
To accomplish good results in obstinate cases of
eczema, the strict supervision of a nurse must be
insisted upon, who must be instructed that she will
have great difficulty during the first few days in
overcoming the objection to the taste of the food.
When begmning this feeding it is important to tell
the mother that the infant will not gain, but may
lose in weight for several weeks, until the eczema
is controlled. The diet can gradually be increased
by the addition of finely chopped or strained vege-
tables, and by fruit juices. An older child may be
given junket, and still later custard.
When eczema causes insomnia, two grains of
chloral hydrate given in conjunction with five grains
of sodium bromide, repeating the dose every three
hours if necessary, will soothe the infant and pro-
mote rest. The urine can be procured from older
children very readily and from younger infants with
little difficulty. On examination indicanuria will
usually be found. Acetone, and occasionally dia-
cetic acid, will be present. In many of these cases
of eczema an acidosis, or a tendency to acidosis, was
noted. That eczema may be a skin manifestation of
acidosis, or a foterunner of this condition, seems
evident in a few cases seen by me. It is important
to make a thorough examination of the urine in all
cases. Glycosuria is occasionally noted. Albumin
was not present in the cases under discussion.
From a study of a large series of cases of eczema
I find that intestinal derangements due to faulty diet
or excessive feeding cause eczema. The treatment
consists in removing the cause — namely, in eliminat-
ing from the diet rich foods which overtaxed diges-
tion. When excessive fat, bacon, pork, butter, and
carbohydrate foods cause eczema, discontinuing the
same will modify the eczema. In some instances I
found that while the quality of food was normal, an
excessive quantity or too frequent intervals of feed-
mg resulted in overfeeding, this latter inducing
faulty metabolism resulting in acute attacks of
acidosis, indicanuria, and usually eczema.
Aside from the reduction of both quality and
quantity of food, as previously stated, the itching
and excoriation are modified by feeding large quanti-
ties of bicarbonate of soda in water; thus one half
teaspoonful of bicarbonate of soda may be given
every hour by mouth. The infant of course is not
to be disturbed during sleep. Active catharsis, by
giving fifteen to thirty grains of phosphate of soda
m water several times a day, is well borne and of
marked benefit. To effect a cure in these cases, I
insisted upon continuing the diet for at least six
months to one year.
155 West Eighty-fifth Street.
November 9. 1918.] JELLIFFE: NERVOUS AND ?!ENTAL DISTURBANCES OF INFLUENZA. 807
NERVOUS AND MENTAL DISTURBANCES
OF INFLUENZA.
By Smith Ely Jelliffe, M. D.,
New York.
{Concluded from page 757.)
Polioencephalitis superior, as a syndrome, is
usually evidenced by the sudden appearance of a
localized convulsion or, in young persons, by a series
of generalized convulsions. The patients then may
develop a mild delirium often with a pseudohysteri-
cal coloring, possibly with laughing or witticisms
(frontal softening) or they develop coma, indicating
deeper involvements of the cerebral structures of the
midbrain (polioencephalitis inferior of Wernicke).
These symptoms occur usually within the first week
of the influenza, in the patients personally seen. The
third day, usually marked by intense febrile states,
103° to 106° F., has been the chief day of invasion.
There are almost invariably meningeal signs as well,
tache cerebrale is frequent, goosefleshing and other
severe pilomotor reactions, Sergent's white line.
Kernig's sign is occasionally elicitable in the coma-
tose state. Lumbar puncture or blood culture may
reveal the influenza bacillus.
As has been stated the residual symptoms, should
the patient clear up from his coma, will depend en-
tirely upon the area or areas involved in the
encephalic process which pathogenically is a greater
or less functional disturbance consequent upon an
edematous or hemorrhagic efitusion. In a few pa-
tients who have been seen in consultation a mild
euphoric silliness has been present. This has been
combined with slight memory defects, tendency to
punning, and mild anxiety states, difficulty in con-
trolling the bladder and increased bowel activity.
These have been mistaken at times for "hysteria,"
but they had none of the psychogenic conversion
features which are essential for this diagnosis. The
symptoms were not mental conversion symbols.
They were direct results of a focalized lesion in
the first or second frontal lobes, chiefly the left side
— enlarged pupil, usually, and pilomotor and vaso-
motor anomalies of the same side — and their usually
favorable prognosis is in no manner to be regarded
as indicating a so called hysteria. Thus Grasset's
and Rauzier's reported case has been cited in litera-
ture as hysterical or hysteroid. The essential sym-
bolic features of this purely psychogenic psycho-
neurosis were absent. It is better considered to be
a multifocal meningoencephalitis with flexed con-
tractured limbs, involuntary urination, hemianes-
thesa, analgesia, etc. A certain emphasis is laid
upon this point because there is such a prevalent
trend among the laity as well as among physicians
to name a peculiar, bizarre and noisily inconsistent
set of symptoms, especially when occurring in
women, as hysteria. This a great mistake. A great
many of the lethargic encephalitis patients which
were also frequent in the epidemic of 1890 and
called "Nona" or living death patients, have been
called hysterical coma and have been foolishly con-
verted into pincusl^ons by over zealous and under
informed investigators. To stick pins in an individ-
ual and when he says he does not feel it, or gives
no evidence of feeling it, and then say — hysteria —
is bumble puppy and not diagnosis.
Certain cataleptic encephalic states are occasion-
ally observable in hospital practice. In very severe
frontal involvement permanent impairment may re-
sult. These show as various dementing states, oc-
curring in indivduals between 60-70; losses of
memory and other indicia of the sudden onset of a
syndrome clinically indistinguishable from senile
dementing types.
When the lesion involves the Rolandic areas vari-
ous forms of monoplegia or hemiplegia result. These
may be temporary or permanent. The general
prognosis in influenzal monoplegias and hemiplegias
is fair. Involvement of Broca's convolution of the
left side produces a motor aphasia and implications
of other speech zones may induce other aphasia
types. I have seen several instances of these
aphasias in the past ten years. Not only have the
arteriosclerotics suflfered but in a number of the
patients with aphasias, which have been deemed
influenzal, there has been no evident arteriosclerosis
as registered by eye ground, palpable arteries, kid-
ney lesion or high blood pressure. This latter group
has had an invariably better prognosis than the
former.
I have seen no hemianopsias or instances of
cortical blindness from occipital lobe encephalitis.
They are known however. Harris has reported a
patient with complete blindness of cortical origin
which cleared up in two weeks.
The numerous complicated midbrain and medul-
lary encephalitides giving rise to the nuclear palsies
of the cranial nerves have already been discussed.
From a topographical point of view the central types
belong in this section.
Mental involvements. There is probably no other
acute infectious disease which gives rise to, or re-
sults in so many diversified types of mental dis-
turbance, ranging from the simplest fatigue states
of a transitory nature to some of the severest defect
mental conditions which may wipe away at a blow
the entire mental life. Fortunately the tendency is
towards the mildest and milder involvements, but
the gamut of possibilities is indeed kaleidoscopic.
This great diversity in syndrome is worthy of the
closest scrutiny for it afifords a very important re-
search background bearing upon the complex
dynamic interdependence of the health of the bodily
organs and interference with the energy receptors,
transformers and effectors. As has already been
observed, there is a special affinity for the grip
toxins whatever they may be chemically, for nerv-
ous structures. The special nervous structures which
apparently handle the poisons with the greatest
difificulty seem to be the sympathetic division of the
vegetative neurons. As is well known functional
balance of the metabolism is chiefly if not exclusive-
ly maintained by the vegetative nervous system.
The fvinctional metabolism of nervous structures
themselves is likewise affected and fatigue is a pre-
liminary warning in consciousness of threatened
faulty adjustment. The fatigue threshold is
dangerously near consciousness because of the most
universal of all afifective goals, indolence. Indol-
ence is ever ready to camouflage its real desires and
8o8 JELLIFFE: NERVOUS AND MENTAL .
by means of a conversion mechanism fatigue states
arise from our conflict with indolence, which varies
with every individual. Hence in those, and perhaps
they are the majority, a slightly added weight by
means at times of a minimal amount of metabolic
imbalance from intoxication which throws up the
danger semaphore (instinctive sense of wellbeing)
the sense of fatigue is doubled or redoubled.
F"light now is the psychological alternative as a pro-
tection mechanism. The robust and healthy stand
up and fight and the victory is won. This robustness
applies to mental rather than to physical robustness.
Many of the muscularly most robust of mankind are
worshippers at the shrine of Narcissus. They are
strong for self aggrandizement. Hence they are
mentally not healthy for mental health means the
direction of one's aims towards socially valuable
rather than individual goals. Right here one may
see a partial answer to the problem which has dis-
turbed the medical mind why so many of the ap-
parently healthiest are so readily laid low by the
influenza organism. Parenthetically, also some light
may here be directed towards the valuable psycho-
logical attitude of the value of a universal muscular
training for the preservation of one's nation, rather
than the advantages to be gained by individual
athletic gymnasium work for the limited, hence
more Narcissistic and infantile glory of this school
or that university or other exhibitionistic aim.
Those less healthy minded then unconsciously run
away and the flight into a protective psychoneurosis
or to a psychosis ensues. Right here may be seen I
believe in its proper setting the whole vexed ques-
tion which has been stated in so many diflferent ways
as to the influence of heredity, of neuropathic char-
acter, of the background, in short, of the individual.
Everybody — bar none — is by necessity, as a bit
of living matter, constantly engaged in struggle.
Speaking mentally what we call neurotic, neuropathic
psychopathic or Vv'hat not, is only a vague way of
attempting to embody the externally observable be-
havioristic features of that struggle by some di-
agnostic label? Because of the great diversity and
complexity of the observable phenomena there re-
sults a great range in attempt to restrict these phe-
nomena by static definition. Those whose conduct
varies more from the average than others, to the
good or bad, it may be mentioned it seems the dififer-
entiation is rarely made by the usual observer, are
stigmatized as neurotic, neuropathic, etc. A stig-
matization it might be observed which has much of
the Pharisee attitude of self laudation about it.
Neurotics, neuropathies, even some psychotics are
•capable and alone are the capable it may be added,
to add to the store of the world's most precious
possessions. The creative artists of the world are
among those usually stigmatized neurotics, etc., but
they are the ones who have successfully struggled
with universal indolence and made something new.
Other neurotics have laid down on the job and be-
come the hoboes, the prostitutes, male and female,
and the failures.
A static definition of neurotic means nothing; a
dynamic definition of neurotic means increased or
diminished capacity for new adaptations — which it
is going to be, plus or minus, is always a question
ISTURBANCES OF INFLUENZA. [New York
Medical Journal.
of fact for the individual and for the moment and
for the particular situation.
So to return to our muttons — the manner in
which each individual is going to react to the grip
virus is going to be determined by his dose and the
way in which he has handled, or is handling, his
conflicts. As these are two, or more, independent
variables, the results, speaking mentally, are legion.
The most frequent of these are the various neu-
rasthenic forms which may show as simple fatigue,
involving attention, or myasthenic states, or a host
of neurotic or fatigue medleys in the viscera. These
influenzal neurasthenias occur with either severe
or with mild systemic signs of infection. There is
for most patients an extraordinary myasthenia with
great depression of spirits. In the majority of in-
stances this clears up in from one to two weeks — in
some after two or three days. But in a still strik-
ingly large number of patients the residual neuras-
thenic fatigue is severe.
By neurasthenia is here meant the pure fatigue
syndrome due solely to the toxemia alone or toxemia
plus the emotional conflicts to which attention has
already been directed.
Some mention has already been made of head-
aches. The persisting localized ones may be the re-
sults of serous meningitides as has been said. They
may also be protective devices of the unconscious
to prevent further disturbance to the individual
forcing him to pay attention to his state of well
being. The somatic instinctive sense of well being
— in the healthy minded of our previous definition
— is an excellent guide for conduct, and here the
protracted headaches say "stop, look and listen."
Such individuals are advised to rest and feed.
Of the other neurasthenic syndromes much may
be said. There are many in which the fatigue is
not the only symptom but in which various visceral
neurotic disturbances persist. Thus in the skin lo-
calized or more or less generalized areas may per-
sistently gooseflesh, or formication may come and
go with every grinding noise, or sudden jar, or un-
accustomed sight. A hair trigger localized vegeta-
tive unrest of the skin structures causes such minor
accompaniments of the fatigue state. Or a similar
mechanism in the blood vessels will bring about
great chilliness, or marked cyanotic blueness — at
times almost passing over into a Raynaud's syn-
drome, thus lending a certain support to, the hypo-
thesis that the vegetative nuclei in the cord may
have been involved. Again there may be mild per-
sistent edemas, or reddish mottlings of the skin,
irregular erythemas, etc. Other visceral signs may
be present such as digestive upsets, diarrheal at-
tacks, polyurias, icterides, etc. One might box
the compass of the various viscera of the body and
find one or two or a host of such mild disturbances
of function in the influenzal aftermaths. The pre-
cise pathology of these we hope to touch upon be-
fore closing this review.
Psychoses. By almost insensible gradations, mild
or profound depressed states develop on a basis of
the neurasthenic toxic condition plus a greater in-
dividual unconscious conflict. ^The flight into the
psychosis may become an overcompensatory one in
those, by no means rare cases, in which suicide is
November 9. 191S.] JELLIFFE: NERVOUS AND MENTAL DISTURBANCES OF INFLUENZA.
809
elfected or attempted. Less severe depressions arc
the rule and are very frequent. It has seemed not
only my own experience but apparently from the
many reports of others, quoted in part in the biblio-
grapliy to have seen depressed states very frequent-
ly, so that they may be termed the most frequent
of the grip psychotic conditions. At times the de-
pression may be accompanied by delusional ideas.
These are not specific. They have no relation to
the influenza per se but are the symbolized products
of the individual's own conditioned reflexes, or com-
plexes, using a physiological (Bechterew, Pavlow)
or a psychoanalytic term (Freud, Jung). They tell
of the patient's conflicts which existed long before
the influenza came along, but which by reason of
what for lack of a better concept we call the "re-
duction in resistence" or "lowering of the psycho-
logical level" because of the toxemia and the at-
tending worries, financial or in the love life, permits
the conflict to break through under various camou-
flaged forms.
Thus one of my patients who had come to a fairly
satisfactory compromise with her difficulties by
means of a compulsion neurosis in which religious
and social cleansing symbols — much praying with
beads and much hand washings — are the chief
hampering activities, has had two or three rather
sharp influenzal attacks during the years I have
known her. She came for treatment comparatively
late in life and gets along with a minimum of com-
pulsions now that their function is somewhat un-
derstood. Following each of these attacks she has
been much depressed and has heard hallucinatory
voices which have referred very plainly to her anal
erotic complexes. Intense constipation which has
lequired frequent enemas or mucous diarrheas have
been also present. From a psychoanalytic view
point it is apparent what important function the
prayers and the hand cleansing serve. These pro-
tective devices, however, break down as substitute
carriers for the unconscious affective conflicts under
the added stress of the grip situation, when these
affects are now handled partly by means of the
direct satisfaction (unconscious) of the anal areas,
constipation or diarrhea, and partly by a projection
of the unconscious preoccupation through the hal-
lucinatory voices which invariably deal with anal
and erotic images. (K — m — A — s) (S — t) are the
most frequently heard expressions. Usually they
are male voices, often heard from passersby in the
street, or occasionally the belief comes to conscious-
ness that a group of men standing on a street cor-
ner are talking about the patient and are discussing
the question of giving her an enema. In such a
patient the nature of the conflict is readily recog-
nized because of the intense work already done with
the analysis of the compulsion neurosis. It is
worthy perhaps of more than passing comment to
note that an earlier attack of grip with a similar de-
])ression and similar voice projections was also re-
acted to by suicidal ideas and a nearly successful
suicidal attempt because of the ideas of great sin-
fulness re — the character of the nasty voices. A
severe increase in the neurosis took up the period
of recovery from the grip. Fifteen years later, how-
ever, with marked lessening of the compulsion the
hallucinatory attack almost gave the finish to the
neurosis for the patient now saw for the first time
that the hallucinatory voices were her own uncon-
scious preoccupations projected upon an outside
source in order to be the more readily camouflaged.
She not only did not pass into a depressed state but
made a distinct step towards freedom from her
unconscious sadistic difficulties.
A great variety of acute hallucinatory and con-
fusional syndromes may be described. The content
of the hallucinations is always of value in casting
light on the conflicts of the individual and thus later
may be of great service, should the opportunity
arise, in showing the patient what has determined
their "neuropathic" make up, not in terms of their
grandmother or other equally elusive ancestral
shade, but for themselves and right now. It may
be very fascinating to know what Mendelian laws
are being verified in the light of heredity in traits
mental and otherwise, but that is all passed and
been rendered static, it is of no service in the actual
alleviation of the patient and really casts not the
slightest scintilla of Hght upon the present difficulty
in the working of the individual machine. It is
perfectly true that a two armed juggler can prob-
ably toss more balls than a one armed oi'we, but the
actual problem is, no matter how many arms the
patient has been fortunate enough to get from his
ancestors, what is he doing with those he has. He
is what he is. How he is going to handle the situa-
tion is the practical problem. A careful study of
the content of the psychosis is then of inestimable
value in further helping the patient to a more
healthy adjustment of his internal difficulties when
he recovers from his psychosis, which latter is the
rule.
At times extremely severe post influenzal psy-
chotic states are observed, Ruju's case of a cata-
tonic syndrome being a case in point. These are
rare but a careful study of similar cases, and they do
occur, is well worth while as throwing some light on
the extremely important problem of dementia pre-
cox, that most widespread and devastating of all the
psychoses. Acute infectious deliria, sometimes
fatal, have been described. To epitomize the entire
literature of the psychotic possibilities let loose as
it were by the influenza toxemia would need a
volume.
Some General Observations. In closing a few
general reflections are tempting. Bacteriologically
the influenza bacillus is probably a specific entity, so
far as species in bacteria go. Like other plants the
products of their metabolism yields complex sub-
stances chiefly protein in their character, which may
or may not be prejudicial to other organisms. There
are some products of the Pfeiffer bacillus which
have a definite action upon certain parts of the
nervous structure.
Indeed, from the very beginning, earlier students
of the disease have been struck by the high inci-
dence of nervous symptoms, and from the eighth
century to the present, there have been those who
have accented this aspect of the situation. Some
have gone so far as to claim that the influenza is
essentially one in which nervous structures are pri-
8lo JELLIFFE: NERVOUS AND MENTAL DISTURBANCES OF INFLUENZA.
[New York
Medical Journal.
niarily involved. That there are certain valid reasons
for this generalization, we shall point out ; or rather
phrasing it slightly differently, we shall say that
influenza is a disease of microbic origin, the poison-
ous products of which have a specific action upon
the vegetative nervous system The part of the
vegetative nervous system bearing the brunt of the
toxemia is the sympathetic. This leads to a host of
physical upsets, chiefly mediated through impaired
balance of the vagus sympathetic adjustment with
pronounced vagotonic predominence, causing vessel
paresis, and the exudative phenomena which form
so essential a feature of the disease. Vowart of Bor-
deaux called it a pneumogastric neurosis in 1881
and many others have reached for a conception of
the neurological features which were so prominent.
These exudative phenomena, depending upon their
location cause the various symptoms, localized vago-
tonias. If cephalic, they give rise to the cephalalgia,
which is universal and in a small number of cases
when severe, and when infection is added, as not
infrequently occurs, gives rise to a serous or non-
purulent meningitis with either a maniacal coloring
(rarer) or mild stuporous states, or milder, neuras-
thenic or hypochondriacal conditions. Epilepsy and
chronic serous meningitis are among the rare re-
sults which have been discussed.
When the exudations caused by the failure of
control of .sympathetic tonus and hence, overaction
of autonomic impulses involve the cranial nerves
they result in disturbances of smell, optic neuritis,
ocular palsies, trigeminal neuralgias, facial palsies,
deafness, vertigo, modifications of taste, pharyngeal
and laryngeal palsies. When the peripheral spinal
vegetative arcs are involved, various neuralgias and
neuritides result. These result chiefly from the
exudation phenomena taking place in the nervi vas-
orum of the nerve sheaths, brachial, intercostal,
and particularly sciatic. Herpes zoster is an indica-
tion of direct implication of the vegetative ganglia
themselves more often an exudate rather than an
infection, since the influenzal zosters, in my
limited experience, have been benign. Its inci-
dence runs high in certain epidemics. The most
striking cervical sympathetic involvement is that of
the pneumogastric and sympathetic adjustment. The
vagus itself, which is autonomic, sometimes shows
its overcompensations by bradycardia, but as a rule
the sympathetic paresis or paralysis permits an over-
action of the autonomic and causes the edematous
flooding which characterizes the pure grip pneu-
monitis. This peculiar exudative character of the
lung manifestation has been noted for many cen-
turies although its fundamental pathology is still to
be more adequately elucidated. The pneumonia
is not to be spoken of as a complication, but as a
primary disturbance of the vegetative nervous sys-
tem control of pulmonary vessels, with edema and
bloody infiltration resembling in its fundamental
characters, the exudative phenomena of asthma or
spasmodic croup, angioneurotic edema, acute ede-
matous arthritis, hay fever, horse serums, protein
poisoning, anaphylaxis, or exudative phenomena of
various origins in which there may be a generalized
or localized vagotonia. Implication of the thoracic
and lumbar sympathetic arcs is responsible for many
of the gastrointestinal vagotonic symptoms ; here
the exudative phenomena are as striking as they
are in the pulmonic areas, gastric diarrhea, etc.
The spleen, liver and kidney disturbances also
show a somewhat similar pathology which has not
been thoroughly elucidated. Joint exudations are
early and frequent. They occur suddenly and the
character of the disturbance is directly indicative
of the disturbed vegetative balance. The joint and
muscle pains are likewise corroborative of this same
general viewpoint. The various eruptive phenom-
ena on the skin and mucous membranes speak in the
same general way. Ei'ythematous, petechial, urtic-
arial types all permit their alignment with similar
eruptive phenomena known to occur in the vegeta-
tive nerve disturbances which accompany the vago-
tonic trends. In many respects the striking anal-
ogies to anaphylactic reactions afford a clue to the
inner vegetative mechanisms. Smith has eluci-
dated these in a striking manner, following Ron-
coroni's classic exposition.
It would make a most alluring hypothesis to
attempt to show that a more or less widespread and
constant though unperceived involvement of the
thyroid might serve as a starting point for this dis-
turbance of sympathetic balance, the thyroid
hormone containing type constituting the chief reser-
voirs for sympathetic upkeep, which is not confined
solely to the thyroid, and therefore when involved
itself adding its own disturbance to further un-
settle the physicochemical balances of the body
fluids. The observations thus far recorded, how-
ever, are still too scanty or too scattered to permit
this generalization. At the same time attention may
be called to the more or less universal adenopathy,
the frequent occurrence of an acute, mild or severe
thyroiditis, and the frequent overcompensatory
character of the adrenal system activity, the acute
sthenic fight put up followed by the great myas-
thenia and other signs clearly indicative of adrenal
exhaustion, Sergent white line, etc., already noted
here.
We cannot carry these suggestions further in
this place. There are abundant sources with patho-
logical protocols to show the probable pathogenic
affinities, say to such sympathetic paralysants, or
autonomic stimulants, such as nicotine, pilocarpine,
physostigmine, or muscarine. And the time is al-
most ripe for a true dynamic pathology of visceral
disease to be written in terms of the reciprocal ac-
tivities of the autonomic and the sympathetic regu-
latory mechanisms.
Every single organ of the body is under the bal-
anced control of these two sets of opposing mechan-
isms. Inhibition is a problem of a resultant of posi-
tive forces — there are no negative ones in a trans-
mitter— for the human body is a mechanism for the
capture, transformation and release of energy. The
physicochemical work for metabolism is regulated
by the vegetative nervous system chiefly, and any
disturbance in one branch of that system is bound
to cause overactivity in the other. Whether the in-
fluenza toxins not only paralyze the sympathetics
but stimulate the autonomics as well, thus causing
an excessive autonomic swing with the unusual
vagotonic predominance is a matter of fact to be
November 9, 1918.]
LEV B ARC: TEMPERAMENT AND NERVOUSNESS.
811
determined only when the poisonous substances are
isolated, their internal structural composition anal-
yzed, and pharmacodynamically proved out. Until
such time arrives more attention should be focussed
upon the neurological problems of influenza, for
herein may lie a key to the control of its many com-
plicated symptoms from a cold in the nose to cold
toes.
Bibliography will be found in the author's re-
prints.
64 West Fifty-sixth Street.
TEMPERAMENT A SYNONYM FOR NERV-
OUSNESS IN SINGERS.
By John J. Levbarg, M. D.,
New York,
Assistant Laryngrologist, New York Polyclinic Hospital; Visiting
Otologist and Laryngologist, Beth David Hospital; Chief
Otologist and Laryngologist, Harlem Dispensary.
Inasmuch as the musical season is about to open,
I think it opportune to write on temperament as
pertaining to singers, as, strange as it may seem, it
falls practically upon the laryngologist to cope with
the nervous condition of the latter. It is a very im-
portant study for the physician and seems to be
one that the profession has almost entirely over-
looked.
Singers, as a rule, who have any physical com-
plaint whether of the stomach, throat, or arm, usu-
ally visit the nose and throat specialist for advice.
Therefore the latter should study his patient very
carefully, paying special attention to his nervous
status
It is safe to say that singers never contract tuber-
culosis. This fact is probably due to their proper
method of breathing, thereby taking in plenty of
oxygen — an important and indispensable factor in
good health. However, it is unsafe to say that they
do not get sick ; in fact, the chief neurotics who
come to the specialist's office for treatment are sing-
ers. It is difficult to account for this condition.
It is my opinion that this neurotic condition, pres-
ent in almost every singer, is mainly due to ex-
treme sensitiveness on his part. Nervousness plays
a salient role in their lives.
Music is very instrumental in producing such a
condition. It causes a marked effect on the nerv-
ous system through its varied vibrations. It has
been repeatedly proved by experimentation that it
will cause stimulation, depression, make the weak
strong, cowards brave, and aid many maladies of
the nervous system.
Temperament in a singer is but a tributary to
nervousness. Temperament will cause an increased
reaction, both mental and physical, to external im-
pressions. An overstimulation of the above will
cause an exhausted or debilitated condition of the
nervous system, which condition is met very fre-
quently in many singers. Most singers possess an
abundance of temperament characterized by mental
force and high strung sensibilities, manifesting
tenseness and vigor as an expression of style. In
other words, temperament is a preponderance of
the activity of the mental over that of the physical
qualities.
Temperament is affected by dififerent conditions
— elevation, temperature, change of climate and al-
titude, and environment. If singers can control
this temperament, or nervousness, their singing will
be clear; but should they lack power of adaptation,
sudden nervousness may result, thereby causing
straining, clouding, muffiing of the voice, and im-
proper breathing.
The treatment of this neurosis requires the
greatest care on the physician's part. The singer's
food, sleep, exercises, and work should be sys-
tematically regulated. Personal hygiene is very
important in such subjects. Their intellectual work
especially should be judiciously limited and should
alternate frequently with periods of repose. Ex-
citement of all kinds should be avoided, and such
patients will do well to be abstemious in the use of
tobacco, cof¥ee. tea, and especially alcohol, which
primarily produces a stimulating effect and then
rapidly causes a depression.
The habit of taking a prolonged holiday, away
from the ordinary environment, such as a trip to the
woods, mountains, or at the seashore, at least twice
a year, should be urgently insisted upon. Cold
baths, before going to bed and in the morning, help
to harden the nervous system. Exercises in the
gymnasium, tennis, rowing, sailing, are of value in
maintaining the general nutrition and help the nerv-
ous system a great deal. Drugs should be avoided
as much as possible, especially habit forming ones.
If the patient is anemic, general tonics may be
helpful.
Their exercises during the day should be sys-
tematized, and by observing the proper hygiene of
health, singers will find that in a short time the
neurosis will begin to disappear, their singing
will improve, and confidence in themselves — a great
and very essential requisite — will thereby be ac-
quired.
1425 Madison Avenue.
CONFLUENT SUFFOCATIVE BRONCHO-
PNEUMONIA IN THE WAKE OF THE
PRESENT INFLUENZA EPIDEMIC.
By Frank A. Jones, M. D.,
Memphis, Tenn.
However much opinion, as to the causative agent
in the prevailing epidemic of influenza may be di-
vided, the fact remains that the pneumonia that
accompanies, or rather, follows it is dramatic and
tragic.
It is to the bronchial tree what cholera is to
the digestive tract, what confluent smallpox is to the
skin.
In the present epidemic the mortality is high and
rapid. It is needless to discuss the laboratory phase
of the question ; it has been sifted from every angle.
In nearly all of the patients which we are seeing in
Memphis, the waxy pallor, together with the
cyanosis, are the insignia of rapid blood changes and
destruction and pulmonary sufifocation ending in
death, in most instances in twenty-four to forty-
eight hours' time. The patient literally drowns in
bronchopulmonic secretions. It is a veritable
8l2
BOORSTEIN: ORTHOPEDIC CASES.
[New York
Medical Journal.
kaleidoscopic bronchopneumonia. There is an ac-
tive pulmonic edema rather than passive. Clinically
speaking confluent suffocative bronchopneumonia
covers the symptoms and physical findings. Surely
vasomotor paralysis plays an important role. Vac-
cines and polypharmacy have been futile.
Much has been said about the patient's physical
state at the time of the attack. The author has
found that the robust have fallen victims just as
readily and rapidly as the devitalized.
Thus far every pregnant woman who has been
attacked has miscarried and died.
INTERESTING ORTHOPEDIC CASES IN
THE FIRST SURGICAL DIVISION,
FORDHAM HOSPITAL
By Samuel W. Boorstein, M. D.,
New York,
Instnictnr of Orthopedic Surgery, Fordham University, School of
Medicine; Adjunct Visiting Orthopedic Surgeon, .Montefiore
Home and Hospital; Adjunct Assistant Visiting Sur-
geon, Fordham Hospital, New York.
Quite often an interesting case is treated in
private or hospital practice and is carefully studied
and watched to see if the prognosis was accurate.
The doctor decides to have a report published but
usually waits either to get a similar case or to study
the literature more extensively ; but often the second
patient never comes ; the literature is never looked
up, and so valuable reports are lost. Of course,
many do review the literature and add one or two
cases, but this is of rare occurrence. CuUen (i)
justly says: "We should publish our rare cases at
once, otherwise they are soon forgotten among the
multiplicity of other duties. The digest of groups of
cases requires sometimes months or years before
they can be analyzed so that the results may be of
real value to the public."
This statement by so prominent a man has
prompted me to look up in my history file rare cases
which I had ready for publication. Some of them
were as vet incomplete, lacking additional informa-
tion, or else I had been waiting for additional cases.
I have now decided to have reports published from
time to time, merely as interesting ones, from the
orthopedic service in one or another hospital. When
1 am fortunate enough to get other similar cases
there will be no difficulty in recording the entire
group in detail.
BILATERAL PATHOLOGICAL DISLOCATION OF THE HIP
JOINT.^
That Tin acute infection at any focus may cause
arthritis at a distant place is already an established
fact. You are probably acquainted with the recent
studies by Billings (2) and are surely on the alert
to seek at once for the place of infection. No doubt
you have vivid recollections of septic arthritis fol-
lowing an acute exanthematous disease. This case
is not exhibited simply to demonstrate arthritis or to
impress you with the necessity of examining all the
tracts before removing the teeth as the sure culp-
able focus. Such facts have been sufficiently
'Presented before Bronx County Medical Society, October 17,
pointed out by Rosenow (3), Billings (4), Mayo
(5), Barker (6), and others, and, in my opinion, the
teeth have rather too frequently been considered
the foremost cause of infection without proper
scientific basis, no other focus being sought — a plan
certainly detrimental to the patient.
The following is a quotation from one of my
previous papers read before this society, which
may recall to you many facts concerning the focus
of infection and will probably help to throw light
upon this case :
"Specific cause. — By far the majority of investi-
gators are now cf opinion that chronic progressive
polyarthritis is infectious in nature. The term
'infectious' is used here in a general sense, i. e.,
aside from the cases in which the infection is found
in the joint directly, it includes cases where there
are minute foci of infection distant from the joint.
In these latter cases there is in the joints a contin-
uous bacteremia of low grade. Under the term
'infectious' are also justly included cases which ap-
pear to be complications or sequelae of other in-
fectious diseases, such as arthritis following in-
fluenza or scarlet fever.
''First, consider the secondary infectious cases,
i. e,, where the causal organism is supposed to be in
a distant focus. Among the culpable distant foci
are placed : Chronic inflammation of paranasal sin-
uses (including the antrum of Highmore) , chronic
abscesses, chronic bronchitis, cholecystitis, chronic
pyelitis, chronic cystitis, chronic urethritis, prostatitis,
v'hronic salpingitis, and chronic endometritis. Thus
we see that the blame of arthritis has been put on
every orean of the body and the organisms causing
the diseases of those organs are supposed to be the
factors of the arthritis (7).
"Can we say positively which case of arthritis is
due to pyorrhea alveolaris only? From the symp-
toms of arthritis, no ; in other words, when a diag-
nosis of infectious arthritis is made, we know there
is an infection in some distant focus, but cannot tell
whether the source of infection is in teeth, tonsils,
or gastrointestinal tract. So, to call a certain case
'pyorrhea alveolaris arthritis,' as one dentist has
lately done in the literature, shows insufficient read-
ing and observation. A patient may have pyorrhea
alveolaris and still have an arthritis due to chole-
cystitis. I am sure many of you. might have been
misled by his misstatements and have thought that
one can designate specifically a case of pyorrhea
alveolaris arthritis. How can we tell even the cause
of pyorrhea alveolaris? In eighty-two patients
with bad teeth I was not able to definitely diagnose
any single one pyorrhea. Often the teeth were at-
tended tO' by good dentists and still the disease pro-
gressed. On reexamining the patient, the real
etiological factor was discovered and when that was
removed, the disease stopped progressing" (8).
The following case, however, is one of the
rarest and worst deformities that may follow infec-
tion and the most interesting fact in the case is that
the deformity is preventable. Only about eighty or
ninety cases have been reported.
Case I. — G. C, age six, male, born in United States.
Family history: Parents in good health. Previous history
has no bearing on this attack. This child has always had fair
health. On February 12, 1917, he became ill with scarlet
November g, 1918.]
nOOKSTRIN: ORTHOPEDIC CASES.
813
fever and was taken, in a serious condition, to a hospital.
On March 21st he showed symptoms of double mastoids.
Being too sick, an operation was not deemed advisable.
At tlic same time he had double pneumonia, followed by
empyema, which, on tapiiins, revealed a consideralile
amount of pus. April 15th the left hip became swollen and
painful. This was followed in a few days by swelling and
Fig. I. Fig. 2.
Fig. ]. — Case i, on August 25, 1917, before beginning of treats
ment. Note prominence of hip, anguished look of child, and his
support.
Fig. 2. — Case i, posterior view, prominence of hip clearly shown
and necessity of support.
pain in the right hip ^nd knee. The pain in these joints was
very severe and the patient held the knees flexed on the
thighs and hips flexed on the abdomen, or, as the mother
expressed it, "doubled up." The mother does not know
whether the hip joints were held in internal or external
rotation. The child was so sick during his stay in the hos-
pital that the physicians devoted their entire time to treat-
ing his general condition and apparently paid no attention
to the position of the joints. He was taken home May
30, 1917, with swollen and painful hip and knee joints,
which he was unable to use. Mother gave the child daily
hot water baths and slight massage to the knees and hips.
The joints improved gradually, pain subsided, and the
knees could be brought to a straight position. The mother
noticed, however, thai the knee and hip joints were almost
straight, but the child could not put any weight on the
right limb. She even noticed a marked deformity at both
hips. The child had not been under a physician's care
since he left tlie hospital. She brought the boy to my clinic
at Fordham Hospital, August IS, iQiy.
Physical examination. — Child was of fair stature but
somewhat anemic and with a languid expression. Teeth
were in good condition. Throat, examined by a laryngolo-
gist, showed enlarged tonsils with distinct evidences of
pus and enlarged adenoids. Nasal cavity — enlarged tur-
binates. The condition of the throat showed still active
lesions, and removal of these sources was imperative. Ear
examination, negative. Heart and lungs showed no ab-
normality. Lymphatic glands : cervical, cuboid, and in-
guinal enlarged. Muscular system showed general atrophy,
more marked on lower extremities. Skin and nails good.
Wassermann, negative. Urine showed no abnormality.
Upper extremities normal. Lower extremities : right hip
markedly dislocated upward and limb kept in a position of
internal rotation and adduction. Head of femur was felt
above the acetabulum. Marked limitation of motion to ab-
duction, outward rotation and extension. Flexion was less
limited (he raised the pelvis and simply dislocated the head
more posteriorly). Left hip showed limitation to abduc-
t:cn and rotation outward, and also dislocated upward.
Patient had marked lordosis to compensate for the dislo-
cated hips and put no weight on the right limb. He had to
support himself even while standing, and could not make
a single step (Figs. 1-2).
Measurements" :
R. A. 2iiA"; R. U. 22/2", R. T. 9'4", R- K. 9". R- C. 7"
L.A. 2134", L.U. 2354", L.T. 9)4", L. K. 9/2", L. C. 7'/4"
There was a shortening of three quarters of an inch on
the right side and atrophy.
The X ray findings are shown in Fig. 3,.
Remarks. — We have here a boy of six years with
Ijadly deformed hips due to septic arthritis. (It is not
necessary to discuss now whether caused by scarlet
fever or throat and ear condition. It is hard to de-
termine which was the real causative factor though
we are inclined to blame the laryngeal tract.) The
joints are in poor condition and the motion in them
not free. The more serious sequel is that the hips
are dislocated at the heads and rub against the ilium
and cause more and more destruction and give very
lax and unstable joints ; more so on the right side.
Perhaps if the lesion is still active there will be
ankylosis due to proliferation but the feet are not
on the same level and thus even if ankylosis is
established it will interfere with proper locomotion.
At present I am not trying to sutnmarize the proper
treatments of septic arthritis at the time of the acute
attack but I do wish to emphasize the need of pro-
tection or prevention of such marked deformities.
The capsules in this case were markedly distended
v/ith fluid and thus it naturally had to cause flexion
and inw;ird rotation of the hips. This is the natural
position that the limb assumes in order to permit
more extension of the capsule (9) and there-
fore it was the most favorable position to cause a
dislocation. It would have been a simple matter to
have prevented that defonnity by keeping the hips
in extended and abducted position during the acute
attack. That could have been done by a double
spica plaster or a Bradford frame with the lower
part split to allow abduction of the feet. Even the
old style Buck's extension might have done the
work.
Treatment. — The right hip seeming the worst we
decided to give more attention to that one for a
while. As permitting the child to walk would have
increased the dislocation, he was at once ptit to bed
and a traction placed on the right foot till a brace
could be provided for him. His general condition
was attended to. The tonsils and adenoids were
removed. Then a Bradford (10) adduction traction
splint brace was applied which prevented putting
weight on the right limb, allowed traction which
might help pull the limb down, and the brace had
also provisions 10 abduct the limbs, thus correcting
the adduction defonnity (Fig. 4).
The treatments wil be kept up for a few months.
Then if the head of the femur is not in, it can be
treated as a regular congenital dislocation of the
^These abbreviations are used by orthopedists to designate cer-
tain definite points from which measurements are taken: R. A.,
distance from right anterior superior spinous process of ilium to
internal malleolus; L. .'\., left anterior superior spinous process;
R. U., umbilicus to right internal malleolus; R. T., circumference
of the right thigh, in this case taken at four inches above lower
border of patella; R. K., circumference of right knee; R. C,
circumference of right calf.
8i4
BOORSTEIN: ORTHOPEDIC CASES.
[New York
Medical Journal.
hip and be replaced by the Lorenz bloodless method.
Of course, it is doubtful whether we will get a
good result. Ankylosis will probably result in either
case but the limbs will be of equal length.
December 15, 1917. — -The treatments were kept
up regularly. Patient was not allowed to remove
Fig. 3. — X ray of Case i, August 20, 1917. Head of right
femur dislocated up on ilium and also adducted; head of left
femur is at upper angle of acetabular cavity, which is consider-
ably enlarged; marked destruction of both heads and acetabuh-e,
with marked bone atrophy.
the brace even while in bed. He walks at present
without support. The general appearance has im-
proved markedly. Has no pain at all. Motion in
the hips is better. The x ray findings are shown in
Fig. 7.
Measurements :
R.A. 21?^", R.U. 23V4", R.T. qH", R.K. 9". R.C. 6V4"
L.A. 22", L.U. 241^", L.T. 9!/^", L.K. 9", L. C 7V4"
Figures 5 and 6 show the right hip almost on the same
level as the left one, with improvement in the lordosis
and also general improvement. Seeing the improvement in
the right leg, we tried similar treatments for the left. As
we could not be sure that infection had subsided, we de-
ferred an open operation — open reduction with orthoplasty
— to a future date.
REMOVAL OF TRANSVERSE PROCESS OF THE FIFTH
LUMBAR VERTEBR/K FOR RELIEF OF PAINFUL
BACK.^
That "painful back" is a stumbling block to many
diagnosticians and a discouraging feature to the
general practitioner and to the different specialists
can be seen from the numerous special articles and
monographs written on the subject. The painful
back is viewed from the neurological, gynecological,
urological, medical, and orthopedic standpoints.
Patients are seen by all these specialists and some
operations are performed, and occasionally relief is
obtained when a proper diagnosis has been made.
Frequently many diverse operations have to be per-
formed. Reading the interesting symposium of all
these specialties delivered at the meeting of the
American Orthopedic Association in May, 1917
(11), we see how far we are from a definite under-
standing of the problem. The latest studies of
^Presented before the Orthopedic Section of Academy of Medi-
cine, New York. January i8, I9'8.
Goldthwaite (12, 13, and 14) and Bohm (15)
showing the abnormalities of the sacrum and lumbar
vertebrae have added greatly to our knowledge of
this phenomenon. The late Professor Dwight (16)
once said : "Anomalies of the fifth lumbar vertebrae
are so common that we hardly know what the
normal should be." Adams (17) reports that of
fifty consecutive cases in which careful rontgeno-
scopy has been made, forty-four subjects showed
bony defects in the sacrum or two lowest lumbar
vertebrae (two cases show one large transverse
process of the fifth lumbar, Bohm type). He ad-
vises removal of the asymmetric overgrowth of the
processes.
On account of the difficulty in diagnosing back
affections (gynecological causes being absent or
eliminated) the reporting of every case on the sub-
ject is extremely beneficial, advisable, and neces-
sary, particularly when the diagnosis is afterward
verified, even if permanent cure has not been ob-
tained. Of course where cure has been obtained the
report is even more important.
This case and the one following present a type of
low lumbar backache due to enlarged transverse
process of last lumbar vertebrae. "An impingement
of such an enlarged transverse process of the fifth
lumbar vertebrae upon the posterior wing of the
ilium produces pain, numbness, and paralysis of the
side and leg, so severe as to cause a patient to be-
come bedridden, is very often seen, but only a few
persons think of such diagnosis" Adams (17).
"Radiographs showing the fifth lumbar transverse
process overlapping the wing of the ilium are fre-
quently seen without any accompaning painful
symptoms for the reason that in the normal skeleton
the process lies considerably anterior to the posterior
wing of the ilium. It is only when some anomaly
of construction exists and changes occur in the re-
lation of the last lumbar vertebrae, the sacrum, and
the ilium, that a painful impingement is likely to be
produced." Blanchard (18), Adams (19), and
Fosset (20) have shown that the enlarged trans-
verse process can be removed and a cure obtained.
Ca.se II. — E. R., female, age eighteen, single, sustained
an injury on her back, June, 1915, by falling several steps
and landing on her back. She was compelled to stay in
bed for a few weeks. At that time she had marked swell-
ing of the entire left lower extremity. On beginning to
walk, she complained of severe pain in that limb. Strap-
ping the sacroiliac, i. e., applying adhesive plaster straps
across the back at the region of the sacrum extending from
one anterior superior spine to the other, somewhat relieved
the symptoms, but they recurred. About two months after
the injury patient came under my observation. Examina-
tion led me to suspect a fracture of the transverse process
of the fifth lumbar vertebra on the left side, for distinct
crepitus was present with marked tenderness. The radio-
graph failed to reveal any fracture, though several views
were taken. A sacroiliac compressor attached to her cor-
set was ordered, and this gave apparent relief. In eight
months she returned, complaining again of severe pain.
She had marked tenderness on the left side and beginning
of tilting of the spine to the right. Again some anomaly
in the transverse process seemed to be present, and several
radiographs, stereoscopic and different views were ordered.
Only then did we discover a distinct fracture on the trans-
verse process, but on the side opposite to the tender one,
i. e., the right side. As the pain was in the left
side, I suspected that it was due to an impinging of the
transverse process of the veretbrje on the crest of that
side of the ilium. This impinging was believed to be due to
the improper position of the fragment of the fractured
November 9, 1918.]
BOORSTEIN: ORTHOPEDIC CASES.
815
transverse process of the opposite side. Patient was ad-
mitted to the first surgical division of Fordham Hospital,
and on April 29, 1916, was operated on by Dr. A. S. Tay-
lor and myself. The left side, that is, where the tender-
ness was, and not where the fracture was, was the side
chosen. We considered that this side should be attacked
first, and in case no improvement resulted, the right side
could be similarly attended to. It was in accord with
Blanchard's (18) opinion that the tender side should be at-
tacked first.
Operation technic. — An incision was made midway be-
tween the spinous process of the last lumbar vertebrae and
posterior superior spine through the skin, fascia, and
erector spinse. The muscle was separated and the enlarged
transverse process could be felt. This was removed en-
tirely with a rongeur. The muscles and skin were sutured
in the ordinary way. Keeping in mind Goldthwaite's dis-
couraging statement, "The removal of a transverse process,
especially if the enlargement be at all marked, is an exceed-
ingly difficult procedure and may result in damage to the
nerve trunk coming out above or below the process," I was
rather surprised at the ease with which it was removed. I
believe that it was due to the excellent neurological surgi-
cal experience of Dr. Taylor. The patient was allowed
to stay in bed without any plaster.
The wound healed by first intention and the pa-
tient was able to leave her bed in three weeks. She
returned to work two or three weeks later and has
not suffered since. She had no limitation of motion
and could walk without pain or limp when she was
discharged. She did not even have to wear the
sacral compressor under her corset and up to the
present, her symptoms have not recurred. Thus
we can conclude that the removal of the transverse
process has cured her completely.
This case demonstrates clearly that if careful
technic is observed the resection of the transverse
process of the fifth lumbar vertebrae where an im-
pingement of the posterior wing of the ilium is
present, may well be advised. Of course mechani-
cal treatment should be tried first.
Case III.— S. G., male, age thirty-five, butcher by occu-
pation, referred to me by Doctor Greenstein. Previous
history has no bearing on the case except that the patient
has always been in poor general health and has been cough-
ing for a year or so, but cough was not believed to be due
to tuberculosis. Present illness dated to fourteen weeks
before consulting me, beginning with constant severe pain
in the back. Many diagnoses were made and treatments
given, but with no relief. Physical examination showed
spine quite flexible in the dorsal and upper lumbar region
but limited in the lower lumbar. Tenderness at the crest
of the ilium but not severe. The sacrum was prominent
posteriorly and normal lordosis was absent, but Gold-
thwaite's sign (flexion of the extended leg on the abdomen
producing pain at the sacroiliac joints) was absent. The
X ray showed enlargement of both transverse processes
of the last lumbar vertebrae. The left v/as more promi-
nent than the right. The sacrum was sagged down between
the wings of the ilia.
An operation was decided on to remove both
processes and was performed on May 15th, by
Doctor Taylor and myself. The same technic was
followed as in the preceding case but the radiogram
after the operation showed that only the right
one was removed completely. The patient was re-
lieved entirely of pain for four weeks, when it re-
curred at the left side where the process was not
entirely removed. Another operation could not be
undertaken, for he was too weak and had to be sent
to the country. We considered at that time that the
improvement on the left side, which was only tem-
porary, proved that unless the entire transverse
process is removed no cure can be obtained.
The patient v/as seen by me again in the Mon-
tefiore Home and Hospital, December, 1917 (seven
months after operation) and I found that the pain
in the lumbosacral region was somewhat relieved
during this interval but he was suffering then
from pain in the sacrum and upper dorsal
region. During this interval he lost considerable
weight and gave the appearance of cachexia due to
some general disease, as tuberculosis or malignant
growth. Though many x rays were taken and he
was examined by different specialists, no definite
diagnosis could be made. It was proved, however,
that the operation had not cured him. The radio-
grams showed that the removed transverse processes
have not been regenerated.
This case demonstrates a few important points :
I, There may be enlarged transvere processes on
the last lumbar vertebrae and these still may not be
the cause of pain in the back. 2, Where an enlarged
process is present it should be removed entirely to
alleviate pain. 3, The stumps of the removed trans-
verse processes do not produce regeneration of the
removed processes.
CHONDROMA FOLLOWING TRAUMA.*
Though Virchow's theory that tumors are caused
by external trauma has not been held to be correct
by many keen observers, still, many cases are on
Fig. 4. — Bradford adduction and traction splint used in tuber-
culosis of the hip.
record where a tumor followed trauma, and every
case added to the literature may help the pathologist.
This case is therefore put on record.
■•Presented before the Orthopedic Section of the New York Acad-
emy of Medicine, April 20, 1916.
8i6
BOORSTEIN: ORTHOPEDIC CASES.
[New York
Medical Journal.
Case IV. — I. G., male, age twenty-three, received an in-
jury to the dorsal surface of the right foot by pressure
of a rocking chair. The foot became swollen, but subsided
within a few days. For three and a half years the patient
wa.^ suffering from pain in the foot. In the beginning the
pain was felt only when walking, and later on only when
the dorsal surface of the foot was pressed. X ray was
Fig. 5- Fig- 6.
Fig. 5. — Case i, on December 15, 191 7, after three and one-
half months' treatment. Right hip less prominent and consid-
erably abducted; patient can put some weight on the limb, though
slight support on chair is necessary. Note change in appear-
ance.
Fig. 6. — Posterior view of Case r, taken December 15, 1917.
negative. Different diagnoses as tuberculosis of the tarsal
bones, traumatic arthritis, flat feet, and fracture of a
cuneiform were made and treated accordingly, but no relief
followed. On December, 1915, while examining the pa-
tient, a distinct swelling the size of a hazel nut was felt
over the external cuneiform. It had a doughy feeling
and was tender to the touch, giving the patient a sickening
feeling. I put in a needle, but no fluid could be obtained.
A temporary diagnosis of neurofibroma was made and an
operation advised, which was performed by Doctor Taylor
and myself on April 4, 1916. At the operation the nerve
filament was found to be normal, but the mass consisted of
a small honj- oroininence containing a cheesy, hard sub-
stance. The pathological examination was chondroma. Pa-
tient made a perfect recovery and has never suffered since.
FIBROSARCOMA OF SOFT TISSUES.^
There are many conditions outside of a joint
which give symptoms simulating arthritis. When
these conditions are to be differentiated one usually
thinks of the common affections and neglects the
rarer ones. This is exactly what happened in the
following case :
Case V. — P. F., age thirty-five, born in United States,
male, musician, admitted to Fordham Hospital, .A.pril 20,
1917, on the service of Dr. A. Harrigan. I am under
obligation to Doctor Harrigan for permission to include
this case. Previous liistorv: Patient had an attack of
gonorrhea at the age of eighteen ; chancroid at the same
time. No secondary svmptoms were noticed. Present ill-
ness dates back to February 23, 1917, when patient com-
plained of severe pain in the right leg (he thought that for
some time previous to that he had some vague pains in
'Presented before Orthopedic Section, Academy of Medicine,
New York, April 20, 19 17.
that region). The pain, beginning at the right buttock,
radiated down to the ankle and was of a gripping, cramp-
like nature. Pain was increasing, preventing the patient
from sleeping. About three weeks previous to admission
to hospital, hip became swollen. The swelling extended
down to the ankle. Finally patient was unable to walk and
had to be confined to bed. I was asked by Doctor Harri-
dan to make a diagnosis. Physical examination : Patient
is e.xtremely ai-.emic and has a cachectic look. Heart and
lungs are negative. Upper extremities are normal. Right
lower extremity is considerably swollen, especially at the
iliac region. Some tenderness throughout the leg and some
redness over the buttocks. The redness was of a dark
hue. Motions of the hip: rotation outward and extension,
free, flexion seemed to be limited by some physical or me-
chanical limitation but not by muscular spasm. Abduc-
tion was slightly limited. Adduction and internal rotation
were markedly limited. Inguinal glands were enlarged.
Urine was normal and Wassermann was negative. Tem-
perature running between 100 and 102 degrees. Blood
count : white blood cells, 14,200 ; polymorphonuclear neu-
trophiles, seventy-nine per cent. ; large lymphocvtes, nine-
ttcn per cent.; small lymphocytes, three per cent.; eosino-
philes, five per cent. ; transitionals, one per cent. X ray
showed no lesion in the hip or upper part of the femur.
Swelling seemed to be mainly in the subcutaneous tissues.
In view of the fact that the hip was free and the limitation
of motion was due to some external trouble, I made a diag-
nosis of a tumor of soft tissues, though the nature of the
new growth could not be determined. An operation was
therefore decided upon.
This is the description of the operation as given
by Doctor Harrigan : "A' longitudinal incision was
made over the most prominent part of the swelling.
A large tumor was attached to the periosteum of the
ilium but there was no evidence that it had any
definite or firm adherence to the bone. The perios-
teum of the ilium was not gouged out. Considerable
bleeding was encountered and it was necessary to
leave a clamp on the gluteal artery. The fossa of
the -ilium was curetted and most of the musculature
which was adherent to the tumor mass was re-
moved."
The pathological report by Doctor Heitzman says :
■'Gross specimen consisted of a tumor mass about
the size of a large grape fruit and weighing about
one and a half pounds. It was round, with a some-
what irregular smooth surface. On section it had
the appearance of 'voluntary muscle fibres' which
had undergone myxomatotis changes. Microscopi-
cally, the tumor is found to consist of partly dense.
])aillv loose fibrous connective tissue with a small
amount of muscle tissue. Imbedded in the connec-
tive and muscle tissues are round and oval nucleated
cells, partly irregularly scattered, partly in alveoli ;
the latter are small and are more or less completely
filled with the cells. The corpuscles are all small
and the nuclei of many show difTerent degrees and
varieties of degeneration, so much so that in some
cells only fragments of nuclei are left. The degree
of infiltration of the connective and mucle tissues
varies greatly ; in some places the cells are closely
packed together, while in other places they are ir-
regularly scattered and less abundant, though their
general character is everywhere the same. Mucoid
degeneration is present everywhere, and hyaline de-
generation is also seen in dififerent places. The
vascular supply is moderate, most of the blood ves-
sels being small and thin walled. The diagnosis
is round celled and alveolar fibrosarcoma with
mucoid and hyaline degeneration."
Patient was discharged June 30, 1917, consider-
November 9, 1918.]
BOORSTEIN: ORTHOPEDIC CASES.
817
ably improved. His physician, however, reported to
me that the patient is not doing well.
SARCOMA OF THE HIP.*' *
The work of Barrie (21, 22) has stimulated the
orthopedists to consider hemorrhagic osteomyelitis
as a diagnosis when the patient gives a history of a
trauma followed by symptoms of osteomyelitis, but
not of an acute infectious type and without fever.
The X ray shows a marked rarefied area in the end
of the long bones which progresses rather rapidly.
These cases used to be diagnosed as sarcoma of the
bones and amputation of the limb was usually urged.
Still, many cases come under the orthopedic ob-
servation where it is hard to differentiate between
hemorrhagic osteomyelitis and real sarcoma and. of
course, where an opportunity is offered to operate
on the case and get the pathological findings it
should be reported.
Case VT. — M M., age thirty-six, Russian, male, married,
waiter by occupation. Came under my observation No-
vember 16, 1917. Previous history negative; has three
healthy children. Present illness dates back to October
3, 191 7, six weeks previous to consulting me, when patient
fell, landing on the right hip. Since that time complained
of pain in the hip. The pain was worse at night and con-
dition was aggravated on walking. Thus patient could not
walk more than two blocks. In a week or two he began to
limp. He was treated for the usual condition of rheuma-
tism with electricity, etc., but no relief was obtained; was
growing progressively worse all the time. Physical ex-
amination on November i6th showed marked limp to the
right, slight limitation to flexion and adduction and abduc-
tion, marked limitation to inward rotation, some limita-
tion to outward rotation. Marked tenderness over the
great trochanter. Some fullness over Scarpa's triangle.
Measurements :
R. A. 325^". R. U. 36H", R. T. 14^", R. K. isVi", R. C. 12V2"
L.A. 323^". L.U. 36M",L.T. is'A", L.K. 13'^", L. C. 125^"
An X ray taken at that time showed marked
bone atrophy involving the entire greater trochanter,
with definite evidence of cavity formation. My
temporary diagnosis was hemorrhagic osteomyelitis,
Fig. 7. — X ray of Case i, taken December 15. 1917, showing
better position of bone.
and I took him down to the orthopedic section of
the Academy of Medicine, November i6, 1917, to
hear the opinion of the section in reference to the
diagnosis. Some were inclined to agree with me
^Presented before Orthopedic Section, Academy of Medicine, New
York, January iS. 1918.
while others diagnosed a sarcoma. All advised
to cut down on it and remove a specimen for exam-
ination.
Patient was admitted to Fordham Hospital where
a second x ray was taken, six days after the first.
Definite evidence of rapid progress was shown.
Pain was increasing all the time. Wassermann
was negative and the temperature was normal. He
was operated on May 22d by Doctor NicoU and
myself. The outer layer of the bone was found
very thin and brittle, almost ready to burst. The
cavity was filled with a mass of grayish or white
color of thick consistency and no bony structures.
The walls of the cavity were of irregular outline and
some bone bridges traversed the corners of the
cavity. There was considerable oozing of blqod.
The contents were removed and the cavity well
curetted. A drain was put in and a plaster cast ap-
plied.
Doctor Heitzman stibmitted a microscopical re-
port and the diagnosis based on this was hemor-
rhagic osteomyelitis with ostitis and periostitis.
Doctor P.arrie, on examining the slide, thought
that it was not the picture of hemorrhagic osteomy-
elitis. His clinical diagnosis was sarcoma. The
pain stopped two or three days after the operation
and the patient was permitted to walk on the cast
two weeks later.
An X ray taken December 31st, showed that the
involved region had evidences of bone condensation,
probably regeneration. Examination January 14th,
showed that patient had no pain. He walked with
a slight limp and there was no limitation of motion
in any direction and no shortening. ♦
In April the patient began to fail rapidly. The x
ray showed a distinct sarcoma of the bone. At
present there is metastasis in the humerus and
lungs. The final diagnosis is sarcoma of the bone.
BIBLIOGRAPHY.
I. Thomas E. Cullen: America's Place in the Surgery of the
World, Surgery, Gynecology and Obstetrics, xxv, No. 4, October,
1917. 2. F. Billings: Focal Infection, 1917. 3. E. C. Rosenow:
Etiology of Arthritis Deformans, Journal A. M A., April 11, 1914,
Ixii, 1146-1147. 4. F. Billings: Focal Infection — Its Broader Appli-
cation in the Etiology of General Dise.Tses, Journal A. M. A., Sep-
tember 12, 1 9 14, Ixiii. 5. C. H. Mayo: Mouth Infection as a
Source of Systemic Disease. Journal A. M. A.. Iviii, No. 23, 2925-
2926. 6. L. F. Barker: Differentiation of the Disease Included
under Chronic Arthritis, Transaction of Section of Medicine of
XVIIth International Congress cf Medicine, 1913. 7. S. W. Boor-
stein: Chronic Progressive Polyarthritis or Arthritis Deformans,
with a Report of One Hundred and F'ive Cases. Medical Record,
June 19, 1915. 8. S. W. Boorstein: Relation of Dental Sepsis to
Chronic Infectious Arthritis, Dental Outlook, ii. No, 3, 73-83, March,
1915. 9. John B. Murphy: Contribution to the Surgery of Bones,
Joints, and Tendons, Journal A. M. A., Iviii, 1912. 10, E. H.
Bradford: Fixation in the Treatment of Hip Disease, American
Journal of Orthopedic Surgery, February, 1913. 11, Symposium
on Lower Back Pain, Op. cit., xv, 803-840, 1917. 12. J. E. Gold-
thwaite: An Anatomic Explanation of Many of the Cases of
Weak or Painful Backs as Well as Many of the Leg Paralyses,
Op. cit,, February, 1913, 13. J, E. Goldthwaite: An Anatomic
and Mechanical Conception of Disease (Shattuck Lecture), Boston
Medical and Surgical Journal, June '.7, 1915. 14. J, E. Gold-
thwaite. C F, Paintetc, and R. B 0,SGOon: Diseases of the Bones
and Joints, 1910. 15, M, Bohm: A Contribution to the Etiology
of Lateral Curvature of the Spine, Boston Medical and Surgical
Journal. January 25, 191 5, 16, H. W, Marshall: Chronic Back-
ache, Op. cit,, clxxiv. No, 17, .■;9i-6fi6, 17, Z. B, Ad^ms: The
Relation of Bonv Anomalies of the Lumbar and Sacral Spine to
the Causes and Treatment of Scoliosis, American Journal of Ortho-
pedic Surficry, 1914, xii, 18, Wallace Blanchard and C, A, Par-
ker: A Resection o-f the Transverse Process of the Fifth Lumbar
Vertebrs- for the Relief of Painful Back, Op. cit,, xiii, 191 5, 19.
Z. B, Ai>\M.<:: Causes of Scoliosis and Their Relation to Treatment,
Transaction of Section of Orthopedic Surgery, 1914. 20, F, J. Fosset:
Late Results of Excisions of the Transverse Process of the Fifth
Lumbar Vertebrae, Op, cit,, 1915, 21, G, Barrie: Hemorrhagic
Osteomyelitis, Surgery, Gynecology, and Obstetrics, July. 1914,
42-52, 22, G, Barrie: Cancellous Bone Lesions, Annals of Surgery,
February, 191 5.
520 CouRTLVNDT Avenue.
Med icine and Surgery in the Army and Navy
MEDICAL NOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland.
Privat-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
TREATMENT OF WOUNDS IN WARFARE.
It is the intention of the writer to call attention
to the treatment, by means of plaster dressings, of
wounds of warfare which have a tendency to slow
cicatrization, because, although the method cannot
be said to be novel, it has at all events, given very
satisfactory results in a number of serious cases.
It has been largely employed in the service of Pro-
fessor Villard, of Lyons, and the following is a de-
scription of the method he employs:
The use of diachylon plaster is indicated in all
cases of superficial wounds of warfare which have,
to a certain extent, offered the usual characters of
atonic wounds or when the evolution of the wound
slows down or ceases and shows no inclination to
repair. In these circumstances the indications for
diachylon treatment are reahzed and its efficacy con-
stant.
If this treatment fails it is because the contrain-
dications for its use have been disregarded.
These are generally manifest at the period of evolu-
tion of the process of repair at the time the
^treatment is applied, that is to say, when the lesion
is «till infected and giving rise to a dirty secretion.
The principal contraindication, I repeat, is when the
wound is still suppurating and therefore, the second
phase of its evolution must be awaited, when sup-
puration has ceased, the wound secretions dimin-
ished, and the infection disappeared to all intents
.and purposes, because, be it understood, a perfect
asepsis, in the strict
sense of the word,
is not sought for.
The method cannot
be resorted to if
there is the least sign
of infection in the
form of lymphan-
gitis or suspicious
redness and tume-
faction around the
wound — conditions
which hardly need
be referred to.
Another condition
for this treatment is
that , the wound must
be superficial, be-
cause otherwise, the
imperfect applica-
tion of the plaster
strips would result
in a sort of clo.sed pocket under the dressing.
Therefore, in order to obtain the wound conditions
requisite for the use of diachylon a line of treat-
ment must be followed out to obtain this end.
Usually all that is required is the application of
Fig. I.— 1)1,
plaster dressing.
moist dressings to clean up the wound surface and
its edges, and, if the granulations are exuberant,
the use of silver nitrate is indicated. By these sim-
ple everyday means the wound finally offers the de-
sired characters. Its edges sink, while its surface
becomes sufficiently flat and regular for the proper
application of the plaster bands.
The French surgeons use the old sparadrap de
diachylon, which is a waxy, agglutinative mass,
having the following rather complex composition :
Simple plaster mass,^ 1,500 grams;
Yellow wax, 250 grams;
Purified elemi, 80 grams ;
Purified galbanum, 25 grams;
Purified gum ammoniac 25 grams;
Olive oil, so grams ;
Burgundy pitch, 100 grams ;
Oleoresin of turpentine, 150 grams.
Old as this formula is, I know from many years
of personal experience that it has a number of ad-
vantages over
many of our more
modern and ele-
gant plaster for-
mulas. The quan-
tity of turpentine
should vary in
order to make the
mass of proper
consistency.
Bands of thin
linen, about one
yard long and
from four to five
inches wide, are
covered on \ one
side with the plas-
ter mass, but it has
the bad quality of
not adhering
enough at a low fig.
temperature and
when kept too long it dries and chips. Therefore,
at the time of applying the plaster bands they
should be slightly warmed, according to the season
of the year.
In order to obtain a perfect application of the
plaster over the wound and its future removal pain-
less, the surrounding area should be shaved. This
done, the wound and its surroundings are cleansed
with ether and alcohol, carefully removing all se-
cretion and cell debris. The length of the band
depends upon the circumference of the limb, but it
should always be at least one and one half times
the length of the circumference.
Each band is taken separately at each end, and
after warming, is applied directly on the wound sur-
face, while an assistant brings the edges together.
Then both ends, having been stuck to the circumfer-
ence of the limb, are crossed over each other on the
*The emplatre simple of the French Codex is composed as follows:
B Pulv. litharge. ]
Adeps > aa 1000 grams;
01. olivae )
Aqux 2000 grams.
-Result of three weeks' treat-
ment.
November g, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY
819
Opposite side from that of the wound. The direc-
tion of the band is sHghtly obhque in relation to the
axis of the hmb.
The next band is applied in an oblique direction
opposite to the first, so that the wound is exactly
covered by an occlusive, adherent dressing. The
dressing is completed by two broad circular bands
placed above and below (see Fig. i). Over the
plastic dressing a layer of absorbent cotton and a
roller bandage are applied, in order to protect the
diachylon. The diachylon bands must be well over-
lapped with care, so that they will adhere to the
wound surface and the wound edges throughout
their entire extent, and to accomplish this requires
attention to details.
In Doctor Villard's service the rule is to leave the
plaster dressing on for a week, but sometimes it is
changed in six days, in other instances, in ten days.
A plaster cast was applied over the diachylon
dressing of one patient who frequently meddled
with it. The lapse of a week or even more before
changing the diachylon is perfectly justified if the
indications for its uses, as outlined above, are
strictly followed and the contraindications observed.
Usually the dressing is removed at the end of a
week, when it is rarely soaked through, but a little
serous fluid often filters through and is absorbed by
the cotton. The diachylon must be removed with
care over the wound surface and the edges where
the epidermis is proliferating. No attention need
be given to the pus found under the plaster. It
should simply be removed by irrigation, when the
wound surface will be found a good rose color,
granulating and healthy.
At each change of dressing the epidermic prolif-
eration will be found extending to the centre, and
finally covering the wound. Epidermization some-
times goes on so quickly that the fibrous tissue of
the cicatrix has hardly time to become organized.
A drawing (Fig. 2) is here appended of one case of
extensive injury to the thigh treated by diachylon
plaster. The wound was completely healed after
three weeks' treatment, four changes of the dia-
chylon having been made during this time.
WOUND OF THE INFERIOR VENA CAVA.
This was an interesting case of injury to the in-
ferior vena cava in a penetrating abdominal wound.
The patient was under the care of Dr. D. C. Tay-
lor. He had been wounded by an exploding tor-
pedo. The entrance aperture through which the
omentum protruded was slightly to the right above
the umbilicus. Laparotomy was done four hours,
after receipt of the injury through the rectus muscle.
There was a great quantity of blood in the abdo-
men. The missile had perforated the gastrocolic
omentum and two omental veins were ligated.
Next a rent in the mesentery was found and one in
the jejunum, which were closed. There was also a
perforation of the posterior peritoneum. When the
intestinal mass had been pushed out of the way a
flood of blood issued forth through a wound in the
anterior wall of the vena cava below the anasto-
mosis of the right renal vein. The wound in the
cava was about one inch long in the longitudinal di-
rection. The wound was successfully closed by
placing seven hemostats along it, and although the
lumen of the cava was diminished, it remained suf-
ficiently patent.
On the fourth day following a hot chloroform
and ether mixture was given and the hemostats were
removed one by one. Only a slight oozing occurred
after the removal of the last hemostat, which was
easily controlled by packing. Ten days later the
patient was transferred to a base hospital and is
now perfectly recovered.
CIRCULAR AMPUTATION.
Most fortunately Dr. G. A. Wright, of Man-
chester, has objected to the general use of circular
sausage amputation. Like a number of other
French and English surgeons, he beheves that the
operation is only indicated in gas gangrene. Other
than in this particular septic process, amputations
done for septic processes in general should be car-
ried out according to the well known methods of
operative surgery, but leaving the flaps unsutured
or even everted.
It is only too well known that during this war a
very large number of wounded, whose limbs have
been amputated by the circular sausage method,
have entered the base hospitals with conical stumps
with a granulating surface at the apex, through
which the necrosed diaphysis protrudes, the pa-
tient presenting a chronic septic state. Reamputa-
tion with considerable bone resection becomes neces-
sary, which frequently results in a considerable re-
duction in the ultimate utility of the stump. Simple
resection of the protruding bone without complete
reamputation does not always result in a satisfac-
tory stump and traction on the soft parts after
sausage amputation, although unquestionably use-
ful, cannot make a good stump out of one bad at
the start.
In trench foot the best practice is to wait until the
line of demarcation has become distinct and then
amputate, because too early an amputation may be
too extensive or, on the other hand, it may com-
promise the vitality of the soft structures which
have been saved but which are insufficiently nour-
ished. When an amputation is performed it is to be
as economical as possible. When the end of a flap
contains cicatricial tissue, before reamputating
higher up in healthy tissue, it is better to wait to
see how useful the stump may really become.
MODERN WAR SQRC^ERY.
Distinguished Visitors Discuss Advances in War
Surgery Before the College of Physicians and
Surgeons — French, Italian, British and
Amcricaii Surgeons Tell of War
Work on the Front.
The group of surgeons who had been detailed
from the allied armies to attend the sessions of the
Congress of the American College of Surgeons in
New York in October arrived in this city only to
find that the prevalence of the influenza epidemic
had necessitated the cancellation of the meeting.
The visitors were invited to make a tour of the
United States, and have addressed the members
of the medical profession in several of the leading
cities. On Wednesday, November 6th, the visitors
were the guests of the faculty of the College of
820
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
Physicians and Surgeons at luncheon. On Thurs-
day' evening' they were entertained at a dinner given
by the medical profession at Delm«nico's. and on
Thursday evening they addressed the members of
the profession at an open meeting held at the Acad-
emy of Medicine, a report of which will appear in a
later issue.
On Wednesday afternoon several of the visitors
addressed the students and the medical public gen-
erally at the College of Physicians and Surgeons.
The meeting was presided over by Dr. Samuel W.
Lambert, dean of the faculty, who spoke with re-
gret of the fate which had befallen him and some
others in being compelled to forego khaki and re-
main at their posts as teachers in order to provide
recruits for the medical corps. Dr. Lambert said
that he would first introduce a member of the fac-
ulty who had spent more than a year in active
service abroad, Colonel George E. Brewer, whom
he was proud and happy to welcome back to his
home.
Colonel George E. Brewer said that he had been
one of the fortunate group of surgeons who had
received orders about a month ago to come to the
United States to attend the Congress of the Ameri-
can College of Surgeons. He had joined the others
of the group who had been detailed for this duty
and had visited various cities, addressing the physi-
cians in those places. In this way he had been
thrown into intimate contact with these leaders in
war surgery and had learned very much more than
he could have possibly learned in any other wav
of what they had accomplished. He assured his
hearers that they were most fortunate in having
with them the men to whom modern war surgery
owed so much. He first introduced Colonel Pierre
Duval, of Paris, who had served on the Eastern
front, as the master who had introduced modern
French methods of treating wounds.
Colonel Duval spoke in French, his remarks being
translated into English by Colonel Bastianelli. of
the Italian Medical Corps. Colonel Duval said that
at first the medical profession had made the mis-
take of Napoleon, in believing that wounds of
war should be treated as they had been accus-
tomed to treat the wounds of peace. They soon
learned, however, that the infection and suppura-
tion which occurred in every war wound often left
sequelce which left patients afifected all their lives
even after an apparent cure. It had been observed
that if the wounds were treated properly the infec-
tion could be prevented from penetrating. This
could only be done by operation within twelve or
fourteen hours after receiving the wound. It was
also learned that every wound was surrounded by
dead tissue which furnished the best possible me-
dium for the propagation of the germs of infection.
These were the first two great truths learned that all
wounds of war were infected and that all were
accompanied by dead tissue.
These facts being borne in mind, three principles
of treatment were adopted, as follows : First, every
wound was opened out completely; second, every
source of infection was removed, and third, the
wound was closed after the excision of all dead
tissue. In this way the contaminated wounds of
v/ar were converted into surgically clean wounds.
which healed by first intention. The great revolu-
tion in surgical practice brought about by war was
the recognition of the fact that any wound could
be made surgically clean and cured in a few day.s.
This was true of the wounds of the soft parts,
ninety to ninety-five per cent, of which healed by
primary union. It was true of wounds of the
joints, ninety-five per cent, of which healed by pri-
mary union. It was true of wounds of the cranium
and of the brain, almost loo per cent, of which
were cured by ])rimary union. Abdominal wounds
and wounds of the lung tissue and lung cavity had
been cured in the French army in about fifty-five
per cent, of the cases.
To be entirely successful, however, it was neces-
sary that the patients operated upon should be un-
der the observation of the operator for at least fif-
teen days. This was possible only during a rela-
tively quiet period, but during the course of active
fighting it was impossible to keep the patient long
enough under the care of the operator. In these
circumstances, in the French army the rule had
been followed of opening the wound completely,
packing the cavity with iodine dressing and send-
ing the patient on to the base hospital where the
operation was conckided and the wound closed two
or three or even as much as five days afterwards.
This method of treatment was termed primary
delaved suturing. It had given most satisfactory
results, almost as good in fact as those which fol-
lowed the prompt primary sutures, as about ninety-
two per cent, of the wounds united by primary in-
tention.
There were renditions in which the application
of this method was impracticable as, i, when too
much time elapsed between the infliction of the
wound and the operation ; 2, when the infection
spread too rapidly ; and, 3, when for anatomical
reasons the wound could not be properly cleansed.
In these circumstances it was necessary to resort
to antiseptics, and the method which had given the
best results in the army was that of Carrel and
Dakin. \Miere this method was applied with due
attention to the technic, eighty per cent, of the
wounded were able to return to active duty within
two months' time. Partial success was observed
in sixty per cent, of the cases, and in six per cent,
the method had failed. Colonel Duval said that the
application of these principles had caused a revolu-
tion in surgery.
Sir Thomas Myles was introduced by Colonel
Brewer as the distinguished author, operating sur-
geon, and organizer, who had rendered invaluable
service as consulting surgeon to the British Army.
Sir Thomas said that he wished to acknowledge the
debt which the world owed to that intellectual
lucidity and logical mind of the French which in
its military aspects showed in the admirable work
being done by Foch as commander of the allied
armies.
He then took up the subiect of war wounds and
said that a study of ballistics showed that the
modern small bore rifle bullet wobbled in its course
from the time it left the muzzle for a distance of
about 200 yards describing a circle of an inch in
diameter on an axis near the middle of the pro-
jectile. At 200 yards it straightened out and. re-
November 9, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
821
volving rapidly on its longitudinal centre, sped a
straight course until it reached a distance of 1200
or 1500 yards when it again began to oscillate about
its middle. If a soldier was struck with a bullet at
a distance of 200 to 1.200 yards from the weapon
fired, the bullet would be apt to make a clean cut
wound of small diameter. If, however, the wounded
man was within 200 yards of the weapon or was
above 1200 or 1500 yards from it, the wound was
apt to be a very large and ghastly affair; for if the
bullet was slightly inclined when it struck, the re-
sistance offered its penetration would probably
cause it to tumble forward and pass through the
body broadside on, thus making a very large wound.
It was this action which was no doubt responsible
for the many charges made by both sides that the
other was using explosive bullets.
Sir Thomas said that one must not assume that
a patient who had apparently recovered entirely
from a wound which penetrated through the eye
ir.to the brain several months laler developed a
drop foot. Investigation showed that the cicatrice
had enveloped some of the brain cells and con-
tracting on these had paralyzed their action, thus
producing the drop foot. He had found one pa-
tient on guard duty who presented arms when he
arrived but who trpon close examination had shown
an ununited fracture of the tibia, while another had
an ununited fracture of the femur though still on
active duty, irie said that he did not want to be
understood as lacking in appreciation of the marvels
that had been accomplished by the newer surgery
during the war, but he merely wished to point out
the farreaching consequences of wounds even
though apparently healed.
Lieutenant Colonel Rail'aele Bastianelli, professor
DISTINGUISHED SURGEONS AT THE OFFICE OF TH
Noted surgeons from Great Britain, France, and Italy are makin
surgery during the war. In the group, seated, are, from left to right:
at the front; .Sir Thomas Myles, of Dublin, Surgeon to the King in
United States Council of National Defense; Prof. Raffaele Bastia
Duval, of Paris. Standing: Major George Grey Turner, of Eng
A. Pettit, of Portland, Ore.; Lieutenant Georges Loewy, an inst
Gask, of London, consulting surgeon of the British Army in Fr
F. Simpson, chief of medical section, Council of National Defense;
Colonel Charles U. Dercle, French representative in the United
France.
Copyright Harris & Ewing.
E COUNCIL OF NATIONAL DEFENSE, WASHINGTON,
g a tour of cities in the United States in the interest of allied
Lieutenant Colonel George E. Brewer, U. S. A., who has been operating
Ireland; Dr. Franklin Martin, chairman General Medical Board,
nelli, one of the best known surgeons in Rome, and Major Pierre
land, a veteran surgeon in the Mesopotamia campaign; Dr. Jos.
ructor in the Rockefeller Institute. New York; Colonel George E.
ance; Dr. Henri Belclere, a noted Paris x ray expert; Dr. Frank
Dr. John G. Bowman, director American College of Surgeons;
States Surgeon General's Office, and Major Adrian PioUet, of Andre,
the favorable statistics given by Colonel Duval
meant that the war surgery was so simple a thing
as it sounded. For even though the wounds were
closed complications might appear later. One
complication which had come up not infrequently
was the production of an arteriovenous aneurysm.
In the hurry incident to surgical work at the front
it was also possible that errors might be made. The
surgical staff of the allied armies was an excellent
one, but human, and whenever the human element
entered there was always a possibility of error. On
one occasion it had been his duty to examine a
large number of men who had been operated upon
and had apparently recovered but in whom some
trouble had developed later. In one of these cases
of surgery in the University of Rome, was intro-
duced by Colonel Brewer as Italy's foremost sur-
geon. Colonel Bastianelli said that Italy had gone
into the war after Great Britain and France, for-
tunately finishing first, and had had the experience
of the British and French surgeons as a guide. But
like the surgeons of their allies the Italians had made
errors, but they had likewise learned the necessity
for a complete cleaning up of the wounds. Some
aspects of this moderin war surgery had indeed
been developed independently by the Italians. In
the surgery of the lung the Italians had been very
successful in the application of artificial pneumo-
thorax.
Major George Grev Turner, surgeon to the
822
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Jourkal.
British Army in Mesopotamia, of Newcastle-on-
Tyne, said that in every war much was unlearned
tliat had been taught before. He reminded his
hearers of a statement made by Ambrose Pare, the
distinguished French surgeon of the Middle Ages,
who had treated the wounds of his patients by pour-
ing into them boiling oil containing various eschar-
otics. Owing to some fault in the medical supply
service the supply of this remedy on one occasion
was altogether exhausted. Pare spent a sleepless
night worrying about the disastrous effects on his
patients of this failure to apply the usual remedy,
but on making his rounds in the hospital the next
morning he found that those patients who had not
been treated with boiling oil were in a better con-
dition than those who had. It might be that we too
would find some of our patients better for lack of
treatment than if they had been treated. Major
Turner pointed out that advances had been made
by French and Italian surgeons and wanted it
made perfectly clear that there was a unity in
surgery as well as in command among the allies
and that every improvement adopted by one of
the armies was promptly passed on to the
others so that all might ' benefit by it. He
said that the Carrel-Dakin treatment had undoubt-
edly produced wonderful results, but it must be re-
membered that the use of this remedy was but the
application ■ of the underlying principles that the
students before him were now engaged in studying.
Colonel Brewer announced that a meeting would
be held at the Academy of Medicine at half past
eight on Thursday at which a wholly dififerent pro-
gram would be presented, although some of the
s.'ime sjieakers -.vould appear. He also announced
that Dr. W. B. Coley would give a demonstration
of malignant disease at ten o'clock on Thursday
morning at which all visitors w.ould be welcome.
Major Adrian Piollet. professor in the school of
medicine and surgeon to the hospital at Clermon,
France, who is now attached to the Rockefeller
Demonstration Hospital, U. S. Auxiliary Hospital
No. I, presented a number of slides illustrating the
result obtained in that hospital by the use of the
Carrel-Dakin technic in 2,223 infected wounds with
delayed suture. Eighty-three per cent, of these
cases had been completely successful, nine per cent,
had been partially successful, and eight per cent, had
been failures. As a rule they had been able to close
these wounds in from twenty-five to thirty days.
The illustrations showed marvelous recoveries, even
where the lacerations had been very extensive.
Colonel George E. Cask, D. S. O., surgeon of
St. Bartholomew Hospital and consulting surgeon
to the Fourth British Army, spoke in a general way
of the role which preventive medicine had played
in the present war. He said that in the whole Brit-
ish Army there had been not more than a hundred
or so cases of typhoid fever in the whole four years
of fighting. He then spoke of war being waged
against vermin and of the important role which
this would play in the prevention of trench fever
and other communicable diseases spread bv body
lice. The exercises were concluded with a few re-
marks by President Nicholas Murray Butler, who
thanked the speakers for the informing addresses
which they had m.ade.
MEDICAL NEWS FROM WASHINGTON.
Major General Ireland Assumes Command. — Appointment
ir. Military Intelligence Bureau General Staff Corps. —
Transfer of Senior Surgeon Joseph H. White.— Food
Nutrition Officers for All Camps.—Decline of Influenza
Epidemic.
Washington. D. C, November 4, 1918.
Major General Merritte W. Ireland, who was ap-
pointed Surgeon General of the Army several weeks
ago, succeeding Major General William C. Gorgas,
who was transferred to the retired list for age,
arrived in Washington from France last week, and
assumed duty at the head of the Army Medical
Department.
:Jc * :f: r^c
Brigadier General Edward L. Munson, Medical
Corps, recently advanced from the grade of colonel,
has been appointed chief of the morale section.
Military Intelligence Bureau of the General Stafif
Corps, with headquarters at Washington. General
Munson until recently was in command of the medi-
cal officers' training camp, at Fort Oglethorpe, Ga.
5k H« * H=
Colonel J. R. Murlin, Sanitary Corps, chief of the
division of food nutrition in the Office of the Sur-
geon General of the Army, reports that the school
recently organized at Fort Oglethorpe, Ga., to in-
struct members of the Medical Department in mat-
ters pertaining to food, will be ready by December
1st to supply all camps in the United States with
food nutrition officers.
The division of food nutrition has been en-
gaged in a series of studies, involving considerable
numbers of men in practical tests of the army ra-
tion, and it is T^eported that a number of changes
looking to a better, balanced ration and more eco-
nomical provision for the troops in camps and on
foreign service will be recommended.
ilf; ^
Reports from both army and navy camps indicate
that the worst is over, so far as the epidemic of in-
fluenza affects those services. Occasional outbreaks
still occur in some of the camps, but there has been
a general decline in cases for the past week or so.
The recent arrival of drafted men at some of the
southern and southwestern camps brought a sharp
increase in the number of cases, although appar-
ently that is temporary. Elsewhere in the army
camps the disease apparently has run its course,
although it may be expected to continue for some
weeks and probably will not be entirely stamped
out during the winter as new men not previously
exposed are brought into camps by the draft.
According to the latest reports, the total number
of influenza cases in the army was 302,252, and the
pneumonia cases rmmbered 49,224, with deaths
from all causes since the outbreak of influenza
amounting to 16,624.
Influenza in epidemic form has left the first,
second, fourth, fifth, seventh, eighth, ninth, tenth,
eleventh, and thirteenth naval districts, and is on the
wane at all other naval shore stations in this
country, except at Paris Island, S. C, and Mare
Island, Cal. The training station at San Francisco,
because of an effective quarantine, has had no cases
of influenza.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT FUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, fifteen cents.
Remittances should be made by New York Exchange,
pest office or express money order, payable to the
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the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, NOVEMBER 9, 1918.
PEACE.
Peace has come. For 1,557 days Germany sacrificed
lives and money without stint, ravaged defenseless
nations, murdered innocent women and children,
and raided peaceful towns and hamlets in its orgy
of frightfulness in the vain hope that it could ter-
rify the nations of the earth into submission to the
dictates of the German Empire. The whole world
rose in arms against that propaganda of frightful-
ness until at last tvventy-two nations stood upon the
side of justice, and of right, committed to their last
drop of blood and their last dollar to the task of
defeating Germany. Now that victory has come
we must make sure, as sure as imagination can
contrive, of some plan which will for all time pre-
vent the recurrence of war. The blood of millions
of men, the sufferings of millions of women, cry out
that that blood shall not have been spilled and that
suffering undergone in vain. The men charged with
the task of dictating the terms of peace have indeed
a weighty responsibility, for theirs it is to devise
terms which will rid the world of war for all time
and give us and our children, and our children's
children, "The Parliament of Man, the Federation of
the World." Then, indeed, may we feel that our
dead have not died in vain for they will have given
to the world for all time
PEACE.
MODERN WAR SURGERY.
We present in our department devoted to
medicine and surgery in the army and navy a
brief report of a series of most interesting ad-
dresses delivered at the College of Physicians
and Surgeons, of Columbia University, by visit-
ing surgeons from the British, the French, and
the Italian armies. In introducing Colonel Du-
val, of the French Army, Colonel George E.
Brewer, of the United States Army, who had
himself spent more than a year on the western
front, said that the revolution in surgery which
had been effected during the war was largely
due to Colonel Duval and his teachings. The
essential feature of this revolution is a recogni-
tion of the fact that all war wounds are infected
wounds, that to prevent further infection it is
essential that all dead tissue be completely re-
moved, and that prompt attention is of primary
importance.
Colonel Duval himself spoke in a most interest-
ing and impressive manner. He told just ex-
actly what had been done to meet the wholly
new conditions which had developed in the pres-
ent war and gave statistics showing an astonish-
ingly large proportion of recoveries by primary
union, the proportion ranging from ninety to
ninety-five per cent, in wounds of the soft parts
to ninety-five per cent, in wounds of the joints
and the long bones, and very nearly 100 per cent,
in wounds of the cranium and of the brain.
These results are in great and happy contrast
to those reported in the initial stage of the war
before the essential elements of success in wound
treatment were recognized and acted upon.
Many cases of wounds of the brain terminated
fatally before the new methods were thoroughly
worked out and applied. Even in abdominal
wounds a record of fifty-five per cent, of recov-
eries was reported in Colonel Duval's figures,
which sound almost incredible in view of the
high mortality which such wounds carried with
them in all previous wars.
One of the most interesting phases of the sub-
ject brought out by Colonel Duval and the other
speakers on this occasion was the successful ap-
plication of what the French term delayed pri-
mary suture. In cases where on account of the
pressure of work it was impossible for the sur-
geons to give attention over a long period of
time, the French open a wound, excise the dead
parts, pack with iodine gauze, and send the pa-
tient back through the casualty clearing station
V
824
EDITORIAL
ARTICLES.
[New York
Medical Journal.
to a base liospital where the final cleaning up of
the wound and suturing may be carried on under
the most favorable auspices by a surgeon who
can maintain his oversight of the patient for at
least fifteen days. Even in these cases of de-
layed primary suture the proportion of recovery
was almost as high, ninety-two per cent., as that
observed in those cases where it had been possi-
ble to give immediate primary suture, about
ninety-five per cent.
It must be understood that this procedure in
no wise detracts from the value of the antiseptic
treatment that is applied in the Carrel-Dakin
technic, for the antiseptic treatment is the only
recourse in those cases where, because of delay
in receiving attention, of rapidity of spread of
infection, or of anatomical complications, exci-
sion and immediate closure of the wounds are
impossible. In such cases antiseptic treatment
must be resorted to, but this means a much more
prolonged convalescence than in cases where the
wound can be cleaned up and sewed up promptly.
The two methods, that of excision and prompt
closure and the antiseptic method, are both great
advances in surgery and are each essential in its
own field to the greatest success. We are in-
deed fortunate in having with us these masters
of surgery, the men who have created a new war
surgery and have thus done so much to salvage
the human wreckage of war.
NEEDED ADVANCE IN TRAIN SANI-
TATION.
It has been well said that "the modern railroad
train rides behind the ghost of an old stage-
coach," for the width of the train, or, at least the
gauge of the railroad, is dictated by what became
the custom when flanged wheels were put on
coach bodies and connected behind a locomotive.
With all our progressiveness in railroad manage-
ment, there are some other features in which train
equipment has lagged behind almost as sadly as
in the narrow roadbed.
The most striking of these is the maintenance,
until the present time, of the open toilet from
which trains scatter contaminating material, not
only over their roadbed but into the small and
large streams of the country, so many of which
feed city and town water supplies. Besides,
these open toilets become infested with flies or
attract them whenever there are stops at stations,
and thus become the means of dist^-ibuting pol-
luted material at the various stopping places to
become sources of infection.
When we knew very little about the mode of
the spread of disease, this did not seem so objec-
tionable. In addition, at the beginning, compar-
atively few people used the trains, and of these,
many took short journeys, so that the nuisance
was, after all, extremely limited ; now, however,
hundreds of thousands of people are literally
compelled every day, by the necessity of circum-
stances, to use these toilet arrangements, and the
danger from them has increased greatly. In
older times, too, when so many of our water
courses did not feed reservoirs, and when so
much water was not used for drinking, domestic,
or agricultural purposes, water contamination
was not so serious a consideration as at present.
After all, the material that is not thrown directly
into the water is eventually washed there by the
rains, through the ditches alongside the train, in-
stead of being brought there by seepage through
the ground, where bacteria would be destroyed.
When this does not happen, as during the dry
season, the peril is perhaps greater, for the ma-
terial is rapidly dried and pulverized and carried
away by the air currents from passing trains, thus
becoming a danger in the form of dust. This is
later blown into the cars or the waiting rooms
and restaurants at stations and becomes a source
of danger. In this way it clings to the clothing
of passengers and is carried to their homes. How
simple a matter is the understanding of the rapid
spread of various contagious diseases in recent
years, once these gain a foothold. Now that the
knowledge of the typhoid carriers has become
general and we know of the presence of a number
of other carriers of disease, present conditions
have become literally intolerable. In these ex-
cretions living bacilli of various diseases are con-
stantly present and it seems almost incredible
that we should permit the further continuance
of this dangerous practice.
Attention has often been called to the abuse,
and attempts at corrective legislation have been
made, for everyone recognizes the utter back-
wardness and dangers of the present train toilet,
but, as can be readily understood, owing to the
fact that railroads were so strong in the influence
they exerted on legislatures, the matter was not
permitted to get further than committees. Now,
however, since the railroads of the country are in
the hands of the Government, this factor of
opposition is eliminated, and we should be able
to secure the long and sadly needed improve-
ment. This would be a benefit to the commu-
nity which would argue in favor of Government
management of the railroads. It is, without
November 9, 1918.]
EDITORIAL ARTICLES.
8^5
doubt, a crying need. The only consideration
has been of the slight additional expense involved
in building sealed closets. The railroads of the
country refused, for years, to equip their freight
trains with selfcoupling devices, to the resultant
serious maiming of many of their men, for the
reason that human beings were less costly than
improved equipment. Surely this argument can-
not hold with the Government when there is a
question of the lives and health of citizens.
Steamboats on mland waters have also distributed
infectious materials at random in the waters on
which they j)ly through the use of open toilets. The
steamers on Lake George, we believe constitute a
notable exception to this general rule. Closed toilets
should be provided for all such steamers and thi'i
preventable contamination prevented.
Army experience has shown us the meaning of
sanitary science. During the first six months of
this war, according to a recent report, half a mil-
lion less soldiers were sick and ten thousand less
died than imder similar conditions in the first six
months of the Civil War. The sanitarian has
been demonstrated to be no dreamer, nor a seeker
after Utopian conditions impossible in ordinary
life, but on the contrary a practical saver of
health and strength, of time wasted over disease,
and above all, of precious lives. The sanitarians
of the country universally demand the change.
The Government is now having new cars built for
the railroads ; it would add very little expense to
have them equipped with sealed closets, and
when cars came back for repair, they might be
similarly equipped. By the end of the war and,
perhaps, of Government control afterwards, so
many of the cars would have been improved in
this way that the problem — one of the most im-
portant sanitary problems now in our hands —
would be ei¥ectually solved for all time.
THE NAMING OF DISEASES.
Names of diseases, like names of other things,
have originated in a variety of ways and have un-
dergone many changes at the hands of the gener-
ations who have suffered from the diseases.
Some, like Basedow's disease or Paget's disease,
have received the name of their supposed discov-
erer ; some, like acromegaly or paralysis agitans,
are called for some pronounced sign or symp-
tom ; others, as malaria, from some apparently
causal condition ; while a few names have had a
more sentimental origin — for instance, syphilis,
which gets its euphonious title by way of a poem
of a sixteenth century physician, named Fracas-
torius. The shepherd, named Syphilis, was
stricken with the disease by Apollo, in punish-
ment for paying divine homage to the king in-
stead of to the god. The disease stuck to the
shepherd and somehow the shepherd's name be-
came firmly attached to the malady. Certainly
it is a more appropriate than mori)us gallicus.
There is often a great deal in the name of a
disease, and we pay too little attention to the
meaning packed away in a few letters. The word
malaria reveals the effort of many generations to
pierce the veil of etiology, nor were they so far
afield in their guess that we should wish to
change the title upon more definite information.
The name poliomyelitis unfolds a picture of the
pathology of what by sign and symptom is more
indefinitely named infantile paralysis. Exoph-
thalmic goitre is an aid in remembering two car-
dinal symptoms of that disease, but now points
clearly enough to the fact that the disease was
not at first recognized, save when these two
symptoms were prominent.
Few diseases have escaped without having
many titles attached, both by the laity and the
profession, and there are still all too many differ-
ent titles for the same thing in practical use. In
the course of their evolution one name was up-
permost for a season, only to give place to an-
other. How our Latin loving predecessors could
have allowed the survival of any common names
is a mystery, but somehow whooping cough is
whooping cough and rarely pertussis. Many
names point to a remote ancestry, such as mea-
sles ; for "spots" are characteristic of many ail-
ments. Even smallpox and measles were once
confused, however, and that not so long ago.
Names of modern origin tend to greater definite-
ness. The names of "discoverers" do not stick
well, for there is no one discoverer. Graves's dis-
ease and Basedow's disease are being forgotten
— and is it to be hyperthyroidism ?
When a name has been found at all satisfactory
it is most essential that it should be unchanged
and that it should have no rival. It may not
have mattered once upon a time — though some of
us have a great curiosity to interpret what, ac-
cording to family tradition, our ancestors suf-
fered and died from — but for purposes of vital
statistics we are helpless and hopeless without a
definite nomenclaaure. That was a great stroke
on the part of Bertillon, establishing the interna-
tional list of diseases, so that all may speak the
same language. No matter how much of a Babel
there has been or may still be in the names of dis-
eases, it is no longer necessary that the statisti-
cian be lost in the uproar.
826
EDITORIAL ARTICLES.
[New York
Medical Journal.
GENERALIZED NEUROFIBROMATOSIS.
Generalized neurofibromatosis is characterized
by tlie following symptomatic triad : cutaneous
and nerv^e tumors and pigmentation of the skin.
To these, various functional disturbances should
be added, such as those of the intelligence, pare-
sis of movement, epileptiform paroxysms, indefi-
nite anesthesias, and severe cramps.
The cutaneous neoforniations are composed
either of grains of molluscum or of neoplastic
masses which may assume enormous dimensions.
The tumors of the nerves develop on the sub-
cutaneous branches and in series along the nerve.
By inspection they cannot be detected, but they
are easily felt on palpation. The cutaneous pig-
mentation forms spots varying both in size and
color, from "cafe au lait" to a reddish brown. In
size they vary from that of a lentil to extensive
patches, while their distribution over the cutane-
ous surface is most capricious. Pilous nevi may
develop. In some few cases the pigment patches
have been known to develop in the mucosa, thus
making a difTerential diagnosis from Addison's
disease a rather difficult matter.
The disease is now considered to be hereditary
and not infrequently familial, and a neurofibro-
matosis occurring fairly late in life must be
looked upon as a congenital afifection. As to the
familial character of the disease, it has been
proved by a number of examples, the most curi-
ous of which is unquestionably the case recorded
some years since by Czerny.
The prognosis is essentially variable according
to the form assumed by the disease in a given
case and is generally in direct relation to the
number of new growths present. When the tu-
mors involve the central nervous system the out-
look is, of course, unfavorable. The prognosis
should always be reserved because, although fre-
quently individuals presenting the afifection from
birth may attain the age of fifty years or more, it
must not be forgotten that very frequently also
the afifection takes on a much more rapid evolu-
tion. The extremely accentuated marasmus in
which these subjects die must also be taken into
account. Finally, the new growths may, at a
given time, take on a considerable development
and cause functional disturbances from size
alone, and further, in spite of their apparent be-
nignity the tumors have been known to undergo
a malignant evolution in the form of a sarcomat-
ous transformation.
The pathogenesis of neurofibromatosis is
rather obscure, and all that can be said is that it
is a disease involving the ectodermic elements,
since the skin and nervous system are the only
structures involved.
The primary malformation of the ectodermic
cells and their secondary lesions result in the de-
velopment of the symptomatology of the affec-
tion. In the nervous system, the lesions of its
elements result in various functional disturb-
ances, while in the epidermis the lesion of its ele-
ments is the origin of pigment spots. Finally,
the elements uniting the skin with the central
nervous system, which are likewise derived from
the ectoderm, are in a condition of inferiority be-
cause they are malformed and also because they
imperfectly conduct the impressions. The result
is the development of teratomata on the nerve
trunks and this represents the first phenomenon
of a process of proliferation. At a later date this
proliferation may increase in intensity, and, al-
though retaining its primary structural nature, it
can give rise to enormous fibromata, or, return-
ing to the embryonal state, produce sarcomatous
growths with all the malignancy characteristic
of this neoplasm.
CANADIAN PENSIONS.
In October, 1917, the Federal Government of
Canada brought into ei¥ect a scale of pensions for
disabled soldiers, which is said to be higher and
more liberal than that of any other country. The
scale is as follows : Total disability, $600 a year ;
widows, $480; parents, $480; children, $96; or-
phan children, $192. In addition, there is a spe-
cial allowance for helplessness, not to exceed
$300. The number of classes of disability is
twenty.
Up to May 31, 1918, the number of soldiers
placed on the pension list amounted to 23,415,
with an annual governmental liability of $5,600,-
145.61 ; while the number of soldiers' dependents
amounted to 24,213, with an annual liability of
$5,600,326. At the present time pensions are be-
ing awarded at the rate of 125 per day; and on
the medical staff at Ottawa there are something
like twenty-two physicians engaged. It is esti-
mated that the liability for the year ending
March 31, 1919, Avill be $15,000,000. Up to April
31, 1918, the Canadian Government has paid pen-
sions to soldiers resident in the United States to
the number of 158; and in the British Isles 1,878.
An interesting feature in this aspect of the pen-
sion question is that the Canadian Government
has entered into arrangements with several coun-
tries for the reciprocal payment of pensions.
November 9, 1918.]
NEWS ITEMS.
827
News Items.
Pediatric Section Postpones Meetings. — Announce-
nieiu is made that all meetings of the Section in Pediatrics
of the New York Academy of Medicine have been indefi-
nitely postponed until they are again demanded by mem-
bers of the section
Nine Thousand Nurses Needed.— The American Red
Cross War Council announces that 9,000 additional nurses
will be needed by the Army before January i, 1919. Thirty
thousand nurses have been enrolled by the Department of
Nursing up to October ist; about iS.ooo of these are on
active service in the Army and about 1,000 on active
service in other lines.
Correction.— In an article on Paget's Disease of the
Bones, by Dr. B. Stivelman, of New York, and Dr. E. L.
Ray, of Louisville, Ky., published in our issue for Octo-
ber 19, 1918, a typographical error occurred. On page
679, left hand column, fourth line from the bottom, the
sentence reading "The blood picture in Case I showed an
eighty per cent, eosinophilia" should have read "The
blood picture in Case I showed an eight per cent, eosino-
philia."
The History of Influenza. — At a meeting of the Sec-
tion in Historical Medicine of the New York Academy of
Medicine, to be held on Wednesday evening, November
13th, with Dr. James J. Walsh in the chair, the history of
influenza will be the topic for discussion. Dr. Lillian K. P.
Farrar will read a paper on Epidemics, Countries, Nomen-
clature ; Dr. James T- Walsh will present historical details
of influenza therapeutics ; Dr. D. Bryson Delavan will read
a paper on the Disinfection of the Nasopharynx in In-
fluenza, Historicallv Considered. The discussion will be
opened by Dr. Gordon K. Dickinson.
Mrs, Sage's Bequests to Charitable Institutions. —
The following is an authoritative list of the gifts of
Mrs. Sage to charitable institutions :
An endowment fund of $10,000,000 to the Russell Sage Foun-
dation, the income to be used for the betterment of social and
living conditions.
To the Russell Sage Institute of Pathology, an endowment fund
of $300,000.
For the Association for Relief of Respectable, Aged, Indigent
Females, an addition to its building on 104th street, $25,000.
Adirondack Cottage Sanitarium, $25,000.
Working Girls' Home on East Twelfth street, $25,000.
To the Young Men's Christian Association, for a new building
for the International Committee on Twenty-eighth street. New
York, $350,000.
For addition to Y. M. C. A. building at Brooklyn Navy Yard,
about $340,000. For building at Fort McKinlev, Philippines,
$25,000; for Long Island Railroad branch, new building at Long
Island City, $100,000; for new building at Fort Slocum, $50,000.
Surgery of the War Zone. — At a stated meeting of
the New York Academy of Medicine, held on Thursday
evening. November 7th, surgery of the war zone was dis-
cussed by delegates sent from the allied armies to attend
the Clinical Congress of the American College of Sur-
geons, which was to have been held in New York during
the week of October 20th. The congress was cancelled on
account of the epidemic of influenza, and the delegates
made a tr:ur of the principal cities of the country, speak-
ing before gatherings of physicians. On Thursday evening
the principal speakers were Sir Thomas Myles, formerly
president of the College of Surgeons of Ireland, Lieu-
tenant Colonel Rafi^aele Bastianelli, professor of surgery.
University of Rome, and Lieutenant Colonel George E.
Brewer, M. C, U. S. Army, professor of surgery. College
of Physicians and Surgeons.
Accommodations for Fifty Thousand Sick Soldiers. —
The Hospital Division of the Surgeon General's Office has
announced that during the past month hospital facilities
have been secured for 19,200 additional patients, bringing
the total facilities outside of camps and cantonments up
to 50,000, nr about one third of the number which it is
estimated will be needed during the next eighteen months.
Wherever pj)ssible hospitals and other buildings already
erected and partia'ly equipped will be obtained so as to
accelerate and facilitate the work. Nine buildings in the
Exposition Park at Rochester, N. Y., have been accepted
by the government rent free. The Westchester Almshouse
ha« been obtained as a general hospital and will accommo-
date 2,000 patients. The army will also take over North
Brother Island now owned by the city of New York and
will accommodate 1,500 patients.
Personal. — Dr. I. S. Wechsler has moved from 212 East
Twelfth Street, New York, to 1291 Madison Avenue.
Dr. John Strother Gaines, Jr., of 200 West Seventy-first
Street, New York, having accepted a commission as assist-
ant surgeon, United States Naval Reserve Force (rank of
lieutenant), on October loth, is now awaiting assignment
to active duty in the naval medical corps.
Colonel William P. Kendall, Medical Corps, U. S. Army,
has been assigned to duty as department surgeon, Hawaii-
an Department, with headquarters at Honolulu.
Polyclinic Hospital to Be Given to Columbia Uni-
versity.— At a meeting of the trustees of Columbia
University held Monday, November 4th, it was announced
that the trustees of the New York Polyclinic Hospital, by
unanimous vote, had proposed to transfer the property of
that institution to Columbia University, to be maintained
and perpetuated for the public service and for advanced
instruction and research in medicine and surgery. By the
acceptance of this proposal the university would come
into possession of a finely equipped hospital, affording
ample clinical facilities for the building up of graduate
studies and research in medicine. The trustees of the
university adopted resolutions receiving with grateful ap-
preciation the proposal by the trustees of the Polyclinic
Hospital, and appointed a subcommittee to arrange the
detailed terms and conditions of accepting the proposed
gift. The university would not be able in any event to
use the hospital until after the conclusion of the war,
since it is now in possession of the Government, being
r.dniinistered as a military hospital.
Meetings of Medical Societies to Be Held in New
York. — The following medical societies will meet in
New York during the coming week :
Monday, November nth. — -Society of Medical Jurispru-
dence; New York Ophthalmological Society; Yorkville
Medical Society (annual) ; Williamsburg Medical Society.
Tuesday, November 12th. — New York Academy of
Medicine (Section in Neurology and Psychiatry) ; Man-
hattan Dermatological Society ; New York (Obstetrical
Society.
Wednesday, November I3th.^ — Medical Society of the
Borough of the Bronx ; New York Pathological Society ;
New York Surgical Society; Alumni Associ^ion of the
Norwegian Hospital, Brooklyn.
Thursday, November 14th. — New York Academy of
Medicine (Section in Pediatrics) ; West End Clinical So-
ciety; Brooklyn Dermatological Society.
Friday, November 15th. — New York Academy of Medi-
cine (Section in Orthopedic Surgery) ; Clinical Society of
the New York Post-Graduate Medical School and Hos-
pital ; New York Microscopical Society ; Alumni Associa-
tion of Roosevelt Hospital; Brooklyn Medical Society.
Visiting Surgeons Entertained.^ — The New York Fel-
lows of the -American College of Surgeons gave a dinner
at Delmonico's on Wednesday evening to the distinguished
surgeons who had been detailed from the allied armies to
attend the sessions of the Clinical Colle.ge of the American
College of Surgeons, which was to have been held in New
York during the week of October 20th but which was
postponed on accotmt of the influenza epidemic. Dr. J.
Bentley Squier acted as toastmaster and introduced the
speakers, the first of whom was Colonel Franklin Martin,
Vv^ho described the tour made by the delegates, which em-
braced Camo Greenleaf, the Mayo Clinic, (Chicago, Phila-
delphia, and other important cities. Colonel William J.
Mayo, as president, then conferred honorary membership
in the college on Surgeon General Merritte W. Ireland
and the foreign siirgeons, citing the specific achievements
of the candidates, each of whom spoke briefly. The for-
eign delegates included Colonel Sir Thomas Mvles, mem-
ber of the Board of Consultants of the British War Office,
former president of the Rova) College of Surgeons in Ire-
land and surgeon to the King; Major Pierre Duval, sur-
geon in the Paris Hospital and consultant to all the armies
of France; Lieutenant Colonel RafYaele Bastianelli, mem-
ber of the Royal Medical .^cademv of Italy and an officer
in the Italian Army; Colonel George E. Gask, British
medical ofticer. Fellow of the Royal College of Surgeons,
with a record of three years' front line service, and Major
George Grev Tiirner, a veteran of far eastern operations of
the British Army. .A report of the visit of the delegates
to the College of Physicians and Surgeons, Columbia
University, appears on page 819 of this issue.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
strophanthus and its active prin-
cipjl.es versus digitalis.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Continued from page 6^j.)
Clinical observations of Vaquez and Lutembacher,
strongly suggesting that strophanthus — at least in
the form of ouabain prepared by the Arnaud meth-
od— exerts a distinct effect on the tonicity and con-
tractility of the heart, were referred to in a pre-
vious issue. Evidence, published by these authors,
was adduced to the effect that digitalis and ouabain
may be, in a sense, complementary in their action,
the former, administered intravenously, often prov-
ing of great benefit where digitalis had lost its effect,
and even restoring the therapeutic action of the lat-
ter drug when subsequently used, presumably by im-
provement of the tonicity of the heart muscle The
general tendency of the conclusions of Vaquez and
his collaborators is to establish a difference in the
clinical action of the two drugs, digitalis acting par-
ticularly on cardiac conductivity and ouabain on the
dynamic functions of the myocardium.
These conclusions have recently (1918) received
support in this country by J. H. Pratt, at least in so
far as an action of strophanthin on the contractility
of the heart muscle is concerned. This author be-
lieves strophanthin has not received from clinicians
the attention it deserves, and states that he has seen
it, when given intravenously, restore the circulation
where the pulse at the wrist could no longer be felt
or the heart sounds heard. Instead of Arnaud's
ouabain or crystalline strophanthin, he uses the
Boehringer preparation of amorphous strophanthin,
in doses not exceeding 0.5 milligram, and never ad-
ministered oftener than once in twenty-four hours.
Improvement was obtained by Pratt from this
measure in forms of cardiac failure that are rarely
relieved by digitalis. Striking benefit occurred in
some cases of heart failure with regular rhythm.
Thus he reports the case of a man aged fifty-nine
years, with the left border of the heart in the midax-
illary line, a blowing apical systolic murmur, normal
rhythm with pulse rate of 76, severe dyspnea with
Cheyne-Stokes phenomenon, restlessness, fatigue,
and an anxious expression. The dyspnea had been
present continuously during the eight days since ad-
mission to the hospital. That the cardiac rhythm
was actually normal was shown by polygraph trac-
ings. Half a milligram of amorphous strophantliin
having been given intravenously, the breathing be-
came less labored within fifteen minutes, and the
Cheyne-Stokes respiration disappeared completely
an hour later. At the same time the anxious ex-
pression and restlessness passed off and marked sub-
jective betterment was experienced. A favorable
effect of the drug on the myocardium is held to have
been shown by the attending changes in the blood
pressure, which, while registering 175 millimetres of
mercury just before the injection, rose in fifteen
minutes to 205, and was 202 an hour after the in-
jection, with the pulse rate 79. Next morn-
ing the patient remained comfortable, and the
systolic pressure was 185, yet the left border of car-
diac dullness was still in the midaxilla. Later
Cheyne-Stokes breathing was resumed and slight
restlessness and anxiety returned. An injection of
0.3 milligram of strophanthin was now given, and
the use of digitalis begun, o.i gram being ingested
three times daily until two grams had been taken.
Prompt and continuous improvement now set in, the
patient remaining comfortable, with a pulse rate of
68, and being eventually discharged one month after
admission.
The salient feature of the action of strophanthin
in this case was the prompt rise of thirty millimetres
of mercury in the systolic blood pressure after the
injection of the drug, without any slowing of the
pulse, such as would have been expected from digi-
talis. That the favorable effect of the strophanthin
was not dependent upon an action of the drug on the
conductivity of the heart seemed indicated, not only
by this absence of slowing of the pulse, but also by
the fact that the heart rhythm was originally nor-
mal, with a normal rate. A difference from the ac-
tion of digitalis, which as a rule distinctly influences
conductivity, is thus suggested. The fact that the
dilatation of the heart, as determined by percussion,
was not immediately reduced seemed to show that
the chief action of the drug was on the contractility
of the heart rather than upon its tonicity. At any
rate the strophanthin appeared to exert a prompt
and definite effect in increasing the strength of the
heart — a conclusion which, as we have already seen,
agrees with Vaquez's conception of the action of
ouabain.
However effectual the strophanthins may prove to
be in certain desperate cases, the mistake should not
be made, as emphasized by Vaquez and Lutembach-
er, of regularly postponing its use until the patient's
condition is practically hopeless. While, even in
such instances, the remedy may yield unexpectedly
favorable results, it will often fail. Its field of use
should by no means be restricted, as has for a num-
ber of years been customary, to cases in which all
other remedies have proven useless. Indeed, ac-
cording to the observers just referred to. its chief
contraindication is advanced cardiac cachexia, with
widespread edema, multiple fluid accumulations in
the pleural and peritoneal cavities, and inflammatory
lung complications. Nor should ouabain be pre-
scribed for patients with severe chronic organic dis-
ease of the kidneys — unless it be with great caution
and with definite knowledge that certain of the
symptoms or signs are due to heart weakness. In
secondary infectious endocarditis running a subacute
or prolonged course, ouabain, like digitalis, is inef-
fectual, and may even lead to disastrous results,
owing to the degenerated condition of the heart
which often accompanies the valvular disease.
{To be continued.)
November o, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
829
Repair of Large Peripheral Nerve Gaps. — Ken-
neth A. J. Mackenzie {Surgery, Gynecology, mid
Obstetrics, October, 1918) draws the following de-
i*— ductions from a limited number of cases: i. Re-
generation and recovery of function are promoted
by the use of nerve flaps. 2. Both central and
peripheral flaps can be used for such purposes. 3.
A peripheral flap, by laying down a nerve path, may
promote regeneration over a great gap. In one
case quoted regeneration occurred over a gap ten
and three quarter inches in length. 4. The approxi-
mation of nerves and their repair should be done in
all cases with the least possible delay. This would
apply as well to cases which are infected as to clean
cases. 5. The arrest of trophic shock can be pro-
moted by early closure of large gaps by flaps. 6.
Unimpaired nerve tissue should always be utilized
for the effective repair of damaged nerves. 7. In
their repair, nerves can be successfully sequestrated
m muscular tissue so as to promote their own re-
generation and that of the muscles in which they
are imbedded. 8. The principle of sequestration
can be utilized in proper cases so as to avoid in-
fected zones in wounds and also scars and other
obstacles to nerve repair.
Pituitrin in Obstetrics. — J. L. Bubis (Ohio
State Medical Journal, September, 1918) uses pitu-
itrin in cases where the progress of the labor seems
to be unduly prolonged by weak and inefficient uter-
ine contractions. One to three minims are injected
hypodermically. Pituitrin will not start labor, but
the uterus responds to it in any stage. The follow-
ing complications occur from too large a dose of pit-
uitrin : Rupture of the uterus or laceration of the
maternal soft parts caused by the rapid descent of
the firm, unyielding part of the fetus ; fracture of
the skull or laceration of the coverings of the brain ;
asphyxiation of the child due to the sudden tension
of the cord about its neck ; premature separation of
the placenta. For retained placenta, one c. c. of
pituitrin should be administered. To empty the
uterus of retained secundines the usual preparation
is made as for a dilatation and curettage. The cer-
vix is then dilated and one c. c. of pituitrin is in-
jected into the patient's arm. The uterus is then
emptied with the curette, placental forceps, or
finger. During the operation very little blood is lost
and the uterine cavity decreases in size as quickly as
the contents are removed. The uterine muscles be-
come firm and there is practically no danger from
perforation. No hot irrigations are necessary. The
cavity of the uterus should be swabbed with a
two per cent, iodine solution ; occasionally an iodo-
form gauze pack is placed in the uterus for twenty-
four to forty-eight hours. Ergot may be given after
the operation is finished. During Caesarean section
one to two c. c. of pituitrin are injected directly into
the uterine muscles after the incision into the uterus
is made. If the injection is made too early there
is danger of asphyxiation of the child. In this
method the action of the pituitrin is almost instan-
taneous. As a galactogogue it is not always satis-
factory. High blood pressure, arteriosclerosis, and
exophthalmic goitre are definite contraindications to
its use.
Treatment of Toxemia of Pregnancy. — J. O.
Arnold {American Medicine, August, 1918) out-
lines the following general plan: i. Morphine for
the temporary control of convulsions, half a grain
or more at a dose, and repeated as soon and as often
as necessary. 2. Bloodletting as early as possible,
fifteen to thirty ounces being withdrawn, depend-
ing on the case and the effect on the blood pressure.
3. Cleansing of the lower bowel and giving, by
Murphy drip, sodium bromide, one or two drams,
and sodium carbonate, two or three drams, to the
quart of normal salt solution as rapidly and as con-
stantly as the bowel will permit. 4. The darkening
of the room and the securing of quiet and freedom
until the convulsions have been brought well under
control. 5. The induction of labor in all cases oc-
curring before the eighth month, if the convulsions
have been at all severe in type, or more than three
or four in number; after the eighth month the ter-
mmation of pregnancy, regardless of the number of
convulsions, letting the circumstances and condi-
tions determine whether the delivery shall be .by the
normal route, following spontaneous or induced
labor, or by the more rapid method of Caesarean
section. 6. No food of any kind by mouth until at
least three days after convulsions have ceased, but
a continuation of alkali salt solution by bowel, or
of alkaline water and salines by mouth, until the
quantity and quality of urine are satisfactory.
Principles of Treatment in Mercuric Chloride
Poisoning. — H. B. Weiss {Journal A. M. A., Sep-
tember 28, 1918) cites the more recent experimental
studies bearing upon the pathology of mecuric
chloride poisoning in man and animals and agrees
with MacNider that the cause of death in the ma-
jority of the cases is the severe acid intoxication
which develops. This conception is shown to be
correct by the fact that only three patients died out
of a consecutive series of fifty-four treated with
reference to overcoming the acidosis. Two of the
three did not come under treatment until very late
and the third had a preexisting nephritis and cir-
rhosis. The administration of alkalies does not
materially enhance the excretion of the mercury.
The treatment should be begun as soon after the
poisoning has taken place as possible, the first
steps being thorough lavage of the stomach with a
quart of milk containing the whites of three eggs,
followed by a saturated solution of sodium bicar-
bonate until the washings return clear. Then nine-
ty to 120 grams (oz. iij to iv) of crystalline mag-
nesium sulphate dissolved in 180 to 250 mils of
water (oz. vi to viij) are left in the stomach. A
soapsuds enema is n«xt given and the alkaline treat-
ment is begun by giving an intravenous injection of
one to two litres of Fischer's solution, this being
repeated on the following day if the urine has not
become alkaline to methyl red. Imperial drink is
given every two hours in amounts of 250 mils (oz.
viij). The reaction of the urine is watched and
must be kept alkaline to methyl red, alkaline treat-
ment being given also by rectum if necessary. The
diet is not restricted. Under this treatment there is
usually very free secretion of urine, its albumin
content rapidly drops, and the blood and casts
promptly disappear. Recovery is usually complete.
830
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Fibroid Tumors Treated with Radixun. — How-
ard O. Kelly {Surgery, Gynecology and Obstetrics,
October, 1918) concludes that surgeons ought not
to be less selfsacrificing than the wise physician who
struggles to put an end to the era of drugs, toxines,
and vaccines, by sanitation and hygiene. While it
is the imperative duty of the surgeon to continue
building up surgical technic, making operations
safer and carrying surgery to a successful issue in
new fields, nevertheless, he feels sure that all are
willing and anxious, wherever it can be done, to
commit an honorable suicide, a sort of hara-kiri of
which posterity will be proud, by introducing
wherever it is possible, newer methods which are
found to be better and safer than surgery. Begin-
ning back in the fifties of the last century, our
predecessors, at infinite cost in life and in pains,
built up the operation of hysteromyomectomy by
which so many lives have been saved, and to which
also so many have been sacrificed. As long as it
can be shown that an operation in a given series
of cases will not only give better health, but also
save lives, the necessary mutilations can be con-
templated with mingled regret and satisfaction.
This attitude of mind, however, is now no longer
tenable, for now that there is a simpler, safer pro-
cedure at our disposal every death in the fibroid
group becomes an indictment. It may be also
emphasized that if radium fails, the operation has
simply been postponed without detriment. Surely
the logic of the facts presented proved that hence-
forth radium rightly demands the first place in a
determination of the best method in a given case.
The Treatment of Wounds of the Genital Or-
gans in Warfare. — Charles Greene Cumston
{Annals of Surgery, September, 1918) states that
if a missile or other foreign body is lodged in the
scrotal cavity it should be removed at once — a
simple matter, requiring no particular skill —
but the treatment becomes a much more delicate
question when the testicle is involved ; not uncom-
monly the gland, be it either intact or injured,
forms a hernia through the aperture in the scrotum.
Now no hesitation is permissible when the testicle
is untouched or only slightly contused, because the
rational treatment is its reduction into the bursa
and suture of the latter. The reduction should be
attempted just as soon as possible in order to avoid
strangulation and its shadow sloughing which al-
ways follows. The reduction may be delayed for a
few days until the scrotal wound has been properly
cleansed if it appears to be infected, as is usually
the case ; but at the same time, the vitality of the
testicle must be carefully watclied. When reduction
is undertaken, the utmost gentleness must be ob-
served. After having carefully cleansed the struc-
tures, the lower or upper angle of the scrotal wound
must be enlarged by incision and the ragged
edges of the vaginalis carefully evened off with
scissors. With the exit of the testicle from the
scrotum, all the tunics will, of necessity, be turned
outward; therefore, since in the circumstances the
vaginalis will form a virtual cavity, the testicle can
be reintegrated if the walls of the vaginalis are first
raised up and retracted. In cases seen shortly after
the receipt of the injury, it may be possible to rein-
tegrate the testicle under its serous covering, other-
wise the gland must be covered by any means pos-
sible, such as a moist dressing, and then await
events. Not uncommonly, the congestion will sub-
side in a few days, the surrounding structures will
relax and the general aspect of the process will as-
sume an aspect of excellent behavior, far from
what might have been assumed when the case first
came under observation. Admitting that the testicle
and its vessels are intact, irreducibility is never an
indication for primary castration. There is every
reason to attempt reduction, even when the testicle
is contused or offers a superficial wound. The par-
enchyma forming the hernia should be carefully
reduced and the albuginea minutely sutured. The
great value of the organ in question should incite
one to attempt treatment along conservative lines.
Treatment of Acute Suppuration of the Middle
Ear.--J. Clarence Keeler {Pennsylvania Medical
Journal, September, 1918) points ou^ that, during
this treatment, it is of supreme importance for the
patient to rest in bed. A brisk cathartic of calomel
should be given. In the early stage of a mild form,
accompanied by moderate pain, douching the exter-
nal auditory canal with hot saline solution, 105° F.,
will afford relief ; where the pain is severe, opiates
may be given. No oily preparations should be used.
Leeching is also condemned because it is unsanitary
and presents grave danger of transmitting serious
infection. The drum membrane may be anesthe-
tized by applying a solution of equal parts of men-
thol and cocaine. A pledget of cotton is saturated
with this mixture and carefully placed in apposition
with the inflamed bulging drum ; the tampon is re-
moved in ten minutes and the membrane incised.
A mild suction pump is employed to draw the in-
flammatory exudate from the tympanum, and the
auditory canal is irrigated with one of the antiseptic
solutions, and a piece of plain sterilized gauze is
placed in the canal to facilitate drainage.
Magnesium Sulphate Solutions in the Treat-
ment of Spastic Contractures of the Rectum and
Sigmoid Colon. — Horace W. Soper {American
lonrnal of Medical Sciences, August, 1918) comes
to the following conclusions : i. Spastic contractures
of the lower colon are etiological factors in many
cases of chronic constipation. 2. These contractures
are the result of disturbances in Meltzer's law of
contrary innervation. 3. A saturated solution of
magnesium sulphate applied locally to the contracted
segment produces a relaxation. Repeated applica-
tions finally overcome the spasticity and permit the
restoration of normal colonic function. 4. Con-
tractures in the rectum and lower sigmoid, with
accompanying dilatation of the colon, are found in
many cases of postoperative abdominal distention.
Magne siuni sulphate enemata are very efficacious in
relaxing the contractures and thereby relieving the
distention and "gas pains." 5. Enemata of mag-
nesium sulphate are also very useful in partial
organic obstructions in the rectum and lower colon,
inasmuch as they relax accompanying muscular
contractures without stimulating peristalsis. 6.
Magnesium sulphate solution applied by means of
the cotton applicator greatly facilitates the intro-
duction of the sigmoidoscope.
November 9, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
831
Cancer of the Breast.— J. H. Jacobson {Ohio
State Medical Journal, September, 191 8) concludes
that, I, the only hope of cure for patients suffering
from cancer of the breast is a radical operation; 2,
a large proportion — 32.86 per cent. — of patients ope-
rated on by the radical method pass the three year
period, and 23.77 P^r '-^^"t- the five year period ; 3,
most patients are operated on when the disease is
too far advanced ; 4, cancer of the breast must be
recognized before the lymphatic glands in the axilla
become involved ; 5, there are no positive dif¥erential
clinical signs for early cancer, and therefore all
breast tumors should be removed and submitted to
microscopic examination; 6, the removal of all
breast tumors, an early diagnosis, and an early radi-
cal operation are the means at our command for
lowering the death rate in cancer of the breast.
Treatment of Syphilis. — Joseph Kaufman
{American Mcdccinc, August, 1918) concludes the
following: i. Every case of syphilis should re-
ceive intensive treatment immediately upon making
the diagnosis. 2. Every case of early syphilis
should be kept under active treatment for at least
two years, with short intervals between courses. 3.
Every case of latent syphilis should be treated if
the spinal fluid is positive; if the fluid findings are
negative, and the patient has not had sufficient treat-
ment, the patient should be kept under the treat-
ment as described. In the positive cases intra-
spinal therapy must be given. 4. The patient should
be given long courses of mercurial injections, keep-
ing the dose at more than one grain, repeated every
five to seven days. All of these patients should re-
ceive iodides. 5. Every case of tertiary syphilis
should be given intraspinal treatment, associated
with mercurial and salvarsan injections and the in-
ternal administration of iodides.
Treatment of Facial Elrysipelas. — Anthony A.
Avata nnd Rollin T. Woodyatt {Journal, A. M. A.,
September 14, 1918) tried all of the methods recom-
mended for the treatment of this infection without
finding that any one was superior to the others until
they began to use Niehans's method of collodion cir-
cumscription. The ordinary nonflexible collodion of
the United States Pharmacopoeia is painted on the
skin in a strip half an inch wide and one inch out-
side the erysipelatous margin so as to surround the
lesion completely. The strip is painted over repeat-
edly until, when dried, it causes a deep furrow about
the lesion. This must be watched to see that it is
perfect and imbroken at any point and repaired bv
further coats if necessary. The lesion will advance
to this furrow but not beyond it. This ring of col-
lodion is left in place until the swelling and tem-
perature have wholly subsided. The enclosed in-
flamed area is treated by the application of cold
compresses of a saturated solution of magnesium
sulphate. This treatment was controlled by com-
parison with patients receiving other forms of treat-
ment and it was found to stop the progress of the
disease, to reduce the toxic symptoms and constitu-
tional reaction, to shorten the average duration of
fever from an average of eight to three and a half
days, and to shorten the period in hospital from an
average of thirty to an average of fifteen days. It
also reduced almost entirely the development of
complicating abscesses.
Protein Treatment of Arthritis. — S. P. Beebe
{Medical Record, July 27, 1918) describes improve-
ment attained in sixty per cent, of chronic aithritis
cases treated by injections of his nonspecific protein
preparation made from millet and alfalfa seeds.
This is used in a two per cent, solution and the dose
starts with ten to twelve minims and is given in in-
creasing doses three times a week from four to ten
months.
Treatment of Syphilis with Novarsenobenzol.
— Erwin P. Zeisler (Urologic and Cufa)uous Rc-
viczv, September, 1918) concludes that: i, Novar-
senobenzol IS a safe and effective remedial agent in
the treatment of syphilis in all its stages ; 2, clinic-
alK and serologically it is equally as effective as
neosalvarsan ; 3, concentrated solutions are to be
preferred on account of the freedom from reaction
and simplicity of technic.
Venesection in Eclampsia. — P. Balard {Presse
medicalc, August 8, 1918) finds that a moderate
bleeding — 500 grams — is sufficient to induce, in
eclamptics with high blood pressure of the renal
type, an immediate and lasting reduction of the
systolic and diastolic pressures, as well as a reduc-
tion in the energy expended by the heart muscle, as
shown by oscillometric studies. These observations
justify the confidence which obstetricians have long
reposed in blood letting in eclampsia.
Stannoxyl in Staphylococcal Infections. — Ar-
thur Compton {Lancet, August 24, 1918) calls at-
tention to the proved value of this agent in the
treatment of various forms of localized staphy-
lococcal infections like furunculosis, ostemoyelitis,
etc.. and records three cases of bronchopneumonia
(two tuberculous) in which its administration seem-
ed to be of distinct benefit, reducing the temperature
to normal and causing an improvement in the pa-
tient's general condition. He believes that the drug
either renders the soil unfit for the organism, or
causes an attenuation of the organism's virulence.
Physiological Action of Alkaline Chlorates. —
J. E. Abelous (Presse medicalc, August i, 1918)
finds that after injection of sodium chlorate there
is no increase of chlorides in the urine ; the xan-
thuric bodies, however, are augmented. There
occurs a distinct diminution in the number of leu-
cocytes, with a relative increase of the polynuclears
at first followed on the second day by an increase
in the large mononuclears, with the appearance of
voluminous, vacuolated mononuclear cells. The
pharmacological reaction of the chlorate is exerted
on the leucocytes and not by a direct oxidizing
effect.
Modified Stokes-Gritti Amputation. — W. A.
Chappie (British MediealJournal, August 17, 1918)
recommends the complete division of the attachment
of the quadriceps to the upper margin of the patella
and the suture of the patella in place on the under
aspect of the lower end of the femur by stitching
its margins to the edge of the periosteum with cat-
gut. One or two additional deep catgut sutures are
usually required and a firm button suture should be
placed through the skin flaps. By this method the
patella is prevented from being displaced through
action of the quadriceps and a good weight bearing
end is provided for the stump.
Miscellany from Home and Foreign Journals
Parathyroid Insufficiency. — Arthur F. Hertz
(Endocrinology, April- June, 1918) reports the case
of a clerk, fort3'-seven years of age, whose symp-
toms appeared to be due to a functional insufficiency
ot the parathyroid glands. He was first seen in
1910 and was under the author's observation for
four years. In 1908 the greater part of the thyroid
gland had been removed because of enlargement of
the gland. After this he had remained well until
four months before consulting Doctor Hertz, when
he had become suddenly depressed, nervous, rest-
less, and sleepless. There was a constant fibrillary
twitching of the eyelids, but tetany was never
present. His eyes were sunken : tlie thyroid gland
could not be seen or felt, and though the patient's
appetite was enormous, he constantly lost weight.
There was some difficulty in swallowing, which
fluoroscopic examination showed was due to an ir-
regular spasmodic contraction of the esophagus. He
passed three or four large stools a day ; the urine
was normal, but diminished in quantity. His pulse
was constantly about 120; his face and neck were
deeply flushed.; his hair had stopped growing, and
he had become completely impotent. A definite
diagnosis was not made, but it seemed obvious that
the disease was of endocrine origin, possibly due to
injury of the parathyroids during the previous
thyroid operation. Various methods of treatment
were tried in the hospital, including the administra-
tion of desiccated thyroid gland and Moebius's
antithyroid serum, opium and bromides, but the
patient continued to lose weight until he began to
take one tenth of a grain of dried ox parathyroid
glands four times daily. On this treatment he
gained 28.5 pounds in the first nineteen days, and
at the end of six months of parathyroid therapy all
his symptoms cleared up, his sexual functions being
restored. Once in 1913, when his pulse was faster
and he was restless, he began to take one tenth of a
grain of parathyroid daily, which he continued tak-
ing for four months. At this time his face became
brick red, the vessels in his neck throbbed, and his
throat was full. These symptoms disappeared on
stopping the parathyroid, and since that time he has
remained perfectly well.
Clinical Aspects of Peptic Ulcer, with Special
Reference to Rontgen Ray Diagnosis. — F. H.
Baetjer, and Julius Friedenwald {Bulletin of tkc
Johns Hopkins Hospital, August, 1918) present the
results of investigations in 743 cases of peptic ulcer
in which the value of the x ray as a diagnostic
means is definitely brought out. The authors find
that x ray examination is as great an aid in exclud-
ing the presence of ulcer as in establishing positive
findings, for in 698 cases ulcer was ruled out by
this method of examination. Another important
application of the x ray is in following the progress
of healing, as revealed by repeated x ray examina-
tions over a long period of time. In 185 cases of
peptic ulcer proved by operation, positive x ray
findings were observed in 147 cases, or 79.4 per
cent. ; in 323 undoubted cases, not confirmed by
operation, the x lay findings were positive in 272
cases, or eighty-seven per cent ; and in 235 some-
what doubtful cases, 210, or 89.7 per cent., showed
positive x ray findings. Such figures clearly show
the value of this means of examination. When ad-
hesions are present the diagnosis is often difficult,
as these conceal the usual findings and make it im-
possible to determine whether there is an ulcer of
the stomach or a lesion of some other organ. When
the ulcer is at or near the pylorus, signs of partial
obstruction often help in arriving at the correct
diagnosis. The x ray picture usually affords suf-
ficient evidence as to the extent and induration of
the ulcer to indicate the need for operation. In
duodenal ulcer there is excessive hypermotility of
the stomach, with rapid evacuation of its contents,
so that the greater portion is expressed in the first
half hour ; there is hypermotility of the duodenum
with formation, usually, of a deformity which
remains fixed in all of the examinations. The
diagnosis of gastric ulcer depends on the function-
ing of the stomach and the finding of the filling
defect, which latter can only be demonstrated when
it is situated along the anterior surface of the
stomach and along the anterior surface of the lesser
and greater curvatures. On the other hand, no
matter where the itlcer is situated, there is always
a certain amount of retention of contents and a
more or less well marked hour glass formation, so
that the authors regard the functional signs often as
important as the filling defects in making a diagno-
sis, particularly as eight per cent, of their cases
showed no filling defects, but the functional changes
pointed definitely toward ulcer.
Pneumonia and Meningitis. — Paul G. Wooley
{Journal of Laboratory and Clinical Medicine, July,
1918,) in discussing the pneumonia and meningitis
problem at Camp Greene, compared the situation
there with that reported in various camps through-
out the country. He believed that the best pre-
ventive method against pneumonia was to send all
recruits to a camp where for a certain period they
would start training and at the same time the upper
respiratory passages of all the men should be disin-
fected as thoroughly as possible without regard to
bacteria. This plan had been tried in Casual Camp
No. I at Camp Greene, and seemed to have been
efifective, as there had been less pneumonia there
than in the rest of the camp, and measles and
mumps, which appeared in the casual camp in con-
tacts from other camps, declined more rapidly in the
casual camp than elsewhere. Apparently in attack-
ing the pneumococci and meningococci in the nasal
passages all the infections of the upper respiratory
tract were influenced. Wooley emphasized what
so many other writers did. the importance of pneu-
monia and meningitis prophylaxis. As both diseases
were due to the invasion of the upper respiratory
tract by bacilH, the only method for preventing
their spread was to apply antiseptic methods to the
nose and nasopharynx ; and this treatment should be
put into practice before the season of the year in
which diseases of the upper respiratory tract be-
came widespread.
November 9, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
«33
Filterable Toxic Product of the Hemolytic
Streptococcus. — Admont H. Clark and Lloyd D.
Felton (Journal A. M. A., September 28, 1918)
find that by growing hemolytic streptococci in rab-
bit's blood, diluted with Locke's solution, a filterable
toxic substance is produced. The formation of
this toxic substance depends on the pressure of
hemoglobin in the medium, as shown by the results
of the various modifications of the culture medium.
The toxic substance is readily destroyed by heat-
ing it to 50° C. for half an hour. It is dialysable
and is not hemolytic in vivo or in vitro. It slowly
loses its toxicity when kept in the cold. The sub-
stance requires an incybation period after its injec-
tion into test animals before it exerts its toxic
effects. An immunity can be developed toward it
rapidly, and animals thus immunized are also im-
mune to the living streptococci. The toxin is, fur-
ther, neutralized by the blood of rabbits immunized
against it.
Moisture in the Air Spaces of the Lungs. —
C. F. Hoover {Journal A. M. A., September 14,
1918) presents a series of observations made upon
gassed soldiers and in other forms of dyspnea
which give new importance to the presence of mois-
ture in the pulmonary air spaces. Where there is
much moisture present, as in the gassed patient,
there is deep cyanosis with relatively slight air hun-
ger and the cyanosis can be relieved by the inhalation
of oxygen, -while the air hunger is little or not at all
affected. Where there is much moisture the entire
air space of the lungs may be occupied by foam at
the end of expiration and this foam is alveolar air
foam. The only area for the gaseous interchange is
that of the cross section of the trachea or larger
bronchi, hence gaseous interchange is reduced to a
minimum. All escape of carbon dioxide from the
blood into the pulmonary air spaces ceases as soon
as this foam contains the same partial pressure of
this gas as that of the blood. In such a case the in-
halation of oxygen for several minutes is capable of
relieving the cyanosis by superventilation of the
foam free units of the respiratory tract, but the air
hunger is not affected because of the continued flow
of anoxemic blood from the other portions of the
lung. This accounts for the dissociation between
anoxemia and air hunger. In other words the in-
halation of oxygen will compensate for the
anoxemia so far as the cyanosis is concerned, but
the continued admixture of this superventilated
blood with the unventilated blood from the foam
filled areas is sufficient to maintain air hunger. The
area for the escape of carbon dioxide is not affected
by the inhalation of oxygen, though the high con-
centration of the latter administered can cause local
superventilation. Thus in any condition in which
a portion of the blood from the lungs is unrespired
there will be cyanosis and some little hyperpnea, and
in such circumstances the gas analysis of the ex-
pired air will not measure the partial pressure of the
oxygen and carbon dioxide in the aortic blood. Such
conditions are found in lobar pneumonia and some
cases of cardiac incompetence, and the observation
of the effects of the inhalation of pure oxygen in
such cases is of diagnostic value to confirm the pres-
ence of excessive pulmonary moisture.
Subacute Bacterial Endocarditis. — H. J. Star-
ling {British Medical Journal, August 17, 1918) re-
cords the detailed histories of five consecutive cases
of this form of endocarditis on account of its com-
parative rarity and because of the peculiar manifes-
tations with which it is associated. Of especial in-
terest in these cases was the development of ephe-
meral spots of painful nodular erythema, as de-
scribed by Osier and by Parkes Weber. Such spots
were found in two of the cases and possibly had
been present in a third. They were painful for
about two days and remained visible for some four
or five days. They might recur on and off for
months and appeared most commonly on the finger
tips or on the palmar surface of the fingers and
caused much distress while painful. Petechife were
present in all the cases at different times and in
varying degrees. Enlargement of the spleen was
also found in all the patients, was associated with a
good deal of pain in the splenic region, and at times
a friction rub was heard over the organ. The fever
was never severe, varying between a normal tem-
perature and 102°, and there were long periods of
apyrexia. Arterial embolism of unusual degree oc-
curred in four of the cases, but no suppurative pro-
cess was associated with these emboli. Embolism
occurred at the bifurcation of the brachial artery
in one patient; at a branch of one of the retinal
arteries in another ; in a third there were emboli in
the radial artery at the wrist, in the popliteal at the
bend of the knee and in a branch of the suprascapu-
lar ; the fourth had emboli in the femoral artery, in
the posterior tibial and in the right axillary at the
junction of the brachial. Pulsation was often felt
distally to the site of embolism in spite of complete
occlusion, probably due to a free collateral circula-
tion. In spite of the various evidences of embolism
in these cases hematuria has not been marked and it
was often necessary to centrifugalize the urine to
discover the few red cells present. Only one case
gave positive blood cultures and that one showed a
gram positive coccus in pairs and short chains. Post-
mortem vegetations were found characteristically on
the mitral and aortic valves, on the chordae tendinae
and within the auricles.
Tonus Waves from the Sinoauricular Muscle
Preparation of the Terrapin as Affected by
Adrenalin. — Charles M. Gruber and Casper Mar-
kel (Journal of Pharmacology and Experimental
Therapeutics, August, 1918) state that adrenalin
caused a disappearance or a diminution in the tonus
waves observed in the sinoauricular muscle prepara-
tion of all the terrapins used, and there was a
simultaneous increase in the force and amplitude of
the contraction, and in some instances an increase
in the rate of contraction. When the solution was
strong, the waves ceased almost immediately ; when
a more dilute solution was used, only a few tonus
waves appeared after the addition of the adrenalin
to the Ringer's solution. The length of time re-
quired after an injection of adrenalin, before the
recurrence of the waves, varied directly with the
strength of the adrenalin solution used. Oxygen
added to Ringer's fluid seemed to hasten the pro-
cess of recovery, which might be only a matter of
hastening the oxidation of the adrenalin.
834 MISCELLANY FROM HOME
Oculomotor Reaction to Labyrinthine Stimu-
lation.— H. B. Lemere {Journal A. M. A., Sep-
tember 14, 1918) concludes from a careful investi-
gation of the reactions, as well as of the actual ana-
tomical positions of the canals in the intact skull,
that there is a direct relationship between the stimu-
lation of the canals and the reaction of the muscles
of the eye. The superior canals influence the su-
perior and inferior recti of the eyes ; the horizontal
canals, the internal and external recti ; and the in-
ferior canals, the obliques. The horizontal canals
are influenced by movements with the head nearly
in a horizontal plane ; the superior, in a longitudinal
plane ; and the inferior, in a transverse plane. The
anterior vertical canals should be called the longi-
tudinal; the posterior vertical, the transverse, and
the conception that the posterior canal of one side is
on a plane with the anterior of the other is erro-
neous and should be corrected.
Tooth Impacted in a Secondary Bronchus of
the Left Lung ; Removal by Lower Bronchoscopy
after T-wo Unsuccessful Attempts by Upper
Bronchoscopy. -St. Clair Thomson {Practitioner,
August, 1918) reports the following, in a child
of ten years. The aspiration of the tooth was
not noticed or even suspected at the time of the
accident. According to the dentist the tooth did not
fall from his forceps in the mouth, but it fell on
the napkin below the child's chin. As she was re-
covering from the nitrous oxide anesthesia she
threw up her arms and made a deep wide mouthed
inspiration. It must have been at this moment
that the tooth was aspirated into the left lung.
The first attempt at peroral removal failed, owing
to the tight impaction of a smooth, hard body,
whose slippery, conoidal surface offered no grasp
for the forceps. The second effort failed because
the patient collapsed before removal had been at-
tempted. The collapse was possibly due to the trac-
tion on the heart necessitated by the obliquity of
the bronchoscope tube in the peroral route. The
removal through an opening in the trachea was
found to be sim])le, safe, and prompt and in no
way comparable to the difficulties and anxieties of
the two peroral attempts. The following con-
clusions are arrived at : Endoscopy of the air
and food passages must always remain in the hand?
of the expert laryngologist. If he is well experi-
enced and in regular practice he will first make his
approach through the mouth, and in most instances
he will succeed. But in a certain number of cases,
particularly the rarer and more difficult ones which
occur in the left lung, the lower route, through a
tracheal opening, is the preferable one to be taken
in the interest of the patient. It will also be the
route taken more readily by those who are less ex-
perienced. The advantages can be summarized as
follows: I. Less anxiety with the anesthetic, as
we all know that the administration through a
tracheotomy opening avoids all pharyngeal and
laryngeal reflexes, and is therefore much smoother
and safer; 2. ability to succeed with several
trained assistants, because there is no longer the
necessity to mobilize the head ; 3. the use of a wide-
and shorter tube, thus obtaining 4. better illumina-
tion, 5. a larger field of vision, and 6. increased
AND FOREIGN JOURNALS. „ [New York
Medical Journal.
facility of manipulation ; 7. less leverage and trac-
tion on the important structures at the root of the
lung ; 8. shorter sitting ; 9. greater certainty in re-
sult ; ID. in the event of failure, or of the foreign
body shifting its position during the seance, the tra-
cheotomy is a decided security. Lower bronchoscopy
will therefore be the necessary method in certain
circumstances, or when foreign bodies are tightly
impacted, or when they have receded to the deepest
corners of the airway, and particularly in the greater
difficulties presented by their entry into the left
chest. The only drawback is the insignficant one of
a slight scar.
Experimental Meningococcus Meningitis. —
Charles R. Austrian {Bulletin of the Johns Hopkins
Hospital, August, 1918) found that the cerebro-
spinal canal can be infected by way of the blood
stream. It was impossible to infect the normal
cerebrospinal canal of rabbits by intranasal injec-
tion of the meningococci. The demonstration of
meningococci in the nasal secretion is to be regarded
as an evidence of their excretion by this route, but
the conclusion is not necessarily warranted that the
organisms find a direct portal of entry to the
meninges through the nose. When the animal is
normal, the presence of a bacteriemia does not lead
to the development of meningitis, but when hyper-
mia of the thecal vessels exists, meningeal inflam-
mation may result. This may explain in a measure
the occurrence of the disease in some persons ex-
posed, while others who come in contact with the
same sources of infection remain well. Austrian
says that his experiments suggest the probability
that epidemic cerebrospinal meningitis, occurring in
man, is to be regarded as a metastatic disease de-
veloping in the course of a general infection.
Noninfluence of Rise in Body Temperature In-
duced by Drugs upon the Protein Quotient and
Enumeration of White Corpuscles. — ^Florence
McCoy Hill {Journal of Pharmaeology and Experi-
mental Therapeutics, August, 1918) found that
fluidextract of ergot, given intravenously in doses
of from one to 1.5 c. c. per kilogram of body weight
caused a steady rise of from 1.5 degrees to 2.2
degrees of body temperature in rabbits. Higher
doses proved fatal, the rabbits dying either im-
mediately on receiving the intravenous injections,
or in clonic convulsions following the injection
directly, and ending in death in twenty minutes.
Calcium lactate, given intravenously in doses of
from five to eight c. c. of a one twentieth solu-
tion, induced an initial fall in temperature of from
0.4 degrees to 0.6 degrees, while in the higher
doses symptoms of calcium fectate poisoning were
noticed. This drop in temperature was followed by
a marked rise of from 1.5 degrees to 2.5 degrees
and disappearance of the symptoms of poisoning.
Doses higher than eight c. c. were fatal. A study
of the leucocyte count and protein quotient in rab-
bits whose normal range was known showed no
definite alteration after administration of sublethal
doses of either fluidextract of ergot or calcium
lactate, so that the experiments show that the
"aseptic fever" produced by the drugs used causes
no change in the globulin content of the blood, nor
in the leucocyte count.
Proceedings of National and Local Societies
MEDICAL ASSOCIATION OF THE
GREATER CITY OF NEW YORK.
Stated Meeting, Held March i8, 19 18.
The President, Dr. Edward E. Cornwall, of Brooklyn,
in the Chair.
{Continued from page 795.)
Camp Sanitation. — Dr. Reynold Webb Wil-
XOX, late major, Medical Reserve Corps, said that
camp sanitation, dealt with, first, the selection of
camp sites ; second, the suitability and excellence of
all foods and drink used by the soldiers ; third, the
disposal of wastes ; and, finally, with individual per-
sonal hygiene. Theoretically, camp sites were se-
lected upon the advice of the sanitary medical offi-
cer attached to that particular body of troops. In
the field, they were selected from military neces-
sity, their value as camp sites from the sanitary
standpoint being a secondary consideration.
The inspection of food and water was an impor-
tant part of camp sanitation. In the mere matter
of meat, for instance, there were regulations which
the contractors were obliged to observe, i. e., accept
only meat of steers between the ages of four and
six years of age. The water supply must be safe
and adequate. If water was used from a reservoir,
either natural or artificial, and this reservoir became
infected with algse, it was easily cured with an ex-
tremely weak solution of copper salts. Ordinarily,
the water which was doubtful in regard to its bac-
terial content could readily be made potable by
the addition of about fifteen grains of sodium hy-
pochlorite to thirty gallons of water. This is usu-
ally done as a matter of precaution on the march,
and in permanent and semipermanent camps. The
Lyster bag with its four spigots at the bottom, with
one tube containing the proper amount of the hypo-
chlorite, rendered almost all of the pathogenic bac-
teria harmless in about thirty minutes. Theoret-
ically, boiled water is the safest, but as a matter of
fact opportunities for boiling water were not always
present and the flat taste of the boiled water became
unpleasant.
The disposal of waste was extremely important.
Ordinarily this could be burned or buried, and some
of it could be sunned, but circumstances might for-
bid the use of any one or two of these methods.
Burning probably was the safest, and the Rock Pit
incinerator of standard size, properly managed, dis-
posed of an enormous quantity of waste. This ex-
cavation was lined with "nigger heads" which would
stand the heat without cracking; and, if used with
care would take care of the waste of a regiment
effectively and safely. Three such incinerators
would take care of the entire waste of 71,000 men.
Human excreta is taken care of in latrines, kept
under careful and continuous inspection, with suffi-
cient accommodation for about five per cent, of the
command at one time. Straw is sprinkled over the
bottom of the pit and then saturated with crude oil
and fired. As soon as the flames become low
enough, the wooden covers are placed over them
and the pit left filled with smoke, which disposes of
all the flies. This made the excreta harmless, so
far as infection of the soldiers was concerned.
Eventually, when the latrines are nearly full, they
are covered in. The picket line was always a
source of great annoyance in camp sanitation, for
horses that were tormented by flies easily got out
of condition and were useless for military purposes.
Constant watchfulness was necessary. All the
horse droppings were raked up, dried in windrows,
and burned as soon as possible. The soil of the
picket line was covered with straw or hay, saturated
with oil every three or four days and the whole set
on fire. This destroyed the larvie of flies in the
upper two or three inches of soil and prevented
those embedded deeper from coming to the surface.
Screening was necessary at times. Every particle
of waste food, crumbs, etc., was destroyed by fire
and the empty cans burned out. Mosquitoes were
abolished by destroying their breeding places. From
the medical standpoint a camp with a large sick call
of soldiers complaining of diarrhea, meant a laxity
in the inspection of foodstuffs and drinks and in the
disposal of wastes. An ideal camp was flyless.
How is all this brought about ? The staff officer
has command only within his own department. He
advises the commander of the camp as a staff offi-
cer as to matters which require attention. The line
officer either approves of his recommendations, or
if he disapproves he states why in his endorsement,
and the recommendations and the endorsement
automatically go to the highest military authority
upon whom rests the responsibility for the personnel
and material necessary for the efficient care of the
sick and wounded in a camp. Camp sanitation con-
sists in doing the necessary things to make the site
safe by using the available material and personnel.
The recommendations of the sanitary officers should
deal with the measures and the conditions of which
the danger was immediate and important. These
recommendations should ignore remote and the-
oretical dangers ; and not only must the sanitary
officer be trained and intelligent, but accustomed to
effective administrative work according to military
methods.
Captain Alec N. Thomson, M. R. C, of the
Division of Venereal Diseases, Surgeon General's
Office, said that he was on his way to Boston to
assist the Health Department of Massachusetts in
a state wide campaign regarding venereal diseases.
Doctor Park had given him a valuable cue in speak-
ing about the carrier rate of the important infec-
tious diseases in the army. No carrier rate had
been computed for venereal diseases in the army,
properly speaking, but there was a tremendous car-
rier rate in the civilian community. Some very
elaborate plans had been started in regard to the
control of syphilis in the service. Doctor PolHtzer
referred to syphilis as it related to the future of the
country. The man in the early stages of syphilis
was kept in the army hospital for a certain period,
usually two weeks, during which time he could be
sterilized with salvarsan. etc. Patients with gon-
orrhea were kept in the hospital until there was no
836
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
discharge, and when they were out of the hospital
and assigned to Hght or even full duty, they were
restricted to the post until a genitourinary specialist
decided that the condition was no longer communic-
able in the, sense of danger to the general popula-
tion. That restriction had been going on for years
with regular army men, and since September with
the drafted men. Doctor Thomson said he knew
of one man who had never been allowed leave once
since he went to camp because he was in a chronic
condition when he came from the civilian comn:u-
nity. He was booked as a communicable venereal
case because he had a discharge from which gono-
cocci were recovered, and he was still kept under
restriction. The man had been in the hospital most
of the time since entering the army, and when his
comrades sailed for France he was left behind.
There was venereal inspection of every man twice
a month in camp, and once just before saiHng. If
any cases were found among the men on their ar-
rival abroad it was unfortunate for the physician
who had made the final inspection. General Per-
shing had a way of inquiring why any case of ven-
ereal disease was permitted to slip through. The
infected soldier would not have a chance to even
try to get "over the top."
Why did the army exercise its authority outside
the reservation to attack venereal disease? For
the same reason that it did so to attack malaria or
yellow fever, or in the control of typhoid. It was
necessary to go outside in the control of venereal
disease, for the source of infection was in the civilian
community, and the cooperation of the civilian com-
munity was essential. The civilian community was
expected to send men to the army fit to fight, and
the army would do its best in keeping them fit.
Doctor Pollitzer had described some of the meas-
ures established for carrying out this work. Health
officers and physicians in general could give much
help in this direction. The vital thing was to
arouse the civilian community to an interest in the
subject and to demand that the police do their part
in keeping the disease from getting into the camps,
via the prostitute. Infected women in this nefari-
ous trade should be handed over, not alone to the
police department, but to the health department,
where they belonged as disease carriers, and held
until their syphilis or gonorrhea was cured. The
proposition before the army was to get at the
source and remove it, as in any other disease. If
the civilian community would earnestly cooperate,
it could be done. The State of New Jersey knew
more about the status of venereal disease within
its own borders than ever before. Every time a
Jersey boy came into the service with venereal dis-
ease the camp sanitary inspector knew it within
three or four days. Upon his reporting the facts
to the State Health Department, they investigated
conditions in that town. New Jersey passed a new
law to help the army; New York State had the
matter under consideration, and the bill would be
brought up before the Legislature in a few days.
California was the first State to pass a law for co-
operation, appropriating $60,000 for this purpose;
hospitals and dispensaries had been established, full
time workers employed, and a state wide campaign
instituted. The zone lieutenants of the army — and
there was one at every camp — kept the matter con-
stantly before the public, and the police well in-
formed as to conditions. Hundreds of sources of
infections were being reached. The first Hne of
defense was education ; the soldier was getting it,
and it:^ eftects were already apparent. They were
realizing the desirability of continence in the big
job that they were training for, to win the war, and
if it was going to help accomplish this they were
willing to stay away from women. Then there was
the matter of prophylaxis. From the reports of
thousands of examinations it would seem that over
fifty per cent, of prostitutes had syphihs, and almost
all had gonorrhea with clinical symptoms. The
men were accordingly told, in the talks given on
prophylaxis, that any woman who would give her-
self to any man but her husband could be assumed
to have venereal disease, and that all men so ex-
posed should be treated immediately after infection ;
that a man who did not submit himself to such early
treatment was not doing his duty but was disobey-
ing orders and would be subjected to discipline,
restriction from leave, imposition of extra duty, etc.,
if he contracted the disease. There was no doubt
that prophylaxis was doing a great deal to keep
down the development of new cases, and in addi-
tion, as a result of the educational propaganda, the
men were not exposing themselves as they did be-
fore all these protective measures were established
by a paternal government.
Major Thomas Darlington, M. R. C, said that
all over the United States there was a feeling of
depression because of the war, and so much would
be lost before it was finished, but it would be a
cause of deep rejoicing if all these people could
hear what had been said tonight regarding the ad-
vantages that would accrue as a result of the care
of the authorities for the enhsted men. The work
which had been described by Major Pollitzer and
Captain Thomson was most encouraging. The at-
titude at Washington and in the army itself, and
as a result what had actually been accomplished,
was splendid, but it should not be forgotten that it
has been due as much as anything else to the civilian
doctors, the men of the Medical Reserve Corps, who
had gone into the army and given their best efforts
without stint, doing everything they could to edu-
cate the people both in and outside of the army, and
spreading broadcast knowledge of how life and
health could be best conserved tmder the new con-
ditions of living.
Dr. Hermann M. Biggs said that the work done
bv the medical officers was on a par with the spirit
shown by everyone engaged in this war ; there was
an eamestness and a high idealism that was very
apparent. The men were healthful, square jawed,
sincere in their desire to do everything to accom-
plish their high purpose. It was like a great cru-
sade. Every means of education, moral, physical,
and intellectual, were being employed for the aid
of these boys. Doctor Biggs said that he had re-
cently met a quartermaster from a nearby camp and
had asked him what sort of books he should send
to amuse the men. The quartermaster told him not
to send any, as the men had no time to read them ;
they were studying nothing but war, and were in-
tent upon that, and had no time to spare for any-
November 9, 1918.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
837
thing else. The medical men and all the others who
were working for the army are to be commended
for the wonderful work they are doing, not only
for the present but for future generations.
Stated Meeting, Held April ij, ipi8.
The President, Dr. Edward E. Cornwall, of Brooklyn,
in the Chair.
X Ray Treatment of Tumors of the Breast. —
Dr. J. H. Branth reported a case in which the
patient had been cured of axillary and mammary
tumorous growths of five years' standing by x ray
and high tension high frequency treatment. She
was now practically well, but was still taking one x
ray treatment a week, of about seven minutes, in the
axilla and also on the breast. Doctor Branth said
that he had had a few other such results, but the
cases required a longer course of treatment than
this one. Nearly all tumors of the breast became
malignant, if they were not so from the beginning.
If cancerous from the beginning, they were local at
the start, and should be excised ; it was practically
too late if the capsule was broken and diffusion had
taken place.
Papillary Cystadenoma of the Ovary. — Dr.
John Corcia, of New York, said that the question
as to whether cystic papillary growth were or were
not malignant, or to what extent they underwent
malignant changes, was not fully determined. Cases,
apparently innocent, sometimes had a very rapid re-
currence, proving to be malignant, while in other
cases which clinically presented all the character of
malignancy, the patients had been permanently
cured by operation.. The following case seemed
worth reporting on account of its peculiar fea-
tures. The patient was an unmarried woman,
ihirty-two years of age, a school teacher. She had
been amenorrheic for six months before coming
under examination. Her abdomen had been grad-
ually increasing in size for a year, eventually
reaching such distention as to interfere seriously
with digestion and respiration. She .complained of
no pain, but of weakness and extreme emaciation.
She also had dyspnea and vomiting and was unable
to retain any kind of food. Physical examination
showed the abdomen to be very much distended,
causing enlargement of the costal arch, and there
v.-as considerable quantity of free fluid in the
peritoneal cavity. Vaginal and rectal bimanual ex-
amination were negative, as it was impossible to
locate the uterus and adnexa. Very careful palpa-
tion gave the im.pression of the presence of some-
thing soHd or semisolid in the abdominal cavity, the
origin and nature of which it was quite impossible
to establish. A diagnosis was made of probable
ovarian cyst or abdominal tuberculosis. Laparo-
tomy was done and on opening the abdomen the
case seemed quite hopeless. In the peritoneal cavity
there were about five gallons of clear liquid and an
extraordinary number of cysts of different sizes,
surrounding with racemose disposition a central
and larger cyst containing more than a gallon of
fluid. On the external and internal surfaces of
these cysts were numerous papillomata which ex-
tended also into the peritoneum, intestines, bladder,
and to the ovary on the other side. After tapping
die central cyst, the whole mass was removed. It
originated on the left side, but no trace of the ovary
could be found. The right ovary was also re-
moved. It was studded with papillary growths and
a few small cysts. As much as possible of the
papillomata scattered on the peritoneum and other
organs was removed and the abdomen closed with-
out drainage. The patient had an uneventful re-
covery and after three weeks was able to leave the
hospital. Seven years after the operation she was
still enjoying good health, presented no sign of re-
currence and could be counted among the cases of
papillary cystadenoma of the ovary reported per-
manently cured. Although its histological examina-
tion did not show real sarcomatous or carcino-
matous degeneration, clinically it had to be con-
sidered malignant on account of the ascites and of
the implantation of the papillomatous growths upon
the peritoneum and other organs of the abdominal
cavity ; and of the cachectic condition of the patient.
To explain the pathogenesis of the proHferating
cysts one must remember that their walls are formed
of three layers, the external of fibrous tissue, the
middle of connective tissue, and the internal formed
by a capillary plexus covered by epithelium.
According to VValdeyer, this epithelium was formed
of very short cylindrical cells, but Mallassez and
De Sinety insisted on the polymorphism of these
cells and demonstrated also a subepithelial endo-
thelial layer, proving that on the same type of cyst
the most varied forms of deformed epitheHum could
be found. Besides, they established a certain rela-
tion between the epithelial cells of these cysts and
that of the epithelioma of the breast. Now the
most hybrid forms of degeneration might be found
in such cysts. The main forms, according to
Waldeyer, were the papillary and the glandular, or
both, according as they originated from the middle
or internal layer. When one or both of these forms
existed it was easy to understand how these cysts
might also have a carcinomatous or sarcomatous
degeneration at any moment, presenting a complete
picture of malignancy. While the dermoid cysts
might be quiescent for many years, the papillo-
matous cysts had a marked tendency to multiply,
thus seriously affecting the general health of the
patient. But unfortunately it was not known yet
to what extent these cysts had to be considered
malignant. Even the pathological examination
might fail owing to the limited area of degeneration
in the neoplasm, but when the aff'ection was
bilateral and when the barrier of the fibrous tissue
forming the external layer of the cysts was broken
and there existed ascites and ihiplantation of the
papillary growths on the peritoneum and other or-
gans, they had to be considered malignant and
allied to carcinoma. Some time ago papillomatous
growths were considered as forming a special class
of malignant tumors, and many times it happened
that cases which at operation presented a very ex-
tensive process had been declared inoperable, with
lethal termination.
From a brief review of the reported cases the
following conclusions were reached' l. Papillary
cystic growths should always be considered clinical-
838
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
!y malignant, but operation might give unexpected-
ly good results ; 2, early operation was always de-
sirable when a diagnosis of cyst was made ; and,
3, in the advanced state, when there was ascites
and great emaciation of the patient, the diagnosis
of cyst was difficult to differentiate from a general
cancerous or tuberculous affection of the abdomen.
Dr. Thompson T. Sweeny expressed his com-
plete agreement with Doctor Corcia's views. Cases
of cystadenoma were generally considered to be
due to the ingrowth of superficial germinal epithe-
lium, and classified under two types according to
their chemical contents, the pseudomucous and the
serous, both rather prone to develop papillomata.
There might be only a few papillomatous growths,
or they might fill the whole cyst cavity, authorities
differed very greatly excepting in regard to the fre-
quency with which proliferating cysts of the ovary
tended to degeneration. Schottlander found one
third of them to be malignant and the other two
thirds to be potentially malignant. Pozzi and
McCallum believed that they were not malignant
in themselves. It was well, however, to suspect
every cyst of the ovary of a tendency to become
malignant. Nicholson and Pick reported an autopsy
on a woman sixty years of age with a cystademoma
of the left ovary which was pseudomucinous. It
was entirely benign histologically, but had destroy-
ed the cervix by direct invasion, and the lungs were
studded with metastases which histologically were
identical with cystadenoma. Yet Pozzi and Mc-
Callum stated that these papillomatous growths
never produced metastases, that they were simply
grafts. Regarding treatment, not every ovary or
both ovaries should be removed because a cyst was
found. The proper treatment was operation and
the removal of the cyst as soon as the diagnosis was
made. Rupture of the cyst and freeing the con-
tents should be avoided, for if it contained papil-
lomata it would invite trouble. Then there was the
question of the frequency with which proliferating
cysts of the ovary might recur in the other ovary.
The question, should both be removed, must be
settled by the operator at the time of the operation.
Naturally, he would hesitate to remove an ovary
that was apparently healthy in a woman who wished
to have children.
Syphilis of the Stomach. — Dr. Albert F. R.
Andrf.sen, of Brooklyn, said that until verv recent
years, syphilis of the stomach was considered a
medical curiosity, references to it in the literature
being rare, and the diagnosis in the few cases re-
ported being based either upon autopsy findings or
upon a disappearance of certain gastric symptoms
under antisyphilitic treatment. The use of the
X ray and the Wassermann reaction had made possi-
ble a more certain diagnosis. Writers were still,
however, very much confused in regard to which
cases should or should not be reported as gastric
syphilis. On the one hand they claimed that only
cases demonstrated by microscopic examination
of the suspected tissue should be so reported, where-
as at the other extreme they based their diagnosis
entirely on the clinical cures of gastric symptoms
after antiluetic treatment. Autopsies had revealed
a very small number of cases in which histological
diagnoses of gastric syphilis were made. The pro-
portion of syphilitics with gastrointestinal symptoms
or lesions of various kinds had been reported in the
literature as being from .3 to 2 per cent. Of one
thousand cases studied by the writer, in which
gastrointestinal symptoms were present, seventy
gave a positive Wassermann reaction although only
one was a definite, demonstrable case of syphilis of
the stomach. It was unwise to class all gastric
ulcer cases with positive Wassermann reactions as
cases of gastric syphilis. The symptoms of gastric
syphilis were not characteristic. In general they
depended upon the character and the location of
the lesion. The small localized areas or small
gummata might produce all the symptoms typical
of gastric or duodenal ulcer, namely, epigastric
pain in definite relation to food intake, sour regurgi-
tation, constipation, and, more rarely, hematemesis
or melena. Perforation, acute or chronic, would
give the same, though possibly not quite as severe
symptoms as with ordinary ulcer. Pyloric sten-
osis usually resulted in hypersecretion of a hyper-
acid gastric juice, just as in pyloric stenosis due to
simple ulcer, and was associated with the same
symptoms of pain and delayed vomiting. More ex-
tensive infiltrations of the stomach wall resulted in
reduction of gastric acidity, even to the extent of
a total achylia, with its attendant dyspeptic, diar-
rheal, and hemolytic manifestations. Hourglass
contractions, occurring usually in cases with some-
what more ej^tensive involvement of the stomach
wall, were also attended by the symptoms of sub-
acidity or achylia, as well as the usual vomiting of
this type of stenosis. Perigastric adhesions might
produce symptoms of hyperacidity or hypoacidity,
depending on the extent of involvement of the
gastric mucosa, and the usual symptoms occurred
when stenosis developed. Loss of weight was a
constant symptom in all types of cases, together
with a more or less severe anemia. Other symp-
toms of syphilis occurred coincidentally. While the
gastric symptoms might be very severe, a fatal
termination always seemed a long way off.
The diagnosis of syphilis of the stomach was
difficult and often overlooked. The lesions most
likely to be confused with gastric syphilis were
gastric ulcer or carcinoma. A routine Wassermann
test in all gastrointestinal cases, especially those
showing evidence of gastric lesions, helped to
detect many cases. A strongly positive Wasser-
mann reaction invited further study of the gastric
lesion. A negative Wassermann reaction did not
definitely rule out syphilis, as spirochetas were some-
times found in the tissues in latent cases, with nega-
tive Wassermann reactions. The presence of luetic
lesions elsewhere was suggestive and, in congenital
cases, the family and previous history and the gen-
eral appearance of the patients should be taken into
consideration. The fact that apparently simple
symptoms had not been relieved by ordinary treat-
ment should occasion a suspicion of their specific
origin. An absolute diagnosis could only be made
on miscroscopic examination of tissues obtained at
operation or necropsy, but even here syphilitic
lesions could not always be differentiated from
tuberculosis. Gastric analysis did not aid materially
in the diagnosis. The x ray examination was a
great help in diagnosis, although it only indicated
November 9, 1918.]
BOOK REVIEWS.
839
the size, location, and general character of the
lesion.
The treatment of gastric lues was primarily the
treatment of the lues itself. On the institution of
the antiluetic treatment, especially on giving sal-
varsan, there might temporarily be an irritation of
the gastric lesion, causing an increased swelling per-
haps resulting in increased obstructive symptoms
for a time. As a rule, however, there was an im-
mediate marked amelioration of all symptoms, with
the maximum improvement attained within from
four to six weeks. Pyloric or hourglass lesions
might be cleared up completely, but more frequently
a cicatricial stenosis developed in these cases.
Patients with perigastric adhesions would improve
under treatment, but, would not be cured, while the
cirrhotic type of stomach would necessarily remain
small. The ulcer or gumma cases were probably the
most favorable for treatment, but in these the ulcer
symptoms should not be neglected. The diet should
"be soft, soothing, and concentrated, with frequent
feedings. Demulcents and alkalies might be in-
dicated, and lavage necessary. Rest was important.
Foci of infection in other parts of the body should
be eradicated if possible. Operative procedures
were indicated only in the presence of complications
and should not aim at the radical removal of the
gastric lesion, but should be purely palliative. De-
formities or stenoses, severe hemorrhages and per-
foration required suitable operations, gastroenter-
ostomy being the usual procedure. As a rule, com-
plete and permanent relief from symptoms did not
occur in more than forty per cent, of the cases,
even where the best treatment was carried out.
Dr. William A. Downes said that his observa-
tions in reference to the incidence of this condition
corresponded to those made by Doctor Andresen.
His own opinion was that syphilis of the stomach
was much more common than was usually supposed,
he himself having seen eight cases. It was very
difficult to determine definitely whether a given
duodenal ulcer in a syphilitic patient was syphilitic
or not, but it was better to give the patient the bene-
fit of syphilitic treatment. One of the most com-
mon symptoms of syphilis of the stomach was ex-
treme loss of flesh. These patients lost in propor-
tion more flesh than any other stomach cases.
One of the patients, a woman, went down from 150
to seventy-five pounds. It was a nonoperable case,
but, treated with salvarsan and mercury, the
patient's weight was doubled in three or four
months. The pathological findings had been very
unsatisfactory. The treatment depended upon the
stage in which the case came under observation.
If there were infiltrating ulcerations before cicatri-
zation had taken place and there was no obstruc-
tion at the pylorus, only medical treatment was de-
manded. Operative treatment became necessary
to relieve the symptoms due to obstruction as shown
by loss of weight, nausea, and vomiting. In five of
the eight cases the patients had been entirely re-
lieved of symptoms, had gained in weight, and were
following their usual occupations. Doctor Downes
believed that it was inadvisable to defer operative
treatment for any length of time, but antisyphilitic
treatment was justified for a short period before
resorting to operation.
Dr. Robert Coleman Kemp expressed his inter-
est in the subject of syphilitic stenosis and presented
some radiographs of cases similar to those shown
by Doctor Andresen. It had been his experience
that in the tertiary stage of syphilis there was gen-
erally a deficiency or absence of hydrochloric acid
and this was to be expected on account of the
fibrosis of the liver, spleen, pancreas, or stomach.
As Doctor Andresen said, there might be a fair
amount of acidity, but generally in the progressiv*;
cases that had lasted for some time the findings had
been very much those of cancer. One did not often
find carcinoma developing upon a syphilitic ulcer,
and when an ulcer of the pylorus or duodenum was
determined to be syphilitic it seemed preferable to
leave it alone. As far as diagnosis was concerned,
a positive Wassermann and the clinical symptoms of
syphilis would be conclusive. There were gastric
cases with tertiary syphiHs and cases of arterio-
sclerosis with a history of syphilis and positive
Wassermann, or with spirochetes in the blood.
They did very well under antisyphilitic treatment.
The speaker agreed with Doctor Andresen that
these cases should be carefully studied and given
the benefit of the doubt before resorting to
surgery. In many cases, however, a gastroen-
terostomy was necessary for the relief of condi-
tions advanced too far for other therapy.
Dr. Tasker Howard, of Brooklyn, said that in a
series of 100 syphilitic patients, he had found only
four with any digestive symptoms. One was in the
secondary stage and had symptoms of gastric ulcer.
The other three were suffering from tahts dorsalis
(To be continued.)
<^
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to revtcii' them all. Nevertheless, so
far as space permits, we rei'iew those in which we think
our readers are likely to be interested.^
Surgery of the Spine and Spinal Cord. By Charles H.
Frazier, M. D., Sc. D., Professor of Clinical Surgery
and Surgeon to Hospital of University of Pennsylvania,
Philadelphia. With Six Colored Plates, Two Charts,
and Three Hundred and Seventy-eight Illustrations in
the Text. New York and London : D. Appleton & Co.,
igi8.
In reading through this book, one is most favor-
ably impressed by several features. In the first
place, the book work is very good, the illustrations
are excellent, both as drawings and because they
illustrate so well the points under discussion.
Moreover, the book is founded on the personal
experience of the author and his collaborators.
There is practically nothing copied from other
books, although frequent references are made to
the work of other writers.
A valuable feature is that the anatomy of the
spinal column and its contents is clearly and con-
cisely given. There is an interesting chapter on the
cerebrospinal fluid, which brings up to date the
results of recent investigation, and a clear exposi-
tion is made of the bearing of variations in the
spinal fluid, both as to quantity and quality, upon
the probable cause of the lesions in the spinal canal.
840
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Joukkal.
In addition, there is given in detail the method by
which each of the tests is to be made. The method
of intraspinal treatment is also given in detail. The
anatomical relations of the spinal segments to their
surroundings and to their peripheral connections
are given in a way that is more easily understood
than is usual in the majority of textbooks, and the
question of reflexes and the influence upon the re-
flexes of injuries to the spinal cord is put forth
very clearly.
The chapter on rontgenology of the spine warns
of the necessity for a careful reading of plates.
Errors that are common because of distortion of
the rays are pointed out and a good working idea
Df hoAv to read x ray plates of the spine is given.
Every surgeon who handles cases of spinal disease,
or injury, should be able to interpret the plates
himself, in order to do his full duty by his patient,
and he will be greatly helped by a careful reading
of this chapter.
Perhaps the most interesting chapter in the book
is the one on fractures and fracture dislocations
with injury of the cord. The experimental work of
Allen on cords of dogs gives the only rational
foundation for treatment in these cases, and while
the indications seem clear, there still is, and prob-
ably will be for some time, a great deal of argu-
ment as to the desirability of applying the deduc-
tions from experimental dog work to the treatment
of human beings, who have suffered from injury to
the spine, with associated cord lesion. In the
human beings, it is usually impossible to attempt the
exposure and splitting of the cord within the period
of three or four hours, which seems to be the time
limit before edema and hemorrhage have caused
serious damage to the cord substance. While the
work here quoted gives a most helpful and hopeful
turn to the perennial discussion as to the best treat-
ment of these injuries, it will be necessary for some
one to have a series of cases, so as to operate in a
portion of them and keep the others tentatively as a
check to determine just how far Allen's procedure
is applicable to the human subject, under the con-
ditions that usually obtain.
One could take up each chapter in detail and find
much to praise definitely, and little if anything, to
criticise adversely. There are a few typographical
errors, which change the meaning of the context
somewhat, but these errors are discounted in the
immediately related context, so that one can, in
those few instances, avoid misunderstanding of the
author's meaning.
On the whole, one is driven to feel that the book
is a very marked accession to spinal surgery, and
every man who is interested in that work should
have the book handy for reference.
<t>
Births, Marriages, and Deaths.
Died.
Artigues. — In San Francisco, Cal., on Tuesday, October
22d, Dr. Joseph Emile Artigues, aged fifty-five years.
Beck. — In Asbury Park, N. J., on Saturday, October 19th,
Dr. Murray D. Beck, aged twenty-seven years.
Brown. — In Houston, Texas, on Friday, October 25th,
Dr. Herbert Eddes Brown, aged forty-three years.
Bryant. — In Carpenter, Ky., on Friday, October 25th,
Dr. William M. Bryant, aged forty-two years.
BuRDicK. — In Oneonta, N. Y., on Monday, October 21st,
Dr. Lewis W. Burdick, aged thirty-seven years.
BuRK.';. — Tn Fresno, Cal.. on Monday, October 21st. Dr.
William Tillman Burks, aged sixty years.
Connors. — In Shelton, Conn., on Thursday, October
24th, Dr. Thomas A. Connors, aged twenty-eight years.
Gorrill.— In Buffalo, N. Y.. on Sunday, October 27th,
Dr. George W. Gorrill, aged forty-one years.
Grosvenor. — In New York, N. Y., on Tuesday, October
29th, Dr. Robert Grosvenor.
Hanson. — In Los Angeles, Cal., on Saturday, October
26th, Dr. Wayne P. Hanson, aged thirty years.
Hawley. — In an Army Hospital, in France, on Friday,
October 4th, Lieutenant Franklin M. Hawley, M. C, U. S.
.A.rmy, of Mercer, Wis., aged fifty-five years.
Hawley. — In Georgetown, Mass., on Monday, October
28th, Dr. John Winthrop Hawley, aged thirty-one years.
Heyen. — In Northport, L. I., on Wednesday, October
30th, Dr. John P. Heyen, aged sixty years.
HoRTON. — In Edgerton, Wis., on Saturday, October 5th,
Dr. Clyde Switzer Horton, aged forty years.
Hull. — In Little Rock, Ark., on Saturday, October 19th.
Dr. Eugene F. Hull, aged thirty years.
Kaufman. — In New York, N. Y., on Monday, October
28th, Dr. Joseph D. Kaufman, aged thirty years.
PCeen. — In Philadelphia, Pa., on Wednesday, October
23d, Dr. James Watt Keen, aged fifty-six years.
Ker.— In New York, N. Y., on Friday, October 2?;th.
Dr. John E. Ker, of Kingston, Jamaica, aged fifty-eight
years.
Kitson.— In Yonkers, N. Y., on Saturday, October 19th,
Dr. Frederick H. Kitson, aged thirty-five years.
L'Africain. — In Hempstead, N. Y., on Monday, October
28th, Dr. Urban L'Africain, aged twenty-eight years.
Lane. — In Boston, Mass., on Tuesday, October 29th, Dr.
Francis A. Lane, aged fifty-two years.
McEwen. — In Summerside, Prince Edward Island, Can-
ada, on Wednesday, October 23d, Dr. Henry E. McEwcn,
aged fifty-four years.
McKay. — In Salem, Mass., on Tuesday, October 29th,
Dr. Andrew J. McKay, aged forty-four years.
Meyer. — In Brooklyn, N. Y., on Thursday, October 24th,
Dr. David W. Meyer, aged forty-eight years.
Miller. — In Millersburg, Ky., on Friday, October 25th,
Dr. William A. Miller.
Norris. — In Florence, Italy, on Tuesday, October 22d, Dr.
Isaac Norris, of Philadelphia, aged eighty-four years.
Olander. — In St. Paul, Minn., on Friday, October 25th,
Dr. Edwin Olander, aged forty-one years.
OzMENT. — In Fort Smith, Arkansas, on Wednesday, Oc-
tober i6th. Dr. Samuel J. Ozment, aged fifty-two years.
Palomeque. — In New York, N. Y., on Thursday, Octo-
ber 31st, Dr. Jose Palomeque, aged seventy-five years.
Reid. — In Roebuck Springs, Ala., on Friday, October 25th,
Dr. L. E. Reid, aged thirty-five years.
Rush. — At Camp Merritt, N. J., on Friday, October
25th, Dr. Playford L. Rush, of Englewood, N. J., aged
twenty-nine years.
Samelson. — In Fresno, Cal., on Saturday, October
19th, Dr. S. Samelson, aged eighty vears.
Schallern. — In Ripon, Wis., on Monday, October 21st,
Dr. Ottman Schallern, aged seventy years.
Schwartz. — In Fresno, Cal., on Monday, October 21st,
Dr. Edward I. Schwartz, aged twenty-seven years.
Stahl. — In Brockton, Mass., on Sunday, October 27th,
Dr. Alfred F. Stahl, aged fifty-two years.
Stephens. — In Gardiner, N. Y., on Wednesday, October
30th, Dr. M. E. Stephens, aged fifty-five years.
Thompson. — In Lakewood, N. J., on Monday, October
14th, Dr. Otto C. Tliompson, aged forty-two vears.
Turner.— At Fort Oglethorpe, Ga., on Sunday, October
20th, Lieutenant Ralph Waldo Turner, M. C, U. S. Army,
of Troy, N. Y.
Vest. — In Clarksville, Va., on Friday, October 25th, Dr.
William Waller Vest, aged forty-eight years.
Webb. — In Winlock, Wash., on Monday, October 21st,
Dr. William Walter Webb.
Whitehead. — At Hoosick Falls, N. Y., on Monday, Oc-
tober 28th, Dr. Ira Conduit Whitehead, aged thirty-two
years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII. No. 20. NEW YORK, SATURDAY, NOVEMBER 16, 1918. Whole No. 2085.
inal Communications
OPERATION FOR SENILE CATARACT.
Some Personal Experiences.
By Frank Allport, M. D.,
Chicago.
This paper is not intended to present any new
facts concerning operations for senile cataract. I
desire merely to outline my own personal views on
the subject ; to tell what methods I like best, and
what procedures have given the most satisfactory
average results in my hands. I do this because the
profession is somewhat at variance as to the best
methods of operating, and the long experience of
any man of average ability, experience, and surgical
skill must be of more or less value in its influence.
It is only by the frank and honest exchange of per-
sonal views and the surrendering of desired and
brilliant, but perhaps impracticable technic, that we
shall ever find our feet restmg on solid ground and
the cataract operation placed in a secure position,
from whence it cannot be disturbed except by strong
and indisputable evidence.
The object of this paper is to narrate in a simple
manner my own method of operating; not that 1
consider it better than other methods, but it is
merely the routine that I have found most sati.^-
factory to me. Other operators have other methods
that very likely are better than mine, methods tha:
seem to suit their particular needs, and it would be
a mistake for them to change unless they sincerely
desired to do so. Neither shall I attempt to go into
details concerning all the steps of the operation, as
this would obviously be almost intrusive, as there
are, of course, some things that everybody does —
no matter what may be their practice in other re-
spects.
In the first place, I never operate upon more than
one eye at a time. Patients should be in the hospi-
tal twenty-four hours before a cataract operation is
performed. By so doing they become accustomed
<"0 their surroundings, are more quiet, and will act
better on the operating table. The bowels should
be moved gently and a careful diet prescribed, so
that indigestion will not be troublesome after the
operation. Besides this, the eye should be carefully
pi-epared for the ordeal by being irrigated three
times a day with a one in lo.ooo bichloride solution,
followed by the use of White's bichloride ointment,
which has the following formula :
Mercury bichloride, i gr. ;
Atropine sulphate .30 gr. ;
White petrolatum .-^000 gr.
An hour or so before the operation the pupil
should be dilated with atropine and the lashes should
be gently but firmly scrubbed with one in 10,000
bichloride solution and gauze, to get them as clean
as possible. The entire face — the eyes, the brows,
etc.— should be well cleansed, and after the patient
is on the operating table the face should be again
washed, the eye irrigated, and the lashes and eye-
brows gently scrubbed.
It is better to perform the operation on the bed
where the patient is to lie, or perhaps in the same
room or ward or, at least, to have the patient
moved as little as possible after the operation. If
the patient is moved from an operating room to a
private room or ward, the moving should be done
as quietly as possible and superintended by a reli-
able and conscientious person. The patient should
not help himself at all.
I always wear thin, tight fitting, rough surfaced
gloves. The operation is much safer and I can
handle delicate instruments perfectly well with
them on.
Good illumination of the field of operation is
essential to the best operating. I prefer a hand
electric light with condensor, and a glazed globe.
Besides this, a trained assistant focuses accurately a
large convex lens on the eye, between the hand
light and the eye. My associate, Dr. James Smith,
has devised what I consider to be the best light for
cataract operation that 1 have ever seen. He
has merely taken a Ziegler hand lamp and fastened
it to an arm that projects out beyond the light. To
this arm is attached a roundish concaved bifurca-
tion, into which can be slipped any strength of con-
vex glass to be found in a trial case. This glass
slips in the bifurcation just as a glass is slipped
into a trial frame. In this way a stronger or weaker
glass can be inserted and a corresponding focus of
intense illumination thrown accurately upon the eye.
I like the hand lamp much better than the stationary
lamp, as you can put it wherever vou want it. This
addition to the Ziegler light, devised by my asso-
ciate. Doctor Smith, produces an ideal illumination
for a cataract operation.
All water used for cleansing and irrigating should
be warm. It should not be dropped on the eye
from a distance, as this startles the patient and may
make him jump, which would be especially un-
fortunate after the eye had been opened by the
incision, as under these circumstances jumping and
squeezing of the eye might be very unfortunate.
The speculum should be introduced gently and the
Copyright, 1918, by A. R. Elliott Publishing Company.
842
ALLPORT: OPERATION FOR SENILE CATARACT.
[New York
Medical Journal.
patient told what is being done. Be careful not to
press on the arms of the speculum. Teach the at-
tendants and the patient to keep quiet, and reassure
the patient by a friendly word once in a while,
telling him what is being done so he will not be
taken by surprise.
^^'hen the initial puncture of the incision is -made,
the handle should be elevated a little so that the
knife does not pass between the corneal layers, but
directly through them all. When the counter punc-
ture is made in the opposite side of the cornea, the
handle should be somewhat depressed, as otherwise
the knife is liable to pass too deeply into the eye
and into the sclera.
I use a solution of one per cent, holocaine with
four per cent, cocaine, and I always put a drop in
the eye not operated upon, as it induces more ocular
quietude. If a conjvmctival flap is made, a few
drops of adrenalin should be used, as otherwise
considerable hemorrhage will occur, which may
flow into the anterior chamber and embarrass the
operator and lessen the chance of a successful re-
sult. A conjunctival flap lessens the chance of in-
fection and hastens healing. Before the iris is cut,
a drop of the holocaine and cocaine solution may be
dropped upon the incision, which will obtund sensi-
bility. The patient should be told that this step in
the operation may be a little painful, and he should
be cautioned not to jump Where it is possible, T
very much prefer to make a preliminary iridectomy.
I am confident that this renders the cataract extrac-
tion much safer and surer. There are several rea-
sons for this opinion. In the first place the attack
on the eye is divided into two parts : first, the iridec-
tomy, and second, the removal of the lens. It is
easier to recover from a thus divided assault than
if both are done at the same time. Besides this, if
the iridectomy is done separately, there is very
little and sometimes no hemorrhage when the lens
is removed, which of course greatly facilitates the
operation. Another important reason for a pre-
liminary iridectom^y is, that a patient, by having
once gone through the iridectomy operation always
behaves better when the real cataract operation is
performed. I might say at this juncture that I con-
sider the cataract operation with an iridectomy a
safer and surer operation than the operation with-
out an iridectomy and for this reason I always make
an iridectomy.
The iridectomy should be as small as possible and
this can be done by holding the scissors vertically,
instead of horizontally. After tiie iridectomy, I
take out the speculum, as this renders the escape
of vitreous much less likely to occur. I then pull
up the upper lid v/ith a strabismus hook and rupture
the capsule with the cystotome, which should always
be very sharp so that the capsule can be easily and
accurately ruptured. The assistant pulls down the
lower lid with his finger. In this way the eyelids
are freely opened without pressure on the eyeballs.
I then press upon the lower portion of the cornea
with a spoon, to gently coax the lens from its bed
and at the same time gently press upon and depress
the posterior lip of the incision with another spoon
in order to open the wound and encourage the
escape of the lens, which should always be slowly
and not suddenly delivered.
For the last few months I have been using the
lid elevators of my friend. Dr. W. A. Fisher, of
Chicago, instead of a speculum, and wish to say
that 1 regard them as infinitely superior to any
speculum that has ever been devised for a cata-
ract operation. An assistant inserts one elevator
under the upper lid and another under the lower
lid. The two elevators are then gently but firmly
separated and raised, thus opening the palpebral
space to its fullest capacity. This provides a wide
operative space and at the same time maintains a
control over the lids, orbicularis muscle, etc., un-
obtainable in any other manner. The danger of
winking, lid movements, etc., is thus eliminated and
the operation, therefore, made just so much safer.
The assistant, while spreading the lids apart by the
elevators, should at the same time lift the lids from
the eye, thus preventing all pressure on the eyeball
and very much lessening the liability of escaping
vitreous. The freedom from this accident renders
the expulsion of the lens much easier and safer. If
the anterior chamber is irrigated, it can be done with
much greater assurance and safety than by any
other method. I leave the elevators in until the
end of the operation and then gently remove them.
Great care should be taken that the upper lid and
lashes do not pass into the corneal space made by
the incision. This might produce infection. In case
the lens seems too large for the incision, its forcible
exit should not be encouraged, but the incision
should be carefully enlarged by small, curved, round
pointed scissors.
After the lens has been delivered and any remain-
ing lens substances gently stroked out (that can
safely be delivered), I carefully wash out the
anterior chamber with warm, sterile, normal salt
solution with a specially devised irrigator. This
consists of a rubber bulb, large enough to fit the
hand. The rubber should be of the best quality —
soft and pliable — and should not flake so that
particles from its interior can be found in the solu-
tion. Some years ago I devised this irrigator and
had it made with a glass end, about the same shape
as a strabismus hook, only flattened in such a direc-
tion that the hand enclosing the rubber bulb could
be at the side of the patient, instead of above the
eye. which is always a constrained position from
which to operate a bulb with a bent end. The glass
end proved to be difficult to make correctly and uni-
formly. Besides this, it broke easily and was a
source of considerable annoyance. I therefore had
an end made of gold and since then have had no
trouble with the irrigator. It is a perfectly satis-
factory anterior chamber irrigator. Not much
force should be used. Loss of vitreous should be
borne in mind and air bubbles should be ejected
from the irrigator before it is used. In an unman-
ageable patient, I sometimes am afraid to use the
irrigator, as a sudden upward turn of the eye, or a
quick motion, might inflict irreparable damage. I
prefer to leave some cortical substance and take care
of it afterward by a needling or some similar opera-
tion, if it proves to be necessary. I take great care,
however, to free the incision of all debris. The
pillars of the coloboma should be carefully replaced
by a spatula with stroking movements outside the
cornea, if possible, inside the cornea, if necessary.
November i6, 1918.]
SA'VDER: SPANISH INFLUENZA.
843
The bichloride and atropine ointment is then placed
inside the lids with a probe and a suitable dressing
over both eyes is applied. An aluminum shield is
also placed over both the eye which has been oper-
ated upon and the slightly covered eye. For two or
three days only the eye which has been operated
upon is protected.
The patient is given a chloral hydrate and bromide
of potassium mixture at bed time for one or two
nights to insure rest. The hands are gently tied with
a bandage cloth to the foot of the bed for a few
nights, and if possible, the services of a day nurse
and night nurse are secured for nearly a week to
watch the patient constantly and administer to his
needs. Immobility of the bowels for two or three
days is secured by giving a small dose of morphine
hypodermically. I then give a mild laxative.
I trust I may be pardoned for dwelling upon these
simple details of the management of cataract cases.
It may be borne in mind, however, that such opera-
tions are essentially a chain of small, fussy, details
and that the operator who most carefully ob-
serves details will, other things being equal, obtain
the best results. I also request that these frag-
mentary notes shall not be regarded as a description
of the cataract operation. They are merely intended
to convey to your minds some of the details that I
have found useful in my operative work.
7 "West Madison Street.
SPANISH INFLUENZA.*
Its Treatment by the Use of Intravenous Injections
of a Xonhactcrial Split Protein.
By R. G.\rfield Sx\'der, M. D.,
Xew York,
Assistant Professor of Clinical Medicine, College of Physicians and
Surgeons; Attending Physician, City Hospital.
The writer's first experience with the intravenous
use of a foreign protein, in the combating of an
acute infection, was gained in 191 5. In that year
a typhoid vaccine was used at the City Hospital in
'Manuscript received November 4, 1918.
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844
SNYDER: SPANISH INFLUENZA.
[New York
Medical Journal.
an effort to check a local epidemic of typhoid fever.
Many brilliant results were obtained, of which
Chart 1 is an example, but at the time tlie severity
of the chill and the danger of its causing a fatal
perforation had the effect of dampening our en-
thusiasm for this form of treatment. It was later
ascertained that this danger was largely confined
six months, treated another series of arthritic cases
— acute and chronic — with intravenous injections of
a secondary proteose prepared from milk^ instead
of the bacterial protein mentioned above. The re-
sults from the secondary proteose preparation have
been equallly good or better than those from the
typhoid vaccine and serve to further illustrate the
97°
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Chart II.
to cases in which the treatment was delayed until
the third week of the illness.
It was assumed, at that pioneer period, that the
beneficial results were due to the action of a specific
vaccine, but during the past year I have seen case
after case of acute rheumatic fever abruptly termi-
nated by the use of this same stock typhoid vaccine,
as recently reported in a paper (i) devoted to the
subject (Chart II). The results of these later
studies clearly indicated that improvement could not
be due to specific causes.
In continuance of this clinical experimentation,
and by way of comparison, I have, during the past
nonspecificity of this type of therapy and the inter-
changeability of the source of protein which may
be used.
Having in mind these experiences with two types
of infection treated with two forms of a nonspecific
protein, I was encouraged in the early part of the
epidemic to consider the possibilities of the applica-
tion of this form of nonspecific therapy in the treat-
ment of Spanish influenza, also as a prophylactic and
immunizing agent. This appealed to me as a ra-
tional procedure. In any event the necessity for
'.Secured throush the courtesy of the research laboratories of
Tile -'\rlington Chemical Corrpany.
November i6, 1918.]
SNYDER: SPANISH INFLUENZA.
845
some direct method of combating this infection was
accentuated by the lack of success of the ordinary
routine treatment.
Acting on this hypothesis, I have treated during
the past month a small series of influenzal cases by
the intravenous injection — occasionally subcuta-
neous— of a nonspecific, nonbacterial protein split
As pointed out editorially in the New York
Mkdical Journal for November 2d various preven-
tive vaccines are being tried, but so far the results
have beep inconclusive. This editorial opinion em-
phasizes my contention that the beneficial results to
be obtained by this form of treatment in influenza
or other infections are in no way due to the use of
Day ol Month
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Chart III.
product, namely the milk proteose mentioned above.
The results have been most satisfactory, as shown
in Charts III and IV. Twenty cases have been
treated so far without a fatality. Twelve had a
general influenzal infection, while eight presented
typical pneumonic symptoms and physical signs. It
is obvious that in resorting to this secondary pro-
teose, no attempt was made to use specific treat-
ment.
I am aware, however, that attempts have been
made to obtain a specific vaccine, made from dead
influenza and associated bacteria, and that prepara-
tions of this nature have been tried to some extent
by physicians, especially in the army.
a specific agent or vaccine. To the contrary, the
results are in fact due to the use of a nonspecific
foreign protein which, as explained in the paper
previously referred to (i), may be bacterial, animal,
or vegetable in origin.
The easy accessibility of a typhoid or other bac-
terial vaccine to the general practitioner, together
with the equally easy regulation of the dose by
numerical count, has commended the use of this
form of foreign protein to many physicians. How-
ever, when obtainable, a secondary proteose — simi-
lar to that used with the influenzal cases reported
herein — is preferable to the bacterial protein of a
typhoid or other vaccine, for the following reasons :
846
SNYDER: SPANISH INFLUENZA.
[New York
Medical Journal.
1. A secondary proteose preparation is free
of bacterial toxins.
2. It is equally free of any toxic peptone
which is, with difficulty, dissociated from bac-
terial proteins, owing to their method of
preparation and incident to the culture media
used.
In view of this irregularity of numerical and
nitrogen content of the bacterial vaccine, it follows
that the amount of protein in the bacterial dose
must vary considerably. This lack of uniformity
probably explains the occasional failure to obtain
the expected reaction for a given dose when the
bacterial type of foreign protein is used.
Da; oi Month
/7
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/9
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100°
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Chart IV.
3. It eliminates the danger of anaphylactic
shock (2).
4. Finally the dose of a secondary proteose
preparation can be accurately standardized by
nitrogen content.
By contrast, the estimation of the dose of typhoid
or other vaccine by bacterial count can be but ap-
proximate. This because there is a relatively large
margin of error in counting bacteria, as is admitted
by competent bacteriologists (3). Further, the per-
centage of nitrogen in the cellular substance of
microorganisms is not constant and has been shown
by Vaughan (4) to "vary from 5.964 in subtilis to
11.765 in violaceous."
For the sake of brevity there has been no attempt
in this paper to review the theories or cite the
literature on nonspecific therapy.
The above ideas, suggestions, and clinical results
are ofifered in the hope that they may prove of time-
ly value to physicians in their present dilemma,
and, in addition, contribute to the successful treat-
ment of acute infections in the future.
REFERENCES.
I. R. G. SNYDER: A Clinical Report of Nonspecific Protein
Therapy in the Treatment of Arthritis, Archives of Internal Med-
icine, August, IQ18, xxii, pp. 224-233. 2. OSBORNE and WELLS:
The Anaphylactic Reaction with So Called Proteoses of Various
.Seeds. The Biological Reactions of the Vegetable Proteins, Journal
of Infectious Diseases. July, 1915, p. 259. 3. G. H. McCOY:
Hygienic Laboratory Bulletin. No. 110. 4. VICTOR C. VAUGHAN.
Poisonous Proteins, Mosby Company, St. Lojis.
November i6, 191 8.]
TIYLOR: INFLUENZAL PNEUMONITIS.
847
THE TREATMENT OF INFLUENZAL
PNEUMONITIS.
Remarks on Accessory or Sitpplcinciital Measures.
Bv J. Madison Taylor, A. B.. M. D.,
Philadelphia. Pa..
Professor of Applied Therapeutics. Temple University, Medical
Department.
From experience, observation, and a review of
niuch data accruing from the recent influenza
pandemic, I am led to mention certain remedial
measures which deserve and have gained confidence.
Only accessory or supplemental agencies are con-
sidered. These, or many of them, may be strongly
recommended as aiding and reinforcing the effects
of medicaments. Used alone, as 'home remedies,"
they aften go far in turrfing the tide toward recov-
ery and economic convalescence. For any form of
pneumonitis they hold good and may be epitomized
as follows :
Rest. — Any or every infection demands rest, as
the first consideration, to prevent aggravation and
complication. This is equally true of surgical in-
fection. At the oncoming of a pneumonitis rest
must be immediate and absolute ; no tampering, no
postponing, no modifying. A chill — other than that
inevitable to exposure to sudden or unusual cold —
portends some serious perturbation of functional
balance, and must not be disregarded. A chill or
chilliness is the characteristic portent of pneu-
monitis. Any one who experiences this, disregards
it. and survives (as I did), will have learned a valu-
able lesson. Rest must be complete. During active
stages no sitting up should be allowed, not even for
examination. I have seen men otherwise perfectly
vigorous and healthy die from this exertion alone.
Posture is most significant in pneumonitis. The
side chiefly afi'ected is down and the competent side
up, but this attitude should be changed occasionally
for short periods. Lying constantly on the back
should be discouraged. The head of the patient
should be toward the light but not facing a window.
Constant glare in the eyes is a severe strain. Only
in this attitude with the eyes protected can the pa-
tient be free to assume conservative postures. The
reasons for avoiding upright or sitting postures are
many and based on biophysics. Among them are
the condition of the blood, which is overviscid ;
stagnation in and extra weight of the lungs, hence
the drag of dependent and weakened organs on the
diaphragm ; irritation of the splanchnic branches of
the vagus; the heart (myocardium) being seriously
overburdened, peripheral resistence is often so com-
plete as to inhibit circulatory distribution.
Cleansing of the alimentary tract. — This is pecu-
liarly important in pneumonitis and tlie colon should
be at once irrigated, slowly, with one quart of warm
water, to which has been added half an ounce (one
heaping tablespoonful) each of sodium chloride and
sodium bicarbonate. Soap may be added if desired
and also any emergency drug which may seem in-
dicated. The main purpose of the saline irrigation
is to cleanse the lower bowel and supply the loss of
sodium chloride by absorption, and to supply
sodium bicarbonate to the kidnevs to act as an
alkaline diuretic. In my judgment any laxative
irritates and is of questionable value. It also hur-
ries the half digested food out of the tract. Even
saline laxatives, while partly efficacious, fail to serve
the manifold purposes of the alkaline colon irriga-
tion. Diuresis is thus efl'ected most efficiently, and
relief to the kidneys is of the greatest value.
Calomel is only incidentally a laxative ; it is used for
other and excellent reasons, and is best supple-
mented by an enema, not by a cathartic.
Revulsion. — This is of great importance as all
experienced clinicians know through a certain and
reliable knowledge. The long discarded poultice or
mustard pack served excellent purposes, but better
means are now at hand. The best form of revul-
sion, in my judgment, is that powerful home
remedy, ironing the back. In pneumonitis there is
often such disturbance of the vasomotor system
and sweat glands that experience shows the peculiar
value of a damp woolen cloth or bit of blanket
applied to the bare back and ironed by a not too hot
flat iron, lifting promptly from contact with the
skin when it burns and continuing for five or six
minutes. This will effect more of good than any
other available revulsive, causing free sweating, and
relieving the backache, headache, dry mouth, and
the stagnation in the lung structures.
Dry cupping is efficacious and strongly endorsed.
A much simpler method of achieving local hyperemia
and revulsion is by subdermal traction, a lifting and
pulling of the skin by the hand from the under-
lying structures all up and down the back, especially
from the fourth to the ninth thoracic vertebrae, and
all over the lateral areas, stimulating subsidiary
sympathetic (vasomotor) subcentres. This, while
painful at first soon ceases to be so, and can be
repeated to advantage every hour or two by the
nurse. The effects are just as emphatic as by Bier's
hyperemic cupping. It will often promptly reduce
or check cough. iJuring the later stages and con-
valescence, much of the cough is due to irritation
of the pharynx and is to be relieved by application
of ten per cent, aqueous solution of argyrol or pro-
largol or cargentos, and yet later by the iodine,
iodide of potasium in glycerin mixture commonly
used by laryngologists, carried well down the
trachea.
Delirium, which so often accompanies pneu-
monitis, causes more disasters, or even deaths, than
clinicians realize. There is good ground for the
opinion, certainly ample warranty for the suspicion,
that most persons in the early stages of lung or
typhoid or other febrile processes, are thereby ren-
dered so confused as to be incapable of appreciat-
ing the seriousness of the situation. There is
usually, perhaps always, mental bev/ildennent which
so impairs judgment that follies are committed, the
most common of which is refusal to take reasonable
precautions. I could relate many illustrative in-
stances since my own eyes were opened by a per-
sonal experience wherein, during the onset of sharp
influenza two or three years ago, I was plainly
conscious of the fact of chills, discussed them with
myself, but being exceptionally busy was incapable
of rightly assessing the value of the observation and
was soon ignominiously landed in bed guarded by a
nurse. A physician on one occasion was conferring
848
KOUTH: MEDICAL SUPERVISION DURING PREGNANCY.
[New York
Medical Journal.
with me on a matter in my office, when I remarked
that he was looking seedy. He athnitted he was
droopy but insisted that nothing was wrong, till I
took his temperature which was 106° F., and per-
cussed his lungs, both of which were so solid that
he could hear the board like pitch.
Suffice it to say any careful clinician should keep
this peril of mental confusion prominently in the
foreground and mstitute treatment for the condi-
tion as well as the vmderlying one. Every wise
person should keep in nnnd the gravity of disre-
garding the plain warning given by v chill as well
as the psychopathy which follows.
It should be a common rule of conduct in all
fever states to go at once to bed and seek expert
advice especially when infections prevail, otherwise
death may ensue and too often does. When mental
confusion is recognized quieting measures are re-
quired. One of the most efficacious measures is the
neutral immersion bath, or tepid soaking in water
at 100° for twenty minutes or so long as comfort-
able. I believe many a life would be saved by
observing so simple a measure, accompanied by a
saline enema, hot drinks, and some sedative medica-
ment. A chill is due to a prolonged perturbation of
function, and calls imperatively for external heat,
and the best and most available relief is a hot bath.
Trypsin, to carry on oxidation, must be fortified
by heat. When delirium persists repeated warm
affusions are indicated, tepid sponging or hot packs
or the heat and pressure of the flatiron over a damp
blanket along the bare back. The violently delirious,
struggling patient often dies, and this fatal result
in pneumonia is more than probably due to the in-
tense overexertion. Thus psychogenic perturbation
comes to be recognized as of the deepest significance.
The significant fact should be always considered
that the sodium chloride loss in pneumonitis is enor-
mous and should be supplied. This is best done by
adding salt in the proportion of normal salt solution
to all drinks at all times.
One final admonition as to care in convalescence
from pneumonitis or any infection. Here again
success or economic care becomes an equation be-
tween the full appreciation by the physician of the
absolute need for abundant rest and time and con-
sistent rebuilding reconstructive measures.
A Rapid Means of Nitrogen Determination in
Blood and Urine. — During a period covering
many years physicians and chemists have endeav-
ored to discover an efficient inhibitor of the foam-
ing tendency associated with the rapid estimation
of the ammonia in urine and blood — brought out
particularly in chemical and microchemical analy-
sis of the latter, especially in instances when the
percentage of the glucose content is abnormal. The
difficulty has been met in the discovery of a new
product, which has been called caprisol and which
has been made available by New York chemists,
Antoine Chiris Co. The addition of a few drops of
caprisol to blood and urine solutions stops effec-
tually any tendency to foam, and thus eliminates
a very annoying feature 'connected, heretofore,
with microchemical determinations.
THE NEED FOR MEDICAL SUPERVISION
DURING PREGNANCY.*
By Amand Routh, M.D., F.R.C.P.,
London,
Consulting Obstetric Physician, Charing Cross Hospital.
Of the infants who die in England and Wales,
(luring their first year of life, about one fourth
die during their first month of life from "causes
connected with birth." This represents about
twenty-five deaths per 1,000 births, and to this must
be added stillbirths and abortions, which are be-
lieved to be about thirty and 120 per 1,000 births
respectively, say 175 per 1,000 in all. So that more
than one in six children die between their concep-
tion and one month after birth from '"antenatal
causes or causes connected with birth." When it is
thankfully remembered that only four women per
1,000 births die as a result of these "causes con-
nected with birth,'' the enormous difference is at
once seen. One mother dies in 250 confinements,
while one child loses its life for every six children
who reach one month of age, or over forty children
die to every one mother, for apart from causes con-
nected with childbirth very few women die during
pregnancy.
Why should the embryo, the fetus and the one
month infant die at this rate, 175 per 1,000 births?
Because the fetus, and still more the early ovum,
has but a small measure of resistance to maternal
diseases, such as antepartum hemorrhage, toxemia,
syphilis, malnutrition, all of which affect its early
development stages. These conditions may lead to
very early death and expulsion of the ovum, often
entirely unrecognized as such by the mother and
attributed to a functional delay. If every pregnant
woman were under medical observation, many of
these and other maternal causes of fetal death
would be eliminated. Doctor Ballantyne has sug-
gested that infantile deaths during the first month
of life should be called "neonatal" mortality.
Statistics seem to show that the following are
approximately the average percentage causes of
antenatal, natal, and neonatal infantile mortality.
APPROXIMATE PERCENTAGE CAUSATION OF ANTENATAL,
NATAL, AND NEONATAL INFANTILE DEATHS.
Syphilis per cent. 20
Toxemia " 10
Prematurity " 10
ProionRcd, difficult, or complicated labor.
including antepartum hemorrhage... " 25
Other known causes " 10
"I^nknown" " 25
100 cases
I wish to speak of only three of these causes
prematurity, syphilis, and accidents and complica-
tions connected with childbirth.
PREMATURITY.
Prematurity was the cause of death of over half
the number of children who died in the first four-
teen days of life in 10,000 consecutive births at the
Sloane Hospital for Women, New York, and Drs.
L. E. Holt, and E. C. Babbitt state that 66 per cent,
of these cases occurred during the first day.
•Rem.Trks made at the National Baby Week Conference, London.
July, 1918, on some Antenatal and Neonatal Factors in Infantile
Mortality.
November i6, 1918.] ROVTH : MEDICAL SUPERVISION LURING PREGNANCY.
849
Prematurity was also the cause of 4 per cent, of
the stillbirths at the same hospital, and in the Johns
Hopkins Hospital, in a similar series of 10,000
cases, it was the cause of 7.1 per cent, of the still-
births and deaths during the first fourteen days of
life.
In Queen Charlotte's Hospital in 1914, 231 (12.9
per cent.) of the total births were "premature," and
30.4 per cent, of the premature births were stillborn
746), or did not long survive birth (24).
At St. Mary's Hospital, Manchester, in the same
year, the premature births were 173, or 20.4 per
cent, of the total births, and 74 per cent, of these
were stillborn (93), or died before they left the
hospital (35)- _
The precise significance of the word incmaturity
needs standardizing, but the last two hospitals use
it to mean "born before the thirty-eighth week of
gestation."
ANTENATAL SYPHILIS.
Estimated fetal mortality. — From a careful con-
sideration of such statistics as have been published,
I have formed the opinion that in urban districts
twenty-five per cent, of the total antenatal deaths
and deaths during the first month after birth, are
due to syphilitic infection of the fertilized ovum or
fetus, and that probably twenty per cent, would be
a fair percentage over the whole of England and
Wales. This would mean that about 27,000 deaths
would occur annually in England and Wales, from
syphilis during the antenatal period and first month
of life.
In addition to those infants who die, a large
number would show no evidence of syphilis till
some weeks after birth, and some would remain
apparently healthy until puberty or early ado-
lescence, when CDrebrospinal disease may become
manifested.
Gravity of congenital sypliilis. — Congenital
syphilis is a more serious infection than primary
syphilis. Congenital syphilis is rarely cured, and it
is said that a positive Wassermann reaction in a
congenital syphilitic child never becomes negative.
This is not surprising fC'Iicn it is remembered that
the infection usually has been present in the child
from the beginning of gestation, and if the mother
is herself infected, the child has been receiving con-
tinuous added infection all the time.
Cases are on record of congenital syphilis being
carried to the third generation, and there is no
doubt that the unrecognized presence of congenital
syphilitic infection explains many obscure complica-
tions of ordinary disease, especially as regard?
affections of the nervous system and of the large
secretory and smaller ductless glands.
Very little evidence as regards the antenatal in-
cidence of syphilis can be obtained from hospital
records, as cases are not usually admitted for abor-
tions or miscarriages, and until quite lately, rarely
admitted in England except to Poor Law infirm-
aries, if foimd to be syphilitic.
Dr. E. W. Hope, medical officer of health for
Liverpool, gives pathological proof that in the Poor
Law infirmaries in that city 16 per cent, of the still-
births are syphilitic. Statistics are recorded re-
garding the stillbirths in 10,000 consecutive labors
in each of two American hospitals — Johns Hopkins
Hospital and Sloane Hospital. In the former,
the stillbirths due to syphilis were shown to be 32
per cent, of the total deaths up to fourteen days
after birth, and in the latter 9 per cent, of the still-
births were syphilitic, though all recognized cases
of maternal syphilis were refused admission.
Stillbirths from antenatal syphilis in unmarried
women are about double such deaths in legitimate
jjregnancies. Thus Doctor Hope states that in two
large I'oor Law establishments in Liverpool, the
stillbirths among illegitimates were sixty-four ])er
1 ,000 births as compared with thirty in legitimate
births, and he says that seventy-five per cent, of
these illegitimate stillbirths were due to syphilis,
toxemia, antepartum hemorrhage and dystocia,
which are universally recognized as the main causes
of antenatal death.
A woman, infected primarily by her husband,
would not thereby be rendered sterile, but she would
readily conceive and would infect her child through
her blood continuously during the pregnancy, and
under such circumstances the child may not survive
the gestation period, for it would often be infected
by both parents, and be stillborn.
It is remarkable that any child born of untreated
syphilitic parents can escape death during preg-
nancy.
This escape is apparently due to the fact that in
the placenta at the points of union of mother and
child, certain processes ai'e going on by the action
of trophoblastic cells of the membranes of the
fertilized ovum, which digest, by a process of
fermentation, the maternal tissues, and so allow the
fetal bloodvessels to penetrate the maternal tissues.
This is part of the "give and take" symbiosis which
Doctor Ballantyne has described and which goes to
prove that the fetus is not a parasite, as some have
taught.
These chorionic ferments or their derivatives (l)
appear to have a powerful action as a chemical
filter, so that germs like" tubercle bacilli and even
large organisms like the mature Spirochseta pallida
of syphilis are either destroyed, or, in the case of
the spirochete, broken up mto "granules."
These granules may, as Noguchi, of the Rocke-
feller Institute, New York, has shown (2), remain
biologically inactive for long periods, and if not de-
troyed may develop later on into the mature or-
ganism.
The chorionic ferments seem able to hold up, as
it were, these granules and control their activity
during pregnancy. Then after labor, when the
mother and child are both removed from all con-
tact with the ferments, the granules may develop
into the spirochetes and both mother and child
would then show clinical evidence of syphilis. In
a few cases both mother and child escape altogether
if the ferments have been able to destroy the life
of the granules. Maternal treatment by mercury in
the early months of pregnancy will usually ensure
a healthy child, but the treatment must be carried
out in subsequent pregnancies ; treatment with sal-
varsan and mercury may permanently cure the
mother and give her healthy children.
850 ROUIH: MEDICAL SUPERVISION DURING PREGNANCY. [New York
Medical Journal.
STILLBIRTHS, OR INFANTILE DEATHS WITHIN A FEW nancy when the threatening compHcations liad been
DAYS OF BIRTH, DUE TO ACCIDENTS OR discovered.
COMPLICATIONS OF CHILDBIRTH. Probably the most serious maternal complication
The chief accidents and complications apart from of childbirth, from the point of view of the child,
toxemia connected with childbirth may be grouped is when birth is associated with maternal ante-
as follows : — partum hemorrhage, for the hemorrhage may come
1. Fetal Conditions. without warning, even in cases under medical
a. Malformations. supervision. In many such cases serious operations
b. Malpresentations. "^e required to save the mother.
2. Maternal Complications.' Thus m the two lying-in hospitals, there were 119
a. Antepartum hemorrhages. '^^.s^s of placenta prsevia and accidental hemorrhage
(Placenta praevia). '^^''^h the mortality of ten mothers (8.4 per cent.)
(Accidental hemorrhage). ^"d ninety children (75 per cent.).
b. Contracted or deformed pelvis. ^ow nearly all these conditions in early or late
c. Pelvic tumors. pregnancy, or at birth, could be materially lessened
The death of mothers from "causes connected ^ ''^f'"^^ supervision during pregnancy and that
with birth" are four per 1,000, one in 250 confine- P'^'^""^ "^o^t urgent ami.
ments, while about 25 per 1,000 children die from contracted pelvis.
the same causes during the first three months of To show the need of medical supervision during
life, six times as many ; or if we include antenatal pregnancy, take one of the most serious complica-
deaths as already mentioned, forty children die to tions of childbirth, viz., contracted pelvis, which
each one maternal death from "causes connected may prevent a normal child from being delivered
with pregnancy and labor." alive at full term without some sort of operative
In lying-in hospitals, a similar but less marked assistance. Here recognition of the condition dur-
proportion exists between maternal and child mor- ing pregnancy will in slight contractions indicate
tality, though here two opposite conditions have to induction of labor one, two, or three weeks before
be noted: i. Expert obstetric skill; 2, admission of full term, with assistance, if necessary, by forceps
complicated cases beyond the average. The Report or version, or if the contraction is more marked,
of Queen Charlotte's Hospital for 1914, thus shows the patient will have Cccsarean section performed in
that the maternal deaths were twelve (at a rate of the hospital at or near labor. In "clean" cases,
six per 1,000 births), the stillbirths were 100, and where no attempts at delivery have been made be-
forty-four infants died shortly after birth, so that fore admission, the maternal mortality is about two
the deaths of children between the mother's admis- per cent, and the child mortality still less. If the
sion and a fortnight later, were exactly twelve case is septic, the maternal mortality is often over
times as numerous (72 per 1,000) as those of thirty per cent. In some severely septic cases,
mothers, in spite of every effort on the part of the Csesarean section would almost surely be fatal, so
expert staff. This rate of infantile death rate does that as alternatives, either the child would have to
not include antenatal deaths of children born before be destroyed (craniotomy) or the womb would
admission into the hospital. have to be removed to give the mother a chance of
It must be remembered that if a woman is not survival,
delivered, no matter what the complication is, she The following table shows the operations that
must almost inevitably die and her child also. had to be done in cases of contracted pelvis at
Attempts to deliver have often been made before Queen Charlotte's Lying-in Hospital, London, and
admission to the hospital, and such women may be at St. Mary's Hospital, Mc^^rnal Department, Man-
aseptic" and their risks thus enormously increased chester, in 1914, with the maternal and infantile
for all forms of the operative measures which may mortality :
be required to deliver them. No. of Maternal infantUc
--T-' 1 • .1 i r ii i „ cases. mortality. tiwrtalitv.
iakmg the I9I4 operation statistics or the two Name of operation Percent. Percent.
British lying-in hospitals already named, I find that induction oi labor... 63 i (1.59) 4 (6.36)
591 operations were performed, to save the lives Fcrceps 44 i (2.;0 1.3 (29.5)
of mothers and children, twenty women died, S7I Version 7 o (0.0) 6 (86)
, • J Af 4.1 1 -u T« „ Craniotomy .V 2 (6.2) 32 (100)
mothers being saved. Of the children, 174 were cesarean section .... 70 3 (4.3) 3 (4.3)
stillborn or died soon after birth, so that only 417
children were saved. The percentage of deaths of Totals 218 7 (3.2) .s8 (26.6)
these mothers and children, in spite of the opera- Here again fifty-eight children died in childbirth
tions done to save them, were thus 3.3 and 29.4 per as compared to seven mothers, so that 211 women
cent., respectively. Thus in these operations nearly and 160 children were saved from certain death,
nine times as many children died as mothers. Of It is almost certain that if these cases had been
.course these deaths were not due to the operation, seen by a doctor during middle or late pregnancy
ior all would have died if these operations had not and had had the date and nature of the treatment
rbeen done. decided upon then, very few, if any, of these
Many of these operations performed in emergen- mothers or children need to have died.
■ cy cases are septic and most of tliese operations Let me urge, therefore, as strongly as I can, that
-could have been prevented or dealt with by. minor all young women be educated and encouraged to
methods without any appreciable maternal or in- voluntarily put themselves in the hands of a doctor
iantile mortality, if admitted earlier in the preg- when they think they are pregnant, and so avoid
November i6, .918.] CUNNINGHAM: ORIFICIAL LUES. 851
such complications as these w hen labor comes, and
also reduce the risks of such further complications
during pregnancy as puerperal convulsions, the
early symptoms of which are usually quite easily
recognized.
The Local Government Board, under the skilled
advice of Sir Arthur Newsholme, has done much to
secure medical supervision of all pregnant women,
by encouraging the formation of maternity centres
and antenatal clinics and by giving them fifty per
cent, grants in aid, by its similar seventy-five per
cent, grants as regards diagnosis and treatment of
venereal disease, and by its endeavor to secure beds
for pregnant women with venereal disease or other
complications in general hospitals.
As Compulsory notification of pregnancy is out
of the question, education of women to enable them
to realize their need of medical supervision during
pregnancy should be our main ef¥ort and aim.
REFERENCES.
I. ARMAND ROUTH: Antenatal Syphilis, American Journal of
Syphilis, July, 1918. 2. HIDEYO NOGUCHI: Ibid., April, 1917.
ORIFICIAL LUES.
B^ William P. Cunningham. M, D.,
New York,
V^isiting Dermatologist to the Misericordia Hospital; Associate Vis-
iting Dermatologist to the Children's Hospital and
Schools, Randall's Island.
It might, at first sight, appear a little anomalous
for a dermatologist to undertake the discussion of
a condition so closely allied with the mucous mem-
branes. However, there are two considerations
which justify his attitude. One is that many lesion.^?
about the orifices of the body involve the skin as
well as the membrane ; the other is that the diag-
nosis of lues is so frequently made upon the cutane-
ous manifestations, that everything confirmatory
falls, naturally, within the province of the dermatol-
ogist. This, to be sure, is confined to the field of
investigation. He does not assume to treat the
alien structures upon which he has ventured in
search of information. For example, an indefinite
eruption upon the trunk might arouse suspicion
which the eye or mouth would confirm. He should
rest content with the aid obtained from scanning
these structures and, if special attention is de-
manded for their diseased condition, he should ad-
vise the intervention of the indicated expert.
Orifices of the body are apertures wherebv
communication is had or may be had with the in-
terior. In the male, they are the mouth, nose, eye,
ear, anus, and urethra ; in the female, the vagina
and nipple are added. This enumeration may
sound ridiculously elementary, as every one is
cognizant of these facts, but it is always advisable
to clear the ground in beginning a discussion. Even
familiar circumstances take on additional impor-
tance if marshalled in unusual relations. Further-
more, the inclusion of the ear in the number of
orifices may demand some explanation. There is
certainly no connection with the interior of the
body via the external auditory canal ; but there is
via the Eustachian tube from the pharynx. There
is a staunch membranous wall dividing the outer
from the inner car. There is no escape of secre-
tions externally and no thoroughfare for mfection.
This obtains in licalth, but in disease the ear may
become an undeniable orifice, by the perforation of
the membrana tynipani. This may be questioned as
a strained construction, but it is perfectly rational
nevertheless.
In the male the commonest location of chancre is
the glans penis. It favors the corona usually, but
occasionally it occurs at the meatus urinarius. Here
it is apt to be accompanied by a purulent discharge,
which on hasty examination may be attributed to
gonorrhea. The infiltration at the meatus in this
interpretation would be ascribed to the pouting due
to gonorrhea. Of course palpation would reveal
the indurated character of the lesion. It is prudent
to palpate every urethra secreting pus, for it has
come to be recognized that chancre may develop
anywhere in its course and, if out of sight, may be
overlooked for the lesser evil. Many of the cases
of lues that have occurred in perfectly frank and
intelligent patients denying an initial lesion have
begun in this Vv^ay. The patient has never seen a
"sore" ; he never had anything but the "clap." A
subsequent roseola, if noticed at all, was utterly mis-
construed. Having had no chancre he would not
be alarmed at a skin eruption of slight extent
causing no inconvenience. The whole thing might
quickly fade away and leave no impression on his
memory. When the suspicious outbreak comes up
for elucidation ten years later all the positive as-
sertions of the patient would be clearly against the
correct diagnosis. When the physician's opinion
has been confirmed by a Wassermann reaction, he
mentally and sometimes (in the case of a dis-
pensary patient) audibly registers his conviction
that the patient is a liar. But this has always ap-
peared illogical and unfair to me, for is there any
reason why he should deny having a chancre when
he admits having the clap? The opprobrium at-
taching to the manner of acquisition is identical in
both conditions. The following is a case in point :
A very intelligent person, who had served as a re-
porter on a Boston daily newspaper presented him-
self with an eruption on his forehead, just at the
hair line and steadily encroaching upon the un-
covered area ; iliis was confined to the left side,
and had a fluted border. It was infiltrated and
scaly, and was obviously luetic. It had resisted
treatment by a number of physicians, because of the
i;atient's unequivocal denial of syphilitic manifes-
tations at any time in his history. It was certain
that if he had been cognizant of such manifesta-
tions he would have admitted it. It was equally
certain from the nature of the lesion that he had
acquired lues. How could these circumstances be
reconciled? The patient confessed to gonorrhea.
A little later on he had been attacked with scarlet
fever. These were the only illnesses within his
recollection. The probable occurrences were : An
urethral chancre and a secondary outbreak mis-
taken for scarlet fever, because of the denial of an
initial lesion. Orificial lues may be of especial
significance in relation to such a history.
In the female, the chancre may occur anywhere
in the vaginal tract from the vulva inward, or it
CUNNINGHAM : ORIFICIAL LUES.
[New York
MEDrcAL Journal.
may occur, as in the male, about the meatus urin-
arius. If inside the vulva its detection may be a
matter of the common precaution so frequently
Incking in the management of vaginal discharges.
The pus is ascribed to ordinary "whites," or gon-
orrhea. If there is too little discharge to excite tho
interest of the patient no attention will be given to
it at all ; the freedom from pain characteristic of
lues will deceive her if she cannot see or palpate
the lesion. Every vaginal discharge is open to
suspicion in a woman who has had intercourse. In
history taking its possible bearing upon luetic in-
fection should be studiously considered. At this
point the up to the minute diagnostician is heard to
interject impatiently, "Why all this fuss about nos-
ing out histories? Why not just take a Wasser-
mann and have done with it? Surely that will go
to the heart of the matter and will usually be de-
cisive." Note the tone of dubiety m the last few
words. But suppose a case is encountered where
it is not decisive. Suppose one is confronted with
a luetic lesion, by all the rules of clinical detection^
and the Wassermann proves negative ; shall one
abandon his opinion and resign the patient to the
ravages of a disease which we know exists, despite
the adverse findings of the serologist? And if the
Wassermann is apt to play such a trick as that, is
it not rational to proceed to develop every other
scientific resource likely to prove of service in ac-
complishing what the test tube failed in proving?
Is it not wise to exert every efifort to show that
there may have been a chancre concealed from the
observation of the patient, and that, despite his
honest denials of conscious infection, he gave a
recital of occurrences warranting suspicion of error
and the application of medication of a specific char-
acter ?
Again, the pursuit of this inquiry into the man-
ner of occurrence of undetected initial lesions is of
importance, not only in establishing a diagnosis in
the case in hand, but in developing precautions
against repetitions of error. For if at the begin-
ning of the disease we are alert to the possibility of
lues masquerading in the trappings of a milder
malady, we shall have all the advantages of position
in making our attack. We shall be protected from
the humiliation of a disagreeable surprise, and even
before the Wassermann is available, may make a
feint in force upon the concealed intruder. This
may uncover his strength, and enable the bringing
of all our resources for his speedy subjection. It
is therefore an act of prudence to have a safer de-
pendence than a serological test for the determina-
tion of so important a question. Needless to say
that a spirochete examination, under the circum-
stances, is impracticable ; that can be utilized only
where the sore is within reach and free from
cluttering secretions. Another reason why the im-
patience of the rapid fire diagnostician of the pres-
ent day for indiscriminate bloodletting must be
firmly controlled is that patients sometimes have
sensibilities and imagination. They frequently
grasp the significance of the procedure and are
deeply wounded by its suggestion. Horrifying
suspicion of conjugal infidelity may be heedlessly
and needlessly aroused ; mental suffering far more
serious than actual disease may be callously in-
flicted. Even if the report is favorable doubt will
often persist and make a syphilophobiac of a
hitherto levelheaded subject. This deplorable state
incites the victim to demand more and still more
Wassermanns, under the delusion that carelessness
or error has affected the results. It would actually
be preferable to have the disease than the unbal-
anced mentality that is constantly suspecting its
existence. We might be able to give the patient
substantial assistance in the one instance, whereas
we are utterly helpless in the other. It is manifest
then that the off hand demand for a Wasser-
mann in every doubtful conjuncture is far from
being the rational road to the heart of the per-
plexity. If it is our business to conserve the health
of the patient it certainly is not our business to "put
him off his head." One must be fairly sure of the
condition which confronts him or of the absolute
urgency of the serological decision before one is
justified in arousing the mental disturbance which
we are powerless to control. The icily scientific in-
vestigator who is bent only on establishing a diag-
nosis, without regard to the psychic upheaval
associated with his methods, may be an admirable
precisian but he certainly is not a true physician.
It would be better for him to deal with agricultural
products or the domestic animals where tactfulness
would not enter as a factor in the problem. The old
fashioned conception which combined in the doctor
the qualities of the gentleman, humanitarian, and
diagnostician, was based upon a rational estimate
of his knowledge of the world. The mere inter-
pretation of symptoms with the absence of sympathy
and a helpful optimism will not go far toward the
alleviation of human ills. We have seen one nation
push scientific precisianism, to a high degree of ef-
ficiency and yet, under stress of territorial greed,
resort to such methods of warfare as would have
made it better for mankind if she and her Kiiltur
had never existed. Any salvage of lives that may
be attributed to her eminent investigators is more
than counterbalanced by the wholesale slaughter on
her selfsought battlefields. Science without soul
has brought mankind to the brink of destruction ;
but the soul aroused in the resisting peoples has
proven more than a match for cold blooded calcula-
tion. This digression is simply to emphasize the
fact that in seeking to come to a speedy determina-
tion in a disputed case of lues there is more to be
considered than the bare scientific details and that
the prudence and altruism that are necessary quali-
ties of the worth while doctor forbid the precipita-
tion of the mental debacle that will put the patient
in a worse condition than the disease we are trying
to identify.
Chancre of the lip has been so often brought to
our attention, that its escape from recognition must
be ascribed to hasty examination. The main dif-
ficulty lies in failure to recall its possibility. Once
it is realized that chancre may occur upon the lip,
certainty is assured. We may be a bit tardy in
arriving, but continued contemplation of the lesion
and its history will bring enlightenment. We miss,
not because we do not know, but because we do not
suspect. The moment the real character of the
November i6. 1918.]
CUNNINGHAM: ORIFICIAL LUES.
853
lesion is suo^gested, we marvel at our want of pene-
tration. The whole thing appears so simple when
explained! Confusion is produced by the accidents
of age and variation of type. In the elderly we are
prone to jump to the conclusion of cancer ; in the
young, if the induration is lacking and little appears
but a persistent erosion, we wander oflf in a diag-
nosis of herpes. The patient, reassured by this
comforting information, gives little heed to the
painless abrasion, and probably docs not return to
the doctor for further observation. After the man-
ner of chancres the "cancer" — if it escapes opera-
tion— will spontaneously recede, to the astonish-
ment of the beholders. The obstinate "lever sore"
will do likewise. Given a roseola that is unobtru-
sive, it is almost certain that the discovery of the
real nature of the condition will not be made until
some remote outbreak of disquieting proportions
compels a thorough investigation. Eccentricity is
so marked a quality of lues that this outbreak may
be delayed for many years or may not occur at all
in the acquirer, but in that of his ofifspring. The
only evidence of infection in the parent may be
spontaneous abortion.
In view of all these consequences of unidentified
chancres, how are they to be differentiated from
their counterfeit presentments on the lip? Youth
excludes cancer ; rare indeed are the exceptions.
Within the cancer zone, other points of distinction
must be relied upon. Induration may exist in both.
This is greater in chancre than cancer but the
comparison of degrees of induration between
lesions not synchronously under the palpating
fingers is a doubtful expedient. Chancre will be
accompanied by a satellite gland in the neck or in
front of the ear. Cancer, unless it has existed long
enough to dispel all doubt as to its identity, will
lack this adenitis. Chancre is a much more rapid
growth than cancer ; it gets to maturity in a short
time. The proportion in speed might be fairly
stated as four or five to one. Chancre having at-
tained its growth, remains thereafter stationary
until recession begins ; cancer steadily advances.
Chancre is painless ; cancer is painful. Chancre has
a shallow ulceration with a purulent secretion that
lends to form a thick crust ; cancer has a shallow
ulceration whose scantier secretion forms an ad-
herent scab that bleeds on detachment and is
promptly replaced. The border of chancre is
simply a grisly rim ; the border of cancer is fre-
quently made up of little pearly bodies that consti-
tute cancer nests and are pathognomonic. All this
has to do with typical examples of each form of
disease. A chancre that is merely a solid papule
will rest only on suspicion. Corroboration is abso-
lutely essential to a diagnosis. A chancre that is
nothing but an erosion may yield spirochete or a
satellite gland and thus dispel the doubt of herpes :
if it does not receive either form of confirmation,
its obstinacy will soon come to our aid with the
same result. The requisite to success is to remem-
ber the likelihood of chancre appearing in such a
situation and under varying aspects.
Chancre of the ala nasi is extremely rare. This
very circumstance should impress one with the
possibility of its underlying a rebellious infection of
the nostril. Persons with the courtly habit of
manual excavation of the nasal fossae would be ex-
posed to this unusual mischance. Also th:it partic-
ular brand of lunatic who pulls hairs out of his
nose as a pastime.
The palpebral fissue is even more rarely visited
by the chancre. A most remarkable combination of
exceptional circumstances would be necessary for
its ap]5earance in that situation, yet a little reflection
will show that that combination might occur with-
out any straining of possibilities. A careless nurse
with a labial mucous patch, might wipe out a baby's
eye with the corner of an apron moistened in her
mouth ! The foolhardy physician who has been
palpating a sore with his ungloved hand might ab-
scntmindedly, rub his eye which shows a propensity
to become itchy just at the moment when it is least
advisable to touch it. While disaster is, happily,
most uncommon under these circumstances, it re-
quires very little imagination to picture its occur-
rence.
The nipple of the female fulfills our definition of
an orifice; it is the port of egress for a secretion
and of ingress for infection. Chancre here will
inevitably come under suspicion as cancer. It may
be due to wetnursing or to osculatory demonstra-
tions on the part of an infected lover. If the patient
is young, as she is apt to be under either of these
etiologic hypotheses, error will lie in trying to prove
an abnormally early malignancy. In the case of the
nursing baby, the truth is likely to suggest itself to
the least penetrating inquiry ; in the other case the
very circumstances attending the infection will be
the cause of^ deflecting the examination to an er-
roneous conclusion. But here again if we bear in
mind tlte possibility of a chancre in this situation,
we shall be a long way on the road to a correct diag-
nosis. It is because this does not occur to us that
we fail to consider it in the light of a possibility.
Chancre of the external auditory canal, in the
very nature of things, must be a very infrequent
mishap. It is conceivable that the use of dirty in-
struments might bring it about, but the likelihood of
the same instruments being used without steriliza-
tion upon succe-^sive patients is very remote. True,
the counterpart of the nose picker exists in the ear
delver, and in pursuit of his absorbing passion he
might have recourse to an implement that had seen
service elsewhere and had become a spirochete car-
rier. The providentially brief existence of the
spirochete, apart from its human habitat, renders
such an unfortunate mischance highly improbable.
Chancre of the internal auditory canal, at the phar-
yngeal end of the Eustachian tube, is likely enough
in the well recognized involvement of the tonsil.
Chancre of the lobe of the ear could invade
the meatus. Its appearance in this situation is
ascribed to the eccentric manifestation of the afifec-
tion known as dermophagia. Ardent lovers some-
times bite their inamorata's ear. Given a mucous
patch in the ardent lover's mouth, the transfer of
spirochetes is easy.
Chancre of the anus may be due to pederasty. It
may also be due to brutish postures in intercourse
between the sexes. It may be due to infected fingers
or instruments in making examinations for hemor-
Cl'NNINCHAM: ORIPICIAL LUES.
[New York
Medical Journal.
rhoids or other rectal diseases. Tliis last contin-
gency is extremely unlikely, owing to the readiness
with which the spirochete succumbs outside the
body.
The mucous patch is a luetic manifestation con-
fined to the mucous membranes. Its commonest
location is the mouth. It may occur on any mem-
brane where the conditions of pressure and moisture
macerate the papule. Its appearance is quite dis-
tinctive. It is decisive corroboration of a dubious
cutaneous outbreak. It is to be differentiated, on
occasion, from the herpetic eruption usually domi-
nated as canker sore. The confusion has arisen
and may again arise. There are points of distinc-
tion. The mucous patch is usually painless ; the
simple erosion is extremely painful. This is al-
ways a significant feature of lues. It does not pro-
duce much pain. Exceptions due to accidental con-
ditions do not invalidate this rule. A simple her-
petic lesion will give more trouble than a mouth
full of mucous patches. The herpetic lesion is
round, the luetic oval as a rule. The mucous patch
looks like the markings made by nitrate of silver
on the membrane. Sometimes there is no inflam-
matory areola, but if there is, it is much less angry
looking than that around a herpes. There may be
a loose pellicle of membrane detachable from an
underlying raw surface. The patch is obviously
the effect of maceration and the herpes of minute
ulceration, the latter being acutely inflammatory and
the former a granulomatous deposit with surface
softenings. On the tonsil massed mucous patches
have simulated diphtheria. The constitutional
symptoms and the Klebs-Loefiler bacillus are both
lacking. At the angle of the mouth the patch will
make a fissure if it is folded on itself. This is
highly suggestive. Perleche is frequently paradiag-
nosed ; the latter is an impetigo. It is commonest
in children, in whom it occurs as an epidemic from
sucking infected pencils. It is a sodden condition
of the epithelium; it is bilateral. On the whole, it
is wise to be deliberate in coming to a conclusion
with regard to perleche in an adult, because of the
well known propensity of lues to counterfeit other
conditions.
The region of the mouth is a favorite site for
the grouping of the macules and papules of the sec-
ondary eruption. A half circle about the angle of
the mouth will throw confirmatory light upon an
otherwise indeterminate condition. It will be well
to pause and consider this fact, for it cannot be too
strongly emphasized. It has cleared the ground of
many a perplexity. If a fissure at the angle of the
mouth is suggestive, so is the tendency of the cuta-
neous outbreak to cluster about it. It is without
question one of the most valuable indications. De-
liberate examination will preclude the confounding
of a herpes with this highly important danger sig-
nal. Herpes will be painful, or at any rate uncom-
fortable ; it will be inflammatory and vesicular ; it
will be transient. The syphilitic manifestation will
be papular or macular in this stage ; it will be dis-
covered by the sense of sight ; it will be inactive ;
stationary. Acne lesions might affect the same re-
gion. But they would be accompanied by similar
lesions elsew^here and their peculiar follicular char-
acter would be conclusive. It is admissible that cir-
cumstances might render distinction difficult on
some occasions, but much of the confusion will dis-
appear if one remembers the likelihood of lues to
produce such an eruption circum or em.
Mucous patches may appear anywhere on the
mucous surfaces ; the vulva and cervix are often in-
vaded. About the genitals, owing to the favoring
circumstances of heat, moisture, and sebaceous lux-
uriance papular lesions are apt to take another form,
which will be described later. The conjunctiva and
the nasal mucosa do not appear to be commonly
affected: the former from some inherent quality of
resistance; the latter from the seclusion offered by
the narrow passages. The angles of the ala? nasi,
however, are affected as are the angles of the mouth.
Fissures due to folded patches indicate the presence
of these lesions in the nose.
Within the vagina there is no doubt of the occur-
rence of these characteristic luetic' phenomena but
they are not so frequently discovered because they
are not so diligently sought for, and because they
may be readily hidden in the folds of the volumin-
ous membrane.
Within the rectum the search for mucous patches
would doubtless be successful, but it is never under-
taken unless some insistent discomfort draws at-
tention to that locality. In general terms, the
mucous patch speaks through the mouth of the pa-
tient and usually with unmistakable emphasis.
The diagnosis of lues is frequently facilitated
by iritis and keratitis. Doubt yields to certainty
upon the discovery of either of these complications
or of their telltale vestiges. We may confirm
acquired lues with otherwise indeterminate mark-
ings, or we may confirm heredolues of the variety
known as tardy. It is true that iritis is ascribed also
to gout and rheumatism, but taken in connection
with the other features of the case its significance
is obvious. It is becoming questionable, moreover,
whether we are not confronted in iritis with a situa-
tion similar to that in tabes before its unique
etiology was definitely settled. Keratitis is frankly
luetic. Glaucoma may produce a hazy cornea but
its associated symptoms are unmistakable.
In the area between the buttocks and about the
scrotum and labia majora papules develop which
are flattened by pressure and softened by heat and
moisture into unmistakable evidences of syphilitic
activity. They are described as moist papules or
condylomata lata. They are present in the second
stage, and often merge into extensive plaques of
dull red, slightly raised, sharply outlined secreting
tissue. They are not likely to be mistaken for any
other sort of dermatosis. They are defined by their
location, their limitation, and their level, moist sur-
face. Venereal warts might come into comparison
with them but veneral warts are inclined to the
cauliflower conformation and do not present the
picture of evenness and sharp circumscription.
Condylomata acuminata and condylomata lata are
exactly distinguished by their titles. Condylomata
acuminata are the result of the irritation of patho-
logical discharges other than those of lues. Gonor-
rheal pus, the pus of chronic vaginitis, filthy habits,
sweltering rolls of fat, all may induce the forma-
November i6, 1918.]
CUNNINGHAM: ORIFICIAL LUES.
855
tion of the nonspecific wart. But this is not flat :
it is acuminate. It is the rank vegetation of a fetid
locaHty. It is the tropic kixuriance of a highly
manured miasmatic soil. The papillae undergo
forced development. That is the whole case. But
Uie condyloma latum is a distinct granulomatous
deposit in the part entirely foreign to it under
normal conditions, and acquiring from the pressure,
lieat, and moisture, not its incentive to growth but
only its peculiar compressed appearance and oozing
surface. Any solid lesion of lues subjected to the
same macerating process will yield the same result.
Vou will find it in heredolues ; in the second stage
of acquired lues ; in the late secondary stage, and
also in the tertiary. While not an instance of
orificial lues its occurrence between the toes may be
noted, in passing, as illustrating the manner of its
production. The tendency of corns to become soft
in this situation is familiar to everybody ; the same
tendency is displayed by papular forms of lues.
Beneath the behemoth breast of certain grossly
obese women, the specific paules are likely to
assume the same pultaceous character.
The secretion from condylomata lata is very con-
tagious, and many an obstetrician ofificiating with-
out gloves has lived to regret his carelessness. Ex-
aminations for supposititious hemorrhoids have
brought the absorbing surface of the physician's
finger in direct contact with the virulent exudation.
In explorations in these localities nothing should
be taken for granted, either from the unimpeach-
able character of the patient or an attractive ex-
terior : the Wassermann reaction has demonstrated
the prevalence of lues in quarters utterly unsus-
pected. We are no longer under any delusions
regarding the "unspotted from the world" reputa-
tion of any class or person. This is far from being
a cynical indictment of the virtuous for there are
many such — very many indeed. Our women are
fairly entitled as a class to the appellation, but
many burns have made us dread the fire of mis-
placed confidence. Here and there we have stum-
bled upon an unusually promising case which has
brought humiliation and embarrassment upon us.
Often our demure young miss has proved to be
a whited sepulchre. Often on the other hand the
fetching sweetness of young rnotherhood has
brought forth a weazened, whining, condylomatous
little old man engendered by a lecherous father.
From the external indications nothing of this could
be suspected. Prior to this day of diagnostic pre-
cision, it was frequently impossible to put the blame
upon the proper person. If the husband was a cur
he could hint at conjugal infidelity on the part of
an innocent woman ; showing nothing, on close ex-
amination, he could indignantly shift the respon-
sibility. But armed as we are today, his assurance
and mendacity would avail him nothing. He would
promptly be placed in the class to which he be-
longed ; his denial would only add the crime of slan-
der to that of blood contamination. Had the Wasser-
mann performed no other service for humanity than
of expo=;ing the slayer of reputation, it would well
have justified its claim for recognition and applause.
A little above we have counselled prudence in the
demand for blood examinations ; but here is a situa-
tion where it would be criminal to forego it.
In the tertiary stage of lues, there is displayed
the same propensity to orificial involvement as in
the preceding stage. It is not alone that the mucous
membrane is susceptible to attack, but that the
locality of the apertures seems to be .selected by the
spirochete for its most significant demonstrations.
About the nose it will weave a curvilinear deposit
of little nodules with ulcerating summits, or it will
produce a solid, inflammatory area sharply defined
and with the characteristic wavy outline. At the
edge of the nostril a gummatous infiltration may
eat away the ala ; within the nose the septum may
suffer similar devastation. Upon the very end of
the nose, like a small eccentrically limited rosacea,
it may blaze forth in ridiculous effulgence. The
sharp limitation and the absence of contributory
telangiectases should arouse suspicion, and means
should be taken at once to verify it. The Wasser-
mann will serve us here most decidedly if we can
have it made without exciting too much mental
disturbance or an vmgovernable fSmily upheaval.
There is a possibility of such a lesion being lupus
or lupus erythematosus. All our diagnostic criteria
go amiss sometimes and rules of differentiation con-
tribute to our discomfiture. Lupus may begin in
the adult. It may be acute enough to upset the
chronology. Lupus erythematosus may early show
no atrophy, and very little, if any, scaling. If we
jump to the conclusion that the phenomenon is
surely lues because it presents the customary mark-
ings, we may get ourselves into a most uncom-
fortable dilemma and set innocent people by the
ears. It is wise to proceed with the caution of the
hunter stalWng the wily beast of prey. Running
in on him will not do ; it may result in a disastrous
scrimmage. He must be trailed until cornered and
then dispatched. Prudence is the watchword where
married people are involved. To be sure nothing
should prevent the physician from doing his full
duty in the premises ; but there may be two ways
of accomplishing it. The wrong way is to embroil
one's self and the parties of the second part ; the
right way will lead to the important point by the ex-
ercise of a little strategy. If we can discover that
our doubts are unfounded without the highstrung
patient being aware of their existence, we shall
prove ourselves better physicians for our discre-
tion.
The painless dysphonia of tertiary lues is a very
striking phenomenon. It is quite decisive. Any
other pathological process resulting in the same
amount of incapacity would be accompanied with
marked distress. Acute laryngitis or tuberculous
laryngitis are both painful. It is true that hysteria
is sometimes accountable for aphonia, but the ab-
sence of pain is compensated by the luxuriance of
characteristic stigmata. Painless dysphagia is in
the same class as painless dysphonia. It is distress-
ing in that the patient has to force the food past
the obstruction but it is not associated with actual
pain.
In tertiary lues the eye sometimes gives inval-
uable aid in establishing the diagnosis and in fore-
warning of graver developments. The reflex
iridoplegia of oncoming tabes is a case in point ;
the choked disc of cerebral syphilis is another. It
is indubitable that both the tongue and eye of the
856
CUNNINGHAM: ORIFICIAL LUES.
[New York
Medical Journal.
infected sufferer are eloquent of the depth of his
affliction.
About the mouth, again, the tubercular ulcerating
or gummatous lesions will be found following the
peculiar law of their being, in arranging themselves
in ellipses, half circles, or festoons. Or there may
be one larger deposit whose necrotic surface will
reveal a similar configuration. Lues, while fre-
C]uently wily and deceptive in pretending to be
something else, almost invariably betrays its iden-
tity by its tendency to grouping .and circinate de-
ployment. So true is this that if one sees an ulcera-
tion with a fluted border or a number of papules or
tubercules in bent bow formation, one is off on
the hunt for corroborative evidence. Any part of
the body may be the site of these dull red sluggish
granulomata, but in the neighborhood of the mouth
or nose they take on added significance. Here also
they are liable to dangerous misconstruction if their
identity is not made out. The most frequent error
is the miscalling'of lues, cancer, and of cancer, lues.
This has been done to the reproach of the surgeon
on more than one occasion. In this event the pa-
tient has simply suffered unnecessary inconvenience,
mutilation, and expense ; his life has not been en-
dangered. But in the other event of an error by
the physician, malignant activity has been permitted
to continue until successful interference becomes
impossible. This calamity is becoming rarer be-
cause of the refusal of most practitioners to abide
by the judgment of their senses in such a serious
dilemma. Here is a situation where the invocation
of the Wassermann is imperative, no matter what
contingent disturbances it may create. With a de-
cision involving the life of the patient demanded
within a short time, no paltering should be toler-
ated : delay is the one unpardonable factor in the
circumstances, li one is sure he is dealing with
lues one should be emboldened to demand the
Wassermann in the knowledge that domestic rela-
tions will not be unnecessarily embittered ; if in
doubt, the gravity of the problem overshadows every
deterrent consideration. If one is certain that he
is dealing with cancer the Wassermann will hasten
indicated interference, and any misgivings aroused
in a jealous mind will be swallowed up in the mag-
nitude of the tragedy.
Gumma has attacked the penis and has given a
highly artistic representation of carcinoma. It is
on record that the penis has been amputated under
this delusion ; however, no cautious practitioner
would venture a positive opinion on the gross ap-
pearances. Histories frequently confound instead
of assisting; they are usually so vague and so "fed
up" by leading questions' that they do not convey
any trustworthy information. Add to this the in-
explicable propensity of patients to favor the pro-
duction of a preconceived or flattering diagnosis, by
coloring their testimony accordingly, and we have
good and sufficient reason for distrusting clinical
histories. At any rate they are to be received with
reserve in grave perplexities. The Wassermann is
as imperative here as in the differentiation of cancer
and lues anywhere. Even with a positive Wasser-
mann, however, we may be facing disaster. For it
is unfortunately true that a luetic may become the
victim of cancer, and right on top of a gummatous
lesion. With a negative Wassermann we may still
be at sea, for in a certain number of tertiary con-
ditions it fails to register correctly. The only sane
]irocedure when the distressing doubt arises is to
take the blood, and if the findings are against lues,
to give salvarsan at once and try for the thera-
peutic test. If this proves abortive one is sure of
his ground and may proceed to the measures in-
dicated for cancer.
Gumma of the penis has been responsible for
that mysterious masquerader denominated chancre
redux. Methods of treatment which pretended to
cure syphilis with great rapidity and certainty have
accounted for the inexplicable reappearance of the
symptoms by postulating a reinfection. Chancre
redux proved the reinfection. And every one of
the inevitable manifestations of the old infection
was pointed out as a consequence of the new. It
was convenient and bewildering. It was what our
dear old friend, Dick Swiveller, would style a
"quencher." The mention of Dickens brings to mind
another quotation apropos of the chancre redux
when in speaking of Mrs. Harris, Betsy Prig said to
Sairey Gamp, "I don't believe there ain't no sich
a person !"
Gumma of the tongue is often one of the most
puzzling conditions that confront us. The problem
is of course to distinguish it from cancer. Usually
it appears in a different situation. It favors the
dorsum while cancer favors the sides. This is
ascribed to the effect of dental irritation in the lat-
ter instance. Why irritation should not precipitate
gumma here as it does elsewhere, is not made at all
clear, but practically the giunma usually does break
forth upon the dorsum. Cancer is painful ; gumma
is ordinarily not painful. This distinction must not
be too implicitly relied upon, as gumma sometimes
hurts inordinately. Both produce an ulcerating
growth. Gumma is speedier than cancer, but rela-
tive degrees of speed are not a safe dependence, be-
cause in a vascular region like the mouth cancer
is rather speedy also. The induration in cancer
should be greater than in gumma. Cancer should
have an associated adenitis of the nearest glands:
gumma lacks this, although it is easy to mistake an
old luetic adenitis for glands invaded by cancerous
metastasis. That is the case epitomized. So nice
is the distinction at times that surgeons have been
accused of removing a tongue which medical treat-
ment would have saved. Complement fixation
stands in the way of a repetition of that enormity.
No man should trust his own senses in framing
an opinion that is fraught with so much risk. The
aid of every method of determination should be
invoked.
Gumma of the palate is not likely to be confound-
ed with anything else after it has produced a per-
foration ; prior to that its location should be regard-
ed as highly suggestive. Cancer is not to be differ-
entiated, as it does not attack the vault.
The cheeks may be the field of extensive tertiary
ulcerations. Depending, it may be, on lowered
vitality or upon conditions impossible to determine,
the mouth and throat may be involved to an in-
credible degree.
November i6, 1918.]
CUNNINGHAM: OKIFICIAL LUES.
857
The floor of the mouth forward of the Ungual
attachment is hable to be the site of either gumma
or cancer. History and palpation will incline the
examiner to one or the other opinion ; but after he
has reasoned himself into a plausible diagnosis he
will conclude by asking for a Wassermann. In-
duration and adenitis make a strong case for cancer
but despite the confidence expressed in the clinical
findings operation will never be advised until the
serologist has reviewed the proceedings. And let
it be ever remembered that luetics are not immune
to other diseases. When your Wassermann has
come back positive do not rush headlong to the con-
clusion that the lesion is unqualifiedly specific. A
luetic may acquire a cancer as readily as another
man. In point of fact his luetic lesion may form
the basis of cancer as in IMarjolin ulcer of the leg.
The serological determination is of vast assistance.
It gives a rational point of departure for interfer-
ence. But after intensive specific treatment has
proven of little avail it will be wise to pause and
consider whether we are not dealing with a dual
pathology. Operation may unfortunately be delayed
too long under a stubborn adhesion to a single
string policy.
The etiology of leucoplakia is going through the
same eliminative process as that of tabes. Time
was when tabes had many causes: infection, cold,
injury, and excessive venery were all admitted into
etiological complicity with lues. An amazing
commentary on our fatuous ignorance. W'e used
to congratulate the patient if we could make out a
history of lues, as we were confident of curing him
on that hypothesis. Gradually as our information
grew, the weeding out process put the whole re-
sponsibility on lues, and we sorrowfully acknow-
ledge that we could not cure it at all. Today leu-
coplakia is credited in the hterature with a diverse
causation. It is a shining example of the tenacity
of tradition. But little by little we are coming to
understand that the spirochete is a jealous being,
utterly averse to sharing its glory with any other.
Consequences referable to its activities are referable
to them alone. Leucoplakia is a keratosis of the
mucous membrane producing white patches or
streaks. It is a late manifestation and very prone
to cancerous degeneration.
Gumma at or within the anal margin will arouse
suspicion of carcinoma, especially in the middle
aged in whom both conditions are likely to occur.
Rapidity of development, absence of pain, of pulpy
instead of grisly feel, all argue for syphilis. Need-
less to repeat that the Wassermann will be resorted
to, if any suspicion of the true state of things occurs
to the observer. Unless he is too hasty in forming
his opinion and too obstinate in maintaining it, he
will expeditiously apply every diagnostic criterion
within his reach.
Gumma may invade the inner aspect of the but-
tock and simulate ischiorectal abscess or fistula. It
may extend from the anterior border of the anus
forward on to the scrotum. In this situation uncer-
tainty has arisen regarding its identity. It has been
supposed to be cancer, of course, but otherwise it
has been paradiagnosed tuberculous. A negative
Wassermann leaves the doubt ; a positive relieves
it. A concomitant affection of the lungs would
clarify the situation greatly. A deliberate consider-
ation of all the circumstances, with an eye to all the
possibilities, will lead to the right conclusion.
Gumma of the labia will evoke the shade of
chancre redux just as will gumma of the penis, if
the deposit is single and the mind of the observer
is of the grandiose (juality that maintains the
radical cure of lues. Gumma may be, on the con-
trary, so diffused and destructive as to permanently
distort tlie invaded tissue. A species of psuedo-
elephantiasis has been described in consequence of
a plastic lymphangitis affecting one or both sides.
Gumma of the introitus may result in narrowing
of the orifice; deeper in it may produce a recto-
vaginal fistula. Another tendency of tertiary lues
is toward the development of fibrous tissue in
situations where its contraction may interfere with
function. \A'e are all familiar with the tabetic
spinal cord. We are not perhaps quite as familiar
with the strictured esophagus and rectum. In our
consideration of lues we are apt to forget that, in
addition to the granuloma which STibsequently
breaks down and leaves a scar, there is this initial
fibrosis — actual scarring — without any preliminary
neoplastic deposit. There may be, and probably is,
histological alteration of which the fibrosis is the
culmination ; but this is inappreciable. Clinically
the first manifestation is interference with func-
tion. Endarteritis resulting in arterial fibrosis is
first revealed by high tension ; just as the fibrosis
of the spinal cord is first revealed by disturbances
of sensation or locomotion. Until the displacement
of functioning tissue by fibrous tissue, we are un-
aware of the insidious process at work.
The orificial manifestations of lues are peculiarly
significant in the inherited disease. The classical
picture of the senile baby with the hoarse cry, puru-
lent coryza, and the condylomatous anal rosette is
familiar to all. We recognize him by the orificial
involvement. We should suspect him because of
his used-up aspect, but we cannot definitely account
for him without the concomitants mentioned. There
is little need of dwelling on this characteristic
group of symptoms. There is no likelihood of mis-
taking it for anything else.
The purpose of this paper has not been to give
a better description of the lesions of lues about the
orifices — because in that it were beaten at the start
— but to emphasize the importance of this localiza-
tion in the forming of correct opinions. If the
eruptio circum orem arouses suspicion, not on ac-
count of what it is but on account of where it is,
the liabilitv to err has been markedly diminished.
If lues will be thought of every time an orificial
lesion is seen it is certain that while one may go
astray in an excess of zeal it shall not be for long
nor in a dangerous direction.
Ultraviolet Light a Symptomatic Cure for
Eczema. — John Bryant (Boston Medical and Sur-
r/ical Joiiriir.l, September 19, 1918) says that ultra-
violet light, while not preventing recurrence, has
proved an active therapeutic agent and an almost
instantaneous specific for the intolerable itching.
858
STEWART: THE INGROWN TOENAIL.
[New York
Medical Journal.
THE INGROWN TOENAIL AND THE COUP
D'HACHE.
By Douglas H. Stewart, M. D., E. A. C. S.,
New York.
It may be mentioned in all kindliness that our
French friends derive amusement from ridiculing
translations that were originally made for the benefit
of readers who were unfamiliar with the French
language, though they were interested in the hatchet
stroke or a certain mode of amputation that is re-
ferred to in France and elsewhere as coup d'hache
or coup d'hachette. Bearing this in mind it becomes
apparent that American editors must have nodded
if they used such title as coup d'hacliis or coup
d'hacher. Ever since that mutation is supposed to
have taken place, there have been witty word plays
that turned upon similarities in the Gallic words
serving as synonyms for the English nouns, hatchet,
hash, choppings, hackings, and mincemeat.
Critics of the matters herein set forth assert that
the author has adapted the hatchet technic to the
ingrown toenail, or to the operation for that condi-
tion. If so, so be it. For that method could hardly
be more indicated elsewhere, nor could it have a
better aim; because the overhanging roof of flesh
and skin and the underlying floor of tissue, will
cover, conserve, and foster every germ energy that
may be pathogenic, mud borne, or have its origin in
any place where the foot of man may tread — -be tha#
place stream, swamp, sewer, stable, trench, ditch,
vault, cellar, or other. Once infected the flesh,
scratched and irritated by the hook of the nail, to-
gether with the cuplike receptacle that is furnished,
forms an ideal nest for incubating, for feeding or
for furnishing a port of entry to any mixed culture
that may accumulate where there is not only advan-
tageous friction, and vaccination by rubbing, during
the act of walking, but even the interference of pres-
sure, as exemplified in siphons of charged waters, is
absent. Pressure is intermittent and absorbed by
the cushion that is furnished by the stocking. There
is no flow nor current to remove germs or to dis-
place their activities to less favorable habitats, as
there is about the prepuce or the anal puckerings ;.
on the contrary warmth, moisture, food, darkness,
protection, and putrefaction tend to make a favor-
able environment. In short, small as is the field,
it lacks but area, though otherwise it is so excellent
for germ cultivation that one marvels at the resist-
ance that is furnished by the host. If the coup
d'hache has a value in the presence of conditions
that make for infection and if sutures or stitches
have the disadvantages of foreign bodies, then an in-
growing nail would seem to be an admirable site on
which to demonstrate that value and to avoid the
presence of foreign bodies.
Operations for ingrowing toenail are many ; yet
their outcome is not at all what it might be, despite
the fact that the first issue may have been satisfac-
tory to the operator. In fact it might have re-
mained satisfactory to the patient had he not been
compelled to wear shoes that never were designed to
agreement with the measurements and structures of
any human foot. Rather were those foot coverings
made with the idea in mind that a big, strong,
straight, well arched, uncallosed, and unde formed
foot was a monstrosity, once admired perhaps,
though only by Greek sculptors, pagan sandal
wearers, and such people, but having no tolerance
among the hobblers who parade the middle aisle
among the so called lucky ones, or among the so
called unfortunates who stand behind a counter or
before a piece of machinery.
The high priced shoe pinches laterally or hori-
zontally, though the cheap shoe bears or presses
down vertically. Therefore the nail hook of the
workman is fairly likely to cut almost directly down-
wards, against the solid resistance of the sole of the
shoe, as that rests upon the ground and the foot is
wedged forward into a narrower and a compressing
space. The uncus of the man of fashion, who
wears a pointed boot, is apt to cut laterally against
the counterpressure of the second toe. This de-
pends upon the bearing of the shoe, though it will
often be found that a right handed man has his
right toe af¥ected and vice versa. If both toes — of
both feet — are involved, the worse is usually upon
the side of the most employed hand.
Anger's and Cotting's operations have been pop-
ular. Anger's requires suturing and Cotting's is
rather easier to perform, while it is rather more cer-
tain of securing success. This latter operation is
performed by a transfixion of flesh and nail with a
sharp pointed knife, and then, from the point of
transfixion, cutting backward and forward so that
a slice containing healthy and unhealthy tissues to-
gether with the hook of the nail is cut away. After
granulation, cicatrization, and contraction of the
open wound are complete, the flesh is drawn away
from the nail and a permanent cure is obtained
through the process of healing.
The method here suggested implies taking two
wooden tongue depressors that should be fixed firm-
ly with adhesive strips in such a manner that the
proximal piece of plaster compresses the bloodves-
sels, by surrounding the proximal phalanx of the
great toe, thus insuring a nonwobbling, bloodless,
operative field that mitigates the dangers of cocaine
absorption by furnishing a free exit through the open
incision, with a blocked entry through the compres-
sion. The distal ends of the two depressors should
have their binding plaster strip free of the toe, i. e..
beyond the outer end. If the wooden depressors
are properly placed, a line drawn with a pencil using
their edges as a ruler and guide, should pass one
eighth inch to the mesial side of the hook of the
offending nail. Whatever projects beyond that
guiding line or protrudes between the guiding edges
of the tongue depressors with which that line was
made should be sawn off with a heavy razor or
suitable knife, and this from a point a full quartc"
inch proximal to the lunula to the distal end of the
slice that is to be removed. Such a slice includes
germ nest, uncus, sound and unsound tissue. Stitch-
ing is not necessary, ligation should be avoided if
possible, and the scar will not touch the sole of the
shoe when walking, later. Healing is expedited by
nonsticking dressings and the absence of the act of
tearing off scabs, together with the employment of
a properly cut shoe. The sole objection to the oper-
November 16, 191S]
LANE: PROPHYLAXIS OF J J AY FEVER.
859
ation is urged upon the grounds of extreme sim-
plicity of method.
The patient should walk well in a week, and usu-
ally has done so in less time; though seventy-two
hours in bed is a great help to rapid healing.
128 West Eighty-sixth Street.
THE PROPHYLAXIS OF HAY FEVER
By H.\rold C. Lane, M. D.,
Denver.
The patient should wear clothing suitable to the
climate, should take cold shower baths in order to
tone up the nervous system, and should abstain
from rich, albuminous, and stimulating foods. These
measures are important in the prophylaxis of the
disease.
Bostock's summer catarrh, or true hay fever, is
very difficult to cure, even the authorities most at
variance with one another are agreed on this point
Adrenalin and the various pollen extracts and anti-
gens give some relief and in many cases apparently
relieve the patient for several years, but as a rule,
eventually the recurrence of hay fever appears. In
addition to the use of pollen extracts, pure white
petrolatiun is a valuable adjuvant if used daily.
It should be liberally inserted in the nostrils, smear-
ed on the roof of the mouth, and rubbed on the
inner and outer canthus of both eyes. It has a
soothing influence and allays the irritation. This
procedure is preferably carried out just before re-
tiring. If the attack is very severe one grain of
powdered pantopon may be used ; the powder is
thoroughly mixed with the petrolatum. This
remedy seems to give great relief. Another im-
portant measure to observe is the brushing of the
teeth. The ordinary tooth powders and pastes are
best discontinued during the course of the disease
as it is known that they contain antiseptics which
are irritating to the mucous membranes when they
are in the inflamed abnormal state during hay fever.
It has been proved that the weakest solutions of
antiseptics will cause an attack of sneezing and all
the other uncomfortable symptoms accompanying
the disease. In brushing the teeth the patient
should not try tc brusff the posterior borders, as
the mucous membrane of the gums in this area are
hypersensitive and often the mere touch of the
tooth brush ushers in the dreaded attack. These
are simple procedures every hay fever patient can
observe. The writer believes the victim of this dis-
ease who follows them will be amply repaid for his
trouble.
Intranasal Operation for Dacryocystitis. — Carl
F. Bookwalter (Annals of Otology, RJi'uwlogx. and
Laryngology, December, 191 /) believes that the re-
sults of the intranasal operation for the relief of
dacryocystitis are ideal if the canaliculi are in good
condition, the operation well done, and the after
treatments carefully carried out. The suppuration
is invariably relieved ; and even in cases with defec-
tive canaliculi, there is little tearing, and then only
at times or with certain positions of the head.
(Published by Permission of the Surgeon General's Office.)
IN MEMORIAL: DR. FRANK BAKER
(1841-1918).
By Fielding H. Garrison, M. D.,
Washington, D. C.
Lieutenant Colonel, Medical Corps, U. S. Army, Surgeon General's
Office.
Dr. Frank Baker, professor of anatomy in
Georgetown University, Washington, D. C., died at
his lesidence on September 30, 1918. Although
well past seventy. Doctor Baker had remained in
full possession of all his powers until the year
1 91 6, when his health began to break and he was
obliged to sever his official relation with the gov-
ernment. Symptoms of heart trouble began to
develop, but his general health was vastly improved
by a visit to the Pacific Coast shortly before his
death.
Doctor Baker was born at Pulaski, N. Y., on
August 22, 1841. His ancestors, who came from
Gloucestershire, England, were New Englanders
who fought in the Revolutionary War, and his
father, Thomas C. Baker, was a well read man.
His schooling was private and local. When the
Civil War broke out, he at once enlisted in the
Thirty-seventh New York Volunteers in 1861,
serving until 1863, when he was transferred to
Washington, where he later entered the government
service and began the study of medicine. On
September 13, 1873, he married Miss May E. Cole,
of Sedgwick, Me., who survives him with six chil-
dren. His son. Colonel Frank C. Baker, M. C, U.
.S. A., is now in France.
Doctor Baker look his M. D. degree at Columbian
(now George Washington) University, and later
received the degrees of A. M. (1888) and Ph. D.
(1890) from Georgetown University. In 1883. he
beci'me professor of anatomy in the Medical School
of Georgetown University, occupying this chair
continuously for thirty-five years (1883-1918). He
became assistant superintendent of the United
States Life Saving Service in 1889, and in 1890 was
made superintendent of the National Zoological
Park, D. C. (1890-1916). Doctor Baker was one
of the founders of the Biological, Anthropological,
and Medical History societies of Washington, was
president of the Association of American Anat-
omists (1897). the Anthropological Society of
Washington (1897-98), the Medical History Clul)
of Washington (1915-16) and secretary of the
Washington Academy of Sciences (1890-1911).
He was editor of the American Anthropologist
(1801-98), one of the collaborators of Billings's
National Medical Dictionary (1890), supplied
the definitions of anatomical and medical terms in
Funk & Wagnalls's Dictionary, and contributed sev-
eral monographs on regional anatomy to the Refer-
ence Handbook of Medical Sciences. His first con-
tribution to medical literature comprised two papers
on President Garfield's case (1881-82), in which he
showed that the wound was caused by the second
bullet and correctly diagnosed its course in a well
accredited diagram made two days after the event.
This was followed by a number of paf)ers on anat-
omy and anthropology, notably The Rational
Method of Teaching Anatomy (1884), What Is
86o
GARRISON: IN MEMORIAM—DR. FRANK BAKER.
[New York
Medical Journal.
Anatomy f (1887), Some Unusual Muscular Anom-
alies (1887), Anthropological Notes un the Human
Hand (1888), Ascent of Man 0890), Nomen-
clature of Nerve Cells (1896), and Primitive Man
(1898). His monoj^raph on the History of Anat-
omy published in Stedman's Handbook compares
favorably with the well known article of Sir Wil-
liam Turner {Encyclopccdia Britannica) , which has
remained the ranking contribution in English. As
one of the founders of the Medical History Club of
Washington, Doctor Baker was a frequent contrib-
utor to its meetings. To these meetings, his wide
knowledge and his kindly presence lent a peculiar
charm, and even before his presidency (1915-16),
he was asked to contribute a paper every year. He
attended nearly every meeting and usually made
highly original comments in the discussion. Since
the death of the late Dr. Robert Fletcher, he was
probably the most erudite physician in Washington.
Among his contributions to medical history were
The Two Sylviuses (1900) and The Relation of
I'esaiixts to Anatomical Illustration (1915), both
read before the Johns Hopkins Medical Society,
a paper on the old Paris Medical Faculty (1913),
the above mentioned History of Anatomy (1913) ;
two papers on Scarpa (191 5) ; and the History of
Body Snatching (1916), still unpublished. Doctor
Baker left a valuable collection of books on
anatomy, all having the well known signs of con-
stant use and study. These have been donated
by his widow to the Library of the Surgeon
General's Office and the Medical Library of
McGill University, Montreal.
Doctor Baker was a man of goodly height and
presence. His fine head was remarkably like that
of some of the great anatomists of the past,
notably Quain and Sir Richard Owen. He had a
lively sense of humor and his pleasant, afifable,
quizzical ways endeared him to all. He was a man
of character, who maintained his views of things,
sometimes in opposition to his fellows, but he was
everywhere beloved and had no enemies. As a
teacher of anatomy, he early saw that didactic
lecturmg has little value, and that the proper place
for instruction is the dissecting room. His lectures,
at Georgetown, therefore, were humanistic, his-
torical, morphological, of ample scope, set off by
demonstrations on the cadaver, which he perform-
ed himself. Latterly, he inclined more and more
to Mall's views of inductive, as opposed to didac-
tic, teaching, while his lectures acquired more of
the historic flavor, through a splendid set of lan-
tern sHdes, selected from the older illustrated
books with rare discrimination. These slides,
which he used with skillful effect at the Vesalian
quadricentennial meetings in the Army Medical
School (Washington) and the Johns Hopkins
Hospital, were not even regarded by him as his
exclusive property but were freely and generously
lent to others. They were remarkably effective in
his lectures to art schools, covering Chotilant's
material and going beyond it. In the classroom,
Doctor Baker had few equals. He was always a
friend of young men, sometimes even fighting
their battles in his impetuous way. As the rector
of Georgetown University said at his funeral, each
of his pupils carried away with him something of
the scholar and gentleman who taught them. In
the medical societies and history clubs, the effect
of his pleasant old fashioned manner was the same;
his comments on papers read were always of
quaint, original quality.
Doctor Baker took the present war very serious-
ly to heart. Familiar as he was with the German
masters of his subject, and imbued with the earlier
Germanic ideals of the romantic period, the de-
fection of Germany from the vanguard of civil-
ization affected him gravely. In his early man-
hood, he became intimate with Walt Whitman and
john Burroughs — all three in fact having been in
the government service together, and remaining
lifelong friends. As a friend and familiar of our
greatest poet, his views of the infinite variety and
impartiality of nature and of the solidarity of hu-
man interests were those of all "liberators of the
hum.an spirit," of whom Walt Whitman was
assuredly one. When the present war broke out.
Baker saw, and even stated, that the Prussian idea
is that of a narrow, selfish clan;,manship, some-
thing very different from the multiform, human-
istic Germany of the past, and that such arrogant
clansmanship, with its monstrous, maladroit am-
bition to reduce all nature to a dreary monotone
and all mankind to a mechanical pattern, in-
variably leads to factional, sectional, racial, and
national hatreds, and so is the true breeder and
perpetuator of wars —
"The children born of thee are sword and fire,
Red ruin and the breaking up of laws."
Fev/ realize how many have broken their spirits
over this war. In 1861, Doctor Baker was one of
those who responded to the first call. The service
flag of his family now numbers no less than five
stars ; he wotild have been an honor to any country,
and dying as he did of heart failure, it is perhaps
no exaggeration to say that, as with Brunton,
Gaskell, Minot, and so many others, he himself
was a martyr to the present cause. Those of us
who were his pupils and whom he honored with
his friendship can only express our deep sympathy
with his family and the sense of an irreparable
loss.
BIBLIOGRAPHY OF DR. FRANK BAKER
President Garfield's Case: A Diagnosis Made on July 4th, IValsk's
Retrosfect, Washington, 1881, IV, 617-622.
President Garfield's Case (again), Medical News, Philadelphia,
1S82. XLI, 11511Q.
The Rational Method of Teaching Anatomy, Medical Record,
New York, 1884. XXV, 421-425.
What Is Anatomy? New York Medical Journal, 1887, XLVI,
4.';i-457-
Some Unusual Muscular Anomalies, Mdical Record, New York,
18S7, XXXII, 809-aii.
Anth- op.-ilogicnl Notes on the Humnn Hand, American Anthropol-
ogist, Washington, 1888, I, 51-75.
The Ascent of Man, American Anthropologist, Washington, 1890,
III, 297-319-
Recent Discoveries in the Nervous System, Nnw York Midical
Journal, 1S93, LVII, 657-685.
The Nomenclature of Ner\'e Cells, New York Medical Journal,
1896, LXIIl. .^73.
The Anatomy ,-ind Physiology of the Ear, National Medical
Review. Washington, 1898-9, VIII, 240-2.14.
Primitive Man, American Anthropologist, Washington, 1898, XI.
357-366.
The Two Sylviuses: An Historical Study, Johns Hopkins Hospital
Bulletin. Baltimore, 1909. XX, 329-139.
History of Anatomy, Stedman's Reference Handbook of Medical
Sciences. New York, .third edition, 1913, I, 323-345.
The Faculty of Paris in the Seventeenth Century, New York
Medical Journal, 1913, XCVIII, 115-121.
The Relation of Ves.alius to Anatomical Illustration, Johns Hop-
kins Hospital Bulletin, 1915. XXVI, 120.
Antonio Scaroa, 1015 (unpublished).
History of Body Snatching, 1916 (unpublished).
Medicine and Surgery in the Army and Navy
(Published by permission of the Surgeon General, United
States Army.)
THE CARREL-DAKIN TREATMENT OF IN-
FECTED WOUNDS.
By William Fuller, M. D.,
Chicago.
Major, Medical Reserve Corps, United States Army.
The price a nation pays in wounded and dead in
time of war is often appalling. Opposition to any
measure whose object and aim it is to lessen the
horrors that follow in the wake of war is un-
thinkable and intolerable. At a time like the pres-
ent, when the nation is calling keenly upon all its
resources, German propaganda and the mutterings
of babbling pacifists are scarcely more harmful than
the teachings and influences which hinder and ham-
per the utilization of lifesaving measures whose
worth and value have been so unmistakably demon-
strated as those of the Carrel-Dakin treatment of
infected wounds.
The object of this preliminary report is, first, to
add another word in support of the evidence which
has already established the unequaled success of
this means of treating infected wounds, and to
point out the selfevident fact that the daily use of
the Dakin solution in the treatment of such wounds,
in many parts of the country, is relegating to their
proper places, the idle and baseless criticisms which
unfortunately found their way into print, and
which had their origin in minds unfamiliar with
what they attempted to write. Secondly, to reas-
sure those whose confidence in the Dakin treatment
has been shaken or shattered by the harmful and
hurtful opinions of those who know but little of the
real merits of the treatment; to urge that the in-
telligent application of an accuratelv made solution,
according to Dakin, instilled into properly prepared
wounds, as directed by Carrel and Dehelly, will
prove no more disappointing to those who thus will
use it than it did to us.
It is strange that men who have borne reputa-
tions for truth and have ostensibly aided in the so-
lution and settlement of mooted questions in medi-
cine should now throw to the winds all regard for
those virtues, and rush into print with condemna-
tion of something, regarding which they possess so
little real knowledge — abundant proof of which is
contained in every line written.
First hand knowledge of the Dakin treatment of
infected wounds is attained only after time, pains,
and patience have been exercised in the personal
use of the treatment. Only from knowledge thus
acquired do we get defenders of and pleaders
for this method of treating infected wounds ; from
such knowledge do we obtain the daily increase in
the number of men who are ready eagerly to join in
protest against those hostile and bitter expressions
which have already done much harm.
Many criticisms of this treatment, doubtless, had
their origin, as we know a few did, in the per-
functory use of solutions which were not Dakin's.
and by employing a technic which is not Carrel's.
One of the severest criticisms lodged against this
treatment grew out of less than a single day's time
spent on the part of one "investigator" in observ-
ing the treatment in action. Some of these reports
have sprung from sources out of which better things
might be expected. Coming from "educators" of
the profession, greater influence for good or bad is
wielded than when coming from less notable mem-
bers of the profession. We should, therefore, deem
it a privilege — indeed a pleasure — to protest till all
such criticisms are crowded well into the limelight
of ridicule where they ultimately find a haven so
befitting them.
The making of Dakin's solution is not "compli-
cated and time-consuming," nor is it "an expensive
plan of treatment on our medical service." One
man can, with time to spare, supply ample fluid for
use in hundreds of wounds as we have demon-
strated. At Camp Cody one young man supplies
all the solution required for treating a large number
of all kinds of wounds, including empyemas, which
require unusually large quantities of the fluid, and
does this at odd moments when not engaged in his
regular dispensary work.
MAIN principles OF THE TREATMENT.
It is indispensable that the wound, first of all,
should receive adequate surgical treatment and
preparation for the instillation of the fluid ; it should
be opened thoroughly, every nook and corner being
exposed to view and within range of the fluid
through the properly placed distributing tubes. Per-
foration of the tubes is important and directions in
this step should be implicitly followed ; they should
be placed in sufficient number, and in correct rela-
tion to the wound surface, so that all parts of the
wound may be bathed thoroughly with the solution
at each and every instillation. The skin must be
protected by pads treated with petrolatum. At each
change of the dressings, the tubes should be exam-
ined to see that they are not blocked and that all
parts of the wound are receiving the solution.
The presence of unsuspected or hidden foci of in-
fection, foreign bodies — bullets, particles of cloth-
ing, overlooked sponges, or gauze strips in the
wound, as happened in one of our cases — or 3.ny\
hindrance of whatever kind that may prevent per-
fect ^nd complete ablution, continually or intermit-
tently, of all parts of the wound, will result in
failure to sterilize the wound.
If concentration of the fluid is maintained and in-
stilled properly into the wound, and all other details ,
looked after, the bacterial count will promptly fall. [
Should the count remain high, after a few days'
treatment, thorough inspection of the wound and
apparatus generally should be made. These steps
will lay bare many unsuspected reasons for lack of
wound disinfection and prolonged suppuration. It
has appeared to me that the surgeon often fails to
fully appreciate the condition of the wound ; that
long drawn out suppurative processes are taken fre-
quently as a matter of course, and are left to time
and good fortune to rectify. It is therefore imper^
862
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
ative that good surgery go hand in hand with a
^ Dakin treatment ; one is indispensable to the other.
Failure to understand this point often has led to
rejection of the treatment, as being useless.
In a general way it may be said that the size and
character of the wound will largely determine the
kind and number of the tubes to be used. They
must occupy a definite position on and in every
wound, and means of thus maintaining the proper
positions of the tubes must be observed. "Reading"
and hearsay evidence will not aflford the required
knowledge, which is to be had only by personal
contact with the treatment. The obstruction of a
single tube, the use of a drop counter with several
tubes, displacement of a dressing, or any error that
may prevent proper instillation of the fluid will lead
to disappointment. The drop by drop method is
possible or desirable only with one tube containing
no holes but open at both ends, or with a single
tube perforated in the usual manner and covered by
tissu espong. The manner of instilling the fluid
into the wound intermittently differs in all respects
from the continuous instillation. Principles of this
kind are often entirely overlooked, if they are ever
appreciated.
Besides having noted the utter lack of apprecia-
tion of the importance of properly preparing the
wound to receive the solution, we have noticed also
that instead of the tubes recommended by Carrel,
large, ungainly drainage tubes, perforated here and
there by awkwardly placed holes made by scissors,
have been used. In one instance of this kind the fluid
in use had not been titrated and its origin or source
was unknown ; the skin was receiving no protection,
and the whole technic constituted a perfect jumble of
ill advised and erroneous steps. Under these chaotic
conditions a fluid, supposed to be Dakin's, at odd
intervals — when not forgotten — was injected into
the wounds. And from this interpretation and un-
derstanding of the Carrel method we read opinions
from time to time as to its efficacy in the treatment
of infected wounds !
These statements are not made to be facetious or
to belittle the efforts of others, but only because
these things actually have been witnessed in opera-
tion, and to point out how utterly wide of the
mark one may actually be led by mere reading with-
out knowing, or looking without seeing.
PERSONAL EXPERIEN'CE WITH THE TREATMENT.
Our opportunities for putting the Carrel treat-
ment to conclusive tests have been very satisfactory.
Empyemas. compound fractures. amputation
stumps that became infected, large and extensive
phlegmons of the trunk and extremities, gunshot
wounds, acute suppurative bone lesions — all have
yielded to the treatment, with but a single excep-
tion.
This exception was in the empyemas, reference
^ to which will be made later. Explanations of
failure to sterili/.e wounds were invariably forth-
coming upon carefullv inspecting the apparatus in
use or the condition of the wound. Almost without
exception a tube was found blocked or dislodged,
the dressing deranged, the fluid was above or below
the required figure, or a little further surgery was
needed in the wound. Following a correction of
the error rapid j^rogress toward wound disinfection
was established. Infected hands and fingers result-
ing in deep palmar abscesses and tendon implica-
tions have never yielded to treatment in previous
years as they have done since the beginning of this
treatment.
The most serious of all infected wounds we met
with was a compound comminuted Pott's fracture.
The fourth day after the injury the patient, a
civilian, fifty years of age, was in a serious condi-
tion. His temperature was high, his pulse rapid ;
the skin sallow and muddy, hot and dry ; there
was a pronounced delirium and the patient appeared
septic and very sick. The wound presented an ap-
pearance with which all surgeons are more or less
familiar : there was a large opening on the inner
side of the ankle through which some two inches of
the tibia protruded ; the wound contained many
ounces of a bloody or dark colored, foul smelling
fluid ; the leg up to the popliteal space was discol-
ored, tense and tight. Several pieces of loose bone
were lying about in the wound.
The treatment of this almost hopeless condition
was begun by ignoring the fractures — an important
feature in treating most compound fractures. The
foot was further everted, the wound opened up in
all directions, the loose fragments of bone were re-
moved, as well as all dead tissue. The calf tissues
were well opened up, and into this most extensive
and septic wound Dakin's tubes were liberally
placed and the treatment started. The temperature
fell, the pulse likewise ; the delirium disappeared,
sleep was restored, pain ceased, the general condi-
tion improved in every way. The wound, which
at first was most offensive, gave out no further
odor ; the drainage diminished daily ; the hard and
tense feel which was so noticeable at first in all the
soft parts around the wound disappeared ; granula-
tions sprung promptly into notice ; the limb could
be handled without causing pain to the patient.
Optimism and good cheer best describe the mood
of the patient. This case is recited somewhat in
detail because it represents a fair problem by which
the efficiency of this treatment can be judged.
It has been my fortune to have had some experi-
ence, in former years, with similar instances, but it
is putting it in the fairest sort of a way to say that
I never have seen any treatment which equaled the
one which here is outlined.
Empyemas offer greater difficulties to us than do
many other suppurative conditions. Explanations
for this are clear when we consider the impos-
sibility of determining the extent and dimensions
of many suppurating pleural cavities. There may
be encysted pus pockets not found at the operations,
or undetected and unknown parts of a single cavity
may remain unexplored. It has been frequently our
experience to find many partitions in the chest cav-
ity dividing the pus collection into more than one
pocket, many of which are not recognized and which
of course, remain unopened and therefore impossible
of irrigation.
Failure to sterilize such a wound as has just been
described should not be charged against any par-
ticular method of wound disinfection, but against
procrastination on the part of the internist in mak-
Xovembir ib. lyi.s.J
MEDICINE AND SURGERY THE ARMY AND NAI Y.
863
ing the diagnosis until extensive and irreparable
damage has been done, and to the inability of sur-
geons to render by operation such conditions ac-
cessible to proper and efficient treatment. Digress-
ing a moment from the issue, may we not suggest
that in a given series of cases of pleural suppura-
tions, if the diagnosis were made very early — be-
fore great pathologic changes have occurred — would
not the surgical therapy be a simple matter? Would
surgeons ever need to think of a Schede or an Est-
lander operation? Could they not under these con-
ditions empty the first small quantity of pus, as a
rule, from a single cavity, whose complete oblitera-
tion would assuredly occur from the prompt ex-
pansion of a lung not yet greatly crippled or fixed
by adhesions?
It has been stated by the internist that the condi-
tion in the pleural cavity here described and often
found by the surgeon may be brought about within
a day or two ; that the compressed and collapsed
lung, firmly bound down by adhesions and bands
which also partition the pleural cavities into many
pus pockets are not due to procrastination on their
part, but are due to the seriousness and virulence of
the infection. From these contentions we will not
dissent, but must call attention to the fact that such
widespread pathologic changes do not occur in so
short a time in any other cavity or tissue in the
human body.
Possibly, when we cease to consider such impos-
sible conditions as unresolved pneumonias and re-
gard such supposed findings as lung abscesses,
tuberculosis, pleural suppurations, or whatever they
may be, pleural empyemas will come into their own,
which is an early diagnosis always, leading in-
evitably to a line of prompt treatment much more
simple and effective than we now possess. This is
the route we followed when we discovered the safe
and certain treatment in kidney surgery, in gall-
bladder surgery, and in the cure of peritonitis
which, regardless of its origin, carries with it a
frightful mortality when not dealt with early, and
unquestionably is the explanation for a notable in-
crease in the percentage of cures effected even in
malignant disease today.
A neutral hypochlorite of soda solution, made;
according to Dakin, kills alike bacteria in vitro and
in vivo. It is so easily demonstrated by the simplest
kind of experiment that any one who so desires can
carry it to quick and satisfactory conclusion.
Wounds can be so completely sterilized that ulti-
mate closure by suture is a final and feasible step,
and can be much earlier carried into execution
than has ever been done before in the management
of septic wounds. This treatment can, and no doubt
will, eliminate the pus service from our hospitals.
The declarations made in this connection by the
authors of this treatment seem, to those who do not
understand, a little extreme ; but such is not the
case. The statement is a modest one, full of truth,
and possible of verification in the hands of any
medical man who knows the work and will follow
the rules that govern the use of the treatment.
ECONOMIC FE.^TURK OF THE TRE.ATMENT.
The economic feature of the Dakin treatment is
one of its important points. By lessening the mor-
l)idity and mortality, it diminishes, by a figure close
10 fifty per cent., the convalescent period, thus ne-
cessitating less care and attention while in the hos-
pital, fewer dressings, and all other items essential
to the care of the sick. The economic value of the
Carrel-Dakin method needs no further argument.
To witness the change of a single dressing in the
treatment of an infected wound is all that is needed
to be convinced that it is the simplest, most effective,
least time consuming, and the most practical proce-
dure of all methods. Bandages are not used, thus
eliminating one of the most difficult parts of wound
dressings ; the patient is not removed to the dressing
room, but is dressed in his own bed. The wooden
clothespins which hold the dressings on the wound
are let loose, and the large outside pads fall away
from the wound much in the manner that one opens
a book. The gauze from around the tubes is re-
moved ; the tubes are changed or inspected ; the
wound is sought in its most unclean localities for
smears, then washed with the neutral soap ; tubes
are then replaced, surrounded by gauze as before,
and the pads fixed on the outside by refastening the
clothespins.
A point not generally touched upon, and which I
here wish to emphasize is this : The patient, the
most concerned of all, will furnish good proof of
the progress that is being made. When all is going
well he is optimistic, suffers little, and often has no
pain. He enjoys the dressings, is pleased with the
way his wound looks ; he eats well, sleeps well,
takes on weight, and his every word and action be-
speak his true condition. Contrast this with the
condition of the patient who, by other or older
methods of treatment, is not doing well : he sleeps
poorly, has no appetite, and is disturbed by having
his dressings done. The handling of his wound is
exceedingly painful, and so much so that he often
begs the surgeon not to touch him, preferring to
leave it untouched regardless of consequences. He
often despairs of improvement and becomes de-
cidedly indifferent as to the outcome. This picture
is not at all strange to the surgeon, who at this mo-
ment can recall many such cases, but is one which I
have not seen in the treatment of any wound which
had timely and efficient treatment with the Dakin
solution.
Bacterial counting during wound repair is neces-
sary. A wound clinically clean, as Carrel has
pointed out and as surgeons generally well know, is
not necessarily so bacteriologically. Daily diminu-
tion in the number of microbes in a wound is proof
.positive that success is assured and that correct
/ reading of the bacterial chart points clearly to the
day at which closure of the wound by suture may
safely be made.
EMPLOYMENT OF TREATMENT.
The Carrel-Dakin treatment is involved in no
mystery. It is easily learned and can be put to prac-
tical u.se by any physician who will take the pains
and time to learn a few essentials. It is not learned
by "reading" or "following" the literature, and an.
opinion thus acquired justifies in no sense an ex-
pression about it, be it good or bad. Personal daily
use of it in all kinds of unclean wounds for a defi-
nite length of time is the only procedure that will
864
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
justify an opinion; this alone will entitle one to
speak upon its merits or demerits.
Satisfactory management of practically all sup-
purating wounds has always been a sad chapter in
surgery ; it has been shunned by the "clean" operat-
ing surgeon, and seen by him — when seen at all — in
the most casual way. The newest intern or the
laziest one, usually draws this as his first hospital
prize, and struggles with it as best he can, often
without help, advice, or suggestion. The patient
frequently swims in his own pus for days, runs a
high temperature, spends sleepless nights, dreads the
dressings, hates the hospital, and feels no great love
for the attending surgeon. Besides contaminating
everything and everybody, he becomes an eyesore to
all, and a burden to himself!
When we were granted the request to take the
Carrel-Dakin course at the War Demonstration
Hospital in New York, we felt, at the end of the
first day's work that the two weeks' time spent there
would be a complete loss, especially after some of
the ablest men of the city warned us that all that
was worth getting could be had in two hours. Major
Stewart, who gave us the first talk on the treatment,
in the course of the work made claims which, to us,
were startling, and made us all feel that right at
that moment, we, too, had opinions worthy of ex-
pression on the treatment. We were plainly told by
that young man that pus in our hospitals was our
own fault, or would be ; that the pus service could
practically be eliminated from the hospital ; and that
of these things we would all likely become con-
vinced before leaving the work. We did, not only
of all that was said there, but of more since trying
it out ourselves.
Pus wards and pus service are odious terms which
have long darkened the pages of surgical history,
and little has been done until the present in eradi-
cating this stigma. The management under v/hich
this chapter in surgical literature bids fair now to
become a forgotten one is meeting with that same
ugly opposition which has always met great and
beneficent changes. Most questions, however, are
satisfactorily settled by time, study, sober and seri-
ous thinking, and by minds and intellects that are
honest, able, and farseeing.
It is also true, as our critic says, that there exists
a "small corps of enthusiasts of the type that is
easily carried away by new and startling methods" ;
but while these men may, at times, prematurely and
hurriedly acclaim the merits of new departures and
discoveries which are insufficiently tried, they, at
least, are alert, aggressive, and are never opinionated
and steeped in methods of stereotyped thought to the
extent of wholly missing the issue until it is about
time to replace it with even better things.
Empyema in Military Camps. — Eugene W.
Rockey (Military Surgeon, October. 1918) con-
cludes as to treatment that : Pneumococcus em-
pyema was treated successfully by rib resection and
simple drainage. From the progress of the yet in-
complete cases Rockey states it is felt that the most
efficient method of treating streptococcus empyema
at Camp Lewis has been by thoracotomy with con-
stant negative pressure.
The Foot Problem in the Army. — Tom S.
Mebane (Military Surgeon, October, 1918) states
that the following is a synopsis of the course of
training at Camp Beauregard of enlisted men, to fit
them to act as company noncommissioned foot offi-
cers and regimental chiropodists: I. Anatomy and
physiology of the foot. 2. Arch trouble ; patho-
logical conditions of longitudinal and anterior
arches, with causes and treatment. 3. Foot defor-
mities involving the forefoot; bunions; hammer
toes, etc. 4. Foot exercises and general manage-
ment of weak feet. 5. The army shoe construction,
care, repair, orthopedic modifications. 6. Shoe fit-
ting. 7. Care of feet; care of socks. 8. Asepsis;
technic in chiropody. 9. Corns and calluses ; na-
ture, cause, prevention, treatment. 10. Ingrown
nails, irritations, blisters, excoriations. 11. Trench
foot ; rarer causes of foot trouble ; circulatory,
nervous, skin diseases. 12. Brief consideration of
sprains. 13. Demonstration of the use of adhesive
plaster ; felt ; straps, etc. 14. Prevention of foot
trouble. 15. General review. At the termination of
the course the men were given an exammation, and
a letter sent to their commanding officers stating the
nature of the men's work. If a man successfully
completed the course, he was certified as able to do
the following, subject to the direction of his com-
manding officer: i. To measure the feet of the en-
listed men for shoes and to see that they received
those shoes. 2. To give the foot strengthening ex-
ercises and see that the corrected shoes ordered by
the orthopedic surgeon are worn. 3. To treat minor
foot conditions, as corns, calluses, irritations, etc.
4. To give first aid foot treatment in the field.
MEDICAL NEWS FROM WASHINGTON.
Additional Demands upon Medical and Hospital Corps. —
Noted Specialists in Medicine and Surgery Conduct Lec-
ture Course. — Health Conditions in Navy. — Changes
Among Medical Personnel. — Release of Officers Follow-
ing Decline of Inflitcnca Epidemic.
Washington, D. C, November 11, igi8.
With the approach of peace additional demands
will be made upon the hospital facilities of the army
and navy as well as upon the personnel of the med-
ical and hospital corps. Now, mori^ than at any
other time since the war began, will occur the slack-
ing up and relaxation that inevitably come with the
release of tension under which soldiers, sailors, and
marines have been for the past year and a half.
Men that heretofore have refused all medical treat-
ment, now that the strain is over, to a large extent,
will apply for attention. Not only that, but the de-
mand for hospital facilities on the other side will be-
come increasingly greater as the forces are with-
drawn from the front. It is believed by the medical
authorities that there should be no let up in the ac-
tivities of their branches of the services or in the
organization and training of additional medical per-
sonnel.
H< 3{c s}c :^
A lecture course of unusual interest, because of
the prominence of the faculty, is being conducted
for the benefit of naval medical officers and nurses
at the naval training station. Great Lakes, 111. The
course consists of a lecture every few days through-
November i6, 1918 ]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
865
out the fall, winter, and spring, upon subjects di-
rectly pertainirtg to the duties of the physician, sur-
geon, and nurse. Among the lecturers will be some
of the most noted specialists in medicine and surgery
in the middle west, and the class will consist of sev-
eral hundred medical officers and nurses.
if if *
With the exception of the third, sixth, and twelfth
naval districts, health conditions in the naval estab-
lishment ashore have reverted to normal. In the
third district, which includes New York city and
vicinity, the epidemic of influenza was slow in de-
veloping and correspondingly is somewhat delayed
in recession. The sixth district includes the im-
mense recruit depot of the marine corps at Paris
Island, S. C, and the epidemic has been kept alive
by the influx of new recruits. At Mare Island,
Cal., in the twelfth district, the epidemic is still
raging.
^ ^ if ^- if
If the recent assumption of duties of the surgeon
general of the arm.y by Major General jNIerritte W.
Ireland is to result in changes of duties of high rank-
ing medical officers at Washington and elsewhere,
it is understood that they will be efifected only after
mature deliberation, if they are made to any extent.
General Ireland proposes to proceed without vio-
lence in his administration of the aftairs of the army
medical department, and so far only the necessary
routine orders have been issued.
The most important change lately made among
the army medical personnel is the assignment of
Colonel Winford Smith, formerly superintendent of
Johns Hopkins Hospital at Baltimore, as head of
the hospital division of the Surgeon General's Office,
as successor to Major General Robert E. Noble,
who recently went to France to succeed General
Ireland as head of the medical department of the
American expeditionary forces. Since the depart-
ure of General Ireland and until the arrival of Gen-
eral Noble, Colonel Walter D. McCaw, Medical
Corps, has been performing those duties.
*****
Surgeon General Rupert Blue, of the Public
Health Service, has sent a letter to Rear Admiral
William C. Braisted, Surgeon General of the navy,
in which he states :
"The medical officer in charge of service opera-
tions in the District of Columbia reports that the
need for medical relief for influenza sufferers has
passed. He was, therefore, enabled on November
1st to release the corps of officers detailed by you
for this work.
"It has been reported to me, both personally and
officially, that the work of your officers deserves the
highest praise. Their unflagging devotion to the
work and the spirit of willingness to serve without
regard to hours or personal comfort was in keeping
with the high traditions of the Navy Medical Corps.
"I congratulate you upon having this splendid
body of officers and assure you of the deep appre-
ciation that I feel for the services which they have
rendered."
New Army Hospital Facilities. — Hospital facil-
ities to care for ty.^cx) men have been procured by
the hospital division of the Medical Corps during
the past month, according to a statement issued
from the Office of the Surgeon General on October
29th. This brings the hospital facilities, outside of
camps and cantonments, up to 50,000, or about one
third of the estimated need of the army for the
coming eighteen months, says the Army and Navy
Journal for November 9, 191 8. The new hospitals
were secured at a lower average cost per bed than
had previously been obtained. This is the result of
several gifts of splendid groups of buildings by
patriotic communities and individuals. Under the
new policy of the Medical Department efforts are
made to secure existing buildings for hospitals,
thereby increasing more rapidly the desired facilities
and at the same time avoiding the erection of new
buildings at a time when labor and materials are
very scarce. To make the new buildings ready for
army hospital purposes alterations costing approxi-
mately $995,000 will have to be made.
The largest hospital secured during the past
four weeks was the St. Louis Sanitarium. This
is one of the finest buildings of its class in the
country and will provide facilities for the caring for
3,000 patients. In point of size and equipment the
Ohio State Hospital for the Criminal Insane is the
next largest secured. It is located at Lima and is
regarded as among the finest types of State hospitals
in America. There are facilities for 2,500 patients.
The use of the buildings is a gift from the State.
Three other hospitals, each of 1,000 or more beds
were secured in Ohio, in Cleveland, Columbus, and
Cincinnati. The Cleveland Hospital was built as a
model factory and its owners, Richmond Brothers,
turned it over as their contribution to the war.
Adjacent are the several buildings of the Deutscher
Turnverein, turned over as a contribution of the
society to the government. Accommodations for
1,000 beds are provided by these gifts. At Colum-
bus the buildings of the State School for the Deaf
are a contribution of the State. Beds for 1,500 sol-
diers are provided by this gift. Through the Board
of Education, the East End High School at Hyde
Park, Cincinnati, was secured. Here alterations
costing about $100,000 will have to be made to con-
vert the classrooms into wards. About 2.000 men
will be treated in this hospital.
The completely appointed hospital built by Henry
Ford for his employees at Detroit, which has a
capacity of 2,000 beds, has been turned over by him,
rent free. The nine buildings in Exposition Park,
Rochester, N. Y., were accepted rent free for hos-
pital purposes. It will be necessary to spend $175,000
to make necessary alterations. The Norfolk. Mass..
State Hcspital, recently built for the cure of drug
addicts, and w-hich has accommodations for 700
beds, was turned over rent free by the State of
Massachusetts. The large armory in Boston has
been rented for hospital purposes, and after altera-
tions, which will cost about $60,000, will be ready
to accommodate 1,200 patients. The Westchester,
N. Y.. Alms House which will accommodate 2,000
l^atients and the West Baden, Ind., Hotel with 1,200
beds have also been taken.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
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tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, NOVEMBER 16, 1918.
LS INFLUENZA DUE TO A FILTERABLE
VIRUS?
In an endeavor to determine whether the pres-
ent epidemic of influenza is due to a filterable
virus, Rosenati introduced the filtrate of the
washings from the nose and throat in two cases
of influenza into the noses of nine volunteers, all
of them enlisted men in the L^nited States Navy.
From the account published in the Official Bulle-
tin it appears that "the influenza cases selected
were typical, with definite history of recent ex-
posure. One was in the second day of the disease
and the other in the fourth day. The nose and
throat of each patient was washed and gargled
with seventy-five cubic centimetres of sterile nor-
mal saline solution. Throat swabbings and spu-
tum were added to the separately collected wash-
ings. Each was shaken with beads in a sterile
bottle and filtered through a Handler diatomace-
ous earth filter by means of a water vacuum
pump. One filter had a positive pressure value
of nine pounds and the other twelve pounds.
Ctiltures were made from the clear filtrates for
control.
"The filtrates were then carried to Deer Island,
where about 0.5 cubic centimetre was introduced
into the nose of each of the volunteers, five re-
ceiving the filtrate from one patient and four from
the other. Three and one half hours had elapsed
from the time of obtaining the nasal washings to
the time of the instillation. The control cultures
were negative for bacterial growth and none of
tlie nine volunteers showed symptoms of influ-
enza during ten days of isolation."
In contrast to this is a cabled newspaper dis-
patch from Paris to the effect that NicoUe has
proved the germ of influenza to be ultramicro-
scopic.
The extremely high degree of infectivity which
characterizes influenza, the frequent occurrence
of epidemics in summer, the finding of PfeifTer's
bacillus in conditions other than influenza, and
the frequent absence of this organism in cases of
typical influenza, make it more than likely that
the disease is caused by a microorganism not yet
identified, and possibly by one so small as to con-
stitute a filterable virus. Further developments
will be awaited with interest.
THE COMMITTEE OF FOURTEEN AND ITS
FIGHT FOR A CLEAN CITY.
It is scarcely possible to do more than call atten-
tion to such a report as that of the work of the
Committee of Fourteen in its fight in New York
city against the social evil. It is a story which must
be read in its entirety. [J. P. Peters : The Story
of the Committee of Fourteen of New York, Social
Hygiene, July, 1918.] It is not alone a story of
social battle in the interests of good citizenship and
a clean city ; it is likewise a chapter of history
which should lie close to medical interest and .'is
a background to medical activity. This is particu-
larly so as the medical profession comes more and
more fully to accept the fact that its stronghold for
public service lies in prophylaxis. And this pro-
phylaxis, in turn, as recent events have brought
home to us, must be most vigorously undertaken in
the field of venereal disease. Here medical activity
and social eff'ort come closely into harmony of aim
and endeavor ; at least it should be most emphati-
cally so.
This report has been made with a recognition of
the fact, at the start, that liquor traffic and prosti-
tution are indissolubly bound, and have been so in
this history of political profiteering in New York
State and city, which is here set down. The story
November i6, 1918.]
ED/TORIAL ARTICLES.
867
begins, chiefly, back in 1896 when the Raines law
was passed and went into effect in order that the
Republican Party for the sake of revenue and
greater power might obtain control of the liquor
traffic of the city of New York. The results of the
actual working cut of the law were unforeseen. In
the first place it abolished the discretion which had
before been wholesomely exercised by the excise
commissioners in regard to the opening of saloons.
The issuance of licenses now became formal and
automatic. The provisions of the law were such
that a strict control might have been secured over
the liquor traffic, but it was exercised not for con-
trol but for revenue, and, moreover, its automatic
cliaracter in the infliction of penalties for its in-
fringement made of it a shield for its violation.
The excise commissioner's first duty became the
obtaining of revenue. Therefore, in the first place,
a lax interpretation was allowed in order that the
number of saloons might increase ; furthermore a
distinction between hotels and saloons incorporated
in the law was destined to work untold evil. Hotels
had the great pecuniary advantage that liquor could
be sold within them at all times, which the saloon
could not. The features which constituted a hotel,
adopted from the State law, were just those which
could be turned to the saloon keeper's further ac-
count financially. If to secure a hotel license, which
meant increased revenue for himself as well as for
the State, he must have the required number of bed-
rooms, with a diningroom and kitchen, these also
would be used for profit. The result was a bur-
geoning forth of prostitution throughout the city,
in localities hitherto under the control of respectable
citizens as well as in spots more favorable for the
fiagrancy with which this business was carried on.
Seduction was the chief of these evil fruits of the
Raines law.
The difficulties which the Committee of Fourteen,
at first the Committee of Fifteen — both composed
of citizens whose desire wtls a clean city — had to
meet were due to the laxity of justice which fol-
lowed upon this train of evils. Rather it fostered
them, as it had in the first place been instrumental
in creating them. The evading and shifting of di-
rect responsibility on the part of those who were
prosecuted merely increased the revenue through
fines imposed without eventually removing the ob-
jectionable saloon or hotel. It continued its busi-
ness under conditions just different enough to be
merely nominal and it was too much trouble or was
not deemed profitable on the part of the prosecutors
to continue the prosecution.
The tale of the efforts of the committees working
really to eradicate the evils is the record of a hard
and determined fight to unearth such abuses, fol-
low them up, persist until those in authority in city
and State must yield and cooperate, even if, like the
unjust judge in the Bible, only because of their
importunity. So broad and reasonable has been the
policy of the Committee of Fourteen that it has
secured the sympathy and support of all forms of
organization, even of the brewers and liquor asso-
ciations in New York city, though at first indirectly
the Raines law hotels and other places where li([Uor
was sold had been under their control.
The present work of the committee has passed
beyond that of the original and long continued
struggle to awaken the public authorities of both
city and State to a sense of responsibility, to* a
knowledge of the evil results following their former
policy and partly, at least, to the conception of con-
trol of liquor traffic as a thing in itself of utmost
importance for the establishment and maintaining
of clean and wholesome conditions and not for
revenue, with an utter disregard or a wilful foster-
ing of the evils which follow in its train. Now the
work can be carried on with more broadly con-
structive plans to provide opportunities for the
healthful discharge of impulse and activity in chan-
nels of clean living and social and recreational pur-
suits. Various permanent reforms in the courts
stand out also as results of the committee's activi-
ties. The gathering of soldiers and sailors due to
the war has given to the work a still broader field of
effort and opportunity.
THE TORONTO MILITARY BASE
HOSPITAL.
The week ending November 2d may be said to
have been a "hot" one in Toronto. The epidemic
of influenza had about reached the crest (the
deaths daily running somewhat over one hundred —
seventy-seven men having died in a month in the
Toronto Military Base Hospital) when a coroner's
jury began inquiry into the death of one of the
Royal Air Force men in that institution. For some
time past complaints had been pouring into the
office of the chief magistrate of the city, Mayor
Church, and to his activity and wholehearted inter-
est in the welfare of the soldier, particularly as re-
gards hospital accommodation and medical care,
must be ascribed the bringing of the Toronto Mili-
tary Base Hospital into the limelight. This insti-
tution, which is the old Toronto General Hospital,
renovated and refitted two and a half to three years
ago, did not begin to meet the requirements of the
soldiers in this military district ; especially during
the active stages of the epidemic. A hospital build-
ing which would be considered overcrowded with
868
EDITORIAL ARTICLES.
[New York
Medical Journal.
400 patients, was required dnring tlie epidemic to
accommodate 700 or more.
At the inquest mentioned Major General John T.
Fotheringham, C. M. G., director general of the
Army Medical Service in Canada, was summoned
from Ottawa to give evidence ; also General Carle-
ton Jones, who formerly occupied that position but
is now in charge of hospitalization \\^ Canada. Gen-
eral Fotheringham stood by the institution and
characterized the adverse criticism in certain sec-
tions of the public press, which he claimed was par-
ticularly directed against the Army Medical Service,
as "dirty, stinking, putrid treatment." The press,
which claims to be not thinskinned, grandiloquently
waved this aspersion aside ; but they were not so
pachydermatous as they would have the reading
public believe, for demands w^ere made for Doctor
Fotheringham's resignation, or, failing that, his in-
stant dismissal. Later on, when General Jones
came before the jury, and his evidence as to the
fitness of the hospital for its purposes was not con-
sidered satisfactory, his head also was demanded.
All this before the jury had inspected the institu-
tion and before that body had given its findings — a
clear attempt on the part of the public press to
force the issue. It appears General Jones had been
in Toronto but had not personally inspected the in-
stitution, making his report thereon from informa-
tion gathered from the Army Department of Medi-
cal Service for the Toronto military district. In that
respect General Jones was lax, but surely both he
and General Fotheringham are entitled to their per-
sonal opinions of the institution as well as any one
else.
General Fotheringham is one of the most high
minded, most eminent and upright members of the
medical profession in Canada. The government of
Canada will make a very great mistake it it pays
heed to the hysterical calls of the press for General
Fotheringham's dismissal.
According to the press the jury which inspected
this institution found 285 patients in residence. Not
a single patient treated in tents died. Sixty-eight
per cent, of the pneumonia patients and ninety-
seven per cent, of the influenza patients recovered;
and the jury heard many patients .'^peak in praise
of the treatment.
In comparison with other places and institutions,
the Toronto Military Base Hospital, whether fit or
not for occupation by soldiers, gives a very satis-
factory mortality rate — only thirty-two and one
half per cent, for pneumonia ; which in the Boston
hospitals is understood to have reached sixty per
cent., and in Philadelphia as high as ninety per
cent.
AN AMERICAN CHEMICAL RESEARCH
INSTITUTE.
After such a political and commercial cataclysm
as was precipitated by the murder of the Austrian
archduke, months will he required for the definite
formulation of the terms of peace, but the drastic
and detailed provisions of the armistice leave no
doubt that peace has come. There was therefore
nothing premature in the discussion by the New
York Branch of the American Chemical Society
of plans for the foundation of an institute for the
promotion of systematic research with a view to
providing for the manufacture of new and im-
proved medicinal agents by American manufac-
turers.
The discussion which took place at the Chemists
Club on November 8th was participated in by Dr.
John J. Abel, of the Johns Hopkins University
Medical School, who sent a paper, not being able
to attend in person, and by Dr. P. A. Levene, of
the Rockefeller Institute for Medical Research ; Dr.
C. L. Alsberg. chief of the Bureau of Chemistry
of the United States Department of Agriculture ;
Dr. A. S. Loevenhart, of the American University
Experiment Station, at Washington, D. C. ; Dr. F.
R. Eldred, of Eli Lilly & Co., of Indianapolis ; Dr.
D. W. Jayne, of the Barrett Company, of Philadel-
l)hia, and Dr. Edward R. Weidlein, acting director
of the Mellon Institute for Industrial Research of
Pittsburgh. A perusal of those names will give some
index of the broad field covered in the discussion
and of the wdde vision of Dr. Charles N. Herty.
president of the local branch of the society, who
has undertaken the agitation for the establishment
of an institute which will do for medicinal products
what is being done in other fields of chemical tech-
nology by the IMellon Institute of Pittsburgh. The
proposed institute will, it is hoped, link up the re-
search worker and the manufacturer in a manner
which will be mutually helpful. There is a sort of
prejudice in the minds of many medical men
against all manufacturers of medicines. Because
some of them have pursued questionable methods
there is a disposition to condemn all. This is most
unfortunate for much of the improvement in our
materia medica is due to the work of farsighted
manufacturers.
The organization of the proposed institute of
chemical research in medicine could do a great deal
toward coordinating the work of biologists, chem-
ists, pharmacologists and of manufacturers for the
good of medicine at large. Incidentally, it is to be
hoped that it will be possible also to protect the
American market against that exploitation by for-
eign manufacturers to which it has been subjected
in the past.
November i6, 1918.]
EDITORIAL ARTICLES.
869
LITERATURE AND SECONDARY PER-
SONALITY.
There are some extremely interesting- contri-
butions to the problems of secondary personality
in literature which are not valued at their proper
worth perhaps, and often are quite unrecognized
as belonging in this category. The question as
to where his best thoughts come from has been
the perennial mystery for the poet and the liter-
ary man. Apparently, not from the "him" that
he knows, for he was utterly unaware of their
presence within him until they flowed from his
pen. Often he is at least as much surprised and
delighted as are others with his thoughts when
they come. He knows that he cannot force them,
for often, when he tries very hard, he fails utter-
ly; at other times, when fie least expects it, there
is an incessant flow, giving him a poem or a story
so easily that there seems almost no efifort in-
volved.
The ancient poets realized this so well and rec-
ognized how little the selves they knew had to
do with the poetry they wrote that they appealed
to the Muse when starting their work, feeling
that it was something quite outside of them-
selves, by favor of divinity, which represented
their best auxiliary. The modern poet talks of
inspiration, which is only Latin for "blowing in,"
as if another being stood beside him and blew
into him his best thoughts, and even his expres-
sions. He is quite sure that there is something
besides the ordinary "he" that he is, needed to
clarify his vision and enable him to express it.
Even the minor poet has something of this feel-
ing, though it is said that one of the reasons why
there is no really great poetry in our day is that
men have neither the time nor the peace of mind
to wait for the promptings of the inner voice
which represents poetic inspiration. The war
has given them the time, at least, and, while its
alarums might seem to be disturbing enough to
prevent proper introspection, it is in the peaceful
intervals that the poets' work has been done, and
war seems only to have stirred up very thor-
oughly all the inner thinking and thus made the
soldier-poet all the readier for the deepest inspi-
ration that his other self can give him.
The recent life of Joel Chandler Harris fur-
nishes some striking material with regard to the
entire subject of the writer's inspiration. He rec-
ognized very well his own state of mind in this
connection. He spoke of "my inner — my inner
— oh, well ! my inner spezerinktum (he evidently
did not want to use the word consciousness) ; I
can't think of another word. It isn't 'self and it
isn't — oh, yes! it is 'the other fellow' who does
all my literary work while I get the reputation,
being really nothing but a cornfield journalist."
Years later, writing to his daughters who were at
school and just beginning to try what they could
do with the pen — very probably in answer to
some questions of theirs as to how he did his
writing — he was even more explicit. He said :
"As for myself — I never have but the vaguest
ideas of what I am going to write ; but when I
take my pen in hand the mist clears away and the
'other fellow' takes charge. You know all of us
have two entities or personalities. That is why
you see and hear people 'talking to themselves.'
They are talking to the 'other fellow.' I have
often asked my 'other fellow' where he gets all
his information, and how he can remember, in
the nick of time, things that I have forgotten
long ago ; but he never satisfies my curiosity. He
is simply a spectator of my folly until I seize a
pen, and then he comes forward and takes
charge."
What Joel Chandler Harris thus described so
clearly is, of course, nothing new; on the con-
trary, it is one of the oldest experiences recorded
in the literature of mankind. We have invented
other terms for the phenomenon, and we talk
about the "other self" and the "secondary per-
sonality," but preceding ages discussed the phe-
nomenon under the terms "intellectual memory"
and "intuition," without any question of dividing
the personality. It was only the curious freaks of
memory which occur in hysterical subjects that
led to the idea of a multiple personality, and it
must not be forgotten that their tendency to put
themselves in the limelight and to make them-
selves remarkable, interesting cases has always
vitiated the significance of observations made
with regard to them. They not only deceive other
people, but they begin by deceiving themselves.
The study of the normal in this matter of sec-
ondary personality would bring what is often
supposed to be a new development directly in
touch with the oldest psychology that men
evolved.
INFLUENZA SITUATION IMPROVING.
The influenza situation continues to improve, the
number of new cases reported in this city and in
practically all the cities on the Eastern Seaboard
declining from day to day. Although New York-
escaped with a smaller number of cases and deaths
in proportion than other cities, the epidemic caused
15,000 deaths in one month. Never before have so
many deaths occurred in a corresponding period.
But even at this, the record made is very much bet-
ter than that of most of the other cities in the coun-
8/0
NEWS ITEMS.
[New York
Medical Journal.
try. During the height of the epidemic the total
death rate per thousand of population was loo in
Boston, 109 in Washington, 1^8 in Baltimore, 158
in Philadelphia, and only sixty in New York. The
favorable record made by New York as contrasted
with that of other cities is the best evidence that
the Board of Health handled this unusual situation
wisely. In discussing the matter at a recent meet-
ing, the commissioner of health. Dr. Royal S Cope-
land, said the results achieved by the Board of Health
in keeping down the mortality in this epidemic was
due to the cumulative effect of the efficient admin-
istration of the office by his predecessors during the
past fifteen years, and not solely to the wise man-
ner in which the epidemic had been handled by the
present authorities. The persistent efforts of his
predecessors to educate the people in matters affect-
ing their health and to enforce adequate sanitary
regulations in the building and management of tene-
ment houses has borne fruit in the present epidemic.
The commissioner had been subjected to every form
of abuse, invective, and thi-eat for the failure to fol-
low the advice of self constituted mentors. He had
sought and profited by the advice of experts in sani-
tation ; he had kept the schools open becanse every
one of the million school children was under some
kind of intelligent supervision during attendance at
school. He had kept the theatres open because they
had large, airy, well ventilated auditoriums. He had
closed a number of the smaller moving picture
houses which he found to be ill ventilated. The wis-
dom of the steps taken have been amply demon-
strated by the low death rate registered in the city.
News Items.
General Gorgas Decorated. — Major General William
C. Gorgas, M.C., who up to the time of his retirement on
October 3d was Surgeon General of tl^ United States
Army, has been made a Grand Officer of the Order of
the Crown of Italy in recognition of his distinguished
services on behalf of military sanitation. The ceremony
of presentation took place in the office of the surgeon
general, the presentation Ijeing made by Maior General
Emilia Guglielmotti, military attache of the Italian Em-
bassy.
Medical Association of the Greater City of New York.
— A regular meeting of the society will be held in the
New York Academy of Medicine building, Monday even-
ing, November i8th, at 8.30 p.m., under the presidency of
Dr. Edward E. Cornwall, of Brooklyn. Dr. Henry L.
Shively will read a paper on End Results in the Tubercu-
lin Treatment of Tuberculosis. Dr. Joseph E. Winters
will read a paper on the Food Factor in the Causation of
Health and Disease, .'\mong those who will discuss these
two papers are Dr. Thomas S. Southworth, Dr. Graham
Lusk, Dr. Warren Coleman, Dr. R. Cole Newton, Dr.
Elias H. Hartley, and Dr. Alfred F. Hess.
The Alvarenga Prize. — The College of Physicians of
Philadt Ipliia announces that the next award of the Al-
varenga prize will be made on July 14, 1919, provided that
an essay deemed by the committee of award to be worthy
of the- prize shall have been offered. Essays intended for
competition may be upon any subject in medicine, but
cannot have been published. They must be typewritten,
and if written in a language other than English should be
accompanied by an English translation, and must be re-
ceived by the secretary of the college on or before May i,
IQIO. For full particulars regarding conditions of com-
petition address Dr. Francis R. Packard, iq South Twenty-
sec( nd street, Philadelphia, Pa. No prize was awarded
in 1018.
Personal. — Dr Cary Eggleston has been made assist-
ant professor of pharmacology at Cornell University
Medical College, New York.
Influenza Quarantine Lifted at Camp Mills. — The
quarantine against Spanish influenza placed on Camp
Mills, Mineola, October 21, 1918, was lifted on Wednes-
day, November 13th.
Siberia Needs Medical Supplies. — Dispatches from
Siberia state that there is great need for medical and sur-
gical supplies in that coti'itry. An epidemic of typhus
fever has appeared in Nikolaivitch. The hospitals there
are practically destitute of medical supplies.
Dr. Etienne Burnet at the Academy of Medicine. —
Dr. Etienne Burnet, of the Pasteur Institute, Paris, .a
surgeon in the French Army, and a member of the mission
of French sclTolars to the United States, delivered a lec-
ture at the New York Academy of Medicine, Friday eve-
ning, November 15th, on Pasteur as a Representative of
the French Scientific Spirit. The lecture was given in
English.
National Committee for the Prevention of Blindness.
— Colonel James Bordley, U. S. Army, of Baltimore, will
be the chief speaker at the annual meeting of the National
Committee for the Prevention of Blindness, which will be
held at the New York Academy of Medicine, Tuesday,
November 26th, at 8:30 p. m. His subject will be The
Goveri.ment and Red Cross Work for Blinded Soldiers.
.Ml who are interested are invited to attend.
A Red Cross Medical Intelligence Bureau. — A medi-
cal intelligence bureau has been opened at Q Rue du Mont
Thabour, Paris. France, by the American Red Cross.
Authors of articles on war, medicine, and surgery are
requested to send two reprints of such articles to the
above address. The bureau has undertaken to supply
medical books and periodicals to medical officers in the
field and in the evacuation hospitals and to furnish them
with abstracts of origmal articles in which they would be
interested.
General Richard Retires. — Brigadier General Charles
Richard, M.C, who had been acting surgeon general
before the return of General Ireland from France, re-
tired from age on November loth. General Richard was
born in Ohio on September 10, 1854. He entered the army
as an assistant su''geon on June 3, 1879, and reached the
grade of colonel on February 19, 1910. He was appointed
a brigadier general in the National Army shortly after
the United States entered the war. In length of service
he was the senior officer in the corps.
Reorganization of the Army. — Plans are being per-
fected for the reorganization of the regular army. The
President has authority to discharge both men and
officers from the army as may be deemed expedient.
Just what will be do^e will depend upon the number of
troops required to police the conquered nations and re-
store law and order there and in Russia. The enlist-
ments in the army have been for the period of the
em.ergency, not for the duration of the war. consequently
the President can retain men in active service so long
as he deems it necessary, even after the final confirma-
tion of the peace treaty.
Medical Society Meetings. — During the coming week
meetings of medical societies will be held in New York as
follows :
Monday, November i8th. — New York Academy of
Medicine (Section in Ophthalmology) ; Medical Associa-
tion of the Greater City of New York; Psychiatric Society
of Ward's Island; Yorkville MeJical Society.
Tuesday, November 19th. — New York Academy of Medi-
cine (Section in Medicine) ; Federation of Medico Eco-
nomic Leagues of New York.
Wednesday, November 20th.— New York Academy of
Medicine (Section in Genitourinary Diseases) ; Medico-
legal Society: Northwestern Medical and Surgical So-
ciety of New York ; Women's Medical Association of New
York City ; Alumni Association of City Hospital.
Thursday, November 21st.— New York Celtic Society;
New York Academy of Medicine (stated meeting).
Friday, November 22d. — Academy of Pathological
Science; Audubon Medical Society; New York Clinical
Society; Brooklyn Society of Internal Medkine.
V
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
STROPHANTHUS AND ITS ACTIVE PRIN-
CIPLES VERSUS Digitalis.
r.v Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Continued from page <5p7.)
That the strophanthins, includin.7 ouabain, may
with safety and advantage be administered intra-
venously, providing preparations of definitely
known and constant power are used and the dose
employed is relatively moderate, seems strongly sug-
gested by recent clinical observations. In a pre-
ceding issue stress was laid on the view, sponsored
particularly by Vaquez and his coworkers, that digi-
talis and the strophanthins act in a qualitatively
somewhat different manner, the former acting most
saliently on the conductive properties of the heart,
and being therefore especially useful in certain dis-
turbances of cardiac rhythm and increased cardiac
rate, while the strophanthins show particular power
to improve directly the contractility and, perhaps,
the tonicity of the organ, and are in consequence of
unusual service in reinforcing the contractions of
many weakened hearts with normal rhythm — on
which digitalis seems to have relatively little hold —
as well as in cases where, after temporary effective-
ness, digitalis has lost its value. As with digitaHs,
however, the use of the strophanthins appears to
demand relative caution where the myocardium is
seriously degenerated, and unable to respond as
usual to the stimulus which their administration in
ordinary doses entails.
In addition to the general indications for succes-
sive or simultaneous use of digitalis by mouth and
the strophanthins by intravenous injection already
mentioned, Vaquez and Lutembacher, 1918, have
called attention to certain special conditions in which
ouabain — prepared by the Arnaud method — has
proved, in their experience, superior in many ways
to digitalis.
Among these are included a group of cases of
mitral disease, chiefly stenosis, in which occurs a par-
ticular type of pain. This pain is located along the
scapula in its upper part, an area which corresponds
to the auricle and is considered by Vaquez to be due
to distention of this chamber of the heart. Pain of
this type is met with frequently, and may be so pro-
nounced as to prevent sleep. It is accompanied by
paroxysms of tachycardia which are forerunners of
the complete arrhythmia ultimately to become es-
tablished, and are in the nature of an expression of
distress on the part of the affected auricle. Ap-
parently all these manifestations are dependent ujx)n
the inability of the auricle to accomplish the excess
of work imposed upon it through the presence of
the valvular disorder. In these instances, as in
cases of ventricular weakness, Vasquez finds dig-
italis ineffectual. Intravenous administration of
ouabain, on the other hand, proved of grea^ervice,
causing the auricular distress to disappear. After
this result had been secured, the customary treat-
ment with digitalis was resumed.
Another group of cases in which an important
difference between the effects of digitalis and those
of ouabain was clinically noticed was that of sub-
jects in whom, in conjunction with mitral lesions
and manifestations of weakened heart action, there
occurs a periodical slowing of the pulse rate or
merely a partial heart block which is due, in all
likelihood, to disease of the auriculoventricular con-
ducting bundle.
Digitalis, as is well known, tends, in humans as
well as in lower animals, to reduce conduction
through this bundle, and therefore to slow the
ventricular heart rate. Heretofore this effect has
been thought to be exerted always through the vagal
inhibitory mechanism, in its distribution to the
auriculoventricular bundle, but recently Cushing has
brought out evidence to the effect that under cer-
tain conditions, as in the ill nourished mammalian
heart and in the human heart in auricular fibrilla-
tion, the reduced conduction is due to a direct action
of the drug on the conducting fibres. Clinically the
tendency to a prejudicial action on the part of digi-
talis in many cases of partial heart block is con-
sidered well substantiated, and even a fatal termina-
tion has been ascribed to its use in at least one in-
stance.
Vaquez and Lutembacher state that they have
been struck by the manner in which, in certain pa-
tients with mitral lesions, digitalis, instead of exert-
mg a favorable effect, has been followed by extra-
systolic disturbances or by abnormal slowing of the
heart rate with complete or incornplete auriculoven-
tricular dissociation. In many instances there oc-
curred at the same time general discomfort, dizziness
and even epileptiform seizures, the combination of
the symptoms constituting an actual exemplification
of the Stokes- Adams syndrome. Pulse tracings yield-
ed unmistakable evidence of the baneful effect of
the French official digitalin solution in patients suf-
fering from disturbed cardiac conductivity. It is
therefore advised that the administration of digi-
talis be discontinued as soon as an abnormal reduc-
tion in the heart rate and a few of the symptoms
mentioned above appear.
The point of chief interest is that among cases of
this type, ouabain proved to be, in the hands of
Vaquez, the remedy of choice. Thus, in one case
the French digitalin solution, in the relatively small
dose of eight to ten drops, caused a slowing of the
pulse rate to forty and immediate aggravation of
the patient's symptoms, with irregularity of rhythm
and Stokes-Adams manifestations. When, on the
other hand, intravenous ouabain treatment was be-
gun, almost immediate improvement took place, with
a rapid increase in the urinary output, and after
three injections of ouabain had been given, the trac-
ings showed a regular heart rhythm without slow-
ing of the rate.
{To be contintied.)
872 MODERN TREATMENT AND PREVENTIVE MEDICINE.
Scopolamine-Morphine Amnesia in Labor. —
VV. R. Livingston {American Journal of Obstetrics,
October, 1918) reports 275 cases of delivery under
scopolamine-pantopon amnesia by the Gauss
method. There was no mattrnal mortality nor any
immediate mortality among the newborn. One child
in the series was stillborn and one died on the
eighth day. Among the disadvantages of the
method are its rather exacting requirements. Its
best results will be obtained in properly equipped
hospitals. Quiet must be secured, and this means
a separate delivery room, well isolated, either by
position or padding. A skilled attendant must be in
constant attendance with each patient during the
whole of the delivery and for two hours subse-
quently. The dose of the drugs is .still a matter to be
decided for each individual patient ; the physician
must therefore be present or within call throughout
the amnesia. The method is not generalb/ suitable
in cases in which delivery is expected within two
hours. Among the advantages to the mother are :
Heart lesions are saved the danger of muscular
efifort and exhaustion ; borderline pelvic contrac-
tions are allowed the full test of labor with a min-
imum of exhaustion ; the mother knows throughout
pregnancy that labor will be practically free from
suflfering ; the cervix dilates with less trauma, and
in first labors more rapidly ; use of high forceps is
relatively infrequent ; afterpains are absent or of
lessened severity ; breast engorgement is less ; there
is absence of shock postpartum, together with ab-
sence of muscular soreness and exhaustion ; con-
valescence is more rapid. In regard to the child,
the advantages are that more babies are born alive
and that they have a better start in life because of
the better mental and physical condition of the
mother and the relative absence, in the milk, of the
toxines produced by prolonged suffering and phv-
sical exertion.
Industrial Aniline Poisoning in Massachusetts.
— Thomas F. Harrington {Boston Medical and Sur-
gical Journal, October 17, 1918) says that the first
aid treatment in cases of aniline poisoning consists
in the removal of the worker to fresh air, keeping
him awake, and if possible oxygen inhalations, pul-
motor, and heart .'•timulants, especially black coffee
and camphorated oil. Sponging with acetic acid
(or vinegar) or ammonium acetate is lielpful. Warm
saline solutions should be given by hypodermoclysis,
by rectal injections, and by direct venous trans-
fusion if the pulse is not too weak. The preventive
measures include the following: Adequate ventila-
tion ; the removal of dust and fumes ; the substitu-
tion of closed nitration method for the more open
one commonly employed ; v/et or vacuum sweep-
ing in place of dry sweeping; adequate washing
facilities ; protection of the skin — gloves, long
sleeves, and special work clothes — against skin
absorption ; respirators ; prohibition against eating
in workrooms where aniHne is manufactured, used,
or stored ; and, lastly, instruction to workmen as to
the danger and early signs of aniline poisoning.
Even when all these protective measures are care-
fully carried out the necessity of periodical blood
examinations and constant medical supervision
promises the surest protection to workers.
(New York
Medical Jouijnai..
Treatment of Anthrax. — John B. Ludy and
Eugene Rice {Journal A. M. A., October 5, 1918)
record their observations and treatment in three
cases ^f anthrax in one of our army camps, and em-
phasize the necessity of reviewing the symptoma-
tology of the disease so as to be able to recognize
it as early as possible and to ensure the most favor-
able chances of successful treatment. The treat-
ment should begin as soon as the diagnosis is estab-
lished clinically and smears and cultures have been
secured from the lesion. The first step is to inject
from thirty to fifty mils of antianthrax serum into
the tissues about the lesion to infiltrate them
thoroughly. A large needle should be used for this
purpose. The entire lesion should next be dissected
out, at least half an inch outside of its borders, with
a nose cautery. The base should also be cauterized.
The wound should then be dressed daily with a
solution of three parts of phenol, seven parts of
camphor, forty parts of glycerin, and one hundred
and eighty parts of alcohol. Seventy-five mils of
antianthrax serum should be administered intra-
muscularly, and a similar dose, diluted with fifty
mils of physiological saline solution, should be given
intravenously. Serum treatment should then be re-
peated every eight hours, according to circum-
stances, and should be continued until temperature
and pulse are normal. By this treatment two of the
patients were saved.
Treatment of Seborrheic Eruptions. — H. W.
Barber and H. C. Semon {British Medical Jourtial,
September 7, 1918) believe that the main factor in
the causation of seborrheic eruptions is a meta-
bolic dyscrasia, and the various external influences
which play a part are merely the excitants. The
metabolic disorder is such as to lead to the develop-
ment of a decided degree of acidosis, and it may
be either congenital or acquired. It is very largely
aggravated by the ingestion of an excess of carbo-
hydrates and proteins and by the want of an ade-
quate abundance of fresh vegetables. The treat-
ment, therefore, should be as much systemic as
local, and many cases can even be cured by systemic
treatment alone. For the purpose of combating the
acidosis the following mixture proves most efficient :
Sodium bicarbonate 4.0 (dr. i) ;
Potassium citrate 2.0 (gr. xxx) ;
Calcium lactate o..'^ (err. v) ;
Magnesium carbonate •. .0..^ (gr. v) ;
Cbloroform water .30.0 (oz. i).
This mixttire is given in daily amounts varying
up to 275 mils, according to the amount required in
the individual case to render the urine definitely
alkaline, at which point it should be kept for some
time. Along with the alkaline internal treatment
there should be an alkaline local application, for
which the following serves admirably :
Calamine, 2.0 (gr. xxx) ;
Lime water 8.0 (dr. ij) ;
Peanut or olive oil to make .•^0.0 (oz. i).
This application is to be renewed at least twice
daily until the erythema and congestion of the skin
disappear, when the parts should be covered with
Lassar's paste on lint. The diet should also be pre-
scribed to contain an abundance of fresh vegetables
and frffits, a reduced carbohydrate allowance, and a
very low proportion of meat.
November .6. .9.8.] MODERN TREATMENT AND PREVENTIVE MEDICINE.
873
Treatment of Goitre. — Leigh F. Watson
[Texas Medical Jonrnui, September, 1918) uses
quinine and urea injections into the thyroid gland.
These injections are preceded by injections of
sterile salt solution and sterile water, in order to
raise the patient's threshold to stimuli. The strength
of the quinine and urea solution depends upon the
type of the goitre and the character of the symp-
toms. Only one injection is giVen at a treatment,
which is repeated at two to six day intervals. Ten
to twenty injections are usually required to produce
marked improvement. The first injections are us-
ually given at the upper pole ; when the thrill over
the superior thyroid has diminished the lower pole
is injected ; finally, the central portion. A few
minims of the concentrated quinine and urea solu-
tion are given at a treatment. The toxic cases
should be watched carefully, and at the first sign
of an acute exacerbation of hyperthyroidism treat-
ment should be stopped, a hypodermic of morphine,
atropine, and digitalin should be given, and ice
bags applied over the thyroid and heart. Prophylac-
tically, syrup of the iodide of iron, in five to fifteen
minim doses, once a day for one week in every
month, may be given to cliildren who live in goitre
districts.
Treatment for Simple Goitre. — H. R. Harrower
{Dominion Medical Monthly. September, i()i8) in
determining the character of the thyroid enlarge-
ment finds it best to give experimental thyroid gland
feeding. For three or four days the patient re-
ceives increasing doses of desiccated thyroid gland:
on the first day three one quarter grain doses ; on
the second day three one half grain doses ; on the
third day five or six one half grain doses and, if
necessary, on the fourth day three or four one
grain doses. Occasionally the pulse, temperature,
and temperament are sufficiently aflfected on the sec-
ond or third day to convince one that the patient is
not definitely hypothyroid, because of the dis-
covered susceptibility to the thyroid that has been
administered. If a patient can take four grains of
dried thyroids, U. S. P., with no evidence of
thyroidism it is safe to presume that the goitre is not
accompanied by increased endocrine function of the
gland. An early or insignificant hyperthyroidism
having been ruled out and a careful search for foci
having been made, a series of cleansing enemata are
given at night and, after evacuation, the patient is
ordered to inject four ounces of plain cotton seed
oil or olive oil. This is repeated three nights in
succession and is continued once a week thereafter
during the treatment. Three and a half pints of a
two percent, glucose solution are warmed to blood
heat and a tube of one of the standai-d cultures of
Bacillus bulgaricus is added. It is then placed in a
fireless cooker for twenty-four hours, cooled, and
the patient is directed to drink one and a half quarts
daily, between meals. Intestinal antiseptics may be
prescribed in addition. From twenty to 100 grains
of alkali are given daily. Finally one and a half
grain of dried thyroids, U. S. P., should be
given daily for several months If the goitre does
not respond to this treatment within several months
it must be regarded as an adenoma, and surgical
treatment should be instituted.
Catheterization in Obstetrics. — Virginius Har-
rison {Virginia Medical Monthly, July, 191 8)
warns against the practice of instructing the nurse
to use the catheter in a given number of hours after
delivery. Obstetrical catheterization is more
dangerous than any other use of this instrument,
owing to the presence of the lochia, bathing the
vulva and mouth of the urethra with a fluid con-
taining the germs from the cervix, vagina, and
vulva, recently expressed from their deep habitats
in these structures. In addition, the urethra and
even the bladder may have been bruised, with cor-
responding reduction of resistance to infection.
Nothing need be done until distention, discomfort,
or both, occur; all means other than the catheter
should then be tried, and the catheter used only as
a final resort. If pituitary extract has been used,
the bladder will surely empty itself as soon as dis-
tention occurs. Otherwise, the patient should be
put on the pan and left alone a while ; next, warm
sterile water may be poured over the vulva ; again,
one may try sitting the patient almost straight on
the pan; if not successful, one should wait a little
longer and try again. A little lochia on the
catheter renders it unfit for use. Two catheters
should always be prepared for this reason. A good
light and good position of the patient are necessary
for proper use of the catheter by the nurse.
Antigangrenous Serotherapy with a Polyvalent
Serum. — H. Vincent and G. Stodel (Presse medi-
cate, August 15, 1918) emphasize the fact that gas
gangrene is due, not to a single germ, but to a
variety of anaerobic organisms, some of which act
specifically, the others as satellites. To be efifectual,
therefore, a curative serum must be prepared with
all these organisms. Again, experiments with the
tetanus bacillus, the vibrio of sepsis, and in hospital
gangrene have shown that the injection of several
organisms in admixture with the specific agent of
these affections imparts a high degree of virulence
to the combination. The investigations of the
authors demonstrated that the same holds good in
the case of the bacterial agents of gas gangrene.
Hence to secure as active a serum as possible it is
preferable to inject a mixture of these germs into
a single horse rather than to use a mixture of
serums from different horses, each immunized
against a single organism. Finally, the gas gan-
grene lesions being due both to bacterial pullulation
in the muscular and cellular tissues and to ne-
crosis of living cells due to soluble poisons, the
serum used clinically should be both antibacterial
and antitoxic. The material used by the authors for
antitoxic immunization consists of a culture on
agar of numerous virulent species or strains of
bacteria, including the Bacillus perfringens, vibrio
of sepsis, Bacillus oedematiens. Bacillus bellonensis.
Bacillus sporogenes. etc. The emulsion of these or-
ganisms is allowed to macerate in the incubator, the
culture then setting free gas and becoming richer in
endotoxins and exotoxins. The resulting second
culture is injected in horses in ascending amounts.
The serum thus obtained led to recovery in severe
cases of gas gangrene and in a few of those treated
permitted of conservation of the affected limb with-
out amputation or disarticulation.
874
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Meoical Journal.
Psychological Treatment of Stricture of the
Male Urethra. — Albert C. Geyser {American
Medicine, August, 1918) reports the use of the
largest calibre steel sound which is capable of pass-
ing through the smallest stricture present. This
is attached to a teletherm high frequency apparatus,
the other pole being attached to a piece of flexible
tin, one inch wide, and applied smoothly to the en-
tire outside of the organ surrounding the sound.
The current is turned on gradually, the amount be-
ing limited to the sensation of the patient and not
to the reading of the hot wire meter. The tempera-
ture of the enclosed tissue will reach 104° F. in a
few mimites. After twenty minutes the high fre-
quency current is turned oflf and the galvanic cur-
rent is substituted, the negative pole in the urethra,
using the same sound without removing. This cur-
rent is turned on until the milliampere meter shows
a reading of not less than seven or more than ten
milliamperes. This current is allowed to act for
twenty minutes, then gradually is reduced to zero.
The electrodes are removed and the treatment is at
an end. The procedure is repeated once a week,
gradually increasmg the size of the sounds. The
author cautions against dilatation, as it neither ab-
sorbs nor removes superfluous fibrous tissue, and
adds that strictures that have been dilated may
again contract ; also that strictures that have been
absorbed by electrolytic action neither recontract
nor reform.
Radical Cure of Genital Prolapse in Women.
— Salva Mercade (Bulletin de I'Academie de mede-
cinc, August 20, 1918) thinks it peculiar that while
there is general agreement that prolapse always be-
gins at the anterior vaginal wall and that cystocele
precedes the descent of the posterior wall and
uterus, surgeons regularly operate on the posterior
wall, hoping, by a posterior colpoperineorrhaphy or
by suture of the levator muscles behind the vagina,
to close the outlet sufliciently to obviate all trouble.
The chief aim should actually be to establish a firm
support for the bladder — the first organ to be pushed
down by the intraabdominal pressure. Anterior
colporrhaphy, as ordinarily practised, is an insuflfi-
cient procedure, and for vaginal cystocele the author
recommends suture of the levator muscles and uro-
genital floor in front of the vagina. He begins by
bringing into prominence the anterior vaginal wall
through accentuation of the cystocele by traction on
the cervix with Museux forceps. An ordinary
lozenge shaped anterior colporrhaphy is then per-
formed, the vaginal flap dissected and excised, and
next, the bladder carefully separated from the
vagina and uterus. This requires liberation of the
posterior aspect of the bladder, careful dissection
of each lip of the vagina in its entire anteroposterior
extent, and liberation of each lateral surface of the
bladder until the vesicolateral vessels come into
view. The cord formed laterally within the ischio-
pubic ramus by the inner border of the urogenital
floor and above by the inner margin of the levator
muscle is then identified and four chronic gut
sutures are passed like a U to unite the two leva-
tores in the midline, thus forming an actual plat-
form for the bladder, which is now pushed above it.
Finally, the urogenital floor is likewise sutured, and
the vaginal margins united in an anteroposterior
direction. No vaginal packing is used, merely a
daily vaginal injection being given. The patient is
not artificially constipated but allowed to go to stool
at any time. A purge is ordered on the third day
and the sutures removed on the tenth. Perfect re-
sults were obtained in six marked cases of prolapse.
Vaccination against Dysentery by the Oral
Route. — Besredka (Presse medicate, August 15,
1918) reports experimental work showing that
when rabbits are caused to ingest killed cultures of
the dysentery bacillus, the same clinical and patho-
logical manifestations are produced as result from
the living virus. According to the weight of the
animal and the dose of bacilli ingested, all forms of
dysentery can be induced, from mild involvement
with evanescent lesions to a grave form with
bloody stools, terminating in death. A very light
attack of dysentery, induced by ingestion of heated
bacilli, suffices to render the animal refractory to
infection by living and virulent bacilli. The im-
munity thus caused is such that the animal is en-
abled to withstand, by intravenous inoculation, a
dose of the virus which kills the control in twenty-
four hours. Besredka believes the procedure
worthy of trial in man both for prophylactic and
curative purposes.
Prevention of Gas Pains. — L. A. Emge {Jour-
nal A. M. A., September 14, 1918) says that voices
of protest have been raised from time to time against
the practice of preoperative purgation, citing the
statements of a number of prominent surgeons in
confirmation, and points out that in spite of these
utterances the practice is dying hard, like most other
medical traditions. That preoperative purgation is
not at all necessary and that its omission is rather
beneficial than harmful have been shown repeatedly
in emergency operations. Such operations have dis-
proved that it is more difficult to pack off an un-
purged bowel than a purged one, and show quite the
opposite to be the truth, for the purged bowel is
often distended with gas and is decidedly congested.
Postoperative peritonitis, while rare, would seem to
be favored bv the practice of purgation, for the dan-
ger of organisms passing through the intestinal wall
is enhanced when the intestine is congested and dis-
tended with gas. The movements of the purged in-
testine are also greatly inhibited, which leads to
stasis and the retention of the contents with in-
creased opportunity for gas formation. Further, the
intestine is prcne to irregular contractions after pur-
gation, which are much more painful than regular
peristalsis. These statements have been proved, not
only by clinical observations in emergency cases, but
also by careful and well controlled experiments on
animals. Tn order to put the matter to still further
test the incidence of gas pains was recorded in two
series of fifty major abdominal operations,^ the one
with, the other without, preoperative purgation. In
the purged cases twenty-six per cent, of the patients
had no gas pains and twenty-two per cent, had se-
vere gas pains, while in the unpurged series only two
per cent, had severe pains and sixty-six per cent, had
none at all. In the patients who were not purged
the only preparation consisted in giving a single
enema to cle>i'- the lower bowel.
Miscellany from Home and Foreign Journals
The Pituitary Body and Polyuria. — B. A.
Houssay {Endocrinology, April-June, 1918), sum-
marizes his observations published in 191 5 as fol-
lows : He says that there occur in pituitary extracts
both renocontractor and renodilator substances, out
or the other predominating accordino- to the circum-
stances, with the diuretic effects running parallel
with the renovascular effects. From the pharmaco-
logical action of pituitary extract it is concluded that
it is not permissible to deduce an insufficiency of
the pituitary body from the successful use of the
extracts in polyuria. Houssay does not agree with
Cushing's claim that the cerebrospinal fluid has the
same effects as pituitary extracts, as he demon-
strated that the cerebrospinal fluid has not the di-
uretic nor the galactagogue actions which are the
most specific tests of pituitary material ; so that he
does not believe that the active components of
pituitary extracts pass to the cerebrospinal fluid.
Operations for the removal of the pituitary gland
produced oliguria in adult dogs and polyuria in
puppies. These effects are due to trauma, and the
intervention of the pituitary in the polyuria can be
excluded, as the same results have been obtained
when the whole gland was removed. In conclusion,
the author adds that the cerebral basal zone can
generate polyuria, and that it is not probable that
the pituitary is a part of this zone, though the
posterior lobe of the gland may be involved. He
cannot accept the theory that polyuria is due tn a
diuretic hypersecretion of the pituitary gland.
Recruits with Doubtful Heart Conditions. —
S. Russell Wells (British Medical Journal, Sep-
tember 7, 1918) discusses some of the observations
made by a committee which investigated 10,000 re-
cruits sent up because of the presence of doubtful
heart conditions. Of the entire number 19.2 per
cent, gave clear and unequivocal histories of acute
rheumatic fever ; 2.6 per cent, of chorea ; 32 per
cent, of "rheumatism" or the various joint and mus-
cle pains and affections classed loosely as such by
the layman ; about forty per cent, of growing pains :
and about thirty-five per cent, of tonsdlitis. The cor-
relation coefficients between these several conditions
were calculated to find out whether or not they were
sufficiently closely related to be regarded as the same
disease. From these results it was concluded that
there was some slight support for the view that
chorea and acute rheumatic fever were the same
rlisease, but there was none at all to favor the view
that acute rheumatic fever was related to tonsiUitis,
growing pains, or "rheumatism," as defined. On
the other hand two other diseases investigated in
this connection — diphtheria and scarlet fever — did
show some definite correlation, though the precise
nature of the relationship was not evident. Exact-
ly two per cent, of the cases gave a history of
syphilis, while approximately six per cent, gave a
history of gonorrhea. This was the same relation
between these two diseases as has been recognized
generally and it indicates that the proportion of men
with syphilis was about correct, though the evidence
Avas obtained from histories only. Muscular strain
was also investigated in its relation to heart con-
ditions and about twenty-seven per cent, of the men
were found to have been subject to cardiac strain.
It was pointed out that the factor of strain had to
be considered in relation to the general habits of
life in each individual case, rather than merely on
an occupational basis. Thus the blacksmith who
had trained himself for years to do many thousands
of foot pounds of work per hour was not likely to
have his heart strained by running up an incline,
rising thirty feet vertically, in a period of half a
minute, while a clerk would probably suffer severe
strain from such a feat. On the other hand the
clerk's occupation should not necessarily place him
in the class not subject to strain, for he might well
overtax his heart's relatively small capacity by long
bicycle rides, etc., on his holiday.
Stammering and Its Solution. — Elmer L. Ken-
yon (Laryngoscope, September, 1918) states that
stammering is a serious disorder distinguished by
emotional disturbance, accompanied by a distress-
ing spasmodic abnormality of action of the peri-
pheral organs of speech. While lay efforts at teach-
ing in such a condition cannot be entirely depended
upon, because of the narrowness of the desired
knowledge, medical efforts sometimes also fail for
the same reason. Only through the combined efforts
of physicians, especially educated and trained for
the undertaking, and of well educated laymen can
the problem be completely solved. The treatment
rests on the principle of educated selfcontrol. The
correct application of this principle is directed to-
ward conscious control of the peripheral speech
mechanism and the direct control of the emotional
and nervous disturbance.
Signs of Death in Military Practice. — Icard
(Presse mcdicale, August 8, 1918) points out that
in the fluorescein test the coloration of the eye is a
feature of only accessory importance. The main
indication, to which attention should especially be
directed, is the golden yellow or orange coloration
of the skin and mucous membranes. This sign is
never wanting and becomes manifest even from the
use of a minimal amount of fluorescein, an amount
insuflicient to color the eyes. No procedure intended
to demonstrate persistence of the blood circulation
can give any result if it is applied at the very mo-
ment at which a subject in a state of apparent death
exhibits complete arrest of the circulation; the cir-
culation may, indeed, become reestablished after the
moment at which the use of the test has been dis-
continued. That which is required to avoid all
sources of error is a means of permanent, auto-
matic control, an actual recording apparatus, by
which the test can be applied as long as is required
without the necessity of repeating the test at inter-
vals. Injection of fluorescein answers all these re-
quirements ; information as to the persistence of life
or actuality of death is available at any moment at
a mere glance. Restoration of the circulation can-
not fail to escape the attention even of mere pri-
vates detailed to handle the cadaver, the peculiar
color of the skin revealing the condition at once.
8/6
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Anesthesia at the Front. — W. B. Howell
(American Journal of Surgery, October, 1918)
says that there are in the Canadian Army Medical
Corps in England and France not more than four
or five specialists in anesthesia. The anesthetic is
frequently given by the most recently joined officer,
with results to the patient which it is not necessary
to specify. The more one sees of the real soldier
the more one feels that nothing is too good for him.
To increase his comfort and safety Howell would
like to see private enterprise supply modern gas
apparatus to all the Canadian hospitals. This can-
not to be expected from the government on account
of the expense. A specialist in anesthesia might be
detailed to go from hospital to hospital to teach the
proper method of using gas and oxygen and to
make suggestions as to the organization of a proper
anesthetic service in each hospital. H the younger
medical officers were kept on anesthetic duty con-
tinuously for three months and their work properly
supervised there would not be so many of the
wounded dreading the anesthetic more than the
operation. Every expert anesthetist sent overseas
means the saving of a certain number of soldiers'
lives and the prevention of an immense amount of
suffering and discomfort.
Experimental Scurvy of the Guineapig in Re-
lation to the Diet. — Barnett Cohen and Lafayette
B. Mendel {Journal of Biological Chemistry, Sep-
tember, 1918) produced scurvy experimentally at
will in the guineapig with suitably chosen diets, such
as exclusive feeding of cereal grains, like oats and
barley. Germinated oats and barley did not produce
the disease, which is in accord witli the reports of
Fiirst and others. Scurvy was also inducted on a
diet of soy bean flour, supplemented by fat soluble
and water soluble vitamine in the form of dried
brewer's yeast, fresh Jersey milk, five per cent, but-
ter fat, sodium chloride, and calcium lactose. Ap-
parently the fat soluble and water soluble vitamines,
which are so important in the nutrition of some spe-
cies, are not the primary factors concerned in the
scurvy of the guineapig. It is an interesting fact
that this same food mixture has proved to be en-
tirely adequate to promote normal growth in rats.
Animals given small amounts of raw milk developed
scurvy, while larger quantities caused the symptoms
to disappear. Experiments were tried in which
roughage in the form of sawdust, shredded filter
paper, and hay were added to the diet, and in every
instance the animals developed scurvy. This is at
variance with the argument of McCollum and Pitz,
that scurvy is due to unsatisfactory physical factors
in the diet, so that roughage appears to play but an
accessory part, if any at all, in the prevention of the
disease. Mendel and Cohen do not consider con-
stipation a causative factor in scurvy, though of
course it may aggravate the symptoms. Five c. c.
of orange juice, the classic remedy in curing scurvy,
preserved animals in good health indefinitely when
given daily, even when they were on a scurvy pro-
ducing diet. Fresh and dried cabbage, and fresh
carrots were effective antiscorbutic agents, while
highly purified lactose did not appear to have any
effect on the course of the disease, which is contrary
to the findings of some workers.
Multiple Disseminated Epitheliomatosis in
Workers Manipulating Tar. — G. Thibierge {Bul-
letin de I'Academie de medecine, August 20,
1 918) reports two cases of this condition and dis-
cusses its pathogenesis. Tar and mineral oils, when
brought in contact with tlie skin, exhibit a strong
tendency to occlude the orifices of the skin glands.
This is sometimes followed by irritative folhcular
or osteofollicular lesions of the acne type, and may
result in multiple tumors, the reaction of the
epithelium leading to the formation of flattened or
exuberant hornv formations, at times assuminj^^
the appearance of the cornu cutaneum. These tu-
mors are for the most part benign, always remain
small, and may ulcerate, later healing spontaneously.
Some, however, pass into large ulcers and require
surgical treatment ; they may even become general-
ized and cause death. The lesions develop on the
exposed surfaces, particularly the forearms and
face. They may, however, occur on the covered
parts, exposed to accidental contact of the noxious
materials, these being carried there by the hands of
the worker, or impregnating the clothes, in which
they may perhaps be fixed by the perspiration.
Thus may be explained the frequent appearance of
the lesions on the scrotum. Heavy oils and even
very pure, refined oils may bring on the condition,
which, however, occurs only in workers who have
been exposed a number of years. Lack of cleanli-
ness is a favoring influence. Indeed, from the in-
dustrial standpoint the disease appears to be an
avoidable one, proper care of the skin being the
main factor of safety.
Prognosis in Trench Nephritis. — S. C. Dyke
{Lancet, September 7, 1918) records the ultimate
outcome in fifty cases of trench nephritis which
could be traced for periods up to a year after their
discharge from hospital. One only of the fifty pa-
tients died, death being due to scarlet fever. The
prognosis as to life is therefore very good. Of the
surviving forty-nine patients sixty per cent, have
been returned to full duty in complete health, while
the remainder have either been disch.'i.rged from the
army as unfit or have recovered only enough to
undertake light duties. Age seems to be an im-
portant factor in ultimate prognosis, about two and
a half times as many under thirty-five years old
becoming fit for full duty as among those over that
age. Arteriosclerosis develops in about half of
those who do not recover completely, but it is not
a common immediate result of the disease, develop-
ing usually at some time between the third and ninth
month after the onset. A past history of renal
disease materially diminishes the likelihood of com-
plete recovery of health. In sixty per cent, of the
patients all edema had disappeared by the end of
the second week of illness, and of thirty-nine pa-
tients in which it disappeared before the end of
the first month twenty-eight became fully fit. The
presence of edema after the end of the first month
is an indication that complete recovery will not fol-
low. The albuminuria usually disappears near the
end of the first, or during the second month, though
it may persist during the third month and the pa-
tient make a complete recovery. Its continuance after
the third month makes the prognosis unfavorable.
November 16, 1918]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
%77
Alkalinity of the Blood and Acidosis in Shock.
— Marquis, Clogne, and Didier {Prcssc mcdicalc,
August 5, 1918) found, in observations on fourteen
cases of traumatic shock, that the alkaHnity of the
blood averaged 2.79 per thousand. As the normal
blood alkalinity is 3.145 per thousand, there mani-
festly exists in shock a hypoalkalinuy of the blood.
In no case did the urine of shock patients show the
characteristic elimination products of acidosis such
as are found in diabetic coma. The intensity of the
hypoalkalinity of the blood in shock is held by the
authors to be of some practical significance. All the
patients who presented an alkalinity of about three
per thousand recovered, while all those with an alka-
linity of about 2.60 per thousand succumbed. The
existence of the hypoalkalinity in shock justifies the
application of Wright's procedure of intravenous
sodium bicarbonate injection in these cases.
Face Masks. — Brewster C. Doust and Arthur
Bates Lyon {Journal A. M. A., October 12, 1918)
conducted a series of experiments with face masks
made of varying thicknesses of gauze and of but-
tercloth, to determine their efficiency in preventing
the projection of infectious material from the
mouth. They found that during ordinary or loud
speech infectious material is seldom projected to a
distance as great as four feet, while during cough-
ing the projection may amount to at least ten feet,
which therefore measures the radius of the danger
zone about a coughing person. Masks made of
gauze, either coarse or medium, of two to ten layers
in thickness, do not prevent the projection of in-
fective material, and such masks are worthless in
preventing the dissemination of respiratory infec-
tions. On the other hand masks made of only
three layers of buttercloth were found to prevent
the projection of infective matter during both speak-
ing and coughing and were still thin enough to be
comfortable to the wearer.
Diabetes Insipidus. — Ketil Motzfeldt {Endo-
crinology, April-June, 1918) believes that this con-
dition is merely a symptomatic evidence of disor-
dered pituitary function, and that it is due to a
deficit in secretion. A study of the older diabetes
insipidus literature reveals a number of cases where
the pituitary origin is prettA' well established, and on
the basis of this investigation the following cHnical
picture is outlined : There seem to be two fairly dis-
tinct types — the obese and indolent ; and the lean
infantile type. These show such featm^es as obesity
high carbohydrate tolerance, sexual underdevelop-
ment, scanty growth of hair in armpits and on
pubes, lassitude, dryness of skin, and slightly sub-
normal temperature. Some of these signs, which
point toward the pituitary body, are usually present
in cases of primary polyuria. Motzfeldt thinks that
the only remedy which has the power to check
polyuria and concentrate the urine is the extract of
the posterior lobe of the hypophysis. A subcutane-
ous injection with an ampule of some of the com-
mercial preparations will usually reach its maxi-
mum efifect in four to five hours, but, unfortunately,
is not lasting. Intravenous injection is unsafe, as it
may lead to collapse. Treatment by mouth, although
not so efficacious, has the advantage of causing no
discomfort, is not dangerous, even in large doses,
and can be carried on indefinitely. When possible,
fresh material from the abattoir should be used.
One of Motzfeldt's cases is cited which had been
treated for two years with intermittent pituitary
feeding. The patient took from two to seven fresh
pituitary bodies from cattle every evening. The
urine output was checked during the night, usually
decreasing from nearly 2,500 c. c. to about 300 c. c.
The general health improved, drowsiness and
adiposity disai)peared, and the menses were reestab-
lished. An interesting point is that after two years
on this regime one hypophysis will now have the
same efifect as was obtained by seven glands at the
beginning of treatment.
A Test for Blood in the Urine, Feces, and
Pathologic Fluids. — Thevenon and Rolland
{Pressc medicale, August 15, 1918) describe a new
test based on the violet color developing from pyr-
amidon in the presence of oxidizers. In addition
to hydrogen peroxide solution, two reagents are
used, the first consisting of a solution of 2.5 grams
of pyramidon in fifty mils of alcohol, and the sec-
ond, a dilution of one mil of glacial acetic acid with
two mils of water. In testing urine for blood, an
equal volume of pyramidon reagent and six to eight
drops of the diluted acetic acid are added to three
or four mils of unfiltered urine. After shaking,
five or six drops of hydrogen peroxide solution are
added. Where much blood is present, an intense
violet color appears at once ; where there is less,
or merely a trace, a bluish violet appears within
fifteen minutes, increases to a maximum, then
passes ofif. To detect blood in feces, a little fecal
matter is triturated with three or four mils of dis-
tilled water ; the fluid is decanted, three or four
mils of pyramidon reagent, six to eight drops of
diluted acetic acid, and six drops of hydrogen per-
oxide added, and the mixture shaken. In positive
tests a violet blue color develops. The same tech-
nic is employed for cerebrospinal or pleural fluids,
etc. In comparative tests with the Meyer reagent
the pyramidon reaction gave like results in all in-
stances and proved equally sensitive. The solu-
tions are easily prepared and keep far longer than
the Meyer reagent.
Kidney Function in One Hundred Cases of
Hypertension. — W. C. Rappleye {Boston Medical
and Surgical Journal, October 3, 1918) has made a
study of the blood urea nitrogen, elimination of
])henolsulphonephthalein, and urine analysis in 100
cases of elevated blood pressure, using the figure
of 150-155 millimetres systolic pressure as the low
value for selection. With but four or five ex-
ceptions, the patients were in apparently good phy-
sical condition and active ; none showed any edema,
dyspnea, fever or other compromising conditions. In
this group of patients it may be said that seventv per
cent, showed blood urea nitrogen values below 16.0
milligrams per 100 cubic centimetres — whether con-
sidering the whole group pr only those showing a
systolic value of over 170 millimetres or a diastolic
figure of over loo millimetres — and sixty-six per
cent, showed a dye excretion of forty per cent, or
higher; sixteen per cent, showed a value of forty
per cent. A slightly lower percentage was found in
those patients showing a higher blood pressure
8/8
MISCELLANY FROM HOME AXD FOREIGN JOURNALS.
[New York
Medical Journal.
(systolic of 170 millimetres or over, diastolic of 100
millimetres or over). Twenty-eight per cent, showed
both a urea nitrogen of 16.0 milligrams or over and
a dye excretion of forty per cent, or less. Ninety
per cent, of the cases showing a urea nitrogen of
16.0 milligrams or over had a dye excretion of forty
per cent, or less. Twenty-four of the cases showed
a blood pressure over 160 millimetres, a urea nitro-
gen below 15.0 milligrams and a phthalein over fifty
per cent. The presence of albuminuria and cylin-
druria in the type of case studied here does not
allow a prediction that the renal efficiency is im-
paired, if we choose to judge the efficiency by the
features to which reference has been made.
Epidemic of Fifty Cases of Influenza. — C. J.
Martin {British Medical Journal, September 14,
1918) made his investigations in a series of fifty
cases developing in the personnel of a military hos-
pital and rapidly affecting practically everyone in
that personnel. Blood cultures during the acute
stage of the disease were negative. The sputum in
the early stages was generally negative bacteriolog-
ically, so far as the etiological agent was concerned,
but as the sputum became mucopurulent it was
usually possible to demonstrate by .smears and by
cultures the presence in it of few to enormous num-
bers of Bacillse influenzae, sometimes almost in pure
culture. In some cases these organisms were found
to persist in the tracheal mucus for as long as two
weeks after the temperature had become normal.
Sodium Bromide in Rontgenography. — E. H.
Weld {Journal A. M. A., October 5, 1918) says
that many of the substances used for injection into
the bladder and ureters to cast a shadow for
rontgenography have more or less marked irritant
actions when retained in the renal pelvis ; many act
as foreign bodies, causing multiple focal necroses in
the kidney ; and thorium nitrate, which is the least
objectionable on these counts, presents decided chem-
ical difficulties in its preparation and is very costly.
Potassium iodide, which is bland and casts a good
shadow, is quite expensive and must be used in con-
centrated solution. The ideal substance is one
which is nontoxic, nonirritating, easily soluble in
the urine, easily prepared, readily sterilized, keeps
well, and is reasonably cheap. Such conditions
seem to be met quite satisfactorily by sodium bro-
mide in twenty-five per cent, solution, and even
in twelve per cent, solution where cystograms are
sought. So far, however, there are no experiments
to show what the effects of this solution are when
retained for considerable periods of time in the
renal pelvis.
Diphtheria Carriers. — Frank R. Keefer, Stan-
ton A. Friedberg, and Joseph D. Aronson (Journal
A. M. A., October 12, 1918) investigated 686 diph-
theria carriers and 461 cases of clinical diphtheria,
with special reference to the carrier state. They
divide carriers into primary transient, primary
chronic, and secondary, ^he primary carriers being
those who have not had clinical diphtheria. They
point out that the carrier state can be determined by
cultures alone ; that a single negative culture has
but little value ; and that the value of nasal cultures
is not properly appreciated. A positive culture
from the throat does not necessarily mean that the
infection is located in the throat, and careful search
is often required to discover the actual site of the
infection. Cultures from chronic carriers should
be tested for virulence, which will often be found
to be high. In practically every case the carrier
state is maintained by some underlying pathological
condition in the aft'ected tissues. The vast majority
of carriers harbor the organisms in the tonsils ; a
few in the nose alone ; and a small group in both
nose and tonsils. The results of local antiseptic
treatment are decidedly problematical because the
organisms are located deep in the tissues. Persist-
ent carriers with the bacilli located in the tonsils can
be cured with certainty only by enucleation of the
tonsils. Among the nasal carriers the most persist-
ent ones are those with chronic inflammatory or
atrophic processes, and in such cases it is almost
impossible to be certain when the carrier state has
been ended. In the treatment of the carrier state
one of the most important measures is the removal
or cure of foci of inflammation in the nose or throat.
No chronic carrier should be discharged until con-
sistently negative cultures have been returned over
a long period of time.
Pain in Dyspeptics. — F. Ramond (Paris medi-
cal, August 31, 1918) thinks most dyspeptics experi-
ence gastric pain at some time or other. He classi-
fies pain among dyspeptics into two major groups —
the radiating pains and the nonradiating or purely
gastric pains. The former may be either anterior,
lateral, or posterior. As a group, they are not
precise in their indications, merely directing the
physician's attention to the stomach, or even occur-
ring in the absence of gastric disease. The nonradi-
ating pains are sometimes largely dependent upon
irritation of the solar plexus, which increases the
sensitiveness of the stomach, or may be due to
diminished secretion of the protecting gastric mucus
or to precipitation of this mucus by excess hydro-
chloric acidity. The main factor of nonradiating
pain, however, is inflammation of the mucous mem-
brane. The condition ranges from a prolongation
of the normal hyperemia of the submucous capil-
laries during digestion to an actual acute or chronic
gastritis. Whether merely congested or inflamed,
the mucous membrane is sensitive to the least irrita-
tion by the acid and pepsin of the gastric juice.
Nonradiating pains are subdivided into those that
are induced by palpation and those that are sponta-
neous. The former occur at the most easily palpa-
ble points of the stomach — in recumbency — viz., be-
low the ensiform, below the left costal margin, along
the external margin of the left rectus muscle, two
fingerbreadths above the umbilicus, at Chauffard's
choleclochopancreatic point, and below the left costal
margin. The fir.st three of these point- relate to
the upper or peptic portion of the stomach and
the last two to the lower or mucous portion.
Tenderness at the former points indicates gastri-
tis chiefly of the upper portion ; at the latter, of the
lower portion. Among the spontaneous pains cr
burning sensations, the site of the pain varies in
different periods of the process of digestion, accord-
ing to the location of the food in the stomach at the
time and, consequently, the section of the mucosa
exposed to irritation by the gastric juice.
Proceedings of National and Local Societies
MEDICAL ASSOCIATION OF THE
GREATER CITY OF NEW YORK
Stated Meeting, Held April 15, ipi8.
The President, Dr. Edwakd E. Cornwall, of Brooklyn,
in the Chair.
{Concluded from page 5jp.)
Some Clinical Types of Nephritis. — Dr. Tas-
KER Howard, of Brooklyn, reported the results of a
study of sixty-eight cases of nephritis which he
found could be divided into at least three entirely
distinct diseases, each differing in symptomatology,
course, treatment, and termination. This referred to
glomerulonephritis, the pure nephrosis of Mueller,
and the arteriosclerotic kidney, any two of which
might be, and not in frequently were, combined in
the same patient. True nephrosis was comparatively
rare. Of the sixty-eight cases but five came under
this category. Its main clinical characteristic was
renal edema with marked retention of chlorides and
water, and its chief histological change was degen-
eration of the tubules. The urine in the stage of
edema was of high specific gravity and loaded with
albumin. The phthalein output was good except as
it was influenced by the edema. A contracted kid-
ney might develop with polyuria and hyposthenuria.
One of the series presented the picture of eclamptic
attacks probably due to cerebral edema. These
patients were particularly susceptible to infections.
Diffuse glomerulonephritis was always due to infec-
tion. The most characteristic lesions were the in-
flammatory changes going on to complete destruc-
tion of the glomeruli scattered here and there
throughout the entire organ. Clinically the most
constant feature was hypertension with cardiac
hypertrophy. The urine was likely to show more
or less blood from time to time, in contrast to the
urine of nephrosis or arteriosclerosis. The kidneys
eliminated water well, salt with some difficulty, and
nitrogenous crystaloids with more and more dififi-
culty. As a result of the accumulation of nitrogen-
ous waste products in the blood, the symptoms of
uremia, anorexia, weakness, twitching, and drowsi-
ness developed, with coma and death following.
The phthalein output varied inversely with the
nitrogen retention. With the difificulty in excreting
the nitrogenous waste products, there developed
{>ari pasH a compensatory polyuria, the .so called
"hyposthenuria. Constant variations from the nor-
mal day and night excretion of urine were ex-
tremely significant. The mixed form combined
findings of the two types just described. The early
acute stage of a glomerulonephritis frequently pre-
sented this picture.
Benign or essential hypertonia was not a kidney
disease at all, but was classed here because it
usually presented some kidney pathology and be-
cause it was so often confused with nephritis. The
kidney in such cases was likely to show patches
of degeneration due to narrowing or obliteration of
the vessels supplying these patches. The glomeruli
involved were as a rule entirely destroyed. Evi-
dences of inflammation were lacking ; indeed, there
might be no kidney changes whatever. Clinically,
the essential feature of this disease was arterial
hypertension with cardiac hypertrophy. There
might be no other finding. The urine might contain
a little albumin and a few casts, and there might
be enough damage to kidney function to cause a
slight polyuria and fixation of the specific gravity.
Nitrogen retention was moderate, never amounting
to enough to cause uremia, unless, as sometimes
happened, there had been superadded an actual
nephritis. From a practical standpoint it should be
remembered that in about ten or fifteen per cent,
of patients with apparently benign hypertonia
symptoms of actual nephritis ultimately developed.
In simple hypertensive cases the phthalein output
remained good until the heart failed, the retinal
changes were those of arteriosclerosis only, and
uremia was absent. The danger lay in the possi-
bility of apoplexy or heart failure.
The combination form consists in the addition of
the inflammatory changes of glomerulonephritis to
the degenerative changes of a widespread arteriolar
sclerosis. The important point lay in remembering
that what seemed to be a simple arteriosclerosis
might turn out to be a malignant glomerulonephritis.
The sixty-eight cases studied were as follows :
No. of
Cases Average
Studied. Age. Youngest. Oldest.
Chronic glomerulonephritis. 33 47 17 64
Nephrosis 5 30 22 43
Mixed form 11 38 17 45
Benio^n hypertension 18 59 42 86
Passive congestion i
Many of the patients studied were in an early
stage of the disease, which had tended to lower the
average pressure. A high diastolic pressure had
been considered as pointing to nephritis rather
than arteriosclerosis, but in this series patients were
encountered with apparently simple hypertonias
who registered diastolic pressures of 130-140 and
150. Aside from the kidney function the phthalein
output was most influenced to slow excretion by
edema. Demonstration of the lack of nitrogen re-
tention indicated the true condition. Study of the
amount and specific gravity of two or four hours
day and night specimens as a whole assisted in
differentiating glomerulonephritis from simple
hypertension. Some degree of nitrogen retention
was invariably found in nephritis cases affecting
first the uric acid. The same was true of ar-
teriosclerosis. In one of the five nephrosis cases
there was also a uric acid retention of five mg.
Urea was a very variable factor and might be
influenced by treatment. A high urea percentage
was dangerous but a comparatively low reading did
not indicate freedom from danger. Albuminuria
retinitis was found in fifteen of the thirty-eight
nephritics examined (including the mixed form)
and in no other condition. Twelve exhibited retinal
hemorrhages and ten papilledema. The only
changes in nineteen simple hypertension cases were
those of arteriosclerosis. The nephrosis cases were
all negative. The hemoglobin in twenty-six
88o
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
nephritis cases (including the mixed form) was
seventy-one per cent. In eight ateriosclerotics it
was seventy-four per cent. In five nephrosis
patients it was sixty-five per cent. Convulsions
occurred in seven of the cases with nephrosis, in
one with arteriosclerosis, and in one with nephrosis
and edema. Twenty-two of the patients died. Of
these, fifteen had nephritis, five arteriosclerosis, one
nephrosis, and one passive congestion. Of the nine
who were studied histologically six had chronic
glomerulonephritis (including the combination
forms), two arteriosclerosis, and one a kidney with
passive congestion.
Dr. Austin W. Hollis said that he had watched
a great many of these interesting cases, and the
study of the chemical and blood findings had helped
a great deal in their treatment. Two of them he
had treated by Edebohls' method of decapsulation
five or six years ago with apparently complete cure.
Of course, a long rest and other supplementary
treatment was carried out also. He had been much
interested in cases of nephritis occurring in young
adults running over a long period of time with con-
siderable amounts of albumin and showing no
clinical symptoms of any kind, and finally develop-
ing into a chronic type of nephritis. Other cases
had cleared up entirely. By the blood and chemical
tests and the urine studies more definite prognosis
in certain classes of cases could now be made,
though as yet the significance of these findings
could hardly compare with the clinical findings and
the symptoms in individual cases. There were
times, however, in which the blood findings, without
any clinical symptoms, were most valuable. Cases
of hypertonia with apparently good function of
the kidney formed a class that was greatly helped
by the study of the chemistry of the blood and
urine.
Dr. L. F. Frissell said that during the past few
years at St. Luke's Hospital he had been studying
the kidney functional tests in twelve selected cases
with especial reference to their prognostic value.
Sixty-nine of these cases had terminated fatally and
some 1,500 obser\'ations, from the earliest record
to the time of death, had been carefully charted.
All of the tests practically agreed in the majority of
the cases. In the two weeks before death, the in-
cidence of very high retention products was marked.
Previous to that time, for perhaps a year, the read-
ings showed moderate retention and moderately low
indices for phthalein. One point in regard to the
value of the use of the nitrogen retention, the uric
acid and creatinin tests alone, was frequently over-
looked ; i. e., their dependence upon the diet.
Dr. Albert A. Epstein expressed gratification
that Doctor Howard had emphasized the im-
portance of the chemical study of nephritis, for
that was perhaps the most helpful phase of the
subject from the viewpoint of prognosis and treat-
ment ; yet there were certain limitations in the
chemistry of nephritis which should be recognized.
For example, in studying the blood and the urine,
as Doctor Frissell said, the diet should be taken into
consideration. Other factors also influenced the
findings in the blood, and these might lead one into
error unless they were recognized.
Stated Meeting, Held May 20, ipi8.
The President, Dr. Edward E. Cornwall, of Brooklyn,
in the Chair.
Health and Sanitation in the Shipyards. — Lieu-
tenant Colonel Philip S. Doane, M. C, U. S. A.,
medical director of the United States Shipping
Board, explained that to maintain the 500,000
troops in the service in France at the present
time, and with the possibility of this quota being
tripled or quadrupled very shortly, it was necessary
that the ocean be bridged. It was roughly estimated
that fourteen tons of supplies a day were required
for every soldier placed on foreign soil, an enor-
mous amount of shipping to maintain a winning
army in France. The shipbuilding programme re-
quired an army of industrial workers employed in
shipyards scattered over 7,000 miles of coast line,
many of them situated in undeveloped country, lack-
ing public utilities or medical or hospital facilities.
The old yards had increased the number of machine
shops and all other constructive buildings. Most of
the new yards were situated in or near cities or
towns and had city facilities to aid in the care ot
the shipbuilder. The problem confronting the De-
partment of Health and Sanitation of the United
States Shipping Board, Emergency Fleet Corpora-
tion, was to secure such conditions in shipyards and
their environments as to enable the workers to be
maintained in a healthy, vigorous condition so es-
sential to speedy construction of ships. The work
might be divided into: i, Medical and surgical; 2,
sanitary engineering ; 3, general service ; and 4, co-
operation with federal. State, and local health
authorities. Medical standards had been established
whereby minimum requirements were made of each
yard. Those employing under one thousand men
had a first aid attendant for each shift, and two or
more doctors on call. The first aid attendant was
required to have taken a regular course in first aid
and passed an examination satisfactory to the at-
tending physician. Yards employing over one thou-
sand men had a resident physician on full time ; he
usually assumed charge of all sanitary work in ad-
dition to his medical duties. Yards employing up to
two thousand men had first aid stations. A yard
employing from two to five thousand men had a dis-
pensary and one first aid station for each additional
two thousand men employed. The first aid station
was furnished with modern equipment, while the dis-
pensary had an increased equipment with addition
of two or more beds. Arrangements were made with
local hospitals for the care of injured employees.
Yards employing over ten thousand men without
the nearby hospital facilities had their own hospital,
constructed according to plans and specifications
outlined by the army, with suitable modifications.
The Department of Health and Sanitation had
made a very careful study of hospital construction,
securing much information from public health serv-
ices, the War Department and a number of large
industries. Ambulances were maintained in those
yards not having their own hospital facilities.
Preparations had been made in all yards for estab-
lishing first aid stations beside the shipways this
summer ; they would consist of tents or temporary
structures with tubs, iceboxes, and other apparatus
November i6. .918.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
881
for the care of heat prostration and sun stroke.
The surgical care of injuries was given special at-
tention. All employees were made to report for
dressing with the slightest injury ; consequently, the
monthly reports of minor injuries show a percent-
age often running as high as fifty per cent, of the
men employed. The use of dichloramine-T and
chlorcosane was being generally introduced into the
yards. In cooperation with the Surgeon General of
the Army, the Surgeon General of the Navy, the
Public Health Service, and the Committee of Na-
tional Defense, a prophylactic campaign was being
carried on both in the shipyards and the cities and
towns surrounding them against venereal disease,
because the efficiency of the shipworker had been
markedly interfered with in many cases. All mem-
bers of crews sailing on ships controlled by the
United States Shipping Board were given medical
care while in service. This was another large under-
taking and one which would rapidly increase as the
ships were launched. The Marine Hospital Service
would care for the seamen after their return to port,
and was increasing its hospital facilities almost fifty
per cent, in order to fulfill all requirements for the
increased merchant marine. Not all vessels would
carry ship surgeons, and the first mate or captain
would be instructed in first aid and the ordinary
care of the sick and have at his disposal a suitable
medicine chest with other supplies for this work.
Sanitation in the shipyards was very carefully
looked after. It was a prime necessity that the
water supply be pure, for the shipworker drank
enormous quantities ; his work was of a strenuous
character and he perspired freely. Yards sufficiently
near cities obtained connections with the pipe mains.
Where the yards must provide their own water
supply, careful investigation was made and the most
economical and safe resource or proper purification
was recommended. Distribution of water by means
of bucket and common drinking cup was con-
demned. Water supply for industrial use and fire
protection was essential, and was usually obtained
from a diflFerent and frequently polluted source.
As regards general service, the worker in the
shipyard desired to appear as a clean member of
Uncle Sam's Army. Accordingly, the installation of
wash room facilities was being urged as well as
dressing rooms with sanitary lockers. The em-
ployees were responsible for the cleanliness of
rooms and grounds. Garbage, principally refuse
from restaurants and lunchrooms, was kept in cov-
ered metal containers. Yards having stables pro-
vided flytight manure pits, with the manure re-
moved twice a week. To insure against fly breed-
ing, the department recommended that manure be
sprinkled with a solution of powdered hellebore.
The eradication of mosquitoes had also been pro-
vided for.
The sleeping quarters provided not less than 500
cubic feet of air space, fifty square feet of floor
space and five square feet of window opening for
each occupant. Sleeping rooms, when possible,
were of a size for not more than two occupants
and equipped with single beds. Vigilance was exer-
cised that employees of restaurants were not af-
fected with any venereal disease, tuberculosis, yel-
low fever, typhoid fever, dysentery, or any other
infectious or contagious disease. Adequate pro-
vision for refrigerating meats, milk, and other food
was essential. Installation of mechanical dishwash-
ing was recommended. Meats, where possible, were
government inspected ; milk, pasteurized. Fly
screening was essential to protect food. In addition
to restaurants, lunch rooms selling coffee and soup
were provided for employees who brought their
lunches. Restaurants and lunch rooms were prefer-
ably located immediately outside of the yard to
aft^^ord employees the privilege of smoking, which
was not permitted in the yard. Before employment,
workmen were examined by physicians to de-
termine their fitness for employment and freedom
from tuberculosis, venereal disease, or any con-
tagious or infectious disease. Vaccination against
smallpox was recommended, and if possible, anti-
typhoid vaccination, the latter at the option of the
employee. The great aim of the Department of
Health and Sanitation of the United States Ship-
pmg Board, Emergency Fleet Corporation, was to
keep the enemy disease and sickness out of the
yards. The ships must be constructed with the
greatest possible speed, the men must be kept well,
strong, and efficient, and in a state of mind to enable
them to carry on their enthusiastic and patriotic
duty. The task was great. Splendid assistance had
been given by cooperating national. State and civic
health bodies ; by the patriotic force of coworkers ;
and by remarkably well qualified physicians in and
about the shipyards. The shipbuilder would be
kept well, and he was going to turn out ships at the
rate of 100 per month before the year was over.
Medical Services at Hog Island, — Dr. J. Jay
Reilly, chief surgeon at Hog Island shipyards, il-
lustrated his address with numerous pictures, the
first showing the condition of Hog Island on
September 13, 191 7, when the 846 acres of land a
little below Philadelphia formed a desolate waste,
without roads, drainage, facilities of access, or ac-
commodations of any kind. Other pictures showed
the stages of progress and equipment of what would
be, when completed, the largest shipyard in the
world, as big as any five now existing in the United
States, and covering twenty-five acres of ground.
There were fifty shipways, operated in groups of
five each, directed by a central organization. These
shipways extend for over a mile along the river
front. Besides this, there are seven outfitting piers,
each 1,000 feet in length, occupying about the same
extent of water front. This layout made it possible
to build fifty ships and to outfit twenty-eight at the
same time.
The Hog Island plant was what was known as a
fabricating plant, the material for the ships being
purchased throughout the United States in some-
thing like 35,000 different plants. This was as-
sembled at Hog Island. To handle this material
was a system of yard tracks totalling seventy-five
miles, together v;ith store houses, and workshops
for such work as could be done at a distance,
em.ergency work, etc. Water pipes had been laid
and a sewerage system established capable of taking
care of 30,000 people. Besides this, barracks for
taking care of about 6,000 men had been built on
882
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
the island, with provision for supplying 10,000
meals a day at a cost of thirty cents a meal. In
addition there were facilities for the transport of
such workmen as came from a distance. A well
equipped fire system had been established with up
to date apparatus located at strategic points on the
island and ninety firemen on duty. All this and
other important details had been accomplished in
less than six months, and there had been utilized in
this development men of all nationalities and all
occupations, the force being as higli as 26,000 men
on some days. At present, the force amounted to
approximately 21,000 men.
Doctor Reili.y also detailed at some length the
measures employed in securing the most suitable
and satisfactory food, and the care taken in pre-
paring it; the measures for securing proper cleanli-
ness and sanitation ; the first aid work and the
emergency hospital, and had laid much emphasis on
the value of the work done in the dental clinic. A
department had also been established for the trans-
fusion of tested blood, and in the few instances in
which this had been employed some remarkable re-
sults had been obtained. Every man engaged in
the work was required to undergo a physical exami-
nation, and while no ef¥ort was made to attain the
army or navy standards the men were required to
be free from infectious conditions, must have both
eyes, both arms, and be free from hernia, etc. Their
preexisting conditions were studied with a view to
safeguarding the government as much as possible,
in accordance with the employer's liability and
compensation laws of Pennsylvania. As a result of
the various measures instituted for the cleanliness
and health of the men. Doctor Reilly said that at
Hog Island there had been few or no cases of
smallpox, nieasles, meningitis, mumps, etc.
Plans for Housing Shipyard Employees. — Mr.
Owen Brain ard said that at the time the great war
plants were instituted the questions of labor and
the concentration and shifting of the centres of
labor produced at once exceedingly grave housing
problems. In this particular Hog Island situation,
remote from any line of rail communication, the
housing at once of from 15,000 to 25,000 men was a
large undertaking. Some of the men were lodged
in the nearby city of Philadelphia. Then, barracks
at the yard provided for several thousand men. The
third solution was the building of workmen's hotels
within walking distance of the plant. Here there
was one bed for one room, one room for one man,
and at least one window for one room and with a
transom over the door. The rooms were painted,
floor, ceiling, and walls. There had been consider-
able discussion as to the number of cubic feet of air
for each man, but that had been settled by the ar-
rangements for ventilation. The speaker reviewed
the regulations adopted by the Department of
Labor and accepted by the Emergency Fleet Cor-
poration and bv other governmental boards stating
the requirements for government housing. These
regulations were formulated by volunteer con-
sultants, consisting of architects, sanitary engineers,
housing specialists, town planning specialists, and
representatives of the National Housing Associa-
tion. They provided that each house be equipped
with full bathroom ; that houses be in rows ; bed-
rooms not to be less than eighty square feet in
floor area, and each house to have one room not
less than ten feet by twelve feet. Minimum ceiling
height was established at eight feet and maximum
at nine feet. The window head was to be placed
near the ceiling, as any space above was more or
less stagnant. Houses of one and a half story were
permitted with the requirement that the space be-
tween the ceiling and the roof should be ventilated.
A closet in every bedroom was required. Water
closets were required to be placed in a compartment
forming three sides of a quadrangle. Under Class
IV were included such buildings, outside of actual
houses and dormitories, as might be needed for the
lite of a community centre. These were built as
part of the housing scheme where the adjacent
already existing town did not conveniently provide
them. In this class were included not only schools,
churches, and recreation buildings, but shops,
bakeries, laundries, and central kitchens. They
compared very favorably in construction with per-
manent small houses of the cottage and bungalow
type in this country, and were even better than
many of these. Cooking by gas was recommended,
as gas was as cheap as coal and the saving in labor
of the housewife was very large. Family life as
far as possible should be separated from lodgers.
War Housing in England. — Mr. G. Trafford
Hewitt, member of the British Garden Cities and
Town Planning Association, pointed out that the sig-
nificant thing about the vast governmental housing
undertakings of Great Britain did not lie either m
the technic of the operation or the result, but in the
fact that good' housing was now recognized as the
most important factor in producing the very best
workmen and the very highest efficiency. War had
explained the fact that the philosophy or the science
of housing, as applied on so vast a scale by Ger-
many, was really inspired by her profound analysis
of what would be necessary, first to prepare for
war, and second to conduct a war. Germany fore-
saw what England had to learn — that a modern
army was dependent upon the industries at home ;
that war demanded more from industry than did
peace ; that the meeting of those demands which
meant national life or death depended upon obtain-
ing the utmost in skill and energv from the workers
who supplied the soldiers ; that workmen could not
put forth those qualities except under living condi-
tions which constantly renewed and thus maintained
the highest vitality. Peace had enunciated this eco-
nomic principle with a voice which had been
drowned to a whisper. War shouted the message
aloud and made it heard above all other cries, and
England had listened so well that in addition to the
plans which had already been executed, under fi-
nancial and industrial pressure which only added Lo
their extraordinary character, she was looking far
ahead into the future and making ready to provide
new living conditions to replace the old. She was
now far seeing enough to understand that the es-
sential principle of her national existence could not
be left to the speculative builder.
The British Garden Cities and Town Planning
Association had been doing great missionary work
November i6, 1918.]
BOOK REVIEWS.
883
in spreading the gospel of good housing and after
long up hill work it was the means of gaining recog-
nition from the British Government in the passing
of the town planning act, which regulated the sub-
divisions of real estate on practical town planning
and garden city lines, and also enabled private
companies following these methods to obtain loans
from the government at a low rate of interest.
When war broke 'out, the government was able to
make use of the experience of this organization,
and call in the best town planners, architects, engi-
neers, etc., to aid in solving the housing problem.
The most important housing operation of the
British Government was undoubtedly the Well Hall
Estate, at Eltham, Kent, situated about a mile from
the great government arsenal at Woolwich, but this
was only one of the housing schemes of the govern-
ment. The development consisted entirely of dwell-
ings for workmen of permanent construction.
There were four types of houses of from two or
four rooms with bath, the rentals being very low.
At Eastriggs, quite dififerent from Well Hall, the
buildings were of four classes: i. Semidetached
family huts ; 2, groups of three blocks of four cot-
tages each ; 3, large completed cottages and staff
houses in which about one hundred single men or
women could be lodged ; 4, shops, schools, churches,
recreation buildings, and other accessories of a small
town. One outstanding feature of these govern-
mental housing schemes had been the great attention
paid to the social Hfe and welfare of the community
in general. At Eastriggs the clubs of the men and
women had been a great factor in stabilizing in-
dustrial conditions about this factory, and the same
held good at other munition plants. The central
hall with its stage was constantly in use for enter-
tainments of various sorts and for dancing. The
first floor in general served as a club for the men,
while the second floor was a club for the women.
All the buildings at Gretna, such as cottages, school,
police station, churches, cinema house, institute,
shops, post office, public hall, and hospital, of a
permanent character, were so located on the plan of
the town as to form a nucleus of the future town
which would probably develop.
Major Thomas Darlington, M. R. C, U. S. A.,
said that it was superfluous to attempt to add any-
thing to what had been said concerning the wonder-
ful work being done at the present time to conserve
the life and health of the workmen. His own
experience in such matters dated back to 1884 and
1885, when he was surgeon to the aqueduct work in
this city and along the Hudson River. He recalled
one shanty which contained eighty men in the day
and eighty other men at night, and there were only
two windows to it, one at each end. At night, the
night men took the place of the day shift. If a man
was sick, he lay in a narrow bed in which another
man was obliged to sleep, or on the floor. On one
occasion, ten cases of pneumonia were taken in one
day from a single shanty. Any one who had heard
Colonel Doane, and then listened to the practical
side presented by Doctor Reilly, the housing plans
by Mr. Brainard, and seen the wonderful pictures
shown by Mr. Hewitt — would realize that it was a
far cry from those days to the present.
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, zvc review those in which we think
our readers are likely to be interested.]
Surgical Treatment. A Practical Treatise on the TheraPy
of Surgical Diseases for the Use of Practitioners and
Students of Surgery. By J.iiMES Petkr VV.^RBasse,
M. D., Fellow of the American College of Surgeons,
American Medical Association, American Academy of
Medicine, New York Academy of Medicine: Formerly
Attending Surgeon to the Methodist Episcopal Hospital,
Brooklyn, New York. In Three Volumes, with 2,400
Illustrations. Volume I. Philadelphia and London:
W. B. Saunders Company, If)i8.
This is the first of three volumes, the whole form-
ing a series whose object is to present as simply as
possible, surgical treatment to the student and prac-
titioner. Necessarily, therefore, the first part of the
volume deals fully with the subject of asepsis, anti-
sepsis, and the preparation and sterilization of sur-
gical material, and with the general preparation of
the common antiseptics with their strengths and in-
dicated uses. The business of the anesthetist is
described fully. The scope of local anesthesia i«
indicated and the technic of spinal anesthesia is
given. In connection with this preliminary part of
the volume the floor plan of an operating pavilion
is diagrammed and surgical knots and stitches arc
described. The topics exhaustively treated in the
book are three : i, aneurysms ; 2, fractures ; 3, opera-
tions on bones and joints. Doctor Warbasse con-
demns the use of nonabsorbable foreign material
in the local fixation of fractures. He says: "Metal
in contact with bone causes rarefaction and absorp-
tion of the bone. It is an unsurgical and make-
shift expedient." He describes very fully the
technic of bone grafting in fracture cases. The
volume would be noteworthy even if the author
had been compelled by space to limit his subject to
fractures.
Bacteriology, Blood Work, and Animal Parasitology. In-
cluding Bacteriological Keys, Zoological Tables, and
Explanatory Clinical Notes. By E. R. Stitt, A. B.,
Ph. G., M. D., Medical Director, U. S. Navy ; Com-
manding Officer and Head of Department of Preventive
Medicine, U. S. Naval Medical School ; Graduate, Lon-
don School of Tropical Medicine; Professor of Tropi-
cal Medicine, Georgetown University; Professor of
Tropical Medicine. George Washington University, etc.
Fifth Edition, Revised and Enlarged. Illustrated. Phila-
delphia: P. Blakiston's Son & Co. Pp. xv-s.'JQ. (Price,
$2.00.)
When the reader opens this book he finds on the
inside covers a complete diagnostic talkie of the
common communicable diseases under the following
headings: Cause, incubation period, source of in-
fection, mode of transmission, period of communi-
cability, laboratory diagnosis, salient clinical fea-
tures, and the method of control, and on the
following page is a recapitulation of the method of
blood counting on the Turck ruling. Everything in
the book is arranged so as to be of immediate
service. Keys are given at the head of each division
of bacteria with their cultural dififerentiations and
the organisms are thus easily separated culturally.
Running through the bulk of the contents the
S84
BIRTHS, MARRIAGES AND DEATHS.
[New York
Medical Journal.
following up to date headings are noticed : Ag-
glutination of meningococci and pneumococci, the
Dreyer method for the interpretation of the ag-
glutination reactions of typhoid and paratyphoid, a
practical method of making Dakin's solution,
Mosenthal's nephritic test diet for renal function-
ing, Schick test for diphtheria immunity, Petroff's
method for culturing tubercle bacilli, Wolff and
Junghan's test for gastric carcinoma, Bronfenbren-
ner's modification of Abderhalden's technic, Lange's
colloidal gold for general paresis, Fontana's spiro-
chete staining technic, etc. There are complete
chapters on preparation of media, methods of stain-
ing, and chemical blood examinations. The treat-
ment of the subject of parasitology is especially
able. The last chapter discusses important diseases
of as yet unknown etiology. An a'ppendix contains
the preparation of tissues for microscopical work,
various methods of chemical analyses, and a table
•of anatomical and physiological normals.
Surgical Applied Anatomy. By Sir Frederick Treves,
Bart., G. C. V. O., C. B., LL.D., F. R. C. S.. Eng., Ser-
geant Surgeon to H. M. the King; Consulting Surgeon to
the London Hospital, etc. Illiistrated. Seventh Edition.
Philadelphia and New York: Lea & Febiger, 1918. Pp.
x-702..
This seventh edition differs but little in essen-
tials from previous editions. Sir Frederick Treves,
it appeared, had anticipated even the emergencies
of present war surgery. In the direction of ortho-
pedic anatomy, knowledge necessary for the treat-
ment of stififened joints and disabled limbs, there
has been, however, considerable addition. Science,
•especially medical science, is rather unbending; even
to her classics she is eternally adding fragments.
In this case it does seem a "wasteful and ridiculous
excess." This classic was originally printed with
the object of encouraging the survival of the fittest
among anatomical facts and offering, on the one
hand, a precise basis to practical procedures that in-
volve more especially anatomical knowledge, and,
on the other hand, of enduing dull items of an-
atomical fact with interest borrowed from medical
and surgical experience. The writer especially ad-
vised its use by students preparing for final ex-
aminations in surgery, and by practitioners whose
memory of their dissecting room work was growing
a little grey.
Gynecology. By William P. Graves, A. B., M. D., F. A.
C. S., Professor of Gynecology at Harvard Medical
School ; Surgeon in Chief to the Free Hospital for
Women, Brookline, Mass.; Consulting Physician to the
Boston Lying-in Plospital. Illustrated. Second Edition,
Thoroughly Revised. Philadelphia and London: W. B.
Saunders Company, 1918. Pp. 885. (Price, $7.75.)
A medical student said to his professor the other
day, "I have Graves's book on gynecolog)^ Will
that do?" and the professor replied, "Oh, yes, it's
the standard textbook. Is yours the new edition?"
This really sums up what we have to say about
Doctor Graves's book. It contains, however, the fol-
lowing new sections : Gynecology and the internal
secretions ; ovarian organotherapy ; ovarian trans-
plantation ; radium treatment of cancer ; and the use
of radium in nonmalignant gynecological diseases.
There is a short section bearing on the relationship
of gynecology to the sex impulse based chiefly on
the Freudian theories regarding infantile sexuality.
Ill the third part of the book a number of new
operations are described and illustrated. In addi-
tion to the ordinary operations of gynecolgy there
are new operations on the abdominal wall, the kid-
ney, the ureters, the bladder, and the rectum. The
Mayo operation for varicose veins is also included.
The very excellent illustrations — and there are five
hundred of them — were made by Doctor Graves
himself.
Births, Marriages, and Deaths.
Died.
Adams. — In Schenevus, N. Y., on Tuesday, October
15th, Dr. Wesley M. Adams.
Backus. — In Stockton, Cal., on Sunday, October 27th,
Dr. William James Backus, aged thirty-nine years.
Baylies.— In Burlington, Vt., on Wednesday, October
23d, Dr. Frederick W. Baylies, aged forty-seven years.
Bowman. — In Brooklyn, N. Y., on Wednesday, October
23d, Dr. John Molyneaux Bowman, aged sixty-one years.
BRtcHT, — In Buffalo, N. Y., on Tuesday, October 29th,
Dr. Frank E. L. Brecht, aged seventy-three years.
Brown. — In Battle Creek, Mich., on Sunday, October
27th. Dr. John C. Brown, aged sixty-five years.
BuRDiCK. — In Maryland, N. Y., on Monday, October
2ist, Dr. Lewis W. Burdick, aged thirty-seven years.
Case. — In Windsor Heights, Conn., on Sunday, October
27th, Dr. Erastus E. Case, aged seventy-one years.
CoNGDON. — In Cuba, N. Y., on Friday, October i8th. Dr.
William Orson Congdon, aged sixty-four years.
Conway. — In Albany, N. Y., on Friday, November ist,
Dr. William F. Conway, aged thirtj'-one years.
Cunningham. — In France, on Monday, October 21st,
Dr. Bertram Cunningham, of Sag Harbor, N. Y., aged
twenty-eight years.
DooDS. — In Oakland, Cal., on Sunday, October 27th, Dr.
Thomas Garfield Doods, aged thirty-three years.
Egbert. — In Custer City, Pa., on Wednesday, October
30th Dr. Riifus A. Egbert, aged sixty-nine years.
Faulkner. — In Elizabethtown, N. Y., on Thursday,
October 24th, Dr. Clarence S. Faulkner, aged thirty-three
years.
Guthrie.- — In Maiden, N. Y., on Thursday, October
31st, Dr. Edward M. Guthrie, aged thirty years.
Herr. — In Okmulgee, Okla., on Tuesday, October 8th,
Dr. A. Harry Herr, aged thirty-one years.
Kellogg. — In Mohawk, N. Y., on Sunday, October 27th,
Dr. Charles M. Kellogg, aged forty-two years.
Kelly. — In Oakland, Cal., on Wednesday, October 23d,
Dr. Alexander Simpson Kelly, aged thirty-nine years.
Kyte. — In Jersey City, N. J., on Sunday, October 20th,
Dr. Calvin F. Kyte. aged sixty-eight years.
Lent. — In Middletown, N. Y., on Sunday, October 27th,
Dr. Isaac H. Lent, aged seventy-two years.
MacDonald. — In New York, N. Y., on Saturday, No-
vember 9th, Dr. John Henry MacDonald.
Mallory. — In Oberlin, Ohio, on Saturday, October 19th,
Dr. William Mallory, aged thirty-eight years.
Matthews. — In Cooperstown, N. Y., on Wednesday,
October 23d, Dr. Louis B. Matthews, aged thirty years.
McGibbon. — In Chateaugay, N. Y., on Monday, October
2ist, Dr. Walter J. McGibbon, aged thirty-two years.
McNuLTY. — In Glen Lyon, Pa., on Monday, October
28th, Dr. Patrick J. McNulty, aged forty-five j'ears.
Price. — In Easton, Md., on Monday, September 30th,
Dr. Joseph H. Price, aged seventy-two years.
Putnam. — In Boston, Alass., on Monday, November 4th,
Dr. James Jackson Putnam, aged seventy-two years.
Sleight. — In Mount Vernon, N. Y., on Wednesday, No-
vember 6th, Dr. Elizabeth Cowan Sleight, aged sixty
years.
SoRGATZ. — At Fort Bliss, El Paso, Texas, on Thursday,
October loth. Captain F. B. Sorgatz, Medical Corps, U.
S. A., of Oklahoma City, Okla., aged thirty-six years.
Spurgeon. — In Seattle. Wash., on Tuesday, October
29th, Dr. Glenn Charles Spurgeon. aeed forty-five years.
Wilson. — In Denver, Colo., on Saturday, October 26th,
Dr. John E. Wilson, aged thirty-nine years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal ?h'e Medical News
A Weekly Review of Medicine, Established 1 843
VOL. cviii. No. 21.
NEW YORK, SATURDAY, NOVEMBER 23, 1918.
Whole No. 2086.
Original Communications
NASAL COMPLICATIONS OF EPIDEMIC consider the contradictory reports of R. W. Allen,
INFLUENZA.* Benham, Will Walter, and of the writer,
iiriv/r i\TT-w Allen studied the bacteriology in 103 cases of
Bv George W.^ Mackenzie, M. D., j^^sal and postnasal catarrah occurring during the
Philadelphia. period of 1909 to igii inclusive, with the following
Influenza, like all of the acute infectious fevers results :
that are air borne, is with us at all times. It mani- Bacillus influenzae 4.3 per cent.
fests itself sporadically and in a relatively mild form Pneuniococcus 66 per cent.
most of the time, and recurs epidemically in a Streptococcus 41 per cent.
r .L-ju^ i. M 1 Micrococcus catarrhalis 66 per cent.
severe form at wide but not necessarily regular Micrococcus paratetragenus 52 per cent.
intervals. Bacillus septus 26 per cent
The infecting organism is the Bacillus influenzae. Bacillus of Friedlander per cent.
a gram negative short rod resembling the bacillus of The following are C. H. Benham's figures (2) for
Koch-Weeks, which is responsible for the more common colds during the period of 1905 to 1908,
common form of epidemic conjunctivitis, and the inclusive :
bacillus of Bordet-Gengou, which n responsible for Bacillus influenzse 16 per cent.
whooping cough. While the Bacillus influenzie Pneuniococcus per cent.
produces the most variable symptoms, it must be Streptococcus — 26 per cent.
1 • • wt. i 1 11 Micrococcus catarrhaiis So per cent.
borne m mmd that it has usually associated with it Micrococcus paratetrager.-,,-^ ^2 per cent.
the pneuniococcus ( I ) . An attack of true influenza Bacillus septus 74 per cent.
is usually ushered in by malaise, headache, bone and Bacillus of Friedlander 11 per cent.
muscle pains, and fever, often accompanied with Dr. Will Waltei's figures for 1908 to 1909 in 100
chills. Preceding the respiratory symptoms there cases of rhinitis (3) are:
often occurs disturbance of the digestive system — Bacillus influenz-e per cent.
vomiting and purging— perhaps less often there are Pncumococcus 7 per. cent.
i r 11 ^. ,1 htreptococcu'^ K per cent.
symptoms referable to the nervous system but at Micrococcus catarrhalis 20 per cent.
times so pronounced as to lead to actual neuritis, Micrococcus paratetragenus 12 per cent.
diffuse or local, with herpes zoster. A pronounced Bscilkis septus per cent.
case of this latter combination was witnessed by the ^'^^1'"^ F-'l^dlander ■ • 7 per cent.
writer, where the fifth, seventh, and eighth nerves ^'^^ writers figures^ for the last six years in in
of the one side were involved. Herpes of the ex- "^T'?' ^^'^essory smus and mastoid diseases, all of
ternal auditory canal and tvmpanic membrane, an ;^'hich were due to the extension of mfection from
almost pathognomonic sign of influenza, was pres- ^'^^ P""'^'"^ "^^'^^ ''^'^ '
ent in this case and aided in the diagnosis. Occasion- r r.egat.ve bacillus 6 per cent.
'„ • f .. . r w , v-^<.^ci3iuii Qr3,xn positivc diplococcus 6 per cent.
ally the intection is confined to the upper respiratory Streptococcus T g per cent.
tract and its adiiexa and does not extend lower. Staphylococcus 8i per cent.
This limitation of the infection however occurs ^''^"^ positive bacillus (but not diphtheria) lo per cent,
less frequently during epidemics than between them. b'^cHh" ! ! : ! 1 1 ; ' ! Ml c^n!'
Our knowledge of the frequency and character of Granting that the laboratory findings of a gram
the nasal complications of epidemic influenza is negative bacillus were in all instances the Bacillus
meagre at present compared with what it will be a influenza, the percentage— six per cent.— is com-
year hence, and the reason is evident to any one paratively low. It was interesting to note that in
who will consider the fact that practically all of our comparing the film with the cultural findings, the
knowledge of the anatomy and pathology of sinus gram negative organisms were recovered from the
diseases dates from the works of Zuckerkandl and cultures far less frequently than they were found
Hajek several years after our last world epidemic in the film, which matches up with Allen's claim
of influenza (1889-1890). As an evidence of our that "the results of examination with smears of
present day lack of knowledge of the subiect. let us 'T^^, Z — '■ \ TT^ \ — ~~ T";
1 1 &^ ^ 1- ju.^jv,»_L, icL ua ixhe writer is not responsible for the description of these organ-
*RparI h-fnrp the PhJl^r!-!,,!,;, r^„„t n/r J- I c ■ . ^ ,^ ' merely quoting from the reports as they were for-
21 10^8 Philadelphia County Medical Society, October warded to him from time to time from the Philadelphia Clinical
^ ■ Laboratory.
Copyright, 1918, by A. R. Elliott Publishing Companv.
886
MACKENZIE: NASAL COMPLICATIONS OF INFLUENZA.
[New Yo«k
Medical Journal.
secretion are notialways confirmed by the results of
plating experiments ; for instance, a smear may
show vast numbers of what appear to be BacilH
influenzae, while a plate prepared from the same
secretion may after even three days' incubation fail
to show a single colony of that bacterium ; confirma-
tion, therefore, is lacking regarding the identity of
the bacillus seen in the smear."
The wide discrepancies in the bacterial findings
from the nose and throat in disease, especially with
reference to the Bacillus influenzae, may in part be
explained by a difference in the period of time cov-
ered by these four investigators — -Allen's 1909-11,
Benham's 1905-09, Walter's 1908-00, the writer's
1911-18; by a difference in the countries and
climates — Great Britain and America ; by a differ-
ence in the technic in securing the secretion ; by a
difference in the laboratory technic in isolating the
microorganisms ; by a difference in the character
of the infectious agents responsible for colds in the
head, which have a tendency to vary from year to
year ; for instance, during the last few years in
Philadelphia, the vast majority of the so called
grippy colds, with accessory sinus and ear compli-
cations, have been due to the staphylococcus, either
pure and simple, or mixed with other organisms.
]n all probability the next few years will see the
pendulum swing away from the staphylococcus as
the prevalent organism responsible for nose, throat,
and middle ear infections and toward the Bacillus
influenzae, while later on as the virulency of the
Bacillus influenzas wanes, one of the other organ-
isms, aided by a sudden piling up of virulency will
supersede it again.
As to the probable character of the intranasal
complications prone to follow this present epidemic
of influenza, we have little to guide us, for the rea-
son, as previously stated, that our knowledge of the
pathology of sinus disease dates from a period too
remote (four or five years) from the last epidemic.
Furthermore, in those cases of sinus disease occur-
ring since then, the Bacillus influenzae has been re-
covered in a comparatively small proportion of the
total number of cases seen, and in this small num-
ber the strain has been relatively mild compared
with that which is found during an epidemic. It is
quite possible that some influenza infections have
escaped recognition on account of the difficulty in
securing a growth of the Bacillus influenzae, the
more so in the cases of mixed infections. It is rea-
sonable to expect that the number of sinus suppura-
tions will increase perceptibly as a result of the
present epidemic of influenza, and furthermore, that
the severity of the attacks will be increased as com-
pared with the attacks of the few preceding years
from the same organism, for the reason that the
present strain is more virulent. Not-vyithstanding
this rather unfavorable prognostication, it is more
apparent than real since the predisposing causes of
sinus disease are less common now than formerly.
I refer to obstructive conditions of the nose, more
especially septal deflections. During the last ten
years rhinologists have been fairly busy — ^but not
too busy, correcting septal deflections, thereby per-
mitting of better ventilation of the accessory
sinuses. Without a doubt septal deflection is one of
the most important .predisposing causes of sinus
disease. Should one be unfortunate enough to de-
velop sinus disease in spite of a corrected deflection,
he stands a much better chance of spontaneous re-
covery and more promptly than the other fellow
v.'ho still carries his deflection. This is a concur-
rence of opinion from all authoritative rhinologists.
Deflections of the septum, especially the high ones,
from the mechanical standpoint, bear a causal rela-
tionship to accessory sinus disease, as much so and
after a similar manner as do enlarged adenoids to
middle ear inflammation. Some one may object on
tlie ground that the adenoid tissue lodges more or
less constantly pathogenic organisms. The answer
to this is, so does the space behind the deviation.
The reply to the question of what is best to be
done to guard against the intranasal complications
of epidemic influenza is: i. Treat the systemic con-
dition for a sufficient length of time to assure as
far as possible a complete recovery from the disease,
v/hich should include rest and avoidance of too
early exposure to unfavorable weather conditions.
2. Avoid the use of local applications to the nose
and throat, for the reason that there is no antiseptic
strong enough to destroy a virulent strain of the
Bacillus influenza; which would not at the same time
injure the mucous membrane to such an extent as to
actually impair the resistance it possessed before its
use. 3. Breathe through the nose and not through
the mouth, and by breathing through the nose is
meant both sides simultaneously. If this is not pos-
sible, then the nose should be put into a condition
whereby it is possible ; for all authorities agree that
the mouth breather is decidedly more prone to res-
piratory disorders than nasal breathers. In further
support of the function of the nose in preventing
respiratory diseases, one needs but to study the con-
dition of the nose in health, when he will find an
abundance of bacteria in the vestibule, fewer in the
inferior meatus, and practically none in the middle
meatus and accessory sinuses. 4. Avoid the use of al-
cohol, for alcohol increases the susceptibility of the
one who uses it, to diseases generally and to in-
fluenza and pneumonia especially. I feel that with
this opportunity afforded me, silence on so vitally
important a matter would be equivalent to shirking
a responsibility. There is an abundance of irrefuta-
ble evidence against the use of alcohol to anyone
who is willing to take the trouble to look it up, while
none can be produced in favor of its use.
The intranasal complication of influenza narroWs
down to affections o f the accessory sinuses ; in other
words, inflammation of the mucous membrane lin-
ing them. The intensity of sinusitis may vary from
the mildest form barely recognizable accompanied
by a mucoid discharge to the severest form causing
suppuration and extensive destruction, not only of
the lining mucous membrane, but also of the bone,
with extension to neighboring and ofttimes vital
structures. The intensity of the inflammatory pro-
cess is determined by the following factors : the
virulency of the infecting organism, the relative sus-
ceptibility of the subject to the particular infecting
organism, and his general resistance (vitality) to
withstand any and all noxious influences. This last
is a very important factor in sickness too often
Ndvember 23, 1918.]
KENNEDY : SURGICAL PATHOLOGY OF INFLUENZA.
overlooked. It is the one which is the especial prey
of alcohol. In the ordinary course of events an
acute attack of influenza causes a rhinitis along with
inflammation of other parts of the respiratory
tract. Occasionally the infection is so intensive
that the sinuses are involved more or less from the
start. In those cases which terminate fatally after
a few days it is a question as to just how exten-
sively and intensively the sinuses are involved. This
is a rich held for investigation. Again, in those
cases in which death ensues promptly of cerebral
complications, it is quite possible that suppuration
of one or more of the sinuses has played an impor-
tant part. Sinus disease arising early in the course
of influenza is rarely seen by the rhinologist. It is
rather those of later development that he sees and
has an opportunity to study. We have every rea-
son to believe that the number of cases of sinus dis-
ease of later onset far exceeds those arising during
the acute stage, since this is the rule with all other
infections of the nose.
Nasal accessory sinus disease, at least the frank
forms, usually develop after the initial rhinitis has
begun to subside. It manifests itself as flare up
in the cold, is ofteft accompanied by a rise in tem-
perature, localized sense of fullness, or pain and
tenderness to pressure. There may or may not be a
unilateral discharge, anteriorly in the case of in-
volvement of one or more of the anterior set of
sinuses (frontal, maxillary, or anterior ethmoidal),
posteriorly in the case of involvement of one or
more of the posterior set of sinuses (posterior
ethmoidal or sphenoidal). In those cases of sinus
mvolvement with pain and localized tenderness
without discharge, the absence of discharge may be
due to lack of drainage from occlusion of the natu-
ral osteum. The occlusion may have resulted from
a temporary, inflammatory swelling of the mucous
membrane about the osteum ; in which event, the
local application of cocaine to the adjacent parts
will shrink the mucous membrane sufficiently to
make the osteum patulous, resulting in temporary
drainage and relief of pressure and pain.
The treatment of sinus diseases due to influenza
is conducted after the same manner as the treatment
of sinus diseases from any other infection. From
the rhinologist's viewpoint, a sinus disease, if
acute, is treated conservatively by establishing and
maintaining drainage. From the standpoint of
treatment, he as a rule pays but little attention to
the nature of the infecting organisms. The objec-
tion might be raised that a knowledge of the nature
of the infecting organism is important and should
be ascertained in all cases, in order to decide better
upon the character of the vaccine to be used.
Theoretically, this objection may seem to be well
founded, but the experience of the average rhinolo-
gist is that those cases in which vacctnes have ap-
peared to operate the most satisfactorily have been
the acute inflammations which are prone to get well
without them. In the more chronic conditions they
have been a dismal failure. Let it be understood
that I do not wish to condemn the bacteriological
study of suppuration or that I would have vaccines
discontinued altogether in the treatment of sinus
disease, but I do insist that the results thus far ob-
served in the treatment of obstinate suppurations
have been far better from surgery alone than from
vaccines alone.
The subject of the diagnosis and treatment of
accessory sinus diseases is one of considerable im-
portance and quite technical. It is a rather new
science, our knowledge of which is already consid-
erable, but only fragmentary compared with what
it promises to be a few years hence, which is my
apology for the earlier confession that "our knowl-
edge of the frequency and character of the nasal
complications of epidemic influenza is meagre."
REFERENCES.
I. ALLEN: Bacterial Diseases of Respiration, P. Blakiston's
Son & Co., Philadelpliia. 2. BENHAM: Quoted by Allen in Bac-
terial Diseases of Respiration. 3. WILL WALTER: Journal
A. M. A., September 24, 1910.
SURGICAL PATHOLOGY OF THE PRESENT
INFLUENZA EPIDEMIC.
By J. W. Kennedy, M. D.,
Philadelphia.
The present influenza epidemic is characterized
by its wide distribution, great prostration, high
mortality, and its difference in course of pathologi-
cal extensions.
That it is a mixed infection there is little doubt,
conforming, however, to the dominance of influenza
bacillus, pneumococcus, and streptococcus. The
pathologists and bacteriologists are in accord on this
point. It is my opinion that the difference in the
virulence and pathology of the present epidemic is
determined and indicated through the mode of ex-
tension of the pathological conditions by the strepto-
coccus.
If you will study i:he pathology of those condi-
tions in which the streptococcus is the infecting
source, you will be impressed by the following facts :
In the first place, the streptococcus is not a
mucous membrane infection, in that it has no tend-
ency to confine its pathological extensions to these
membranes. Surgically we see this typified in the
puerperal infections which we assigTi to the ravages
of the streptococcus. The puerperal infeciions are
particularly fatal on account of the diffuse and in-
filtrating modes of extension of the pathological
conditions which are little influenced by either serous
or mucous membrane; therefore, this type of in-
fection does not confine itself to a particular
structure which is limited by mucous or serous mem-
brane, but infiltrates the structure throughout with
little tendency to become localized. This is the rea-
son the puerperal infections are little amenable to
amputation surgery (removal of pathological con-
dition).
The surgical complications following this epi-
demic have all the earmarks of the puerperal or
streptococcus infections. One remarkable feature
in this epidemic has been that we have not had the
usual great number of operations for appendiceal or
gallbladder conditions which uniformly follow or
accompany the ordinary influenza epidemic which
is a mucous membrane condition, the appendiceal
and gallbladder lesions simply being extensions of
the mucous membrane infection. Another impor-
tant point is that we have not had the usual num-
ber of operations for empyema which follow the
ordinary pneumonias. In the cases where it has
888
SABSHIN: INFLUENZA IN U. S. MARINE HOSPITAL.
[New York
Medical Journal.
been necessary to open the chest cavity we have not
found the pus collection at its usual location or in
the usual amount. The usual pus collection is low
down and posterior in the ordinary pneumonias,
such as one might expect from the infection of the
pleura. So again we find in this epidemic the in-
fection has not extended or confined itself to the
serous membrane of the pleura but has more deeply
infiltrated the lung tissue. Never before have I
opened the chest cavity following a pneumonia as
high as the third rib, and never before have 1 opened
the chest as far anteriorly as the nipple line. So
again we find the extensions of the pathology in this
epidemic have not conformed to the governing or
controUing rule of the mucous or serous m.embrane
lesions. The abscesses opened in chest cavities
seem to be small and honeycombed, thus again con-
forming to the rule of an infiltrating infection not
confined or limited to the normal membranes.
The surgery of the lung in this present epidemic
will not be followed by the brilliant results obtained
in the ordinary empyema following a classical pneu-
monia, as the accumulations of pus are small and
multiple, indicating the mode of infection, and little
accessible to surgical drainage. The infection
throughout the structure of the particular viscus not
limited by the ordinary barriers of serous and
mucous membrane has been the determining factor
in this merciless epidemic.
The pathologists will probably tell us that there
is not the usual consolidation within the vesicles and
small air chambers which is typical of the classical
pneumonia, but that the extension is infiltrating and
has not confined itself to the bronchi and their ex-
tensions. Now the hemorrhages which have ac-
companied this epidemic are further typical of the
extensions of the infection beyond the mucous
membrane to the deeper structures of the alimentary
canal. Great muscular weakness, the frequent heart
collapse, and diffuse hemorrhage into the tissues are
further evidence of an unlimited and infiltrating in-
fection. ^^'e find it a strong working factor in
surgery that those lesions which strike between the
mucous and serous membranes have a frightful
mortality. This is brought before the medical pro-
fession in this epidemic as I have not seen it before.
It is a matter of record in this epidemic that in
those camps or institutions where it was necessary
to congregate large numbers of persons the mor-
tality was high, just as it was in the puerperal epi-
demics which occurred in the early history of that
fatal infection, the mortality being much higher in
hospitals than in homes.
The metastases following the present epidemic
have been most typical of a streptococcus infection
in the formation of multiple abscesses in the muscu-
lar and connective tissues which is another indica-
tion of the route of infection and a further evidence
that the infection is not confined or influenced by
either serous or mucous membrane. Again these
multiple muscular lesions are an indication that the
infection travels by or through the lymphatics of
bloodvessels and not by the normal membrane.
We thus again see the similarity to the puerperal
infection which is a wound infection and extends in
unlimited direction through the lymphatics and blood-
vessels. It is most probable that the combination
of the influenza and streptococcus infections ex-
plains in force the wide distribution and the great
mortality : the Pfeiffer bacillus responsible for the
wide distribution and contagion and the strepto-
coccus for the high mortality, infiltrating involve-
ment, and metastatic conditions. The pneumo-
coccus is present but I doubt if it is an influencing
or a determining factor in mortality. The appalling
death rate of the prematurely delivered woman dur-
ing this epidemic points so strongly to the great
puerperal epidemics that we are forced to the con-
clusion of a similar etiology. The full term preg-
nancy has been accompanied by a mortahty peculiar
to this epidemic, but fortunately not with the ex-
ceedinglv high mortality of the premature delivery
or miscarriage. This, in my opinion, is not alto-
gether due to the fact that the patients at full term
have a higher point of resistance, but probably is
due to the greater risk of infection through me-
chanical or operative means incident to the care of
the premature case.
If the surgical finger ever had to be cleansed, it is
most indicated during this epidemic. In my insti-
tution, the Josepii Price Hospital, God has been
good to us during the epidemic as, so far, we have
escaped surgical mortality. We have followed the
most rigid West Point regulations in all sanitary
rules ; we have been unrelenting in every detail of
sterilization, ventilation, and isolation. Short of
such extravagant precaiilion surgery during this
epidemic would have been accompanied by fatal and
prohibitory complications.
241 North Eighteenth Street.
INFLUENZA.
Clinical Observations of the Present Epidemic in
the U. S. Marine Hospital.
By Z. I. Sabshin, M. D..
Stapleton. N. Y.
Acting Assistant Surgeon. U. S. Public Health Service, U. S.
Marine Hospital.
It is, indeed, to be regretted, from the public
health point of view, that we are not in a position
to state definitely the nature of the etiological agent
of the present epidemic. In spite of the fact that
for prevention and cure stress must be particularly'
laid on the infective agent, we still face the ravages
of this epidemic without a clear idea of the nature
and method of control of the causative organism
or organisms. Our own laboratory findings, as well
as information from other laboratories, at present
fail to give satisfaction. While the only term now
heard is influenza, we observe a pneumonia epi-
demic, most probably independent of the influenza.
We admit that a great number of the pneumonias
observed are complications of influenza, but we have
seen in our wards too great a number of old
fashioned lobar pneumonias to escape the observa-
tion of a separate epidemic. Notably the present
epidemic is caused by a variety of microorganisms.
The pulmonary lesions produced by the Diplococcus
pneumoniae are more or less typical and identical,
although during life it is hardly possible to detect
November 23. 191S.J
SARSHIN: INFLUENZA IN U. S. MARINE HOSPITAL.
8S9
the differences in the lesions caused by various
bacteria. Chnically, however, we observe in this
epidemic definite groups of systemic disorders, to
the extent that wo may say with certainty that we
deal with a variety either in the infectious agents
themselves or their virulence, as we have met the
exact clinical pictures in various patients, with the
only possible exception, to our mind, of race —
namely, there was a proportionally greater number
of fatalities in our colored patients. We shall,
therefore, give here an account of our clinical notes,
regardless of the direct or indirect causative agents.
We have met four distinct groups as follows :
1. Mild or abortive cases.
2. Ordinary cases.
3. Malignant or toxic cases.
4. Irregular or protracted cases.
The daily olSservations in the wards, the charts,
and records, not only make this classification char-
acteristic, but suggest an idea that we deal with
four cHnical entities. Roughly, the di'stribution of
the cases at present is as follows : thirty per cent, of
the first group, forty per cent, of the second, twelve
Time of
Day.
M.
E. 1 M.
E.
M. j E.
.11.
M.
r.
M.
1
E. ; M.
i
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Chart I.
per cent, of the third, and eighteen per cent, of the
fourth group.
Mild or abortive cases. — The patient is usually
young. He generally has a fever of about 38° to
.\o° C. (see Charts T and II) and complains of head-
ache, backache, or general aching of bones and
joints. A number of patients give a history of not
being at all well for a few days. The complaint
may be limited to the fever only, or to a chilly
sensation.
The physical examination elicits a flushed face,
dry lips, coated tongue and sometimes slight con-
gestion of pharynx. There is a slight acceleration
of the pulse, and in a few cases a systolic blow may
be present. A considerable number of patients give
some pulmonary signs : most commonly harsh vesic-
ular breathing over one or both upper lobes, or distal
breath sounds over one or both lower lobes. In
very few patients were there musical rales in the
axillcE. and in one patient crepitant rales over apices
were found. Loss of appetite is common. Consti-
pation predominates, and only few complain of too
loose bowels. The reflexes are mostly normal, but
some give sluggish reactions. These patients re-
cover rapidly. The temperature drops in twenty-
four to forty-eight hours after admission, and they
are discharged in good condition within three to
five days.
Ordinary cases. — This group subdivides itself into
those that have recovered, with no definite signs of
Time of
Diiy.
J-
M.
E.
X.
y.-
M.
£.
M.
E.
M.
E.
M.
E.
M.
E.
M.
1
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.
3G
_
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1
t
Chart II.
pneumonia ; those that recovered or died with signs
of bronchopneumonia ; and thirdly into those that re-
covered or died with signs of lobar pneumonia. We
use the term lobar simply from the physical view-
point, as we have foimd the areas of one or more
lobes giving dullness, bronchial breathing, associated
with shallow painful respiration, disregarding the
question whether the infection is primary, or the
lobe became involved by the spread of the infection
from the lobule or lobules. We do include in this
group a number of old fashioned lobar pneumonias,
running the typical course, and the description of
which is unnecessary, being a well known picture.
The patients of this group vary in age, but in our
experience not many were above forty years. They
come in, or are brought in with a temperature of
about the same as the previous group, or sometimes
lower. They complain of headache, pain in the
neck, or general malaise with a cold in the chest,
cough, weakness, and loss of appetite. A great
number give a history of a preceding chill; but it is
characteristic of this epidemic that we do not get
the history and findings of the well known acute
coryza. caused by the Micrococcus catarrhalis.
Time ot
Dny.
1
717
30
I-
I 38
37 '
_
-
-
1
Chart III.
There is no sneezing, no clear irritating secretion
from the nose in the early stage, and no turbid dis-
charge later. Neither is the voice that of the
ordinary coryza, with the stuflfed-up nose, but either
normal or husky.
890
SABSHIN: INFLUENZA IN U. S. MARINE HOSPITAL.
[New York
Medical Journal.
The physical findings of these patients vary. A
considerable number of them look desperately ill on
admission. The face is very flushed or even con-
gested; the eyes frequently show a conjunctivitis;
the tongue is dry and coate'd with a thick white or
yellowish membrane. The circulatory system is
Chart IV.
mostly disturbed. Congestion is common, but the
blood pressure is not high in this as in the other
groups. A soft systolic blow over the mitral or
tricuspid area is not infrequent. A striking feature
is that very few give a high pulse rate ; on the con-
trary, the pulse is rather slow in proportion to the
temperature. The lung findings are variable, but
very few give no signs at least of a mild bronchitis
— hardly five per cent, of this group gave no signs
of some pulmonary disturbance. A considerable
number gave tenderness and increased resistance
over diff u.^ed abdominal areas. Almost all the cases
gave sluggish reflex reactions, and in many cases
the knee jerk was entirely absent.
The course of these cases is typical. In twenty-
four to forty-eight hours the temperature drops,
then rises again the next morning to the same level
or somewhat below, and then comes down slowlv.
sensation. There is almost an immediate rise of
the temperature, and the cough which in most of
the cases has not yet entirely disappeared, increases,
with pain in the chest and depression. 'J'he voice
grows husky, the patient is restless, and a broncho-
pneumonia is picked up with the stethoscope within
two days.
The clinical course of these bronchopneumonias
difiers from the usual bronchopneumonias in that
the respiration is not as high, the pulse not so rapid,
the cough not as hard and distressing ; on the other
hand there more commonly is cyanosis, nosebleeds,
foul odor from the mouth, and a cutaneous perspira-
tion instead of the hot dry skin in the usual broncho-
pneumonias. Delirium is more common ; otherwise
the fever comes down by lysis, fluctuating occa-
sionaljy, within three to four weeks (see Cliarts III,
IV, and V).
Malignant or toxic cases. — The third clinical
group, as we observe it, can properly be called
malignant, dr toxic. Its severity, the apparent suf-
ferings of the patient and the more or less rapid
fatal terminations are all unique. The age of these
patients is between twenty and thirty-five years :
there was one exception — a patient of forty-one
years. They are admitted with a fever, not neces-
sarily very high, and complain of general malaise.
They seem to be depressed and indifi'erent during
the first twenty-four to forty-eight hours, but the
color of the face is suspicious and typical to one
who has seen cases of this nature previously. It is
not the feverishly bright flush associated with a high
temperature; neither is it the limited round flush of
the cheeks seen in the pneumonias. It is a con-
gested dif¥use red color with a bluish tinge, or ashv
gray hue.
The symptoms may be obscure or masked. On
the second or third day after admis.sion the patient
grows restless, anxious, assuming all kinds of pos-
tures, and soon begins to suft'er from a tightening
Chart V.
with very slight fluctuations, within three to five
days, the patient recovering. Unfortunately, not all
cases terminate in this manner. After two to four
days of a normal temperature about twenty-five per
cent, of these patients again complain of a chilly
pain in the anterior lower chest, more to the left
side. The fever is up (see Charts VI, VII, and
VIII) and -usually^ stays high, very few giving
fluctuations. Congestion is noticed all over the upper
half of the body. Epistaxis ^and a sanguinopuru-
November 23, 191S.]
SABSHIN. INFLUENZA IN U. S. MARINE HOSPITAL.
891
lent expectoration is present in almost all of them
The patient moans, holding one hand over the chest
and the other hand ready, near the cup, to spit or
vomit. Notably these pangs come in paroxysms,
about four to five during the day, each lasting five
Time of
Day.
M.
E.
M.
£.
M.
E.
M.
E.
M.
F..
M.
E.
M.
E.
M.
E.
40
3:1
1
—
—
—
1
z
1
>
i
37
3G
_
Chart VI.
to ten minutes, with wretching and vomiting, mostly
in the mornings. The face is wrinkled, the eyes are
kept closed, the tongue is dry, and the patient bends
over and sometimes doubles up, or prefers to be' in
a half sitting posture. One of these patients had
an attack of hiccough, lasting twenty minutes.
There is a profound prostration. Physical examina-
tion gives a rather indefinite picture of a broncho-
pneumonia, with a prostration out of proportion to
the findings, which we consider a characteristic
feature. The moaning is very loud and disturbing.
One of our first patients was suspected of exag-
Time of
Day.
M.
E.
M.
E.
M.
E.
M.
E.
M.
M.
E.
M.
E. 1
1
M.
~~
E.
40
39
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38
1 37
_
_
_
1
Chart VII.
geration or malingery, but the cases following have
all demonstrated the very same expressions of
pangs, caused by some toxic condition of the vaso-
motor and respiratory centres. There is a low
blood pressure, and the patient sinks into a condi-
tion of collapse. The features are shrunken, the
voice very husky or lost, extremities cyanosed,
clammy perspiration all over the body, and with con-
sciousness retained mostly up to the end, the pa-
tient dies in from three to seven days, from
asphyxia, asthenia, or pulmonary edema. Few last
longer, and not over four per cent, very slowly re-
cover.
The irregular or protracted cases. — This group is
admitted with about the same complaints as the
ordinary group. The subjects are almost all young
persons. The temperature is continuously above
normal with a variety of fluctuations (see Charts
IX, X, and XI). Some run a fever for a few days
with a sudden drop, as if by crisis, but with an im-
mediate rise, then again fluctuating variously. Oc-
casionally during the course there is a hectic tem-
perature for a few days. Finally there is a slow
decline, the process lasting three to five weeks.
The physical findings vary greatly, and are ir-
regular ; the same applies to the subjective symp-
toms and general dispositions of the patients. Some
go through an irregular course with the only find-
ings of a mild bronchitis. These cases resemble
Timo of
Day.
M. j
E.
M.
E.
M.
E.
M.
E.
M.
M.
E.
M.
E.
_
E.
1 40
1
1
z
11
ft
I
_
1
M
39
If
f_
zt
_i
i ,
W[_
z
\
38 y
_
\i
1
: 37
V
_
1/
_l_
_
1
Chart VIII.
clinically a mild course of typhoid fever. Some
show signs of pneumonia, localized or scattered, and
the clinical picture is that of a typhopneumonia, but
with a negative Widal and negative blood culture
for the Bacillus typhosus. Others run a course
very much the same as a miliary tuberculosis. One
patient had all the signs and symptoms of a tubercu-
lous bronchopneumonia, with a positive sputum,
followed by recovery. Another patient of this
group gave a positive sputum for tuberculosis, fol-
lowed by numerous negative tests, and was dis-
charged in good shape. The x ray in another
patient shows mottled areas scattered over both sides
of the lungs, and a shadow over the left base, sug-
gestive of a thickened pleura, or fluid. The needle
gives neither pus nor fluid, but the sputum finally
shows the tubercle bacillus. The patient takes his
nourishment fairly well, but is rather indifferent,
and remains in bed most of the time, running an ir-
regular fever.
So we note that while the onset and the premoni-
tory symptoms are about the same, this group on the
one hand gives cases obscurely protracted, clinically
resembling bronchopneumonia, or typhopneumonia,
almost all recovering, and on the other hand cases
892
SADSHIN: INFLUENZA IN U. S. MARINE HOSPITAL.
[New York
Medical Journal.
simulating miliary tuberculosis, with a number of
positive sputa. The question arises, what is the re-
lation of the present epidemic to tuberculosis? Is
it simply an attack of influenza superposed upon an
old or healed tuberculosis lesion, converting it into
an active disease ? We can not answer this question
cells. In the other groups albumin is very com-
mon, also pus cells and casts. In one of our ordi-
nary cases we found sugar, which disappeared in
two days.
Blood : The blood cultures gave indefinite results,
as far as the search for some organisms is con-
— -
1
Time of
Day.
30
—
—
—
—
—
—
—
—
—
—
—
38
37
1
3C
1
1
Chart IX.
now. A little later there may be recorded a great
number of pulmonary or other forms of tubercu-
losis with a history of influenza during this epi-
demic ; at present we can but note that there is
some connection between the two.
GENEKAL OBSERVATIONS.
Incubation. — Judging from the few cases that set
up an influenza, while admitted to the ward for
some other reason, in the beginning of the epi-
demic, the incubation period is from one to four
days.
Pathology. — Anatomically our autopsis gave
nothing of importance as far as the etiology is con-
cerned, and no more than the clinical picture could
suggest. We had the usual findings of pneumonia
— one case having a little pus in between the lobes,
and another some pus in the pleural cavity. The
cerned. In one case we found the Streptococcus
hemolyticus. The blood cellular counts have al-
most uniformly shown a leucopenia, in some cases
as low as 3,000 white blood cells per centimetre,
with no disturbance in the relative number of the
various white blood cells. Only in the more or
less typical pneumonias was there a slight leucocy-
tosis. We have also tried the Wassermann test on
some of the convalescing patients with no history
of syphilis, and found the results negative.
Sputum : The sputum was examined to determine
the pneumonic group, and most of the reports
proved to be of Group IV". As stated above, some
of the protracted cases gave a positive tuberculo-
sis in the sputum.
Blood pressure. — Notably, the blood pressure
either remained normal, or was slightly below nor-
Time of
Day.
1
38
_
37
_
3G
ri
Chart X.
spleen is not enlarged, and the kidneys mostly show
a state of cloudy swelling. It is apparently sug-
gestive that the disease is a toxemia with little ana-
tomical changes, as far as the present reports go.
Laboratory. — Urine : In the mild cases the urine
is mostly negative, but some gave a trace of albu-
min, squamous epithelial cells, and occasionally pus
mal, but hardly any rise was observed in any group.
Complications. — Skin: In the ordinary group we
had half a dozen of diffuse erythemas, in one of
which the rash would come and go with big red
areas about two inches in diameter. Some of the
protracted cases had scarlatinal rashes all over the
body.
November 23, 1918.]
SABSHIN: INFLUENZA IN U. S. MARINE HOSPITAL.
893
Special senses : Blepharitis marginalis was noted
in a few cases ; conjunctivitis in about half a dozen ;
and in one the pneumococcus was found. Otitis
media was present in about ten per cent, of the
cases, and a number had a purulent discharge. The
condition usually subsided with the general dis-
show the trachea to be a point of selection for the
Bacillus inlluenzse.
Instead of mentioning bronchopneumonia as a
complication, we shall state here that the stetho-
scope proved to be the best and most reliable means
of diagnosing this condition, whatever the criti-
I ime 01
DHy.
39 ^
3S
37
36
1
1
Chart XI.
ease ; only one patient left the hospital with im-
paired hearing and a slight discharge.
Gastrointestinal tract : Foul odor from the
mouth was noticed in a few cases. Vomiting was
a grave condition in all malignant and some of the
ordinary patients. The vomitus was of an acid
reaction, occasionally bloodstained, and consisted
of a yellowish or greenish fluid. Hiccough was
present in one of the malignant cases. Constipa-
tion was very obstinate in three cases, diarrhea in
two, and blood in the feces in only one.
Bronchopulmonary tract : Epistaxis was present
in about seven to eight per cent, of our cases, most-
ly at the onset. One patient of the ordinary group
had a puhnonary hemorrhage, leaving the hospital
cism may be. To diagnose by judging by the
appearance of the patient, and even by percussing,
would surely mislead in this epidemic. I found
one woman with scattered areas -of consolidation
over both sides, and very weak, whose private doc-
tor told her that same day to leave bed, simply be-
cause he did not use his ears. If patiently used,
the stethoscope will elicit a pneumonia in proper
time.
Genitourinary tract : In one of the protracted
cases we had a retention of virine, and the patient
had to be catheterized for two days. Several of
our patients had an exacerbation of gonorrhea, i. e.,
they had been cured from this disease several
months, and have set up a urethral discharge in
TicQO of
Day.
39
38
37
36
Chart XI (Continued) .
with no evidence of pulmonary or gastric disease.
Loss of voice was common in all malignant and
.some of the other cases. The husky voice is typ- '
ical and associated with pain in the chest, the pa-
tient always pointing to his upper chest. The local
laryngeal findings were not severe enough to ac-
count for the hoarseness or total loss of voice. It
is rather a toxic condition of the nervous control
of the larynx, or a tracheitis, as laboratory reports
three to five days after the attack of the influenza.
Nervous system : Delirium was common in the
ordinary group, being the delirium mostly o^ a low,
muttering nature. Fighting snakes and catching
flies is a common story. One of the protracted
cases had a delirium resembling a uremic coma,
with a locked jaw, so that this patient had to be
fed through his nose for two days. This patient
recovered. In the malignant cases the delirium
894
FRANKEL: PROPHYLAXIS OF SPANISH INFLUENZA
[New York
Medical Journal.
was a kind of drowsy restlessness. Three patients
had supraorbital neuralgia, and one had a neuritis
of the lower extremities.
Surgical cofiiplications. — Beside otitis media,
mentioned above, we had one case with an alveolar
abscess and abundant pus. Another patient had
all signs and symptoms of a cholecystitis, but his
condition still does not warrant a laparotomy. In
another patient with symptoms of a septicemia,
pus developed in the forearm and in the groin and
axilla on the opposite side. He died before drainage
was rendered.
PROGNOSIS.
Our records show more than 450 cases with a
mortality of between fourteen and fifteen per cent.
Our treatment was mostly symptomatic, with trials
of all the well known measures, but I must frank-
ly admit that we cannot point to any one as being
definitely good. Atropine seems to prevent a great
number of pulmonary edemas.
Generally, the picture may change within twen-
tv-tour hours from a favorable to an extremely un-
favorable one. Leaving the bed too early has sent
a good many to the grave. At least four days in
bed after the temperature has become normal is an
absolutely necessary measure.
The favorable points, as we have noticed them,
are older age, a. slow onset, and a fluctuating tem-
perature. The grave signs are constant tempera-
ture, even not very high, vomiting, and partial or
total loss of voice. Delirium is not of importance
as far as prognosis is concerned. Colored patients
have given a proportionally higher number of mor-
talities.
SUMMARY.
1. Apparently we have had two epidemics: influ-
enza and pneumonia.
2. There is one group of cases, very toxic, the
physical, and particularly the chemical, nature of
which we do not know.
3. We face a problem of tuberculosis in connec-
tion with this epidemic.
PROPHYLAXIS OF SPANISH INFLUENZA.
By Bernard Frankel, M. D.,
New York.
Although its name suggests to the laity some new
outlandish disease, we find Spanish influenza to be
distinguished only by the greater virulence of its
infection from the ordinary grippe which has be-
come almost endemic with us and has been espe-
cially prevalent here during the fall, winter, and
spring seasons of the past few years.
I have made a careful study of its various mani-
festations for the past ten years, and as early as
T909 observed in a child a very interesting case of
influenza ushered in by the typical eruption and in-
vasion of scarlet fever. My diagnosis of influenza
in that case was confirmed by Dr. L. Emmet Holt
who saw the case with me, and I described it in
detail later, in my article on pseudoscarlatina (i).
Later I observed and described gastrointestinal,
nervous (2) and pulmonary (3) forms and about a
year ago also the exanthematons and other forms
of influenza (4).
In the last named article I pointed out the pseudo-
measles, pseudoscarlatina, pneumonic and pseudo-
tuberculous forms among others, and also the fact
that instead of the Pfeififer bacilli, streptococci were
the real causative agents of influenza — in severe
cases probably the Streptococcus hemolyticus.
As prophylactic measures I urged quarantining
every case of influenza and keeping even mild cases
at rest in a warm, well ventilated room at a dis-
tance from open windows and drafts of cold
outside air in order to prevent complications (4).
This recommendation was in direct contrast to the
then verv popular slogan of "wide open windows in
grippe" which was promulgated by the medical au-
thorities and which induced grippe patients to seek
the proximity of wide open windows to ward oft'
pneumonia, with the result of bringing on that very
complication. In my article. Influenza versus Tu-
berculosis. I pointed out the fallacy of this open air
treatment of grippe and asserted most emphatically
that influenza is the disease most adversely affected
by exposure.
In view of the rapid spread all over the world of
the present influenza epidemic I deem it my duty
to elucidate in greater detail a fact of great pro-
phylactic importance which I mentioned in a pre-
vious article (3). I refer here to what I then termed
■'latent grippe" by which I meant a stage sometimes
preceding and sometimes following an acute attack
of influenza and characterized by rather vague
symptoms, such as loss- of appetite, exaggerated
sensitiveness to cold — the patient feeling comforta-
ble only in a warm room, a feeling of general weak-
ness or asthenia accompanied by very profuse
perspiration upon the slightest exertion and also in
bed at night (3).
According to my observations this latent stage of
influenza, which, if not properly treated, may last
for weeks, marks the period of the patient's greatest
susceptibility to the infection and also the period
of greatest danger of relapses or complications by
pneumonia, for whereas during the acute attack of
grippe most patients will remain m their rooms,
very few if any would consider the vague symptoms
of the latent stage as justifying the taking of the
necessary precautions against exposure.
It seems to me, therefore, that it is the duty of
the medical authorities and of the profession at
large to impress upon the laity the importance of
the proper prophyllxis during the latent stage of
grippe. In addition to rest in a warm and well
ventilated room I- find quinine of great and almost
specific value as a prophylactic measure in the latent
stage of grippe ; its use in doses of from ten to
twentv and more grains daily for a few days will
invariably abort an impending acute attack and
frequently ward off dangerous complications if
properly used in the early stages. Quinine seems
to exert a great inhibitory influence upon the infec-
tive agents of influenza and is strongly indicated
during the latent stage and also during the course
of the disease and its convalescence which it hastens.
In fact I feel justified in strongly urging its universal
use by persons exposed to the contagion of influ-
enza and by everybody during the prevalence of an
influenza epidemic like the present. Such universal
use of quinine both as a prophylactic and curative
November 23, 1918.]
VON TILING: INFLUENZA AND SUPRARENAL GLANDS.
895
agent would, I am convinced, contribute greatly to
cutting short the course of such an epidemic. I
have seen repeatedly impending attacks of Spanish
influenza aborted by large doses of this drug aided
by diaphoretics and mild laxatives — strong cathar-
tics are contraindicated as likely to induce trouble-
some diarrhea and even symptoms of enterocolitis
in some instances.
REFERENCES.
I. Pseudoscarlatina, New York Medical Journal, October 21,
1916. 2. Enteritis, Infantile Paralysis, and Influenza, Ibid., De-
cember 2, 1916. 3. Influenza versus Tuberculosis, Ibid., January
27, 191 7. 4. Exanthematous and Other Forms of Influenza, Ibid.,
February 16, 1918.
1234 Madison Avenue.
INFLUENZA AND SUPRARENAL GLANDS.
By Johannes H. M. A. von Tiling, M. D.,
Poushkeepsie, N. Y.
During the present epidemic of influenza I ob-
served several cases which suggested a line of treat-
ment that seemed to be of so much benefit that I
feel justified in outlining it briefly.
I saw several patients who presented almost the
classical symptoms of acute Addison's disease, ex-
treme muscular weakness, tendency to syncope,
insomnia, low diastolic pressure with high pulse
pressure, and, in two instances, the unsolicited re-
mark was made by a member of the patient's family
that he was looking "so brown." In several in-
stances we saw attacks of dizziness and faintness
caused bv the slightest exertion, as for instance
turning the head or lifting an arm, and we saw sud-
den collapse with marked mottling of the skin and
cyanosis followed by a feeling of chilliness and
extreme weakness, and yet there did not appear to
be any failure of the heart and no dilatation, but a
slow regular pulse and apparently a good pulse
pressure. In two patients, known to me for years,
who are not at all of nervous temperament, the tak-
ing of the blood pressure alone brought on such
attacks. These symptoms in one instance were so
alarming that, frequently, I did not feel justified in
taking the blood pressure in other similar cases.
The results of the administration of suprarenal
gland substance, and especially of repeated injec-
tions of epinine and adrenalin chlorid solution, were
such that I became convinced that the extreme
weakness seen so often in cases of influenza during
the attack and also in the period of recovery was
caused not so much by a weakened heart miUscle as
by adrenalin deficiency. Another observation of
interest in this connection was the fact that a num-
ber of patients complained of a distinct localized
pain and soreness in the region of the kidneys, after
the general backache and headache had disappeared,
and this backache was frequently very promptly re-
lieved by epinine. It gave the impression that the
administration of suprarenal substance or epinine
had taken a load from the suprarenal glands.
I am not in a position to scan medical literature
for confirmation of the theory that adrenalin defi-
ciency may be responsible for weakness and death
in many cases of influenza, but the seriousness of
the present epidemic and the striking results* ob-
tained by the treatment suggested above seem to
me to be sufficient justification for these remarks.
DANGER OF THE MASK FOR PROTECTION
AGAINST INFLUENZA.
A Better Device.
By J. C. Minor, M. D.,
Hot Springs, Ark.
The ultramicroorganism is unimpeded by the
mask in its flight through the nasal passages, even
by the six fold gauze, so forceful is the inhalation
of air as compared with the exhaling through the
mouth and nasal passages. The return of the air
breathed in is arrested by the mask and thus a sec-
ond shot is taken at rebreathing air vitiated not
only by the microorganism of influenza, but it is
necessary to rebreathe the normal output of the
lung excretion in addition.
I am offering as a more sensible filter the inch
gauze pledget folded to a cone shape and inserted
into the nostril. Cut the gauze about one inch
square, or carry in the pocket a one inch gauze
roller bandage and with pocket scissors cut one inch
of the gauze and fold it three times. Insert one of
these pledgets in the nostril right and left whenever
the mask would be indicated.
The public might be instructed by the family
doctor to use this not unseemly precaution when at
home or on duty or when traveling or shopping.
The nostrils should not be stuffed. The pledget
should rest lightly in each nostril as a miniature
filter and must not impede breathing through the
nose.
I do not approve of the mask nor do I believe
that spraying the air pasages with irritating lotions
is of any value. On the contrary, the most soothing
lotions to the sensitive areas of the nasal and throat
passages should be used. The ideal lotion to my
mind is made from the alkaline antiseptic tablets
which have been familiarly known co the profession
for years. There is no just reason why every one
should not carry a supply of these inch gauze cut-
tings wrapped in tinfoil or paraffin paper at all
times to be used frequently during the day or night.
The mask is impractical, because the entire popu-
lation of a town cannot be coerced into using it.
It is not generally used by the doctors. It is ex-
pensive ; it is dangerous, because it is filthy ; it can-
not reasonably be rendered aseptic for using over
again. Cotton is twenty-six cents a pound in the
field. There are a hundred milhon of us.
"Kadu" Infection. — M. L. Kamath (Madras
Medical Journal, January, 1918) draws attention
to the dangers which await new comers even in the
simple art of fishing. He gives three or four cases
of infection through a prick with the scales of the
kadu, which is a fresh water fish found in Malabar,
four feet seven inches in length with a spine on
either side the oral cavity, which it uses in attacking.
Within a day or two violent cellulitis sets in with
much redness, swelling, and pain in the fingers and
palm. The cellulitis spreads up the forearm and
sometimes goes on to suppuration, and, in cases
brought too late, there is sloughing of tendons and
erosion of bone necessitating amputation of pha-
langes or metacarpals. The pus has a peculiar, of-
fensive stench. Recovery is slow.
896
SHAWEKER: A WASSERMANN MODIFICATION.
[New York
Medical Journal.
A WASSERMANN MODIFICATION.
By M.\x Shaweker, M. D.,
Brooklyn,
Lieutenant, M. C, U. S. Navy; U. S. Naval Hospital.
For conducting the complement fixation tests in
the diagnosis of syphiHs, many modifications have
been suggested in the last few years. Most of these
are designed to simplify the technic or to overcome
the natural antisheep amboceptor which occurs in
variable quantities in human sera. Bauer, Hecht,
Weinberg, and Gradwohl, however, have utilized
this natural antisheep amboceptor against sheep
cells. The last three of these workers also
utilized the native complement present in human
sera. Few serologists use hemolytic systems other
than antisheep or antihuman. Detre and Brezovsky
used an antihorse system. Browning and Mac-
kenzie an antiox system. The use of human cells
and active sera as recommended by Noguchi is
rapidly gaining favor. The homohemolytic method
lately suggested by him has been used in our labora-
tory with satisfaction, the only objection being the
difficulty in obtaining good amboceptors. It so hap-
pens in the navy that systems utilizing human cells,
or the cells of small animals such as can be con-
veniently carried on ships, are more practical than
those requiring larger animals— as the sheep, horse,
or ox. With this end in view we attempted the use
of guineapig cells. Although literature from vari-
ous sources credits guineapig cells with immunity
to the natural hemolysins in human sera, we find
and given two or more subsequent washings with
normal salt solution. Natural agglutinins have not
been observed. The cells "handle" well and as we
use them in a one per cent, suspension, the readings
have much the appearance of an antihuman system.
The patient's serum is used in doses of o.i c. c. to
each tube and should be fresh, free from cells, and
not hemolyzed. In testing a spinal fluid, o.i c. c.
of a known negative serum must be used to furnish
complement and amboceptor.
The titrations required in this modification are to
determine the anticomplementary unit of the antigen
used and the cell load which can conveniently be
handled by the 0.1 c. c. of patient's serum used.
The ice box fixation is used for the first step, four
hours to overnight being the time allowed. One or
two shakings of tubes is sufficient.
The technic is very simple and requires the fol-
lowing :
APPARATUS.
Leur syringe, lo c. c.
Centrifuge tubes.
Test tubes, 9 by 9
cm.
Test tube racks.
Graduated pipettes.
Water bath, 37 de-
degrees.
Icebox.
Centrifuge.
Glass stoppered flasks.
REAGENTS.
Salt solution, 9 per
cent.
Sodium citrate solu-
tion, 2 per cent.
Acetone insoluble an-
tigen.
Patient's serum (un-
known).
Patient's serum
(known positive).
Patient's serum
(known negative).
ANIMALS.
Guineapig.
The steps of the test are shown in Table A.
The titration of the cell dose is made by placing
tubes as indicated in Table B, a one per cent, sus-
pension of washed guineapig cells being employed.
TABLE A.
Set for diagnosis.
Unknown.
Patients' serum ... 0.1
Sodium chloride so-
lution .9 per cent. i
Unknown.
Patients' serum . . .
Acetone, insoluble an-
tigen (i per cent.)
First Step.
Positive control.
Known positive.
Patients* serum ... 0.1
Sodium chloride so-
lution .9 per cent. i
Known positive.
Patients' serum ... 0.1 c. c.
Acetone, insoluble an-
tigen (i per cent.) i c. c.
Negatiz'C control.
Known negative.
Patients' serum ... 0.1
Sodium chloride so-
lution .9 per cent. i
Known negative.
Patients' serum ... 0.1
Acetone, insoluble an-
tigen (i per cent.) i
Second Step. Third Step. Fourth Step.
(i c. c. of a one per cent, antigen should represent one quarter the anticomplementary dose.)
- ri r- "
° ° K a" S.5
3 O
I, ° E o S
_a " (u o o .
S-S " " 5 to
C n j3
•3 S °'S " C.1
-5^ 5 >-.l!>«.2 i
that practically all human sera contain natural anti-
guineapig cell hemolysins in fairly constant
amounts. In two hundred tests we have found only
two sera which would not hemolyze the cells in
suspension used. Incidentally, these same sera were
from patients receiving intensive treatment, and
both were slightly anticomplementary in the con-
trols. The classic Wassermann tests were used for
controls in most cases.
In the proposed tests, besides the diluents, only
three reagents are used, namely: patient's serum,
which must be fresh ; acetone insoluble antigen ; and
guineapig cell suspension. The patient's serum
serves the triple capacity of complement, ambo-
ceptor, and reagent. Antigen is made after the
method of Noguchi and used in strength of one
fourth the anticomplementary unit. When active
serum is used, the acetone insoluble antigen must be
used to reduce the chances of false prototrophic
fixation. The cells are collected by cardiac puncture
of an anesthetized guineapig. The blood is citrated
The dose of cell used is one half of the maximum
suspension that is completely hemolyzed in fifteen
minutes incubation at 37° C. We have found the
maximum dose to be one c. c. of the one per cent,
suspension in most cases ; the working dose then
being 0.5 c. c. of a one per cent, suspension. If any
doubt exists concerning any one or several sera
they should be titrated separately for the ambo-
ceptor content in the same manner as the average
dose is determined, using pooled sera. Using the
homohemolytic system of Noguchi, we have occa-
sionally encountered a serum in which complement
was absent. So far we have not encountered such in
the sy.stem proposed. No doubt they will occur how-
ever and to handle this condition we propose to add
O.I c. c. of a known negative serum and then titrate
the cell load required. We have not tried to inactiv-
ate the unknown strums and then reactivate with
known negative, but would expect a good working
test by this method. This introduces a different
proportion of amboceptor and complement however.
November 23, 1918.]
SHAWEKER: A WASSERMANN MODIFICATION.
897
TABLE B.
C Pooled serums .... o.i c. c. Patients' serums .. o.i c. c. Patients' serums .. o.i c. c. Patients' serums .. o.i c. c.
Guineapig cells ... 0.5 c. c. Guineapig cells ... i c. c. Guineapig cells ... 1.5 c. c. Guineapig cells ... 2 c. c.
Sodium chloride so- Sodium chloride so- Sodium chloride so-
W lution 1. 5 c. c. lution i.o c. c. lution 0.5 c. c.
.2 2 Guineapig cells ... 0.5 c. c. Guineapig cells ... i c. c. Guineapig cells ... 1.5 c. c. Guineapig cells ... 2 c. c.
E g Sodium chloride so- Sodium chloride so- Sodium chloride so-
O lution 1.5 c. c. lution i c. c. lution 0.5 c. c.
•o .
o t Incubate for 15 minutes at 37°.
TABLE C.
o, Pooled negative Pooled negative Pooled negative Pooled negative Pooled negative
a serums .... 0.1 c. c. serums 0.1 c. c serums 0.1 c. c. serums 0.1 c. c. serums O.I c. c.
w Guineapig cells Guineapig cells i c. c. Guineapig cells i c. c. Guineapig cells i c. c. Guineapig cells i c. c
I per cent... i c. c. Antigen 2 per Antigen 4 per Antigen 6 per Antigen 8 per
.S Antigen i per cent i c. c. cent i c. c. cent i c. c. cent i c. c.
fa cent 1 c. c.
•o .
o « Incubate for 15 minutes at 37°.
TABLE D.
Shaweker Noguchi , Wassermann ^
Acetone Homohemolytic Acetone Cholester-
insoluble Acetone insoluble inized
Remarks. antigen, insoluble antigen. antigen.
Previously positive; vigorous treatment Neg. antigen. Neg. Neg.
Genital sore, early Neg. Neg. Neg.
Secondary eruption on body + + -!-+ + + + + +4- + -f-
No history Neg. Neg. Neg.
No history Neg. Neg. Neg.
Negative history Neg. Neg. Neg.
Positive history, old; "606" and mercury Neg. Neg. Neg.
Secondary eruption on body; no treatment + + + + + + + + + + +
Secondary eruption; slight mercury +-|--|--|- 4""l" + "l" 4" + + +
Positive history; vigorous treatment Neg. Neg. -f + +
Positive history; "606," mercury Neg. Neg. +-+• + -!-
Positive history (accident) No test.
Donor of antipneumonia serum Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Genital lesion, early Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Positive history, five years' standing Neg. Neg. + + +
Positive history; Wassermann (in Sept., 1917) Neg. Neg. -+--+- +
Secondary rash; slight mercury + + + + + + + + +4- + +
Slightly anticomplementary reaction -]--t- + 4- 4- + + + (a) -|- -i--i-4-
History negative. "Cold in head" Neg. Neg. -i--i--t-
Papular rash specific + + -{-+ + + + -(- 4-4- + +
Gastric ulcers Neg. Neg. Neg.
Donor of antipneumonia serum Neg. Neg. Neg.
Positive history, eight years' standing + + ++ + + + + + + + +
Positive history, nine years' standing (continuous treatment) 4" Neg. 4-4--i-4-
Negative history Neg. Neg. Neg.
Negative history Neg. Neg. Neg.
Primary sore, six weeks' standing +4" + + + + + + +4" + +
Primary sore in April, 1918; no other symptoms Neg. Neg. -l--f-
Positive history since 1915; "606" and mercury + + + Neg. +-(- +
Foreign sailor; no history -|--J--i-+ + + + + 4-4-4- +
Positive history, one year standing 4- + 4-4- 4-4-4-4" 4-4-4-4-
Primary lesion eighteen months ago; "606" and mercury Neg. Neg. -+-4-4-4"
Primary lesion one year ago; "606" and mercury; pot. iod + + + + ++ -+-4-4-4-
Syphilis in July, 1918; no treatment 4-4-4-4- 4-4- + + 4-4-4--!-
Primary lesion, six weeks' standing; no treatment Neg. Neg. Neg.
Chancre one year ago; "606," three doses Neg. Neg. Neg.
Primary lesion eighteen months ago; mercury + + + + + + + + + +
Primary in 1914; Wassermann then + + + -[- 4--i--|-+ 4-4-4-+ 4-4-4-4-
Genital sore 191 6; mercury recently Neg. Neg. Neg.
Primary three weeks ago; Wassermann neg. then Neg. . Neg. Neg.
Denies history (Wassermann, 10-10-17) + + + + n +4" + + + + + +
Negative history No test. S Neg. Neg.
Primary for four weeks; no treatment Neg. ^ Neg. Neg.
Positive history zYz years; Wassermann previously + + + + ++ H ++ + + + +
Negative history; previous Wassermann neg.; much treatment Neg. ^ Neg. -j-4-
Sore year ago; slightly anticomplementary in Shaweker test (a) Neg. ^ Neg. Neg.
Primary in August, 1918; no treatment Neg. pi Neg. Neg.
Donor of antipneumonia serum Neg. i; Neg. Neg.
Donor of antipneumonia serum Neg. Q Neg. Neg.
Positive history, ten years' standing; mercury ++ i + + + + + + +
Sore for five weeks; Wassermann previously neg Neg. Neg.
Sore six weeks ago; rash at present + + + + + + + +
Sore six months ago; no treatment Neg. Neg.
Chancre for one month; mercury Neg. + + + +
Multiple sores five years Neg. Neg.
Charfcre one year ago + + + + +
Chancre one month ago; rash now 4" + + + 4-4-4-4"
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum " Neg. + + + +
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum Neg. Neg.
Donor of antipneumonia serum . Neg. Neg.
Chancre in June, 1918; Wassermann neg. in July Neg. +4^ + +
Sore, three weeks' standing Neg. Neg.
898
ROY: EYE INJURY.
[New York
Medical Journal.
TABLE B— (Continued).
SHAWEKER
Acetone
insoluble
antigen.
Sore, three weeks' standing ' + + + +
Chancre four months ago +-'--'--1-
Sore since (Jctober i, 11,18 Neg.
Ache chest and back Neg.
Positive history three years; no treatment lately Neg.
Rash over liody ; Wassermann in .'Xn^ust + + + + Neg.
Sore three weeks ago Neg.
Sore, two weeks' standing + + + +
No history Neg.
Positive history; vigorous treatment Neg.
Positive history; Wassermann (July, 1914) + + + + Neg.
Positive history in 1913 Neg.
Chancre fifteen months ago + + + +
No history (M. Kahn, Ph. M., second class) 4- + -|--t-
No history (M. Kahn, Ph. M.. second class) Neg.
No history (M. Kahn, Ph. M., second class) + + + +
No history (M. Kahn, Ph. M., second class) + + + +
No history Neg.
No history Neg.
Negative history (typhoid) Neg.
Donor of antipneumonia serum Neg.
Donor of antipneumonia serum Neg.
Donor of antipneumonia serum Neg.
Donor of antipneumonia serum Neg.
Donor of antipneumonia serum Neg.
No history (spinal fluid) Neg.
No history (spinal fluid) Neg.
Donor of antipneumonia serum Neg.
Secondary lesions, macular + + + +
Secondary lesions, macular Neg.
Secondary lesions, papular + + + +
Old history; much treatment Neg.
Donor of antipneumonia serum Neg.
Surgical case (spinal fluid) Neg.
No history (M. Kahn, Ph. M., second class) + + + +
No history (M. Kahn, Ph. M., second class) +
No history (M. Kahn, Ph. M., second class) Neg.
No history (M. Kahn, Ph. M., second class) Neg.
No history (M. Kahn, Ph. M., second class) (. . . . + + + +
No history (M. Kahn, Ph. M., second class) 4- + + +
Genita! sore in October , + + + +
Genital sore in January; intensive treatment Neg.
Positive history one year ago; much treatment Neg.
No history Neg.
Genital sore one month ago; much treatment + + + +
Rash over body, pains in head; no treatment Neg.
Primary, two months' standing; Wassermann previously neg Neg.
Genital sore in August; no treatment + + + +
No history Neg.
Rash specific; routine treatment + + + +
No symptoms Neg.
Positive, six months' standing; "606," mercury Neg.
No history Neg.
Carcinoma (operated) Neg.
Carcinoma (operated) Neg.
Carcinoma (operated) Neg.
Carcinoma (operated) Neg.
Carcinoma (inoperable) Neg.
Carcinoma (inoperable) Neg.
NOGUCHI
Homohemolytic
Acetone
insoluble
antigen.
Neg.
Neg.
Neg.
+ + + +
Neg.
+ + + +
Neg.
Neg.
Neg.
+ +
+ + + +
+ + + +
Neg.
+ + + +
+ + + +
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
+ + + +
+ + + +
Neg.
Neg.
+ + + +
+ + + +
+ + + +
Neg.
Neg.
Neg.
+ + + +
Neg.
Neg.
+ + + +
Neg.
+ + + +
Neg.
Neg.
+ + +
, Wassermann >
Acetone Cholester-
insoluble inized
antigen.
antigen.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
+ + + +
Neg.
+ + + +
Neg.
Neg.
Neg.
+ + + +
Neg.
Neg.
Neg.
+ + + +
Neg.
Neg.
+ + + +
Neg.
+ + + +
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
+ +
+ + + +
Neg.
+ + + +
Neg.
Neg.
+ + +
+ + + +
Neg.
Neg.
+ + +
.+ + + +
Neg.
Neg.
+ + + +
Neg.
+ + + +
Neg.
+ + +
+ + +
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
as the amboceptor is practically thermostable while
the complement is thermolabile. The antigen should
be titrated from time to time and not more than
one fourth of the anticomplementary dose used in
test. (See Table C for method.)
In delicacy we have found this method compares
favorably with the original Wassermann test using
acetone insoluble antigen, but it is not so sensitive
as the Wassermann using cholesterinized antigen.
We have not found it so delicate as the homohemo-
lytic test lately suggested by Noguchi. Table D
gives comparative results.
This test is not intended to replace any of the
several good tests now in use, but is merely a sub-
stitute which by its simplicity may seem more ex-
pedient to use on shipboarcl and where complete
equipment is not at hand to perform the classic
Wassermann or Noguchi tests.
The Treatment of Gonococcic Infections with
Silver Iodide. — A. E. Cerf (Urologic and Cutane-
ous Rcviczv, July, 1918) concludes that silver iodide
is stable in solution or suspension uiider ordinary
conditions. It is nonirritating and has the proper-
ties necessary for an eftective medicament for
topical use in any part of the genitourinary tract.
EYE INJURY.
Clinical Report of Three Interesting Cases.
By Dunbar Roy, A. B., M. D., F. A. C. S.,
Atlanta, Ga.
Case I. — Clarence H., colored, aged twenty-eight years,
received a most peculiar injury in his right eye on June
16, 1916, while performing his daily labors at the Atlantic
Steel Works. In rising from a bending position and turn-
ing suddenly to the right with some force, a small steel
rod which was projecting outward, penetrated the upper
eyelid and passed through the orbit and orbital plate of the
ethmoid into the nasal cavity of the same side. There was
considerable hemorrhage from the right nasal cavity imme-
diately following the accident. He was seen by me one
hour after the injury. An examination showed consider-
able hemorrhage from the right nasal cavity and also into
the nasopharynx. There was a large irregular jagged cut
through the skin and muscular tissue of the right upper lid
and underneath this a wound leading into the orbit and ex-
tending through the ethmoidal plate into the nasal cavity.
The whole of the upper bulbar conjunctiva was lacerated
and hanging loose from the sclera; the superior rectus was
torn entirely through and its attachment to the sclera was
hanging down over the cornea. There was of course ex-
travasation of blood beneath the other portions of the bul-
bar conjunctiva. The eyeball itself did not seem to be in-
jured and a rough examination of the vision indicated that
it was normal.
On account of the hemorrhage from the skin
wound I immediately closed this with, interrupted
November 23, 1918.]
ROY: EYE INJURY.
899
silk sutures, appHecl a wet bichloride compress and
sent the patient to the hospital. Three hours later
the conjunctiva and rectus muscle were operated
upon. Under cocaine anesthesia the parts were
thoroughly cleansed with a warm boric acid .':olution
and all clots and tags of debris removed. Not being
able to find the proximal or orbital end of the sev-
ered superior rectus muscle, I had my assistant
grasp the distal end of the muscle which was lying
down over the cornea and, with the patient looking
down, as f;ir as possible push this end through the
torn opening of tiie conjunctiva as deep in as pos-
sible. At the same time the writer grasped the
upper edges of the torn conjunctival opening, pulled
it down, and with interrupted silk sutures closed en-
tirely the conjunctiva] opening, the assistant not
releasing his hold on the rectus until the last suture
was tied, thus leaving the rectus stretched out en-
tirely beneath the conjunctiva in its normal position
but not anchored bv any sutures. The whole pape-
bral opening as well as the outer surface of the lids
were filled with bichloride petrolatum (white) and
a compress bandage applied. The patient made an
uninterrupted recovery and left the hospital three
days after the injurv. Two months later the eyes
were examined. The injured eye showed a vision
of 20/20 and the phorometer tests showed only a
slight retarded movement upward. There was no
diplopia.
Remarks. — In the first place this case is remark-
able in that so serious an accident did not also pro-
duce some traumatism of the eyeball. This was
largely due to the tough and fibrous structure of the
sclera. The conjunctiva was literally peeled ofif this
structure and it could be seen^ that the latter was
even scraped. It is also remarkable that the con-
cussion produced on the eyeball did not also produce
some kind of intraocular hemorrhage. Close exami-
nation with the ophthalmoscope showed no trace of
this condition. The other remarkable feature was
the most excellent result obtained in the functional
restitution of the completely severed and lacerated
superior rectus muscle and this also obtained with-
out sutures and with only tlie thorougli replacement
of the muscle beneath the sutured conjunctiva. The
writer was at least expecting some deviation of the
eye downward but the restricted movement was only
seen when the patient looked in the extreme upward
direction.
Case II. — D. B. McG., white, aged forty-three years,
motorman on the Atlanta Street Railway Co. On July 8,
1916, the patient accidentally grasped a live wire which had
fallen across the car tracks. The shock was so severe that
he was thrown to the ground and struck his right temple
and upper orbital ridge. He was rendered unconscious,
carried to the hospital, and remained there for several
weeks. Stitches liad to be taken. He remained in a dazed
condition for some time and, even after he left the hos-
pital, he suffered from such excruciating pain as to neces-
sitate the frequent use of narcotics. He was tmder the
constant care of the street railway surgeon. His subjective
symptoms not being relieved and there having developed a
double vision which materially interfered with his walking,
he was referred to me by the company with instructions to
take charge of the case.
Examination. — The patient walked into the room in a
groping, staggering manner with his head turned down-
ward to the left. He appeared physically in good condi-
tion. On being questioned he informed me that he had
spells of intense pain accompanied by a dazed feeling and
inability to concentrate his mind. The old scar above his
right eye could be seen. There were no si.gns of
paralysis in any part of his l)ody. His chief eye com-
plaint was that of seeing double especiallv when look-
ing to the right. He kept the right eye closed most of the
time. The left eye movements were normal in all direc-
tions. The movements of the right eye were much re-
stricted downward and outward. By means of the candle
test a typical case of partial paralysis of the right superior
oblique muscle was elicited. Refraction, R. E. V. = 20/50;
L. E. V. = 20/50. Retinoscope showed marked hyperopic
astigmatism. Vision in both eyes was easily corrected to
normal by the following glasses : R. Eye plus I d c axis
180; L. Eye plus 1 d c axis 180. These were prescribed
and worn continually. Three days later the patient returned
wearing these glasses. The change in his appearance was
remarkable. He walked into the room with head erect and
a firm step. Said the pains in his head were much relieved
and only when he turned his head markedly to the right
was he troubled with the double vision.
From the very first consultation the patient was
placed upon gradually increasing doses of iodide of
potash although a Wassermann was negative. In
addition he was given a mild galvanic current over
and around the eye. From this time on the patient
gradually imi)roved so that he could accomplish some
work as an office man. The last reports, however,
showed that he was still suflfering from occasional
spells of pain and his mentality was far below
normal. Whether this man will ultimately recover
is still uncertain, for the severe blow over the eye
must have produced a hemorrhagic disturbance in
the frontal lobes which in time may lead to severe
degenerative changes. The fact that correction of
the hyperopic astigmatism produced such an im-
provement in the external ocular movement shows
the close relationship between errors of refraction
and the external muscles of the eyes. This marked
relief lasted only a few weeks, however. Later the
patient complained of a little more of the double
vision than had been present immediately after the
lenses were prescribed.
Case III. — Margaret S., white, aged nine years. On Jan-
uary 5, 1917, while riding a bicycle on one of the residential
streets she was run down by an automobile, was picked up,
and carried to the city hospital where she remained uncon-
scious for five hours. Examination showed that she was
struck on the right parietal region but the x ray did not
reveal any fracture. There was bleeding from nose and
mouth. In a few hours there was complete ptosis and
exophthalmoplegia externa with decided proptosis. She
was kept in bed and her various' symptoms were treated
with appropriate remedies. Patient suffered no pain ex-
cept on trying to move the eyes. The history showed that
the patient had some fever and considerable offensive dis-
charge from the nose, which lasted several weeks.
Up to April 4, 1 91 7, the patient had been under
the care of a general surgeon, but on this date the
writer was asked to take charge of the case, since
the eye condition was now the only symptom ot
which the patient complained. There was still
marked proptosis, almost complete ophthalmoplegia
externa with decided ptosis which of course was ex-
aggerated on accoimt of the exophthalmos. It wa?
evident from the history that there had been consid-
erable hemorrhage deep in the orbital cavity at the
time of injury and this blood had not yet been ab-
sorbed. The ophthalmoplegia externa was evidently
due to the exceedingly high degree of exophthalmos
which restricted rhe movetnent of the eyeball. The
pupil was of normal size, reacting to both light and
900
DELFINO: CARBOLIC ACID IN TETANUS.
[New York
Medical Journal.
accommodation. Vision was 20/70. No fundus
changes could be seen on ophthalmoscopic examina-
tion. Treatment consisted of the internal adminis-
tration of gradually increasing doses of potassium
iodide Avitli mercurial inunctions to the temple every
other night. Three times a week a mild galvanic
current was used over and around the eye in order
to keep up the muscle tonus in the external muscles.
The patient's general health was good, and the men-
tal condition seemed normal.
On May ist, the exophthalmos had markedly de-
creased and there was decided movement of the
right or injured eyeball. The patient complained of
double vision. The same treatment was continued,
and on June ist the exophthalmos was hardly
noticeable. The eyeball moved nicely but, as would
naturally be expected, was most limited when
turned toward the nose. At this time the patient
went North on a vacation and did not return until
October 15th. Examination at that time showed a
continued improvement in the lessening exophthal-
mos and the external movements of the eyeball.
Refraction taken at this time showed R. E. =
20/70 w plus 1.50 c ax 90; L. E. = 20/20 Hm.
plus 1.50 c ax 90. These glasses were prescribed
and the patient allowed to return to school doing a
hmited amount of work. The faradic current was
continued over the eyeball twice weekly and the
iodide taken for short intervals. On May i, 1918,
the patient moved away from Atlanta but the last
examination showed very slight restriction in the
movements of the eye. There was no pain or
double vision and the patient was very happy over
the final result.
GrvXND Opera House.
CARBOLIC ACID IN TETANUS,
With Report of a Case.
By D. Delfino, M. D.,
Columbus, Ohio.
Methods of treating diseases such as tetanus are
extremely varied. In fact, one's teachers tell of
different ways in which this condition is to be
treated. Some men claim a fair percentage of re-
coveries with methods which are ridiculed and con-
sidered unscientific by others.
Good aitthorities say a true case of tetanus means
death. Recently I saw a case in which tetanus, so
diagnosed, supervened, following a second degree
burn of the foot. This was a woman of middle age.
She presented a typical textbook picture as the
symptomatology, such as is described in Osier's Prac-
tice of Medicine. The patient was given heroic
treatment with antitetanic serum injected into the
wound intravenously, intraspinously, and into the
nerves of the leg. This patient made a recovery
after several weeks.
An interesting case was under observation and
care in the Protestant Hospital, Columbus, in which
a young man developed tetanus following a punc-
ture wound of the foot caused by a rusty nail. The
nail wound occurred July 10, 1918. Flaxseed
poultice was applied to the wound, and after sev-
eral days, the wound was apparently healed. In
about ten or twelve days the patient began to de-
velop pain in his back with orthotonus and tris-
mus of the jaw. Risus sardonicus was manifest
within a short time after the rigidity of the neck
muscles appeared. The temperature was never
above 105° F. ; the pulse at one time reached 160.
The patient remained conscious excepting for about
twenty-four hours, during which time delirium was
present. At least ten physicians saw the case and
all agreed it was tetanus. I am sorry to state that
a bacteriological examination, to confirm the diag-
nosis, was not made.
On July 26, 1918, upon entrance to the hos-
pital, the patient received 5,000 units of antitetanic
serum which was injected into the sciatic nerve of
the affected side. The following morning an open-
ing was made through the foot opening up the in-
fected area. There was not much pus, apparently.
On this same day, July 27, 1918, 10,000 units of
serum were injected intraspinously. No change
was noted in the condition of the patient.
On July 28, 1918, 5,000 more units were in-
jected subcutaneously.
Regarding treatment, Baccelli of the Clinic of
Roma about twenty years ago through experimen-
tation with phenol in these cases claimed good re-
sults. He used one to two per cent, carbolic acid
in sterile oil ; injections of two to four c. c. subcu-
taneously were given and finally increased to as
much as seventy-five c. c. daily. Babes came to the
conclusion that the carbolic acid acted directly on
the tetanus bacillus while the other men thought
the phenol neutralized or destroyed the tetanus
toxin. Maragliano claims cures in a number of
tetanus cases with carbolic acid alone.
On July 28th, ten c. c. of two per cent, phenol in
sterile oil was injected; on July 29th, fifteen c. c.
were injected ; on July 30th, ten c. c. The patient
now developed a dermatitis, from the phenol, which
practically involved the whole face. The urine was
scanty and cloudy ; it contained album.in and phenol.
He gradually became relieved of symptoms and
made an uneventful recovery.
Whether the phenol was responsible is still an
open question. Nature is frequently kind, and
when she leads one from mystery to light we claim
that our feeble methods were efficacious and that
relief is due to the power of the drugs ; so we robe
ourselves with glory and pseudoscientific proof of
our real help in the case.
As phenol was manifestly the cause of this young
man's recovery, we shall give it to other poor vic-
tims of the dread disease, in the hope that it will
prove equally efificacious.
103/2 East Poplar Avenue.
Collosol Palladium in Epilepsy.- - A. C. King-
Turner (British Medical Journal, September 7,
1918) has secured strikingly favorable results in a
group of twenty-three confirmed epileptics by the
intramuscular injection, every three days, of half a
mil of collosol palladium. The drug seemed to
cause a prompt diminution in the frequency and
severity of the fits.
Med icine and Surgery in the Army and Navy
WOUND AND SHELL SHOCK AND THEIR
CURE*
By Fenton B. Turck, ^l. D.,
New York.
The conquests of medical science in this war will
take their place on the scale of achievement close
beside the Allied victories in battle. Dr. W. W.
Keen (i), in a recent volume, declares that typhoid
fever, "which has been one of the chief scourges of
armies throughout all history and all over the
world, has been completely suppressed." Tetanus,
another almost equally desolating disease, has also
been conquered, but the most horrible scourge of
all, wound stupor and shell shock, remains uncon-
trollable. The verdict of the Allied military con-
gress is of the same tenor as that of Gray (7) and
other surgeons at the front (4), who from the
beginning of the war to the present time have
spoken of appalling wounds and the hopelessness of
shock.
The reason for this tragic failure to prevent or
cure shock is explained by Bayliss, who admits that
the actual nature and immediate cause of shock are
still obscure, and that there is as yet no agreement
as to the methods of treatment. According to
Charles (3), the preoperative treatment of wounded
men consists principally of an attempt to deal with
shock, and he states that, on arrival at casualty clear-
ing stations, three classes of conditions are ob-
served. First, dying condition ; second, varying de-
grees of collapse ; third, good condition and ope^r-
able. He adds, however, that even in this third
class a secondary shock takes place from twelve
to twenty hours after the operation, and "even in
abdominal wounds the chief danger is not peri-
tonitis, but shock." Walters, Rollinson, Jordan
and Banks (5) agree that when death occurs it is
due to shock.
The importance of these statements will be seen
when we consider that if wound stupor or shock
could be eliminated mortality among soldiers would
be enormously reduced. According to some au-
thorities it is estimated that as high as fifty per
cent, of recoveries would result if the collapse
called shock could be counteracted. Wound treat-
ment, according to the experience of military sur-
geons the worid over, consists primarily in the at-
tempt to prevent the poisoning which follows a
wound. Gray (7, 8), says, "This war has proved the
hopelessness of shock when treated according to an-
tiquated theories, theories woven out of the symp-
tomatology and psychological findings of the past."
Careful studies of the proceedings of the Allied and
French War Congress indicate that a wrong system
in the treatment of wounded men has caused the
loss of many thousands of lives on the battlefield
and in hospitals. On the other hand, all observers,
even the most empirical, have recognized that
wound stupor or shock always follows closely upon
*Read before the New York Celtic Medical Society, October 17,
1918.
the disintegration of bodily tissue which results
from a mechanical or chemical injury. The truth
is a wound becomes at once a spot of injured flesh
undergoing decomposition, whose decay puts into
the blood stream a deadly poison which is of the
nature of a peptone. Shock and death follow upon
the absorption of the products of selfdigesting
muscular tissue.
A very simple experiment will indicate the nature
of this process. If the leg of an animal is bruised
in imitation of a shrapnel wound and an Esmarch
rubber ligature is placed above the wound area, thus
preventing absorption, and if, after waiting the us-
ual time i)efore shock symptoms appear (from two
to four hours), the ligature is removed, and the
products of the injured tissue massaged into the
animal's system, a fall in blood pressure and in
temperature immediately results and death may en-
sue, according to the amount of the poisonous
product formed and depending upon the animal's
immunity. Furthermore, the biuret reaction of
this tissue substance will show that typical poly-
peptids have formed and that these products, when
injected into the same or another animal of the
same species, cause immediate death from shock(9).
The logical conclusion to this experiment is this :
// death from shock is caused by a toxin arising
from selfdigested muscular tissue, it follows that
an antitoxin can readily be produced, and that it is
possible to establish, by means of it, active and
passive immunitv to wound stupor or shock. In
point of fact, this has been accomplished. It has
been found that the best antigen for the purpose of
immunization is the heart muscle. If the heart
is ground up and allowed to autolyze and an emul-
sion made from it is injected, in repeated increasing
doses, into the veins of a horse, a serum is pro-
duced which prevents autolysis and neutralizes the
toxic products of decaying tissue, thus becoming
a most effective preventive and cure of shock. The
repeated injections of isoautolyzed tissue (in 0.5
to one gram doses) in salt solution, produces
active immunity after injection (9).
It remains to show that the action of germs has
only indirect connection with the condition called
wound stupor or shock. As mangled flesh be-
comes rich soil for the growth of germs their pres-
ence naturally hastens the selfdigestion of tissue,
thus throwing an increased amount of shock poison
into the system. Therefore, in formulating an anti-
toxin which shall antagonize wound infection it is
necessary to use for the antigen not only the self-
same autolyzing tissue in which the germs are grow-
ing but also the germs themselves. When this com-
bined product of the germ and the tissue poison is
injected into a goat or horse in repeated doses an
antitoxin of specific action is obtained. By the use
of this antitoxin an immunity from shock and in-
fection is obtained which the mere use of germs
grown in ordinary media could not secure.
The following protocols briefly described will give
the different types of shock production both in
go2
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
vivo and in vitro experiments presenting similar
reaction.
Experiment A. — Into a tank we placed a fish, a
frog, and a turtle together with a sealed tube of
gelatine, and also a small amount of fresh drawn
blood in a paraffin syringe. A blank cartridge was
then discharged from an ordinary 38 calibre re-
volver with its muzzle submerged under the water,
and the following results were noted : The fish,
frog, and turtle were dead and on postmortem
examination, showed the usual venous stasis in the
liver, upper intestines, and lung. The most marked
congestion was confined to the portal vein zone
in the liver, the pulmonary arterial zone in the lung
and the submucous veins of the intestines. The
liquid gelatine had coagulated and the blood within
the syringe, which was placed in the water a few
seconds after aspiration from the vein, was also
coagulated. The controls were made by submerg-
ing similar tubes of liquid gelatine and a paraffined
syringe of blood in water of the same temperature
Tcmote from the shock discharge. The controls re-
■mained liquid, the drawn blood in the controls tak-
ing the usual time for coagulation.
Experiment B. — In this experiment air took the
place of water as the medium of the shock impulse.
A gun with blank cartridges was fired into a box
cage in which a pregnant guineapig, a rabbit, a
mouse, and an embryo chicken in the egg had been
placed together, with a tube of liquid gelatine and
a syringe of fresh drawn blood, as in Experiment A.
The animals were all killed or fatally shocked.
From those which were stunned but still alive, we
removed the liver, lungs, and intestines. All dis-
played the same congested conditions as those in
protocols in Experiment A. The embryo chick
killed by the explosive discharge showed the same
visceral stasis. The embryo of the guineapig suf-
fered the same colloidal reaction as the mother.
These results correspond to those produced by sim-
ilar experiments (9) in which a pregnant guineapig
was subjected to air disturbance brought about by
placing the animal one inch distant from the single
projecting arm of a centrifuge revolving at a high
speed (12,000 to 15,000 revolutions a minute). All
the viscera except the brain showed marked con-
gestions and hemorrhages. The embryo was not
spared in this reaction, but the brain and spinal
cord, well protected against air pressure, were un-
injured. The tube of gelatine, as well as the fresh
drawn blood, was coagulated as in the shock dis-
charge through the medium of water.
Experiment C. — In this experiment the blood was
left in the filled vessels and they, with the tissues
quickly ligatured, were removed from the living an-
imal and immediately subjected to similar shock ex-
plosions, both in salt solution and in air. A loop
of intestine in which the venous blood was allowed
to accumulate by a slight pressure, together with the
mesentery, was ligated, producing the minimum
trauma, then quickly resected and placed in the
shock box into which a .38 calibre cartridge was dis-
charged. The blood in the vessel immediately
clotted, so that no blood ran out from it on cutting
the vessel. Coagulation of the entire tissue fluids
occurred, so that rigor mortis of the muscle wall
of the loop of intestine was complete. The con-
trol loop removed from the animal at the same time
showed the blood in the vessels still fluid, and the
blood poured out on opening the vessels, with no
rigor mortis of the muscle wall.
Experiment D. — Without general anesthesia,
muscle tissue taken from an animal under local an-
esthesia was ground fine, mixed with an equal
weight of salt solution, and left in the incubator
eight hours. It was then centrifuged two or three
minutes. The heavy particles appeared in the bot-
tom of the tube, the fluid at the top, and the more
toxic moiety in the upper middle zone. One c. c.
of this fine suspension intravenously injected into
the same animal from which the muscle tissue had
been removed (isoautolyzed muscle) caused the
death of the animal within three minutes. Upon
examination congestion of the upper intestinal ves-
sels, liver, and lung was observed, as in other shock
experiments. The controls did not suffer from
shock, that is, animals subjected to the same exper-
iments that were immunized by vaccination with
isoautolyzed muscle tissue and those that were in-
jected with the antitoxin.^
Experiment E. — This group of experiments was
conducted with living skeletal and smooth muscle
tissue, and comparison made with expressed muscle
plasma of the same animal. The muscle plasma was
obtained by the Kiihne von Furth method. Blood
free frozen muscle was ground and pressed out
with a meat press kept at 40° C. ; blood free muscle
tissue extract with normal salt solution and ex-
pressed with a meat press was kept at a tempera-
ture below the coagulating point. From the living
animal small portions of the skeletal muscle were
quickly resected and also involuntary nonstriated
muscle tissue from which the plasma was extracted
and expressed by the von Furth and Kiihne method
and placed in closed tubes. Small pieces of living
and skeletal and involuntary muscle were placed in
the shock box in a cold room and .38 cahbre cart-
ridge discharged. The muscle tissue immediately
showed rigor mortis and the muscle plasma within
the tube instantly clotted. The control muscle
tissue was normal and the plasma remained un-
coagulated.
In the following experiments shock is seen to
follow injuries of the tissues by means in which
the mechanicophysical forces do not play the decid-
ing role. Nevertheless it will be seen that similar
results in the nature of tissue autolysis (through
the velocity of the catalytic action of the tissue fer-
ments) caused the absorption of the proteins, pre-
cipitation of the body fluids, with increased viscos-
ity, coagulation and death.
Experiment A. — Two cats under anesthesia were
ligated with thigh elastic Esmarchs at the sacroiliac
articulation. Extensive wounds of the thigh mus-
cles were made by cutting and bruising the tissues.
At the end of three hours, the usual time that pro-
found shock occurs after such injuries, the ligature
was removed from one cat and the products from
the injured area massaged upward into the body.
'See writer's article (9) giving additional protocols with refer-
ences to previous work; also microphotographs of sections from
the intestines, liver, and lungs, taken from animals in shock and
from immune animals.
November 23, 1918.] MEDICINE AND SURGERY IN THE ARMY AND NAVY.
903
The animal displayed the usual shock symptoms,
i. e., fall in temperature and lowered blood pressure,
and soon died.
Experiment B. — Instead of releasing the elastic
ligature in cat B, products from the injured tissue
were pressed from the tissue and allowed to auto-
lyze further for thirty minutes. This was intra-
venously injected and the animal died with the same
shock symptoms as the cat in Experiment A.
The (juestion naturally arises, how can these anti-
toxins be clinically applied? In our own clinical
work, in consultation cases in which injuries are
followed by shock and in bad surgical cases, we
make a point to reproduce in our laboratory similar
conditions in animals for the purpose of comparing
results in the treatment of patients. -
The following case of a child serves well to illus-
trate the method we are employing:
Case. — A male child, four years old, havins been run
over by an ice wagon, was brought to Bellevue Hospital
for treatment. Examination disclosed the fact that the
child was suffering from a fracture of the femur, and
from a crushed and contused side and thigh, together with
other iniuries of a very serious character. He was in
profound shock, and during the night efforts were made
to reduce the shock by the use of saline solutions, drug
stimulation, and the application of heat.
On arriving at the hospital in the morning the
boy was found to be failing fast, with marked pal-
lor, very rapid pulse, and shallow breathing. Death
seemed imminent. A 30 c. c. dose of shock anti-
toxin was injected. Within one hour the boy's tem-
perature began to rise, the pulse improved, the res-
piration began to deepen, and the wound stupor dis-
appeared. On the following day the child was still
gaining, but to make sure of the results and to
hasten recovery, an additional injection was given
of 30 c. c. of the shock antitoxin. This caused the
expected reaction against shock, and the child's con-
dition became normal. Not only was recovery un-
interrupted, but the wounds healed with unusual
rapidity. Another report is now prepared for pub-
lication which includes clinical protocols from dif-
ferent hospitals which parallel throughout our ex-
perimental work on animals. Diseases produced by
microorganisms in conjunction with isoautolyzed
tissue have been treated by the writer with anti-
toxin made from antigen, human tissue, and the
oflfending organisms. Wound infections, rheuma-
toid infections, acute infections, particularly of the
respiratorv tract, and other conditions in which au-
tolyzed tissue plays the leading role in the etiology,
have cleared up under this treatment. These cases
'It happened by a curious coincidence in connection with the
work in our laboratory that a pet Angora cat fell from the window
of the building adjoining our laboratory and lay for the most of
the night on the pavement, unconscious and apparently fatally
injured. A veterinarian, who was called in to treat the wounded
animal, brought it to the laboratory. On examination the cat was
found to be suffering from multiple fractures of all four legs, its
jaw was badly torn, and it had sustained other injuries, internal
and external. We injected five c. c. of shock antitoxin, and were
highly gratified to observe the prompt effect which we had pre-
viously obtained from our experimental cats. The restoration from
shock was immediate and we were able to place the animal under
anesthesia. Its legs were put into casts and its jaw dressed. Dur-
ing the following night the owner of the cat, under the mistaken
belief that the cat was suffering from the bandages, removed them,
together with all the casts. In order to have the casts replaced
the cat was again brought to the laboratory. Before placing the
cat under anesthesia a five c. c. dose of wound infection and shock
antitoxin (Antitoxin B) was administered in order to prevent the
toxic effect of the mangled flesh, and to make certain that no
secondary shock would arise from the anesthesia and the manipu-
lation necessary to replace the casts. Infection also was thus pre-
vented. The animal made an uninterrupted and rapid recovery.
have been classified in a special report which veri-
fies the experimental work here presented.
REFERENCES.
1. W. W. KEEN: Medical Research in Human Welfare, igi/.-
2. W. M. BAYLISS: Intravenous Injection in Wound Shock,
May 18, 1918. 3. R. CHARLE.S: Gunshot Wounds at the Casualty
Clearing Station, British Medical Journal, March 23, 1918. 4.
E. W. ARCHIBALD and Captain W. J. McLEAN: Observations
upon Shock with Particular Reference to the Conditions Seen in
War Surgery, Annals of Surgery, September, 1917. WALTERS,-
ROLLINSON, JORDAN, and BANKS: Lancet, London, 1917,
cxcii, 207. 6. H. I M. W. GRAY: Surgical Work at Evacuating'
Hospital, New York Medical Journal, February 9, 1918. 7. II. M,
W. GRAY: British Medical Journal, March 30, 1918. 8. H. M. W.
GRAY: British Medical Journal, March 10, 1918. 9. TURCK: The
Primary Cause of Shock. Additional Experiments Induced by the
War, Medical Record, New York, June i, 1918. 10. KUHNE:
Lehrbuch d. Physical Chem., 5272; Untersuch u. das Protoplasm,
Leipsig, 1864. VON FURTH: Archiz: f. exp. Path. u. Pharmakol.,.
Leipsig, 1895, Bd. xxxvii, S. 231; ibid., 1896, Bd. xxxvii, S. 389.
14 East Fifty-third Street.
MEDICAL NOTES FROM THE FRONT,
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-dooent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
paraspecific serotherapy.
Considerable attention has been given in France
during the war to paraspecific serotherapy given
by mouth, particularly in certain ocular a flections,
and by this means to stay the progress of infections
due to the streptococcus, pneumococcus, staphylo-
coccus, and gonococcus.
Paraspecific serotherapy is a powerful stimulant
of the vital energy of the entire organism, and for
this reason places it as a condition to more easily
resist the infectiou.e agents. It is, in a way, a de-
fensive serum opotherapy, bringing to the diseased
organism a serum laden with defensive elements
elaborated by healthy animals, ofter having been
subjected to an intensive immunizing training, so to
speak.
Paraspecific serotherapy will act all the more
rapidly and with greater energy, the earlier it is
resorted to in an infectious process localized in a
richly vascularized tissue, because the arrival of
defensive antibodies will take place with a greater
intensity.
The most constant results of paraspecific sero-
therapy by mouth in ocular injections is a decline of
pain and an analgesic and euphoric action. In-
travenous or subcutaneous injections are, perhaps,
surer and more scientific than a paraspecific serum
administered by mouth, but in both the medicine
and the surgery of warfare require the simplest of
treatments when possible, and as this method is
devoid of any risk whatsoever, it commends itself
for trial. All accidents in serotherapy are unknown
when the serum is given by mouth and it can be ex-
hibited with impunity for several days. Here is
the formula :
Antidiphtheritic serum, 10 c. c. ;
Syr. rubi idaei, 30 c. c. ;
Aq. dest no c. c.
M. S. : A soupspoon.'ul every hour for the first three
days, and every two hours after the third day.
The efl'ects of this treatment are not long in
making themselves manifest, and at all events the
time gained will in no way interfere with treatment
with other sera or vaccines if the infectious pro-
904
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
cess is not cured by the paraspecific serotherapy.
Typhoid fever is an all important subject in
military medicine and for this reason I would
report the case of a soldier, twenty-two years of
age, who was discharged from the front because he
had complained of feeling tired for several days,
with nausea and headache. There was likewise
anorexia, abdominal pain, and diarrhea. The
temperature was not taken but he felt feverish at
night.
When he entered the hospital, the patient was
entirely prostrated, complaining particularly of his
head, and replying with difficulty to questions; but
it was at length ascertained that he had been ill for
a fortnight or thereabouts. His face was drawn
and pale, covered with perspiration, his tongue
coated, temperature 40° C, his pulse weak — 96 a
minute. The abdomen was neither painful nor dis-
tended and inspection revealed nothing pathognom-
onic. The spleen was slightly tumefied. Diarrhea
was profuse and the urine scanty and highly col-
ored. Heart and lungs were normal. What was
most striking in the examination of the patient
was the tumefaction in the region of the right
parotid gland, which was edematous, red, and very
painful on pressure. The patient also complained
of violent pain in the right ear.
On the following day the tumefaction of the
parotid had increased and by palpation a soften-
ing of the parotid area could be detected which led
to the supposition that pus was present. Examina-
tion of the ear revealed a suppurating otitis media.
The patient was still in a state of complete pros-
tration with a high temperature and profuse, fetid
diarrhea. A serodiagnosis was made and found
positive at 1/50, and hemoculture showed the pres-
ence of the typhoid bacillus in the broth.
The next day the patient was still profoundly
prostrated, and incision of the abscess of the parotid
followed. In spite of the exit given to the pus the
patient died the same evening. No autopsy was
permitted.
Here was a case of a typhoid fever beginning
with an abscess of the parotid gland before the
clinical signs permitted the making of a diagnosis,
and this was also delayed on account of the in-
tensity of the general phenomena.
The parotidides of typhoid usually arise when the
infection is at its height and of a severe type, or
they may take place during convalescence.
Among the cases of typhoid having an atypical
commencement, primary meningeal and parotid
localizations are to be mentioned and kept in mind,
as with the progress of the war abnormal evolution
of generally well recognized diseases is becoming
rather frequent.
Since we are on the subject of typhoid, let me
refer to another aspect of the disease as it is met
with in the armies at present. Up to within a van/
few vears typhoid fever was regarded clinically as
a single infection, but it is often in reality a multiple
infection, composed of a mixture, in various pro-
portions, of the three bacterial species composing
the typhoid class. The invasion of the organism
usually takes place progressively, as if one of the
bacteria prepared the soil for the invasion of an-
other species, but it must not be forgotten that it
may take place at once. In the former case the
intervention of a new germ is clinically made mani-
fest by changes in the temperature curve (amphi-
bolous stage, relapse, reiteration, etc.). The latter
are, consequently, merely the clinical expression of
the intricateness of the typhoidal infections. And
what is extraordinary is the fact that relapses are
always absent in infections which are of the multi-
ple variety from the start.
Blood examination, if only resorted to once,
whether hemoculture or agglutination, or both, only
reveals the fact that the process is typhoidal in
nature. In reality, it only gives an incomplete idea
of the bacteriological evolution of the infection.
From all this it naturally follows that the method
of mixed antityphoidal vaccination, as advocated by
Chatemesse some years since, and employed both
in the French army and navy since 191 5, is the
proper method.
As is known, cerebrospinal meningitis has been
present ofi and on in all the armies at war since the
early days of hostilities. Now as a complication of
meningococcic meningitis iridocyclochoroiditis has
been found to supervene in from four to six per
cent, of cases. It is rarely bilateral.
The lesions may commence in the anterior seg-
ment, giving rise to an iridocyclitis, sometimes of
an acute and purulent type, usually followed by a
subacute plastic panophthalmia, resulting almost
alwavs in atrophy of the globe. In other circum-
stances the deeper structures of the eye are the
first to be infected, resulting in either a suppurating
choroiditis which may secondarily invade the an-
terior segment, or the formation of a pseudoglioma
or even — when the infectious process is very mild —
to sim.ple disseminated foci of choroiditis.
The new data acquired of late on meningococcic
septicemia, occurring before or during a cerebro-
spinal meningitis, naturally lead to the supposition
that there is a metastasis by the blood in many
cases, which accords well with the majority of
recorded clinical facts and the rather rare patho-
logical examinations.
When the lesions are deepseated from the start
a direct extension of the meningeal infection to the
globe, by way of the optic tracts, has been main-
tained by several observers, but although this
hypothesis would at first sight appear to be quite
logical, no satisfactory demonstration has been
made up to the present.
The evolution of the affections sometimes termi-
nates in a simple diminution of the visual acuity, but
generally it results in blindness with atrophy of the
globe, or yet the formation of a pseudoglioma.
The treatment of the meningitis itself 'may, per-
haps, lessen the frequency of the ocular complica-
tions, but has no action over them when once they
are declared. Serotherapy by intravenous injec-
tions has no appreciable efifect, while, on the con-
trary, local injections of serum in the vitreous body
seem to have given a few really favorable results,
but it is yet too soon to form a definite opinion.
TALIPES EQUINUS.
Talipes equinus follows various lesions of war-
fare of the lower limb. In wounds of the calf
equinism is of great frequency, even following a
November 2j, .918.] MEDICINE AND SURGERY IN THE ARMY AND NAVY.
905
simple through and through bullet wound, with no
injury to the bones, nerves or blood vessels. Repair
may take place without any phenomena of sepsis.
The lesions appear to be limited to the muscles or
their remains and the most thorough palpation fails
to discover either induration or cicatricial nodule.
In these circumstances the equinism is clearly the
outcome of contracture of the posterior muscles of
the leg, followed by secondary retraction when the
vicious attitude is prolonged.
In other cases the destruction to the tissues has
been severe. The calf is more or less irregular and
multiple incisions are required because septic phe-
nomena have developed. When cicatrization is
complete the calf will be found to be greatly atro-
phied. The skin is scored by sometimes very ex-
tensive adherent cicatrices, and this cicatricial tissue
dips down deeply, penetrates the muscles and trans-
forms them into hard, sclerous cords. In these cir-
cumstances the equinism results from muscular re-
traction as well as myositis.
It is interesting to study the influence of move-
ments of the knee on the position assumed by the in-
step. In many cases the equinism is changed by the
position of the knee. When the knee is extended,
the equinism increases, while, when the knee is
flexed, the equinism decreases, and the foot may
reach a right angle to the leg. The cause of these
variations of the equinism resides in the insertions
of the gastrocnemius to the posterior aspect of the
condyls of the femur. When the knee is extended
the condylar insertions of the gastrocnemius be-
come more distant from the heel and pull upon the
tendo Achilles, therefore there is an increase of
equinism. The inverse phenomenon is produced
when the knee is flexed.
From these facts interesting clinical data can be
obtained. When the equinism is completely reduced
in flection of the knee it may be surmised that
neither the soleus nor the muscle forming the deep
layer enter into the mechanism of the equinism and
that the gastrocnemius is the sole cause. On the
other hand, if the equinism is fixed and not influ-
enced by movements of the knee, the cause resides
in a contracture or retraction of those muscles
whose insertions are purely in the leg — soleus,
flexor longus digitorum, tibialis Dosterior.
An interesting consequence of this sohdarity of-
ered by the gastrocnemius between the positions of
the foot and the knee is the frequent coexistence of
equinism and permanent flexure of the knee. The
shortening of the gastronemius causes flexion of
the knee, then, having placed the tibiotarsal joint in
a position of extreme extension, the gastrocnemius
pulls beyond this limit on the femoral insertions of
the extensor. However this may be, the influence
of flexion of the knee on the vicious position of
the foot should never be overlooked in examining
a case of talipes equinus, as it is a very simple
means of appreciating the condition and action of
the flexors of the foot on the knee. By flexing the
knee the gastrocnemius and tendo Achilles are re-
laxed and thus allow the antagonistic muscles to
manifest their activity. Besides the anatomical soli-
darity created by the gastrocnemius there likewise
exists a physiological solidarity between the posi-
tions of the foot and knee. In point of fact the
equine position of the foot has resulted in making
the involved limb too long during walking, and from
this it results that the subject keeps his knee perma-
nently bent in order to compensate this elongation.
This position of flexion, which at first is functional,
ends by becoming fixed.
In wounds of the knee and thigh, equinism, al-
though somewhat less frequent than that following
wounds of the calf, is nevertheless far from being
uncommon. Take for example an arthritis of the
knee or an injury of the posterior muscles of the
thigh. It is a well known clinical fact that these
lesions cause permanent flexion of the knee. This
flexion takes place at once after the receipt of the
injury, and if care is not taken it becomes perma-
nent and persists after cicatrization has taken place.
As soon as the patient resumes walking the limb
will be found too short, and in order to compensate
for this shortening the foot assumes the position of
equinism. This attitude, in the first place func-
tional and temporary, slowly becomes permanent
and in relation with the retraction of the posterior
muscles of the leg. The same mechanism is met
with following fractures of the femur in wounds
of warfare. In these circumstances shortening of
the leg is usual, either from overlapping of the frag-
ments or from elimination (spontaneous or surg-
ical) of large sequestra, and may reach as much as
two to three inches. As soon as walking is possible
the foot becomes extended in order to lengthen the
shortened limb.
It is of the greatest importance from the thera-
peutic viewpoint to fit these patients with orthopedic
boots without any delay, and thus the functional
equinism at the beginning of walking will be avoided
or at least will not become transformed into an irre-
ducible equinism, incompatible with a well made
orthopedic apparatus. The inclined plane formed
when a marked degree of equinism exists makes a
bad point of application for the correcting cork
sole.
When the external popliteal nerve alone is in-
jured paralysis of the muscles of the anterior ex-
ternal aspect of the leg naturally results in foot-
drop, and since the posterior group of muscles be-
come preponderant, they finally produce fixation of
the foot in hyperextension on the leg. When the
lesion of the nerve is located higher up on the sci-
atic, all the muscles of the feet are paralyzed. The
foot is at first flail and limp, but under the influence
of gravity is becomes drooping and finally the
equine position becomes permanent on account of
retraction of the posterior muscles.
Every wounded man, complaining of a painful
affection located in the lower limb is fearful of put-
ting his weight on it, and consequently he is given
crutches. The patient then as a matter of course
flexes the thigh on the pelvis and the leg on the
thigh. Correlatively the foot undergoes hyperex-
tension on the leg with relaxation of the muscles
and drops by its sheer weight. When this position
has been maintained month after month it ends by
becoming permanent from retraction of certain
muscular groups, and thus the crutch "hook-leg" is
formed.
go6 MEDICINE AND SURGERY
In the case of patients who are not up and about
of course the effect of crutches is out of the ques-
tion, but the part played by weight remains still im-
portant. The equine position (or rather more ex-
actly varus equinus) is the position of rest and per-
sists indelinitely in the horizontal position and is
still more accentuated by the weight of the bed
clothes. Many are the cases of tibiotarsal extension
which insidiously develop during the treatment of
some injury of the lower limb, oftentimes at some
distance from the tibiotarsal joint, as the hip, thigh,
or knee, when care has not been taken to mobilize
the joint from time to time and to maintain the foot
at right angles to the leg in a suitable apparatus to
correct the deformity.
When equinism has developed several methods
are at our disposiil for dealing with the situation,
but the only one to be commended is tenotomy of
the tendo Achilles. The divided tendon will under-
go repair if care is taken not to divide its fibrous
sheath. The treatment of equinism must go hand
in hand with treatment of the flexion of the knee ;
but straightening of the knee is facilitated by ten-
otomy of the tendo Achilles. Complete extension of
the knee can always be reached if one proceeds by
steps, applying plaster casts in succession. Com-
plete recovery from equinism is obtained in the
majority of cases from tenotomy of the Achilles,
but a complete one of flexion of the knee is a less
easy affair as there is a tendency to recurrence and
in many cases the patient has to wear a leather
kneecap in order to give support to the joint.
CAUSES OF BREAKDOWN IN FLYING.
Dr. Norman S. Gilchrist, a captain in the Royal
Army Medical Corps, attached to the Royal Air
Force of the British Army, has made an analysis of
10(1 cases of breakdown in flying, which is published
in the British Medical Journal, October 12, 1918.
Nothing v,'as done in the way of selecting cases,
which all came under review by the Royal Air Force
Special Medical Board, E. E. F. Breakdown was
the term chosen to describe those patients who were
rejected by the board as "permanently unfit," for
permanent could not be looked upon as other than a
relative term. None could tell how far many of
those rejected might ultimately recover, but in the
opinion of Captain Gilchrist none would be fit to
fly for six months, most of them not for years, and
some, in the case of those who broke down under
training, probably never.
The following is a summary of the author's ob-
servations in the cases studied :
1. Nervous family history. — Twenty-seven per cent, of
failures gave such a history. I do not want to labor the
value of this, but it is very certain that unstable nervous
temperament is hereditary, and, though this alone is not
very important, its existence should call for the further
history to be very carefully sifted.
2. Nervous personal history (forty per cent.). — By this
I mean they were nervous as children, had St. Vitus's
dance, habit spasm, bit their nails, avoided the usual rough
and tumble of children's sports, etc.
3. Actual nervous brcakdoivn (thirty per cent.). — Noth-
ing I know of will m.ore surely lead to failure in air work
(especially piloting) than the previous history of a seri-
ous nervous breakdown. I do not refer to a breakdown
of a week or a fortnight, but to those lasting two or three
IN THE ARMY AND NAVY. [New York
Medical Journ.m..
months, often involving cessation of duty (but not neces-
sarily so), producing, however, definite neurasthenic symp-
toms, with mental depression, insomnia, loss of power of
concentration, and so on. I do not think it matters much
what produced this, whether worry at the office, or an
accident in the hunting field, or a bomb in battle, so long
as the symptoms have been pronounced, nor do I consider
it essential that present symptoms exist, though usually
one can detect them if one observes closely enough. Some-
times these symptoms occur after concussion, and when
they do they make the acceptance of such a candidate
more and more hazardous.
Does it matter at 2vhat age the breakdown has occurred?
I hardly think so, except that if it be said to have occurred
before nine or ten years of age, that is, before puberty,
I should be inclined to doubt its reality and would ignore
it in the absence of other signs. From puberty on I think
it is about of equal signficance at all ages.
Does it matter hozv long ago? Again, no, if sufficiently
definite and prolonged, and not occurring in infancy. The
nervous system does not recover enough to warrant ac-
ceptance for training, at least under war conditions.
Should it apply to observers who come up for training
as pilots? In many cases, yes ; they should not be ac-
cepted, but here one would except certain men whose
strength of will and character stamp them as far above
the average — only they must be very carefully chosen,
show no active symptoms, and have had a prolonged rest
since the breakdown.
Does the same apply to qualified pilots? Not to the
same extent. Much will depend here on the cause of the
breakdown — for e.xample, simple stress of service or ma-
laria should be recovered from in time, and again much
depends on the individual. It is here that experience in
dealing with flying people counts for much. I do not mean
to imply that all such subjects will fail to qualify as pilots
if given the opportunity to do so. What one finds is that
a large percentage fails in training, and of the few who
qualify, only a small proportion can stand the strain of
active service sufficiently long to justify the time and
money spent in their training.
4. Dreams, nightmare, and somnambulism (in infancy
twenty-one per cent.; in adult life fifty-five per cent.). — I
am. convinced that nightmare in infancy (or somnam-
bulism) is a sign of an unstable nervous system, and that
its presence to a pronounced degree should mark a candi-
date as suspect, and is enough to call for a searching ex-
amination of his nervous system otherwise. In adult life
it is even more important especially where there is a
history of accident or injury, flying or otherwise. But
nightmare is invariably associated with other derangement
of the cerebral functions to be detailed later. One would
roughly lay down that even a qualified flying officer should
be free from nightmare for eight or ten weeks at least
before starting to fly again. Indeed, collateral symptoms
will usually demand a much longer rest.
5. History of concussion or shell shock. — Thirty-seven
per cent, gave such a history. Although these are not by
any means the same entities, yet their effects are so similar
that they may be taken together. Their importance varies
considerably, depending on whteher one is dealing with an
officer who can fly or with a candidate for admission.
(a) Candidates. — In these a history of concussion should
always be regarded seriously, but several details should
be taken into account in coming to a definite decision. If
the concussion was accompanied by prolonged unconscious-
ness— for example, three or four days — then acceptance
should be very carefullv considered and granted only in
very special cases. If followed by serious nervous break-
down, then reject in every case. These conclusions apply
equally to shell shock, which on the whole seems to be
more often followed bv a nervous breakdown, and is
therefore more serious for flying purposes. A good deal
depends upon the age at which the concussion took olace
and consequently on the lapse of time since. Thus, if it
happened before the tenth year, I think, broadlv speaking,
it is much less serious than from the tenth to the twentieth
year.
(b) Qualified pilots. — Even though unconscious for two
or three days, if there has been no fracture of the base, if
recovery is specdv and complete without impairment of
the higher cerebral functions and without nervous break-
down, such, after three months' or even after two months'
November 23, 1918.] MEDICINE AND SURGERY IN THE ARMY AND NAVY.
rest, may be safely employed again as flying officers in
not too strenuous circumstances. A good deal depends in
these cases on the individual's own wishes as regards con-
tinuing to fly. Conridence is a most essential asset in
forming conclusions in these cases. They should be given
light "graduated flying" duties, with dual control at first,
and their performances carefully watched before being
launched as fully responsible instructors, ferry pilots, etc.
indeed, it is possible that with a year or two's rest many
more may ultimatelv be classified fit than is at present the
case. But 1 would like to utter a word of warning in cases
that have sustanied more than one attack of concussion,
even though recovery has been apparently quick and com-
plete. They should be given very prolonged rest before
flying again, even if they are not totally rejected.
6. Affcc'.ion of higher cerebral junctions (occurred in
fifty-two per cent.). — By this is meant derangement of
memory, powers of concentration, judgment, temper, af-
fections, including, I doubt not, reaction times, and inti-
mately associated with dreams, nightmare, and manifested
in a very serious way as actual obsessions and hallucina-
tions. In both candidates and flying officers these derange-
ments, whether past or present, are to be regarded seri-
ously, and no matter what their cause their presence in
the history will weigh heavily in the balance against fitness
for flying duties, most heavily in the case of candidates
for admission as pilots. It does not matter whether, as
is most usual, they are associated with an admitted nervous
breakdown or not. This is a frequent concomitant of con-
cussion and shell shock. Of course, such symptoms to be
serious must be m-ore than transitory — that is. lasting two
or three weeks at least. They are probably also less seri-
ous after a definite accident or injury than if coming on
as the result of pure mental worries in a neurasthenic sub-
ject. With experienced flying officers the case is some-
what dift'erent, and after two or three months' rest and
absence of symptoms they may safely be allowed to re-
sume flj^ing — light base duties. But so far I have no notes
or recollection of any who have successfully tackled serv-
ice as pilots after such a breakdown if at all prolonged.
Some have tried as observers, others as pilots, but they
do not last. If ever they are to become fit for service
flying again they need more rest than it has so far been
possible for them to have while under my observation. How-
ever, not a few have made good as very capable instructors.
Much depends on the individual ; if he is keen and wants
to fly he will often by mere will power get over any tem-
porary subjective difficulties. If the will is absent it is
useless to force him, and even when the will is present it
mav be painfully tragic to allow him to flv. Great dis-
jrunination is needed, and personal knowledge of such
officers in private life helps enormously in forming the
right conclusion.
7. Malaria. — Thirty-six per cent, gave a history of fairly
recent malaria. Of this number twenty-five per cent, was
in flying officers back from active service. I cannot put
down too strongly my conviction that malaria is often the
direct cause of a most profound breakdown of the nervous
system, and especially of the higher cerebral processes,
producing depression, bad memory, loss of concentration,
irritability, delaved reaction times. When the possibility
of such an infection exists let us never neglect to examine
the blood — not for parasites alone, but also for any in-
crease in large mononuclear leucocytes. Under rest and
•appropriate treatment these cases do well and are to be
regarded in most cases as b\it temporarily unfit.
3. Refle.ves. — Eighty-two per cent, had exaggerated re-
flexes. This is included partly in order to protest against
too much significance being attached to this phenomenon.
How many hundreds — thousands, mav be — of excellent
pilots have exaggerated knee jerks! Taken by itself the
knee jerk is almost useless as a test of the soundness of
a prospective pilot's nervous mechanism. Taken with
other symptoms and signs its value is definite enough.
g. Tremor (seventy-three per cent.). — Almost the same
remarks apply as for reflexes, vet tremor of the tongue is.
if marked, a very useful clinical symptom, I think, of
nervous instability. But, again, it must be taken only in
association with other symptoms.
Suppose, then, we come across a candidate with a defi-
nite history of mild nervous instability, in fact, a highly
strung person — are we to accept or reject him, and on
what grounds? It is well known that some men of this
type make the finest, the most brilliant flying officers. The
choice is not without responsibility, for the slightest mis-
take in training will ruin their chances. One has to con-
sider the man's individuality. He is nervous, but are his
nerves well under control? This is not easy to test, and
though certain methods have been suggested, a good deal
must still be left to the insight and judgment of the ex-
amining medical officers. Will he fly two hundred hours
on service? Then accept him, for in that time he will
probably justify training expenses. Further, it is suggested
that one would much sooner accept a well educated ner-
vous type as a pilot than one whose mental training has
been very limited. For the nervous, pale faced, introspec-
tive. East End clerk, with little or no experience of out-
door exercise and sport, whose habit of life almost com-
pels him, to think tar too much of himself, one would
probably advise rejection; while for the university ath-
lete, equally nervous, but trained to ignore himself and to
control his feelings, trained to act and think of and for
others, of good physique and broad in mental outlook,
one would on the whole advise acceptance. The one is
by habit and training habituated to selfcontrol, the other
to sclfcommiseration.
This leads me to say that much depends in these cases
on the manner in which the pupils are handled in training.
These nervous subjects are very sensitive of criticism and
cursed with an anxiety to do well which exceeds their
powers of execution. Having been found fault with, per-
haps somewhat brusquely, they begin to worry over their
mistakes, think they are stupid and slow, become over-
anxious, and, instead of progressing, get worse. Flying
occupies their dreams, and soon fills their minds to the
exclusion of everything else — in short, flying becomes an
obsession. An instructor who is himself nervous is es-
pecially disastrous for such pupils. Akin to this is the
error of "stunting" a timorous b"eginner in the hope of
mcreasing his confidence.
Finally, a word with regard to medical officers of the
Royal Air Force. There still exist, unfortunately, doctors
who believe that the neurasthenic is a fraud, that his ail-
ment is imaginary, or, more accurately, that his ailment
is voluntarily assumed and capable of being equally volun-
tarily set aside. Such types should not be chosen as medi-
cal officers for flying schools. There is great scope for
the finest scientific minds in the investigation of all aerial
medical problems.
A United States Naval Hospital in England.—
In a recent isstie of the Saturday Evening Post,
Samuel G. Blythe tells of one of two hospitals main-
tained by the United States Navy on the coast of
Great Britain, as follows :
"The hospital that was in operation when I was
there is domiciled in a summer and health resort in
the hills, and has taken over two or three big hotels,
remodeling them into complete and well equipped
hospitals. This hospital is in executive charge of a
naval medical officer of the regular service, and it
is staffed by a hospital unit recruited in California.
Tt has accommodations for a large number of pa-
tients, and all its equipment is of the latest scientific
and sanitary sort, all brought from the United
States.
The doctor in charge of the hospital work is a
famous Californian and his assistants are all men
of high attainments. The place is equipped for all
contingencies, from casualties arising from engage-
ments at sea to the ordinary diseases. It has many
.specialized wards and inany specialists. Its operat-
ing rooms are the equals of any in the most modern
hospitals at home, and its nursing staff is ample and
competent.
Among other places taken over was a hydropathic
establishment ; for there are mineral springs here
and the waters of them have been utilized in the
9o8
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal
usual way. Inasmuch as recourse to German and
Austrian baths is closed by the war, there was a fear
lest the navy would close these baths, too, and thus
deprive certain citizens who seek to boil out their
gouts and rheumatisms and obesities of the oppor-
tunity for such endeavor.
The ofhccrs in charge are kind and compassionate
men, and they said that persons outside the service
might have the benefit of the waters and the baths
free, but that a Red Cross contribution box would
be placed in the lobby of the spring house for such
voluntary contributions as might be made. This
works very well, except in occasional instances. On
the day I was there they found some threepenny
silver bits in the box, which shows that some thrifty
souls had been along.
A hotel keeper in the place, who was very loud in
his denunciation of the navy plan for taking over
the main hotels and turning them into hospitals, on
the ground that it would not only ruin his business
but impoverish the village because the usual sum-
mer boarders would not come, and who protested
all the way up to the War Council, showed some
thrift himself after* he saw that his protests were
unavailing. He advertised in many British papers
that, though the springs had been taken over by the
United States Navy, the navy was treating all
comers free ; and that, of course, the only place for
the afflicted to stop, those who took advantage of
this wonderful generosity and liberality on the part
of the United States, was at his hotel. That didn't
last long.
A good success has been secured at this hospital
in the treatment of shell shock cases, those un-
fortunates who lose control of their nerves through
their experiences in battle and who are most pitiable
objects."
MEDICAL NEWS FROM WASHINGTON.
Brigadier General Charles Richard, M. C, U. S. Army,
Placed on Retired List. — Achievements in Medical De-
partment of the Navy.
W \SH1NGT0N, D. C, November i8, igi8.
Brigadier General Charles Richard, Medical
Corps, who has been on duty in the Ofificc of the
Surgeon General of the Army during the war, was
placed on the retired list, with his permanent rank
of colonel, on November loth, upon reaching the
age of sixty-four years. At the time of his retire-
ment he was, in point of length of service, the senior
ofificer of the Medical Corps of the Army.
He was born in New York in 1854, and he re-
ceived the degree of B. S. from the College of the
City of New York in 1874 and the degree of M. D.
from New York University two years later.
He afterward served in the Charity Hospital of
New York, the Randall's Island Hospital, and the
Essex Market Dispensary. In June, 1879, was
appointed an assistant surgeon in the army, and he
reached the grade of colonel in February, 1910. In
August, 1917, he was appointed a temporary briga-
dier general in the Medical Corps.
General Richard served twice in the Philippine
Islands. He was in command of the Army Medical
School for two years, and served twice as chief of
the Army Medical Supply Depot in New York. He
was the sugeon of the Department of the East with
headquarters on Governor's Island when he was
made a brigadier general. In December, 1917, he
was assigned to duty at the Surgeon General's
Ofifice in Washington and became acting surgeon
general when Major General Gorgas went to Eu-
rope.
Sfi ijC ^
At this time, when fighting has been suspended
and a state of peace approaches, those interested in
the Medical Department of the Navy are calling
attention to its achievements since the United States
entered the war in April, 191 7.
When the war began, the Medical Corps of the
Navy numbered about 300 commissioned officers.
Today there are that many on duty in European
waters and ashore in foreign countries. Now the
Medical Corps consists of some 3,000 officers, all
of whom are actually required for the present needs
of the service, and that number would not be suf-
ficient in the event of further expansion of the naval
personnel and its activities.
All the new officers were taken into the Medical
Corps after physical and professional examinations,
and they have received special training for the naval
service and special professional training at the
Naval Medical School at Washington, at naval
hospitals, on board cruising ships of the na\'y, and
at great medical centres like New York, Boston, and
Philadelphia, where intensive courses, both didactic
and practical, were conducted for their benefit by
the best professional talent in the country.
Serving in the field with the marines in France
are medical and dental officers. The first commis-
sioned officer of the navy proper to die in battle in
France was Dental Surgeon W. E. Osborne, who
was wounded fatally while carrying a wounded
comrade from the field. He, posthumously, was
awarded the distinguished service cross by General
Pershing.
Ec|ual courage and fortitude has been shown by
members of the Hospital Corps, the male nurses of
the navy, who serve on battleships and go into action
with the marines, sharing every danger with their
comrades of other branches of the service. The
Hospital Corps in July, 1916, numbered 1,585 men.
Today the corps consists of 14.000 men, for whom
there are four large, thoroughly organized training
schools and many smaller centres of instruction.
The Female Nurse Corps of the Navy includes
T,i26 women, of whom 260 are serving at our naval
hospitals and dispensaries in England and France.
We have more than doubled, nearly trebled, enroll-
ment of female nurses since last year.
During the first year of the war there was com-
pleted sufficient naval hospital construction to in-
crease the previously existing hospital facilities in
eighteen regular naval hospitals, with their 1,600
beds, by 144 new buildings constructed and
equipped. By July, 191 7, 2.700 additional beds had
been provided. The buildings since completed or
now nearing completion or contracted for or under
way will give the Medical Department of the Navv
a i)atient capacity of between it, 000 and 12,000
beds.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., ScD.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
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Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, twenty-five cents.
Remittances should be made by New York Exchange,
pest office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, NOVEMBER 23, 1918.
NEOPLASMS OF THE HYPOPHYSIS AND
ROENTGEN RAYS.
Neoplasms of the hypophysis are among the
number of pathological conditions requiring both
radiodiagnosis and radiotherapy. The diagnosis
of these tumors is frequently a difficult matter, par-
ticularly at the beginning of the process, on ac-
count of their silent evolution, the rather mild
character of the symptoms, and the multiplicity and
diversity of the morbid pictures which simulate
them. The signs of intracranial compression,
headache, vertigo, and vomiting; ocular disturb-
ances particularly characterized by concentric nar-
row^ing of the visual field; an abnormal growth of
the skeleton assuming the clinical type of giantism
and acromegaly; disturbances of the general nutri-
tion realizing the type of genital infantilism with
fatty overgrowth, such are the principal sympto-
matic forms, either isolated or variously associated,
of neoplasms of the hypophysis.
Given any of the symptoms which may lead one
to suspect a growth in this gland, radiologic explor-
ation of the skeleton should always be methodically
practised. When applied to the long bones, it re-
veals the condition of the cpiphysary cartilages, and
whether they are ossified or have remained with-
out adult changes beyond the normal time. It will
decide if growth of the limbs has been achieved, if
the height of the patient has arrived at its maximum
or if the body may still grow; in other words,
whether the case is one of fixed giantism or giant-
ism still in evolution. Applied to the skeleton of
the hands and feet when they are enlarged, it dis-
tinguishes the part due to hypertrophy of the soft
parts from that due to an increase in the thickness
of the osseous tissue, thus revealing the lesions of
the bones properly belonging to acromegalia.
Applied to the skull, it shows the unequal in-
crease in thickness of the cranial bones, the vary-
ing spreading of the external and internal tables
at different points, the enlargement of the cavities
of the face, the frontal, maxillary, and sphenoidal
sinuses. Thus the diagnosis of the silent types of
acromegalia is made.
When directed to the sella turcica, it reveals its
shape and size, particularly in the vertical and an-
teroposterior, directions, showing if the cavity of
the pituitary fossa is simply increased without
broadening of the opening by which it communi-
cates with the cranial cavity, or if it is both enlarged
and more or less considerably excavated. It will
also show if the bone structures, the clinoid apo-
physes and blade of the sphenoid, which circumscribe
this opening, are preserved or have been more or
less partially absorbed. Thus, indirectly, radiogra-
phy reveals the existence of a new growth of the
hypophysis, indicating its size to a certain extent,
and even shows if the tumor is developing toward
the nasal cavity or in the direction of the brain.
By some clear cases, although not in large num-
bers, it is definitely proved that in certain neoplasms
of the hypophysis, methodical radiations of the gland
with Rontgen rays has resulted in a remarkable
improvement in the symptoms, particularly in a de-
crease, at all events partial, of the ocular disturb-
ances. Such fortunate results may be explained
by the elective sensibility of the gland cells and neo-
plastic cells in general to the destructive action of
the rays. Excepting instances of undoubted lues
which should be treated with mercury, the treat-
ment of tumors of the hypophysis reduces itself to
two methods : the surgical removal and radiother-
apy. On account of the necessarily incomplete and
purely palliative action of surgical interference,
radiotherapy should always be preferred, or at least
it should always be attempted in the first place.
Generally speaking, radiotherapy of growths of the
910
EDITORIAL ARTICLES.
[New York
Medical Journal.
hypophysis will be more successful when applied
early, with method, and an irreproachable tech-
nic ; hence the importance of an early diagnosis.
In the ophthalmic form, it offers considerable
chance of improving the ocular disturbances if
atrophy of the optic papilla has not yet taken place.
In the giant and acromegalic types, radiotherapy is
of course powerless to cause a retrocession of the
already acquired lesions, although it is quite capable
of arresting the evolution of the abnormal skeletal
growth.
THE WAR AND THE DRUG SUPPLY.
Before the war all countries were largely, too
largely by far, dependent upon Germany for drugs
— owing to various reasons, partly perhaps to ex-
cellent organization and to crafty advertising. Ger-
man chemical firms had secured a practical mo-
nopoly of the synthetic drug industry. German
scientific chemistry represented the acme of pro-
gress in this direction, and Erhlich was the high
prophet. The medical men of other nations humbly
learned at the feet of the mighty German profes-
sors and proclaimed aloud that there were none
like these and that the Teuton synthetic products
possessed such remarkable therapeutic properties
that it was idle for chemists of the inferior races
to attempt to vie with them. A rich harvest of
fame and wealth was gathered by erudite profes-
sors of the Fatherland, who were not too proud to
make much money from their efforts to heal suflfer-
ing humanity. The synthetic drug industry was es-
tablished upon a strictly commercial basis.
Since the war began, Germany has been a negli-
gible quantity as far as supplying drugs to other
countries is concerned. Strange to relate, that al-
though the call for therapeutic products of every
description during the past four years has been im-
mensely increased, the call has been met in a satis-
factory manner.
In the first instance, it has been demonstrated
that when the necessity arises, chemists other than
Germans can manufacture reliable synthetic reme-
dies. In the second place, and this phase of the
situation is even more important, it has been shown
that synthetic drugs are not indispensable, that
many of the old time drugs, especially those of the
vegetable world, and which had been elbowed aside
and viewed with scorn in favor of the more modern
cure-alls from the land of the all highest, do pos-
sess therapeutic agents of great efificacy.
As a matter of fact, synthetic remedies and other
drugs, which have proven their worth by the in-
fallible test of clinical experience, all have their
places, and while the potency of the remedial pro-
ducts derived from Germany has been somewhat
unduly extolled, no one will aver that they are bar-
ren of results. A few are essential in the treatment
of disease and many are useful ; and the same thing
may be said, with added emphasis, of a goodly
number of the oldtime remedies. In the main, and
this statement applies in particular to vegetable
remedies, they are considerably safer than the "most
modern chemical conceptions.
It is then gratifying and soothing to our pride to
know that Americans can make good synthetic
drugs. Whenever there has been an urgent demand
for a particular substance, American science, rein-
forced by American chemical industry, has coped
with the situation successfully and the outcome has
been that the needed substance has been forthcom-
ing in requisite amounts and of requisite purity,
within a reasonable period of time.
Vegetable drugs are being more largely grown
and more largely used ifrian ever before. It is per-
fectly, true that there is a shortage of drugs, and
consequently their cost is increased. However, this
lack is greatly due to army requirements and to the
fact that the time and energv" of all the workers of
all nations engaged in the war are directed more to
the destruction than the saving of life. All things
considered, the supply of drugs is satisfactory and
the lesson has been fully learned that American
chemists can make synthetic drugs and that vege-
table drugs should not be relegated entirely to the
background.
THE DOCTOR'S PART.
The doctor's part in this war exceeds in import-
ance that played by the doctor in any preceding war.
His most important role has been played in preven-
tive medicine.
Dr. W. W. Keen has said that during the Civil
War 80,000 of the troops engaged suffered from
typhoid fever. During the war with Spain in the
army of 180,000 there were 20,700 cases. During
the present war, less than 200 of the troops in our
own army have had this disease. The new lipo
vaccine T. A. B., of the French Army, which gives
immunity after a single injection, promises not only
to simplify and accelerate the administration of the
preventive vaccine but will probably lower the mor-
bidity and the death rate still further.
The prophylactic measures against ventral disease
have also had a very marked effect, though this apn
pears more strikingly in the lower sick rate than in
the mortality ; but the low sick rate is a matter af-
fecting vitally the effectiveness of a command.
The nutrition of our troops has been handled by
the medical department from a wholly new point
November 23, 1918.]
EDITORIAL ARTICLES.
911
ot view. 7'he quality of the food is checked up con-
stantly, of course, so as to protect the soldier from
inferior or decayed food. This has been done, more
or less efficiently, in all armies and in all wars. But
nutritional surveys are something never before at-
tempted. A nutritional survey of a company, a
regiment, a camp, or a hospital means that experts
are sent by the surgeon general to that company,
regiment, camp, or hospital, to live wi?h that com-
mand for days, to study the methods of obtaining,
handling, cooking, and serving food and to analyze
the food as it is actually consumed, not only as to its
preparation but as to its palatability and its nutri-
tional value. Much food which is good when is-
sued is ruined before it reaches the consumer ;
much of it is wasted in the serving; much of it is
prepared so unpalatably that it is not consumed, and
much of it goes into garbage, which can be recov-
ered for other than food uses if the garbage is
handled intelligently. All this is covered by the
food survey, and as a result of hundreds of these
food surveys carried out in every phase of the
soldier's life, we have accumulated invaluable data
for the guidance of the quartermasters of the army.
The studies of trench fever in the armies on the
western front and of the plague on the eastern
front have convicted the Pediculus vestimenti of
being a murderer instead of a mere nuisance, and
we therefore have entomologists under the doctors'
direction studying the life history of these pests
and devising improved means for their elimination.
The fiendish ingenuity shown by the Germans in
adding new horrors to war by the use of poisonous
and irritant gases has called for the display of an
equal or superior degree of ingenuity in creating
means of defense, and this too has been the doc-
tor's part, for the gas defense service was origi-
nally organized by the surgeon general though the
work is now carried out by chemists.
In the field of treatment, too, the doctor's part
in this war transcends in importance that played
by the doctor in any previous war. The Carrel-
Dakin, the De Page and other methods of treat-
ing wounds, and the De Sandfort method of treat-
ing burns, the method of treating gas burns, de-
vised by our own pharmacists in the chemical serv-
ice, the wonderful results achieved in plastic facial
surgery and in reconstruction are all new, and these
form but a portion of the doctor's part in the war.
Through these curative methods, something like
ninety per cent, of the wounded are returned to
duty.
We are indebted to Colonel James R. Church, of
the Medical Corps of the United States Army, for
this happy phrase, the doctor's part, for that is
the title of the book [Colonel James Robb Church:
The Doctor's Part, What Happens to the Wounded
in War, D. Appleton and Company, New York], in
which he tells, in simple, nontechnical lan-
guage, what he saw during more than two
years of service on the western front, as
an accredited military observer from the United
States before we passed out of the category of
friendly neutrals. He does not tell all that he saw,
for military reasons demand reticence on some
points, while a detailed recital of the horrors of
war such as has been made by Henri Barbusse in
Under Fire and Ellen La Motte in The Back Wash
of War, can serve no good purpose now, though
they may later help to build up such a just appre-
ciation of what war means as to make a recurrence
of war impossible.
To write of war is also the doctor's part and
reams have been written by the doctor, most of it
technical and didactic. For the doctor who is in
active service in this war is a student in the great-
est medical school of all time, and must perforce
put down for the help of others what he has him-
self but just now learned. It is indeed significant
of the place filled by the doctor that, with us, the
term doctor, which in its original significance meant
teacher, should come to mean practitioner of medi-
cine. For every practitioner of medicine is a
teacher, the general practitioner teaching his pa-
tients the laws of health and the methods of con-
serving it, while the specialist in turn teaches his
fellow practitioners what he learns in his own par-
ticular field. The doctor's part in this war has in-
deed been most helpful and most creditable both as
a participant and as a teacher.
A STUDY OF THE OCULAR LESIONS PRO-
DUCED BY MUSTARD GAS.
Careful and extensive experimental studies have
recently been made of the ocular lesions produced
by mustard gas with a view to discovering more
adequate means of treatment [Warthin, A. S., Wel-
ler, C. v., Herrmann, G. R. : Ocular Lesions Pro-
duced by Dichlorethylsulphide, Journal of Labora-
tory and Clinical Medicine, October, 1918]. Thus
far literature has yielded only unsatisfactory re-
ports upon these lesions, all of which prove exist-
ing treatment inadequate.
In order to consider every possible phase of the
effect which would be produced either by direct ap-
plication of the mustard gas in liquid form or by
exposure to the vapor, the experimenters utilized
two methods of application. In the first a standard
droplet of the former was administered to the cen-
tre of the cornea of the rabbits and dogs experi-
912
EDITORIAL ARTICLES.
[New York
Medical Journal.
mented upon. In the second, the animal was put
into a gassing chamber and exposed for a fixed pe-
riod to a definite concentration of the vapor. The
symptoms and gross pathology which resulted from
both forms of application differed only in degree,
not in kind ; therefore, the former constitutes the
better means for experimental work. It is con-
venient, accurate, and all complications of respira-
tory and cutaneous involvement are avoided.
There is at first a definite irritation of the con-
junctiva, with increase of lacrimation. A well
marked hyperemia soon appears, followed by an
edema which steadily increases for twelve hours.
This is earliest and most marked in the palpebral
conjunctiva after direct application, but frequently
appears first in the bulbar conjunctiva after ex-
posure to the vapor. In man the edema is less
marked and regular, but the hyperemia more dis-
tinct. By the end of the third day the edema
begins to subside, but does not entirely disappear
for several weeks.
The cornea shows a necrosis, visible usually in
five or six hours, and manifested by a definite
cloudiness, which a little later becomes a charac-
teristic bluish white opalescence. Frequently there
is an opaque band running horizontally across the
cornea, just inferior to its transverse diameter.
Microscopic examination reveals that the necrosis
of the cornea is much greater in degree than that
of the conjunctival epithelium, although the latter
also shows widespread necrosis and desquamation.
Shallow ulcers appear at the palpebral margin.
There is an extreme edema of the subconjunctival
connective tissues, which results usually in lique-
factive necrosis. Healing takes place with a readily
occurring regeneration of the conjunctival epithe-
lium, but the conjunctiva is permanently thickened
because of the formation of fibroplastic tissue.
One of the marked features is the production of
a seropurulent exudate which increases and seals
the eyelids for several weeks, or until the inflam-
matory process begins to subside. It was found
that forcible separation of the lids and removal of
the accumulated exudate was very important in les-
sening this stage of purulent exudation, as well as
preventing a secondary infection and perhaps also
suppurative panophthalmitis, with complete destruc-
tion of the eyeball.
After the subsidence of the edema, the upper lid
presents a characteristic ruffled appearance with
a combined entropion and ectropion — the latter be-
coming sometimes a complete eversion — while the
lower lid shows a smooth ectropion. Depilation
occurs on the lids and on the face about the orbit.
From the third week on, the lesions show the same
progress toward resolution and repair that are char-
acteristic of skin lesions caused by mustard gas.
The final sequelae are corneal cicatrization and
thickening of the eyehds and nictating membrane,
with marked impairment of vision. Even in the
lesser exposure in man, visual disturbance and re-
duction of vision follow upon the chronic course
of the edema and hyperemia. There may also be
increased susceptibility to the vapor.
Because of the unsatisfactory character of the
treatment in the clinical cases brought to the authors'
attention, they also investigated methods of treat-
ment of these lesions. Dakin's solution is too irri-
tating in severe forms, but they found that repeat-
ed irrigation with one half to one per cent, or an
even stronger solution of dichloramine-T in chlor-
cosane will in severe cases prevent secondary in-
fection, and in milder cases act as a prophylactic,
where it may be followed by boric acid irrigation.
The use of argyrol, silvol and cocaine they consider
unwise. Such simple measures as irrigation with
boric acid, light compresses of the same, hot vapor
baths, and protection from the light are suggested.
It is most important not to permit the lids to become
glued together by accumulations of the exudate,
also that there should be no pressure upon the eye-
balls through heavy compresses or tight bandaging.
Actual disturbances of vision are matters to be re-
ferred to a competent ophthalmologist later.
PROBLEMS OF DEMOBILIZATION.
The terms of the armistice are such as to pre-
clude the possibility of a general resumption of hos-
tilities. There may be an occasional clash between
the army of occupation which is now nearing the
borders of Germany and troops, or Bolsheviki. It
is possible that a prolonged military occupation may
be necessary to settle the question of disputed
boundaries and to police Europe in order to insure
the establishment of stable forms of government.
Save for such exceptions we may consider that the
war is a thing of the past. The military authorities,
acting on this assumption, have announced the order
in which the troops in the United States will be
demobilized. It has been intimated that the demo-
bilization of the American Expeditionary Forces
will begin with the return of the sick and wounded.
With these will be sent back the casuals, the fighting
divisions being probably the last to return to the
United States. In demobilizing troops every soldier
must be given a critical examination by a competent
military surgeon, for the physical condition of each
soldier must be accurately determined at the time
of his discharge so as to avoid the possibility of
overlooking some disease contracted during the war
on the one hand or opening the door for unjust
claims for pensions on the other. In view of the
service required of the surgeons in dismissing the
troops, it vnll be seen that the physicians who have
entered the service are not justified in looking for-
November 23, 191 8.1
NEWS ITEMS.
ward to a very early discharge. In fact medical
units are still being sent to Europe. The question
of the future of our regular army will depend very
largely on the outcome of the peace conference.
Under the terms of the National Defense Act, we
must continue to maintain an army of not less than
175,000 men or more than 187,000. It seems not
improbable that unless the peace conference makes
provision to the contrary, there will be a demand for
universal military service of short duration, prob-
ably six months, with a cadre of professional sol-
diers to act as instructors.
^
News Items.
Symposium on Influenza in Pregnancy. — At a meet-
ing of the Section in Obst 'trics and Gynecolosy of the
New York Academy of Medicine to be held Tuesday even-
ing, November 26th, the program will consist of a sym-
posium on epidemic influenza in pregnancy. Dr. Lillian
K. P. Farrar will present a paper on the Visitation of
Influenza and Its Influence on Gynecological and Obstetri-
cal Conditions. Dr. George W. Kosmak will read a paper
There will be a general discussion.
Total British Casualties.— The British War Office
announces that the total casualties on all fronts of British
troops amounted to 3,049,991, of which 2,032,122 were
wounded, 658,665 killed, and 359,145 missing or prisoners.
These figures include the troops from India and from the
Dominions, as well as those from Great Britain. The
killed included 37,836 officers and 620,829 men. Of the
wounded 92,644 were officers and 1,939,748 were enlisted
men. Of the missing a'nd prisoners 12,094 were officers
and 347,051 were enlisted men.
The High Cost of Rations. — ^Statistics issued by the
Subsistence Division of the Army, quoted in The Army
and Nany Journal, state that in 1897 the average daily
cost of food for each soldier was a little less than thirteen
cents. In 1900 the average cost had advanced to twenty-
four cents. During the campaign in Mexico, the average
cost rose to twenty-five cents, and now the food cost is
from forty-eight to fifty cents a day. This, of course, is
the cost of the food alone and does not include the cost
of transportation and service.
Tuberculosis Among European Nations at War. — At
a stated meeting of the New York Academy of Medicine,
held Thursday evening, November 21st, Dr. James Alex-
ander Miller, associate director of the Commission for the
Prevention of Tuberculosis in France, delivered an address
on Tuberculosis Among European Nations at War. The
subject was discussed by Dr. David R. Lyman, president
of the National Association for the Prevention of Tuber-
culosis, and Dr. Wickliffe Rose, general director of the
International Health Board.
Section in Laryngology and Rhinology of the Acad-
emy of Medicine. — This section will hold a clinical
meeting Wednesday evening, November 27th. Dr. E. R.
Faulkner will present a patient exhibiting an unusual form
of laryngeal paralysis. Dr. Max Unger will describe a
new method of radiographing the accessory nasal sinuses,
illustrating with x ray pictures. Dr. D. Bryson Delavan
will read a paper on the Successful Disinfection of Non-
suppurative Infections of the Upper Air Passages. Dr.
John E. MacKenty will read a paper on Papilloma of
Larynx Cured by Surgical Methods.
Medical Society of the County of New York.— The
one hundred and thirteenth annual meeting of this so-
ciety will be held on AJonday evening, November 2=th, in
Hosack Hall, New York Academy of Medicine, under the
preiiidency of Dr. Howard C. Taylor. After the transac-
tion of routine business, officers will be elected and annual
reports of various committees will be received and passed
upon. The following papers will be read : The Respiratory
Tract as a Portal of Entry for Infectious Diseases, by Dr.
Irving W. Voorhees; The Two Most Important Signs in
Chronic Appendicitis, by Dr. Robert T. Morris. Doctor
Voorhees's paper will be discussed by Dr. John E. Mac-
Kenty, Dr. Rufus Cole, Dr. Walter Lester Carr, and Dr.
James G. Dwyer.
Change of Address.— The Anglo-French Drug Com-
pany announces that it has opened a depot at 1270 Broad-
way, New York, where all communications should be ad-
dressed.
Dr. Frederic Estabrook Elliott announces the removal
of his office from 232 Seventy-seventh Street to 245
Seventy-fifth Street, Brooklyn.
Meetings of Medical Societies to Be Held in Phila-
delphia.— The following medical societies will meet in
Philadelphia during the coming week:
Monday, November 2Sth. — Genitourinary Society;
North Branch of the County Medical Society.
Tuesday, November 26th. — Jewish Hospital Clinical So-
ciety ; Northern Medical Association ; West Philadelphia
Medical Association.
Wednesday, November 27th. — County Medical Society ;
Neurological Society.
Friday, November 20th. — Medical Club (board of direc-
tors).
Personal.— Dr. Samuel G. Tracy, of New York, has
been placed in charge of the physiotherapeutic depart-
ment of the Hotel Chamberlin, Fortress Monroe, Va.
Doctor Tracy practised medicine in New York for over
twenty years, and was formerly connected with the elec-
trotherapeutic department of the New York Post-Graduate
Medical School and Hospital. He studied the Nauheim
method in Nauheim, Germany, and upon his return to
America was made medical director of the New York
Artificial Nauheim Baths.
Influenza More Deadly than War. — The Bureau of
the Census at Washington has published the statistics for
forty-six large cities, with a total population of twenty-
three million, which show that from September 8th to
Noven:ber 9th inclusive, 82,360 deaths occurred from in-
fluenza and pneumonia. Normal deaths from these causes
for the same period would be 4,000, leaving approximately
78,000 deaths attributable to the epidemic. The total loss
of life in the American Expeditionary Forces to date is
estimated by the bureau to be between 40,000 and 45,ooo.
From this it appears that the deaths occurring in the
forty-six cities with a population of only one fifth of
the total population of the United States nearly doubled
the number of deaths in the American Expeditionary
Forces. Philadelphia shows the highest death rate with
7.4 in a thousand during nine weeks. Baltimore came next
with a rate of 6.7 in a thousand for the same period.
$40,000,000 to Charity. — According to the terms of the
will of the late Mrs. Russell Sage, approximately $40,000,-
000 will be divided among thirty-six religious, educational,
and charitable institutions, in sums ranging from $10,000
to $200,000. Among the specific bequests to charitable in-
stitutions are the following : Woman's Hospital in the
State of New York, $50.000 ; Charity Organization So-
ciety of New York, $20,000 ; New York Institution for the
Deaf and Dumb, $25,000; Servants tif Relief for Incurable
Cancer, $25,000; Mount Sinai Hospital, $100,000. The
residuary estate is to be divided into fifty-two equal parts,
each of which will amount to approximately $800,000. Of
this the Russell Sage Foundation will receive seven parts ;
Woman's Hospital in the State of New York, two parts ;
Children's Aid Society, two parts ; Charity Organization
Society, two parts: New York Infirmary for Women and
Children, Presbyterian Hospital, and State Charities Aid
Association, each one part.
Meetings of Medical Societies to Be Held in New
York. — The following medical societies will meet in
New York during the coming week:
Tuesday, November 26th. — New York Academy of
Medicine (Section in Obstetrics and Gynecology) ; New
York Dermatological Society ; New York Medical Union ;
Metropolitan Medical Society of New York City ; New
York Otological Society (annual) ; New York Psycho-
analytic Society ; New York City Riverside Practition-
ers' Society ; Therapeutic Club ; Valentine Mott Society ;
Washington Heights Medical Society (annual).
Wednesday, November 27th. — New York Academy of
Medicine (Section in Laryngology and Rhinology) ; New
York Society of Internal Medicine ; New York Surgical
Society ; Brooklyn Pediatric Society.
Friday November 29th. — New York Academy of Medi-
cine ^Section in Surgery) ; New York Microscopical So-
ciety ; Practitioners' Society of New York ; Alumni Asso-
ciation of Roosevelt Hospital; Gynecological Society 'if
Brooklyn (annual) ; Hospital Graduates' Club, Brook! n.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
STROPHANTHUS AND ITS ACTIVE PRIN-
CIPLES VERSUS DIGITALIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
{Continued from page 8yi)
The advantageous effects of strophanthus in
comparison with the results from digitahs in cases
of mitral disease with pain in the left scapular
region and attacks of tachycardia, as well as in
heart cases with a tendency to heart block, were
pointed out in the preceding issue, on the basis of
clinical observations recently recorded by Vaquez
and Lutembacher. Tracings were made by these
authors showing marked improvement in cardiac
action, without further slowing of the rate, in a pa-
tient with impaired conduction, and the improve-
ment resulting from intravenous injections of
moderate doses of ouabain prepared by the Arnaud
method. Digitalis, previously administered, had
caused an increase of conduction disturbance and
symptoms of Stokes-Adams's disease.
Yet, where there is muscular insufficiency of the
heart in valvular and other cardiac affections, with
associated arrhythmia in the form of extrasystoles
and, in particular, an increased rate of contraction,
ouabain has been found by Vaquez and his co-
workers to be capable of slowing and regulating
the heart, and of affording marked general improve-
ment where digitalis, after a more or less prolonged
period of useful service, has lost its effect. Trac-
ings illustrating the favorable action, in these re-
spects, of injections of one half milligram of
ouabain in a case of insufficiency of the left side of
the heart, have been published by these authors.
Before treatment, the heart rate was rapid and
showed marked extrasystolic arrhythmia. After a
single injection the rate was reduced and few pre-
mature contractions occurred. After four injec-
tions, normal regularity of the contractions was re-
stored.
It is almost generally conceded that the adminis-
tration of digitalis and its derivatives in the circula-
tory failure of febrile disorders does not yield the
results that are obtained from these agents in the
absence of fever. While, according to Cohn, 191 5,
patients in whom auricular fibrillation develops un-
der these conditions are strikingly benefited, its use-
fulness otherwise appears to be correctly summar-
ized by Sollmann, 1917, who states that in the early
stages of the disease, when the heart is inefficient
but the blood pressure is still maintained, the drug
may improve the pulse, rendering it fulfer and more
regular ; on the whole, however, the utility of
digitalis is rather limited in such cases. On the
other hand, in the light of recent researches and
clinical observation, the question seems worthy of
investigation, whether the cardiac action of the
strophanthins, including ouabain, is not more
effectually exerted in the presence of fever, than
that of digitalis. Granting, for the moment, a more
prominent vagal than musculotonic action in the
case of digitahs under all circumstances, and a more
prominent muscular than vagal action in the case of
the strophanthins, it is readily conceivable that the
nervous — slowing and regulating — effect of digitalis
could be impaired in fever through intoxication of
sensitive nervous tissue while a drug exerting
more prominently a direct tonic action on the
myocardium might better preserve its therapeutic
properties. There is some evidence, experimental
and clinical, to tlie effect that such a difference in
the behavior of the two drugs in the presence of
fever actually does exist.
Jamieson. 191 5, found the action of strophanthin
to be identical in normal animals and in animals in-
fected with pneumonic germs. While experimental
and clinical doses by no means always correspond,
this observation suggests that the action of
strophanthin upon the myocardium may be definite-
ly exerted under both afebrile and febrile condi-
tions. From the clinical standpoint, Cornwall, 1918,
states that he has seen remarkable improvement
from injections of a strophanthin prepared from.
Strophanthus gratus in acute, heart failure in both
typhoid fever and pneumonia. He administers
one five hundredth grain of this strophanthin hypo-
dermically every four hours or one one hundredth
grain in a single dose. In one case of pneumonia on
the fifth day, with an almost imperceptible pulse and
extensive pulmonarv edema — apparently brought on
by the patient's getting out of bed in delirium — this
author saw an injection of one one hundredth grain
followed promptly by cardiac recovery, clearing up
of the urgent symptoms, and after two days, by de-
fervescence. These results seemingly support the
analogous observations of Vaquez and Lutem-
bacher, who report gratifying effects from intra-
venous ouabain medication in alarming cardiac
em.ergencies in the course of acute disorders such as
typhoid fever and pneumonia. These effects they
do not deem surprising, having already become
convinced, in other varieties of cases, of an effectual
action both on cardiac tonicity and in raising the
blood pressure on the part of ouabain. As already
pointed out in an earlier instalment, Pratt, 1918,
similarly observed definite effects from intravenous
injections, not given oftener than once in twenty-
four hours, of one quarter to one half mgm. of
amorphous strophanthin in cases of heart failure —
afebrile, however — with regular cardiac rhythm.
Danielopoulo, in a recent communication, has em-
phasized the favorable results obtained by him from
intravenous strophanthin injections in cases of
typhus fever witfi severe toxemia. In brief, the
special availability of the strophanthins as heart
remedies during fever, if not as yet well established,
may at least be said, it would seem, to be deserving
of further study, both experimentally and clinically.
(To be concluded.)
November 23, 1918.] MODERN TREATMENT AND PREVENTIVE MEDICINE.
915
Resection of the Hip for Secondary Arthritis
in War Wounds. — P. Chutro {Presse medicale,
August 5, 1918) has found it possible to pertorm
this resection in less than ten minutes and without
loss of blood by combining several different portions
of former procedures. An incision fifteen to twenty
centimetres long is made, beginning at the anterior
superior spine and passing down in the interval be-
tween the tensor of the fascia lata and the gluteus
minimus, on the outside, and the anterior rectus and
psoas, within. Two vessels are ligated, opening of
the psoas sheath avoided, and the anterior aspect
of the joint capsule exposed by retracting the psoas.
The capsule is opened by a longitudinal incision to
the base of the neck. The femoral head is not lux-
ated out, but a broad bone chisel introduced and an
oblique osteotomy of the neck of the femur effected,
the plane of section being directed from without in-
ward, from before behind, and from below upward.
The section begins in the middle of the lower sur-
face of the neck and terminates near the posterior
cartilaginous flange on the head of the femur. The
trochanter and part of the neck fall posteriorly and
the head is easily removed with a curved gouge or
Lane lever. Foreign bodies or bone fragmgnts, if
present, are now removed, the parts cleansed, six or
eight Carrel tubes inserted, and the wound left
widely open, to be closed later, with a diachylon
dressing. No counteropening is required, and in
some cases the author even closed the posterior
wound which originally led to the arthritis. Con-
tinuous extension of both lower limbs in maximum
abduction is instituted, with a five kilo weight on
each side. Counterextension is supplied by raising
the foot of the bed fifteen centimetres. Excess of
inward rotation is carefully avoided and the exten-
sion continued for six or eight weeks. Massage is
practised as soon as healing occurs. Spontaneous
movements are permitted. Crutches are eliminated
as^oon as possible, as they promote elevation of the
pelvis and external rotation and adduction of the
limb.
Dried Milk in Infant Feeding. — Roger H. Den-
nett (New York State Journal of Medicine, July,
1918) records his observations, in a variety of cases,
on the use of plain dried milk as an infant food,
and concludes that it is very satisfactory and has a
number of advantages over other forms of feeding.
Dried milk is better tolerated than raw or boiled
milk mixtures by infants who have previously suf-
fered a food injury, indicating that it is better and
more readily digested. It is also of great value for
the infant who does not prosper on the various milk
mixtures, and should be given in such cases without
delay. Its use often controls vomiting within twen-
ty-four hours and intestinal indigestion is overcome
immediately. If given along with orange juice,
after the first week or two, its prolonged use does
not produce either rickets or scurvy. It is extraor-
dinarily simple to prepare, being merely mixed in
the prescribed proportions with hot Avater. To sup-
ply fifty calories daily per pound of body weight,
three lablespoonfuls of the dried milk, levelled with
a knife, must be given for each pound of body
weight. This is too high a food value for any but
very poorly nourished infants, and most babies will
gain adequately on forty calories per pound per day.
The maximum concentration of the dried milk mix-
ture should not exceed one tablespoonful of the milk
per ounce of water. When beginning the use of
dried milk in any case in which there has been food
injury, much less should be prescribed than called
for by the body weight, and the amount should then
be raised rapidly as tolerance is established, just as
with any other change in diet in the infant. The
very ready 'digestibility of dried milk may possibly
depend upon the fact that the casein in it does not
clot in the stomach in large masses, but the small
grains merely swell and are therefore very easily
attacked both by the gastric and intestinal secre-
tions. The milk also has a low fat content when
diluted with the proper amount of water and con-
tains a larger proportion of the fatty acids than
whole milk. These tend to form soaps very easily
and these soaps in turn favor the emulsification of
the fat and enhance its digestion. The relatively
high protein content of the dried milk makes desira-
ble the addition to it of sugars or gruels or both
after the digestive disturbances have been controlled,
and this addition also avoids the possibility of the
urine becoming excessively ammoniacal when large
amounts of the milk are being taken. Other advan-
tages of dried milk are its convenient form, its ster-
ility, and the fact that it will keep for long periods
of time even after the container has been opened.
Ulcer of the Stomach. — Martin E. Rehfuss
(Medicine and Surgery, June-July, 1918) discusses
the treatment of gastric ulcer as based on the newer
conceptions of its etiology and those of the gastric
functions. Owing to the etiological importance of in-
fection in a certain proportion of cases it is es-
sential that every effort be made to find the focus
of infection, if present, and to remove it by appro-
priate means. To this end the tonsils, the postnasal
space, pyorrheal teeth, and the bile should be cul-
tured and a vaccine prepared from the organisms if
there is probability of their being influential in the
production of the ulcer. The tonsils, if infected,
should be removed. From the psysiological aspect
ulcer causes a break in the normal physiological se-
quence of the digestive and interdigestive phases ; in-
creases vagus tone, and induces hypersecretion and
spasm ; and ultimately produces a vicious cycle in
the stomach. Unquestionably the best condition for
healing of a gastric ulcer is the prolongation of the
interdigestive phase, since during that period the
total and free acids are at the minimum, tryptic re-
gurgitation and intestinal reflux are at their height,
peristalsis is stopped, and the walls of the ulcer are
approximated. Starvation fulfills these conditions
the most adequately, and after a period of this treat-
ment the interdigestive interval can be prolonged by
giving only two feedings daily of eggs and butter,
or very frequent feedings mav be given with com-
plete neutralization of all acidity. F'requent feed-
ings in some cases result in glandular fatigue and
irritation and hypersecretion, but in the great ma-
jority such is not the case if the food given is wholly
nonstimulating. Foods meeting this requirement
include the carbohydrates preeminently, while the
proteins induce high acidity. Fruits and vegetables
may be used along with the carbohydrates.
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Medical Treatment of Graves's Disease. — H. C.
Gordinier {Dominion Medical Monthly, October,
1918) points out that every case should be examined
for focal infection. Mild or incipient cases are
cured by prolonged rest, hygienic and medical
means; fifty per cent, of the more advanced cases
are curable by the same methods. If a case has
been under medical care for some time without im-
provement it should be placed in the hands of an
experienced surgeon, skilled in thyroid work.
Cases showing myocardial insufficiency or serious
arrhythmias, as alternation, fibrillation, or flutter,
should be treated medically. X ray pictures of the
chest should be taken to discover extraneously
placed accessory or dipped thyroids and to de-
termine the size of the thymus gland. The ideal
treatment is enforced therapeutic rest.
Treatment of Trachoma. — A. B. Grain {Texas
Medical journal, October, 1918) employs a specially
devised forceps, two small scalpels, a horn spoon,
Desmarre's forceps, a tooth brush, 1-2000 bi-
chloride and plain sterile gauze. The lid is inverted,
scarified, and the granules incised superficially with
the scalpel. The surfaces are gone over with the
tooth brush and the bichloride solution and followed
by a thorough use of the gau^e. Local anesthesia is
usually used but general anesthesia may be neces-
sary. Immediately after the operation the conjunc-
tiva is washed with boric acid solution with the
eyelids everted. The eye should be cleansed every
three hours with boric acid solution followed by
twenty per cent, argyrol. After five or six days, if
uneven granules are present, the lids should be
everted and brushed with two per cent, silver nitrate
solution.
Sulphur Solution in Psoriasis and Other Con-
ditions.— L. Bory (Presse medicale, August 22,
1918) at present uses a stronger sulphur solution
than formerly. The formula is as follows :
R Sulphuris prjccipitati puri i gram ;
Guaiacolis 5; srrams ;
Camphorae 10 grams;
Eucalvptolis 20 grams;
Olei sesami, ; q. s. ad 100 mils.
In the treatment of psoriasis, the minimal
amount injected is six mils ; the maximum ten mils,
and the usual dose eight mils. Febrile reactions,
lasting about twenty-four hours and with copious
sweating are neither more marked nor more lasting
than with the much smaller doses of sulphur form-
erly used. The urine and lungs should be ex-
amined before the treatment is applied. In women
the sulphur oil exerts an emmenagogue action, in-
ducing menstruation for one to three days. In
psoriasis four or five sulphur injections are given
at weekly intervals. If combined with painting of
the lesions every day or every other day with pure
coa' tar, two sulphur injections are often sufficient
for a cure, and the patient nearly always leaves the
hospital in three weeks. Later recurrence is pre-
vented by injection of ten mils of the oil every
month or two for six months, then at longer inter-
vals. Interesting results were obtained by injection
into the buttocks in cases of recent, extensive, and
painful gonorrheal orchiepididymitis. Within one
to three days the testicle returned to its normal size
and sensitiveness. Gontrol injections of the oil,
without the sulphur, in other patients showed the
sulphur to be the main beneficial factor, such in-
jections causing some improvement, but far more
slowly. The sulphur is not held to act on the
gonococcus, which persists unchanged in the urethral
discharge, but is considered to exert an exceeding-
ly marked decongestive action on testicle and tunica
vaginalis affected with gonorrhea. The value of the
sulphur oil in gonococcal rheumatism has already
been reported.
Operability of Primary Malignant Tumors of
the Bony Thorax. — Meriel {Presse medicale, Au-
gust 22, 1 91 8) had occasion to remove a sarco-
matous growth of the anterior wall of the thorax —
at first sight seemingly unremovable. He succeed-
ed in eliminating it after ascertaining its breath and
depth by exploratory thoracotomy and states that
one should not hesitate to carry out this procedure
whenever it is necessary to make sure of the oper-
ability of a primary tumor of the bony thorax. Its
advantage lies in the fact that the tumor in its en-
tirety can thereby be investigated with the senses of
touch and sight. Exploratory thoracotomy is no
more serious an operation than exploratory laparot-
omy, the latter likewise calculated to show the feasi-
bility of a difficult operation.
Acidosis in Children's Diseases. — Roland C.
Gonnor {Interstate Medical Journal, August, 1918)
considers that the immediate administration of
alkalies is warranted by the following group of
symptoms : enlargement of the liver, hyperpnea.
vomiting, thirst, dry mouth and lips, restlessness,
acetone odor of the breath, strong odor of ammonia
in the urine, and heavy acetone ring in the urine.
Alkaline treatment is advisable in all infant diar-
rheas, and the routine use of alkaline fever mixtures
as a preventive. For most purposes a four per cent,
solution in glucose or cereal water by mouth, or the
same strength intravenously, is best. If there is no
diarrhea they mav be given by the bowel, and when
there is vomiting small doses of a more concen-
trated solution may be given. A large draft of
water should be taken two or three times a day.
Control of Fragments in Gunshot Wounds of
the Jaw. — H. P. Pickerill {Lancet, September 7,
1918) discusses the various factors which tend to
produce displacement of the fragments in gunshot
fractures of the jaw, laying special stress upon the
role of muscular action and entering into a detailed
presentation of the most important actions of the
individual muscles, alone and combined. He then
presents a number of suggestions, with illustrations,
as to the various methods which may prove of value
in controlling the fragments, and concludes with the
statement that there should be no "best method" of
controlling fragments, but that each case should be
treated individually according to its special require-
ments. The one aim of the method employed
should be the control of the fragments but not their
absolute immobilization, since the presence of some
motion greatly enhances the progress of union.
Wherever possible loose teeth and small bone frag-
ments should be retained and controlled with func-
tion, rather than be sacrificed, to secure a quick but
inferior result.
November 3, 191 8.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
917
Fallacies of the Face Mask in, the Control of
Acute Infectious Diseases. — Archibald L. Hoyne
{Illinois Medical Journal, September, 1918) is of
the opinion that the observance of aseptic nursinoj is
of much greater vakre than the use of masks.
Where all the details of aseptic nursing cannot be
carried out the following precautions may be taken :
I, The hands should be scrubbed with soap and
running water after handling the patient; 2, a sep-
arate gown should be worn in handling each patient ;
3, all attendants who have a positive Schick should
have active immunization by the toxin antitoxin
method ; 4, nurses and physicians should have a
throat culture made twice a month ; 5, no nurse with
diseased tonsils or carious teeth should be allowed
to handle contagious cases until such defects are
remedied ; 6, a face mask is advisable where work
of any kind is to be done on the throat, nose or
mouth of a contagious case.
Musculospiral Nerve Disabilities. — Astley V.
Clarke and N. I. Spriggs (British Medical Jour-
nal, September 14, 1918) attempted to determine
the most suitable position for the hand to secure the
optimum relaxation of the tendons of the paralyzed
muscles by careful measurements on the cadaver.
The measurements were made for each individual
muscle involved in musculospiral paralysis. None
of the several positions commonly employed pro-
duces any relaxation of the extensor ossis metacarpi
pollicis or of the extensor brevis pollicis, such re-
laxation being possible only by extension of the
thumb and simultaneous abduction of the hand, a
position impossible of attainment when the other af-
fected muscles are relaxed. The position offering
the greatest all-round advantages for prolonged
maintenance is that provided by the short "cock-up"
splint which leaves the thumb and fingers free for
use. The long cock-up splint which supports the
first phalanges is of great value for temporary use,
as at night for patients wearing the short splint, as
this provides perfect relaxation for the long com-
mon extensor and the long extensor of the thumb,
, which is imperfect with the short splint.
Antimony in Bilharziosis. — -J. B. Christopher-
son {Lancet, September 7, 1918) records the results
of his observations on the intravenous administra-
tion of tartar emetic in a series of thirteen cases of
bilharziosis, and believes that the treatment is ex-
tremely satisfactory. The drug is administered in-
travenously in distilled water in the proportion of
thirty milligrams in four mils. For adults the
initial dose is thirty milligrams and on each
alternate day the dose is increased by that amount
until the dose reaches 0.13 to 0.2 gram every other
day. The dose for children should be proportion-
ately less at the beginning, but the smaller of the
maximal doses stated may be reached. A total of
about two grams should be given in the course of
treatment. The injections are made into one of the
cubital veins and great care must be exercised to be
sure that none of the fluid escapes into the sub-
cutaneous tissues, as it will cause necrosis. The ad-
ministration of the drug must be watched with care,
as it is a slow and cumulative poison. Of the thir-
teen cases so treated, not all received the full course.
Three patients had relapses after insufficient courses
of treatment; two passed from care before the
treatment had been completed ; and the remaining
eight were apparently cured. The acute toxic sympn
toms from the drug include vomiting, vertigo, deli-
rium, fever, diarrhea, and cramps in the calves of
the legs. Their appearance demands the interrup-
tion of treatment with later return to smaller doses.
Chronic poisoning is indicated by weakness, loss of
weight, anemia, glossitis, cracked tongue, and diar-
rhea, and requires both suspension of the antimony
injections and the institution of appropriate treat-
ment.
A White Substitute for Vidal's Red Plaster. —
L. A. Longin (Pressc medicale, August 29, 1918)
states that while Vidal's plaster is very efficient in
pyogenic skin affections it is disadvantageous in that
it stains the linen and skin when the plaster dress-
ing has slipped or run over at the edges. He pre-
fers a white preparation consisting of calomel, three
grams ; lead carbonate, six grams ; and rubber
plaster, thirty grams. In some instances the addi-
tion of six grams of zinc oxide is serviceable. The
resulting combination is better borne by irritable
skins than that without the zinc oxide. In its cura-
tive effects the white plaster is equally as powerful
as the Vidal red plaster.
Rontgenotherapy in Tuberculous Glands of
the Neck. — Charles A. Pfender {Medicine and
Surgery, April, 1918) bases his conclusions on his
personal experience and an extensive analysis of
the literature when he says that rontgenotherapy
gives the best results of all therapeutic measures
in acute, .subacute, and chronic tuberculous glands
of the neck, both suppurative and hyperplastic. The
simple hyperplastic form should not be treated
surgically until rontgenotherapy has been tried and
has failed, while the suppurative form should be
evacuated by simple incision or aspiration, preceded
and followed by rontgenization. Old sinuses re-
spond promptly to surgical drainage and the use
of X rays. Medicinal, dietetic, and heliotherapeutic
measures should be combined with the use of the x
rays. There are no contraindications to rontgeno-
therapy.
Causes of Failure and Untoward Results in
Conductive Anesthesia. — Richard H. Riethmiiller
{American Journal of Surgery, October, 1918) with
regard to conductive ane.sthesia, concludes as
follows : When we consider the thousands of in-
jections of novocaine-suprarenin being made in
every large community every day witliout any un-
toward results whatever, the remarkable safety of
this method of anesthesia is patent. Surely few
operators would be wilhng or able to do without
conductive anesthesia in their practice today, after
they have once come to fullv realize its incompara-
ble advantages over older methods. A knowledge
of the causes, however, of possible untoward re-
sults which may arise seems most desirable, and it
is to be hoped that the teaching and practice of this
method will be left to the fully competent, else
dentistry may again — as has happened with other
methods before — be cheated out of the blessings of
a doctrine which has proven itself to be a boon to
humanity.
Miscellany from Home and Foreign Journals
Epidemic Influenza — Le Marc'hadour and
Denier [Bulletin dc I' Academic de mcdccine, Sep-
tember lo, 1918), in a partially censored communi-
cation, point out that the influenza symptoms are
accompanied by an increase of urea concentration
in the urine together with a decreased elimination
of chlorides. The blood shows a leucocytosis, with
polynucleosis of eighty to ninety-five per cent. The
red cell count progressively diminishes and with it
the hemoglobin percentage. In grave forms of the
type of disease they witnessed, pleural disturbances
were a feature. In addition to the facies of infec-
tion, dyspnea, and tachycardia, there occurred a
stitch in the side, radiating to the abdomen. A
seropurulent or purulent effusion rapidly devel-
oped, often accompanied by pericarditis with ef-
fusion. Septicemia was frequent and the prognosis
alv/ays doubtful, many deaths occurring from one
to five weeks after the onset of symptoms. The
form with initial hyperthermia, more or less ex-
tensive pulmonary congestion, breathing somewhat
tubal, and fine crepitant and subcrepitant rales gen-
erally terminates in recovery but requires a pro-
longed convalescence during which the patient con-
tinues to harbor bronchopneumonic foci, these
gradually subsiding. Blood cultures revealed strep-
tococci in six grave cases. Inoculation of pleural or
pulmonary fluid likewise yielded streptococci in all
instances, as did also all metastatic abscesses met
with. In all autopsies in influenza cases made in
the course of several months, streptococcic septi-
cemia was concluded to have been present. The
streptococcus isolated from these patients exhibited
the properties of streptococci in general, but its
marked virulence in man was shown in the case of a
physician, accidentally infected in the course of a
pleurotomy in an influenza case, who thereupon suc-
cumbed to a streptococcic septicemia. In short, the
influenza epidemic imder observation appeared to
owe its special virulence to streptococcic complica-
tion. Antoine and Orticoni report bacteriological
studies in a group of cases characterized by early
pulmonary complications, not infrequently fatal.
Blood cultures and sputum and pleural fluid ex-
aminations revealed, in some patients, gram positive
encapsulated diplococci often disposed in short
chains in th^ culture bouillon. In a few cases, blood
cultures revealed a gram negative, nonmotile bacil-
lus, aj^arently with most of the morphological
staining, and vital attributes of the Pfeiffer bacillus.
That this organism was actually the Pfeiffer bacil-
lus was confirmed by Martin and Legroux, of the
Institut Pasteur of Paris. This germ was also
found in pleural pus, always in association with
diplococci in single pairs or cocci in short chains,
positive to gram's. In the sputum the pneumo-
coccus was often the predominant germ, not only
in the period of pneumonic jellylike sputum but also
in the white air filled, often blood streaked sputum
of the early stage. No Pfeiffer organisms were
ever found in the sputum. In two fatal cases,
bronchial mucus showed the Friedliinder pneumo-
harillus — in one instance practically in pure culture.
The question arises whether the influenza bacillus,
not found by any one in the blood in the course of
the first, mild epidemic of influenza occurring in.
France, was not already present at the time and
assumed increased virulence in the more recent,
severe epidemic. Or, the recent disorder m.ay be an
entirely different affection due to a particularly
resistant and virulent strain of the Pfeift'er bacillus.
Researches conducted for the purpose of elucidating
this question are in progress.
Trinitrotoluene Poisoning. — A. W. Gregorson.
and F. E. Taylor {Glas'gow Medical Journal, Au-
gust, 1918) report five instances of this condition,
including two fatal cases. Both of the latter had
toxic jaundice, one case showing in addition a swol-
len and cyanosed face, mental torpor, severe head-
ache, abdominal and lumbar pain, tinnitus, a feel-
ing of pins and needles in the arms and legs, a rash
of purple, discrete papules, a subnormal tempera-
ture, almost complete obliteration of liver dullness,
and much bile in the urine. Bloody vomiting, pal-
lor, twitchings, and progressive weakness preceded
death. The second case, that of a worker in a
munition factory for two months, ended fatally and
was characterized by jaundice, vomiting, hemor-
rhages from various muccus membranes, with
marked enemia and leucopenia. The leucocytes-
consisted entirely of badly staining, degenerate look-
ing cells, somewhat resembling abnormal lympho-
cytes— a condition never before encountered by the
authors in any other disease. Autopsy findings in
both cases are given. Itching of the skin, which
usually accompanies jaundice, was absent in these
patients. The principal channels of absorption ap-
pear to be the lungs and stomach, the poisonous dust
being, in the latter case, swallowed with the saliva.
Gastric disturbance and peripheral neuritis were
the earliest symptoms, headache, anemia, and jaun-
dice following in the order named. The intensity
of the jaundice varied from week to week, being at
times a deep yellowish green. When the color faded
there was general improvement. As for the treat-
ment, absolute rest in bed and warmth are essential.
Milk, with five grains of sodium bicarbonate to the
ounce, is given every two hours, to the amount of
six ounces. Barley water, fish, rabbit, vegetables-
are allowed in moderate amounts, and fatty and .sac-
charine foods prohibited. Alkaline beverages are-
given freely. Calomel and a saline are adminis-
tered at the outset, and later cascara and sodium
sulphate. To correct intestinal acidity whenever
this develops, magnesium carbonate is given. The
patient also takes a mixture containing po-
tassium citrate, sodium bicarbonate, and sodium
sulphate every four hours. Later, he may be given
potassium bicarbonate with tincture of ginger, com-
pound rhubarb tincture, and infusion of gentian.
Rectal salines with sodium bicarbonate, two ounces
to the pint, are given every six hours. Intravenous
or subcutaneous saline injection, when the patient
is first seen, gives great relief, and inhalation of
oxygen through warm ether is a valuable stimulant
in such cases.
November 23, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
919
Cardiovascular Disturbances as a Cause of
Aviation Accidents. — D. Berthier {Bulletin de
I'Acadhnc dc medecine, September lo, 1918) re-
ports the cases of two aviators who, when at high
altitudes, were often seized with tinnitus, dazzling,
dizziness, and even unconsciousness. Both had
large livers, in one instance apparently due only to
congestion of the organ, but in the other manifestly
associated with organic disease. Cardiac examina-
tions showed clear heart sounds, a strong apex
beat, and slight irregularities of rhythm. Blood
pressure estimations with the Pachon instrument
showed a systolic pressure of 190 mm. and a dia-
stolic of only sixty in the one case, and a systolic of
150 and diastolic of fifty in the other. Upon ex-
amination in bed on awakening, the beats were
found regular but weak and infrequent. In one
case the rate was but fifty and no apex beat was
noticeable. These aviators had both lost weight and
become subject to gastrointestinal disturbances.
Whether the enlarged liver is the cause or the effect
of the low arterial tension in such cases — in the ab-
sence of all valvular disease — is not clear. Nervous
fatigue may also be a cause of low pressure. That
high altitudes may induce unconsciousness through
additional diminution of blood pressure in subjects
already suffering from low tension, due to cardio-
vascular disease is well known. The aviator with
initially low pressure is likewise threatened with
syncope when the pressure drops too rapidly, and
this possibly accounts for the sudden falls to death
of numerous aviators. The blood pressure of all
aviators should be tested periodically, with special
examination of those who report nervous disturb-
ances, dyspnea while in flight, or who have hepatic
trouble. An aviator with a diastolic pressure of
sixty or below should be considered temporarily
disqualified for the work. A thermal course of
treatment at Royat was found to relieve such sub-
jects rapidly.
Differential Diagnosis between Functional
and Organic Paraplegia. — R. T. Williamson
{British Medical Journal, September 14, 1918)
emphasizes the need of early differentiation between
the functional and organic paraplegias and the great
advantages of early diagnosis of organic lesions
from the standpoint of treatment. He says that
certain reflexes are of the greatest value in these
respects, especially the Babinski or Oppenheim re-
flex and the loss of the Achilles reflex because these
evidences may be detected before other changes have
occurred. The main difficulty arises when the knee
jerks are not lost and when ankle clonus, rectus
clonus and clasp knife rigidity are absent. The pres-
ence of the Babinski or Oppenheim reflex in such
cases is diagnostic of organic disease, while in the
absence of the Babinski type of reflex the loss of the
tendo Achilles reflex is diagnostic of organic disease.
The three indications of greatest help in especially
difficult cases are the presence of the Babinski type
of reflex, the loss of the Achilles reflex, and the loss
of the vibrating sensation with the preservation of
other forms of sensation. The following combina-
tions are of diagnostic importance : Paresis with
loss of the Achilles reflex, as in early anterior polio-
myelitis ; paresis with loss of the plantar reflex and
of the Achilles reflex, in many organic diseases ;
paresis with double sciatica and loss of the Achilles
reflex, as in early cauda equina lesions ; paresis with
loss of the Achilles reflex, loss of the vibrating sen-
sation, and pains in the legs, as in early peripheral
neuritis ; very slight paresis and incoordination with
loss of the vibrating sensation, with or without a
Babinski, as in early posterolateral degeneration of
the cord ; paresis with the Babinski reflex, as in
many organic lesions ; paresis with loss of both Ba-
binski and vibrating sense, as in several organic cord
lesions ; root i)ains or symptoms, followed after
weeks or months by paresis, as in spinal meningeal
tumor.
Suppuration of Goitrous Thyroid Following
Administration of Thyroid Extract. — Edward A.
Tracy {Endocrinology, April-June, 1918) describes
a case which illustrates the care with which thyroid
extract must be given. The patient was a widow,
aged fifty-one years, was sleepy in the daytime and
melancholic, probably owing to the fact that her son
was in prison. She had a moderate sized goitre.
One half grain of desiccated thyroid after each
meal was prescribed. After a week of treatment
the right lobe of the thyroid became painful, and
the treatment was discontinued. After two weeks
the painful lobe reddened, and later broke. After
three days the patient, prescribing for herself, ap-
plied a bread and water poultice. The appearance
of the sloughing lobe of the thyroid was alarming,
so that a sulphonaphthal poultice was applied everv
three hours. After a few days the dead thyroid
tissue was snipped off, and antiseptic treatment
continued until healing occurred four months later.
In passing, it may be remarked that the mental
symptoms cleared up quickly after the administra-
tion of the desiccated thyroid. In goitre with
myxedematous symptoms Tracy recommends an
mitial dose of one half grain of desiccated thyroid
daily, with careful attention to the least sign of
trouble, such as pain in the thyroid, when medica-
tion should be stopped. The dose may have been
sufficient to awaken the tissue to renewed activity,
but if not, treatment with the same careful watch-
ing should be begun again.
Complement Fixation in Tuberculosis. — V. H.
Moon {Journal A. M. A., October 5, 1918) reviews
at length the literature upon the subject of com-
plement fixation as a diagnostic method in tuber-
culosis, and concludes that this should be regarded
as an established technic which is well past the ex-
perimental stage. The value of the test is greatest
in the diagnosis of very early tuberculosis where a
positive complement fixation should be regarded as
a valuable point in reaching a definite conclusion.
The test should be regarded in precisely the same
light as the Wassermann test, that is, not as one
which alone is diagnostic, but as evidence to be con-
sidered together with other findings. Of the vari-
ous antigens employed by different workers that
prepared from a number of strains of tubercle
bacilli by the method of Miller is the best and gives
the most satisfactory results. In every case the
test should be accompanied by a Wassermann test,
since false positive reactions to the tubercle antigen
are frequent in Wassermann positive serums.
920
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Susceptibility of the Antiscorbutic Principle
to Alkalinity. — A. Harden and S. S. Zilva {Lan-
cet, September 7, 1918) have found, by careful ex-
periments on animals, that the treatment of orange
juice with sodium hydroxide, so as to render it as
little as one twentieth to one fiftieth normal alkaline,
wholly or very largely destroys the antiscorbutic
principle. Most antiscorbutic vegetables are neutral
or very slightly acid in reaction and any manipula-
tion in cooking which includes alkaline treatment to
even a very slight degree will be likely to destroy
or very greatly reduce their antisorbutic properties.
This fact assumes special importance at the present
time when fresh fruits are difficult to procure.
Vascular Changes Produced by Adrenalin in
Vertebrates. — Frank A. Hartmann, Leslie G.
Kilborn, and Ross S. Lang {Endocrinology, April-
June, 1 918) in order to determine whether the dila-
tor action of adrenalin was confined to carnivorous
animals, studied its action on the following species :
snapping turtle, fowl, opossum, horse, goat, cats and
dogs, ferret, raccoon, rats, rabbits and monkeys.
This extensive study led them to conclude that the
usual vasomotor reaction in skeletal muscle was di-
latation with moderate doses of adrenalin, except in
the case of rodents; and because of the uniform oc-
currence in other mammalian orders, as well as the
presence in the monkey, it was believed that these
mechanisms were also present in man.
Vitiligo. — A. W. Harrington {Glasgow Medical
Journal, August, 1918) reports four cases of this
disease seen during seventeen months' service in
Macedonia. Three cases occurred in Serbian sol-
diers and the fourth in a Bulgarian prisoner. One
patient was aged thirty-three years and another
forty-nine when the condition appeared, while in the
remaining two it had begun at the ages of eleven and
twenty-four years respectively. In textbooks it is
said rarely to attack those over thirty years. In
three cases the condition made its first appearance
after a severe illness. In all, it began as small
round or oval white spots, which gradually enlarged
and coalesced until extensive areas were affected.
In no case was there loss of hair pigment.
Septicemia of Buccodental Origin. — Dufour-
mentel and Prison {Prcsse medicale, August 8,
1 918) report having met, in the French Army, with
what appeared to be almost an epidemic of in-
fectious processes starting in teeth. Practically
all were merely local, ranging from simple peri-
ostitis to extensive gangrenous and phlegmonous
conditions. Phlegmons themselves at times passed
into gangrene, and where they developed in the
floor of the mouth suggested Ludwig's angina, in-
terfered with respiration, and led to widespread
cervical infiltration. In three cases a general septi-
cemia supervened and the patients succumbed. In
the first the condition was associated with hyper-
toxic cellulitis of the neck ; in the second, with
phlebitis of the craniofacial venous system ; while in
the third there was no definite pathological accom-
paniment, the autopsy revealing nothing other than
marked enlargement of the spleen and kidneys. No
effectual treatment for these septicemic cases is
known, and a fatal termination may be said to be
one of their characteristic features. A relationship
appears to exist between the severe forms of local
buccodental infection and the septicemias with
venous involvement or devoid of pathological
changes ; these cases develop progressively and
secondarily. The lymphophlegmonous form, on the
other hand, causes death, not in a week to a month,
but within twenty-four to forty-eight hours, and
appears to be a violent intoxication, a septicotox-
emia, rather than a septicemia. The mind remains
clear, but the pulse becomes small, compressible and
irregular, and dyspnea due to direct bulbar intox-
ication is a feature. Inoculation of a guineapig
from the author's case caused death with wide-
spread edema in twenty-six hours. Whether Lud-
wig's angina is a definite nosologic entity remains
a question. Sebileau looks upon it simply as a
particular form of buccal sepsis.
Nevi Appearing in Adults. — H. Gougerot
{Paris medical, August 31, 1918) protests against
the prevailing belief that nevi are always congenital
or appear in the first few months of life. He re-
ports a number of, cases in which the typical "birth-
mark" lesions develop only in adult life, and points
out that the definition of nevi should include those
cases which appear in adults, providing the lesions
which develop at this time are identical with those
of congenital origin. Some persons appear to be
born with a nevic tendency, i. e., with potential nevi.
These may not show themselves, in the absence of
an exciting factor, but make their appearance if
some influence arises which will bring to life the
nevic predisposition and induce a localization of the
nevi. Thus, in one case a wound of the hip caused
a capillary angioma to develop on the injured ex-
tremity. In a second, exposure of the arm to cold
was followed by the appearance of an extensive
venous and capillary nevus. In a tlnrd, freezing of
the left foot was followed after over three years by
the occurrence of a dozen confluent angiomatous
nevi on the dorsum of the foot and just above it.
and of additional nevi higher up on the same limb.
Origin of Daughter Hydatid Cysts. — F. Deve
{Presse medicale, August 8, 1918) asserts that in
man the presence of a multivesicular hydatid cyst
means that the original cyst has been subjected to
some unfavorable influence, e.g., senescence of the
membrane surrounding the mother cyst, spontane-
ous or purposive evacuation of the cyst fluid, in-
fection of the perivesicular or endScystic space, or
in the case of cysts of the liver, the oozing of bile
into the perivesicular space. The last two causes
act mainly by impairing the vitality of the wall of
the mother cyst. From the general standpoint, the
echinococcic vesicle constitutes the mode of defense
of the parasite, reacting against some unfavorable
influence which threatents its vitality. Clinically
such threats to the existence of the parasite are, in
a measure, avoidable. From both the medical and
surgical standpoints it is highly advantageous to
adopt preventive measures. No hydatid cyst should
ever be tapped. All hydatid cysts should be treated
by operation as soon as their existence is recognized.
Clinicians should make it a point to diagnose hydatid
cysts early. This applies to adolescents and chil-
dren as well as adults, for the majority of hydatid
cysts met with in adults date back to early life.
Proceedings of National and Local Societies
PHILADELPHIA COUNTY MEDICAL
SOCIETY.
Meeting Held Wednesday, October 9, 1918.
The President, Major Frank C. Hammond, M. C,
U. S. Army, in the Chair.
SYMPOSIUM ON THE PRESENT EPIDEMIC OF
INFLUENZA AND ITS COMPLICATIONS.
Influenza in Naval Hospitals. — Dr. Judson
Daland, Lieutenant Commander, U. S. N., called
attention to the fact that in this epidemic the cases
observed have been in men from eighteen to twenty-
six years of age, the men being selected because of
their physique. It should be remembered that the
organism of infection may float in the air for many
hours, and that it enters the human body more
particularly by way of the respiratory tract. The
period of incubation, apparently, is very brief —
from twelve hours to two days. The onset is varia-
ble ; there may be slight coryza, dry cough, pains in
the head, back, and limbs, with slight fever. Rep-
resenting the other end of the cycle were two big
husky men, in the pink of condition, at work on
board a ship who, when admitted to the hospital
within twenty- four hours, were so prostrated that
they could not sir up. Doctor Daland found that
the mild type is often accompanied with bursts of
perspiration; there is profound weakness with fever
lasting perhaps only twenty-four hours. There is
marked circulatory depression, and such a patient
may remain weak for several days, though fever and
symptoms are transitory. The second type have
more marked headache and backache, with general
soreness of the entire body. There is dry cough
for two or three or more days and the eyes are
markedly brilliant. The majority do not sneeze.
The perspirations present in the ordinary cases
seem to be beneficial ; in this type also the fever
tends to be remittent. The pulse rate in both mild
and severe types is disproportionately low with the
fever. The respiratory rate is not much altered.
The m.ild type presents a varying amount of rales of
the bronchitic character, and later moist rales. It
is a striking fact that in a large number of cases
nothing is heard in the lungs ; at one or both bases
there is silence. The explanation of this nonfunc-
tioning lower lobe is probably due to the fact that
the act of respiration is greatly interfered with on
account of the toxemia. Whenever, in a large pro-
portion of cases, a silent lower lobe, with or without
impairment of percussion resonance, is found, un-
mistakable evidence of lobar pneumonia will be
apparent on the second or third day. During an
epidemic no physician should put his head to the
chest of a patient, but should use the double stetho-
scope, and if, during the examination, the patient is
asked to cough to bring out the auscultory sounds,
the physician should be shielded from the direct in-
fection he is liable to incur. The stupor attending
the severe form resembles the typhoid state. The
men of extraordinary physique have shown no more
ability to combat the disease than the less physically
strong. The remarkable change in color — the
blueness usually seen in these severe cases — is more
marked about the tips of the nose and ears. The
pulse shows extraordinary weakness. This is no
doubt due to the toxemia which seems to affect
more especially the vasomotor and cardiac apparatus
through the nerves or muscle fibre. Thin, salmon
tinted sputum is looked upon as an unfavorable
omen. The usual signs guiding us in ordinary times
do not guide us in times of epidemic ; vast changes
inay occur in from six to eight hours in the pul-
monary or cardiovascular system. The complicating
pneumonia in the influenza makes one think of a
primary infection and secondary invasion by one of
the types of the pneumococcus. The pneuniococcus
seems to belong largely to Type III or Type IV ;
occasionally we find Type I. In an extraordinarily
large number herpes febrilis and epistaxis have
been noted ; a certain number complicated by
jaundice in which the sputum has sometimes been
canary color. In these more than half have suc-
cumbed. Doctor Daland was inclined to look upon
the pneumonia as a part of the picture of the in-
fluenza rather than as a complication.
In prophylaxis the following were important con-
siderations : I, avoid crowds ; 2, any one who coughs
should be avoided ; 3, nurses and physicians should
invariably wear masks ; 4, the patient and the
articles in the room should be touched as little as is
possible ; 5, the physician's stay in the sick room
should be as short as possible. Doctor Daland had
seen severe toxemias of malaria, of typhoid, and of
typhus, but had never seen more grave examples of
intense toxemia than in this epidemic. The mild
forms will recover if kept absolutely at rest in bed
and given nourishing food. In the severe forms
with loss of appetite beneficial results have been
obtained from the use of the Murphy drip — three
pints in twelve hours. It seems probable that the
nausea is of toxic origin, and we have met it by the
use of water, thus giving the body opportunity to
eliminate the toxins by sweats, the urine, and by
the bowels.
Bacteriology of the Present Epidemic. — Dr.
Randle C. Rosenberger said that in an epidemic
like the present two questions present themselves —
the questions of the cause and of duration. Dur-
ing the last three or four years the weather has been
uncertain regarding sunlight, one of the best of our
natural disinfectants. It has been proven by experi-
ment that persons who are ill have shown peripheral
leucocytosis with increase in lymphocytes in about
an hour's exposure to sunlight. In our bacteriologi-
cal studies of this epidemic we have failed to dem.-
onstrate influenza bacilli. We have found what we
thought was the influenza bacillus, but we cannot
be certain that it is without having a culture to sub-
stantiate our findings. The organism miost fre-
quently found is the pneumococcus. We have not
yet had time to type it. The next in frequency is
the Micrococcus catarrhalis. Streptococci and
staphylococci are also present. The cough and the
922
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
sneeze are the chi.if mediums of dissemination. The
mouthing of toys and the passing of food from one
child to another offer a favorable medium also. In-
vestigation of restaurants and cafes shows that
drinking glasses are not sterilized. Individual
drinking cups should be instituted. The smoking
car is another means of dissemination of the dis-
ease. It sliould be called a "spitting car." The
great amount of sputum on the floors of these cars
is a severe indictment. From the constant grinding,
by being walked over, the sputum becomes dust
which is inhaled. In the protection of the nurse
against infection the secretions should be handled
with the utmost care ; the same is true of the un-
dertakers' assistants. In the fatal cases there is a
marked edema of the lungs, and fluid is discharged.
Doctor Rosenberger strongly advises the use of the
mask, though he has little faith in the efficacy of
vaccines except, perhaps, in perfectly healthy per-
sons without abnormal symptoms.
Dr. Henry Beates, Jr., said that reference has
been made to the failure of the lungs to function-
ate ; the air vessels become filled with serum and
the patients actually drown in their own fluids.
The same is seen in the gastrointestinal type. In
this type the pain is almost as acute as in acute
pancreatitis. The bowels refuse to move, and
volvulus is suggested, but the physical signs of ob-
struction are absent. In the cerebral type there is
sudden intense pyrexia with maniacal dehrium, the
patient needing to be restrained and passing into a
state of coma. A patient recently seen had a tem-
perature of 107° after the development of what
Doctor Beates regarded as acute cerebritis, because
the symptomatology of meningitis was wanting.
Another form seen raises the question of anterior
poliomyelitis. In one case, an adult, weighing two
hundred pounds, awoke in the night with paralysis
of the extensors of the head, of the spinal column,
legs, and arms. In a few days the patient recovered
except for some weakness of the muscles of the leg.
Four cases showing such paralysis were seen within
a few hundred yards of each other. In one case of
a child there was complete loss of power of the legs,
which disappeared on the fourth day. It seems as
though there is nothing to which this could be
attributed except the toxemia of this socalled in-
fluenza. In the cases of coalescing lobar pneumonia
fair success was obtained in what would be con-
sidered enormous doses of quinine combined with
caff^eine, camphor, and digitalis. Feeding is very
important, and predigested food was given, by
rectum when necessary.
Ijeutenant a. F. Case, Naval Hospital, Phila-
delphia, regretted that he could discuss the subject
from the laboratory standpoint only, and felt that
this had been rather unsatisfactory. While the dis-
ease behaves like the epidemic form of influenza the
conservative opinion is the better one to assume
from the bacteriological point of view since, in this
connection, the subject is by no means settled. In
225 uranalyses, ] 50 showed albumen ; in eighty-three
cases casts were foimd, indicating a very distinct
kidney irritation. A great manv of the cases are
as.sociated with marked kidney irritation, if not dis-
tinct nephritis. The blood cultures in twenty-six
cases were negative except in one pneumonia case
in which Type IV pneumococcus was isolated.
Failure to isolate the influenza bacillus does not
mean that it is not present. The matter of the
value of vaccine as a prophylactic is still experi-
mental, and before being accepted all data should
be subjected to critical examination.
Dr. Francis J. Dever said that the peculiar
temperature curve of this epidemic should be noted.
For the first twenty-four to thirty-six hours it is
ustially febrile ; there is then sometimes a very sharp
drop which may last for a day and a half. If the
patient is kept in bed, at the end of thirty-six
hours, there is usually no fever, but later there will
be a rise of temperature. It was noted that in the
patients admitted with temperature of 105° and a
respiratory rate of twenty with the low pulse rate,
recovery would often ensue. It was most astonish-
ing to see these men come in with faces flushed, and
conjunctiva, red ; dropping down in the first place
they could find, and going off to sleep as soon as
they were put to bed ; in forty-eight hours they
were in a much better condition. On the other
hand the patient admitted with a temperature of
ioi'\ and not appearing to be very sick, with
respirations of twenty-five and over, needed most
careful watching. In a considerable proportion of
such cases lobar pneumonia developed, the mor-
tality of which is extremely high regardless of any
management. Doctor Dever felt that the impor-
tance of wearing the mask should be placarded all
through the city.
Dr. JuDSON Daland read a message from Cap-
tain Pickrell, U. S. Navy, which stated that in the
Fourth Naval District there were 15,000 men; that
of these, 3,305 have had influenza — twenty-two per-
cent.; of these 3,305 cases fifteen per cent, had
pneumonia ; and of these cases of pneumonia thirty-
one per cent, died, the average mortality being 5
per cent.
Meeting Held Wednesday, October 2^, ipi8.
The President, Major Frank C. Hammond, M. C,
U. S. Army in the Chair.
SYMPOSIUM ON THE FURTHER STUDY OF EPIDEMIC
INFLUENZA.
Value of Active Immunization with Vaccine
Virus against Influenza. — Dr. John H. Kolmeb
considered that sufficient time had not elapsed to
permit of definite conclusions regarding the value
of vaccines in the prevention and treatment of epi-
demic influenza, and wished his remarks to be inter-
preted purely as preliminary statements. By most
bacteriologists the disease is regarded as due to the
influenza bacillus. In our own work he felt that
we were experiencing considerable difficulty in iso-
lating this bacillus. The streptococcus, according
to our observations, seems to predominate in our
findings. The vaccine which we have prepared con-
tains not only the influenza bacillus, but likewise the
pneumococci, particularly Types II and IV, which
we have found to predominate in the sputum and
in the pulmonary lesions, also many strains of
streptococci and of Micrococcus catarrhalis. At
the present time there are certain serological inves-
November 2j, 19.8.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
923
ligations under way to determine tiie more exact
relationship of these organisms to the disease, and
in a preliminary way, Doctor Kolmer felt that such
evidence is at hand indicating that the streptococcus
and Micrococcus catarrhalis are also concerned in
the pathology of the infection, possibly not as pri-
mary agents, but as secondary factors of consider-
able importance. That we might not reduce the re-
sistance small doses of the vaccine had been given
at intervals of three days until three injections
were given. A distinction should be made as to
the practical value of commercial stock vaccine and
that prepared of organisms from the present epi-
demic. Several thousand doses of the vaccine we
have prepared have been distributed in this city. It
would seem that the administration of the vaccine
at intervals of three days does protect a certain
number of persons against influenza, but it does
not confer absolute immunity. Reports, by direct
correspondence from Boston, Rochester, and other
cities are of a similar nature. We may, therefore,
tentatively assert that the vaccine is worthy of trial,
particularly in institutions and hospitals where a
large number of people necessarily congregate. In
the treatment of the disease with the bacterial vac-
cine we must be even more conservative. The ma-
jority of clinicians who have used our vaccine are
of the opinion that it has cut short the febrile pe-
riod and mitigated the symptoms. Doctor Kolmer,
however, was not prepared to make any definite
statement, though he believed that the vaccine was
well worthy of trial in the prevention of disease,
that it might even prove of distinct benefit in treat-
ment, provided it was given early and in small doses.
He considered that the dose bore an important re-
lation to the results.
Physical Findings in Pneumonia Complicating
Epidemic Influenza. — Dr. M. Howard Fussell
added a few points in regard to the clinical picture.
In his experience he found that the simple case of
influenza began with cough, pain in the legs and
back, depression, temperature of from 98° to 103°
for a day or two dropping back to normal, again
rising and again dropping. In a case in which the
temperature, after having been normal for three or
four days, rises to 103° and 104° and remains at
that point for two or three days lung involvement
might be expected. In his experience in hospital
and privcrte work he has been impressed with the
fact that one of the greatest factors in bringing
about severe cases of pneumonia is that the patient
with influenza has been well for two or three days,
has gone about, and then develops pneumonia.
This has been borne out in the experience of the
nurses in two hospitals. In one hospital eighteen
out of twenty-four nurses have been sick with in-
fluenza ; two or three of these developed pneumonia
and all recovered. In another hospital sixty-five
nurses had influenza, three had pnermonia, and all
recovered. This was not because of any specific
treatment, but due to the fact that the instructress
of nurses was told that the moment ihey developed
the first symptom they should be put to bed and
kept there imtil the attack was entirely over.
In the pneumonia, dullness over the afifected area is
heard first; coincident with this there is crepitation;
in a day or two moist large rales are found ; later,
when the patient is almost well, blowing breathing
is heard, and, instead of ending in a few days, the
whole chest becomes involved. The other cases of
pneumonia begin suddenly like lobar pneumonia ;
the patient soon becomes cyanosed ; the pulse is not
very rapid until the very end ; the tremor and cya-
nosis indicate an overwhelming toxemia, and the
patient succumbs in spite of any treatment. Doctor
Fussell felt that all efforts had been of no avail, the
cases resulting fatally. The length of time that the
physical signs last is a curious factor. In one in-
stance the patient had had no fever for ten days,
but the physical signs in the chest were about as bad
as when the temperature went to normal. The
blood in the sputum lasts a long while ; the patient
may be apparently well and yet spit about as much
blood as in the beginning. The menses are apt to
appear at an unusual time. Nosebleed is common.
In the majority of cases the mentality is clear al-
though the infection is so terrific and is going to end
seriously in a few hours. Only two persons over
fifty in Doctor Fussell's experience have had the
disease; only four have had empyema; there have
been three or four cases of parotiditis. These sup-
purate and may rupture, causing death by sepsis.
The patients he had seen recovered by the ordinary
surgical methods. The mortality of the disease, of
course, is very high ; in 320 cases there were ninety
deaths. This does not mean death by pneumonia,
for many patients died within twenty-four hours.
There were only four recoveries among pregnant
women.
Acute Appendicitis Complicating Influenza. —
Dr. Moses Behrend said that the recent epidemic
of influenza, often accompanied with its lethal com-
plication, pneumonia, had furnished many occasions
for the differential diagnosis of a chest, or an abdom-
inal condition. When this differentiation cannot be
made it is advisable to operate with the aid of
nitrous oxide gas and oxygen anesthesia. In the
event of a mistake the course of pneumonia, in his
experience, has not been altered, all the cases end-
ing in resolution. Close inspection without the aid
of physical signs will often make the diagnosis.
The one sign which, more than any other, differ-
entiates pneumonia from appendicitis is rapid
breathing with playing of the alae of the nose. ^This
is absent in acute appendicitis. It has been a constant
observation that cases of appendicitis increased in
number after epidemics of influenza. Lechten-
stern believes the condition a typhlitis rather than
true appendicitis, that exceptional cases of true ap-
pendicitis may occur, and that coincident appendici-
tis simply accompanies an attack of influenza. In
only one of the eight cases observed by Doctor
Behrend was there history of several attacks of ap-
pendicitis, nor can he subscribe to the theory of
typhlitis. Such cases were primarilv appendicitis.
The Nasal Complications of the Nasopharynx
and Their Treatment. — Dr. G. W. Mackenzie
presented his observations on this phase of the
epidemic. He considered that practically all our
knowledge of the anatomy and pathology of sinus
disease dates from the works of Zuckerkandl and
Hajek some years after the last world epidemic of
924
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
influenza (1889- 1890). The contradictory reports
of R. W. Allen, C. H. Benham, Will Walter, as
well as his own, upon the bacteriology of the dis-
ease demonstrated the present day lack of knowl-
edge of the subject.
Septal deflection is one of the most important
predisposing causes of sinus disease. To guard
against the intranasal complications of epidemic in-
fluenza, treatment should be directed to the systemic
condition to secure a complete recovery. There
should be avoidance of local applications to the nose
and throat, for the reason that there is no antiseptic
sufHciently strong to destroy a virulent strain of the
Bacillus influenzae which will not injure the mucous
membrane. One should breathe through the nose
and not through the mouth, and by this is meant
breathing through both sides simultaneously. The
use of alcohol should be avoided. In influenza pa-
tients who died promptly from cerebral complica-
tions, suppuration of one or more of the sinuses has
probably been an important factor. From the
rhinologist's viewpoint an acute sinus disease is
treated conservatively by drainage. Results thus
far observed in the treatment of obstinate suppura-
tions have been better from surgery alone than
from vaccines alone. The subject of the diagnosis
and treatment of accessory sinus disease is iinpor-
tant technically. The science is a rather new one,
our knowledge of which, while considerable, is but
fragmentary compared with that which is promised.
Mortality in Influenza in Pregnant Women. —
Dr. Richard C. Norris stated that the extraordi-
narily high mortality of influenza in pregnant
women is undoubtedly due to the fact that these
women are overwhelmed with toxemia while their
resistance is reduced by the process of pregnancy.
The arrangement of the Preston Retreat has made
it peculiarly free from epidemic influences. There
had been relatively few cases and these were , iso-
lated at once, having abundant room for them. The
cases were at once put in charge of a special nurse
and contact was prevented with the rest of the
house, the food supply being taken to each patient's
room. There had been no deaths. One woman
brought in by the ambulance from another hospital
where there was no room had a pulse of 138-140,
and was cyanotic. She got well and did not mis-
carry. Whether she had pneumonia or not was not
ascertained. Her temperature was 104° ; respira-
tions thirty-two ; pulse 138. Not a sign of pneu-
monic change had been detected. Doctor Norris
questioned whether the respiratory rate was a better
guide to the diagnosis of pneumonia than the rise
of temperature. At the Methodist Hospital the
.story was entirely difl'erent. Within a week there
were ten women brought into the institution with
pneumonia, and of these, nine died. Out of that
entire group there were but three living children. In
private practice, he had seen five influenza cases
unaccompanied by pneumonia. All had recovered ;
three have had living childreij. In consultation
work he had seen manv cases stricken with influenza
and pneumonia, in which he had been asked to
advise concerning induction of labor. Doctor Nor-
ris concluded that if a woman carrying a load of
cither influenza or pneumonia had added to her
carrying capacity the extra load of falling into labor
she was very greatly handicapped and had better be
left absolutely alone. In two earlier instances in
which the cases were borderline cases labor had
been induced and the patients died. Since that time
he had declined to induce labor, and found that
wherever he had heard of it being done it had not
lessened mortality. However, in three cases with
no signs of pneumonia he had thought it necessary
to induce labor in two because of the added toxemia
of pregnancy. In that type of case it appeared to
be the duty of the obstetrician to act for the ad-
vantage of the patient. These women liave re-
covered. In multipar?e, some of which were ex-
posed to the most virulent type of influenza and
others showing slight fever, pregnancy had been
terminated and all made good convalescences and
the children have all lived. This, however, was not
justifiable in priniipara;.
Symptoms and Complications of Influenza. —
Lieutenant Russell S. Boles, M. C, U. S. Army, said
that in cases observed by him the most noticeable
feature was the marked drowsiness with the men
falling into deep slumber. The onset of the infection
was sudden, the incubation period being apparently
from twelve to forty-eight hours. There was a lack
of coryza and sneezing; a very harrassing cough,
however, was observed. The epistaxis present may
have been due to the congestion with coughing.
Fever of ioi°-i05° was nearly always present.
There was severe lumbar backache, attributed to the
intense degree of nephritis which had developed. A
peculiar cyanosis like that from acetanilid was noted.
The abdominal pain confused the condition with
appendicitis. These symptoms were all distinctly
ameliorated, especially the cyanosis, as the disease
progressed. In the 525 cases of infTuenza there
were 168 cases of pneumonia, with fortv-eight
deaths. In five cases there was severe relapse after
sending the boj's back to the training camp. In
these apparently early recoveries emphasis should be
placed on the importance of carefully guarding
them after they are thought to be well. The com-
plication of nephritis was sometimes very severe.
Otitis media was present in some ten or fifteen
cases ; four suppurated. There were many so called
ma,stoiditis cases but none went on to suppuration.
The gastrointestinal complications when severe were
regarded as unfavorably influencing the prognosis.
Pleurisy and empyema were relatively uncommon.
It was felt that immunization with the vaccine,
while not an absolutely sure preventive, had some
value.
Treatment in Influenza. — Dr. Thomas C. Ely
stated that in the recent epidemic he had treated
influenza patients by first cleansing the intestinal
tract with calomel and a saline purge, followed im-
mediately by the active administration of the
alkalies, sodium bicarbonate, potassium citrate and
lime water. Granted that the organisms enter
through the nose and mouth they are quickly trans-
ferred to the alimentary tract. At the outset and
throughout the attack he had given every patient the
three well known alkalies which combat acidosis —
bicarbonate of soda, citrate of potash, and the cal-
cium salts in the form of lime water. To every
patient is administered a teaspoonful of bicarbonate
of soda to a pint of lukewarm water every four
November 23. .9.8 ] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
925
hours by enema. In routine treatment the follow-
ing simple prescription, to spare the overworked
druggists, was given :
Sodii bicarb 5ss ;
Aq. month, pip., Jiv.
Sig. : One teaspoonful every two hours.
The following was alternated with this :
Potass, citr Bss;
Aq. menth. pip , 3iv.
Sig.: One teaspoonful every two hours.
The calcium salts were given in the form of lime
water, one third, and milk two thirds. Some pa-
tients with fulminant attacks of vomiting and ter-
rific headaches could not tolerate the potash salts;
and to such were given only the sodium bicarbonate
mixture every hour, and the soda enemas, as above.
Even in severe cases the soda will relieve the early
pains in twenty- four to forty-eight hours. Neither
aspirin, coal tar series, heart depressants, seruins, or
vaccines were prescribed. The common heart and
respiratory stimulants were employed. Doctor Ely
does not think that all these patients, so desperately
ill, could have recovered in so fatal an epidemic
without the basic treatment by the alkalies on the
acidosis theory. When well tolerated quinine, four
grains, were given morning and evening, quinine
was recommended quite universally, in connection
with the soda salts as a preventive. The following
was in the form of a tablet also given every four
hours during convalescence, and even earlier :
Strychnine gr. 1/40;
Quin. bisulph., gr. ij ;
Takadiastase gr. i.
It is Doctor Ely's belief that early sweating by
hot drinks and the giving of water only during the
first twenty-four hours are beneficial procedures.
Dr. S. SoLis-CoHEN stated that he was convinced
that the use of mixed bacterins is highly scientific,
useful, advisable, and necessary. They prevent the
incidence of influenza and pneumonia ; when they
fail to prevent the incidence they render the attack
much less severe and give greater promise of favor-
able issue. The mixed bacterins seem to give some
protection against the streptococcus, the most deadly
of all the bacteria concerned. We have drugs that
will protect against the pneumonia bacillus, but
none that will protect against the streptococcus. He
would hesitate to give them in the presence of in-
fluenza and streptococcic toxemia at a late stage but
when they can be given early he stood firmly upon
their efficacy as upon the use of mercury in syphilis
or of quinine in malaria. Regarding the question,
why so many pregnant women die, Doctor Solis-
Cohen agreed with Doctor Ely that early alkaliniza-
tion of the blood was an imperative duty.
Dr. William Egbert Robertson said that he
had been impressed with the small number of col-
ored people who have been afifected in this epidemic,
and thinks it is the general experience that this race
has been rather exempt. His results in the early
intravenous administration of bacterins, particularly
the sensitized bacterins, in the present epidemic,
have been little short of brilliant. He was surprised
to find that food had been withheld from patients
with temperature, for he felt that if a patient was well
fed his opportunities for recovery were enhanced.
AMERICAN ASSOCIATION OF OBSTETRI-
CIANS AND GYNECOLOGISTS.
Thirty-first Annual Meeting, Held in Detroit, Mich-
igan. September i6, ly, and iS, i^/i'l.
The President, Dr. Albert Goldspohn, of Chicago, in
the Chair.
The Benefits of Stab Wound Drainage in Pel-
vic Infections. — D. H. Wellington Yates, of
Detroit, drew the following conclusions: i. It
should be our constant endeavor to close without
drainage in so far as safety would permit. 2. Drain-
age materials should be removed, earlier than the
general practice now obtaining. 3. The great ma-
jority of all infected areas in the pelvis were suit-
able for culdesac or stab wound drainage. 4. The
abdominal incision should be left free to close by
primary union. 5. Stab wounds were securely and
quickly united after the drainage was withdrawn,
with no fear of subsequent hernia. 6. The mus-
culature of the areas usually chosen for stab wound
drainage was our greatest asset to a speedy closure
of the drainage opening.
Dr. Gordon K. Dickinson, of Jersey City, N. J.,
stated that drainage was a misnomer. We did not
speak accurately. He did not chink that gauze
acted as a drain when it was stuck in a wound. It
was a local irritant and because of that property it
walled off to a certain extent the local processes and
made things fairly safe. We did have wonderful
drainage in the abdomen, however. Some ten years
ago he made what he thought was the first research
study of the literature and of his own work regard-
ing the value of the omentum in abdominal drain-
age, and he came to the conclusion then thatjhe
omentum, properly applied, would drain more in
ten minutes than any gauze would take out in a day.
Dr. J. Henry Carstens, of Detroit, said that the
late Dr. Joseph Price was a firm advocate of drain-
age. Some fifteen years ago the association held a
meeting in Pittsburgh, and he and a number of
others performed operations at the hospitals there.
He had the worst kind of a case to deal with, with
extensive adhesions and pus. Doctor Price was
there and talked about drainage, and the speaker
said we could get along without drainage in many
instances. He operated in this case, cleaned out
the abdomen thoroughly without washing it, and
closed the incision without drainage. Other men
who at that time operated upon patients and drained
lost their patients, but luckily for the speaker his
patient recovered. Since then he had resorted to
drainage very little.
Dr. John W. Keefe, of Providence, R. I., said
that drainage was a subject that we all had to con-
tend with froin time to time. Hard rubber drain-
age tubes in the abdomen were largely discarded
today. Recently a report from a certain canton-
ment came to Washington, of a case of appendicitis
with a fecal fistula, and the officer to whom this
report was sent wrote to the cantonment to know
why the patient had a fecal fistula. When it was
found that the patient had been drained with a
drainage tube, word was sent back that that officer
would be court martialed for placing a rubber drain-
age tube in the belly follov;ing an operation for
926
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES
[New York
Meuicai. Journal.
appendicitis. Most surgeons felt that a hard rub-
ber drainage tube should not be put next to the
intestine. There was no question but what an in-
cision into Douglas's poucli for drainage was a de-
sirable thing in a few cases. In looking back over
the literature of gynecology one could see how many
patients died from placing drainage tubes in the
pelvis, and nurses withdrawing the serum that
formed every half hour, or sometimes every three
hours. As soon as surgeons began to close the belly
and not interfere with nature these patients recov-
ered.
Dr. Charles L. Bonifielu, of CiAcinnati, stated
that just as soon as surgeons began to keep drain-
age tubes' out of the abdomen abdominal surgery
progressed and better results were obtained. While
this was partly true, it was not the whole truth.
One reason why surgeons secured better results
now was because they were improving in their
technic and drainage became less necessary.
Dr. Hugo O. Panzer, of Indianapolis, Ind., con-
curred heartily in what Doctor Bonifiield had
said. Hovv^ever, there were cases in which wc
could not get along without some form of drain-
age. There were cases in v/hich there was an ac-
cumulation of pus indicating that the peritoneum
was unable to cope with it at that time, and hence
some form of drainage was necessary.
Doctor Yates, in closing, stated that drainage had
been made use of altogether too often in the past,
and drainage tubes should be used in the future
much less frequently than they had been heretofore.
However, there were certain instances in which it
was essential to drain, and in still others it seemed
best to drain from above. He suggested that the
primary incision should be left to itself and to heal
without discomfort.
Pathological Conditions of the Pelvic Viscera,
the Result of Induced Abortions Causing Ster-
ilization, Disclosed by Abdominal Section. —Dr.
Francis Reder, of St. Louis, Missouri, stated that
this paper was prompted by eight cases of steriliza-
tion, the result of induced abortions. All the women
were married, in good health and none over thirty-
five years of age. In each instance the abortion was
induced soon after the first period had been missed,
usually the second or third week. It was of in-
terest to note the number of abortions induced in
these women.
Three women were relieved five times in two years.
Two women were relieved six times in two and one half
years.
One woman was relieved nine times in three years.
One woman M'as relieved eleven times in three years.
One woman was relieved fourteen times in five years.
In later years when these women desired to have
children they fotmd themselves sterile. They cheer-
fully submitted to treatments which buoyed them
with hopes from month to month, only to find that
at the end of their course of treatment they were
just as sterile as they were before they consulted
the gynecologist. The treatment was generally of
a routine nature and consisted of dilatations, cur-
ettements, the introduction of intrauterine wire pes-
saries, tampons, and the so called uterine tonics.
Most of these patients were und^er treatment for
many months. It must be said in due justice to such
treatments that they we^e often successful in reliev-
ing certain forms of sterilization, especially when
a chronic endometritis or a retroflexion was the
active agent responsible for the sterile state. How-
ever, when a patient had been under the care of a
conscientious gynecologist for two or three years,
and the desired result had not been achieved, a con-
tinuance of these measures was hardly warranted.
It must then be inferred that other conditions were
responsible for the sterility, and their presence, if
possible, should be determined. In the eight cases
cited the true lesion was not diagnosed before op-
eration. For this the reasons seemed cogent.
The physical examination in cases of this charac-
ter revealed nothing definite relative to an intra-
pelvic condition which might be present. It was
true a retroflexed uterus could be readily made out ;
a prolapsed ovary, always painftil to the touch, could
be recognized ; a small ovarian cyst might be pal-
pated, and a chronically diseased appendix diag-
nosed, but as to the condition of the tubes, the char-
acter of the4esion usually remained in doubt. There
was only one diagnostic way by which the true nature
of the intrapelvic condition could be disclosed, and
that was by abdominal section. It was not often
that a woman who had become sterilized through
induced abortions was desirous of having her con-
dition cleared up in this manner ; however, there
were some women, anxious to have children, who
were prone to accept any advice which they believed
would be to their advantage. During the last six
years Doctor Reder said that he had operated upon
eight women in the hope of relieving their sterility.
The operation, an exploratory abdominal section,
was in each case performed after these women had
been subjected to therapeutic and minor gynecolog-
ical measures for a time which seemed sufficiently
long to give convincing evidence that without any
further intervention the sterile state bade fair to
remain permanent. It could be assumed from a
limited experience that no woman sterilized through
the induction of abortions should be subjected to a
major operation unless her condition had for at
least two years received careful study with the ap-
plication of such minor gynecological measures as
were indicated.
Summing up the operative findings in these
cases it was revealed that in all, except one, the
ostium abdominale of both tubes was closed. This
was the positive factor in rendering the women
sterile. In five of the cases there was a bilateral
hydrosalpinx ; in two there was a unilateral hydro-
salpinx. The opposite tube in those cases was col-
lapsed and presented a sacculated appearance, the
lumen giving evidence of a number of strictures.
In one case no hydrops of the dviducts was pres-
ent ; they were sacculated, however, and the uterine
ends were stenosed. In each case the tubes were
dislocated into Douglas's pouch and usually bound
down with firm bands of adhesions and false mem-
branes. On the left side the tttbe was buried under
the sigmoid, while the tube on the right side was
attached by side adhesions to the cecum and ap-
pendix. Examination of the ovaries revealed that
pathological- processes had invaded these organs.
No ovary was found in its normal position ; all were
more or less prolapsed and adherent to the tubes.
November 23, 1918.]
BOOK REVIEWS.
927
In several instances there was a matting together
of ovary, tube, uterus, and rectum. Some of the
ovaries were twice their normal size and all gave
evidence of cystic disease, i. e., a cystic degenerative
process. As a result of these operative measures,
two of the women conceived and went to full term
within twenty months after the operation. These
women had a bilateral hydrosalpinx and required
resection of both ovaries. They were the youngest
of the series and were respectively twenty-six and
thirty years of age. The remaining six women,
operated upon within the last four years, were still
in a state of sterilization.
Caesarean Section. — Dr. Abraham J. Rongy, of
New York, said that his experience with this op-
eration consisted of 109 cases, in tight of which
the patients died. Seventy-four patients upon whom
eighty-two sections were performed were first seen
in consultation with the family physician. All of these
patients had been in labor from a few hours to twen-
ty-four hours or longer. The remaining twenty-
seven cases were in his own practice, and the opera-
tion was pefrformed on twenty-two pjitients. That he
had always been very conservative in choosing the
abdominal route for the delivery of a living child,
could be judged by the fact that during a period
of twelve years he saw approximately 1,500 women
in labor, in consultation with other physicians, all
of them presenting some form of dystocia which
made the attending physician anxious, and that out
of this great number he resorted to Caesarean sec-
tion only eighty-two times. Caesarean section had
no place in eclampsia when Nature had already
commenced to do her work, that is, when labor had
already set in. In such cases large doses of mor-
phine were the best form of treatment. He still
held that Caesarean section had no place in the pre-
eclamptic stage. In such cases one always had time
to induce labor, and the results were usually very
satisfactory. The indications and contraindications
for Caesarean section must be carefully considered.
Only one who was well trained in obstetrics had a
right to decide upon this operation. A general sur-
geon had not the necessary knowledge to be com-
petent to pass judgment on such an important ques-
tion— important not only to the woman and to her
future pregnancies, but also to the nation. If Caes-
arean section was to be performed indiscriminately,
there was bound to be a decrease in the birth rate,
for the average woman would not submit too many
times to this operation. For this and many other
reasons, Caesarean section should be left entirely to
the well trained obstetrician.
Caesarean Section under Local Anesthesia. —
Dr. William Mortimer Brown, of Rochester,
N. Y., stated that in doing this operation under a
local anesthetic there were two important elements
that were necessary for success. The first was to
get the confidence and cooperation of the patient
and the other was a thorough infiltration of the
operative area and an exquisite delicacy of manipu-
lation. No matter how careful the preparation
might be, one could not hope to block all the un-
derlying nerves, and it was very easy to pass from
easily borne discomfort to unbearable pain. It was
not difficult to anesthetize the abdominal wall so
completely that the peritoneum might be opened
without appreciable pain. The fundus was without
sensation and could be incised readily without the
knowledge of the patient. The pain was attendant
on the dragging or manipulation of the organs,
either uterus or intestines. The ideal operation
must be done without soiling the peritoneum, with-
out lifting and pulling on the uterus. With these
requisites in mind, Doctor Brown had found a
method, which he had employed for several years,
of peculiar advantage. It was his custom, after the
abdomen was opened and the uterine incision partly
made, to fasten the uterine incision out to the ab-
dominal incision with four or five ordinary towel
clamps. These clamps held the uterus to the ab-
dominal wall and prevented the blood or amniotic
fluid from gettit^into the peritonec! cavity. They
were left in place until the uterine wound was
largely closed, and did away with most of the trac-
tion on the uterus, rendering it unnecessary to pack
gauze into the abdomen. Local instead of general
anesthesia could not be a routine procedure in this
operation any more than it could be in any other
field of major surgery, but a careful study of all
the conditions surrounding each case would some-
times convince us that certain patients were very
much better operated upon in this way.
{To be continued.)
^
Book Reviews.
[We publish full lists of hooks received, but we acknowl-
edge no obligation to review them all. Nevertheless, set
far as space permits, we review those in which we think
our readers are likely to he interested.]
"A Manual of Physiology. With Practical Exercises. By
G N. Stewart, M.A., D. Sc., M. D. Edin.. D. P.H.
Camb. ; Professor of Experimental Medicine in Western
Reserve University, Clinical Physiologist to Lakeside
Hospital, Cleveland ; Formerly Professor of Physiology
in the University of Chicago ; Professor of Physiology
in. the Western Reserve University; George Henry
Lewes Student ; Examiner in Physiology in the Univer-
sity of Aberdeen ; Senior Demonstrator of Physiology
in the Owens College, Victorial University, etc. With
Colored Plate and Four Hundred and Ninety-two Other
Illustrations. Eighth Edition, University Series. New
York: William Wood & Co., 1918. Pp. xxiv-1150.
(Price, $5-00.)
Physiology stands, no doubt, as one of the most
cardinal of the branches of necessary preparation
for the student and the practitioner of medicine.
The functions of the body, while not more impor-
tant than the structure, ought to take precedence in
any inquiry which deals with the healing art. While
it is true that the functions and structures are neces-
sarily correlated, a didactic attitude toward medi-
cine clearly demonstrates a marked increase in the
interest in the functions as represented in various
types of conduct as contrasted with that shown in
the structure and its alterations. What the machine
does, therefore, is always rather more interesting
than what the machine is. When these studies
are taught but are not correlated, great difficulty
arises in the mind of the student and the interpre-
tative inteUigent processes are frustrated. The vol-
ume under consideration is an eighth edition. Lit-
928
BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
tie, therefore, need be said about it further than that
it has stood the test of many years of use — twenty-
three in fact — and still retains its value. Hardly
much more need be said of any book that can boast
of so many years of service. One might expect
that a book that has been published for so long a
period had fallen behind in the march of active prog-
ress which has been so enormous. Interesting to re-
late, however, it has not. The author has been
keenly alive to the many teachings of the time and
has woven them into the structure of his work with
considerable skill, showing the essentially valid
foundation upon which he originally built. We can
commend this book most heartily as a sound, con-
cise, and extremely valuable volume.
The Medical Clinics of North America. Chicago Number.
March, IQ18. Pp. 240.
This mmiber of the Medical Clinics maintains the
high standard of quality which has characterized
these volumes in the past and embraces subjects of
a wnde range of interest. It would be impossible
in fairness to the other authors to select one, two,
or more of the articles for special comment, as well
as a task quite beyond our powers. The truth is
that the articles are so different that they cannot be
compared, for each will make its appeal to a differ-
ent man, depending upon his particular interests.
The papers include discussions of aortic regurgita-
tion, aortitis and aneurysm of syphilitic origin, the
diagnosis of cardiac lesions, juvenile diabetes in
twins, the Karell treatment, treatment of angina
pectoris ; radium treatment of leukemia ; epidemic
respiratory infection ; Vasquez's disease ; abdominal
lesions in the right upper quadrant ; aortic syphilis ;
reflex gastric disturbances ; tuberculin skin reac-
tions in children; nephritis, splenomegaly and
hepatic cirrhosis ; insomnia ; hysteria ; asthma in
children ; the rontgen examination of the appendix,
and pyeHtis in children.
La Gangrene gazeuse. Bacteriologie, reproduction experi-
nientale, serotherapie. Par M. Weinberg, chef de labo-
ratoire, et P. Seguin, boursier, a I'lnstitut Pasteur. Avec
quarante-cinq fisrures, huit planches en noir, et huit
planches en couleurs. Paris: Masson & Cie, IQ18. Pp.
viii-.i8i.
This book presents a very full and detailed report
of a study of gaseous gangrene. It treats of all the
phases in which the subject would present itself to
the bacteriologist, whose chief interest is the prac-
tical desire to come to the aid of the surgeon in
combating this particular form of complication to
wounds at the front. The study was tmdertaken at
the urgency of the British medical staff after the
battle of the Marne. So well have the authors of
the work responded to that request for a thorough
study of the infection and its treatment that their
work has not only attained its immediate end, as far
as possible, but has gone far beyond this in its
scope of investigation. It stands therefore as a re-
sume of preceding studies, a compendium of bac-
teriological research detailed in its report of method
and results, and also well illustrated in its exposi-
tion of experiments as well as graphically in freely
interspersed plates.
Its scientific interest, like its practical surgical
value, can be only briefly indicated but its fullness
and clearness will well repay more thorough special-
ized study. The authors conclude that gaseous gan-
grene is due to a number of infectious agents. The
number, and variety of these agents give a varied
pathology and also render the question of an effec-
tive vaccine therapy a complicated one. Both the
variety of germs which cause the gaseous gangrene
and the presence of other infectious agents at the
seat of the wound indicate that an autovaccine
would be most effective prepared from the patho-
logical sera present and rendered innocuous by io-
dide. Vaccine therapy has been used for curative
rather than preventive purposes. The latter would
be especially difficult of accomplishment, owing to
the variety of the infectious agents and their un-
doubted presence in the dirt which, in the trenches,
affords such a fruitful harborage for them. The
curative power is limited because the toxemia de-
velops very rapidly and soon attacks the nervous
centres. Yet a notable reduction in mortality has
been the result of combining a vigorous serotherapy
with surgical treatment. Indications are also that
a mixed antigangreous serotherapy will be worked
out so that wounded soldiers will be greatly bene-
fited, and the attack upon this form of complication
will meet with greater success. Both the scientific
knowledge of this extensive and mischievous form
of infectious complication and the means of com-
bating it have doubtless been greatly advanced by
this study.
<j£}
Births, Marriages, and Deaths.
Married.
Parke-Woods. — In Philadelphia, Pa., on Tuesday, No-
vember I2th, Dr. William E. Parke and Miss Grace Woods.
Wveth- Chalifoux. — In New York, on Friday, Novem-
ber 15th, Dr. John Ailan Wyeth and Miss Margerite
Chalifoux.
Died.
Augur. — Tn Binsrhamton, N. Y., on Thursday, October
31st, Dr. Amelia M. Augur, of Hartwick, N. Y.
Babcock, — In Buffalo, N. Y., on Thursday, November
7th, Dr. Cyrus W. Babcock, aged eighty-one years. ,
Bagxall. — In Norfolk, Va., on Friday, November ist,
Dr. Richard Daingerfield Bagnall, aged eighty years.
Chapman. — In Brockport N. Y., on Friday, October
25th, T)T. Edward B. Chapman, aged thirty-six years.
CoNLEY. — In Naples, N. Y., on Friday, November 8th,
Dr. David Harrison Conley, aged seventy-four years.
Cox. — In Penn Yan, N. Y., on Thursday, October 24th,
Dr. Joseph T. Cox. aged fifty-two years.
Frttweli,. — In San Jose, Cal.. on Friday, November ist.
Dr. William J. Fretwell, aged fifty years.
Hamblen. — In Bedford, Mass., on Sunday, November
lOth, Dr. Edward E. Hamblen, aged fifty-fonr years.
Keller. — In Spokane, Wash., on Sunday, November ,3d.
Dr. Sebastian Keller, aged eighty-nine years.
LoCKWOOD. — In Coscom, Conn., on Wednesday, Novepi-
ber 13th, Dr. Frederick W. C. Lockwood, aged sixty-tjvo
years.
LooMis. — In Lockport, N. Y. on Wednesday, October
30th, Dr. Warren H. Loomis, aged sixty-three years.
Martin. — In Binghamton, N. Y., on Monday, October
28th, Dr. Joseph S. Martin, aged thirty-three years.
Meltzer. — In New York, N. Y.. on Friday, November
15th, Dr. John S. Meltzer. aged thirty years.
Oswald. — Tn Buffalo, N. Y., on Friday, November 8th,
Dr. Albert F. Oswald, aged thirty-five years.
Savage. — In New York, N. Y., on Tuesday, November
i^th. Dr. Thomas Rutherford Savage, aged sixty-six years.
Stannard. — In Troy, N. Y., on Tuesday, October 2Qth,
Dr. Frank T. Stannard, aged fifty-two years.
Tefft.— In Utica, N Y., on Thursday, October 31st,
Di. Charles Byron Teflft, aged eighty-one years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII. No 22.
NEW YORK, SATURDAY, NOVEMBER 30, 1918.
Whole No. 2087
Original Communications
A NEW METHOD OF MAKING THE GON-
ORRHEAL COMPLEMENT FIXATION
TEST.
With Remarks on the Bacteriology of the
Gonococcus — A Preliminary Report.
By R. B. H. Gradwohl, M. D.,
St. Louis.
Director of the Gradwohl Biological Laboratories, and the Pasteur
Institute.
Before the discussion of the question of diagnosis
of gonorrhea by means of blood tests, a few words
should be said concerning the gonococcus and its
identification by means of direct examination of
purulent material, its staining qualities, and its
cultural behavior.
It might be well to bear in mind that for a long
time gonorrhea and syphilis were thought to be the
same disease, this idea having prevailed from the
time of their earliest description until the epoch
making work of the great French physician Ricord,
in 1832, proved the duality of the two diseases.
Fournier (i), Langlebert (2), and Profeta (3) fur-
ther corroborated Ricord's contention, although Di-
day(4) and Zeissl (5) contended against it for some
years after the first pronouncement. Ricord failed
to determine the causative factor in gonorrhea,
even though he separated it as a disease from
syphilis. Following him, various workers attempted
to prove the real cause of the disease. For instance,
Donne (6) found a so called trichomonas, Thiry
(7) a "virus granuleux," Jousseaume (8) an alga,
which he called "genitalia," and Salisbury and
Hallier a fungus. It remained for A. Neisser (9),
in 1879, to describe the real cause of this disease,
namely, the gonococcus. It might be interesting to
note that in Neisser's original communication he re-
ported the finding of this new form of micrococcus
in thirty-five cases of urethritis in the male, nine
cases of vaginitis, two cases of gonorrheal oph-
thalmia in adults and seven in new born babies.
Bokai (10), Aufrecht. Weiss, and others rapidly
confirmed Neisser's observations. Bumm (11), in
1885, first secured a pure culture of the gonococcus
on coagulated human blood serum, and from these
cultures reproduced gonorrhea in the male by plac-
ing pure cultures on the urethral mucosa of healthy
subjects. Thus the entire chain of specificity proof
was comnleted.
MORPHOLOGY AND IDENTIFICATION OF THE
GONOCOCCli.S BY DACTERIOLOGICAL METHODS.
The gonococcus is a biscuit shaped diplococcus
resembling a cofifee bean in shape. It is formed as
a result of a prolongation of the single coccus into
a figure-of-eight formation, then a splitting in the
middle of the figure, resulting in the appearance of
two distinct cocci. From pole to pole Bumm de-
scribed gonococci as measuring 1.6 microns each,
with a width in the middle of 0.8 micron. Their
size is dependent on age and on length of staining,
light stained cocci appearing smaller than those
more heavily tinted. They are surprisingly similar
in appearance to the meningococcus of Weichsel-
baum. Neisser's original description of the gono-
coccus devoted so much space to the intracellular
disposition of this micrococcus that one involun-
tarily thinks of th; organism only as an intracellu-
larly located baccerium, just as we think of the
meningococcus just alluded to. The diagnostic
value of the finding of the diplococcus of Neisser
within the cells has some value but this is not an
infallible test, as they often appear extracellularly.
From all the evidence we have in the literature, and
from our personal experience, we believe that in
the very acute primary stage of gonorrheal ure-
thritis we may find in the first mucous discharge,
before the purulent character of the discharge has
been established, practically no gonococci within the
cells ; in fact, in this stage we find only epithelial
cells. Later on when pus appears, we find many
cells within which are plainly seen the typical biscuit
shaped organisms. It seems fairly well established
that the intracellular disposition of these cocci is a
phenomenon of phagocytosis.
Scholtz (12) considers it so for the following
reasons :
1 . Fresh pus mixed with ascites bouillon, phi?
a pure culture of the gonococcus, shows the
gonococci entering the cells.
2. Inoculation of dead or living gonococci
into the abdominal cavity of a guineapig is fol-
lowed by phagocytosis.
3. Foreign bodies, taken up by the phago-
cytosis activity of leucocytes, may be demon-
strated by vital staining of these cells, as shown
by Plato (13).
As for the staining characteristics of the gonococ-
cus, we know that they are easily stained by the ordi-
nary methods. Much diagnostic importance has
Copyright, 1918, by A. R. Elliott Publishing Company.
930
GRADWOHL: GONORRHEAL COMPLEMENT FIXATION TEST.
[New York
Medical Journal.
been attached to the so called gram method. Orig-
inally, Roux (14), Allen (15), Wendt (16), Stein-
schneider and Galewski (17), Heymann (18),
Hogge (19), Krai (20), Keifer (21), Hijman Van
der Bergh (22), and Scholtz (23), considered this
.<:taining method of great value in their identifying
studies; but Bumm (24), Furbinger (25), Totuon
(26), and others spoke against it. It is to be noted
that the gram method of identification is reliable
only to a limited extent under certain conditions,
and then only if the method is very carefully car-
ried out in respect to decolorization and washing
out. Unless absolute alcohol is used, the method
gives poor results. It is our practice, too, to use the
carbol-gentian solution instead of the older anilin-
oil-gentian violet method. This carbcl-gentian solu-
tion of Czaplewsky (27) is made by mixing ten
parts of saturated alcoholic solution of gentian
violet with ninety parts of 2.5 per cent, solution of
phenol (carbolic acid). This makes a permanent
solution. It is used as follows :
I. Stain one minute. 2. Pour off. 3. Flood with Lucrol's
solution one minute. 4. Pour off. 5. Repeatedly flood with
absolute alcohol. 6. Wash with water. 7. Counterstain
with watery safranin one minute.
CULTIVATION OF THE GONOCOCCUS.
The original culture medium on which Bumm
(24) first isolated the gonococcus was coagulated
human blood serum, obtained from placental blood.
It may readily be obtained by venipuncture. Other
mediums have since been successfully used, notably
Finger's urine ; Turro's acid gelatin ; Wertherim'.^
agar, a mixture of blood serum and glycerin agar ;
Krai's agar, which is calf blood and agar ; Heiman's
agar, which is pleuritic fluid and agar ; Wildholz's
agar, which is agar plus ovarian cystic fluid; Pfeif-
fer's blood agar ; Bezangon and GrifYon's blood
agar ; Nasstikoff's agar ; which is yolk of an egg and
agar ; Leipschutz's agar, which is Merck's powdered
egg albumen and agar, and Steinschneider's agar,
which is coagulated urine and agar. We have been
very successful in cultivating gonococci on a mix-
ture of egg and agar plus human bood serum on
plates. We make successive streaks across the
plates, and in this way secure pure cultures. The
growth is then perpetuated in tubes of the same
material. We have found no difficulty in securing
cultures from fresh cases of gonorrheal urethritis
in the male, more difficulty in subacute and chronic
cases, and the greatest difficulty in cultures from the
vagina and cervix, owing to heavy bacterial flora
contaminating these parts.
As a diagnostic measure, cultivation of the gono-
coccus is not practical, for the reason that in those
situations in which we most desire light, namely, in
the chronic cases in the male and the subacute and
chronic case in the female, other organisms are
likely to overgrow the gonoccoccus. Pure cultures
may be obtained easily from the very acute case in
the male ; in fact, this is a practical, clinical, diag-
nostic measure, if such is needed. It is not in this
class of cases, however, that any corroborative diag-
nostic measure ordinarily is necessary. The chronic
cases with "occult" manifestations, with prostatitis,
seminal vesiculitis, etc., also the cases of women
with salpingitis, metritis, pyosalpinx, etc., are dif-
ficult to' culture for diagnostic purposes. The
methods of provocation of discharge by means of
the injection of chemical irritants into the urethral
canal are only of relative usefulness.
Again, we must remember that there are pseudo-
gonococcic fiindings, which have taxed the expert-
ness of the best talent to dififerentiate from the true
gonococcus. For instance, four times in eighty-six
cases, or 4.65 per cent., Steinschneider and Galew-
ski (17) found gram negative gonococcilike diplo-
cocci in the male urethra, which were extracellularly
situated. Twice in sixty-three cases, von Hoffman
(28) found gram negative diplococci resembling
gonococci, once a gram negative coccus in chains,
and three times a gram negative staphylococcus. In
twenty-four healthy male urethras Pfeiffer (29)
found on one occasion a gram negative diplococcus.
In twelve cases, Baermann (30) found in the cervix
a diplococcus which strongly resembled the gono-
coccus.
DIFFERENTIATION OF GONOCOCCUS FROM
MENINGOCOCCUS.
The difficulty of dififerentiating the meningococcus
from the gonococcus has already been noted. The
possibility of genital lesions caused by the meningo-
coccus must not be lost sight of. Schottmueller
(31) reported a case of epididymitis as a complica-
tion of cerebrospinal fever. Reutter (32) reported
a case of periorchitis purulenta as a complication
of cerebrospinal fever. The meningococcus was
isolated from the spinal fluid and from the purulent
discharge from the testicle. Pick (33) reported a
case of seminal vesiculitis due to the meningococcus
in the course of leptomeningitis. Owing to the
biologic similarity of these two organisms, mani-
festly it would be difficult to separat>; a case of cere-
brospinal meningitis with a complication of menin-
gococcus. urethritis from a case of cerebrospinal
meningitis with an accompanying gonorrhea.
Another difficulty in diagnosticating the gonococcus
is seen in the case of extragenital mucous membrane
infections, notably purulent conjunctivitis, in which
gram negative diplococci, not gonococci, have been
found by Abelsdorf and Neumann (34), Kruken-
burg (35), Urbahn (36), Axenfeld (37), Morax
(38), and others. An organism that very closely
resembles the gonococcus is the Micrococcus catar-
rhalis, and, in fact, this organism is difficult to dif-
ferentiate from the meningococcus, a fact not to be
lost sight of in our present attempts to classify
meningitis carriers by nasal cultures.
Close and prolonged study of cultures of these
three organisms will help to dififerentiate them. The
colony of the meningococcus has a diameter of from
two to three millimetres. The gonococcus measures
from one to 1.5 millimetres. The meningococcus
under low power has no scalloped edge, while the
gonococcus is always scalloped. The gonococcus
has an elevated centre, the meningococcus never.
Both show the same light yellow or yellow brown
colorations. Gonococci ferment glucose only ;
meningococci ferment maltose and gluco.se. Cul-
tures of the Micrococcus catarrhalis show small,
white, irregularly rounded colonies. They grow
well on all mediums, and do not ferment carbohy-
drates.
November 30, .918.] GKADIVOHL: GONORRHEAL COMPLEMENT FIXATION TEST.
931
With the knowledge of the difticulty in practical
work of quickly differentiating gonococci from non-
specific infections, it is not at all surprising to know
that attempts were made very early to apply comple-
ment fixation test for this purpose. Bruck (39.)
first pointed out the presence of the gonococcic anti-
body in the circulating blood in 1906, but Mueller
and Oppenheim (40) in the same year, first applied
the method of complement fixation to the blood in
a case of gonorrheal arthritis. Bruck (41) later
tried the test in two cases of gonorrheal disease of
the adnexa and one case of recurrent iridocyclitis.
Bruck could not find the complement binding sub-
stances at that time in the blood of uncomplicated
gonorrheics. Meakins (42) in 1907, confirmed this
work. Watabiki (43) carried out considerable ex-
perimental works in rabbit.s, proving the same phe-
nomenon. Nancioni (44) tested thirty-three cases,
obtaining positive reactions in eight of them.
Dembska (45) in 100 cases of adnexa disease found
the reaction positive in all cases of over two weeks'
duration. Teague and Torrey (46), in this country,
carried the work further. Possibly the greatest
impetus was given to this line of investigation by the
publication of Schwartz and McNeil (47), in 191 1,
in which they advocated with good results the use
of an antigen made from a number of stains of the
gonoccoccus.
At the 1012 meeting of the American Urological
Association, the writer reported (48) the results of
complement fixation in fifty selected cases, using the
technic advocated by Schwartz and McNeil. The
conclusions from this limited experience were as
follows : That this is a specific test ; that it is not
present in anterior urethritis ; that the test is valu-
able when it is impossible to find the gonococcus by
microscopic and cultural methods ; that a blood
which is first positive and then becomes negative
probably means a serologic as well as a clinical cure ;
that the test is very useful in the female, particularly
in forensic cases ; and finally it is particularly valu-
able to the operating surgeon in differentiating be-
tween a gonorrheal and nongonorrheal pus collec-
tion in the adnexa. Gardner and Clowes (49),
reporting at the snme meeting, came to somewhat
similar conclusions regarding the male cases, but
they expressed the belief that in certain severe cases
the reaction may persist for some time after a cure
has been affected. Since the time of this publica-
tion, we have examined a number of blood samples
for complement fixation, using the methods already
noted, with what might be termed fairly good suc-
cess. From time to time, we have failed to obtain
positive results in cases that were unquestionably
gonorrheal, and that, too, with complications. For
this reason, we have struck out to get results with
new methods. In 1914, we (50) reported our re-
sults with complement fixation in syphilis, utilizing
the ideas of Hecht and Weinberg (51), with a
modification that has since been called the Hecht-
Gradwohl method. This was based on an experi-
ence with 1,000 cases. In 1916, we reported (52)
results with the new method in comparison with
the straight Wassermann technic on 5.000 cases, and
again (53) in 1917, on 10,000 tests. We wish to
be understood now as basing our statements in
reference to complement fixation in syphilis with the
Wassermann and Hecht-Gradwohl tests on a study
of t6,ooo Ijlood samples, exclusive of the 165 gonor-
rheal blood samples which are now imder discussion.
Having shown to our own satisfaction, and that of
many others, such as Ileidingsfeld (54), Louis
Schmidt, Wolbarsf, Gruskin (55) and Kolmer (56)
that by the use of our method, comprising the com-
bined technic of Hecht and Weinberg and Grad-
wohl. that we were able to obtain between twenty
and thirty per cent, more positive reactions than
could be obtained with, the classical Wassermann
test, it occurred to us that the same method might
well be applied to the gonorrheal complement fixa-
tion test. There was apparently just^as much prac-
tical necessity for departing from the regulation
gonorrheal complement fixation test as advocated
by Schwartz and McNeil, as there was in departing
from the Wassermann technic in syphilis. The
necessity arose from the fact that many complicated
gonorrheal subjects gave negative results with the
.Schwartz-McNeil technic, clearly indicating flaws in
technic. We began the work on male blood speci-
mens, and quickly obtained some very remarkable
results. The work was then continued on female
blood specimens, obtained mainly from patients
from the wards of the St. Louis City Hospital.
THE NEW TECHNIC.
Before we discuss these results, the new technic
might well be described. We might add here that
the technic in the main agrees in all particulars with
that described by us in connection with the comple-
ment fixation test for syphilis, except in the use of
an antigen derived from culture of the gonococcus.
It is as follows : In a rack should be placed fourteen
small test tubes. The first ten of these tubes are
used to determine the hemolytic index of the sus-
pected blood. By this we mean the exact amount
of hemolytic amboceptor present in the given blood
serum. The last four tubes are used in the actual
test. One c. c. of fresh unheated patient's blood
serum should be added to each of the first ten tubes.
Then decreasing amounts of physiological sodium
chloride solution siiould be added to these ttibes,
beginning with one c. c, then 0.9, 0.8, 0.7, 0.6, 0.5,
0.4, 0.3, 0.2, 0.1 c. c. to the succeeding nine tubes.
Next there should be added increasing amounts of
fresh five per cent, suspension of sheep's blood,
starting with o.i c. c, and ending with one c. c. The
rack should be placed in the water bath for one half
hour. The tube which last shows complete hemo-
lysis constitutes the "hemolytic index." If it is in
Tube 4, the index is 4, because this tube had re-
ceived 0.4 of sheep corpuscles. Therefore, we have
obtained an idea as to how much sheep's blood is to
be added to the last four tubes. The first three
tubes — II, 12, and 13 — constitute the tubes for the
actual test, while the last tube in the rack — 14 —
serves as the serum control tube. Tubes 11, 12, and
13 therefore receive the patient's serum, the proper
amount of sheep's corpuscles, dependent on hemo-
lytic index, and rising strengths of antigen, but no
complement and no amboceptor. Ttibe 14 receives
only sheep corpuscles, but no antigen.
In the new technic for gonorrheal complement
932
GRADWOHL: GONORRHEAL COMPLEMENT FIXATION TEST.
[New York
Medical Journal.
fixation test, we use in Tube ii o.i c. c. of a diluted
antigen determined by titration (usually a dilution
of I to 6 is correct), 0.15 c. c. anti,!:^en to Tube 12,
0.2 c. c. to Tube 13, and none to Tube 14. In order
to equalize the volume of fluid in all these tubes, we
add 0.2 c. c. normal saline to Tube 11, 0.15 c. c. to
Tube 12, 0.1 c. c. to Tube 13, and 0.3 to Tube 14.
The tubes are then agitated and placed in the water
bath for half an hour. The last four tubes are
filled at the time we make the addition to the first
ten, and are left with them in the water bath for
one half hour for fixation of complement. The
rack is then taken out and the hemolytic index
computed. If the index is low, say between i and
4, we add o.i C. c. of sheep's blood to the last four
tubes. If the index is between 5 and 7, we add 0.15
c. c. of sheep's blood to the last four tubes. If it is
between 8 and 10, we add 0.2 c. c. If the index is
more than 10, we rack up ten more tubes and repeat
the titration of the natural complement and ambo-
ceptor. Then we estimate that. If the index is be-
tween II and 15, we use 0.25 c. c. ; if between 15
and 18, we use 0.3 c. c. : and if between 18 and 20,
we use 0.35 CO. If the patient's serum has an
index of only i, we regard the reaction as of doubt-
ful value. If it is larger than i, we regard it as
absolute.
The reaction is read oflf exactly as in the Wasser-
mann test, that is, for inhibition or noninhibition ot
hemolysis. If the amount of complement or natural
antisheep amboceptor is very low, we may add the
proper amount of guineapig's serum, or rabbit's
immune serum, ascertained by preliminary titration.
We wish to state here that the addition of guinea-
pig's serum for com.plement and artificial antisheep
amboceptor is only necessary in about two per cent,
of the blood specimens examined, provided the
blood is not kept too long before examination. In
^he 158 oases here recorded, it occurred but twice.
We wish to emphasize the fact that blood from a
distance does not necessarily lose its natural comple-
ment or natural amboceptor in transit, as we fre-
quently receive bloods that have been in transit
forty-eight hours, which have still retained sufficient
natural complement to carry out this procedure.
This is true both for the test for syphilis and the
test for gonorrhea. The complement may go down,
but the amboceptor persists. The absence of com-
plement or natural antisheep amboceptor is not
always referable to undue retention of blood before
examination, as we have seen both f^hsent soon after
blood was withdrawn, that is, within two or three
hours. This kind of case constitutes two per cent,
of patients in whom it is necessary to add artificial
amboceptor and complement in carrying out these
modifications. It should be noted that we use three
different amounts of antigen, of which the dilution
is I to 6. Our purpose in using these three difYerent
quantities of antigen, of course, is to titrate, as it
were, the gonorrheal antibody supposed to be
present.
THE ANTIGEN.
Our antigen used in this research was kindly
furnished by the Parke, Davis & Co. research de-
partment. It consists of a number of strains of
the gonococcus in the form of an alcoholic extract.
We have made various antigens from multiple
strains of gonococci, and have found but little dif-
ference in the results obtained under the older
technic, using several antigens on the same blood.
We do not believe, therefore, that improvement in
technic must come from any change in the antigen,
inasmuch as the antigen used in our tests is uni-
formly successful within the limitations of the test
as previously performed. Our contention is that
the discrepancy which we obtain in the various cases
listed further on is not due to any fault in the
antigen, rather it is due to an improper technic,
namely, the use of heated serums, and the introduc-
tion of foreign amboceptor and complement into the
reaction. The new method, we believe owes its
superiority to the fact that in using unheated
serums, we are catching all the gonorrheal anti-
bodies, some of which may be "destroyed by heat,
just as in the case with the syphilitic antibody, as
proved by our own results, and the researches of
Busila (57) and Noguchi (58) on the destruction of
syphilitic antibody by heating blood serums to
temperatures of 45° to 56° C. I also wish to call at-
tention to the selfevident fact that in no case did
we get a positive reaction with the older method
without obtaining the same result with the new
method. In addition to this, before I present our
figures, permit me to note here that we obtained
something like eighty per cent, more positives with
our method than we did with the Schwartz-McNeil
technic.
SURVEY OF TABULATED DATA.
We examined altogether 158 samples of blood
with this dotible technic. A number of these blood
specimens were introduced into the study as con-
trols. In most instances we knew no details of the
history of any of the cases before the results were
reported. We do not, therefore, wish it to be un-
derstood that we have here reported on 158 known
clinical gonorrheal subjects. Many of them were
candidates for matrimony, giving every evidence of
a clinical cure. There were a number of cases of
women recovering from curettement after abor-
tions, with no history or symptoms of gonorrheal
infection. There were seventy-nine male blood
specimens and seventy-nine female. In seventy-
seven cases a negative reaction was obtained by both
methods. In sixteen cases, we obtained a strong
positive reaction with both methods. In sixty-nine
cases we obtained a clear negative reaction with the
older method, and a strong positive with our own
method. In three cases, an instifficient amount of
blood was submitted to make both tests, therefore
these three cases are eliminated from the figures.
In other words, the older technic yielded but twenty
per cent, of positive reaction in patients unquestion-
ably harboring gonococci, whereas the technic wc
are describing yielded 100 per cent, of positive re-
actions in these sixty-five cases. This means that
the new method is eighty per cent, more accurate
than the other method. We do not wish to be un-
derstood, how ever, cis stating that the new method
yielded 100 per cent, positive in all gonorrheal cases
in v/hich a reaction was to be expected.
As a matter of fact, we do not wish to go further
in drawing conclusions regarding this technic than
November 30, 19.8.] GRADWOHL: GONORRHEAL COaII'LEMENT FIXATION TEST.
933
TABLE 1.-
Case. Name.
. A. J.
2 w. vv.
3 T. E.
4. J. P.
5 T. A.
6 J. C.
7 R. G.
8 F. C.
9 S. S.
10 K. G.
II. A. C.
12 W. C. B.
13 L. B.
14 T. M.
15 F. C.
16 T. L.
17 BP.
18 F. C.
19 S. G.
20 G. S.
21 R.
22 Y.
23 A. B.
24 L. K.
25 K. A.
26 R. L.
27 G. S.
28 A. L.
29 E. G.
30 F. C.
31 T. M.
32 L. M.
33 H. H.
34 F. C.
35 K. T.
36 R. L.
-CASES IN WHICH THE GONORRHEAL COMl'LEMENT FIXATION TEST WAS APPLIED BY THE SCHWARTZ-
McNEIL AND GRADWOHL TECHNICS.
Schwartz-
McNeil
technic.
Gradwohl
technic.
Negative Negative
Positive
Negative
Positive
Positive
Positive
Positive
Negative Positive
Males — 79 bloods.
Chronic gonorrhea prostatis four
years' duration Positive Positive
Anterior posterior gonorrheal ure-
thritis one year's liuration. "clin-
ically cured." No discharge . .
Chronic prostatis, one and one
half years' duration. Smear
positive Negative
Gonorrhea two years ago, "clin-
cally cured" Negative
Gonorrhea two years' duration,
with seminal vesiculitis, "morn-
ing drop" Positive
Gonorrhea for one year, with
bilateral seminal vesiculitis, right
sided epididymitis Positive
Chronic gonorrhea for three
years. No complications test made
after third month of treatment.
Smear negative Negative (No index)
Gonorrhea one year's duration
with chronic prostatitis and sem-
inal vesiculitis bilateral. Nega-
tive smears Negative
Gonorrhea anterior posterior three
years ago, clinically cured. No
discharge Positive
Subacute gonorrhea, anterior pos-
terior urethritis, duration now
four weeks. Smears positive... Positive Positive
Chronic gonorrheal prostatis, one
year old. Negative smears Negative Positive
Acute anterior gonorrhea, dura-
tion two weeks. Positive smears. Negative Negative
Gonorrheal arthritis in course of
anterior posterior urethritis, ex-
isting one month. Smear positive.
Anterior posterior gonorrheal
urethritis existing six weeks.
Smears negative Positive (No index)
Same as Case 8, eighteen days
later Negative Positive
Gonorrhea two years previously,
no symptoms, anterior urethritis,
no discharge Negative Negative
Anterior posterior urethritis, one
year old, no complications. Neg-
ative smear Negative Positive
Same as Cases 8, 15. Test made
twenty days after last date
(Case 15) Negative Positive
Gonorrhea three years' duration,
prostatitis, bilateral seminal ves-
iculitis. Negative smear Negative Positive
Candidate for matrimony, gonor.
rhea three years ago, clinically
cured, no discharge Negative Negative
Chronic gonorrhea four years'
duration, now has bilateral sem-
inal vesiculitis and epididymitis.
Negative smears Negative Negative
Acute anterior urethritis two
weeks' duration, slight discharge.
Negative smear Negative Negative
Gonorrhea for six years, prosta-
titis. Negative smear Negative Positive
Chronic gonorrhea for one year,
with seminal vesiculitis, double
vasotomy thirty days ago, no
discharge since Positive Positive
Chronic gonorrheal prostatis and
vesiculitis, one and one half
years' duration. Positive smears. Negative Positive
Acute gonorrhea anterior two
weeks' duration. Positive smears. Negative Negative
Candidate for matrimony. Had
gonorrhea uncomplicated ten
years ago. No discharge Negative Negative
Candidate for matrimony. Gonor-
rhea two years ago, uncompli-
cated. No discharge Negative Negative
Gonorrhea six months' duration
with epididymitis. Negative
smears Negative Positive
Same as Cases 8, 1$, 18. Test
made three weeks later than
Case 18 Negative Positive
Gonorrhea for four years with
epididymitis. Smear negative.. Negative Positive
Arthritis in course of gonorrhea
existing for two months. Smear
negative Negative Positive
Arthritis in course of four weeks'
old anterior posterior urethritis.
Smear positive Negative Positive
Same as Cases 8, 15, 18, 30,
Test made two months after
Case 30 Negative Positive
Uncomplicated gonorrhea four
years ago. Clinically cured. No
discharge Negative Negative
Chronic gonorrheal prostatitis ex-
isting one year. Positive smears Negative. Positive
Schwartz-
McNeil Gradwohl
Case. Name. Males — bloods. technic. technic.
37 A. N. Candidate for matrimony. Un-
conii)licated gonorrhea one year
ago Negative Negative
38 L. G Candidate for matrimony. Poste-
rior gonorrhea two years ago.
Clinically cured Negative Negative
39 J- T. Chronic posterior urethritis exist-
ing for one year. Smear nega-
tive Negative Positive
40 M. M. Chronic gonorrhea with vesiculitis
existing three months. Negative
smears Positive Positive
41 O. S. Chronic gonorrheal prostatitis and
vesiculitis for ten years. Smear
negative Negative Positive
42 A. B. Gonorrhea for two months, with
cystitis, epididymitis, prostatitis.
Positive smears Negative Positive
43 K- B- Posterior gonorrhea for two
months, no treatment for two
weeks, no discharge, clinically
cured Negative Positive
44 E. P. Anterior posterior urethritis, with
epididymitis; duration six weeks. Positive Positive
45 F. C. Same as Cases 8, 15, 18, 30. 34.
Test made three months after
Case 34 Negative Positive
46 T. B. "Morning drop," gonorrhea one
year ago. Now has chronic pros-
tatitis. Smears negative Negative Negative
47 N. D. Anterior posterior urethritis, two
weeks' duration. Smears positive. Negative Negative
48 F. C. Same as Cases 8. 15, 18, 30, 34,
45. Test made two months after
Case 45. Smears always nega-
tive Negative Positive
49 F. H. Gonorrhea eight years ago; now
has "morning drop." Smears
negative Negative Positive
50 L. M. Gonorrhea for six months; now
seminal vesiculitis, prostatitis.
Smears negative Negative Negative
51 O. K. Gonorrhea one year duration
with vesicles and prostate now
infected. Smears positive Positive Positive
52 C. E. Chronic anterior posterior ure-
thritis for six weeks. Positive
smears Negative Positive
53 A. B. Gonorrheal anterior urethritis for
three weeks. Smear positive.... Negative Positive
54 D. K. Gonorrheal anterior posterior
urethritis for two months. Smear
positive Negative Positive
55 G. E. Gonorrhea duration one year, with
prostate and vesicles now in-
fected. Smear negative Negative Positive
56 P. B. Acute anterior gonorrheal urethri-
tis one week. Smear positive... Negative Positive
57 R. B. Chronic gonorrheal prostatitis
and vesiculitis for six months.
Smear negative Negative Positive
5S T. S, Chronic posterior urethritis with
prostatitis duration eight
months. Smear positive Negative Positive
59 W. B. Anterior posterior urethritis for
two months. Smear positive... Positive Positive
60 M. L. Candidate for matrimony; clini-
cally cured of gonorrhea occur-
ring three years ago Negative Negative
61 F. C. Same as Cases 8. 15, 18, 30, 34,
45, 48. Test made three months
after Case 48 Negative Positive
62 J. G. Gonorrheal ophthalmia duration
ten days. Positive smear from
eye. Also has subacute gonor- '
rheal infection posterior urethra. Negative Positive
63 H. L. Candidate for matrimony, gonor-
rhea uncomplicated one year
ago Negative Negative
64 H. W. Sexual neurasthenia, no venereal
history of infection. No dis-
charge Negative Negative
65 O. A. Gonorrhea three years ago with
epididymitis, clinically cured. No
discharge Negative Negative
66 H. O. Candidate for matrimony. Gonor-
orrhea with epididymitis three
months before. Clinically cured. Negative Negative
67 E. M, A medicolegal case; claims trauma
of testis, but has history of ure-
thritis and swelling of epididy-
mis six months ago. Smears
said to be negative Negative Positive
68 A. L. Gonorrheal urethritis existing three
months, with shreds, but no dis-
charge. Smears negative Negative Negative
69 K. Chronic gonorrhea urethritis three
years ago. Clinically cured .... Negative Negative
70 L. Anterior urethritis existing three
months. Smear positive Negative Negative
71 B. Gonorrhea seven years ago; no
complications. Clinically cured . Negative Negativa
934
GRADWOHL: GONORRHEAL COMPLEMENT FIXATION TEST.
[New York
Medical Journal.
TABLE I.
Case. Name.
72 G. J.
-CASES IN WHICH THE GONORRHEAL COMPLEMENT FIXATION TEST WAS APPLIED BY THE SCHWARTZ-
McNEIL AND GRADWOHL TECHNICS— Conhiiwed.
73
74
7S
76
77
78
79
F.
S.
P.
Z.
K.
P.
W.
S.
Case. Name.
I A. L.
2 E. T.
3 V. C.
4 T. N.
5 A. B.
6 A. J.
E. L.
H. O.
9 L. N.
10 R. H.
11 D. D.
12 R. H.
13 G. W.
14 L. M.
15 M. T.
16 A. S.
17 E. M.
18 A. F.
19 O. B.
20 N. B.
21 H. K.
22 M. G. K
23 E- F.
24 R. McN.
25 D. C.
26 M. S.
27 M. T.
28 E. G.
Schwartz-
McNeil Cradwohl
Males — 79 bloods. technic. technic.
Gonorrhea twenty years ago, with
double epididymitis. Vasotomy
now owing to purulent vesiculi-.
tis. Smear negative Negative Negative
Gonorrhea uncomplicated ten
years. Clinically cured Negative Negative
For eighteen months chronic gon-
orrhea with prostatitis. Smear
positive Negative Positive
Urethritis and prostatitis for eight
months. Smears positive Negative Positive
Sixteen months' old chronic ure-
thritis and prostatitis. Smear
positive Negative Negative
Three months' old posterior ure-
thritis. Smear positive Negative Negative-
Acute anterior urethritis for one
month. Smear positive Negative Negative
Anterior posterior urethritis seven
months ago. Clinically cured.. Negative Negative
Schwartz-
McNeil Gradwohl
Females — 79 bloods. technic. technic.
Old endocervicitis. Purulent dis-
charge, chronic gonorrhea in hus-
band. Smear negative Negative Negative
Arthritis. No history. Smear neg-
ative Negative Negative
Vaginitis. Smear negative Negative Positive
Gonorrheal arthritis clinical diag-
nosis, infected husband. Smear
negative Positive Positive
Vaginitis, profuse discharge from
cervix; no other data given.
Smear negative (Wassermann
positive) Negative Negative
Endocervicitis. No history of gon-
orrheal exposure. Smear shows a
gram negative diplococcus .... Negative Negative
Salpingitis. Smear negative .... Negative Negative
Chronic endometritis; one miscar-
riage. Smear negative Negative Negative
Chronic cystitis, endometritis, vag-
initis. Smear positive Negative Positive
Vaginitis, double pyosalpinx. Pos-
itive smear Negative Positive
Vaginitis acuta. Smear positive. . Negative Positive
Subacute gonorrhea both tubes
and ovaries; infection two months
old; exacerbation of old case.
Operated and drained. Smear
negative Negative Positive
Chronic salpingitis, double tubo-
ovarian abscess existing three
years. Operated, drained Negative Positive
Gonorrheal vaginitis. Negative
smear Negative Positive
Ascending gonorrhea five weeks
duration; diphtheria, syphilis.
Smear negative Negative Positive
Gonorrheal vaginitis. Negative
smear Negative Positive
Vaginitis, Bartholin gland abscess. Negative Positive
Acute vaginitis, duration two
weeks. Negative smear Negative Positive
Pelvic cellulitis. No other clinical
data available. Negative smear. Negative Positive
Smallpox. Control case Negative Negative
Salpingitis. Negative smear .... Negative Positive
Vaginitis in child. Diphtheria.
Smear negative Negative Negative
Vaginitis in child. Negative
smears Negative Positive
Vaginitis in child in which sta-
phylococci found in smear Negative Negative
Vaginitis in child — a very old
case. Smear at one time posi-
tive Negative Positive
Subacute gonorrheal vaginitis and
urethritis and cystitis. Smear Negative Positive
Chronic salpingitis. Negative
smear Negative Positive
Ascending gonorrhea, double pus
tubes, chronic metritis, broncho-
pneumonia. Negative smear . . . Negative Positive
Case. Name.
29 M. R.
30 C.
31 M. L.
32 J. N.
33
34
35
36
37
3«
39
M. C.
D. P.
N. C.
L. P.
E. W.
E. C.
H. H.
40 R. P.
E. R.
N. McN
M. S.
44 M. J.
45 -M. McM.
46
47
4S
49
5"
51
5-2
53
54
62
63
64
65
I. T.
M. D.
F. J.
D F.
R. B.
H. P.
M. S.
V. N.
F. D.
55 C. M.
56 P. C.
O. D.
E. McD,
A. S.
N. W.
G. C.
N. B.
B. L.
L. K.
C. M.
66 M. S.
67 M. S.
68 S. S.
69 G. J.
70 M. G.
71 H. L.
72 G. C.
73 M. W.
74 K. \V.
D. F.
E. D.
75
76
77
78
79 E. G.
A. L.
L. M.
Schwartz-
McNeil Gradwohl
Females — 7) bloods. technic. technic.
Ascending gonorrhea; no other
clinical data available. Smear
negative Negative Positive
Ascending gonorrhea, salpingitis. Negative Positive
Relaxed pelvic floor. No smears
examined. No history of gonor-
rheal symptoms Negative Positive
Syphilitis; no present evidences of
gonorrhea Negative Positive
Abscess Bartholin gland Negative Positive
Chronic salpingitis, double pyosal-
pinx, metritis Negative Positive
Ascending gonorrhea, acute sal-
pingitis Negative Positive
Abortion; no clinical data on gon-
orrhea Negative Positive
Chronic salpingitis Negative Positive
Chronic salpingitis Negative Positive
Cyst of ovary; no other clinical
data Positive Positive
Cerebrospinal syphilis; no gonor-
rheal history Negative Negative
Abortion. No other data Negative Negative
Abortion. No other data Negative Negative
Abortion. No other data Negative Negative
Adhesions of peritoneum. No
other data Negative Negative
Syphilis. No other data avail-
able Negative Negative
Syphilis, endometritis Negative Negative
A healthy control Negative Negative
Retroflexio uteri Negative Negative
Ascending gonorrhea Negative Negative
Syphilis Negative Negative
Ascending gonorrhea. Positive
smears Negative Positive
Double pyosalpinx, operated and
drained Positive Positive
Acute gonorrheal vaginitis. Posi-
tive smears Negative Negative
Chronic salpingitis; probably gon-
orrheal from standpoint of his-
tory Negative Negative
Ascending gonorrhea existing Ion".
No other data Negative Negative
Chronic salpingitis; no miscar-
riage; clinical diagnosis gonor-
rheal in origin Negative Negative
Syphilis. No clinical data Negative Positive
Acute gastritis. Control case.... Negative Negative
Metritis Negative Negative
Chronic salpingitis Negative Positive
Bilateral oophorectomy for puru-
lent salpingitis and abscess of
ovary. Test made ten days after
operation. No other data Negative Negative
Chronic salpingitis Negative Positive
Miscarriage. No other data Negative Positive
Chronic salpingitis Negative Positive
Postoperative neurasthenia. Con-
trol Negative Negative
Chronic salpingitis Negative Positive
Syphilis. No other data Negative Negative
General peritonitis, following mis-
carriage. No other data avail-
able. Fatal issue Positive Positive
Retroversio uteri. No other data. Positive Positive
Left salpingitis. Operated. No
other data. Condition existed
over one year Negative Positive
Chronic salpingitis. No other
data Negative Positive
.\cute salpingitis Negative Negative
Baby, aged 3 weeks, ophthalmia
due to gonococci. Case yielding
to treatment Negative Negative
Mother of Case 73; no examina-
tion made, as mother was simply
accompanying child to hospital. Negative Negative
Old adhesions; operated for ad-
herent uterus Positive Positive
Ascending gonorrhea, two months'
duration Negative Negative
Double pyosalpinx. No other data. Negative Positive
Chronic salpingitis. No other
data Negative Positive
Inguinal adenitis. No clinical or
microscopic data Negative Positive
to say that it gives eighty per cent, more information
than the older method, and that, when positive, the
reaction certainly indicates the existence of gonor-
rheal antibodies in the blood. When the reaction is
negative, which has occurred frequently with both
kinds of technic in manifest gonorrheal cases, one
vcannot necessarily eliminate the [ ossibility of the
existence of gonococci in the given patient's system.
As a matter of fact, we found seven male cases with
active foci, in which the new test, as well as the
older method, failed to give a positive reaction. We
also found eight female subjects with chronic lesions
in which a reaction was to be expected, but in which
both methods failed. We found in seventy-seven
November 30, 1918.] GRADWOHL: GONORRHEAL COMPLEMENT FIXATION TEST.
935
cases, of which thirty-six were males and forty-one
females, that the reaction was negative with the old
method and positive with our method. The seventy-
seven cases all displayed clinically signs of active
foci of infection. Adding these fifteen cases, in
which there were clinically active foci, to the sev-
enty-seven cases in which we found a positive with
our method and a negative with the other method,
plus the sixteen cases in which we found a positive
with both methods, the result is a grand total of io8
TABLE 2.— COMPARISON OF RESULTS IN USE OF OLD
AND NEW METHODS. Cojw.
Males 79
Females 79
Total 158
Results :
Negative in both methods 03
Negative in old method 1
Positive in new method J
Positive in both methods 16
No index 2
clinically positive cases of gonorrhea in which the
complement fixation test should have been positive.
Expressed in terms of percentage, both methods
failed in 12 24/27 per cent. The older method gave
a positive reaction of 14 22/27 per cent. only. Our
method gave a percentage of positive reaction of
71 8/27 per cent. Expressed in tenns of compari-
son, the new method yielded 56 13/27 per cent, bet-
ter results than the old method in all cases of
gonorrhea in v/hich gonorrheal antibodies occur.
This serves to explain the statement just made,
that we did not wish to be understood as stating that
the new method yielded 100 per cent, positive in all
gonorrheal cases in which reaction was to be ex-
pected. There is still a percentage of 28 19/27 per
cent, of clinical gonorrhea, according to our figures,
in which both methods failed to give a positive re-
action. Whether this is due to the fact of the
fluctuation of the antibody, or to the fact that still
more strains of gonococci must be added to the
antigen to make it absolutely ideal, we cannot say
at this writing.
We wish to go on record here with respect to
proteotropic or false reactions, both in regaid to this
gonorrheal technic, and in regard to the Hecht-
Gradwohl method in syphilis, by stating that we
have never seen such a condition, and that, in every
TABLE 3.— CASES NEGATIVE IN BOTH METHODS.
Cases.
Males 31
Females 32
Total 63
Males Negative in Both Methods.
Clinical cures and controls 20
Anterior urethritides (infection under 4 weeks) 5
Cases with apparently active foci, where test failed 7
Total 32
Females Negative in Both Methods.
Clinical cures and controls 21
Acute infections (no reaction expected) 2
Chronic cases reaction expected (failed) 8
Total 31
instance in which we have found the positive reac-
tion with this new technic, and a negative with the
older methods, there is ample clinical evidence of
the disease whose immunologic reactions we have
been studying. We do not offer this technic as a
supersensitive one, nor as a technic that shows
antibodies that are not present. We offer it as one
that catches the antibodies that are actually de-
stroyed by the older technic before the test is ap-
plied, just as the Wassermann reaction destroys
syphilitic antibody before the test is under way.
Again we wish to emphasize the fact that while the
Wassermann test is actually a test of scientific ac-
curacy to limited extent, the gonorrheal complement
fixation test is a true antigen-antibody phenomenon,
which is capable of more lucid scientific explanation
than is the Wassermann reaction.
INTERPRETATION OF RESULTS.
The interpretation of these positive and negative
results brings us to a discussion of the character of
the cases with which we have been dealing. In the
male, the positive reactions were obtained on per-
sons with a definite history of gonorrhea. The in-
fection had existed from periods of time varying
from four weeks to seven years, and the cases were
uniformly complicated by prostatitis, seminal
vesiculitis, epididymitis and orchitis. We have
failed to obtain a positive reaction in the male in
TABLE 4.— CASES POSITIVE IN BOTH METHODS.
Cases.
Males 9
Females 7
Total 16
Males Positive in Both Methods.
Cases with clinical foci 8
Cases with no clinical foci i
Apparently cured 9
Total 18
Females Positive in Both Methods.
Cases with clinical foci 6
Cases with no clinical foci i
Total 7
any case of anterior urethritis of less than four
weeks of infection. We are inclined to believe that
the reaction never occurs in the male except when a
"complication intervenes," when the gonococci pene-
trate more deeply into the urogenital tract than they
do in case of a mere surface or subsurface infection.
The fact that we have repeatedly obtained negative
reactions with both kinds of technic in persons with
gonococci in smears in posterior urethritides speaks
either for the fact that the reaction cannot be caught
even by our most sensitive method, or that the re-
action never occurs unless there is a deep migration
of the gonococci into recesses admitting of lym-
phatic absorption into the general blood stream. In
the female, we are convinced that the same condi-
tion obtains, namely, that the advance of the gono-
cocci into the fundus uteri, the tubes, or ovaries, or
into the Bartholin glands is necessary before any
reaction is set up.
In discussing some of our findings we find that
we obtained a positive reaction with the new-
method, and a negative with the older method, in
two cases of vaginitis in young children. We do
not recall having seen any data on this particular
TABLE s.— CASES NEGATIVE WITH THE OLD METHOD
AND POSITIVE WITH THE NEW METHOD.
TVT 1 Cases.
Males
Females . 41
Total 77
group of cases in the literature in regard to gonor-
rheal complement fixation. We also obtained a
clear negative reaction with both kinds of technic
936
MARLOW: LATENT OCULAR DEVIATIONS.
[New York
Medical Journal.
in the blood of a child with clinical ophthalmia
neonatorum, whereas the mother gave a strong posi-
tive reaction wilii the new technic, and a negative
with the older technic. We also have a record of
four examinations of the blood of one patient ex-
tending over a period of one year, with a uniform
positive reaction with the new technic at each test,
and a uniform negative reaction with the other
technic. This was a case of gonorrheal prostatitis
not under treatment. It might be added that in a
number of cases there was a Wassermann positive
reaction, that is to say, in which syphilis and gonor-
rhea coexisted. No difficulty was experienced in
obtaining a complement fixation for both diseases.
CONCLUSIONS.
From the foregoing study, which is presented
simply as a preliminary report, we wish to be un-
derstood as concluding that this new technic offers
possibilities of greater accuracy in respect to gon-
orrheal complement fixation than is obtainable with
the methods now in vogue. We believe that a con-
tinuation of the work will still further strengthen
these figures, and that ultimately later studies will
in every particular bear out our contention, namely,
that the use of unheated serums for complement
fixation in microbic diseases in general is the ideal
method ; that the utilization of the natural ambo-
ceptor and natural complement is also the procedure
of choice ; and that the technic utilizing heated
scrums must finally be judged inadequate, and capa-
ble only of demonstrating the grossest examples
of infections, rather than the moderately severe and
lightest degrees, so far as antibody production is
concerned.
I cannot refrain from emphasizing what has been
said before regarding the identification of the gono-
coccus by microscopic and cultural methods that the
finding of the coffee bean diplococcus in a very
acute stage of urethritis in the male, in its intra-
cellular habitation, with its gram negative tintorial
characteristics, is fairly good evidence on which to
base a bacteriological diagnosis of gonorrhea ; but
that cultures in this group of cases are advisable, es-
pecially in forensic cases. Further, the normal
urethra and the normal and abnormal vagina may
harbor gram negative diplococci that are not gono-
cocci. Also, it is unusual to find intracellular diplo-
cocci in discharges from the female vagina, or cervix,
or urethra. Cultures from these organs require pro-
longed and careful study for the purpose of identi-
fication of the gonococcus. Therefore, the diagnosis
of gonorrhea in the female by microscopic methods
is a most difficult procedure, and one should be
cautious in either excluding or including gonorrhea
by these methods. Complement fixation, especially
by this new method, offers possibilities that should
be investigated before the investigator comes to a
conclusion regarding the absence of gonorrheal in-
fection.
I wish to thank the following colleagues for as-
sistance in carryirg on these tests : Doctors Gellhorn,
Powell, Kerwin, Curtis, Taussig, and Tost.
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I. FOURNIER: I.econs clini(iiie reciieillies, 1S70. 2. L.ANGLE-
BERT: Traite theoretique et pratique des maladies veneriennes,
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buch der venerisclien Krankheiten. 1903. 6. DONNE: Cours de
microscopie, Paris, 1S44. 7. THIRY: Cours de microscopie, Paris,
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Wissenschaften, 1879, 28. 10. BOKAI: Allgemeine medicinische
Central Zeitiing, 1880. 11. BUMM: Deutsche medizinische IVoch-
enschrift, 1885, 53. 12: SCHOLTZ: Archiv fur Dermatologie und
Syphilis, 49, No. i. 13. PLATO: Berliner klinische Wochenschrift,
1899, No. 49. 14. ROUX: Archives generates de medicine, i866.
15. ALLEN: Journal of Cutaneous and Genitourinary Diseases,
1887. 16. WENDT: New York Medical Press, 1887. 17. STEIN-
SCHNEIDER AND GALEWSKI: Verhandlungen der deutschen
dermatischen Gesellschaft, 1889, p. 159. 18. HEYMANN: Medical
Record, 1895. 19. HOGGE: Annates des maladies des organes
genitourinaires, 1893. 20. KRAL: Archiv fiir Dermatologie und
Syphilis, 1894, 28. 21. KIEFER: Berliner klinische Wochenschrift,
1896, 28. 22. HIJMAN VAN DER BERGH: Monatschrift fiir
praktische Dermatologie, 1895, 21. 23. SCHOLTZ: Vorlesungen
iiber Pathologic und Therapie der Gonorrhoe des Mannes. 24.
BUMM: Miinchener medizinische Wochenschrift, 1881, No. i;
Fischer, Jena, 1904. 25. FURBINGER: Die Storungen der Ge-
schlechtsorganen des Mannes, in Northnagel's Spezielle Pathologic
und Therapie, Vienna, 1895. 26. TOTUON: Berliner klinische
Wochenschrift, 1892, No. 51. 27- CZAPLEWSKY: Hygienische
Rundschau, 1896, No. 21. 28. VON HOFFMAN: Centralblatt fur
die Krankheiten der Ham — und Sexual — Orga-ne, 1903, 14, No. 5.
29. PFEIFFER: Archiv fiir Dermatologie und Syphilis, 1904, 69.
30. BAERMANN: Zeitschrift fiir Bekdmpfung der Ceschlechts-
krankheiten, 1904, p. 4. 31. SCHOTTMUELLER : Miinchenrr
medizinische Wochenschrift, 1905, Nos. 34-36. 32. REUTTER:
Ibid., ref., 1905, No. 34. 33. PICK: Berliner klinische Woclicn-
schrift, 1907, Nos. 31 aud 32. 34. ABELSDORF and NEUMANN:
Archiv fiir Augenheilkunde, 2, 37, and 38. 35. KRUKENBURG:
Klinische Monatschrift far Augenheilkunde, 2, 37, and 38. 36.
URBAHN: Archiv fiir Augenheil Ergebnisse, 44, Bergman, Wies-
baden, 1901. 37. AXENFELD: Spezielle Bakteriologie des Auges,
Handbuch von KolleWassermann, 3. 38. MORAX: Bibliotek
general de medicin, Paris, 1894. 39. C. BRUCK: Deutsche medi-
zinische Wochenschrift, 1906, 34. 40. MUELLER and OPPEN-
HEIM: Wiener klinische Wochenschrift, 1906, 29. 41. C. BRUCK:
Deutsche medizinische Wochenschrift, 1909, 35, 470. 42. J. C.
MEAKINS: Bulletin Johns Hopkins Hospital, 1907, 18, 255. 43.
T. WATABIKI: Journal of Infectious Diseases, 1910, 7, 159. 44.
NANCIONI: Tentavi di fissatione del compl., nella blen., Atti
accad. med., Fioretini, 1910. 45. DEMBSKA: Dermatologische
Zeitschrift, 191 1. 46. TEAGUE and TORREY: Journal of Medical
Research, 1907, 17, 223- 47- H. J. SCHWARTZ and A. McNEIL:
American Journal of the Medical Sciences, 191 1, 141, 693. 48. R. B. H.
GRADWOHL: Transactions of the American Uroloaical Association,
1912, 6, 260. 49- GARDNER and CLOWES: Ibid., 1912, 6, 337.
50. R. B. H. GRADWOHL: The HechtWeinberg Reaction as a
Control over the Wassermann Reaction, Journal A. M. A., July 18,
1914, p. 240. 51. HECHT and WEINBERG: Wiener klinische
Wochenschrift, 1909, 22, 256. 52. R. B. H. GRADWOHL: The
Hecht-Weinberg-Gradwohl Test in the Diagnosis of Syphilis, Journal
A. M. A., February 17, 1917, p. 514. 53. R. B. H. GRADWOHL:
American Journal of Syphilis, 1917, i, 450. 54. M. L. HEIDINGS-
FELD: New York Medical Journal, April 8, 1916, p. 673. 55.
L. E. SCHMIDT, A. L. WOLBARST, and B. GRUSKIN: Discus-
sion to Gradwohl (reference 52). 56. J. A. KOLMER: Journal of
Immunology, 1916, 2, 23. 57. BUSILA: Comptes rendus de la
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028 North Grand Avenue.
THE DETECTION AND MEASUREMENT OF
LATENT OCULAR DEVIATIONS.
Tlic Inadequacy of the Ordinary Methods Used.
By F. W. Marlow, M. D., M. R. C. S. Eng.,
F. A. C. S.,
Syracuse, N. Y.,
Professor of Ophthalmology, College of Medicine, Syracuse
University.
Failure to relieve by glasses or other measures
symptoms apparently due to eyestrain is of common
occurrence. This is true not only of cases in which
the symptoms are definitely ocular in character, and
definitely associated with the use of the eyes, but
also of cases in which the symptoms are more re-
mote, such as headache, vertigo, gastric disturbance,
and the other symptoms grouped under the term
neurasthenia, in which other etiological factors
seem to have been excluded. One of the causes of
failure is undoubtedly the inadequacy of the ordi-
nary methods used for demonstrating the presence,
kind, and degree, of latent muscle imbalance. The
object of this communication is to call attention to
the increased knowledge which may be obtained by
modifying the so called cover or screen test, by
lengthening the time for which it is used.
November 30, 1918.]
MARLOW: LATENT OCULAR DEVIATIONS.
937
Ordinarily the test is applied by directing the
patient to fix his eyes upon a distant object,
usually a small light, six metres away, A card
or screen of some kind is held for a fraction of a
minute in front of one eye and then shifted to the
other. If a deviating tendency is present the cov-
ered eye will take up its position of rest, whether
that be one of divergence, convergence, or vertical
displacement, and on moving the screen to the other
eye a movement of recovery will be seen. At the
same time, the patient will observe an apparent
movement of the object looked at. Though un-
doubtedly the most reliable of all the methods used
for the detection and measurement of latent devia-
tions, and particularly so because it has both an
objective and a subjective side, it fails in many
cases to reveal the truth, because the period of time
for which it is used is insitfficevt to permit its ob-
ject— ^the relaxation of the extrinsic muscles — to be
attained. Just as in hypermetropia, the whole
error or part of it may be kept latent by persistent
spasm of the accommodation, so in heterophoria.
the whole or part of the deviating tendency may be
held in abevance by spasm of the extrinsic mus-
cles. In hypermetropia, the action of the accom-
modation can be eliminated by the use of a cyclo-
plegic, but there is no drug at present known which
has a similar effect on the extrinsic muscles. By
greatly extending the period of time during which
the eye is kept covered however, very much more
information may be obtained.
In practice I have adopted the plan of making the
patient wear a ground glass in front of one eye for
several days, usually seven, the other being fur-
nished with a full correction of its refractive error.
I have used the method in a considerable number
of cases and present herewith a report of a few of
the more striking ones, illustrating in particular the
three following points :
1. In many cases, but by no means in all, an error
is found which had been previously undetected, or
the error proves to be of much higher degree than
previous tests had indicated.
2. The abduction as measured at preliminary ex-
aminations is found to be an unreliable guide to the
amount of exophoria present. The degree of exo-
phoria found by the prolonged occlusion test may
be greatly in excess of the abduction as originally
measured.
.1. In some cases the character of the deviation is
changed. Thus, an esophoria before may become
an exophoria after occlusion, but the commonest
incident of this kind is a change from R. to L
hyperphoria, or the converse. This occurs in a
notable number of cases, and is commonly asso-
ciated with the manifestation of exophoria.
The cases reported below have been selected for
the purpose of illustrating the advantages to be de-
rived from the use of this method, and the pro-
longed suffering and repeated failures which may
be incidental to such cases, when the ordinarv
methods for the detection of muscle imbalance alone
are available.
Case I. — Mrs. C. W. A. ronsulted me first at the age of
eighteen, in 189'!, on account of headache and asthenopia.
Examination showed a low degree of hypermetropia and
astigmatism and orthophoria. The correction of the
errors of refraction save her no relief. She disappeared
from my observation and I heard later that she had been
greatly benefited by prism exercises. Nevertheless, she
reappeared seven years later with the same symptoms,
stating that the benefit she had received from prisms had
been partial and temporary only. This time she showed
more astigmatism and 1/2° of right hyperphoria. The re-
fraction was again fully corrected, but with very slight
relief. Further test revealed still riglit hyperphoria V2°
or less, exophoria 2°, abduction 8° ; adduction, is°.
At a later date she showed exophoria i° for distance,
12° in accommodation. Prisms relieved her headache at
first. She then disappeared and was apparently in the
hands of other oculists until 1912, when she again came
under oliservation. She was then wearing a stronger
astigmatic glass ovei each eye, which repeated tests showed
to be an overcorrection. This time there was exophoria
2°, abduction 6°, in accommodation exophoria 10° P. P. C.
end of nose. A careful correction of the refraction after
cycloplegia and of the hyperphoria again failed to give
relief. In January, IQT3, she showed, with full refractive
correction, orthophoria all over her field. She again dis-
appeared, returning on April 21st, iQi.S, having been to
still another oculist with an aggravation of her symptoms.
In the glasses there was Vj° prism base down for the right
eye. Up to the present time she had been somewhat in-
subordinate as to the constant wearing of glasses, but she
had finally realized the necessity of wearing them all the
time. There was T° of exophoria, no hyperphoria, the
abduction was 8°. She was advised and readily consented
to wear a ground glass over one eye for a week and ex-
I)erienced inimediate relief from her symptoms. On re-
moving the ground glass, tests showed L. hyperphoria l4°,
e.xophoria 11°. The last report of this patient was that she
was perfectly comfortable with the constant use of glasses
correcting her refraction and part of the exophoria.
This case shows that a high degree of exophoria
may exist and be undemonstrated by the ordinary
tests ; that the exo])horia may even exceed the ab-
duction, as measured previous to occlusion ; that a
right hyperphoria before, may become a left hyper-
phoria after occlusion.
Case IT.— Miss M. E. R., age 19. First seen on April
10, 1915. Symptoms, nervousness, photophobia, front,' and
occipital headaches with occa?'':ial nausea and vomiting.
Has been wearing glasses s years, last change having been
made in June, I9f4-
Wearing R. — J.oo S L. do 150"
— P.25 C 15° do
'-y Prism 1). up. 5^° Prism b. down
Examinat'on after cycloplegia showed
R. —1.50 S L. — 1..S0 S
—0.37 C 3.";' —0.50 C i42'/2°
V 6/6 each
Muscle tests showed exophoria 4°, and left hyperphoria
2°-f- before and after cycloplegia.
Glasses prescribed giving full refractive correction and
prisms and p. I'A' in up Ax. 30°, R. eye, L. in down axis
30°, giving very definite but incomplete relief, so that on
July 20th she returned on account of headaches. The re-
fractive correction was found to be accurate, and there
was L, hyperphoria 1° and exophoria 3° or 4° plus her
glasses, the abduction being 12°, plus her glasses.
After occlusion of L. eye with a ground glass for eight
days, she showed L. hyperphoria 10°, and exophoria 15°.
This seems an ample explanation of failure to obtain relief,
but it seems unlikely that a satisfactory result can be ob-
tained except by radical operative correction.
Case III. — Miss M. H., age 30. First seen July 20, 19x5.
Symptoms (4 years), asthenopia, photophobia, occipital
headaches.
Wearing -(-i-.'5o S
4-0.37 C 90° each
Examination showed refractive correction to be approxi-
mately accurate. Exophoria 3°, hyperphoria 0°, abduction
T2°.
As the errors revealed seemed insufficient to account
for the failure of the glasses to give relief, a ground glass
was prescribed over the L. eve. On removal seven days
938
MARLOIV: LATENT OCULAR DEVIATIONS.
[New York
Medical Journal.
later, there was L. hyperphoria 4°, and exophoria 14°. and
a diplopia which was difficult for her, at first, to overcome.
Here again we find a manifestation of exophoria ex-
ceeding the original abduction, and of hyperphoria of
which the ordinary tests gave no indication.
This patient was greatly relieved by a partial prismatic
correction of her imbalance.
Case IV. — Mrs. E. D. R., age sixty-five. First seen June,
1915. Symptoms, extreme photophobia, asthenopia, con-
stant pain in eyes, dating apparently from change of
glasses in November, 1Q14. Had been to several oculists,
without material relief.
Wearing R. -fi.oo S L. -I-1.50
+0.50 C Q0° -f 0.50 C. 00°
On examination R. -Hi.ss S L. -I-1.25
chose -f-0.87 C ax 70° 4-o.7SC ax 97K-°^
Muscle tests showed exophoria 3° to 4° at 6 m, and 10°
for ^3 M. R. hyper, i/^'" or less, abd. 8°.
1° prism base in each eye over hers gave very definite
and immediate relief, and on June 30th she was given as
a permanent formula :
R. -f 1.25 L. -I-I.2S S
-f 0.87 C 70° +0.7S C
V/t" in down 160° 1° in
These glasses gave her decided relief until she took a
ride in very bright light, followed by an aggravation of her
symptoms. The refractive correction was found to be
accurate. R. hyperphoria exophoria 1° to 3°, abduc-
tion 7° (with her glasses). She was then given a ground
glass, which she wore for seven days, and on its removal
showed L. hyperphoria 2°, exophoria 10°, having been very
much more comfortable while wearing the ground glass.
In this case the character of the hyperphoria was re-
versed, and the final exophoria exceeded the original ab-
duction. A fuller correction of the muscle error was fol-
lowed by definite improvement in symptoms.
Case V. — Miss M. E. T., age thirty-two, nurse. Seen
September 14, 1913. Symptoms, granulated lids, severe
asthenopia, indistinctness of vision, temporal headaches ;
had lost sixty pounds in three years, menses regular, but
diminishing in amount and color. Thought nose was
larger. No change in hands or feet.
Wearing R. -l-i.oo S. L. — 3.00C. 180°
— 4.S0 C. 180°
Examination under
cycloplegia gave R. +i-.iO S. V = 6/9
-S-SO C. 5°
L. -2.7.S C. 175° V = 6/9
Muscle test— Exophoria 7" to 9° L- hyp. 2^°
Glasses correcting the refraction and about 2/3 of the
muscle error gave very definite but partial relief. In July,
1915, she reported lids better; nervous symptoms about the
same. Examination showed refraction correction accurate.
L. hyp. iVz", Ex. 6° in addition to that corrected by
glasses, ground glass was prescribed, and at the end of
seven days showed L. hyp. 8°+ somewhat diminished in
upper part of field; Ex. 10°
It is obvious that jhe amount of uncorrected hetero-
phoria is an effective bar to any material improvement in
her symptoms.
Case VI.— Miss R. P., age twenty-three. Seen Novem-
ber 28, 1917. Asthenopia, headaches, stomach trouble. Not
wearing glasses. The first examination showed practically
no error of refraction, or muscle balance. After cyclo-
plegia accepted R. -fo.2.s S. L. +0.50 S. and there was
-\-0.12 C. 75
Exophoria 2° and L. hyperphoria
Shortly after this, she was operated upon for appendicitis,
and three weeks after the operation she returned, still
complaining of strain.
Examination gave
R. EM. L. -1 0.2? S L. Hyp. Va°
4-0.12 C 7S° Exophoria 2°,
Abduction 7°
A ground glass was prescribed for the left eye, and on
removal a week later, there was L. hyperphoria 3°, and
exophoria 8°. It will be noted that not only was there a
great increase of deviation in both directions, but the
exophoria was greater than the original abduction.
Case VIL— Miss F. B. R . age twenty-two. First seen
November 20, 1917. Lifelong svibject of headaches.
trontal, temporal, and occipital, occurring three or four
times a week, lasting all day.
Has worn glasses one year, but without relief.
-fi.7S S 90° each
-1-0.25 C
After cycloplegia accepted
R. -I- 1. 75 S L. -f-2.2S S
—0.37 C 10° — c.so C 15°
Muscle tests showed exophoria 2°, L. hyperphoria Yi" at
first examination, orthophoria at second (cycloplegia).
Was ordered full correction for refraction less 0.25 S.
She returned on January 18, 1918, unimproved as to head-
aches. Refraction accurate, L. hyperphoria exophoria
1°, abduction 10°. A ground glass was prescribed. At
the end of a week she showed L. hyperphoria 4°, exophoria
8°, having been a great deal more comfortable while wear-
ing the ground glass.
Temporary relief followed a partial prismatic correction
of the imbalance. The test was repeated in April and May,
1918. After occlusion lor fourteen days, examination re-
vealed L. hyperphoria 4°, ex. 12°.
Operative correction was advised.
Case VIII. — Mrs. L. J. D., age thirty-two. Fi«st seen
January 24, 1918. Asthenopia, photophobia and lacrima-
tion. Temporal and frontal headaches, aggravated by
wearing her glasses. Had been prescribed for in New
York three years previously, following operation, and
again more recently in this city; in both cases without
relief.
Her glasses were R. — 1.12 C 180° : L. — 0.75 C. 180°
Examination after cycloplegia gave:
R. +0.50
— 1.50 C 175° Uxophorio 1°
L. -f 0.25 S
+0.75 C 85" R. hyperphoria 5^°
She wore a ground glass for seven days and examina-
tion then revealed L. hyperphoria 1°, and exophoria 15°
evidently amply explaining the previous failures to relieve.
In this case the form of hyperphoria was reversed. The
amount of exophoria greatly increased. The original ab-
duction is not recorded.
Case IX. — Miss G. E. C, age twenty-seven. First seen
December 27, 1917. Had worn glasses twelve years, last
change being February, 1917, on account of severe head-
aches and asthenopia, but without relief. Her glasses were
-(-1.25 C. R. Ax. 70° ; L. 105°, and were found to be quite
accurate. She showed L. hyper, 1°, for which she was
given a correction— without benefit. Subsequent examina-
tion February 17, 1918, showed no change. A ground
glass was prescribed ; on removal seven days later there
was L, hyperphoria S°-l-, exophoria 11° — a more than
ample explanation of the previous failures to relieve her
symptoms.
Prismatic correction gave marked but incomplete relief
and operation was advised.
Case X. — Mrs. C. D. S., age thirty-one. First seen Feb-
ruary ig, 1918. Photophobia and headaches, occipital and
mastoid, to which she had always been subject, accom-
panied by nausea and sometimes vomiting; she had tried
to wear glasses eight years previously, but they nauseated
her. Examination showed V. 6/6, accepting -I-0.12 C in
each, exophoria 3° to 4°, hyperphoria 0°, abduction
12°. She accepted after cycloplegia R. -l-i.oo
-fo.2'5 C. 100"
L. do
do 120°
and showed exophoria 6°, L. hyperphoria '/2°.
After wearing a ground glass for seven days, she
showed L. hyperphoria 2° and exophoria ii°-t-.
Case XT.— Miss S. C, age twenty-four. First seen No-
vember 10, 1917. China decorator ; nervous breakdown in
college three years ago. Headaches with nausea since.
Photophobia, insomnia from headaches. Headache oc-
cipital, cervical and. since glasses, behind the ears also.
Wearing -I-0.50 C. 90°
1° in each
Examination :
R. -1-0.50 C. 8s° 6/6
L. H-0.25 Exophoria 3°, hyp. 0°, abd., 10'.
-1-0.62 C. 85° 6/6
November 30, 1918.] LAMBRIGHT : CLINICAL OBSERVATIONS IN SPLANCHNOPTOSIS.
939
After cyclopleRia :
R. +1.00 Exop. 2°
+0.62 C. 85° 6/6 L. hyp. Vi"
L.
<i (I <>
Ground Glass one week. Has been unable to work. On
removal L. hvp. 2V2'' , exoph. 11°. Unconquerable diplopia.
Ordered R. +0.7$ L. +0.75
+0.62 C. ■ +0.62 C. 85° ^
3° in up 10 3° in down 20°
In April, 1918, patient reported that she had had no
trouble since commencing the use of new glasses.
Case XTL— Mrs. L K.. age thirty-six. First seen April
22, 1908. Symptoms, very severe headache, with nausea
and vomiting, lasting three days, occurring at intervals of
one to three weeks and astlienopia.
Wearing glasses for hypernietropia and astigmatism
prescribed to her by a well known Philadelphia ophthal-
mologist. Examination without, and with cycloplegia,
showed some slight variation in the refraction, and also
revealed L. hyperphoria 1° to 2°; she was given a full
correction for her refraction and a 54° prism base down
L. eye. She seems to have been fairly comfortable with
these glasses, except that the headaches continued. I did not
see her again until 1915. In the interval she had seen her
Philadelphia ophthalmologist, who made some changes in
the refractive correction, omitted the prism, gave her a
presbyopic correction, and said it was necessary to wear
the glasses for near work only.
Some cnanges in refraction were again demonstrable,
L. hyperphoria 1°; the correction of which, and the con-
stant wearing of the glasses made her more comfortable.
She was prescribed for by me again in 1917 with only
partial relief. In the meantime other possible causes of
headaches had been investigated, and as far as possible
removed. Tonsillectomy had been done, and some teeth
removed, but with no effect tipon the occurrence of head-
aches.
In May, 1918, while in the hospital for the treatment of
colitis, having had several headaches of the greatest sever-
ity, it seemed worth while to investigate the muscle bal-
ance more thoroughly, and a black patch was worn con-
tinually over the left eye for a week. At the end of that
time, examination revealed L. hyperphoria 4'/4'' ; exo-
phoria 8°. A partial correction of the heterophoria by
prisms gave great relief, so that no headaches occur unless
the patient does much near work.
The patient was so r^jich impressed by her own experi-
ence of the value of the test, that she suggested using it
in the case of her son.
Case XIII. — D. K., son of the preceding patient, who
had been under my observation since 1909, when he was
five years and four months old, on account of twitching of
the eyelids and blepharitis. At that time there was a low
degree of hypermetropia and orthophoria. I have seen
him every year since 1913, examination showing astigma-
tism gradually increasing in degree, but orthophoria has
always been present. He has also been prescribed for
by a Boston opthalmologist, always with incomplete relief,
some asthenopia and twitching of eyelids and face per-
sisting. After seven days' occlusion of one eye by a black
patch, examination showed L. hyperphoria varying from
8° to 6° and exophoria from 4° to 5. On removing the
patch an unconquerable diplopia was present.
Many .similar cases could be cited in confirmation
of the statement made at the be^inninsr of this paper
that the methods commonly in use are quite inade-
quate for the detection and measurement of faults
of the muscle balance. There are points of interest
upon which prolonged occlusion throws light, not
dealt with here ; for instance, the effect of exercise,
of the prolonged wearing of prisms, and of opera-
tion. The writer, from an experience with this
method now extending over many years, believes it
should be used in all cases of asthenopia in which
the correction of demonstrable errors fails to relieve
symptoms presumably ocular in origin.
CLINICAL OBSERVATIONS IN
SPLANCHNOPTOSIS.
By George L. Lambright, M. D.,
Cleveland, Ohio.
(From the Medical Dispensary of Western Reserve
University and Lakeside Hospital.)
Our knowledge of downward displacement of
thoracic and abdominal organs is of comparatively
recent origin. Before 1889 the term gastroptosis,
coloptosis, enteroptosis, visceroptosis, etc., had not
appeared in the medical literature. Organs were
often spoken of as being prolapsed in the same
manner as we still speak of prolapse of the ovary
or uterus.
Glenard at that time described in detail some
well marked cases of enteroptosis that had been
sttidied by him, and showed that there was a well
defined group in which proper treatment would re-
place the displaced organs in their natural positions
with complete relief of symptoms. Stiller and his
coworkers about the same time clearly described a
certain type of individual, with developmental
defects in the osseous, somatic, and nervous systems,
in whom organs were almost always not in the
position described in the anatomies. Because of
their generally lowered strength, the term congen-
ital asthenia universalis was given to this class.
Lane and his followers, a little over a decade ago,
did considerable research work in this field, confin-
ing their attention particularly to the colon. The
frequency with which the colon was found in posi-
tions other than customary, and the kinks in its
course at the various curvatures caused much spec-
ulation in their minds. Many varied systematic
manifestations in the cases studied were suspected
to have resulted from the pathological conditions
described, and in some cases operative measures,
which eventually spread to this country, were insti-
tuted. From his work and that of other able in-
vestigators we have been made to realize that dis-
placement of organs may markedly interfere with
the carrying on of their normal functions. The
recent advances in rontgenoscopy and rontgenog-
raphy have confirmed the work of the early investi-
gators, in so far as the shape and position of the
organs is concerned, and have raised many ques-
tions of a clinical nature.
With our well established methods of physical
examination, so ably assisted by x ray evidence, we
have had no difficulty in discovering organs in a
prolapsed position. The difficulty has been in de-
ciding to what extent the symptoms might be at-
tributed to these conditions, and often the truth has
only been supplied by end results in treatment
directed along suspected Hues. One author has
arranged a working classification which he applies
to these cases as follows : First, one or more organs
may be displaced but the subject enjoys good health;
second, the patient is sick but symptoms can be
relieved without special reference to prolapse of
the organs ; third, the patient is sick and cannot be
relieved without reference to prolapse of the organs.
There is much of merit in this arrangement, for it
prohibits the prompt classification of the cases and
requires a more thorough clinical study. For the
940
LAMBRIGHT: CLINICAL OBSERVATIONS IN SPLANCHNOPTOSIS. [New York
Medical Journal.
purpose of making this discussion with some de-
gree of completeness I think we should accept the
classification which seems to be the most applicable
and affords the most accurate working basis, viz. :
Group I, congenital visceroptosis ; Group II, ac-
quired visceroptosis.
CONGENITAL VISCEROPTOSIS.
Some authors may object to a consideration of
this class of visceroptosis on the basis that it is not
a true form, but it would seem that a very limited
view of the subject would be given if the type so
ably portrayed by Stiller were not included. His
original description I shall give, together with ad-
ditional information which has been gathered as
a result of time and study.
The subjects are of a definite type and encoun-
tered in all walks of life, often enjoying the very
best of health. They are of long, lean build, and
when stripped, will be seen to have steeply falling
ribs, wide intercostal spaces, and an acute epigastric
angle. The thorax impresses one as being unusually
long, and when the distance from the lowest rib to
the crest of the ileum is measured it will be found
to be much less than in a person of average con-
tour. This factor alone will produce a smaller ab-
dominal cavity, and the pelvic cavity will appear
large with the organs accommodated therein. In
some well marked cases one cannot but recall that
the chest compares favorably with a type that has
long been recognized as being predisposed to tuber-
culosis. If the cardiac area is observed it may be
noticed that the impulse is lower than usual and
sometimes there is a cardioptosis, but more often
it only appears so from the steeply faUing ribs and
wide spaces. The recent army examinations have
shown a number of the men examined to have harm-
less systolic functional murmurs. An examination
of the spine may show scoliosis or kyphosis. As
has been stated, the panniculus is poor. With the
bowels thoroughly evacuated, the right or both kid-
neys may be quite frequently palpated, or moveable,
this becoming more marked in the upright position.
The spleen or liver may also be palpated, but this
is not so usual. Gastric and colonic inflation, with
percussion, will reveal the organs to be displaced.
To the radiographer we owe much, for his contri-
bution relative to the size and conformation of the
stomach, as well as its location. Having seen this
work, we no longer believe in one stereotyped stom-
ach for all. There appear to be two large groups.
First, the cowhorn ; second, the fishhook ; and there
may perhaps be a third or more exaggerated form
of the latter — a water trap form. Our observations
in fluoroscopic screen work have shown that types
one and three are found most frequently in the
class of subjects we have under discussion. It may
be concluded that if there is no retention of a meal
over six hours, and motility, peristalsis, and contour
are normal, the functions, in so far as one is able
to discover, are being carried on in a normal man-
ner regardless of the position of the organs. Such
a case will cause much speculation as to the cause
of gastric symptoms and will give the poorest re-
sults in the way of treatment.
From a rather close analysis of the literature, to-
gether with the opportunities I have been fortun-
ate in having for the studying of such cases, I have
been led to consider these patients as not suffering
from symptoms dependent upon the position of the
organs. They often complain of various complex-
ing manifestations with reference to the gastroin-
testinal tract that are difficult to explain, unless they
have some connection with the neuromuscular or
endocrine system, of which we still know far too
little. The latter system may have had something
to do with the development of the anatomical con-
tour. It should be borne in mind that the etiolog-
ical factors which are much better known in the
second, or acquired, group are more virulent in
action in this predisposed group, and they may fall
easily into a true type, and relief will be obtained
when the causative factors are removed. Their
recognition will not be difficult then, as abnormal
functioning, which I will take up under the sub-
ject of acquired splanchnoptosis, will be apparent.
ACQUIRED VISCEROPTOSIS.
In order to form some idea of how displacement
of abdominal organs may come about in a previous-
ly healthy person to such an extent as to produce
symptoms, a description of the natural factors that
support the organs might be helpful. The abdomen
may be regarded as a flattened cylinder with the
spine, sacrum, ribs, and muscles passing from the
pelvis to the lower ribs, forming a strong barrier
which cannot yield. The ribs are also lower at the
sides than at the front, where they curve sharply
upward to join with the sternum. In front the con-
dition is somewhat different and a longer distance
is present from the thorax to the pelvis, which is
not supported by framework. The muscles are the
only supporters. Anything that weakens the an-
terior abdominal support will allow downward dis-
placement of the organs to the extent of their sup-
porting ligaments. Likewise if the barrier yields,
i. e., the centre of gravity changes from fatigue,
defective balance, etc., there will be displacement
to the extent of the relaxation of the ligaments,
which are nothing more than bands of peritoneum
with fat enclosed, and it is doubtful if they are ever
a primary factor. An additional and important
factor in holding the organs in position is abdominal
fat. Its greatest role is seen in maintaining the
kidney in place, but it also acts as a pad in filling
in the interspaces between abdominal organs. It
can now more plainly be seen how important it is
to preserve the strength of the anterior abdominal
muscles during confinement, as any well marked
weakening of the muscle fibres which form the sole
support in front may lead to a ptosis of the abdom-
inal organs severe enough to produce symptoms.
It is not an uncom.mon experience, when examining
women who have had multiple pregnancies, to dis-
cover that the muscle fibres of these muscles feel
like tissue paper. If much adipose has accumulated
in the abdomen it is difficult to palpate the muscle
fibres, but the protuberant abdomen below the nav^l
and concavity above, when in upright position, will
be of some assistance in forming an opinion. It is
just as common an experience to palpate displaced
viscera ; and in any case where gastrointestinal
symptoms have their origin very shortly after con-
November 30, 1918.] LAMBRIGHT : CLINICAL OBSERVATIONS IN SPLANCHNOPTOSIS.
941
finement these findings should have most careful
consideration. Another very frequent factor is the
weakening of the abdominal muscles and decrease
of intraabdominal tension after the removal of large
tumors. The following history will illustrate a case
of this nature :
Case. — A. G., age forty-four years ; single and unoccu-
pied ; of good physical build and health. Was operated upon
ten months before coming under observation and a large
fibroid of the uterus removed. At ihat time her weight
was 150 (jr 155 pounds. Since the operation she had been
constipated, Anorexia was quite marked and after eating
there was considerable distress in the epigastric region and
under the costal margin?. At varying intervals there were
crampy pains across the epigastric region and at other
tim.es across the abdomen below the umbilicus. One ar-
ticle of food after another had been discarded in the hope
of improving digestion, but the symptoms had grown
steadily worse. Insomnia, depression, irritability, head-
ache, cold extremities, and weakness were complained of.
Recently there had been some pain in the left hip joint, but
there were no local findings. Examination showed that
there was a loss of weight of thirty-five pounds. The skin
and mucous membranes were pale. There was a relaxa-
tion of the abdominal muscles and the abdomen was pro-
tuberant below the umbilicus. Both kidneys were freely
movable. Blood examination showed hemoglobin of fifty
per cent, and red cells 3,880,000. Uranalysis was negative
except for a large amoimt of indican present. Fractional
.gastric contents showed a slight diminution in acids of
the stomach. Under the fluoroscope the stomach was seen
to be quite low in the pelvis with a great deal of sagging
of the greater curvature, making it U shaped. Peristaltic
waves were slow. At the end of seven hours a slight
amount of the barium meal remained in the stomach.
When the meal reached the colon ptosis was noted, and
after seventy-tv/o hours it still remained. With rest in
bed. high caloric feeding, daily enemas for the first few
days and an occasional doie of mineral oil the patient
reached her former weight in two months, and since then
has gained an additional five pounds, with complete relief
of symptoms. At the end of this time the stomach was
foimd to be completclv above the umbilicus and empty
inside of six hours. The colon was also in much better
position. The patient was instructed to lead an outdoor
life and follow exercises which required the use of the
abdominal muscles.
Other very important factors that will be discov-
ered are faulty habits and attitudes, anemia, de-
crease in intraabdominal tension following the re-
moval of large amounts of fluid or after the re-
moval of large abdominal tumors. Long, exhaust-
ing diseases will produce the condition.
When ptosed organs are known to be present
operations should be instituted with a great deal
of consideration, with a view to the possibility of
relieving the symptoms. Just recently a patient
was seen in whom the symptoms are dependent upon
prolapse of organs. This patient has been operated
on two different occasions without relief. On the
first occasion the symptoms were of a gastric nature,
and on the second, the appendix was removed.
The mistake of operating upon a floating kidney
without knowledge of the position of the other ab-
dominal organs and conclusive proof that it is
developing symptoms is not very frequently made
at present. It should also be kept in mind that
colicky pains in the abdomen may simulate gall-
stones, appendicitis, or renal colic.
The diagnosis of ptosed organs offers no particu-
lar difficulties, and the methods mentioned under
congenital visceroptosis will give complete informa-
tion. If there is doubt about the findings being
sufficient to account for the symptoms the patient
may be placed at rest in bed for a few days and the
comfort afforded will help in making a decision.
Tuberculosis develops easily in a weakened condi-
tion, and a very thorough examination of the lungs
should be made in every case.
TREATMENT.
In deciding on the course of treatment it is well
to keep the fact in mind that the symptoms have
arisen from the displacement of the organs, and
before any measures can be taken to increase their
power and strength they must be replaced, as nearly
as possible, in their normal positions. This can be
accomplished most thoroughly by keeping the patient
absolutely at rest in bed, with the foot of the bed
slightly elevated; also, although less satisfactorily,
l>y the use of suitable abdominal supports. After
the organs have dropped back give small amounts
of food having a high caloric value at frequent in-
tervals. If the feedings are carried on according to
the subject's ability to assimilate them and the total
calories carried are above 4,000, the patient will
make a steady gain in weight and within a very
short time assume a cheerful and cooperative atti-
tude. I have followed the plan suggested by Wil-
liamson in this respect and have met with complete
success. In several months the patients should re-
gain their normal weight and healthy digestion.
Following this the etiological factors should be
considered. If the abdominal muscles have lost
their power of support through any of the causes
mentioned attention must be directed to strengthen-
ing them or the patient will soon revert to his
former condition. This is done by appropriate ex-
ercises. A few of the simple ones follow : The pa-
tient lies flat on his back, on the floor, and slowly
flexes the thighs on the abdomen, alternately, then
together, ten times, and as strength is gained the
frequency is increased. Sometimes the power of
the abdominal nmscles is weakened to such an ex-
tent that the thighs can hardly be raised from the
floor. After this has been carried out the thighs
may be flexed on the abdomen and abducted and
adducted alternately and together. These same ex-
ercises should later be carried out against graded
resistance, with the hands, which, though a rather
crude way of estimating the amount, will answer
for most purposes. Later the bear walk may be
done, i. e., walking on all fours. The ear tickler
exercises, which consist in touching the lobes of the
ear with the knees, are also of benefit. If such
procedures are carried out for a suitable length of
time the pendulent abdomen, if due to weakened
muscle fibres, will assume a more rigid character.
Measures have been suggested to increase the sup-
porting strength of weak perineal muscles which
may play a minor role in supporting the organs.
They consist of voluntary efforts, as if attempting
to restrain an urgent bowel movement. If the at-
titude is faulty exercises should be instituted to
correct it.
Before dismissing the patient instructions should
be given to live a life with plenty of outdoor
exercise, and above all to follow a highly nutritious
diet which will maintain the weight up to standard.
In the event of any complicating illnesses a close
observation should be kept in order that the strength
and weight may be maintained.
942
BRAM: NONSURGICAL TREATMENT OP EXOPHTHALMIC GOITRE. [New York
Medical Journal.
NONSURGICAL TREATMENT OF EXOPH-
THALMIC GOITRE.
By Israel Bram, M. D.,
Philadelphia,
Instructor in Clinical Medicine, Jeflferson Medical College.
As the clinical manifestations of hyperthyroid-
ism or Graves's disease, are largely those of the
nervous and circulatory systems, in w^hich there
is overexcitation with resulting chronicity of
effects and often consequent fatal fatigue of the
elements constituting these systems, it is obvious
that the primary indication in a condition of such
aberration of function is rest — physical rest and
mental rest. The heart runs, and occasionally
gallops away at the rate of one hundred and forty
cycles per minute, undergoing at first hyper-
trophy of its musculature to enable itself to prop-
erly do twice as much work as it was formerly
wont to perform ; this hypertrophy continues on
to the hypertrophic dilatation as a sequence to
the ever persistent whipping of the heart by the
thyroid substance surcharging the blood ; and
finally, in the course of a year or more, as is the
case in all other vital organs and tissues in the
presence of continued marked stimulation, degen-
eration occurs, degeneration of the myocardium
with marked dilatation. Last of all, there is rel-
ative insufficiency, until loss of compensation
closes the scene. During all this time the blood-
vessels, large and small, even to the most minute
capillaries, including also the lymphatic and
venous systems — since they are a continuation
of the heart, acting in a manner somewhat simi-
lar to the outgoing and incoming ramifications of
a large water system, the heart of course acting
as the motive centre — also partake of this patho-
logical state. The pressure within these vessels
is altered ; the constituents and their contents are
modified ; the walls of these vessels undergo a
degree of pathological change, not unlike those
occurring in the myocardium, and as a result of
all this, the body nutrition and every unitary cell
of the bodily tissues are more of less neglected in
the matter of anabolic and catabolic changes.
For the same toxic reason, the nervous system
is in a state of extremely high tension — the sen-
sory-motor, the sympathetic, and the mental.
The tremor of the outstretched fingers and the
toes and also of the tongue ; the markedly in-
creased reflexes; the extreme insomnia; the high
tensioned mental state of the patient as evidenced
by his readiness to flare up in anger, fear, grief, and
other emotions on the slightest provocation ; the
ease with which lacrymation and hysteria occur ;
and not infrequently the marked change in dispo-
sition, with recurrent periods of melancholia and
mania; these all present a picture of a kind of
delirium, so to speak, of the various nervous cen-
tres, through the medium of the irritating thy-
roid substance issuing from the hyperplastic thy-
roid gland. We cannot here ignore mention of
the disturbed nervous control of other organs.
The stomach suffers with the evidences of the
nervous aberration as manifested by the typical
symptoms of "nervous dyspepsia"; there is alter-
ation in the tonus of the intestines giving rise to
diarrhea, constipation, or a periodic alternation
of the twoj the excitability of the bladder reflex
is evidenced by the frequent diurnal and noc-
turnal micturition; and even the sweat glands are
not forgotten, for in most cases there is marked
hyperidrosis.
All this indicates nothing less than a turbulent
state of the various vital functions, directly and
indirectly induced by one of the most potent,
though least understood, biochemical substances
known, which has been dubbed "the active prin-
ciple of the thyroid gland." And the most im-
portant element in the management of condi-
tions where irritation and hyperexcitability pre-
dominate is rest — rest of the body and the mind ;
not mere sleep nor mere reclining, but a pre-
scribed kind of rest outlined carefully by the sci-
entific medical attendant, embracing not only the
matter of rest in the abstract, but, more than
that, the quality as well as the quantity of rest
and the variations of this same rest which merge
into a kind of activity when the latter is indi-
cated. The writer of this paper is aware of the
obstruseness of these remarks and for that reason
proceeds to elucidate :
Some observers send their patients to the hos-
pital for the "rest cure" as a routine procedure.
My experience proves that this is not only un-
necessary, but even harmful in some cases. We
are dealing with a patient who has lost a consider-
able fraction of the body weight. What is indicated
in a case of this sort? Is it to make the vital func-
tions, especially the digestive organs, sluggish by
keeping the patient inactive in bed ? In the average
case the rest cure rests neither body nor the mind.
The mind, entirely unoccupied and left to itself, be-
comes introspective and, as a result, more turbulent
than ever ; the body, because of this mental state,
becomes even less stable than ever. Thus, rather
than a reduced tension of body and mind, an in-
creased tension — a tension the strain of which occa-
sionally leads to the breaking point — is induced by
the rest cure. Hence patients who have been kept
in bed for six, eight, or ten weeks at a time often
leave it in a worse condition than they were
formerly. Except in cases of extremely dangerous
cardiac insufficiency, I have found complete rest in
bed strongly contraindicated in the treatment of
Graves's disease. Patients can rest quite as satis-
factorily by sitting in an armchair, and surely feel
more comfortable and contented ; this comfort and
contentment, though, at first thought a trivial mat-
ter, means the difference between the presence and
the absence of a sharp appetite. Moreover, pa-
tients need not be deprived of the pleasure of
sitting at the family dinner table and even of a nice
slow walk in the open. All these, instead of fur-
ther devitalizing the patient, as is the case with the
complete rest cure ui bed, strengthen'the circulatory,
nervous, and respiratory systems, improve the ap-
petite, enhance the digestion and .nutrition, and help
the patient to take and assimilate greater quantities
of food, besides rapidly increasing the body weight.
I am therefore strongly opposed to hospital treat-
ment in the usual sense. The congenial home is
November 30. .918.] BEAM: NONSURGICAL TREATMENT OF EXOPHTHALMIC GOITRE.
943
the ideal place where proper results are most
promptly achieved; and if the home, for some rea-
son, is not congenial or is otherwise objectionable,
then a sanatarium with environments as near like
home as possible is the next best choice. In the
latter instance we' assume, however, that the at-
tendants of the institution possess the qualifications
herein implied.
However, where the patient's mentality is such
that response to reason is not forthcoming to the
satisfaction of the doctor — instances in which the
patient is really sufTfering with a degree of dementia
or melancholia, and in a household which is lacking
in proper moral fibre, where its members could
not be brought to the point of recognizing the vital
importance of strict discipline and indomitable ad-
herence to the doctor's orders — a nurse or two
must be put on the case. The nurse in attendance
must be capable of being trusted with a difficult
charge; she must have complete control of the pa-
tient in the absence of the doctor, notwithstanding
what the members of the household may say or
think. The nurse must be diplomatic, tactful, kind,
and sympathetic, yet firm as steel ; under no circum-
stance must there be the slightest yielding to unrea-
sonable demands of the patient or relatives. At a
stated moment, precisely, must the patient retire,
and at another precisely stated moment must the
patient rise. The bath must be given at exactly this
or that temperature ; meals must be taken at the
very moment indicated by the doctor ; their duration
and manner of chewing must also be carefully
supervised. The transactions of the day, including
the afternoon nap, rest, exercise, conversation, read-
ing, light games, etc., must all be under the eye of
the nurse in these difticult cases if we would win
the battle for health. This rigid plan must be ad-
hered to for as long a ttme as is necessary to bring
the heart beats down to normal, and until the
nervous manifestations of the disease have disap-
peared. Not until then may the nurse be dis-
charged and the patient be permitted to follow the
doctor's orders alone.
Friends, in cases of this sort, had better stay at
home. Subjects of hyperthyroidism are peculiarly
susceptible to suggestion or suggestive influences.
Most of them are hysterical neurasthenics, more or
less. Friends are often inclined in their sympathetic
attitude to overdo matters, and, in their talkative-
ness to recall the patient's past experiences, which
would manifestly be harmful. Moreover, the patient
in the presence of friends cannot be at ease, since he
will feel that his duties as host are obligatory, and
this situation, of course, is incompatible with com.-
plete physical and mental repose, and hinders con-
valescence.
The matter of an oversupply of sympathy and
extreme indulgence with the petty whims of the
patient must also be considered from the angle of
the immediate relatives, especially the fond help-
meet or the parent. It must be firmly stated in the
household that sternness in obedience to orders shall
and must characterize the treatment, and the physi-
cian must take the trouble to elucidate clearly the
reasons for his stand. Regularity of sleep, rest,
exercise, feeding, proper attention to bathing, the
quality and quantity of foods and beverages, the
kind of recreation to be indulged in, each and all
must be given careful attention, lest the patient step
back from a greatly improved state to his former
miserable condition. To become the least bit slip-
shod or indififerent to the strict regimen outlined
by the physician is to play with fire and invite a
serious, if not fatal, relapse.
It is assumed, of course, that the doctor who
undertakes the cure of a case of exophthalmic
goitre is sincere in his willingness to leave no stone
unturned in his eflforts to find what will benefit his
patient — for all cases are benefited by one or the
other combination of remedial measures. The
doctor will not only keenly desire to restore the
proper relationship between the organs involved as
quickly as possible, but he must be fully equipped
with an armamentarium of the recent researches in
glandular experimentation and therapy. He must
be keenly alive with regard to the variations which
present themselves in a disease which is rarely
typical in manifestations ; he must be a broadminded
student of human nature and especially of the
psychology of a brain continually stimulated by an
excess of potent thyroid secretion surcharging the
blood ; he must treat his charge as he would a
mental case, and must therefore be, in part, a sort
of alienist, and as such capable, through proper
suggestive influences, of bringing pressure to bear
upon the necessary emotional channels, with a view
to inspiring complete willingness and determination
to cooperate, in order to secure as prompt and com-
plete a result as possible. The essential point, then,
is implicit, unconditional confidence of the patient
in the doctor ; the patient must consider his medical
caretaker as his truest friend, at least until recovery
is achieved. The patient must look up to and re-
spect the doctor as one who is superior in knowl-
edge and wisdom, and to be consulted whenever the
slightest question in any phase of the treatment
arises. The patient must not take the slightest
chance in this respect, but if there seems to be the
least doubt concerning diet, medication, or any other
particular, and if the doctor is not due for some
time, rather than risk an unwise step, the medical
adviser should at once be consulted by telephone.
CONCLUSIONS.
In conclusion, I cannot resist the impulse to say
a word or two concerning the fallacy of surgery in
the treatment of exophthalmic goitre. Except in
cases \vnere malignant changes are evident in the
thyroid gland or where there are dangerous pres-
sure symptoms, surgery is distinctly contraindicated
in Graves's disease. But the exceptions in which
surgery in Graves's disease is indicated are very rare
indeed, so that we may feel justified in making this
generalization : Hyperthyroidism is not a surgical
entity, but is a disease which belongs strictly to the
realm of the internist, for the following reasons :
1. Recent researches prove that Graves's disease
is not a local condition, nor has it a local etiology.
2. Though surgeons report very favorable sur-
gical recoveries, clinical recoveries are rare, and in
a vast majority of cases there is a postoperative
return, occasionally with even greater vehemence
of all the signs and symptons of hyperthyroidism.
944
WEIDLER: CONGENITAL FISTULA OF- LACRYMAL SAC.
[New York
Medical Journ..i..
3. The patient wlio has been operated upon, and
who does recover cHnically, gets well because of a
carefully outlined system of postoperative nonsurgi-
cal treatment or because of the fact that the case ui
question is one of those instances of spontaneous
recovery and would have terminated favorably in
spite of treatment.
4. Internists who specialize in thyroid gland ther-
apy cure more than seventy-five per cent, of their
cases of hyperthyroidism by dietetic, hygienic,
nif dicinal, and clectrotherapeutic measures.
In my series of cases, to be reported in another
paper, I have been able to cure nearly every case
of hyperthyroidism that came under my care, and
this was accomplished by nonsurgical and remedial
measures.
1714 North Seventh Street.
CONGENITAL FISTULA OF THE
LACRYMAL SAC.
A Report of Three Cases.
By Walter Baer Weidler, M. D.,
New York.
There have been reported in the literature, up to
1908, according to Tyson (i), only seven cases of
congenital fistula of the lacrymal sac, including his
own. It is difficult to say whether all of these were
genuine cases of congenital fistulous openings into
the lacrymal sac or whether some of these were not
the direct or indirect result of an inflammation of
the lacrymal sac, which may have occurred some
time after birth. No satisfactory theory has yet
been advanced to explain the formation and pres-
ence of these congenital fistul?e of the lacrymal sac.
Manz (2) is doubtful whether any of these
fistulas are congenital in their origin. If they are
congenital, they must be due to an arrest of develop-
ment and an imperfect closure of the groove, which
in the embryo runs from the eye to the olfactory
pit.
Harman (3) writing of this condition calls it
fissura facialis and thinks that it is due to a small
deficiency in the union of the lateral, nasal, and
frontomaxillary processes, which, with the fronto-
nasal process form fhe face. These depressions or
fissura facialis are exactly in the line of the nor-
m?lly obliterated fissures. The small variability in
their position is covered by the extent of the fissure.
It was formerly thought that the tear duct was
formed by the persistence of the part of the cleft
between the lateral, nasal, and maxillary processes ;
but Born has more recently shown that in many
animals the duct arises after the closure of the
fissure, by the formation of a cordlike thickening
of the rete mucosa, which sinks into the dermis, and
later becomes canalized.
Harman explains his two cases in the following
manner: There was first the closure of the fissure;
then the formation of the tear duct ; and later on,
the reopening of the fissure and communication
with the duct.
De Wecker (4) in reviewing the reports of the
case of Scarpa and Baer, says that the openings
were of the capillary variety and that the lacrymal
fluid did not discharge through the defect in the
walls of the sac, except when the subject cried or
when gentle pressure was made over the region of
the sac itself.
In some of the cases the patient was not aware of
the presence of the opening until it was observed by
some member of the family. There are no definite
groups of symptoms associated with this condition.
There may be a troublesome epiphora which is
always more pronounced when the patient is ex-
posed to high wmds. Occasionally these people are
aware of the presence of a tear drop exuding on the
face at the side of the nose, and this is especially
brought to their attention after laughing, when the
contraction of the facial muscles causes the tears to
be pressed out of the fistulous opening. In rare
cases there may be chapping of the face with a
slight degree of eczema from the continued irrita-
tion of the skin, due to the presence of the tear.
Case T. — Miss A. E., age three years; born of Italian
parents. Birth was normal ; no history of any inflamma-
tion of the eyes or lacrymal sac. Parents noticed at times
a small drop of water on the right side of the face, along-
side of the nose, the presence of which they could not
explain. When seen at the Manhattan Eye and Ear Hos-
pital a small fistulous opening about 1.5 millimetres in
diameter was observed on the right side of the nose, at
the lower margin of the lacrymal sac. There was a small
tear blocking the opening of the fistula most of the time,
and on massage or gentle pressure upon the sac there oc-
curred an increase of the flow of tears from the fistula.
The fluorescin test was not made and operation was ad-
vised, but up to the present time the parents have not con-
sented.
C.\SF. li.' — Mrs. J. VV., age forty-two years; born of
American parents. Birth normal ; slight degree of epi-
canthus, with no history of inflammation oi the lacrymal
apparatus or conjunctiva at the time of or after birth.
Patient thinks she has had the condition all her life. Re-
members being conscious of the presence of tear drops on
right side of face, alongside of the nose, which she was
especially aware of when shfe laughed, thus causing a
great increase in the flow of tears from the fistulous open-
ing. Wlien a probe was passed into the sac bv way of the
puncta it could be touched by the one entered through the
fistula. There was no opening found on the left side, and
there was no family history of such a condition in any
other member of the family. Her two children showed no
similar defect.
Case HI. — Mr. J. B., age twenty-four years; born of
Irish parents ; family and personal history negative for
congenital defects or abnormalities, except for the presence
of the small opening on the right side of the nose near the
lacrymal sac. No definite history as to the possibility of
any inflammation of the lacrymal sac was available. The
patient had had this condition as long as he could remem-
bei The test was made with the probes and it was possi-
ble to get direct contact of the probes in the sac. Cauter-
ization of the fistula opening was advised, but refused.
Case IV. — Miss M. C, age six years; born of Irish
parents. Mother stated that two months after birth there
was some slight inflammation of the coniunctiva of the
right eye, which was treated at the Babies' Hospital. The
child had one treatment and the eye got well. The fistula
on the face was not noticed until at a later time — the
exact time she did not remember. There was a small de-
pressed opening at about the lower margin of the lacrymal
sac on the right side. The tears ran out of the opening with-
out pressure, and the fistulous opening was always filled
vith a tear. The fluorescin test showed the colored fluid
at the opening in about three seconds. A cauterization
of the opening with silver nitrate done two years ago did
not close the opening. Cauterization with the actual cau-
tery partially closed the opening.
This condition as a rule does not give a great
'This case was reported before the Section in Ophthalmology' of
the New York Academy of Medicine, December 21, «9i4-
November 30, 1918.]
SPIVAK: MECHANICS OF DEFECATION.
945
deal of discomfort to the patient ; neither is it very
disfiguring. It no doubt exists for years without
the person being aware of its presence. The gen-
eral physician, the pediatrist, and the surgeon must
see this anomalous condition quite as often as the
ophthalmologist, and it is my opinion that it occurs
much more frequently than the number of cases
reported in the ophthalmic literature would lead us
to believe.
There seem to be two methods of treatment for
this defect: The use of the actual cautery which was
entirely satisfactory in Tyson's case and partially
so in my own ; and the dissecting of the margin of
the fistulous opening with a pair of scissors and the
bringing together of the edges with a purse string
suture. REFERENCES.
I TYSON: Archives of Ophthalmology, xxxvii, 396, 1908.
2 MANZ GRAEFE-SAEMESCH : Handbuch der gesamten Augen-
heilkiinde, ii, 113. 3. HARMAN: Transactions of the Ophthalmo-
logical Society, xxiii, 256, 1903. 4- DE WECKER: Traite compet.,
d'ophthal., iv, 1103.
i.^i East Sixtieth Street.
MECHANICS OF DEFECATION.
By C. D. Spivak, M. D.,
Denver, Colorado.
Thirty years ago Dr. A. W. Abbott, of Minneapo-
olis (i), and Dr. Edward T. Williams, of Boston
(2) , advocated the squatting posture as the natural
and proper attitude to assume in defecation. They
sang its praises as a sine qua non in the rehef of
constipation, in healing hemorrhoids, and in the
prevention of uterine displacements. "The squat-
ting position," asserts Doctor Abbott, "is naturally
assumed by monkeys and apes and by man in the
savage state and on the frontier." "Watch any of
the lower animals," exclaims Doctor Williams, "the
dog, the cat, the pig, the ape at the menagerie, even
the horse and cow when hard bound — always an
approach to the same attitude." Doctor Williams is
dissatisfied with the lavatories of his day, and makes
the following suggestion: "One of the best arrange-
ments, for men at any rate, would be to abolish the
seat altogether, and have merely a stone or marble
slab with a hole in it. as is often seen in Europe, at
or near the level of the floor." Horace Fletcher
(3) is also a believer in the virtues of squatting.
He writes : "Z is the form'^ the body must assume to
render emptying of the digestion residue natural and
easy. Man was built to squat on his heels in def-
ecating, and sitting erect on a modern seat is like
trying to force a semisolid through a kinked hose."
Even the Bible was drawn upon to prove that such
is the correct position to assume. "Covering one's
feet"^ is considered by all commentators, except
Kimchi, to be a euphemism for defecation (4).
Man is a luxury loving creature. He gave up
the primitive mode of squatting and "covered his
feet," at first, by supporting his thighs on a pro-
truding branch, a stump, or a stone. Later the edge
'The letter Z represents the kneeling posture, not the squatting
posture. The Hebrew letter Lamed is the nearest to represent
squatting.
^"And he came to the sheepcotes by the way, where was a cave;
and Saul went in to cover his feet." (I Samuel 24, 4.) "And they
(the servants) saw and behold, the doors of the upper chamber
were locked; and they said: 'surely he (Eglon, king of Moab) is
covering his feet in the cabinet of the cool chamber.' " (Judges 3,
24.)
Fig. I. — Anatomically incorrect
schema of a squatting man. A, knees;
B, first cervical vertebra; C, coccyx;
D, metatarsal bones.
of a plank laid the foundation of the modern
chamber, and as man continued to fall from grace,
his indolence and love of comfort degraded him to
such an extent that his toilet room has become of
so much concern to him hygienically and estheti-
cally that it vies with his drawing room, as re-
gards air, sunshine,
cleanliness, and
beauty. Even after
he was warned by
three eminent men
of the dire calamity
which would befall
mankind if it did
not take up open air
squatting, man, the
gregarious stub-
bornly refused to
run ten miles daily
to the next open
field there to "cover
his feet," or to ex-
pose his nether
anatomy to the sub-
terranean draughts
issuing beneath the
"perforated slab." As sinful man dines on things
that are an improvement on nature's raw products,
so does he wish to respond to the "calls of nature"
amidst surroundings no less elegant than those of
his dining room. Of course if a seat were designed
which would conform to the posture of squatting,
the problem, it was hoped, would be solved.
Dr. Zan D. Klopper, of Chicago, after an interval
of thirty years (5), suggests a modification of
the seat of the lavatory chamber which is described
as follows : "The horizontal seat is raised under the
thighs, while the
projected step as-
sists in elevating the
legs." In other
words, the perfo-
rated seat and the
rim of the basin
upon which it rests,
instead of being
placed horizontally,
as those in vogue in
our day, are made
to slant from above
downward and for-
ward, at an angle of
about forty-five de-
grees. This arrange-
ment, according to
Doctor Klopper,
makes the body as-
sume the squatting
posture. I con-
structed a seat ac-
cording to Doctor Klopper's plan, and tested the
effect of the fusion of the primeval and the
artificial. As a result I am convinced that the rais-
ing of the thighs is a faulty procedure because the
body assumes an unnatural position.
The foregoing authorities are under the impres-
FiG. 2. — Anatomically correct
schema of a squatting man. A, knees;
B, first cervical vertebra; C, coccyx;
D, metatarsal bones.
946
ANGEVINE: CEREBROSPINAL MENINGITIS.
[New York
Medical Journal.
sion that the thighs, with the body in a squatting
posture, are at an acute angle to the trunk, but
when the body is seated on a straight cover the
thighs are then at a right angle to the vertical line
of the trunk. It is obvious that if their assumption
is correct, the modern posture must be changed.
From careful measurements and observations we
have become convinced that the thighs in squatting
naturally assume a horizontal position, and conse-
quently the seat of the toilet now in vogue is physi-
ologically perfect, and needs no improvement. The
only difference between primeval and modern posi-
tions is in the point d'appui. In primeval squatting
the whole weight of the body is supported on the
limited surface of the metatarsal bones ; in modern
squatting the weight of the body is supported upon
the whole length of the thighs. In modern squatting
the support of the legs is unnecessary. A man with
both legs amputated can now squat on a modern
toilet chamber — a feat which he cannot perform
primitively.
What is the end to be attained in squatting? To
increase the intraabdominal pressure by compress-
ing the abdominal viscera between the vertebral
column and the thighs. In order to accomplish this
it is necessary to bend the body forward at an angle
of forty-five degrees, which position, according to
my observation, is assumed unconsciously. In
primitive sf|uatting, it was compulsory to bend the
back and keep it at this angle during the whole
process of defecation; in modern squatting, the
bending of the back is voluntary and resorted to
only when necessary. In short, the modern position
is an improvement on the old, and squatting is not a
lost art.
REFERENCES.
I. W. A. Abbott: The Unnatural Posture During Defecation and
Its Relation to Constipation, Hemorrhoids, and tjterine Displace-
ments, Northwestern Lancet, March i, 1888. 2. Edward T. Wil-
liams: Postural Treatment of Constipation, Boston Medical and
Surgical Journal, August 23, 18R8, 119, 178. 3. Horace Fletcher:
The A. B. Z. of Our Own Nutrition, p. 11. 4. Posture and Rectal
Disorders, Medical Record, May 12, iRSS, 33. 522. 5. Zan D.
Klopper: The Practicability of ' the Modification of the Lavatory
Chamber, Journal A. M. A., May 18, 1918, 70, 1459.
206 Metropolitan Building.
CEREBROSPINAL MENINGITIS.
A Case Treated by Ten Serum Injections.
By Robert W. Angevine, M. D.,
Rochester. N. Y.,
First Lieutenant, M. C, U. S. Army.
(Frnin the Medical Service of the Rochester General
Hospital.)
A case of cerebrospinal meningitis was recently
treated at a Rochester hospital by ten daily injec-
tions of Flexner's serum ; 450 c. c. of the serum
being employed. The number of doses given is
larger than is required in the average case, but in-
jections were indicated by examinations of the fluids
taken.
The patient entered the hospital on May 5th,
having been ill for five days, and complaining
chiefly of intense headache and weakness. He had
been on duty until the last of April, when he noticed
soreness of the throat. On examination, the patient
was evidently in severe pain, the face was drawn.
eyes sunken, and color poor. The headache was
described as violent, and the patient also told of
pain in the back and down both legs, and of in-
definite abdominal pain. On physical examination,
general muscular rigidity was noted. There were
mcreased reflexes, a definite Kernig sign, and
marked Brudzinski's phenomena. The pupils were
dilated and reacted to light. The lungs were nega-
tive ; heart sounds somewhat irregular. There was
no definite opisthotonos. Purplish blue hemorrhagic
areas were made out over the abdomen. Pulse,
temperature, and respiration were registered as
seventy-eight, 102, and twenty, respectively. Vom-
iting occurred without previous nausea in three
instances. Herpes appeared on the tenth day.
Thirty c. c. of a slightly cloudy fluid under in-
creased pressure were withdrawn and examined.
The fluid contained many pus cells ; globulin and
albumin were positive and many meningococci were
found, both intracellularly and extracellularly.
Thirty c. c. of antimeningococcic sCrum were in-
jected into the spinal system and fifteen c. c. were
introduced into the blood stream. Lumbar puncture
was done each morning, checked by examination of
the fluid and during a period of ten days amounts
of fluid approximating forty c. c. were removed
and a like amount of serum injected intraspinously.
The temperature 1 cached 102.6° as a maximum and
showed a definite rise of about 2.6° approximately
eight hours after each treatment.
The fluid was returned negative for organisms on
the eleventh day after admission, and the patient
was discharged well on the twenty-fifth day. On
the eighteenth day of care in the hospital, the pa-
tient complained of pain and tenderness in the right
lower abdominal quadrant. There were no definite
physical signs coupled with these symptoms and
they disappeared within a week. There were no
other complications.
Placenta Praevia. — A. Lakshmanaswami (Ma-
dras Medical Journal, March, 1918 ) in speaking of
this condition, says the interests of the mother and
child are diametrically opposed. When a pregnant
woman bleeds in the seventh or eighth month of
pregnancy, the safest thing is to end the course of
labor as soon as possible ; but, so far as the child
is concerned, if the hemorrhage can be stopped and
the pregnancy allowed to continue, the prognosis
improves with the length of the period of pregnancy.
Palliative treatment should be undertaken only
where the patient can be constantly under observa-
tion, as she may collapse in a severe flooding before
medical help can be had. Women are so accus-
tomed to the periodical loss of blood that they
scarcely recognize the seriousness of the condition
in its early stages. The third stage of labor should
be conducted with great caution as postpartum hem-
orrhage is very likely to occur, owing to the situation
of the placenta. Even a small amount of bleeding,
which would seem insignificant to the ordinary pa-
tient, may be sufficient to turn the scales against her
in a case of placenta prsevia. It is wise also to give
an intravenous injection of saline solution before
any symptoms of collapse are seen.
Medicine and Surgery in the Army and Navy
MEDICAL NOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
TREATMENT OF INFECTED WOUNDS.
The purpose of this article is to outline the treat-
rrient of wounds of warfare as carried out in Ger-
many and Austria, in the early fall of this year.
First of all, be it said that the Huns have come to
the conclusion, for a long time denied by them, that
the large majority of wounds resulting from burst-
ing shell and hand grenades are generally profound-
ly infected from the start, and that the same applies
to injuries from shrapnel. Likewise bullet wounds
are more frequently the seat of an initial infection
than the learned Hun was at first inclined to sus-
pect.
It is evident from the reports coming from Ger-
irany during the past four years that the majority,
if not all the surgeons, had absolutely no idea of
what the effects of modern missiles would be, and
this fact shows that from the start they were
quite as ill prepared to deal with injuries of modern
warfare as were the French and English.
The first result attained from their observations
was a loss of confidence in aseptic treatment, and
many surgeons began to resort to antiseptic methods.
Now, as the requirements of an antiseptic are that
it shall have an elective bactericidal action, that it
possess a continued action, and, lastly, that it shall
have no injurious effect on the tissues by direct local
destruction or interference with the local defensive
force of the organism and shall not cause toxic
symptoms when absorbed, they at once perceived
that neither carbolic acid nor sublimate could ful-
fill these requirements. There were many cases of
poisoning from carbolic solution in the German
army during the early days of the war, and from
the intensive or even reckless fashion in v.fhich the
Hun surgeons used it. The wounds did badly on
account of the destruction of tissue which naturally
ensued.
The Germans did not discover, as did all other
surgeons in the various countries, that the sooner a
wound was submitted to the action of an antiseptic,
and particularly that when the case was one of a
closed cavity, such as a joint, it should be freely
exposed by one or more incisions. They instead
resorted to the ancient method of puncture and in-
jection of tincture of iodine ! Some Hun surgeons
even claimed and still maintain that they have ob-
tained good results by the prudent use of Chlum-
sky's solution (carbolic acid, camphor, and alcohol)
injected into cavities. Others have obtained suc-
cessful results with a four per cent, solution of car-
bolic acid in camphorated oil. Some Germans speak
well of Morestin's solution, which is composed of
formalin, alcohol, and glycerin, equal parts, but I
am under the impression that its use has been given
up by the French surgeons on account of the severe
pain caused through its use.
Balsam of Peru is considered a good and harmless
disinfectant, for surgical use, if it is carefully pre-
pared, but it only envelops the bacteria just as gly-
cerin or honey does, and all three have been em-
ployed by the Huns in wound treatment. They be-
lieve that oxygenated water principally develops a
purely mechanical action — and only a temporary one
at that — and they prefer medicated pencils contain-
ing hydrogen dioxide in a solid form, which are in-
troduced into the wound in which the action of the
oxygen lasts for quite a long time.
At the beginning of the war von Eiselsberg em-
ployed various aniline dyes which, when well di-
luted, he considers very strongly bactericidal and
without any injurious action on the tissues. But
he was obliged to give them up on account of the
staining caused to the linen and hands, and espe-
cially because it was not proven that they did not
exert an untoward action on the renal parenchyma.
Von Eiselsberg also points out that tincture of
iodine has no antiseptic action, its value being that
it sets up a hyperemia. But its real indication is
for painting over the integuments surrounding a
wound for the purpose of fixing the bacteria present
on the skin surface. In this respect it acts in the
same way as mastisol, a patent preparation much
used in Germany since the war.
In respect to iodoform, both in powder or gauze,
the Germans believe that it gives off iodine in a con-
stant way, although in small quantity, in the form
of gas, and thus penetrates the tissues in the wound.
Likewise it develops a constant action. For these
reasons it is very largely employed both in the Ger-
man and Austrian hospitals, particularly in infected
wounds. The concensus of opinion seems to be
highly favorable to this old surgical friend, and the
Huns maintain that when employed in moderate
quantities, either as powder or as gauze, it does not
give rise to toxic effects and that the fear of iodo-
form poisoning has been greatly exaggerated in the
past.
The Huns have adopted the Carrel-Dakin treat-
ment very generally, it seems, from all the informa-
tion I can gather, and among those who have par-
ticularly sung its praise recently are Dobbertin and
Winkelmann.
The Austrian War Office a year or more ago
issued an order to powder wounds with a mixture
of one gram chloride of lime to ten grams of bolus
alba, particularly in cases of recent wounds in which
the development of gas gangrene was suspected.
Several Austrian surgeons have employed this pow-
der as a prophylactic means with, they state, great
success.
At von Eiselsberg's surgical station, I am told th?'-
for over a year the Carrel-Dakin treatment has beerr
carried out, not only in recently wounded men com-
ing directly from the front but those who offer in-
fected wounds of even serious nature, the receipt
of the injury dating back for at least three days or
more. He is loud in his praises, believing that the
results obtained are remarkable in as much as the
solution attacks the bacteria but with only a mild
948
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
action on the tissues and the production of hy-
peremia.
Some fifteen years ago you will remember that
von Mikulicz introduced injections of nucleic acid
as a prophylactic measure against suppuration fol-
lowing operations. This treatment has been revived
in Germany during the war but has been given up
since E. von Grafif showed that it was devoid of any
real value and also because of the untoward effects
to which nucleic acid gave rise — particularly a high
elevation of the temperature.
Among other substances having a more or less
bactericidal action, the Germans have used subcu-
taneous or intravenous injections of coUargol, and
find that besides mducing leucocytosis, this product
has an undoubted action on mild infectious processes.
Heliotherapy, particularly in infected wounds, has
given good results, either by the solar rays or with
the quartz lamp. The irradiation may be increased
by covering the wound with dressings soaked in an
eosin solution as Wiesel has lately pointed out.
From the same viewpoint potassium iodide has been
given to the patients, after which the wound is ex-
posed to the solar rays with the object of Hberating
free iodine vapor in the wound under the influence
of the active rays.
The use of venous stasis against infectious pro-
cesses has also been put to test on a large scale, and
Bier himself has of late resorted to his procedure in
cases of gas phlegmon, but the results do not appear
to be at all convincing. Von Eiselsberg tried it in
one case of gas phlegmon resulting from a bullet
wound accompanied by suppuration in the joints,
and the result was fair, but in numerous other in-
stances of acute suppurative processes, particularly
in the joints, results were unsatisfactory, and the
Vienna surgeon discontinued this treatment.
It is evident that from the large number of
products and methods recommended for the treat-
ment of infected wounds that no one of them has
been found perfect, and it seems safe to say that in
both Germany and Austria more faith is placed in
the Carrel-Dakin treatment and iodoform dressings
than in any other treatment. At all events, the
Huns do not appear to be convinced that chemical
disinfection applied alone possesses any certain ac-
tion upon which one may rely, but they appear to be
unanimously in favor of the French and English
methods of mechanical disinfection, although as a
matter of course a certain surgeon, Friedrich by
name, is given the credit of devising this treatment.
Not only does the Boche want to loot the world of
its goods, but as in the past he loots the scientific
discoveries of others in the most shameless bare-
facedness imaginable.
Therefore, they are now busy with knife, scissors,
and curette in cleaning up their wounds and, as
might be expected, their results in recent wounds
I.ave been as good as those obtained by our French
and English confreres. Their technic appears to
be about the same, namely, the excision of all
necrotic tissue and such as is in danger of becoming
devitalized, this being followed by drainage in the
most declivous portions of the limb. But they insist
on the fact that the best results are obtained in fresh
wounds — a fact well established for some time.
For the treatment of gas phlegmon, Schaffer rec-
ommends the introduction of small gauze bags filled
with a preparation called hyperol into the wound,
likewise powdered crystals of potassium perman-
ganate. Springer, after freely incising the tissues
insufflates a ten per cent, iodoform-carbon powder
in the wound. Denk, who has noted an odor of
acetone in these phlegmons, has successfully em-
ployed intravenous injections of sodium carbonate
(a treatment useful in diabetes) in doses of from
500 c.c. to one litre of a five per cent, solution. But
the consensus of opinion is that gas phlegmon should
be treated above all by free, deep incisions, and if
this is unsuccessful, amputation must be done.
And speaking of amputation, the following seem
to be the rules generally adopted by the Huns. Am-
putation is indicated: i, when there is extensive
crushing of the limb ; 2, when the limb is cold and
no pulsation can be detected or when gangrene is
already manifest ; and 3, when the patient's general
condition is bad and the radical removal of the dis-
eased focus can only be attained by removal of the
involved member.
In all other cases long, deep incisions should be
resorted to, followed by excision of all necrotic
or suspicious tissue, and, if necessary, deep incisions
into the muscles are to be made. The wound is kept
open by gauze plugging in order to prevent the edges
from coming in contact with each other.
The Huns also insist upon the importance of
making an early and exact diagnosis of gas phleg-
mon. For this they rely upon the clinical symptoms,
such as the expression of the patient's face, the sen-
sation of tension complained of, and the tympanic
note obtained by percussion, the latter sign being
particularly insisted on by Bier. However, some
surgeons quite rightly point out that crepitation may
only occur when the process is advanced and that
gas production in a wound is not of necessity a
proof that gas phlegmon exists.
The results obtained with Conradi's perfringens
serum are doubtful, and the Hun surgeons about
this time were singing a hymn, not of hate, but of
hope that some prophylactic serum might be discov-
ered for gas phlegmon, as well as for suppurative
processes in general.
Since their fearful losses from tetanus during the
early months of the war, the Germans have become
convinced of the necessity of prophylactic immun-
ization against the tetanus bacillus, and now admit
that the French were correct in their practice of
immediate injection of antitetanic serum in every
case of injury, no matter how trifling.
It seems to be the general practice of the Huns
not to interfere with wounds at the dressing station
except to control hemorrhage. Instead of irri-
gation they prefer to apply an aseptic gauze dress-
ing and then transfer the patient to the field hos-
pital.
The Germans have also adopted the viewpoint of
the Italian surgeons, namely, that experienced sur-
geons should attend to the wounded at the field
hospital and not to have the cases attended to by
young and inexperienced men. It is apparent that
we have nothing to learn from German Kultur in
the surgery of warfare.
November 30, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
949
MODERN MILITARY ASPECTS OF LUNG
SURGERY.
Views of French, Italian, and British Surgeons.
Several distinguished surgeons were detailed by
the French, Italian, British, and American armies
to attend the Clinical Congress of the American
College of Surgeons, which was to have been held
in New York in October. On account of the epi-
demic of influenza prevailing at that time, plans for
holding a congress this year were abandoned. The
delegates visited several of the larger cities of the
United States and the training camps for medical
officers. Several of them delivered addresses before
the College of Physicians and Surgeons on Wednes-
day afternoon, November 6th, a report of which
appeared in the New York Medical Journal for
November 9th, and a dinner was given in their
honor by the New York Fellows of the American
College of Surgeons, at Delmonico's, in th'; evening.
At a stated meeting of the New York Academy of
Medicine, held on the evening of November 7th,
surgery in the war zone, with special reference to
surgery of the thoracic cavity, was discussed by
them. Dr. Walter B. James, president of the acad-
emy, occupied the chair.
Doctor James in introducing the speakers,
said he felt that this was an exceptional occa-
sion, even for an academy audience, and occur-
ring on an exceptionally interesting day, in
which the outbreak of cheers and enthusiasm in
New York that greeted the announcement of the
advent of peace must be echoing around the world.
Everyone knew what the Allies had suffered during
the past four and half years of war and what it
would have meant if their line of defense had
broken down. There were many who liked to think
that the medical men, not only those fortunate
enough to be in khaki, but those who stayed at home
and did their part, had had a share in the winning
of the war. There had been dreadful losses from
disease alone in previous wars and unless a different
state of affairs had existed during the last four and
a half years than that which existed during the
Civil War, the Boer War, and other wars, it would
have been impossible for armies the size of those
engaged in this last great struggle, to have endured
so long. Those who carried stethoscope and scalpel
instead of sword had lent a good hand in the
glorious outcome. It was very gratifying to have
here a group of men representing surgical science
among the Allies, a group standing at the very top
of the medical profession. It was a pleasure also'
to feel how closely this war and its accompanying
trials had drawn the members of the medical pro-
fession throughout the world together, that is, that
part of it which was worthy. The closeness of the
ties that had been created had reached even those
who had not been able to go to the front, and there
now existed so strong a fraternal feeling among the
surgeons of France, Italy, Great Britain, Belgium,
and America, that it was with strong emotion we
viewed the presence of some of them on the plat-
form. We had lived to see the peritoneal cavity
handled with impunity under the protective influence
of modern surgical methods, but it came as a sur-
prise to learn that the thoracic cavity had been con-
quered and that surgeons no longer hesitated to
treat the contents of the thoracic cavity any more
than they did the abdominal cavity. The first
speaker was a man Who had done much to develop
lung surgery, Major Pierre Duval, consulting sur-
geon to the French Army.
Major Duval expressed his pleasure at the op-
portunity to present a few of his views on thoracic
surgery which had developed greatly during this
war. At one time the chest was considered inac-
cessible, but now it, as well as the lung, was dealt
with the same as the organs of the peritoneal cav-
ity. This development had passed through several
stages. At first it was thought that these wounds
should be treated expectantly, but it was soon recog-
nized that the mortality was very heavy, the death
rate, for the French, reaching forty-five per cent.
Then they tried the experiment of treating chest
wounds according to the same principles which had
been found useful in the treatment of wounds of
other parts of the body. In the French army this
principle had been extensively applied, though per-
haps less extensively than in other armies. Almost
any war wound could be cured by the treatment
conducted according to one principle, the excision
of all traumatized tissue and primary union. With
this, one could expect to have results in fifteen days.
This principle could be applied to lung wounds, for
a technic was soon devised which permitted access
to the lung and the treatment of it in a very safe
way, which had been a great revelation in chest
surgery. It was hindered in the beginning of the
war by the slowness in abandoning the principle de-
rived from German schools, that the lung should
not be touched except with special appliances which
made it safer, but in time the method was adopted
of opening largely the chest wall and not being
afraid of the production of artificial pneumothorax.
The lung was seized, pulled out of the wound, in-
spected and sutured, the same as might be done
with the intestine. Having this technic well started
lung wounds had been treated under three condi-
tions. First, when death threatened because of se-
vere hemorrhage which usually brought a man to
death in a few hours ; secondly, when asphyxia
menaced; thirdly, when the lung wound itself did
not seem dangerous but might bring about danger-
ous infection. In hemorrhage the results had been
the following : In these cases the rule had been to
open the thorax, check the hemorrhage and suture
the wound, and the result was a saving of sixty-five
per cent, of the men who had severe hemorrhage.
In the cases of torn open chest, not only was closure
of the chest wall resorted to but also the lung was
inspected and its wound treated. The results had
been about the same as for the cases of hemorrhage.
In the chest wounds with lung lesion the chief com-
plication was infection which came from the lung
itself or from a foreign body lodged therein. It
was clear that the best way to prevent such infec-
tion was to remove the foreign body, treat the
wound according to the general principles of war
wounds by the excision of the margins of the wound,
check the hemorrhage, and suture the lung wound
and chest wall. The general results obtained with
this method showed that while, previously in army
950
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
hospitals, the general mortality was about thirty per
cent, for chest wounds; after the adoption of this
method the mortality was lowered to nine per cent.
It had been a total revelation in chest surgery. The
method was based on two principles ; first, large
opening of the thoracic wall, producing pneumo-
thorax, total" and complete, with prolapse of the
lung ; secondly, taking hold of the wounded tissue
and pulling it out and treating the wound the same
as any other wound of the body. The creation of
pneumothorax was not dangerous in itself ; the pro-
duction of artificial pneumothorax was without
danger ; part of the technic lay in the large opening
of the chest wall and deflating the lung so that one
could get easy access to the cavity. This was the
technic which Willy Meyer devised for access to the
esophagus. The lung was seized with forceps, each
lobe pulled out of the wound, one by one consecu-
tively, and the wound was treated according to
existing conditions. The thoracic wall must be
closed completely and no drainage inserted. The
pleural cavity was rendered aseptic by the measures
taken and would take care of itself. The results had
been very good and very encouraging. In the last
thirty-three operations performed by the speaker
not a case was lost. In addition, the cure which
was obtained by this treatment was superior to any
other cure obtained by any other means because it
left the function of the lung perfect ; the man came
through not only with his life but with perfect lung
function. In other words, he was a new man.
Lantern slides were then thrown on the screen
illustrating some of the remarkable results obtained
in the lung and pleural cavity after this method of
treatment of the most serious wounds.
Lieutenant Colonel Rafaele Bastianelli, pro-
fessor of surgery, LTniversity of Rome, and con-
sulting surgeon to the Army of Italy, called atten-
tion to the fact that this sound principle as outlined
by Major Duval, would bring good results in civilian
practice as it had in war wounds. In Italy, the
evolution of chest surgery had been the same as in
the other armies of the Alhes. In the beginning of
the war, interference with chest wounds had been
prohibited, but it was very soon noticed that the
percentage of mortality under the expectant treat-
ment was very heavy, from missiles coming from
both long and short range. They learned that in-
fection came from the lung wound as well as from
the external wound. The external wound attracted
their attention first and they began to treat it first,
by the removal of the splinters of fractured rib and
suturing for primary union. They tried to bring
about a union which would be air tight. This was
the first principle and it proved very sound, for the
patients so treated improved at once. Secondly,
their attention was drawn to the lung wound itself
and in this respect they adopted the same procedure
which Doctor Duval had described. Chest wounds
could be divided into two categories : First, those
in which the wound was closed naturally and did
not permit of air coming in, and secondly, those in
which the wound was open. The question of treat-
ing the second series of cases by the Duval method,
called the complete operation, was very easy, espe-
cially if the chest wall was largely opened, for in
this case it was natural to inspect the cavity and
examine and clean the lung. But in those with
closed chest wounds it was for the purpose of pre-
venting infection from the lung itself that the
principle was adopted of examining the lung wound,
and for this a more simple method had been adopted
than that used by Duval in the French Army and
Cask in the British. Their method was easy for
them but it was not easy for every one, in particular
for the inexperienced surgeon, and it was better
that the wounded man should go home with an im-
perfect lung than that he should not go home at all.
A few words might be apropos about the wound
itself. The lung wound, as was well known, was
sometimes a perforating one and sometimes not.
There were also contusions of the lung which were
very important. The lung wound bled, and the
bleeding was so intense that sometimes the man ar-
rived at the hospital almost bled to death. Another
kind of wound was the one where there was a small
amount of blood in the cavity on first examination,
but the next day the amount was larger, and the
next day still larger, exploratory puncture removing
pure blood which meant that hemorrhage was still
going on. These prolonged hemorrhages were more
frequently encountered than one would expect.
Respiration acted as a pump causing constant suc-
tion on, the wound and the torn vessel was kept
open. The chest wall was naturally not immovable
which was unfortunate for the healing process of a
wound. Nevertheless, when a man had a wound of
the lung with hemorrhage in the pleural cavity it
was many times observed that a cure was ef?ected
by nature. The factors which stopped the hemor-
rhage were thrombosis of a vessel, or pressure
exerted on the vessel by blood in the pleural cavity,
or by air — the pneumothorax. That the blood might
exert favorable pressure, however, was not ad-
mitted. As soon as the chest cavity was opened the
lung could be seen to collapse, becoming very small ;
the vessels did not appear and the hemorrhage did
not show. If artificial collapse of the lung could be
produced hemorrhage could be checked by putting
it in a condition of immobility which was essential
for any wound. If the blood was left in the cavity
it sometimes clotted extensively and this was a fav-
orable medium for infection and the lung took on
adhesions from the partial expansion. If the lung
was completely surrounded by air it could not take
on adhesions. If the pressure of the air was in-
creased the lung would be effectively compressed.
When the air began to be resolved the lung ex-
panded and even if there was no inflammation there
would be adhesions, and these adhesions would cor-
respond to the position of the lung. This kind of
adhesion was not unfavorable for function. From
these principles came the consequence that when a
patient presented a closed wound and lung wound
it was necessary to remove the blood from the
cavity of the pleura and introduce air in the cavity,
putting the lung at rest. This was called artificial
pneurnothorax and was introduced by the late Doc-
tor Murphy, of Chicago, for the treatment of
tuberculosis. The procedure could be summarized
in a few words. Close any case of wound of the
chest wall which was open and close it air tight; if
November 30, 1918.] MEDICINE AND SURGERY IN THE ARMY AND NAVY.
there was a big gap, suture the muscle as well as
possible, put a plug on top and suture the skin on
top of the plug for a few days, and if expansion had
followed the plug could then be removed. In an
emergency rubber bags had been found useful; they
could be inflated and the man was at once changed
to another condition, breathing quietly, and the rest
of the treatment could be done later. Secondly, as
much blood as possible should be removed. Thirdly,
air should be put in with some apparatus, or in other
words, artificial pneumothorax should be done.
There were a few contraindications, for instance,
when the lung was adherent, and if there was ex-
tensive emphysema, it was advisable to free the
lung ; when the chest wall could be closed totally
or when through the lung wound the air escaped
into the trachea. In these cases one had to resort
to complete operation. There was no danger in re-
moving the blood from the pleural cavity. The lung
tended to expand and the wound to break open and
produce infection, but if air was introduced just
preceding or at the time of removing the blood, this
was obviated. Suppose there were adhesions and
one went into the lung with the needle, there was no
danger of air embolus if the apparatus of Professor
Morelli was used. In 290 cases of penetrating
wounds the mortality was only eighteen ; 206 of
these patients had closed chest wounds and of these
seven died : eighty-four had open chest wound and
of these eleven died. This low mortality rate con-
vinced the speaker that artificial pneumothorax in
these conditions was worthy of being studied.
Sir Thomas AIyles, consulting surgeon to the
British Army, agreed with Professor Bastianelli
that there were not many surgeons at the front with
the skill of Major Duval or Colonel Cask who had
been most successful in the early treatment of chest
wounds, and there had been sent back many men,
injured in the chest, who still had projectiles im-
bedded in their lungs. The fact that these patients
escaped the surgeons at the front and reverted to
the surgeons at home was due to the exigencies
which were so dreadful in wartime. It was impos-
sible when one had 500 to 600 patients waiting for
attention to pick and choose, and if a man was not
losing very much blood or suffering too much from
shock, the surgeon could not sacrifice the time
necessary to look into that lung when another man
beside him was bleeding to death from a wound of
the femoral artery. So when these patients reached
the base hospital they presented a variety of condi-
tions. Some of them might have a bullet in the
lung but giving no trouble. The majority had
physical signs, though some had none. Nearly all
had symptoms, such as pain in the chest or shortness
of breath on efTort. When called upon for extended
effort of any sort they complained of shortness of
breath and frequently of pain in the side. So that one
had to deal with men who, in addition to the x ray
evidence, presented objective symptoms. Added to
that was another phenomenon ; many a man with a
vivid imagination developed a "bullet in his mind"
and every time he got short of breath he attrib-
uted it to the bullet in his lung. There were two
schools of thought as to how this latter problem
should be approached. In regard to the extraction
of projectiles, Moynihan believed they could all be
reached from one spot, but Turner believed that it
was not justifiable to adopt the customary method of
approach and was certain that one should approach
the projectile in the lung by the shortest route.
The operation devised by Moynihan and practised
by many surgeons in the British Isles was as fol-
lows : It was first necessary to make a careful ex-
amination of the chest with the cooperation of the
radiographer and with the physician by auscultation,
palpation, percussion, etc. Incision was made along
the fifth rib along the lateral line of the sternum and
extending about five inches. The ril) was lifted up
through the intercostal space. The next step was to
divide the pleura and periosteum. If the lung col-
lapsed it presented a picture different from that to
which one was accustomed. When a lung was in-
flated it was very large, but when it was collapsed it
shrank to a very small compass ; it was no bigger
than a hand. It was also no longer vascular; it was
practically bloodless. One was now dealing with
something that was quite mobile and which could be
handled with perfect freedom. All that was neces-
sary was a rather large forceps. The lung could be
moved from the thorax in whole or in part. On the
other hand one might come to a series of cases in
which there was partial adhesion and it was ad-
visable to break these down when possible to do this
with safety. This could be done by gentle manipu-
lation in some cases and in other cases with the
scissors, but one could generally succeed in detach-
ing the lung from the pleural parieties. If the cause
of the persistent symptoms were the adhesions then
one should try to cure these adhesions and this
coidd be done if one could keep the surface of the
pulmonary pleura and the parietal pleura apart for
a few days. When the adhesions were broken down
the next step was to swab out the thorax thor-
oughly, it being especially necessary to remove all
of the blood found in the cavity. It was possible
to leave the cavity quite clean. The lung was then
put back into place, the rib replaced in its normal
position and sewed there, the edges of the muscle
drawn together and the skin completely closed and
no drain was ever applied. Pneumothorax was of
great value in promoting recovery.
Now one came to cases where the lung was
believed to be adherent and where just from a
priori evidence the shortest route was not from the
fourth rib. If there were extensive adhesions one
could understand that it might be easier to reach
the bullet from elsewhere than the fourth rib. If
the bullet could be extracted more easily from below
this was done. Many American soldiers would
come back with fragments in the lung and Ameri-
can surgeons would probably find improvements in
method and technic over those developed abroad in
the last few years, but they had done what they
could over there and with a fair measure of suc-
cess. Here in New York was the home of the great-
est experimental institutions in the world, and the
speaker suggested that it would be v/ell to start ex-
perimental work in many directions along the line
of after war surgery, particularly on the brain, and
he suggested as excellent subjects for experimental
work in the latter branch, the Hohenzollern family.
95-'
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
MEDICAL NEWS FROM WASHINGTON.
Permanent Commissions in Army and Navy. — Admirable
Work by Medical and Hospital Corps. — Appointments in
Medical Corps.- Actiz'ities in Public Health Service. —
Military Rank for Army Nurses.
Washington, D. C, November 26, igi8.
Some consideration has been given in both the
army and navy to the subject of keeping perma-
nently in the Medical Corps of those services some
of the physicians and surgeons who have been serv-
ing under temporary commissions for the period of
the war. Of course, it is not believed that many
members of the medical profession who had large
and remunerative practices in civil Hfe would be
willing to stay in the army. For one thing, the
salaries attached to the commissioned grades are
too low, as compared to their civil incomes, so that
generally they could not afford to accept perma-
nent army commissions. On the other hand, there
are many serving temporarily in the Medical Corps,
some of whom had extensive practices in civil life,
who like army life and would be glad to stay.
It will be necessary to change the law to permit
permanent appointments to be made in grades above
that of first lieutenant in the army and junior heu-
tenant in the navy, and to permit appointments to
be made to these lower grades in cases of those over
thirty-one years of age.
Legislation in this connection now is being
drafted for the navy. If the plan is approved by
Congress, all medical officers of the navy now
serving in a temporary status may be authorized to
appear before examining boards to determine their
qualifications for commissions in the permanent
establishment in the grades now held by them, and
reserve officers in grades not higher than that of
lieutenant. In case the bill becomes a law. those
temporary medical officers and medical officers of
the naval reserve force who desire to enter the
permanent Medical Corps will be expected promptly
to signify their wishes to the Surgeon General of
the Navy. It is contemplated to examine the candi-
dates for the grades they now are holding— except
that reserve officers are Hmited to the grades of
lieutenant and junior lieutenant ; but, if a candidate
fails to qualify for his present rank, the examining
board may recommend appointment to a lower rank.
Brigadier General Jefferson R. Kean, Medical
Corps, recently on duty with the American Expedi-
tionary Forces in France, is on sick leave.
^ ^ ifi
Colonel Charles R. Daniall, Medical Corps, has
heen assigned to duty as executive officer of the
Office of the Surgeon General of the Arm v. He
was chief of the division of supply and finance up
to the time the duties of that division were taken
over by the general staff'.
The following promotions have been made in the
Public Health Service : Passed Assistant Surgeon
French Simpson to surgeon, and Assistant Surgeons
Robert L. Allen. Ora FT. Cox, Marion S. Lombard,
Carl Michel, William F. Tanner, and William C.
Witte to passed assistant surgeons.
The Commander in Chief of the Atlantic Fleet,
Admiral Henry T. Mayo, has taken occasion, in a
letter published to the fleet, to express his appre-
ciation of the work performed by the officers and
men of the Medical and Hospital Corps durino- the
recent epidemic of influenza. The admiral com-
mends the {personnel of the medical department for
their untiring care of the sick, in the restriction of
the spread of the epidemic in the fleet, and an entry
has been made upon the record of each of them em-
bodying his commendation.
Deficiency estimates aggregating $2,054,000 for
the Public Health Service have been sent to Con-
gress. The appropriation is urgently needed for the
following reasons ;
The increase in the officers of the higher grades
of the service becomes necessary at this time, so
that important health activities may be satisfactorily
directed and directors assigned to sanitary districts.
An appropriation of $2,000,000, to become im-
mediately available and remain available until ex-
pended is required to enable the service to carry
out the respsonsibilities with which it now is charged
by existing law and by the executive order of July
I, 1 91 8, placing all public health and sanitary activi-
ties due to the war under the direction and control
of the Secretary of the Treasury.
Among the duties with which the Public Health
Service now is charged, are the following: Sanitary
supervision of areas adjacent to cantonments and of
other areas to which the soldier and sailor have free
access : sanitary supervision of government works
and adjacent zones ; cooperation with State and local
health authorities in sanitary work ; sanitary super-
vision of shipyards and shipyard personnel; co-
operation with the Department of Labor and with
the Army Ordnance Department in the hygiene of
war industries ; medical and surgical care of seamen
of a greatly increased merchant marine, patients of
the War Risk Insurance Bureau, and injured fed-
eral employees ; operation of a national system of
maritime quarantine; control of interstate spread of
disease ; control of venereal diseases ; and railroad
sanitation.
Efforts to secure military rank for armv nurses
have been renewed. A pending bill provides the
relative rank of major for the superintendent of
the Army Nurse Corps ; rank cf captain for assist-
ant superintendents, directors, and assistant di-
rectors ; first lieutenant for chief nurses ; second
lieutenant for ward nurses.
It is proposed that thev shall have authoritv as
regards medical and sanitary matters, in and about
hospitals, next after the medical officers of the
army, and shall wear the insignia of their rank.
The proponents of the legislation claim that nurses
are handicapped by lack of authority and conse-
quent conflict with enlisted men on dutv at the
hospitals. Thus far. no official endorsement of the
measure has been forthcoming from the War De-
partment, although at a hearing before the House
Military Committee Colonels V. C. Vaughan,
Franklin H. Martin, and William J. Mayo ex-
pressed approval.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D-
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT FUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price:
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, twenty-five cents.
Remittances should be made by New York Exchange,
pest office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Oi?ice at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, NOVEMBER 30, 1918.
DEMON OR GERM.
"There, I told you so thousands of years ago — it's
all due to the demons." Professor Jastrow, who is
well able to translate for us what they said and how
they said it in ancient Babylon and Assyria thou-
sands of years ago, hears this word out of the past
shrieking itself today into the ears of the "ultra-
modern pathologist." He brings together a great
number and variety of interesting facts out of such
early records and foreshadowings of medicine and
surgery [Morris Jastrow: Babylonian-Assyrian
Medicine, Annals of Medical History, October,
1917I.
On the one hand, the believer in demon posses-
sion as the source of disease who lived in those past
days may seem himself, could he return, to have
long ago discovered the same truth to which science
has laboriously progressed. On the other hand, we
may consider unspeakably absurd the ancient ex-
planation in the light of exact science and its in-
vestigations. If, however, evolution of thought and
knowledge as of material forms is conceived in its
essence, will there not be found a something which
is the same, existent under two dissimilar forms of
expression ? Language is an external garment
which thought wears. True, that it conforms
largely to its inner vital content just as the child's
carelessly dropped glove is eloquent of the interests,
the activities, the very moods in which that child is
accustomed to pursue its aims.
Demonology, therefore, or bacteriology, be-
come the two ways of expressing the same thing,
divided by centuries of experience and growing
exactitude, but activated by the same need to search
and find not only health but knowledge and inter-
pretation of processes and events which so vitally
concern the race. This point of view puts a new
value upon such studies as these because it finds
that the history of medicine and its progress, even
through mistake and seeming absurdity, has been
continuous, and so there is greater illumination of
the essential nature of the art of healing in its re-
lation to human need.
The beginning of the study of anatomy among
these ancient peoples lies, according to this writer,
in the practice of divination, and that expresses just
as strong a need for safety, success, and efficiency
generally as does the healing of sick bodies. The
observation of the livers of sheep, the sacred ani-
mal, brought to light the great number of diflfer-
ences in their structure and condition. These varia-
tions were held to be indicative of the accord
between the liver as the seat of the soul of the
animal and the god to which it was consecrated.
Specialists therefore had to be trained in liver anat-
omy and in the interpretation of the differences
discovered. Out of such an earlier beginning an
elaborate and detailed study and anatomical system
of names, at least, arose. The accuracy of the
anatomy is somewhat obscured by the, to a large
extent, figurative nomenclature, but there is evi-
dence among the many terms of an extensive fol-
lowing out of anatomical study along the lines
which actu.al practice demanded. The surgeon was
not held in high repute, for dealing as he did with
external evidences of disability, his failures could
not be shoved off, as in the case of medical prac-
tice, upon the demons of possession, and therefore
he had to stand or fall by the more than obvious.
The medical man, however, wis the representa-
tive of the deity who presided over the water cure,
a purifying rite directed against the possessing or
nifecting demon. Gradually he passed over into
the tiue physician when actual medical remedies
were added to the mere symbolic treatment. The
continuation of the use of remedies, together with
tilt incantation, is interestingly pointed out to exist
954
EDITORIAL ARTICLES.
[New York
Medical Journal.
still amoiij; those who consider the mysterious
prescription as efficacious as the actual ingredients
prescribed or at least an essential supplement to
their virtue. The list of medicines which gradually
term an extensive pharmacopseia include many
herbs, parts of certain trees, rock salt, and am-
moniac, and also many substances from the human
and animal body. The latter probably constituted
not so much a means to drive forth the demon by
their disgusting qualities as the author believes, but,
we can readily believe, had in themselves some par-
ticular virtue by reason of their symbolism and the
homeopathic magic therein contained to work in a
more positive manner their effect upon the ills
which the possession created. These substances
were admmistered internally or applied in various
external ways. With all this there is a gradual
building up of a medical science through all the
vagaries and obscurities of superstition and demon-
otherapy and magic use of natural means. The
incentive behind and within it lies in the ceaseless
effort and necessity of man to discover and apply,
not merely the means of healing his diseases, but
that power over his environment and his own ability
to exercise himself in the fullest use of himself,
which is the very essence and complete meaning of
health. We may have called it a demon yesterday,
and may call it a germ tomorrow. Our effort against
it is the same, our strife arises out of the same
necessity operating without interruption. It stimu-
lates the gathering of more knowledge, digging
deeper in investigation. It values also in this spirit
the acquisitions of the past, and recognizes neces-
sarily a psychology which makes all this actual, and
in continuing the struggle, makes it progressive.
The continuity of such historical study represents
therefore the continuity of that which exists within.
NAPOLEON AND MEDICINE.
The physician and patient are made up of the
same sort of clay, and have experience with the
well or ill working of the same sort of bodily
machine. Save for a little technical knowledge,
their mental traits and degree of clairvoyance of
truth average much alike. But many laymen
have far keener mental insight into the gen-
eral working and management of the body
than many physicians, and are, besides, un-
trammeled by the traditions of the trade. Tra-
dition does not hold sway in medicine as it
once did, but undoubtedly it blinds many of
us more than we realize. A century or two ago
the role and rule of tradition were far stronger,
and, prior to the nineteenth century, the best ad-
vice on health matters was, with some rare ex-
ceptions, found not in books by physicians, but
in the teachings of Locke, in the essays of Bacon
and Montaigne, of Addison and Franklin, in the
sallies of Moliere and the talk of Samuel John-
son. The routine medical practice of the times
was not held in high esteem by these seers, nor
did it deserve more at their hands.
No keener Gordian knot cutting mind than
that of Napoleon ever looked into medical prac-
tice, and his remarks on the subject were signifi-
cant. Like two great contemporaries, Washing-
ton and Jefferson, he looked indulgently upon
physicians as necessary to society and he always
had several in his service, but he was exceedingly
wary of their advice and preferred his own drug-
less treatment to the powerful physic of the time.
Napoleon liked to converse with physicians
about their art, and he was so much interested in
the body that he had his professional attendant,
Corvisart, bring him some wax models of the
heart, stomach, and other organs. His anatomi-
cal studies were cut short, however, by the fact
that the models made him sick, for, strange to
say, though when in camp he could be callous to
all disagreeable sensations, in the palace he was
extremely sensitive to offensive sights and
smells.
Napoleon considered that bleeding — a treat-
ment for wounds as for all other ills — was the
withdrawing of so much life fluid, and he be-
lieved that the use of physic "only led to the need
for more physic." He rightly summed up the
current use of drugs as mostly conjectural and
too often harmful. He himself was seldom ill
before his imprisonment at St. Helena, and when
so it was only from hasty feeding. His cure for
this was to fast, to drink large quantities of bar-
ley water, to ride on horseback at high speed
thirty-five or forty miles, and to bring on violent
perspiration by hot baths and many blankets.
After great fatigue he always condemned himself
to twenty-four hours of absolute rest. On one
occasion he went for five days and nights with-
out sleep, but afterward slept continuously for
thirty-six hours.
He had a high opinion of surgery. "Sur-
geons," he said, "do not work in the dark as do
the physicians. There you at least have day-
light, and your senses to guide and assist you."
Napoleon had a great regard for Larrey, head
surgeon with the army, of whom he said that "in
the most inclement weather, and at all times of
the night or day, Larrey was to be found among
the wounded. He scarcely allowed himself a mo-
November 30, 1918.]
EDITORIAL ARTICLES.
955
ment's repose, and kept his assistants eternally at
their post. He tormented the generals, and dis-
turbed them out of their beds at night whenever
he wanted accommodation or assistance for the
wounded or sick. They were all afraid of him,
as they knew he would instantly come and make
a complaint to me."
Corvisart was the only member of his numer-
ous medical staff in whom Napoleon felt much
personal confidence, and that confidence ^eems
to have been aroused, not only by his high repu-
tation but by the thoroughness of his physical
examinations and by the simplicity of his means
of cure, which, in the case of his first treatment
of his illustrious patient, consisted in the applica-
tion of a mustard plaster to his chest.
We are indebted for much information, in re-
gard to Napoleon's last years, to O'Meara, the
British naval surgeon who served him at St. He-
lena. O'Meara seems to have been far more use-
ful for his society than for professional purposes ;
for Napoleon sufifered most in his island prison
from scurvy, and the medicine of the times was
as helpless in its treatment as it is today in the
cure of the disease of which the Emperor died —
cancer.
DOMINION LEGISLATION FOR VENE-
REAL DISEASES.
Education in Canada directed toward the people,
for two decades, in regard to many matters of
public health, has brought about a profound
change in the mental orientation of the public.
Formerly they were apathetic, indifferent, suspi-
cious even of professional advocacy of a measure
looking to the good of the public. They could
not quite understand how it came about that the
doctors who profited by much sickness were the
first to call for medical officers of health, notifi-
cation of disease, isolation, quarantine, medical
inspection of school children, ministries of health,
etc. For many years the people stood aloof,
complacently looked on, and wondered where the
"nigger in the fence" was, but they could not see
him. Gradually some really public spirited citi-
zens were brought around, and even the news-
papers, at first decidedly chary, began to publish
isolated items of public health news ; now they
tumble over one another in their eagerness to
make a "scoop." Not only that, but ever with a
watchful eye, woe betide the medical officer of
health who makes a mistake, or appears to be
derelict in his duty! Why and wherefore the
change? Large sums of money are now being
spent by federal, provincial, and municipal gov-
ernments and the taxpayer simply wants to know
if he is getting the worth of his money. That
the people are prepared to go the limit in expense
in order to protect communities from communi-
cable diseases seems assured; and the now active
interest on the part of many citizens, both among
the educated and wealthy, points to a brilliant
future for preventive medicine. Quite recently
they have become vitally interested in the vene-
real disease problems and their prevention and
eradication.
While several or most of the provinces in Can-
ada have enacted legislation to govern the vene-
real problem, the Dominion as a whole has not
yet manifested any particular desire or interest
to cooperate. Dr. Peter H. Bryce, Ottawa, chief
medical officer of the immigration department,
in a letter published in the Canadian Medical As-
sociation Journal, points out that, in view of the
diversity of provincial health laws, some federal
legislation is essential to the fullest control of
venereal diseases throughout all of Canada ; the
situation demands a central authority at Ottawa.
To make a slight digression, the Canadian people
were probably more seized of the desirability and
practicability of a ministry of health in the Cana-
dian cabinet during the progress of the epidemic
than ever before as, so far as is known, no at-
tempt v^hatever was made to keep the influenza
out of the Dominion — and the full returns will
show that the scourge took a toll in deaths that
was appalling. Any such public health author-
ity must of course dovetail in with the adminis-
tration of public health matters in all the prov-
inces.
To quote from Doctor Bryce : "What the sit-
uation seems to demand is a resolution setting
forth the dangers to the public and to the nation
of the presence and continued prevalence of ve-
nereal diseases among the people, the existence
of well attested means of treatment and cure, and
a statement both of the need for federal legisla-
tion to coordinate official action between the fed-
eral and provincial authorities, and some indica-
tion of how this can best be brought into effect."
Canada, like other nations, has learned much
from war. To back up those at the front, the
Dominion has just shot past its objective in the
fifth Victory Loan by $100,000,000. To war
against diseases at home the people will never
again whine against large expenditures where hu-
man life and health are concerned. Will they
not rather demand of governments that they raise
special loans from the people for these purposes
where the money is not forthcoming from ordi-
956 EDITORIAL
nary revenue? With Canada's depleted popu-
lation and diminution in man efficiency on ac-
count of war mutilation, the country will need by
every means in its power to conserve efficiency,
health, and life in every way. The people can
have as much health as they are willing to pay
for.
TORPEDO SHOCK.
It would be surprising if during the four years
of the world storm just subsiding, great search-
lights were not thrown upon the psychology of
the people, revealing them as "all too human," to
quote the half mad prophet of the superman.
The emotional strain incident to haling civiliza-
tion forth from the path of peace and thrusting
it into the ways of war has had the same effect
upon individual psychology that the gradual
strain accompanying years of ineffectual adjust-
ments and unappeasable demands would have
had ; and acute manifestations of psychoneuroses
came into being, to which the euphonious and
alliterative name of shell shock was given.
Analogous cases have lately come to the atten-
tion of the military surgeon where the fright and
fear due to ships being torpedoed have given rise
to symptoms suggestive of shell shock. Doctor
Clunet, in a communication to the Neurological
Society of Paris, has described the mental effects
observed when on board a ship which was tor-
pedoed. He divides the phenomena somewhat
arbitrarily into four stages, but this classification
has no psychological value. He distinguishes a
first stage, from the time the ship was struck
until it sank ; a second, on the life rafts ; a third,
on the rescuing ship ; and a fourth, a return to
normal.
After the first stupefaction following the at-
tack, it was observed that several passengers dis-
charged guns into the air or into the sea. In
other words, the pentup nervous energy found re-
lease in letting loose the immense energy concen-
trated in explosives. Similarly it is well known
at the front that a long day of waiting in the
trenches is productive of more cases of shell
shock than a day of active engagement with the
enemy.
Next cases noted, chronologically, were a few
cases of suicide among the passengers. These
passengers were on the whole calm enough, even
on the life rafts. It was only when they were on
the rescuing ship that psychoneurotic phenom-
ena began to develop, including mutism, spas-
modic weeping, laughter, tremors, spasmodic
movements of the limbs, etc.
ARTICLES. [New York
Medical Journal.
All the symptoms shown disappeared after a
short time, which is what we should expect. In
shell shock recoveries are much more difficult to
effect, and many cases go on to actual psychoses.
TPIE ANTISCORBUTIC PROPERTY OF
DESICCATED VEGETABLES.
Resort to the desiccation of vegetables on a large
scale^during the past year has given importance to
the question of whether or not vegetables thus treat-
ed retain their antiscorbutic properties. The answer
is of serious import since desiccated vegetables
are issued to the Army under certain circumstances.
The subject has been studied by Hoist and Frolich,
v/ho found in experiments on guineapigs that the
antiscorbutic properties of carrots, of dandelion, of
cabbage, and of potatoes were destroyed by pro-
longed drying. Chick and Hume stated that the
antiscorbutic vitamines were deficient in all dried
foodstuffs, the temperature used being a matter of
indifference. The subject has been given further
study by Givens and Cohen [Journal of Biological
Chemistry^ October, 1918J in the Sheffield Labora-
tories of Physiological Chemistry at Yale, who
found that cabbage dried at a low temperature, from
38 to 52 degrees C., appears to retain a great part of
its antiscorbutic value and that some of these virtues
are retained even after drying in a current of air
at 40 to 52 degrees C. Cabbage cooked for thirty
minutes and then dried for two days lost all its anti-
scorbutic virtues. The same was true of potatoes.
The authors do not agree with McCollum and Pitz
that the texture of the foodstuff is a factor in its
antiscorbutic value, in so far as guineapigs are con-
cerned. These experiments are of very great in-
terest at this particular time when the question of
the dietary of large bodies of troops is under con-
sideration.
News Items.
The Navy Wishes to Retain the Medical Staff.— The
Bureau of Medicine and Surgery of the Navy is formu-
laling a bill under which all temporary medical oflicers
of the navy sliall lie offered an opportunity to qualify for
an appointment in the permanent establishment in the
rank now held.
General Gorgas Heads Yellow Fever Commission. —
Major General Williain C. Gorgas, recently retired for
age from the office of Surgeon General of the United
States Army, has resumed his position as chief of the
Rockefeller Commission on Yellow Fever and will soon
sail for Central America to supervise the studies which
are being carried on there by the Rockefeller Commission.
The Discharge of Emergency Officers. — All the
emergency officers in the Medical Corps have received
circulars from the War Department requesting that they
-tate whether they wish for (i) immediate and complete
discharge from the army, or (2) appointment to the Re-
serve Corps, inactive, or (3) appointment to the regular
army. The wishes of the officers will be complied with
in so far as is consistent with the good of the service.
Guarding against Infectious Diseases. — The War De-
partment announces that all troops returning from over-
seas will be kept in observation camps for at least two
weeks prior to embarkation and that suspects will be de-
tained until all possibility of the development of infec-
tious diseases is over. The health of the troops on the
whole is excellent, and the returning troops will be made
Snich more comfortable than on their outward journey.
November 30, 1918.]
NEIVS ITEMS.
957
Navy Hospital Ships in Army Service— The Navy
hospital ships lUercy and Comfort, which can accommo-
date from 300 to 500 patients, are now in French waters
and have been turned over to the army since there were
so few casualties in the navy that they were not needed.
American Physicians Elected to Honorary Member-
ship in French Medical Society. — The Societe medicale
des Hopitaux de i'aris at a recent mc^'tinK elected the fol-
lowing American physicians as honorary members of the
society : Dr. Beverley Robinson, of New York ; Dr. Wil-
liam S. Thayer, of Baltimore; Dr. Alexander Lambert,
of New York; Dr. Simoii Flexner, of the Rockefeller In-
stitute for Aledical Research, New York; Professor Mor-
ton Prince, of Tufts Medical College, Boston ; Dr. James
T. Case, chief of the radiological service of the American
Army in France. At the same time five British physicians
were elected to honorary membership, as follovvs: Sir
Bertrand Dawson, Sir Almroth Wright, Sir William
Leishman, .Sir Thomas Barlow, and Sir Dyce Duckworth.
Personal. — Captain Philip Leach, Medical Corps,
U. S. Navy, will be retired for age on December 28, 1919.
Captain Francis S. Nash, Medical Director, U. S. Navy,
reached the age of retirement on November 23, igi8. His
last assignment to duty was in Washington as a member
of the naval examining and retiring boards. His retire-
ment will create no vacancy, as there is an additional
number in his grade.
Lieutenant James G. Hall, M. C, of Toledo, Ohio, has
been cited for bravery in action near Montauville, on
September 12th and 13th, while serving with the 316th
Infantry.
Lieutenant Colonels G. E. Brewer and A. Lambert of
Nev^ York were promoted on November 12th to the rank
of Colonel, M. C. (Emer.).
Demobilization Problems. — A general demobilization
order was issued by the War Department on Novem-
ber i6th to the effect that the men in the United States
will be demobilized as rapidly as is consistent with the
needs of the government. It is explained by the Secretary
of War that every man who is discharged from the army
has to undergo a physical examination and have a very
careful record made for statistical record and instead of
furloughing and then discharging, they will be discharged
so that there will be no subsequent claims against the
government. All of those men will have to be examined
by the doctors and the Medical Department is prepared to
take over the question of rapid examination and discharge.
This will be done as soon as it conveniently can. Pre-
sumably this will do away with the indefinite furlough
for industrial purposes provided for in General Order 94,
Section IV.
Debarkation Hospital No. 3 Opens. — On Saturday
afternoon, November 23, Debarkation Hospital No. 3,
which ocupies the Greenhut and Cluett buildings, on the
east side of Sixth Avenue from Eighteenth to Nineteenth
Streets, received its first patients. This hospital, which
has a capacity of over three thousand beds, is under the
command of Major W. J. Monaghan, Medical Corps, and
is cue of a group of thirteen in or near New York city
which come under the stipervision of Colonel J. M. Ken-
nedy, Medical Corps, Surgeon of the Port of Embarka-
tion. The first patients to arrive were a group of eighty-
eight, only four of whom were litter patients. It is ex-
pected that the hospital will quickly be filled to capacity.
The hospital is complete in every detail, including two
moving picture theatres and recreation rooms. When
operated at full capacity, the -complete stafT will comprise
about seventy officers, seven hundred enlisted men, and
two hundred nurses. An escort detachment of about seven
hundred men is also quartered in the Cluett building. The
nurses are quartered in the Trowmart Inn, at Abingdon
Square and Twelfth Street, which has been taken over for
that purpose by the government. This and the other de-
barkation hospitals at the port will be used as evacuation
hospitals, where patients will be received on arrival from
overseas, assorted, and forwarded as promptly as possible
to the special hospitals best suited for their respective
cases and nearest the homes of the patients. Major
Monaghan has been showered with invitations from pa-
triotic citizens who desire to entertain such of the patients
as are able to leave the hospital.
Praise for the Medical Corps of the Atlantic Fleet. —
Albert VV. Gram has issued a circular as Vice-Admiral of
the Atlantic Fleet giving expression to his appreciation
of the work performed by the officers and men in the
medical and hospital corps and praising the skill, the un-
tiring energy and the self-sacrificing effort displayed in
raring for the sick and in restricting the spread of in-
t:i;ei';-a under very trying conditions.
American Women's Hospitals to Stay in France Six
Months. — It is reported that the three units of the
Women's Overseas Hospitals will continue in active serv-
ice in France for another six months. One unit, known
as Doctor Finley's unit, will spend the winter in the vicin-
ity of Nancy. The gas unit, the last to go over, will stay
where it is at present, while another unit, at work among
the refugees in the south of France, will continue its work
of caring for the refugees until they can be taken back
home. At the request of the French War Department,
this unit recently added a one hundred bed unit military
hospital to it;- civilian Vi^ork.
Meetings of Medical Societies to Be Held in New
York.— The following medical societies will hold meet-
ings in New York during the coming week :
Monday, December 2d. — Society of the New York Poly-
clinic Medical School and Hospital ; Brooklyn Hospital
Club.
Tuesday, December 3d. — New York Academy of Medi-
cine (Section in Dermatology and Syphilis) ; Medical So-
ciety of Harlem Hospital; New York Neurological So-
ciety; Society of Alumni of Lebanon Hospital (annual).
Wednesday, December 4th. — New York Academy of
Medicine (Section in Historical Medicine) ; Bronx Medi-
cal Association (annual); Harlem Medical Association;
Psychiatrical Society of New York; New York Urological
Society; Society of Alumni of Bellevue Hospital (an-
nual) ; Brooklyn Society for Neurology (annual).
Thursday, December Sth. — New York Academy of Medi-
cine (stated meeting) ; Brooklyn Surgical Society.
Friday, December 6th. — New York Academy of Medi-
cine (Section in Surgery) ; New York Microscopical So-
ciety; Practitioners' Society of New York; Society for
Serology and Hematology ; Alumni Association of Roose-
velt Hospital ; Brooklyn Gynecological Society.
Saturday, December 7th. — Benjamin Rush Medical So-
ciety.
American Public Health Association to Discuss Iii-
fluenza. — The annual meeting of the American Public
]-Ieaith Association will be held in Chicago, December gth
to I2th, under the presidency of Dr. Charles J. Hastings,
of Toronto. The program will consist principally of a
symposium on influenza and an effort will be made to
bring out all the available information concerning the
management of epidemic influenza, as public health of-
ficials fear a recurrence of the epidemic. The various
phases of the disease will be discussed as follows: Eti-
ology of Influenza, by Major W. H. Welch, Dr. W. H.
Park, Lieutenant Commander Keegan, U. S. Navy, and
others ; Mobilization of Medical and Nursing Forces, by
Assistant Surgeon General J. W. Schereschewsky. United
States Public Health Service, Dr. W. C. Woodward, and
others ; Influenza and Pneumonia Vaccines, by Dr. E. C.
Rosenow, Dr. G. W. McCoy, Dr. Timothy Leary, and
others; The Use of Sera in Influenza, by Doctor Mc-
Guire, Doctor Redden, Dr. H. E. Hasseltine, and Dr. Jo-
seph Goldberger ; The Face Mask, by Colonel Charles
Lynch and Dr. George W. Weaver ; The Value of Open
Air Treatment, by Surgeon General W. A. Brooks, Mas-
sachusetts State Guard ; Organization of State and Fed-
eral Forces in Epidemics, by Assistant Surgeon General
A. W. McLaughlin and Dr. E. R. Kelley; History and
Statistics of the Epidemic, by Assistant Surgeon General
B. S. Warren, Dr. W. H. Guilfoy, Dr. W. H. Davis. Dr.
Lee K. Frankel, and others. Reference committees will
be appointed who will report on the various phases of
epidemic influenza both at the annual meeting and during
the year 1919. While extensively devoted to influenza, the
program also contains papers on other aspects of public
health; mental hygiene, industrial hygiene, social prob-
lems, sanitary engineering, etc. Headquarters will be at
Hotel Morrison, Chicago. Inquiries may be addressed to
the association at 989 Boylston Street, Boston, Massa-
chusetts.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
STROPHANTHUS AND ITS ACTIVE PRIN-
CIPLES VERSUS DIGITALIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
(Concluded from page pi 4)
The value of and indications for intravenous ad-
ministration of the strophanthins, in the light of re-
cent clinical reports, have been discussed in pre-
ceding issues. Evidence suggesting that under some
conditions these principles, when introduced directly
into the circulation, are of greater therapeutic as-
sistance than digitalis was also referred to, with
special emphasis on the possibility that at times the
strophanthins may exert actions qualitatively dif-
ferent from those of digitalis. There remain to be
considered certain recent observations concerning
the oral and hypodermic use of strophanthus and
the strophanthins.
The most interesting of these reports is that of E.
E. Cornwall, 191 8, who believes he has found reason
to establish a clinical distinction between the indica-
tions of strophanthus and those of digitalis, when
used by mouth or hypodermically, somewhat simi-
lar to that already ascribed to Vaquez and his co-
workers in relation to intravenous use. It is a fact
easily verified by experimentation that in the lower
animals strophanthus exerts its pressure and toxic
actions in amounts far smaller than those required
in the case of digitalis. In frogs, for example,
strophanthus, when injected, is lethal in doses about
100 times smaller than digitalis, and among mam-
mals the difference is about equally striking. One
might expect that in the oral employment of these
drugs in man a similar discrepancy in the necessary
dose would prevail ; yet as a matter of fact, in the
official doses of the tinctures of these agents — 0.5
and one mil, respectively — only a one to two ratio
is recognized, while in the case of the powdered
drugs the official doses are alike, viz., one grain in
each instance. This difference in the relative
activities of strophanthus and digitalis when inject-
ed in the lower animals and ingested by man has
been attributed to imperfect absorption of the
former drug from the alimentary tract. Again, it
has been asserted that the active constituents of
strophanthus are so decomposed in the gastrointesti-
nal canal as to lose part of their activity. Some
have laid stress on the variability and uncertainty
of the absorption of this drug, and have been fear-
ful of possible harmful results in individual in-
stances in which, owing to some altered local condi-
tion, the drug might enter the system in a larger
proportion than usual.
In Cornwall's, clinical experience, the view that
the active principles of strophanthus undergo im-
pairment in the alimentary tract has not been sub-
stantiated. In fact, the dose he has found most
effective is smaller than that officially recognized ;
he generally administers but one and a half to three
minims of the tincture every four hours, well di-
luted with water. As a direct augmentor of the
cardiac propulsive function he has found stro-
phanthus to have a wider range of applicability than
digitalis. In young adults with a relatively normal
myocardium digitalis may prove the more effective,
but in all types of heart disease in children requir-
ing direct stimulation, in mitral stenosis, in aortic
insufficiency, and in acute or chronic myocardial de-
generation, strophanthus has proved of greater
value in his experience. In a child of three or four
years, the usual dose is one half minim, and in older
children, one minim or a minim and a half. In diph-
theritic myocarditis, in which the myocardium re-
sponds but sluggishly to heart stimulation when it
is required, somewhat larger amounts are used. In
typhoid fever with notable signs of myocardial de-
generation, Cornwall gives strophanthus tincture in
two and a half minim doses every four hours. Es-
pecially manifest, in his estimation, is the superior-
ity of strophanthus over digitalis in advanced
chronic myocardial degeneration. Ambulant cases
of this class are given one or two minims, and
cases confined to bed, one to three minims every
four hours. It should not be overlooked that ex-
perimental evidence now available does not support
Cornwall's opinion of a regular and dependable ab-
sorption of strophanthus from the alimentary tract.
In common with Vaquez and many others, Corn-
wall deems intravenous injection of strophanthin an
efffcient procedure ; but he resorts more frequently
to hypodermic injection because of the greater con-
venience of the latter mode of administration. The
statement frequently made that hypodermic use of
strophanthin causes intense pain locally has not been
borne out by his experience ; not infrequently local
irritation has been complained of, but this was
usually slight. One patient received three injections
of strophanthin daily for eleven months without
any local disturbance other than a tingling sensa-
tion. As with other remedial agents, the local irri-
tation from strophanthin is minimized by injecting
deeply. A definite brand of strophanthin, made by
a well known firm, is used by Cornwall in doses of
from 1/1,000 to 1/250 grain, every four hours or
less often. Larger amounts, up to 1/ 100 grain, are
given under certain conditions, but never oftener
than once in twenty-four hours. Diarrhea, anorexia,
or nausea, while occasionally noted after oral use of
strophanthus, have never been observed by him from
hypodermic injection of strophanthin. The sub-
lingual method of strophanthin administration, in
which a hypodermic tablet is placed under the
tongue and allowed to dissolve and become ab-
sorbed, also proved feasible.
As mentioned in the preceding installment, Corn-
wall includes various forms of acute cardiac failure
among the indications for hypodermic use of stroph-
anthin. Even in the course of chronic heart affec-
tions, however, he frequently resorts to this pro-
cedure. Thus, in valvular disease with consider-
able decompensation strophanthin is given hypo-
November 30, 1918.] MODERN TREATMENT Al
dermically in the dose of i/ 1,000 grain every four
hours. In extreme decompensation in mitral ste-
nosis, with auricular fibrillation, it is similarly used
in doses of 1/500 or even 1/250 grain, usually in
conjunction with enough morphine to alleviate
dyspnea and restlessness. At times, to maintain
compensation after it has been restored, stroph-
anthus in reduced doses is continued for an indefi-
nite period.
On the whole, it would seem that enough data
have been presented in this series of communica-
tions to suggest, rather strongly, that there exist
definite differences in the clinical actions and indi-
cations of digitalis and the strophanthin bodies.
These differences, if substantiated by additional
studies, will manifestly enlarge the already exten-
sive and important field of application of the digi-
talis series and their active principles, and augment
further the clinical utility of this valuable group of
drugs.
Teeth and Tonsils as Causative Factors in
Arthritis. — Roland Hammond {American Journal
of the Medical Sciences, October, 1918) thus sum-
marizes the mooted question of the relation of the
teeth and tonsils to arthritis. Billings and his fol-
lowers point to the careful work of Rosenow and
others on the bacteriology of arthritis and to the
numerous cases of improvement and cure of arthri-
tis following removal of diseased teeth and tonsils.
They believe that this proves the accuracy of their
contention that a focus of infection exists in the
head in many of these cases. On the other hand,
many trained pathologists and reputable clinicians
have been unable to reproduce either the laboratory
findings or the clinical results of the Chicago work-
ers. Consequently they either reject the theory as
a whole or accept it in a greatly modified form. It
is probable that the pendulum has swung too far in
the direction of the wholesale removal of teeth and
tonsils. The truth will probably be found in a mid-
dle ground somewhere between these divergent
theories. There is undoubted improvement in
numerous cases of arthritis following the removal of
an abscessed tooth or a diseased tonsil or when a
case of active pyorrhea has received proper treat-
ment. On the contrary, many such cases are given
similar careful treatment without aflfecting the
progress of the joint condition in the shghtest de-
gree.
One reason for the failure to obtain successful
results in arthritis by treatment of dental and ton-
sillar disease is that the cases have been selected
without knowledge of the exact pathological condi-
tion present in the organ in question. Many apical
abscesses in which nature has effected a cure by
walling ofif the disease have been treated by ex-
traction of teeth. This has resulted not only in the
loss of valuable teeth, but has at times been the
cause of a dissemination of the infection to other
parts of the body, with dire results. In the same
way the crypts in certain areas of a tonsil may
overcome an existing infection. These crypts are
perfectly harmless. A tonsil in which the crypts
are seared over by scar tissue, perhaps as the re-
sult of an incomplete tonsillectomy, may be a source
D PREVENTIVE MEDICINE. 959
of potent danger if the crypts contain an active
focus of infection. Success in treatment of these
foci lies with the men who can distinguish the apical
abscess and the diseased tonsil which are overcom-
ing their infection by nature's methods. They must
know by careful and special training when a tooth
or a tonsil is an active agent of infection. Such
knowledge must be supplemented by accurate inter-
pretation of dental rontgenograms and skillful
laboratory work. Trite as the saying is, cooperation
in such endeavor is the keynote of success. Another
reason for failure in arthritic cases is due to the
fact that the focus of infection lies in some other
part of the body. It may be discovered by further
careful search in the lungs, heart, kidneys, genito-
urinary or gastrointestinal tracts, ductless glands,
the nervous system, and elsewhere. A certain
number of cases are due to syphilis and to tuber-
culosis. Unfortunately in many cases it is never
brought to light. Many cases of arthritis are be-
lieved by thoughtful physicians to be due not to a
localized collection of microorganisms but to an
entirely different etiology. This class of cases is
supposed to result from some disturbance of the
metabolism, probably chemical in nature, which pro-
duces joint changes not always to be distinguished
from those caused by bacterial agency. They com-
pose a fairly large share of the cases of chronic
progressive arthritis seen in the daily routine of
practice. A general flaccidity of tissues and relaxa-
tion of important organs accompanied by ptosis of
the abdominal viscera often characterize these cases.
In acute arthritis the probability of producing a
cure or improvement by the removal of a supposed
focus in the teeth or tonsils is greater than in cases
in the chronic stage. It is unreasonable to suppose
that a restoration of function can be brought about
in joints where extensive pathological changes have
taken place. One very" suggestive fact brought out
in this investigation has been the marked improve-
ment in the general health of the patients when dis-
eased conditions of the teeth and tonsils have been
properly treated. This was often noted even when
no change was apparent in the joint condition.
Operative Treatment of Ankylosis of the Jaw.
— M. S. Henderson and G. B. New {Surgery,
Gynecology and Obstetrics, November, 191 8) de-
scribe a method of operative treatment of ankylosis
of the jaw. The operation is an arthroplasty, be-
cause it has as its object the establishment of suffi-
cient motion to permit function of the part afifected.
It is pointed out that the facial nerve and the in-
ternal maxillary and superficial temporal arteries
are the structures the surgeon must bear in mind
and familiarize himself with before undertaking the
operation. Hartley has described an operation
very similar to that used by Henderson and New
who believe that the essential points of this method
of treating articular ankylosis are: i, It removes
sufficient bone to make a space one half an inch
between the skull and the ramus, thus obtaining a
stable functioning joint ; 2, it is an incision that
gives good exposure to the joint and does not injure
the facial nerve ; 3, it approaches the joint from
above by removing part of the zygoma.
960
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Treatment of Gunshot Wounds of the Face
Accompanied by Extensive Destruction of the
Lower Lip and Mandible. — V. H. Kazanjian and
Harold Burrows {British Journal of Surgery, July,
1918) describe several cases of gunshot wounds of
the face in which extensive destruction of tissues
occurred. With regard to early treatment they say
that, apart from urgent complications, the amount
of surgical interference required in the early stages
will be small and will be limited to the removal of
dirt, loose fragments of bone, teeth, and roots. A
little later, when the wound begins to show healthy
granulations, a certain amount of early secondary
suturing may be done. This will be effected under
local anesthesia, and will be limited to sewing up
the outlying radiations of the wound, and closing
as much of the main wound as may be done with-
out impeding drainage. With regard to dressings,
the authors think there is not much to be said. The
wound is widely open, and is continually washed
with an abundance of the patient's own saliva. This
necessitates frequent changes of dressing, and on
each of these occasions the mouth is syringed with
antiseptic solution, usually listerine or a solution of
potassium permanganate. The principal points of
treatment to be observed are: i, The preservation
of the surviving portions of the mandible in the de-
sired position ; 2, the substitution of lost bony tissue
by vulcanite appliances before the performance of
plastic operations on the soft parts ; 3, postponement
of the main plastic operation until suppuration has
ceased and the patient is in good physical condition ;
4, the use of a similar scheme of flaps in all the
cases. The authors conclude by saying that an ideal
restoration of a lost mandible would involve re-
establishment of bony continuity by grafting. They
hope that means will be found to achieve more per-
fect results by such a method. At the present
time, however, it is satisfactory to know that an
artificial jaw can be both a useful and a practical
substitute for one that has been lost.
Saline Solution with Organ Extracts in Shock.
— Descomps and Clermonthe {Presse medicale,
August 22, 1918) treated thirteen cases of shock,
chiefly cases of hemorrhagic or toxic shock coming
under observation six to twenty-four hours after
injury, by intravenous injections of a fluid consist-
ing mainly of Hedon's solution — a hypertonic solu-
tion of about the same composition as Ringer's and
Locke's solutions — together with a few mils of
soluble extracts of the thyroid, hypophysis,
adrenals, testicles and spleen, and a little strychnine
and digitalin. The object of this preparation was
to make up, in the shocked cases, for the reduction
or temporary absence from the blood of the main
secretory products of the endocrine glands. The
latter, controlling the functional activity of the
sympathetic and maintaining the action of the vaso-
motor centres, play an important role. In all forms
of shock, circulatory disturbances occupy a prepon-
derant place in the symptomatic picture. In
hemorrhagic shock, furthermore, a sudden lack of
endocrine products in the blood is to be apprehend-
ed. Of the thirteen patients treated, eight recovered,
while in five the procedure failed. In the former,
the pulse became more regular and forcible within
six or eight hours after the injection. The blood
pressure rose rapidly. At the same time a per-
sistent diuresis, sometimes very considerable, was
noted, and the daily output of urea increased above
the average to twenty-nine up to forty-two grams,
apparently showing an action of the solution on the
functions of the liver. The chloride estimations
were always low — 0.2 to 0.5 gram per litre. The
specific gravity of the urine, where tested was
always normal or above normal, suggesting excita-
tion of the various glandular activities. Elimina-
tion by sweats following the injections was ob-
served in three cases, and likewise the sedative
effect of the fluid on the brain centres, restlessness,
delirium, and mental disturbances diminishing and
then disappearing in the cases treated.
Treatment of Paresis by Inunctions of Mercury
and Drainage of the Cerebrospinal Fluid. — Alan
D. Finlayson {American Journal of Insanity, April,
1918) reports the intensive treatment of fourteen
paretics, the method used being the daily inunction
of mercurial ointment (fifty per cent.) with the
withdrawal every ten days of from twenty to forty
c.c. of spinal fluid. In half the cases the blood
Wassermann reaction became negative and re-
mained so for varying periods; in six cases 'the
spinal fluid showed a like behavior. In no instance
did either fluid become permanently negative. The
cell count showed an irregular decrease in every
case. In four cases the colloidal gold reaction be-
came negative, but did not remain so. One case
showed a good remission mentally, and another pa-
tient a fair one, but the remaining cases showed no
apparent change attributable to treatment. Doctor
Finlayson concludes that there is so little correlation
between serological and psychological results that
the apparent great improvemicnt in the former does
not inform us as to the value of the treatment.
Operation for Paralytic Genu Recurvatum. —
Willis C. Campbell {Journal A. M. ^....September
21, 1918) makes a linear incision through the skin
and superficial tissues in the middle line for a length
of five or six inches, exposing the patella and its
ligament. The tendon above the patella is cut with
a Z shaped incision like that used 'for lengthening
the tendo Achillis, and through this incision the cap-
sule is opened. The cartilage is then removed from
the lower third of the patella, exposing the spongy
bone, and the periosteum is stripped up for one
eighth of an inch on the anterior surface. A cavity
is next made on the upper anterior aspect of the
tibia to receive the lower third of the patella. The
natella is placed in this cavity and united to the tibia
bv suture of the periostea of the two bones
along the margin of the denuded patellar sur-
face. The tendon above the patella is then sutured
at neutral tension after closure of the joint cavity,
the fascia and skin layer is closed, and the extremity
put up in plaster at an angle of 20° of flexion at the
knee. After eight weeks in this dressing a brace is
applied and worn for six months. The two thirds
of the patella projecting above the articular surface
of the tibia acts as a positive mechanical ston to
hvperextension of the knee. The operation gives
excellent results where it is desired to produce bony
ankylosis of the knee in paralytic patients.
November 30, 191S.J
MODERN TREATMENT AND PREVENTIVE MEDICINE.
961
Atrophy of Denervated Muscle. — J. M. Lang-
ley and M. Hashimoto {Journal of Physiology,
April, 1918) have made a study of the effect of
treatment upon denervated muscle and conclude
that neither the use of the gal'-anic current, produc-
tion of contraction, passive movements, nor mas-
sage— which include all of the present modes of
treatment of such muscle — can do more than slightly
delay atrophy. It would seem that any one of them
might be supplanted by a method equally beneficial
but not requiring such expenditure of time or
money. It is especially difficult in man to measure
the effect of other treatment since it is too much
obscured by variability in time of recovery as well
as by unascertainable conditions at the point of su-
ture. Measurements of the limbs at intervals of
stimulation cannot be relied upon, since connective
tissue growth may have been caused. Growth of
muscle would moreover mean that atrophy could al-
together be prevented, which is more than one can
at present claim. The only other method of test-
ing, to which these experimenters could resort, is that
of comparing the electrical irritability of the muscle
that has been treated with that which has been left
alone. In order to minimize the errors that must
arise a great number of experiments were made
upon animals and careful watch was kept for error.
The experiments were made only during the earHer
stage of atrophy, when it would seem that treat-
ment would be more likely to produce its effect. Still
in the later stage conditions are different, since the
arteries gradually recover tone and there may be a
change in the quantity of blood flowing through the
muscles. Only one experimental method of treat-
ment appears to offer any hope of considerably re-
ducing the rate of atrophy, and this is ionization
with a potassium salt, and even this gave a positive
result only once out of three experiments.
Treatment of Rectal Fistula. — Charles J.
Drueck {Texas Medical Journal, October, 1918)
states that if the abscess has not yet ruptured it
should be freely opened away from the rectum and
the cavity thoroughly and carefully drained. The
incision should be made in a line radiating from the
anus. Palliative treatment is not very effective.
The bowels should be kept open — enough to allow
a soft uniform movement. After ever}' bowel
movement the rectum should be flushed out with an
enema of warm water. Tuberculosis is, as a rule,
not a contraindication to operation. Operations are
divided into tentative and radical. Tentative opera-
tions include the injection of astringents and the
several methods of dividing the tissues with a
ligature. Of the astringents, iodine, zinc, sulphur,
carbolic acid, and ergot are the best. The injection
is made with a hypodermic needle, which should be
three inches long, with a blunt tip. The injection is
made in and around the sinus, the left index finger
being placed over the internal opening as a plug to
prevent the escape of the fluid. In applying a
ligature, it is passed through the external opening,
along the fistula and brought out at the anus. A
knot is then tied and the ligature allowed to slough
through. Silk, or an elastic rubber band, may be
used. The fistula may be divided with a Paquelin
cautery. The radical operations are incision and
excision. The advantages of a radical operation
are: i. Every sinus can be hunted out; 2, overlaj)-
ping edges may be removed ; 3, free drainage is
obtained and abscesses are prevented ; 4, the opera-
tion is quickly and thoroughly done. In the after-
treatment the bowels are moved by a cathartic on
the fourth day, the movement being immediately
preceded by a copious enema. The wound should
not be dressed too frequently, the packing should
not be too light, and antiseptics should not be ap-
plied too energetically.
Use of the Douche Pan in the Second and Third
Stages of Labor. — C. J. Andrews (American Jour-
nal of Obstetrics, October, 1918), observing that
the third stage is usually conducted under the
disadvantage of having the patient's buttocks more
or less immersed in a pool of blood and liquor
amnii, and sometimes feces, has been using a sterile
douche pan under the buttocks during both delivery
and the third stage. It is placed in position usually
when the head is on the perineum. Occasionally, in
multiparae, it is adjusted before the bag of waters
ruptures. A folded sterile towel is placed under
the sacrum. If there has not been opportunity to
sterilize the pan, it is thoroughly covered with
sterile sheets or towels. By this procedure not only
are all discharges received in a pan and soiling
avoided, but the amount of hemorrhage can be ac-
curately observed. Examination of the i^erineum
is rendered much easier and small tears can
be more conveniently repaired. The vulva may be
freely bathed with antiseptic solution, and vulvar
dressings applied before the patient is moved.
Often it is not necessary to change a sheet.
Effects of Intravenous Saline Infusion after
Severe Hemorrhage. — Richet, Brodin, and Saint-
Girons {Fresse medicale, August 5, 1918) studied
the action of various kinds of intravenous infusions
in severely bled dogs. Placing at the arbitrary figure
100 the volume of blood and the number of red
blood cells remaining in an animal succumbing to
simple, untreated hemorrhage, the authors observed
that the blood volume and cell count might vary
greatly according to the nature of the intravenous
injection administered. Thus, the effects of horse
serum varied with the animal supplying it. In the
most favorable instances there was a reduction up
to twenty-three per cent., while in the less favorable
there was an increase up to 125 per cent. An
isotonic solution of sodium chloride with five or ten
per cent, of glucose added proved clearly more
effectual than simple physiological salt solution.
Unexpectedly, Locke's solution proved greatly in-
ferior to normal saline solution. After hemorrhage
followed by therapeutic injection the mean variation
between dift'erent animals, both as to blood volume
and cell count, was much less than after hemorrhage
without injection. It may he maintained that where
the amount of blood remaining exceeds thirty per
cent, of the original blood volume, and where the
cell count exceeds five per cent, of the initial num-
ber, some toxic action on the heart has occurred
in the event of death. The general conclusion
reached is that copious saline injections may enable
the system to recover from hemorrhages which, in
their absence, would have entailed immedipte death.
962
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
Shell Shock — Psychoneuroses of War. — C. S.
Holbrook {New Orleans Medical and Surgical
Journal, October, 1918) tells us that at the begin-
ning of the war the psychoneurotic cases were all
sent from the trenches to the base hospitals, and
then to England. Recently this plan has been much
altered and these unfortunate men were treated
comparatively close to the firing line. Special hos-
pitals were organized in the zone of activity and
psychiatric wards were added to the large general
hospitals. The trend of treatment was to give in-
tensified therapy near the front and to send to
England only such patients as were not expected to
recover in a few weeks or months. Psychoanalysis
has a place in the treatment of shell shock cases,
but, owing to the time required and the considerable
experience required on the part of the physician,
this method of treatment could be used in only a
few cases. The results are excellent. Hypnotism
had many advocates during the first years of the
war and the results were good, but recently this
practice has lost much of its popularity. There are
three principles involved in nearly all methods :
suggestion, reeducation, discipline. The aim of
suggestion is to make the patient believe he will be
cured, and to lead him on from this to the belief
that he is cured. Reeducation brings the desired
function back to the normal by directing it until the
bad habit is lost, and disciplinary treatment breaks
down the unconscious resistance of the patient to
the idea of recovery. The results of treatment have
been quite variable. Percentages of cures have
ranged from twenty-six to ninety-eight per cent.
With appropriate treatment, given shortly after the
neurosis develops, over ninety per cent, of these
patients should recover, but should be discharged or
assigned to home duty.
Treatment of Pseudarthrosis. — Chutro (Presse
medicale, August 5, 1918) presents conclusions
reached after experience with seventy-five cases
resulting from war wounds. Apart from the cases
in which union may be obtained by a mere freshen-
ing of the bone fragments and adequate immobiliza-
tion, the metallic plate remains the best method in
the involvement of single bones such as the clavicle,
humerus, and femur, while in the case of the bones
of the forearm and leg, bone grafts should be used.
In a few cases, however, in which the humeral or
femoral fragments are in contact, bone grafts after
the method of Albee may be resorted to. In
osteosynthesis by the plate method, the author
adopts Sherman's technic and instrumentation. In
transplanting bone, he has discarded Albee's saw,
which liberates too much heat, thus entailing a risk
of killing the transplant, and also occludes the pores
of the bone with bone dust. He prefers the Murphy
chisel. The transplants, always from the tibia, are
made thin rather than thick. Fixation of the trans-
plant with wire is considered unnecessary ; the
grafting is carried out by contact, as in horticulture,
and the periosteum of the graft is placed in con-
tinuity with that of the bone fragments. The time
of immobilization in a plaster cast is never less than
three months. Later, x ray examinations are made
from time to time, and as soon as the cortical layer
gives a distinct shadow, massage is begun.
Experiences with the Kondoleon Operation for
Elephantiasis. — W. E. Sistrunk {Journal A. M.
A., September 7, 1918) records seven cases of ele-
phantiasis in which he has performed this operation,
slightly modified from the original, with very favor-
able results. He finds that the results are rather
more favorable in the lower extremities than in the
upper. The modified operation consists in making
an elliptical incision including the skin to be re-
moved, extending nearly the entire length of the
extremity. The skin is then reflected from the fat
for one to one and one half inches from the outer
margin along the entire circumference of the inci-
sion. Retracting this skin, the fat and aponeurosis
is incised as far out as possible and in a line parallel
to the skin incision. The two lateral incisions are
then connected at their upper ends by a similar
transverse incision, the end is grasped, and while
traction is made the entire mass of fat and edema-
tous tissue, including the aponeurosis, is dissected
free from the underlying muscles. Bleeding is
checked with clamps, and the wound is closed by
suture of the skin margins with interrupted silk-
worm gut stitches. After eight or ten days in bed
an elastic bandage is applied and the patient allowed
to get up. This bandage should be worn for several
months.
Conservative Surgery of Chronic Intestinal
Stasis. — P'rank C. Yeomans {Nczv York State
Journal of Medicine, September, 1918) contends
that the surgery of this condition cannot be stand-
ardized, but that in each case the patient must be
made the subject of separate * study and treat-
ment applied, which is designed to eliminate the
causes. Thus anal fissure or irritable rectal ulcer
will cause obstruction through the production of a
hypertrophic and spasmodic sphincter muscle. Ex-
cision of the ulcer and superficial division of the
sphincter will cure the condition. Fibrotic Hous-
ton's valves may also produce obstruction, and this
can be relieved promptly by division of the valves
through the application of a spring clip. Flabby and
atrophic sigmoid may be the cause of the stasis and
this can often be overcome and the sigmoid re-
stored to normal by the frequent instillation of
warm olive oil or liquid petrolatum, which is re-
tained over night. Spastic enterostasis is usually
due to some local inflammation or to reflex irrita-
tion, and removal of the inflammatorv process, such
as the appendix, or cure of putrefaction by medical
means will cure the spastic condition. General
enteroptosis is another frequent cause of intestinal
stasis and can be much benefited by the perform-
ance of relatively simple operations for the replace-
ment and fixation of the dilated and prolapsed
portions of the gastrointestinal tract. Many cases
of stasis are found to be due to peritoneal bands
and omental adhesions, and the removal or section
of these often cures the patient. Ileosigmoidostomy
should be abandoned, for it violates the cardinal
surgical principle of leaving the entire colon open
above the stoma. Total colectomy should also be
given up on account of its danger. On the other
hand, cecosigmoidostomy may be employed in cer-
tain obstinate cases with good results in about two
thirds of the operations.
Miscellany from Home and Foreign Journals
Indications and Limitations of the Induction
of Labor. — R. C. Norris (American Journal of
Obstetrics, October, 1918) believes the termination
of pregnancy for grave systemic disease of the
mother, diseases or accidents of the product of
conception, and serious disproportion of fetus to
pelvis, is becoming more and more restricted. There
remain, however, several important indications for
which it should be more frequently used. Among
the early complications is tuberculosis ; pregnancy in
a woman who has recently contracted this disease
should usually be terminated. In grave chronic
nephritis, spontaneous abortion is the. rule ; mild
cases should be watched constantly, and often the
interruption of pregnancy will be indicated. Early
induced abortion is advisable in all cases of true
diabetes, in hydatid mole, and in acute hydramnios
with dyspnea and marked interference with the
circulation. In pyelitis, if ureteral and renal pelvis
irrigations with a silver preparation fail to relieve
promptly, labor should be induced. In insanity, the
family history, failure of eliminative and sedative
treatment, and especially suicidal mania, justify
termination of pregnancy. In a series of 140 cases,
labor was induced for pelvic deformity in eighty-
three instances ; toxemia of pregnancy, thirty-six ;
prolongation of pregnancy, fifteen ; grave cardiac
disease, three ; exophthalmic goitre, acute hydram.-
nios, and fetal death, one each. There was no
maternal mortality. In pelvic contraction, induced
labor should be restricted to conjugates above 8.5
centimetres, and most frequently to multiparse with
histories of difficult labor and lost babies. Primi-
paras with conjugates below 8.5, unless the fetus is
distinctly under size, are best treated by Csesarean
section.
Rontgenographic Studies in Chronic Mouth
Infections. — Arthur D. Black (Journal A. M. A.,
October iq, 1918) draws his conclusions from a
study of 6,000 films from 600 mouths. Definite
areas of bone destruction about the teeth were
found in seventy-eight per cent, of the cases. The
frequency of these areas of bone destruction in dif-
ferent age periods ran as follows : Between the ages
of twenty and twenty-four, seventy-five per cent. ;
twenty-five to twenty-nine, sixty-four per cent. ;
thirty to thirty-nine, eighty-eight per cent. ; forty to
forty-nine, ninety per cent. ; and above fifty, ninety-
eight per cent. The percentages for persons over
forty years old were probably too high. The areas
of destroyed bone were of two types : The one lo-
cated along the sides of the teeth from infections in
the gingivse, called peridental infections ; the other
at the apices of the roots, called alveolar abscess.
The peridental infections were very seldom found
in persons less than twenty years old and were
specially lesions of adult life, increasing in fre-
quency with increasing age. On the other hand
alveolar abscess was found at all ages and would
increase in frequency with increasing age, were it
not for the fact that extractions tend to preserve a
balance. Ten per cent, of all the teeth in the mouths
of the persons examined contained root canal fill-
mgs and these were studied with reference to their
bearing upon alveolar abscess. Of 343 good root
fillings in large root canals only thirty-one were ab-
scessed, while of 570 poor fillings in similar canals
356 were abscessed. Of the small canals 184 were
well filled and showed only nineteen abscesses as
compared with 271 abscesses among 413 poorly
-filled small canals. The totals showed only nine per
cent, abscessed among all the good root canal fillings
and sixty-three per cent, among all teeth with bad
root canal fillings. Improvement in dental practice
has been taking place with an increase in the num-
ber of extractions to eliminate infections and a
decrease in crowns and bridges. This change in
practice also includes a determined eflfort on the
part of progressive dentists to free all mouths of
infection and to take every possible means of pre-
venting the occurrence of infection. This in turn
is a very great factor in reducing serious .systemic
infections.
Drink and Its Control in Relation to Work and
Health in Great Britain. — Sir Robert Armstrong-
Jones (American Journal of Insanity, April, 1918)
comments on the third report of the Central Control
Board for Liquor Traffic. This board is charged
with diminishing the accessibility of drink and also
its alcoholic content. Typical of this work was the
case of Carlisle, a quiet cathedral city, whose mah
population was suddenly more than doubled by the
incursion of highly paid ammunition workers, with
the result that drunkenness increased 800 per cent.
The board bought five breweries and all licensed
places in town, closed two of the breweries and one
third of the taverns. The keepers of these latter
were informed that their profits would depend upon
the amount of food sold and that they would make
nothing from the sale of beverages. The board
reports a marked diminution in convictions for
drunkenness, an improvement in the condition of
the street and, in general, better public order.
Role of Ascariasis in Gallbladder Disease. —
J. Aviles (Surgery, Gynecology, and Obstetrics,
November, 1918) concludes, on the above subject,
as follows: i. The diagnosis of gallbladder or of
biliary duct disorders due to migration of Ascarides
lumbricoides is not easy. 2. Such disturbances are
rare. At times the prognosis is grave, and in some
instances cases end fatally in a very short time ; in
others death comes suddenly. 3. A person who is
seized with heptic coliclike pain, accompanied with
vomiting of Ascarides lumbricoides, has the syn-
drome necessary for suspecting that the case is one
of migration of the parasite or parasites into the
biliary ducts or gallbladder; and unless the sjrmp-
toms subside, surgical intervention is indicated. 4.
Antihelminthic remedies must be administered as a
prophylactic measure in those cases in which a his-
tory of ascariasis accompanies disorders of the
gastrohepatoduodenal system. 5. In those cases in
which surgical intervention has been practised, anti-
helminthic remedies must be given to avoid new
serious complications.
964
MISCELLANY FROM HOME
AND FOREIGN JOURNALS.
[New York
Medical Journal.
Intestinal Protozoal Infections. — Doris L.
Mackinnon {Lancet, September 21, 1918) made
routine examinations of the stools for intestinal
parasites in a series of 1,680 consecutive, unselected
cases, in 1,549 of which six examinations were made
on as many consecutive days. Nine hundred and
fourteen of the cases were admitted to the hospital
as convalescents from dysenteric or diarrheal con-
ditions, and 766 were admitted for other conditions.
Only 447 of these men had ever been outside of
France or England, that is, in tropical or subtropical
countries. Over fifty-one per cent, of the total
number of men were infected with protozoa, En-
tameba histolytica being found in 12.4 per cent.,
Entameba coli in twenty-six per cent., Entameba
nana in eighteen per cent., Giardia jntestinalis in
13.4 per cent., Chilomastix mesnili in five per cent.,
and Trichomonas hominis in 0.7 per cent. There
was a slightly larger proportion of carriers of En-
tameba histolytica among the cases giving a dysen-
teric history than among the others, and a consid-
erably larger proportion among the men who had
been in the tropical or subtropical regions at some
previous time than in those who had not. One man
who had never been out of England harbored
Entameba histolytica cysts, but he had been in
attendance upon dysentery patients for some time.
Sixty-nine carriers, out of 131 who received treat-
ment with emetine bismuth iodide for twelve days
each, relapsed and at least fifty-eight per cent, of
the relapses occurred within the first week after
treatment.
Biopsy in Cancer. — Jerome M. Lynch {Inter-
national Journal of Surgery, 191 8) says that he is
very much opposed to biopsy, that is, the removal
of a portion of the tumor for histological diagnosis,
as it tends to disseminate the growth and serves no
useful purpose. He maintains that the liability to
err is just as great as it would be with one unfa-
miliar with the characteristics of the growth. Abbe,
in a paper read before the New York Academy of
Medicine, on the Influence of Radium in Cancer,
stated that the last part of the tumor to heal was
that from which a piece had been removed. It is
known from experience that even the rough
handling of a tumor is very often sufficient to dis-
seminate the cells : how much more is the cutting
into it apt to be harmful. There is only one condi-
tion for which carcinoma can be mistaken, exclud-
ing sarcoma, and that is an inflammatory nodular
tumor, due to a nonspecific inflammation, but when
one is uncertain it is almost always benign rather
than malignant. As a general rule the inflammatory
condition referred to is much more extensive and
not as prominent as a carcinoma, and the patient
gives a history extending over a long period.
Now while cancer may exist for two years
without making appreciable inroads into the health
of the patient, in an inflammatory tumor the history
is of much longer duration, and there is greater
undermining of the patient's constitution than there
is in a malignant tumor. One might be justified,
under such circumstances, in resorting to biopsy,
but it happens so infrequently that one has to make
this decision, that it may be considered almost
negligible.
Importance of Blood Cultures in Pneumonia.
— J. E. McClelland {Journal A. M. A., October 19,
1918) finds that septicemia, as shown by positive
blood cultures, is more frequently associated with
the more virulent strains of pneumococci and with
the Streptococcus hemolyticus than with the less
virulent strains. The taking of blood cultures as a
routine in pneumonia cases is of value in j)rognosis
and in the use of serum therapy. The septicemia
due to Type I pneumoccoccus responds very
promptly to the intravenous use of the correspond-
ing immune serum. Septicemia due to Type IV
pneumococcus may be recovered from rapidly and
spontaneously, while that due to the Streptococcus
hemolyticus is extremely fatal, though this organism
may at times cause a slight and transient septicemia.
Serological Test in Typhus Fever. — C. M.
Craig and N. Hamilton Fairley {Lancet, September
21, 1918) record their observations on the Weil-
Felix reaction, and conclude that this agglutination
test is an invaluable aid in the diagnosis of typhus
fever, the reaction commonly appearing only in that
disease. Using Garrow's agglutinometer, a rapid
agglutination of the proteuslike organism in a
dilution of one to ten of serum is sufficiently sus-
picious to justify the isolation of the patient. This
degree of reaction is especially indicative of typhus
in persons previously uninoculated against the
typhoid paratyphoid organisms or cholera. That the
proteuslike organism giving this reaction is not the
cause of typhus fever, or even a necessary constant
secondary invader, seems to be indicated by the in-
ability to cultivate this organism from the urine or
blood at any stage of the disease, save in very
exceptional instances ; also by the absence of any
immune body against this organism in the serum of
typhus cases, as shown by the absence of comple-
ment fixation. The test, though wholly nonspecific
and of the nature of a pseudoagglutination, is still
of the utmost clinical value and can be compared in
this respect to the equally nonspecific Wassermann
reaction.
Complications of Senile Nephritis. — Malford
W. Thewlis {Medical Reviciv of Reviews, Sep-
tember, 1918) says that senile nephritis causes many
symptoms in other organs, while displaying little
evidence of disease in the kidneys. The causes of
complications are : Toxins from the diseased kid-
neys afifecting other organs ; increase in blood pres-
sure due to kidney disease ; cardiac complications
resulting from overwork of the heart due to renal
disease. Minor symptoms which may become
.severe and classed as complications are dead fingers,
cramps in the calves of the legs, deafness, sensation
of electric shock on lying down, sensitiveness to the
cold, and nocturnal micturition. Uremia may affect
one organ only, as gastric, renal, or cerebral uremia.
Other complications are indigestion, gastrointes-
tinal disorders, pyorrhcca alveolaris, neuritis and
neuralgia, cerebral symptoms, and uremic fever.
Many of these conditions improve when attention is
given to the diseased kidnevs. Senile nephritis is
very treacherous and frequently is diagnosed onlv
on postmortem examination. The urinary picture
may be clear on some day? and obscure or entirely
hidden on others.
November 30, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
965
Hemophilia. — Harry Lowenburg and A. I. Ru-
benstone {Journal A. M. A., October 12, 1918)
tested the influence of the tissues of a hemophiliac
boy, who died from uncontrollable bleeding, upon
the coagulation time of oxalated normal plasma
after the addition of calcium. They also made
control observations with corresponding tissues
from a normal person. They found that the tissues
from all of the internal organs including the brain,
thyroid, heart, liver, kidney, suprarenals, pancreas,
spleen, muscle, and bone marrow accelerated clot-
ting when derived from a normal subject. All of
the same tissues except the thyroid and liver from
the hemophiliac boy also accelerated clotting, these
two tissues markedly prolonging the coagulation
time.
Multiple Neurofibromatosis (von Reckling-
hausen's Disease) and Its Inheritance. — Samuel
A. Preiser and Charles B. Davenport {American
Journal of the Medical Sciences, Octobe'", 1918)
describe the occurrence of von Recklinghausen's
disease in a father and son, with the autopsy find-
ings in the case of the father, in whom the disease
lasted thirteen years. The presence of the disease
in the son was associated with definite mental in-
feriority and delayed sexual development. The
writers give a review and analysis of 243 cases of
multiple neurofibromatosis frorri the literature, and
an analysis of thirty cases of the familiar type,
with charts of families in which there were two or
more affected persons in one family. This estab-
lishes the hereditary tendency of the disease, show-
ing the hereditary factor to be dominant, there being
something, apparently, in the germ plasm that
positively facilitates the production, under appro-
priate stimulation, of tumors of the nerve sheaths.
The tumors at times assume a malignant character.
Comparison of Immediate and Delayed Suture
of Gunshot Wounds. — In a report {British Jour-
nal of Surgery, July, 1918) of research work at a
casualty clearing station, Forbes Fraser, director,
it is stated in the report that while it is evident that,
with careful selection of cases and efficient opera-
tion, immediate suture may be counted on to meet
with a large measure of success, and while imme-
diate suture must be the operation of choice for
certain classes of wounds, such as those of the
head and chest and those involving joints, yet the
investigators incline to the belief that for general
use in the average wound delayed suture is safer
and more certain in its results. During periods of
active fighting, when cases cannot be retamed for
at least several days after operation, delayed suture
is the only means of early closure at disposal. This
method has the advantage that the presence of
virulent infection can be ascertained before the
wound is closed, by chemical evidence and micro-
scopical examination. In this way wounds with
virulent infection, the majority of which if sutured
would be failures, can be excluded from closure
until later periods when the infection has been
overcome. In the case of severe wounds, and when
the operator is in the least doubt as to whether he
has succeeded in efficiently removing dead and
damaged tissue, delayed suture should have the
preference, as a general rule.
Blood Pressure in Amyloid Diseases of the
Kidney. — K. 1 lirose {Bultcliii of the Johns Hop-
kins Hospital, August, 1918) studied fifty-nine cases
which showed definite amyloid in the kidney, in
each instance associated with chronic nephritis. His
observations will confirm the general impression, in
that the blood pressure was either normal or sub-
normal in the great majority of the cases and that
iherf was cardiac hypertrophy in only ten instances.
Seasonal Variation in the Iodine Content of the
Thyroid Gland. — Frederic Fenger {Endocrinol-
ogy, April-June. 191S) reports the results of an-
alyses carried out from 1914 to 1917 on the desic-
cated thyroids of cattle, hogs, and sheep. This
work confirms his previous investigations, showing
that there is two to three times as much iodine
present in the glands between the months of June
and November as between December and May.
These fluctuations seem to be due to temperature.
Laryngotracheal Stenosis. — Henry L. Lynah
(Laryngoscope , September, (918) believes that tra-
cheotomy, when performed properly and with suffi-
cient time allowed, is one of the most lifesaving
operations we have in surgery, while the stab
emergency tracheotomy has been responsible for
much of the high mortality rate. Fatal results are
usually attributed to the tracheotomv, when in fact,
in many instances, the tissues of the neck are sev-
ered only and the trachea not even opened.
Malarial Mastitis. — H. de Brun (Presse medi-
cale, August 22, 1918) reports six cases of malarial
inflammation of the mammary gland. Ten more
have been seen by his colleagues. The condition
seems to belong more particularly to the secondary
phase of malaria, the earliest among his cases show-
ing it three months after the initial fever and the
latest, fourteen months. It may begin to appear
either during a paroxysm or during apyrexia. Pain
persists throughout its course, and obstinately re-
sists treatment by morphine, belladonna, chloral hy-
drate, antipyrine, etc. Often it radiates to the
shoulder or other regions. Pressure on the breast,
even slight, is at times extremely painful. At night
the weight of the bed coverings proves intolerable
and the patient is apt to lie for a time upon the
affected side. The standing position is the most
comfortable. The degree of mammary swelling is
entirely out of proportion to the amount of pain ;
swelling is sometimes practically absent. The gland
itself participates but little in whatever swelling
exists, the latter being probably due mainly to in-
filtration of the skin and deeper connective tissues.
Palpation regularly reveals a small, lobulated mass
of almost cartilaginous consistency in the region
about the nipple. The condition may be unilateral
or bilateral ; if bilateral, one side is u.suallv afifected
far more than the other, even though they were
simultaneously involved. No constitutional reaction
is awakened, but an acute malarial paroxysm often
induces local congestion, enlargement, and a great
increase of pain. The affection lasts from a few
weeks to several months, and always terminates in
resolution without fibrosis. All the author's pa-
tients had large spleens and livers. Quinine, even
in large doses, seemed to have no effect on the
mammary condition.
Proceedings of National and Local Societies
AMERICAN ASSOCIATION OF OBSTETRI-
CIANS AND GYNECOLOGISTS.
Thirty-first Annual Meeting, Held in Detroit, Mich-
igan, September i6, Tj, and i8, ipi8.
The President, Dr. Albert Goldspohn, of Chicago, in
the Chair.
(Conchidcd from page 927.)
Gallbladder Disease and Its Differential Diag-
nosis.— Dr. John Erdmann, of New York, said
that the sex preponderance was in the female and,
as Deaver aptly put it, "Beware of the female fair,
fat, and forty, or past, who belched wind." Never-
theless, in the great proportion of his case records,
the year of onset, or early visitation of symptoms,
was between twenty-five and twenty-seven years, a
few as early as eighteen, and in one, a common duct
case in which he operated, there was a history of
jaundice (following colic) at fourteen years, the
operation being done by him when the patient was
seventeen. The colic or cramp was described as
being in the upper right quadrant, without exten-
sion ; with extension into the back, lumbar zone ;
up the back, under the shoulder blade — in the space
between the shoulder blades ; in the left shoulder
and occasionally in the left and right neck. Fre-
quently and usually when the stone was in the cystic
duct, the colic was said to travel across the midline
upwards — under the left nipple and breast (pseudo-
angina). The attacks were very prone to occur
between 7 p. m. and i a. m. — in markedly different
relationship to the pain in ulcer of the duodenum.
Jaundice was a symptom or sign made much of
years ago but now accepted only as a confirmatory
evidence of some obstruction to the outflow of bile,
or some destructive blood condition, as in hemolytic
jaundice, etc. Frequently a greater loss of weight
was seen in a given short period of time in gall-
bladder involvement than in many cases of malig-
nancy. This loss was to be assigned to several
sources — the limiting of diet, improper metabolism
due to impaired bile, and also to pancreatic associa-
tions. Pruritus was in early evidence in all patients
with jaundice and frequently with those in whom
the pancreas was involved. In examining these pa-
tients evidences of pruritus presented themselves as
long scratches or small petechial spots all due to
both conscious and unconscious scratching. Upon
straining the stools stones might be found, but the
infrequency of finding stones and the definiteness
of symptomatology led the practitioner of the pres-
ent day to forego the procedure.
The preponderance of ulcer of the duodenum
occurred in the male. In {Physical makeup, judging
from the cases presented, the patients were of the
slender, wiry variety, frequently classed as neuras-
thenics, usually between twenty-five and thirty-five
years of age, and nonalcoholic in habit. When ob-
struction was well advanced, the patient lost weight
and was very likely to have a chain, of mental symp-
toms, equal to those of starvation. In addition to
these subjective .symptoms the analyses of stomach
contents might show blood and usually did show
hyperacidity both in combined and free hydro-
chloric acid, with the other undigested contents, etc.
Acute perforation of the ulcer might take place
without any preceding symptoms of moment. The
onset of the disease was marked by pain of intense
character, requiring morphine in liberal quantity ;
shock, boardlike rigidity in the upper right quad-
rant ; thoracic breathing, and later pain in the right
lower quadrant simulating appendicitis. This pain
was due to irritation of the peritoneum by escaping
contents of the stomach and duodenum. Opera-
tive intervention in the early stages might be fol-
lowed by overlooking the ulcer because of its not
being calloused or indurated. Lues, with its abdom-
inal crises, must always be considered as a con-
fusional factor of great weight in upper abdominal
disease. Recently in a definite ulcer history, and so
diagnosticated, a very markedly chronic appendix
was removed from under the gallbladder and di-
rectly over a duodenal ulcer the size of a twenty-
five cent piece.
In acute hemorrhagic pancreatitis, we had a
disease that was so acute in its onset and so over-
powering in its symptomatology that frequently the
j)atient was seen in shock or collapse. In these in-
stances it was with great difficulty that a history
was obtained. Nevertheless, the intensity of onset,
pain, shock, collapse, and a peculiar abdominal liv-
idity all pointed to pancreatitis. Should the patient
survive, she would tell you that she had had a most
severe abdominal pain and, perhaps, a backache,
that she might have had a previous mild attack, or
gallstone attack, etc.
Dr. Herman E. Hayd, of Buffalo, N. Y., stated
that perhaps the most important of all signs and
symptoms of gallbladder disease and ulcer was the
anamnesis. If men would spend more time in get-
ting careful history of their patients they would
make fewer mistakes. He believed that mistakes
were due to carelessness rather than ignorance. A
strong point brought out was that a patient never
suffered from acute pain in ulcer of the stomach
or duodenum until the ulcer had encroached upon
the peritoneal wall. Just as soon as there was a
tendency to erosion of^the peritoneum and a pos-
sible perforation the patient suffered from an acute
agonizing pain such as was characteristic of gall-
stone colic.
Dr. Hugo O. Pantzer, of Indianapolis, Ind., said
he had been delighted with the excellent digest of
symptoms and signs presented by the essayist in
these cases of gallbladder disease. With the present
acceptance of bacteriemic disease, the exanthemata,
and what not, we were too restricted in our clinical
conceptions.
The Prevention of the Recurrence of Symp-
toms Following Operations for Gallstones. — Dr.
Julius H. Jacobson, of Toledo, Ohio, drew the fol-
lowing conclusions: i. Recurrence of symptoms fol-
lowing gallstone operations v.-ere more frequent than
was generally supposed to be the case. 2. Refor-
mation of stones after cholecystotomy occurred
from retention of infected contents, rather than
November 30, 19.8.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
967
from leaving gallstones behind at the primary op-
eration. 3. Routine gallstone operations should be
made more thorough and complete by the use of
adequate incision, by cholecystectomy, and by ac-
curate exploration of the ducts. 4. When the com-
mon duct showed marked dilatation it should be
opened and explored and special attention should
be given to the terminal portion of ihe duct for the
detection of calculi and constrictions. 5. The de-
tached gallbladder from its bed on the liver acted
as an efficient tractor, and greatly aided in making
the exploration of the ducts complete.
A Study of Various Cases of Pregnancy Toxe-
mia.— Dr. Georg'j: Clark Mosiier, of Kansas City,
Mo., described the following technic which involved
least shock: i. Preliminary dilatation gradually by
Hegar's dilators up to No. 20 ; 2, Voorhees bag No.
4, if at term, introduced by Reed's method — cigarette
roll held by Pean's forceps ; 3, lavage of soda bicar-
bonate, two per cent., after uterus was emptied.
Cases of the fulminating type — long hard cervix (in
which no vaginal examination had been done) were
best treated by classical C?esarean section. When,
after contamination by frequent digital examina-
tions, infection was almost surely to be expected, a
Porro or other hysterectomy should be done in the
interest of the mother. A woman v ithout a uterus
was better than an anatomical specimen.
The results in the series of cases from which these
conclusions were drawn, showing ninety-five per
cent, recoveries of mothers, and at least eighty-five
per cent, of the children at term, warranted the be-
lief that his results were far above the average, since
Tweedy's tables showed a maternal mortality of 18 ;
DeLee, 20; Williams, 25; Cragin, 28; New York
Lying-in, 30; the average American, 38, and the
Royal Maternity of Edinburgh, 66. (These figures
were taken fromi DeLee's Year Book, 1918.) His
patients might have been less toxic than those en-
countered elsewhere, but this was not likely to have
been the case. From his own experience and from
that of other observers, including a m.ost interesting
report just received from Dr. Ben Meyers, who did
a large work in obstetrics in Alaska and who found
that in the last year, an unusually cold, wet season,
twelve per cent, of his patients sufit'ered from tox-
emia, the conclusion was drawn that the weather
did at least aggravate the tendency to this condition.
As there was such a close relation between the
toxemia and the nervous system, was it not fair
also to ascribe to the war an incidental effect as a
causative factor.
Accidental Removal of Intestines Through the
Vaginal Vault. — Dr. Edward J. Ill, of Newark,
N. J., thought that as a result of his study and ob-
servation, the following points seemed important :
T. Any portion of the bowel could be pulled away
bv traction with a forceps through a rent in the
uterus or vagina. 2. The point of separation would
be the junction of the bowel with the mesentery.
3. In some subjects the separation would be extra-
peritoneal in a large measure. 4. The mesentery
could not be pulled away from its origin of the
;pine or elsewhere. He had reported this because
Tf its medicolegal aspect and that it might form a
Tuide for others.
Clinical, Pathological, and Sociological Obser-
vations upon Ninety Interned Venereal Patients.
— Dr. James K. Davis, of Detroit, Mich., stated
that all patients in the series were examined sero-
logically by the State board of health serologist. •
Bacteriological examination of the smears taken
from the urethral meatus, Bartholin duct meati,
cervix uteri, and vagina were repeatedly made
under the supervision of Mr. H. L. Clark, hospital
bacteriologist. Methylene blue and gram strains
were employed using the diagnostic criteria of in-
tracellular organisms of characteristic morphology
disposed in definite clusters and having the neces-
sary specific staining affinities. Patients clinically
anc' bacteriologically cured were so judged after the
clinical disappearance of all lesions, and after ob-
taining negative Wassermann reactions before and
after provocative salvarsan injections and after five
consecutive smears, preceding which provocative
doses of gonococcal vaccine had been administered.
STJMMARY.
Average age of patients seventeen years :
married 14
Average number of weeks patient was con-
fined in hospital 13
Average co?t to the State per patient $195.00
Gonorrhea and syphilis, total number of
cases g9
Syphilis, total number of cases 46
Gonorrhea, with positive laboratory findings 72
Gonorrhea, clinically positive, laboratory
findings negative 10
Extent of involvement:
Urethritis 40
Bartholinitis 45
Vaginitis 49
Cervicitis 63
Endometritis 14
Salpingitis 37
Oophoritis 30
Treatments :
For syphilis:
Novarsenobenzol, average number of
treatments for each patient 4-.1
Mercury salicylate average number of
treatments for each patient 11
For qnnorrhea :
Silver nitrate, 10 per cent, solution,
average number of treatments 14
Iodine, 3 t per cent, solution, average
number of treatments Ii
Vertigo of Menopause. — Dr. K. I. Sanes, of
Pittsburgh, Pa., stated that in most of his patients
the vertigo was of the objective type, i. e., they
experienced a sense of rotation aroimd them of the
visible or palpable environments. In some of them
the vertigo was of a subjective type, i. e., a sensation
of motion of the body itself. A few of his patients
described the vertigo as a sort of swimming move-
ment, a feeling of being intoxicated, an extremely
embarrassing condition (the pseudonarcotism of
Tilt).
Vertigo was seldom the only prominent meno-
pause symptom ; it was almost alwavs accompanied
by such disturbances as hot and cold flashes, cold
perspiration, palpitation, blurred vision, flickering
before the eyes, headache, nausea, tinnitus, etc. The
relation of vertigo to climacteric fimctional hyper-
tension was of interest, and it was asserted bv some
that it was responsible for the menopause vertigo.
Excluding as far as possible the cases of organic
hypertension (cardiovascular and renal) he found
968
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
that in 102 subjects with vertigo whose blood press-
ure had been specified on the records, only forty-
five, or forty-six per cent., had blood pressure above
ISO and only twenty, or thirty per cent., above 160.
The severity of v;?rtigo. of course, varied. In most
of his patients, the vertigo was only slight, just a
mild dizziness, in others again so severe that they
feared walking by themselves on streets on account
of the frequent falls and even loss of consciousness
during the attacks of vertigo.
In regaid to treatment, it was necessary first to
make sure that the case was one of climacteric
vertigo. Such pathological conditions as lesions of
the internal ear or of any other part of the balance
mechanism, such diseases as cardiovascularrenal
and ocular, especially muscular imbalance of eyes,
must be excluded. If the case could definitely be
diagnosed as that of climacteric vertigo, the treat-
ment to be outlined must be that for the menopause
in general. As the metabolism was always below
par in menopause, the nutrition and elimination of
the patient must be looked after and, as the insuf-
ficiency or absence of the ovarian internal secretion
was the underlying cause of the symptoms, ovarian
organotherapy was logically indicated..
In the treatment of his cases of vertigo of the
menopause Doctor Sanes had been using a prepara-
tion, each grain of which represented a grain of the
fresh ovarian sub.stance ( varium). The dose he used
was five grains, two to four times a day. He rarely
foimd any particular advantage in using larger
doses. The results that he obtained from the use
of this ovarian substance as shown in his records,
were improvement in about thirty-seven per cent,
of his cases, and complete control in about twenty-
five per cent. In some cases relief from vertigo
preceded, in others followed, and in others again
accompanied the relief from the rest of the meno-
pause symptoms. The length of time the ovarian
substance was used by the patients was variable.
Some used it just a month or so, others for man\'
months, and in one case it was used for three years
before the final cessation of the annoying symptoms.
The results obtained from the ovarian substance,
while sometimes strikingly good, were so fre-
quently negative as to raise the question whether it
had within it the same finished product or products
that the internal secretion consisted of ; and if it
had, whether it was competent to take care of the
functional changes of the correlated endocrinal
glands brought about by the functional changes of
the ovarian secretion.
Sarcoma of Ovary in a Child Twenty-three
Months Old.— Dr. Herm.\n E. Hayd, of Bufifalo,
N. Y., stated that he had removed from the right
ovary of a baby twenty-three months old a small
round cell sarcoma about the size of a goose egg.
The child who was cutting her eye teeth, had been
running a temperature of 101°, was peevish and
irritable, had lo.st considerable flesh and had been
sick for about ten days. There were some bron-
chitic sounds in the chest, with areas of broncho-
pneumonia in both lungs. The liver dullness was
much increased. The bowels and kidneys were
functionating satisfactorily. In the lower right
r|uadrant could be felt a large movable smootli
tumor, not painful to the touch. The points which
engaged his attention, were the nature of this swell-
ing ; what should be done with it under the present
condition, and, was it in any way responsible for
tlie symptoms which the child was presenting. She
was taking milk and liquid nourishment freely, so
it seemed best in his judgment to treat the sj'mp-
toms, irrespective of the abdominal condition. In
the course of four or five days the temperature be-
came normal, the child began to play, took consid-
erable semisolid food, the tongue cleared up, the
feverish condition of the mouth and lips passed
away, and the mother was told to take the child
into the country and return in a few weeks, or
earlier if the child's condition did not continue to
improve. Naturally several possibilities came into
their minds as to the nature of this movable mass ;
was it a chronic intussusception, an omental tuber-
culosis, a localized peritoneal tuberculosis, r. chronic
appendicitis, dermoid cyst, a fecal impaction? The
child remained away for ten or twelve days, when
she was sent back to him by Doctor Mann, under
whose care she had been. The lungs were clear,
but the abdomen contained considerable fluid and
the mass, which was still movable, was tender. The
child looked sick, her temperature was 100° and
she was again fretful and irritable. She was pre-
oared immediately for an operation, was given
ether, and the tumor, which was free in the ab-
domen, was removed, with the right tube attached
to it, through a central incision. The appendix was
long and curled upon itself and it was also removed.
The uterus and the left tube and ovary were normal.
Quite a little bloody fluid came away when the
abdomen was opened. The liver was palpated and
found to be very much enlarged and filled with
nodular masses. The child suffered very little
shock and made an uneventful surgical recovery
and left the hospital on the thirteenth day. She
died at the end of the fifth week, no doubt from ex-
haustion and perhaps general sarcomatosis.
Dr. Edward J. Ill, of Newark, N. J., said that
he disliked to take issue with Doctor Hayd. Tuber-
culous pus tubes occurred in about seven per cent,
of all cases operated on where the tubes were re-
moved for pelvic disease. In his own experience
he had found twelve per cent, of the tubes to be
tuberculous. There was no reason why a woman
should not go through a pelvic illness with peri-
toneal involvement without pain. It was frequentlv
seen in pus tubes that the women were able to move
about and had very little pain.
Dr. Thomas B. Noble, of Indianapolis, stated
that his experience with sarcoma of the ovary com-
prised four cases in children, three of whom were
dead, and one, a girl of sixteen, operated on four
years ago, who was still living. A gonorrheal in-
fected tube produced an exudate in the cavity to the
extent manifested in the specimen exhibited and
was associated with a perisalpingeal exudation
which gave a much heavier coat than was seei;i in
the specimen. Perisalpingitis existed in gonorrheal
infection of the tubes to the extent that there was
fixation and fusion with periadjacent substance, so
tliat we did not get motility often in the tubes of
the uterus such as was seen in this specimen.
November 30, 1918.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
969
Dr. Gordon K. Dickinson, of Jersey City, N. J.,
said that Doctor Noble seemed to forget that there
were different kinds of gonorrheal pus tubes. The
kind he mentioned was common, but once in a while
the surgeon met with the sacciform type of pus
tubes, with no adhesions. It was free in the ab-
domen and pelvis, and looked like the very thin
walled distended type of tube.
Dr. Bertha Van Hoosen, of Chicago, said that
she became very much interested in the bacteriology
of pus tubes in the last five years and could safely
say that the tuberculous tube or the tube that had
been infected by streptococci always had the fimbri-
ated end open, and that in pus tubes the end was
ohvavs turned in. If there was any accumulation
of fluid in the tube, it was produced by postabortive
infection; it was due not to the inturning of the
end of the tube but to a collection of material just
a little away from the tube. She believed the diag-
nosis could be made upon the condition of the ends
nf the tubes and whether they were turned in or
not.
The Heart of a Pregnant Woman. — Dr. Louis
BuRCKHARDT, of ludiauapolis, Ind., said that an
early diagno.sis was the chief factor in successful
therapeutics. The menstrual disturbances, the
aversion to physical exercise, and the vasomotor
symptoms already described would help to single
out suspicious cases. To depend on marked ob-
jective changes in the heart and the general system
would cause a loss of valuable time. If a heart
afifection had progressed to a point where drastic
measures were -unavoidable, irreparable damage had
been inflicted on mother and fetus. Under drastic
measures, prolonged and absolute rest in bed, the
use of opiates, and large doses of digitalis wer^
included. They all would interfere with normal
metabolism, however, so essential in this condition.
The first prophylactic step should be to prevent
impregnation, by prohibiting marriage or by avoid-
ing conception. If, however, conception had taken
place the pregnancy in all but the severest cases
must be carried to term. The interruption of preg-
nancy offered as many chances of a cardiac break-
down as a normal well conducted delivery — except-
mg an abortion induced before the formation of the
placenta had begun. If a patient with a well com-
pensated heart lesion presented herself for our
prenatal care we must impress upon her mind the
necessity of preservation of energy. Saving alone
did not suffice, but working up new vital forces was
ii^cded. Not rest alone, but rest and exercise. Reg-
iilai- exercises and careful attention to elimination
were demanded in every normal case. We must
control both of them most carefully in heart cases.
The blood pressure readings were of great assist-
ance, their significance where heart lesions and
toxemia coexisted had been pointed out before.
Between the thirty-fourth and thirty-fifth week of
pregnancy daily observations would be necessarv in
order to determine the proper time of intervention.
During this period such patients were best strictlv
cor.fined to bed. As soon as settling had occurred
a considerable amelioration of svmptoms was fre-
quently observed and the patient might be given
more liberty of action.
Do Not Sterilize Women When Operating for
Tuberculous Peritonitis.— Dr. J. Henry Car-
STENS, of Detroit, Mich., stated that there were
thousands of tuberculous nodules left in the abdo-
men which were absorbed and disappeared ; hence
physicians had a right to believe that the few
nodules that were left on the tubes and ovaries
would also disappear after the abdomen was opened
with or without irrigation or drainage. His con-
clusions were: i, The thousands of tubercles on the
]3eritoneum were, as a rule, absorbed and disap-
peared after laparotomy; 2, there was no use
removing the tubes if they were only afTected by
tubercles ; 3, many of the women were young and
unmarried, and should not be needlessly sterilized.
Problems of Urethral Surgery in Gynecology.
— Dr. George V.\n Amber Brown, of Detroit,
Mich., drew the following conclusions: i. The
problem of transplantation of the ureter is often
puzzling. 2. In hysterectomy for malignancy of the
cervix, one should always isolate the ureters early.
3. In closure of the ureter one can never tell the
destiny of the kidney. 4. X ray and urinary findings
are probably the greatest source of error. 5. In
urology the solution of choice, opaque to the rontgen
ray, is either sodium or potassium iodide. 6. The
destiny of a kidney whose ureter has been tied
cannot be easily foretold. 7. No form of operation
is ever done until as complete an investigation as
possible of both sides has been made.
Recognition and Management of Labor In-
juries.— Dr. Arthur T. Skeel, of Cleveland, Ohio,
stated that the use of gas had done much to make
more careful work possible. The resumption of
gas analgesia, or of anesthesia, if needed, involved
very little discomfort to the patient, and Tendered
the whole procedure simple. The author wished to
emphasize four points, viz.: i. Limiting or entirely
avoiding vaginal examinations during labor was a
routine preliminary part of the technic of primary
repair of labor injuries. 2. Immediate inspection of
the cervix, with primary repair of its injuries, re-
duced the risk of subinvolution and of uterine dis-
placement. 3. Ihe routine use of buried sutures in
the perineum for the repair of second degree lacera-
tions permitted accurate coaptation and restoration
of the parts. 4. Perineal lacerations were more
surely repaired than was subpubic damage. There-
fore, slow delivery and skill in directing the small
diameters of the head through the vulvar ring
should be sought. Forcing the head against the
pubic arch produced more damage than it pre-
vented.
Pancreatic Cyst in Association with Tubercu-
lous Kidney and Intestinal Complications. — Dr.
J. E. Sadlier, of Poughkeepsie, N. Y., stated that
his object in reporting this case was largely for the
pur])ose of demonstrating the number of varied and
serious conditions that might exist in a person who
had considered herself in good health. It was true,
that pancreatic cystis were rare — this being the very
first one it had been his privilege to see — but in this
case he had, i, a patient with acute intestinal ob-
structive symptoms, which, unquestionably, resulted
in a natural anastomosis between the ileum and the
transverse colon, thereby overcoming the obstructive
970
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES
[New York
Medical Journal.
syniploms. 2. He had a condition of tuberculous
nephritis, with extensive perinephritic infection —
operation for which resulted in recovery from the
tuberculous condition — and also the unfortunate
establishment of a colonic fistula in' the lumbar re-
gion. 3. He had the discovery (and treatment) of
the pancreatic cyst — a complex condition which re-
quired a great deal of careful thought, study, and
work, in order, finally, to bring the patient to her
present condition of good health.
Intestinal Actinomycosis. — Dr. John W.
Kkefe, of Providence, R. I., said that actinomy-
cosis of the digestive tract practically never oc-
curred in the stomach or small intestine, possibly on
account of the acid contents of the stomach and the
fluid secretions found in the small intestine being
less irritating to its mucous lining. An acute or
chronic inflammation of the appendix might open
the door for the entrance of the actinomycotic or-
ganism. In general, it might be stated, that actino-
mycosis was practically never carried by the
lymphatics and but rarely by the blood stream.
The method of extension was by continuity of
tissue. Thus it was that general actinomycosis, un-
like tuberculosis and blastomycosis, was extremely
rare. Many of tlie abdominal organs might become
mvolved, as extension of the process usually took
place through retroperitoneal tissues, sometimes de-
stroying muscular and even body structures. The
early diagnosis of actinomycosis was generally
overlooked. A firm swelling, painless on pressure,
occupying either the right or left inguinal regions,
usiially the right, was the sign most frequently
found in cases of intestinal actinomycosis. The
surgical measures to combat the disease consisted
of excision, in some cases ; in others, incision, and
curetting of disease tissues together with the use of
antiseptics and the maintenance of free drainage.
Injections of four per cent, formalin solution had
been employed with success. Vaccines and serums
had been found cf value only in a few reported
cases. The x ray had not shown any marked bene-
ficial effect. In a few instances radium had been
given with marked immediate results. Large doses
of potassium iodide, ninety grains three times a day,
had been given v/ith success in many cases. Some
authors had been so favorably impressed as to
assert that it was a specific in this disease. The
marked eftlcacy claimed for this drug was readily
explained by the fact that it promoted the absorp-
tion of granulation tissue, acting in very much the
same manner as in the case of granulomata of
tertiary syphilis.
The Role of Congenital Colonic Membranes as
a Causative Factor in Disease. — Dr. J. P. Run-
van, of Little Rock, Ark., said that colectomy was
a radical operation for the relief of intestinal stasis,
and in the skilled hands of Lane might be fairly
safe, but it had always appeared to him unjustifi-
able, provided a simpler and a safer operation could
be devised. No matter what we might think of the
advisability or inadvisability of doing colectomy for
its relief, we were doubtless agreed that intestinal
stasis was a menace to good health, and that we
should endeavor to ascertain the underlying cause,
and if possible, correct it. Some patients suffered
in such a slight degree, that it was questionable as
to whether they should be subjected to operation,
while others were so miserable that even colectomy,
with its high mortality, might be preferable, if we
could not offer a treatment just as effective without
its dangers. Acting upon the hypothesis that in-
testinal stasis was due to colonic membrane forma-
tion, the result of imperfect embryological develop-
ment, which caused more or less angulation of the
bowel, he began dividing or removing this mem-
brane, after the manner of Jabez N. Jackson, with
most gratifying results. He submitted it as a
splendid, tafe, and sane substitute for colectomy in
the treatment of intestinal stasis, and an operation
devoid of mortality and most satisfactory in its re-
sults.
Dr. William Seaman Bainbridge, of New
York, said it would be unfortunate indeed if it
should be considered that stasis was not constipation,
and constipation was not stasis, and colectomy was
not done for the treatment of it by Mr. Lane. Con-
stipation was a symptom just as diarrhea was a
symptom. The worst cases of stasis were those in
which the condition was accompanied frequently
by diarrhea. The frequency of the stools did not
mean that the putrifying and noxious material was
not there ; the retained stool was being ;ibsorbed.
There was an overflow of retention in the bowel
just as there was overflow of retention in the blad-
der. This point Mr. Lane had emphasized repeat-
edly, and the worst cases of stasis were of that type.
When the intestinal canal was dammed, the body as
a whole or in part could not take care of the added
amount of poisoning which such retention involved.
As to treatment, to say that Mr. Lane or any of
those that followed him advocated colectomy for
stasis was so radical that it did harm. Lane put
himself on record in regard to this in 1901 Vv^hen he
said that nine tenths of the patients with stasis
ought never to see a surgeon.
Dr. James E. Davis, of Detroit, Mich., said that
the body in its development usually followed the
law that function determined anatomical form. In
cases in which there was some arrest in embryonic
development, no interference with normal function
occurred. He had seen instances of this over and
over again. If one studied a large series of cases
he would be impressed with the fact that the func-
tions of the bowel might be performed in an ap-
parently normal manner in a great many cases.
Why this was so it was impossible to determine in
every instance ; but there were a certain number <yf
cases in which the arrested anatomical form did in-
terfere definitely.
Within the past year he had had the opportunity
of doing an autopsy upon a child which he thought
illustrated this point very well. A child of six
weeks died apparently of inanition. The autopsy
findings revealed this very interesting condition :
The right lobe of the liver appeared displaced well
down into the pelvis ; in fact, it could not be a true
displacement ; it seemed to be a development and a
displacement. The gallbladder was in a right
angled position with the midaxis of the bowel. The
lower border of the right lobe of the liver was down
in the lowermost part of the pelvis. Through the
November 50, 1918.]
BOOK REVIEWS.
right hernial ring the cecum and appendix were
herniated. The child gave this symptomatology :
For the first four days after birth there was no
trouble whatsoever, then there began a train of gas-
trointestinal disturbances, and a little later meta-
bolic disturbances were found. The terminal pic-
ture was that of ordinary inanition. In his judg-
ment this abnormality of position was the etiologi-
cal factor of the gastrointestinal and metabolic dis-
turbances.
Dr. Gordon K. Dickinson, of Jersey City, N. J.,
said that in the June, 1918, issue of the Annals' of
Surgery there was a very interesting article on the
anatomy and embryology of this subject, and it
looked as though the theory advanced by the author
was correct. He had forgotten the name of the
author. His observations were based on em-
bryological researches, the literature and otherwise,
and the position was taken that all of these bands
.that were observed and called Jackson's membrane
and Lane's kink, were embryonal and could be
traced back to the very early period of fetal life.
Dr. Hugo O. Panzer, of Indianapolis, Ind.,
said he was pleased to see that surgeons were be-
coming more and more harmonious in their views
regarding this subject. In time they would know
more of the symptomatology of the disease and go
more specifically after it. These conditions were
very often associated with a narrow costal angle,
visceroptosis, congenital defects, and so on. By
percussion one could tell whether the cecum was
over the pelvic brim, and by auscultation and per-
cussion one could tell a good deal about the abdomi-
nal contents.
<^
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which zvc think
our readers are likeh to be interested.]
Anatomy of the Human Body. By Henry Gray, F. R. S. ;
Fellow of the Rova! College of Surgeons; Lecturer on
Anatomy at St. George's Hospital Medical School. Lon-
don. Twentieth Edition. Thoroughly ^Revised and Re-
edited by Warrf.n' H. Lkwis, B. S.. M. D., Professor of
Physiological -Anatomy. Johns Hopkins University, Balti-
more, Md. Illustrated with 1247 Engravings. Phila-
delphia and New York • Lea & Febiger, igi8. Pp. 1346.
(Price, $7..S0 cloth; $g leather.)
This twentieth edition of Gray's Anatomy marks
an epoch in the long 1-ife of this greatest of all text-
books on anatomy. Lewis, of Johns Hopkins, has
proved worthy of the task of its extensive reediting
and revision, and Gray's Anatomy is indeed a field
worthy of the power and scientific acumen of this
living master. This great work has so valiantly
stood the test of time and has so consistently at-
tracted masters of anatomy when progress de-
manded revision, that the most pertinent comment,
it seems, includes, almost exclusively, announce-
ment of the new and last changes in presentation
and subject matter. It has remained for Lewis to
leaven and vitaHze this great descriptive anatomy
with the physiological conception. In this revision
the original plan has been followed in general, with
only such change "as advance in the science made
necessary in order that this work may reflect the
latest accessions to anatomical knowledge." These
"latest accessions" have, however, necessitated
changes v/hich students of Gray will recognize as
radical and epochal, and it is at once apparent that
the newer conceptions of and emphasis upon physi-
ological anatomy are responsible for much of this.
New matter on physiological anatomy, laws of bone
architecture, mechanics and variations of muscles
has taken the place of former sections on applied
anatomy. Accordingly, also, sections on the ductless
gland and the nervous system have been rewritten,
and physiological and pharmacological work has
contributed to the presentation of the sympathetic
nervous system many new and valuable charts, dia-
grams, and descriptions. A striking feature of this
edition is the marked increase in the frequency of
the use of colors to emphasize salient points in the
cuts. Improvement in the preparation and selection
of illustrations is noticeable, especially in the sec-
tions on the central nervous system and muscles.
Another important departure is the topical distribu-
tion of histological and embryological material.
This inakes for greater unity and coherence, and
adds to the practical value of the work. We have
not the previous edition at hand for comparison, but
believe that considerable work has been done in the
small print sections on relations, mechanism, and
movements under syndesmology and myology and
in matter on important related topics not strictly
and exclusively descriptive anatomy. All this, of
course, quickens the subject and enhances the value
of the Anatomy as a guide in dissection and later
reference. We have here, in short, in Lewis's edi-
tion, a real and fundamental strengthening of that
keystone of medicine, anatomy.
Rontgen Diagnosis of Diseases of the Head. By Dr.
Arthur Schijller. Head of the Clinic for Nervous Dis-
eases at the Franz-Joseph Ambulatorium. Vienna.
Authorized Translation by Fred F. Stocking, M. D.,
M. R. C. With a Foreword by Ernest Sachs, M. D.,
Associate Professor of Surgery in Washington Univer-
sity. Approved for Publication by the Surgeon General
of the United States Army. Tllustrated. St. Louis:
C. V. Mosby Company, 1018. Pp. 300. (Price, $4.00.)
This book, the preface tells us, was translated by
the editor when it first appeared in German, he be-
ing, at that time, a student in the clinic of Doctor
Schiiller in Vienna. Needless to say, the subject is
one of considerable importance, and it may also be
added, has not been entirely neglected in English lit-
erature. In fact, no body of more enthusiastic
rontgenologists may be found anywhere than in this
country. The use of the x ray still lags consider-
ably behind and the present book marks a welcome
increase to the literature hitherto made available in
this most important field of investigation. The half
tones, however, are very unsatisfactory, as most
half tones would be on x ray matter, but these are
evidently half tones made from other half tones and
are therefore particularly confusing. Apart from
this, the text is interesting and profitable, and the
difficult subject of intracranial diagnosis very much
furthered by the appearance of this work which
offers almost for the first time, a comprehensive and
fairly complete 'resume of the extremely scattered
9/2
BIRTHS. MARRIAGES, AND DEATHS.
[New York
Medical Journal.
literature of this subject. Typograi)hioally, the ap-
pearance of the book is all that could be desired and
is a welcome addition to the working library of the
surgeon, rontgenologist, and tlic neurologist also lo
such internists who enter the neurological field by
way of the glands of internal secretion.
Oiai DiSi'ascs and Malformations. Their Diagnosis and
Treatment. Bv Gf.orgf Van Tngen Brown, D. D. S.,
Al. D., C. M., F. A. C. S. With Five Hundred and Seventy
Engravinps and Twenty Plates, and a Selected List of
Examination Questions. Third Edition. Philadelphia
and New York: Lea & Fehiger, 1Q18.
In the preface to the first edition of his book the
author states that it is designed as a work of refer-
ence touching many different medical interests in
their oral relation, it being his purpose to "include
all important pathological conditions that affect or
are influenced by the oral cavity and its immediate-
ly surrounding parts ; to deal thoroughly with the
etiology and symptoms of these affections and to de-
scribe the necessary operative procedures clearly
and concisely with sufficient detail to give a thor-
ough luiderstanding of the most approved methods
of treatment, the risk involved and the probable re-
sults." This very ambitious program has, with few
possible exceptions, been admirably carried out in
the third edition of his work, to which has been add-
ed an excellent chapter on war surgery, in which the
principles of plastic and oral surgery, as applied to
war injuries, are clearly set forth. The volume
opens with a study of anesthesia, hemorrhage, and
shock, in which the relative value of anesthetics is
considered, the classification and treatment of
hemorrhagic conditions, together with causes and
treatment of shock. Pathological dentition, is com-
prehensively treated in chapter two, including the
surgical treatment of impacted teeth.
Syphilis is given a large place in the chapter on
infectious diseases. The statement "that many
causes of arrested development, other than syphilis,
which leave the record of their occurrence upon
teeth in the form of grooves, pits, eroded surfaces,"
etc., apparently b'orne out by clinical experience, is
positively denied bv excellent authority and with
very good evidence in support of their claims. Cus-
pal hypoplasia of the first permanent molars is the
most common of these dystrophies, and according to
the French school, is unquestionably pathognomonic
of hereditary syphilis, quite as mtich so as is Hutch-
inson's teeth. Occurring at about the sixth month
of intrauterine life, it can only be catised by some
profound trophic disturbance affecting the fetus
through the mother.
Doctor Brown's statement that "faulty metab-
olism, due to many causes which may affect the
mother, and later the diseases of infancy, may be
accountable for the imperfect form of tooth crowns
and marks upon their surfaces," etc., is not very
convincing. Moreover, no clear distinction is made
between those fugitive anomalies of arrested devel-
opment and those symmetrical erosions which are
located at the same level, and always on the same
group of teeth, affecting only the cuspal or incisal
enamel.
The subject of focal mouth infections is briefly
and conservatively treated — too briefly, it would
seem, in view of its importance. Diseases of the
glands, maxillary sinus, bones, and mucous mem-
brane of the mouth, are ou.tlined at considerable
length, and as a whole the subjects are excellently
treated. Most unsatisfactory is the description
given of pyorrhoia alveolaris and its treatment. The
term "interstitial gingivitis" is without justification;
it is no more descriptive of the pathology of the
disease thar. is -jyorrhiea alveolaris and has the add-
ed disadvantage of being almost unknown, especi-
ally among medical men. Beyond the statement
that its causes are "predisposing and exciting, local
and general," almost nothing is said about its eti-
ology. Regarding its pathology, the author is
wholly silent. The treatment reconmiended is the
use of cathartics, diuretics, diet, etc., care being
observed to overcome the acidosis Except the
splinting of loose teeth, nothing is said about local
treatment : not a word about the exceeding impor-
tance of root surgery and mouth hygiene, without
which it is impossible to effect a cure in any case.
No distinction is made between malocclusion and
traumatic occlusion. Undue space is given to the
endameba-emetin scandal, which needed to be re-
ferred to, only to be condemned. It is obvious that
the author is unfamiliar with present day knowl-
edge regarding the etiology, pathology, and treat-
ment of pyorrhea.
Chapters on nasal deformities and diseases in re-
lation to the maxillae, tumors, harelip, cleft palate
and defects of speech, cover these subjects thor-
oughly and well. The volume closes with an up to
date chapter on war surgery. The text is well
illustrated with several colored plates of a high
order of excellence. The index is good, but could
be improved. On the whole, the book is worthy
of careful study, and can be highly recommended to
all those interested in the subjects under consider-
ation.
^
Births, Marriages, and Deaths.
Died.
Bri-din. — In East Orange, N. J., on Sunday, November
17th, Dr. Stephen L. C. Bredin, aged eighty-four years.
Ci'DPEB\CK. — h^ Rochester, N. Y., on Friday, November
1st, Dr. Willis D. Cuddcback, of Aurora, N. Y., aged forty
years.
Dickinson. — In Des .\rc. Ark., on Saturday, November
9th, Dr. Putnam Dickinson, aged seventy years.
Ford. — In Loomis. N. Y., on Friday, November 22d, Dr.
James S. Ford, aged thirty-three years.
Forward. — In Dubuque, la., on Monday, November nth,
Dr. Charles Pulford Forward, aged twenty-nine years.
HiTCHrocK. — In Oswego. N. Y., on Monday, November
iith, Dr. Pherson H. Hitchcock, aged eighty years.
Knight. — In Portsm.onth, England, on October 28th, Dr.
Frank H. Knir,ht, Captain. Medical Corps, U. S. Army,
of Brooklyn, N. Y., aged fortv-two years.
MFUCK.--In Fort Edward, N. Y., on Friday, November
8th, Dr. William B. Melick, aged sixty years.
Arii.LiNGTON. — In Greenwich, Conn., on Friday, Novem-
ber 8th. Dr. John Millington, aged seventy-two vears.
Murray. — 1n Hagcrstown, Md., on Sunday, November
17th, Dr. George Edward Murray, aged sixty-one years.
Paine. — In Brooklyn, N. Y., on Monday, November
i8th. Dr. Charles Fmerv Paine, aged thirtv-six vears.
Patiikun. — In Danville. 111., on Tuesday, November
i2th Dr. Jamf's Cc>rbett Palhbun, aged thirtv-seven years.
Strasskr. — In .Arlington. N. J., on Wednesday, Novem-
ber 2oth, Dr. August Adrian Strasser, aged forty-four
vears.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journahh'e Medical News
A Weekly Review of Medicine, Established 1 8 43
Vol. CVIII, No. 23.
NEW YORK, SATURDAY, DECEMBER 7, 1918.
Whole No. 2088.
Original Communications
THE BLIGHT OF THEORY ON THE AC-
QUISITION OF ANATOMICAL KNOWL-
EDGE BY THE ANCIENT EGYPTIANS.
By Jonathan Wright, M. D.,
Pleasantville, N. Y.
". . . Long ago they appear to have recog-
nized . . . that their young citizens must be
habituated to forms and strains of virtue. These
they fixed, and exhibited the patterns of them in
their temples; and no painter or artist is allowed
to innovate upon them, or to leave the traditional
forms and invent new ones. To this day, no alter-
ation is allowed either in these arts, or in music at
all. And yon will find that their zvorks of art are
painted or moulded in the same forms which they
had ten thousand years ago; . . . I know that
other things in Egypt are not good. . . . This,
however, must be the work of God, or of a divine
person; in Egypt they have a tradition that their
ancient chants are the composition of the Goddess
I sis. . . ." — Plato: Laws II, 656-657.
Despite daily observation of the skill displayed by
the authors of the headlines in one's morning paper,
one is frequently at a loss to give such a title to an
•essay that the reader can at once enter sympatheti-
cally into the subject to be discussed. After a pro-
longed recasting of words into various sequences, I
have abandoned hope of setting forth in the title of
this paper more than one of the causes of the re-
tardation of medical knowledge in the civilization
which arose on the Nile before the dawn of legiti-
mate history. The one I have finally chosen, the
pruning hand of the editor will doubtles.s still fur-
ther cut down for the running head.
The initial difficulties can only be overcome by a
few prefatory remarks, for I wish to make clear
at a glance that theory was only one of the blighting
factors responsible for the low position ot the art
■of medicine in an empire of many million souls,
formerly extending from the Mountains of the
Moon far into the plains of Mesopotamia, and from
the southern Red Sea straits of Bab-el-Mandeb to
the Western Isles along the shores, and thence to
the mainland of Asia Minor. The complexity of
political organization necessary to hold the congeries
of peoples who dwelt in this vast region together,
even for a generation or two, can readilv be im-
agined ; yet, in a somewhat less expanded area, it
lasted for thousands of years — thrice the time of
the duration of Imperial Rome. We now know that
its general culture was a part only of that which
■spread far into the hinterland of the shores around
Copyright, 1918, by A. R.
the Mediterranean, but it was by far the mightiest
part. The complexity, diversity, and extent of its
political and social life was but a counterpart of its
religious expansion.
Nowhere but on the continent of Africa has
dogma and practice, sincerity of belief and spiritual-
ity of tendency, been so developed. It is not a
difficult taslc to trace the magical and religious ideas,
which ancient Egypt exhibited in such astounding
profusion, back to those which existed in the dawn-
ing intelligence 3f primitive man. In doing so, how-
ever, the researcher is keenly conscious of the tre-
mendous mental activity which must have accom-
panied the formation of that infinite variety of
theory, of imagination, of puerile reasoning which
imposed on the peoples' consciousness the cults of
a thousand divinities, with all their ramifying af-
filiations and their profound and ever present in-
fluence on everyday life and imperial policy.
Egypt's marvelous achievement in architecture and
in plastic art formed the basis of Greek culture and
secondarily of our own, and in certain directions
has never been surpassed. I might point out other
marvels of the material prosperity and spiritual
insight into life which Egyptian civilization ex-
hibited, but as I only desire to contrast the puerility
of its anatomical knowledge with the splendors of
these records, I have perhaps said enough and may
now turn to some of the apparent causes of this
backwardness.
This brings me again to my initial complaint —
that the modern demand for brevity in titles com-
mits one to the charge of cherishing a faith in the
simplicity of etiology, against which I try never to
lose an opportunity to protest, whether in the discus-
sion of disease or in the consideration of the causes
of phenomena more widely debated in the current of
contemporary thought. The focussing of medical
thought on bacterial etiology or on serological reac-
tions, like the ancient focussing of thought on de-
monology and the "pneuma," are but illustrations in
present day interests and historical perspective of
this striving after etiological simplicity where none
exists.
It is perhaps the instinctive conservation of men-
tal energy which gives vent to this universal tend-
ency of human thought, but it is a stumbling block
in the path of the pursuit of truth. There are
causes for things, but there is no one cause of a
thing. Just as the editor of the New York Medi-
Elliott Publishing Company.
974
WRIGHT: THE BLIGHT OF THEORY ON THE STUDY OF ANATOMY. „ [New York
Medical Journal.
CAL Journal will be compelled by the exigencies of
space to abbreviate a page heading so that it bur
vaguely expresses the purport of this paper, so is
one often compelled to discuss etiological relation-
ship from a false standpoint. Simplicity takes the
place of complexity because complexity does not
lend itself to clarity of exposition — not because it is
a true expression of etiology. So, because of the
necessity for economy in space and in demands on
the mental powers of author and reader in current
literature, a lamentably deficient perspective in the
causation of cosmic events results when it is dis-
cussed from the simplified point of view of only one
of its factors.
The causes of the remarkable idea the Egyptians
held of the anatomy of the human frame, most com-
monly alluded to by those familiar with the subject,
centre around the overshadowing power of sacerdo-
talism ; while perhaps the most comprehensive
group of causation is expressed by the biological
term of the unfitness of the environment for the
germination of the seeds of anatomical observation.
I desire to avoid the first because of its timeworn
conventionality, and the second because of its lack
of limitation, though 1 shall not be entirely success-
ful in omitting either. The "blight of theory" on
the advance of positive knowledge is something
which in this era appeals to those who believe
blindly in the orthodox canons of scientific method,
and possesses the further advantage of being a
factor in the causation of this particular instance of
stagnation of science which has not been discussed.
This latter, I confess, is the principal reason why I
have chosen chiefly to discuss this one aspect of the
causation of the persistence of crude ideas of anat-
omy in a people of great achievements in other
wplks of civilization — not because it can be consid-
ered the chief factor, nor because it is not entangled
intimately in the general mesh of etiological phe-
nomena.
I have alluded to the surprise repeatedly ex-
pressed at the backwardness of medicine in the civ-
ilization of ancient Egypt ; usually perceived as
intimately dependent on the ignorance of anatomy
that prevailed from the advent of the first dynasty
until the empire fell under the sway of the
Ptolemys. This surprise is still further deepened
by the consideration that during practically all these
thousands of years a very large number of the
privileged caste — the priests — -were daily busy, not
only with the care of souls and the art of preserving
the health of the body, but with preparing both for
eternal life through the processes of embalment,
which included much handling of the organs, both
in*:crnal and external. An incision was made in the
left inguinal region and through this the abdominal
organs were extracted. These were preserved out-
side the body in canopic jars. Then a way was
made, either by means of this incision or of another
through the diaphragm, and the thoracic organs
were likewise removed and preserved. The brain,
as is well known, was drawn out by a metal hook
through the nasal fossa- and the cribriform plate
of the ethmoid. This sort of thing was being done
daily in the Nile Valley for more than a thousand
years, perhaps twice that long, and this is the result
of what the Kher-heb, or head priest, and his
minions learned of human anatomy, as given in a
translation, by Joachim, of the Papyrus Ebers •}
This is the beginning of the secret book of the physician,
the knowledge of the pace of the heart and the knowledge
of the heart itself. In it are the "metu" to the whole
body. As for these, every physician, every sekhet priest,
every magician, whether he lay his finger on the head, or
the back of it; on the hands, the cardiac region, the two
arms, or on the legs — everywhere, he feels the heart be-
cause its "metu" run to all parts ; hence it is called the
centre of the vessels of all parts of the body.
There are four vessels in the two nostrils, two carrying
mucus and two blood. There are four vessels inside the
two temples. After they have given off blood to the eyes
there arise through them all sorts of eye disease, because
they are open to the eyes ; when water comes out of them
the pupils of the eyes furnish it; or another view is that
sleep brings it to the eyes. There are four vessels which
divide in the head and which spread out to the back of
the head, which after a while bring forth a lot of hair.
It is the birth of the hair upward (?). When the breath
goes in at the nose it flows to the heart and to the rectum ;
these latter supply the body abundantly with it. When
one hears something among them the two vessels bring it
about which go toward the clavicle; or if one recognizes
them among them, it is those which go to a person's upper
jawbones; while it is the raw wind which cuts into a
person if he of his own accord inhales its breath. Or if the
heart sucks in water the parts all wither up. If the heart
is smitten, it is that vessel, the 'clutcher' is its name, which
does it; it gives off water to the heart or to the eye, when
it is obstructed. If he listens through the opening of his
mouth, all his parts are benumbed, after confusion has
seized upon his heart. If anger arises in the heart there
is an expansion to the divisions of the great gut and of
the liver, his ear is pricked up, his vessels collapse, after
their expanding heat has loosened everything.
There are four vessels to his two ears, two to the right
and two to the left side. The breath of life goes in at
the right ear and the breath of death in at the left; or
with other words the breath of life enters the right side
and the breath of death the left.
There are six vessels that go to the two arms, three to
the right and three to the left, and they lead down to the
fingers. There are six that go to the two feet, three to
the right and three to the left ; they reach to the soles of
the feet.
There are two vessels that go to the two testicles. There
are two vessels to the kidneys, one to one kidney and the
other to the second. There are four vessels to the liver,
which carry moisture and air to it; subsequently (?) they
bring about all sorts of sickness in it, as they are mixed
with blood. There are four vessels to the large gut and to
the spleen, which likewise give them moisture and air.
There are two vessels to the bladder, which carry the
urine.
There are four vessels which open out in the anus; they
produce and bring to it moisture and air ; therefore the
anus communicates with every vessel on the right and
the left side clear down to the feet and is mingled with
the feces.
Before commenting on the physiology that is as-
sociated with this conception of the human anatomy
channeled by vessels carrying .moisture and air, I
must now refer in a few words to the theory of the
"pneuma." It was first pointed out by von Oefele
( I to have existed in the conceptions of the ancient
Egyptians, before it reached its great development
in Greece. In previous articles (2) I have at-
tempted to show that the ideas associated with this
theory of the cause of life and death, which subse-
'I make use of the translation of Joachim not because it is the
best possible, but because it is the only consecutive one. Despite its
faults, which have been perhaps unduly emphasized by Egyptolo-
gists, it has been of great utility in revealing to medical men of
today the medical knowledge of the men of the most remote an-
tiquity. We have reason to hope that in the near future Wre-
szynski will do us the great service for the Ebers which he has
accomplished for the Berlin Papyrus.
December 7, 1918.] IFRIGHT: THE BLIGHT OF THEORY ON THE STUDY OF ANATOMY.
975
quently underwent such development at the hands
of the Greeks, had a common origin with the ideas
of the soul held by many races — especially the
African races — of primitive man. Its appearance
in Egyptian medicine was due to differentiation and
evolution. I have, then, endeavored to make clear
the association of the observation of respiratory
movements with the existence of a something ex-
pelled from the mouth and nostrils, and again in-
haled, which is invisible and which became the
mystical or spiritual part of the conception of life
and death.
Owing to the hopes for the continuation of life
entertained by primitive man, his budding reasoning
powers early conceived the idea that there is some-
thing associated with his corporeal frame which per-
sists after death. That crystallized into his faith in
an immortal soul, which became identified with^The
mysterious something passing in and out during the
respiratory movements. At first this doubtless was
identified with the respired air itself, but as all such
materialistic beliefs (like fetichism) became more
or less symbolized, the soul, as the idea of air grew
into a material substance, became the spiritual part.
This however was a later development. The idea
of life itself was also undifferentiated from that of
the soul. Both these ideas are still pressing for
solution of their mysteries upon the more experi-
enced reasoning powers of primitive man's latest
descendant. Something plainly passes out of the
dying man with his last gasp and does not return.
That was the soul. That was the breath of life
which the Lord Jehovah breathed into the nostrils
of man when he had made him out of the dust of
the earth. In an Egyptian hymn to Osiris he is
saluted as "the father and mother of men. They
live from, thy breath."
In going over the record of observations of the
actions of the physician to primitive man, we should
find him not infrequently trying to blow the breath
of life into the patient's mouth or even into his
rectum. We should find him with his blowing cure
trying to puff away the evil breath of disease — the
breath of death. Enough has already been said in
the contributions I have made to the columns of this
and other journals to picture the medicine man
chasing escaped souls to put them back into suffer-
ing patients. In the Scottish highlands the gifted
still see the wraith of the departing soul — its film
is deposited on the mirror held before the mouth.
The columns of the daily paper occasionally give
space to the assertion of someone who has seen it,
as the last breath leaves the body.
Now there can be no doubt that by the time the
primitive Eg}'ptian, floating on the rising tide of
civilization, com.es into the purview of the archaeolo-
gist— and long before he arrives at the pages of
history — he has begun to diff"erentiate between not
only life and the soul, but, singular to say, both he
and the North American Indian (3) began to evolve*
a multiplicity of souls belonging to each individual
to account for various physical and physiological
phenomena. We have seen too how, in the Phsedo,
Plato incidentally refers to the current belief in the
soul among the Greeks which plainly harks back to
the breath as embodying it, and we can easily find
there traces of a belief in a multiplicity of souls.
Even Plato makes Socrates refer to multiple, and
more or less independent, functions of the soul.
Finally, we have in previous papers noted the
important part that disorders of the soul, the envi-
ous acts of the souls of the deceased, demons, and
the innumerable spirits of a pantheistic view of
nature (all interrelated concepts and close kindred
to the "pneuma") play in the causation of disease.
Out of this primal concept (which, though almost
inconceivably vague, may have been simple at first)
there ensued a chaos of differentiating applications
which pervaded all social, and especially all relig-
ious, life. 1 think von Oefele has clearly exhibited
the trail of the pneumatic theory in Egyptian medi-
cal thought, at least of the later dynasties. In
ascribing to the earliest dynasties the anatomy above
given of the vessels that carry the "pneuma," he
has the statements of the book itself to support him,
which, if they can be trusted, clearly indicate its
antiquity. The Egyptians were so given to lending
dignity to their assertions by ascribing them to the
remotest times and the holiest and kingliest of men,
that I question if such evidence can be unhesitat-
ingly accepted. Into the further support which
von Oefele finds for the antiquity of this anatomy
I cannot go, nor is it essential to the chief interest
of this essay. In outline I have given here a sketch
of the evidence, which may easily be filled in by the
curious and the diligent, of a way of looking at
disease that necessitated the invention of such an
anatomy.
Now we can go back to the rendering I have
given of Joachim's translation from the original.
There has been a statement repeately made that the
Egyptians in their word "metu," channels or vessels,
confounded not only the air passages, the blood-
vessels, the intestinal canal, and the various ducts,
but the muscles, the tendons, and the nerves. T
distrust an explanation which pictures a human be-
ing putting the aorta in the same class with the gas-
trocnemius. They knew the flesh and they saw the
intestinal tubes, the bloodvessels, etc. The rest was
simply a theory to fit the demands for the access of
the "pneuma" — the breath or the soul — to all parts,
even as far as the fingers and the soles of the feet.
I am far from denying that in their conception also
lay the germs of humoral theories, and of much
else ; but what I am concerned with here is to show
that the demands of the primordial theories of
primitive man. as they began to develop in ancient
Egypt called for the creation of materialistic con-
cepts to accommodate them. The dominant idea
was that of the "pneuma," an offshoot of the all
pervading theory of the soul in a primitive African
people. When this "pneuma" or breath of life went
in at the nostrils it had to go to the heart as the
seat of life and soul and thought, for this also was
a part of the fabric of Egyptian theory.
Let us repeat, then : Before they began to con-
ceive of thought as having any habitation or, in-
deed, existence, we find the breath, the life, the
soul — originally all one — dwelling in the heart. In
the course of ages life has been moved about to
various organs. The breath has been materialized
and transferred to the lungs, but with the old
9/6
STEINFIELD ■ LESSENED RESISTANCE IN FOCAL INFECTION. [New York
MEDICAL Journal.
Ei^yptians it must go also to the anus, for thence
flatus escaped, and Hfe must also be "carried abun-
dantly to the whole body." "Blood is the life" also,
but that is another story which does not belong to
Egyptian, as it does to primitive African, medicine.
Here it is the breath which is the life, and ii goes in
at the ear on the right side ; but there is also the
breath of death, which goes in at the left ear. Von
Oefele gives a not very good explanation of this
which involves an inkling which he intimates the
Egyptians had of the carbon dioxide content of the
expired air and the assumption that the left ear
gave exit to this.
Further along in the Papyrus Ebers text, which
after describing the vessels of the body becomes a
queer mixture of physiology and psychology, we
have other indications of the "pneuma" idea. In
the moisture which accompanied the "pneuma" we
see the beginning of the moist and dry tempera-
ments. It is chiefly the water here which gives
trouble, although no complications seem to arise
from that supplied to the rectum ; but "when the
heart is troubled it is the taciturnity ( ?) of the
heart or its vessels are obstructed and not recogniz-
able under the hand. They are full of water and
wind." I translate literally obscure passages from
Joachim, because there is evidently a reference in
them to the "pneuma" in a connection interesting to
us because of the rectal blowing cure I have men-
tioned, which is told of some doctor among the In-
dians of the northwest coast of America. When
some sort of a disease enters the left eye, appearing
perhaps at the navel, "it is the breath (blown
through?) the hand opening of the priest, which the
heart admits to its vessels," for this rendering is
suggested through the reading in another place that
"if the heart is ailing, if it is overburdened {ausser
sich gcrathcn) it is because of the breath blow!i
through the hand opening of the Kher-heb priest ; it
penetrates to. the rectum in such fashion that the
heart appears ( ?) and loses itself in the disease."
I am unable to pass on the validity of this
jumbled rendering, because of my ignorance of the
lore of hieroglyphs. The original itself was in
von Oefele's view, written in an ancient script un-
familiar to the copyists by whom in succession the
manuscript was repeatedly rewritten, finally to be
set forth in a modern language and later here trans-
ferred to another. I intrude the passages here only
for their evident pneumatic bearing — the thought of
that Kher-heb priest blowing through his hands
into the rectum lii<e the doctors Bancroft (i) tells
of among the Northern Indians, who for inward
complaints "blew zealously into the rectum or ad-
jacent parts." That unfavorable results should be
mentioned by the original recorder does not appeal
to our modern sense of the fitness of things, well
acquainted as we are with the reluctance of clin-
icians thus frankly to publish cases they prefer to
have pass into oblivion. We must conclude either
that some recorder, copyist, or translator in the
course of the last 6,cxx) years has erred, or that the
result was a success.
The date of the Papyrus Ebers — the period when
fit is su])posed) some scribe copied the things it
contains — was some 3,400 years ago. The section
of the book containing this idea of anatomy is said
to have been deposited under the feet of the god
Anubis during the reign of the fifth king of the
first dynasty. Now a moderate date for the begin-
ning of the dynasties would make this section, if
the old copyist told the truth, about 1,90x3 years old
when the Ebers manuscript in the Leyden Museum
was written. This would make the anatomical
description date back about 5,300 years.
It is not of much consequence to us whether the
scribe told the truth or not. The point is : This is
the sort of anatomy furnished the student of
medicine through a hand book at the height, or near
it, of Egypt's glory and culture. If after enduring
for 1900 years it still existed as good copy, then in-
deed the conservative hand of sacerdotalism rested
heavy upon the land, for it compelled an entirely
absurd conception of anatomy to persist in order to
support a theory. But beyond all that — beyond the
theories and the sacerdotalism — is the necessity to
recognize that the fabric of civilization is such a
close knit one that no fact can be woven into the
pattern until innumerable other threads are in place
to hold it there.
In conclusion, I think however it will seem ex-
tremely probable to the reader that this Egyptian
conception of anatomy was invented and preserved
to accommodate the theory of the "pneuma," and
therein we are justified in seeing a striking example
of the "blight of theory."
REFERENCES.
I. FELIX VON OEFELE: Extracts from Puschmann, Theodor
edition, Handbuch der Geschichte der Medizin, Jena: G. Fischer,
1902; Materialien zii einer Geschichte der Pharaonenmedicin VI.
Aegyptische Pneumalehre im Auslande; Praqer medisinische Woch-
enschrift, March, 1905. 2. JONATHAN WRIGHT: New York
Medical Journal. July 20, 1918; August 10, 1918; August 17. 1918.
3. JAMES TEIT: The Thompson Indians of British Columbia,
New York, 1900. American Museum of Natural History Memo-
randa, Vol. 2. Anthropology, i. Jesup North Pacific Exped. 4.
THE SITE OF LESSENED RESISTANCE IN
FOCAL INFECTION.
By Edward Steinfield, M. D.,
Philadelphia.
Through the efiforts of the orthopedic surgeons a
marked advance has been made in the detection of
underlying causes of many painful conditions of the
muscles and joints, hitherto of obscure etiology.
These have been found to be fostered in a great
measure bv mechanical conditions such as flat foot,
sacroiliac sprain, exostoses of bones, anomalous
conditions such as cervical rib, chronic inflamma-
tory conditions of the bursae such as subacromial
bursitis, and other conditions of an orthopedic
nature. With the appropriate mechanical and surgi-
cal treatment a considerable number of these cases
can be helped. The attention being directed toward
these lesions, a wide range of painful conditions
usually labeled "rheumatic" were gradually recog-
nized as having a more hopeful prognosis and were
enthusiastically attacked along these lines.
Due to the attention of the internist and bacteri-
ologist upon the subject, there arose the conception
of focal points of intection in the body, often not
apparent, nevertheless allowing the absorption into
the lymph and blood channels of toxins and bac-
teria, the latter usually of an attenuated strain.
December 7, 1918.] STEINFIELD: LESSENED RESISTANCE IN FOCAL INFECTION.
977
Because of the obscurity of some of these sites, the
term '"cryptogenetic infection" was appHed to these
cases, but since patient search usually reveals the
actual area of infection, the term "focal infection"
has become more appropriate. These infective
areas may exist anywhere in the body, though
greatest interest has centred about those located in
the head area.
There are certain types of cases in which both
mechanical and septic elements cooperate to produce
the final disabling lesion. In these cases, trauma,
overuse, or mechanical fault in a part render it sus-
ceptible and it becomes the elective site for bacteria
from a point of focal mfection. It is in these cases,
on account of concentration upon one or another
factor alone, that the results of treatment may
not be satisfactory. For example, a too ob-
vious flat foot may satisfactorily explain a painful
condition of the foot or leg, until perhaps later an
extension of symptoms to other extremities may
ultimately show this has only been the expression
of infection coming from diseased tonsils. Again,
a pain in the sacroiliac region during an attack of
influenza may be accepted as analogous to the gen-
eral muscular pains from which the patient is suf-
fering, though in reality it is the first manifestation
of a mechanical fault or strain previously existing
in the joint or muscles about the joint.
SITES OF FOCI OF INFECTION.
The areas of focal infection are more commonly
situated in the head. These may be in the sinuses,
mastoid cells, middle ear, the lymphoid tissue of the
tonsils and adenoids, especially in the concealed
crypts of atrophic and diseased tonsils, in the alveo-
lar spaces of teeth, in gums — particularly in the
presence of decayed teeth, crowns or bridgework.
The nasal and pharyngeal mucosa in states of acute
Of chronic inflammation may be avenues of infec-
tion. In other parts of the body there must be
considered the possibilities of gallbladder infection,
chronic appendicitis, intestinal stasis and purulent
salpingitis. The importance of infection of the
genitourinary tract as a cause of systemic disease
has been recently emphasized by B. A. Thomas (i).
He includes in the list of conditions, acute suppura-
tive nephritis, pyonephrosis, pyelitis, tuberculous
kidney, renal and perirenal abscess, uretefTtis,
cystitis, prostatitis, seminal vesiculitis, epididymitis
orchitis, and urethritis. It must be noted that in
diseases of the kidney and pelvis of the kidney that
the infection may here be secondary to some other
site, such as the tonsil.
In the acute respiratory infections included under
the terms grippe, coryza, rhinitis, bronchitis, or
"colds." the nasal and pharyngeal mucosa may be-
come temporarily the site for entrance of infection.
In influenza the sinuses may remain infected after
the subsidence of the attack and subsequently act as
an infective focus. Reilly (2) has called attention
to the importance of attacks of ordinary "head
colds" in the production of painful conditions of
muscles and nerves. The attacks of apparent
"nuiscular rheumatism" appear within one or two
weeks after the onset of the cold and usually after
the subsidence of catarrhal symptoms.
B.\CTERI0L0GY.
The greatest interest has centred about the strep-
tococci. Other pathogenic organisms found in the
localities mentioned above are pneumococci, Bacil-
lus influenzae. Micrococcus catarrhalis. Bacillus
protcus, and Bacillus coli. However, of those har-
bored in the head area, the streptococcus has been
proved to he the most important as regards patho-
genic significance in these conditions. It has been
claimed on the basis of experimental evidence, that
the streptococci found in certain inflammatory
lesions of joints, heart valves, gallbladder, ap-
pendix, ovaries, etc., have a selective affinity for
these organs or structures. That is, a streptococcus
found in an appendiceal abscess is one of a special
strain having a selective action upon the appendix,
a streptococcus producing an arthritis is one having
a selective action upon joints. This would necessi-
tate an accurate tabulation of many strains of
streptococci. Except on the basis of morphology,
length of chain formation, characteristics of col-
onies on blood agar and the fermentation of carbo-
hydrates such as lactose, mannite, or salicin, which
at best are not constant, we have no definite basis
for classification beyond large comprehensive
groups. However, it is evident that some more
certain and probably biologic classification, such as
exists in the case of the pneumococci, is to be hoped
for. Though the doctrine of selective affinity may
be true for a certain percentage of cases, we believe
that for the greater number of peripheral lesions
the cause for localization in any given case will be
found to be due to a state of predisposition of the
part. To bring about this vulnerability, there have
been acting such causes as trauma, overexertion,
mechanical faults producing a condition of strain
and previous states of inflammation.
The streptococci found in the blind or closed
dental abscesses are usually of the viridans strain.
The hemolytic streptococci as a rule are found in
those abscesses having some degree of drainage.
The Connellan-King diplococcus, a gram negative
diplococcus harbored in the tonsils, has been impli-
cated in some types of arthritis. The role of a
filterable virus in production of colds, has been re-
cently studied by Foster (3). Since, as mentioned
before, the mucosa of the nasopharynx may become
the site of focal infection due to transient disease,
the possibility of a filterable virus is to be consid-
ered. We have noted after the passage of cultures
of pneumococci through Kitasato and Berkefeld
filters, that the resultant fluid could be made, by
incubation in blood glucose bouillon over several
days, to give a slight turbidity. Stained smears of
these cultures would show nothing, but on hanging
drop preparations large numbers of organisms could
be seen. These were smaller than the original
pneumococci, though the morpholog}' was similar,
that is, they were diplococci with a distinct halo
about them. They could be transplanted and grow
somewhat better in the subculture, but still show
lack of staining properties. It has seemed rational
to regard this simply as a manifestation of attenua-
tion. With the exception that the bodies found by
Foster only grew under anerobic conditions, there
would be some resemblance to these attenuated
pneumococci.
9/8
STEINFIELD: LESSENED RESISTANCE IN FOCAL INFECTION.
[New York
Medical Journal.
DIAGNOSIS OF FOCUS OF INFECTION.
By close questioning in the case history, a lead
may often be gotten which will facilitate the finding
of the infected area. The occurrence of acute in-
fections of the upper respiratory tract before the
onset of symptoms, recurrent attacks of tonsillitis,
dental treatment followed by undue painful condi-
tions of the gums, actual gum abscesses, pains over
the sinus areas, may all be suggestive of infection
localized in the head. In a like manner, the history
may be made to yield data pointing to the intestinal
tract, gallbladder, or genitourinary tract. In the
evaluation of the physical findings, it is necessary to
have the cooperation of the laryngologist and otolo-
gist, genitourinary surgeon, dental surgeon, and
rontgenologist. X ray plates of the sinuses, and
especially films of the teeth are usually necessary.
The outward condition of a tooth often reveals
nothing which could give the suspicion of the alveo-
lar abscess shown by the x ray. The seminal
vesicles as well as the prostate may be chronically
infected though the original gonococcal condition is
replaced by an infection due to secondary invaders,
such as the streptococcus, staphylococcus, etc.
Rectal examination, especially in the hands of a
specialist, is usually necessary. A gonococcus com-
plement fixation reaction is at times of value in
indicating a gonorrheal etiology. The presence of
some other systemic condition must be rigidly ruled
out in all cases. Of special importance are syphilis,
chronic nephritis, gout, and diabetes. Routine
Wassermann reactions, in addition to all other
routine laboratory data, are to be made. Toxic
conditions due to alcoholism, lead poisoning, or
chronic arsenical poisoning are to be considered.
SECONDARY, REMOTE, OR DISABLING LESIONS.
A variety of painful conditions due to involve-
ment of muscles, bones, joint structures, tendons,
and nerves may result in consequence of the com-
bination of strain and infection. Naturally, the
sites vary with the particular group of structures
aflfected. There seems, however, to be a preponder-
ance of disabilities localized in the lower extremi-
ties, such as sacroiliac conditions, sciatic nerve pain,
and painful conditions of the muscles of the thigh
and leg. In the explanation for the election of any
of these areas as a deposit of infection, we must
consider the following factors: i. Overexertion,
either tem])orary or continvied as in occupational
conditions ; 2. mechanical causes producing a con-
dition of strain; 3. trauma, recent or remote; 4.
previous states of inflammation in the part.
Overexertion of acute nature, such as occurs in
competitive sports or games, often produces what
may be called j)hysiologic pain or soreness. This
should, however, subside or improve in a few
days. The persistence of the symptoms should lead
to the suspicion of some actual lesion in the part,
with or without a focus of infection elsewhere in the
body. The term overexertion also impHes the more
insidious and less violent exertions due to repetition
of some motions in daily occupation ; it may simply
be a tendency to bear the weight on one leg or to
rest upon one arm. These conditions are especially
prone to occur when some new line of work has
recently been taken up. At these times new and
varied duties bring into play hitherto unused mus-
cles, often with unfavorable consequences. In
eliciting the factor of overexertion, unless apparent,
the actual duties of the patient's occupation should
be rehearsed. At times peculiar distribution of
muscular pain is explained by their overuse in oc-
cupation. Thus, in one case, pain confined to the
trapezius and deltoid muscles of both sides occurred
in a baker, apparently due to his motion in kneading
bread. In this connection, I have noted that a
number of cases which might have been called
simply occupational conditions, are really not en-
tirely so, but are combinations of infection and
occupational strain.
In the mechanical causes are included such con-
ditions as sacroiliac disease, flat foot, faults in
posture and the like. That is, they are cases that
require the attention of the orthopedic surgeon
probably both for diagnosis and treatment. In those
cases seen at the Philadelphia Polyclinic in which
the patient presented possible orthopedic condi-
tions, we have routinely referred them for opinion
to the clinic of Dr. James K. Young. Trauma of
recent origin is usually not overlooked. The im-
portance lies in not missing avenues of infection
when the disability has a tendency to linger unduly.
Curiously enough, the factor of remote or previous
history of trauma is brought up by the patients
themselves in many instances, and they inquire
whether this has any bearing on their case. The
element of previous disease of the part affected by
the disabling lesion has been noted in only a small
percentage of cases. Previous pyogenic infections
in these areas have constituted the majority of these
cases.
It is possible to distinguish three types of cases,
on the basis of priority of lesions, as follows : i. The
area of focal infection has existed for some time,
but symptoms arise in a remote part, suddenly
rendered vulnerable. 2. The factor of strain in the
remote part has existed for a variable period of
time. The focus of infection suddenly arises, as in
tonsillitis or infectious rhinitis, and symptoms begin
from this time. 3. The point of lessened resistance
and the focus of infection have both existed for
some time without any apparent symptoms arising,
probably due to the resistance of the subject against
the organisms in the infected area. A condition of
constitutional strain arises, such as hunger, ex-
posure, other infections, loss of blood, etc., with the
consequent letting down of the barriers against
infection, which in turn attacks the area of greatest
vulnerability.
The following cases are illustrative of some of
the points considered in the preceding lines.
Case I.-— C. H., male, age twenty-three years. Pitient
complained of pain and disability of both feet and ankles.
The clinical history reveals the fact that about the time
of onset of symptoms he had put on new and extremely
tight shoes. His feet became so painful that the next day
he had to temporarily discard the shoes, but subse-
• Cuently put them on as?ain. with renewal of pain, and
though after this they were completely discarded the pain
peisisted to such an extent that the patient practically
hobbled about. Gonorrheal infection was ruled out. The
Wassermann was negative and ihe urine and blood pressure
shewed no evidence of kidney disease. Examination of the
feet revealed slight swelling with only a slight degree of
flat foot Large doses of salicylates had previously ■»een
December 7, 1918.] STEINFIELD: LESSENED RESISTANCE IN FOCAL INFECTION.
979
given without market benefit. In search for a causative
focus, a history of a severe tousiUitis was elicited, which
occurred two months before present symptoms began. Pa-
tient had remained pale and liad lacked energy since this
attack. The left tonsil was found cryptic with scarlike
areas suggesting a chronic diseased structure. A culture
taken from the crypts of this tonsil gave a pure culture of
streptococci, short chained, hemolytic, not coagulating
serum water inulin media, though producing a slight de-
gree of acidity. Colonies were minute and grayish in
color. After tonsillectomy, an encapsulated abscess was
found in the left tonsil, thougli both were found markedly
diseased. A noticeable improvement occurred with the
aid of small doses of salicylates, not more than fifteen
to twenty grains a day. I-arge doses of salicylates pre-
viously given had been without effect. The general ap-
pearance of the patient also improved markedly in a few
months with restoration of former vigor.
Cask IT. — C. G., male, age thirty-six years. Patient
complained of pain in lower lumbar region of back of two
weeks' duration. There was a history of sore throat about
three days before onset of pain. The painful area was
found to be localized at the sacroiliac joint of both sides
and the history indicated that the patient's occupation
necessitated the lifting of heavy weights, bending over to
move heavy barrels, and other duties of a like nature.
There was congestion of the pharyngeal mucosa but the
tonsils were not enlarged, nor were they atrophied and
cryptic ; the sore throat had apparently been an acute pro-
cess. Other causes having been ruled out, it seemed ap-
parent that the tonsils and pharyngeal mucosa had acted
as a temporary area of infection, while the sacroiliac
strain had no doubt ex'Sted for some time as a latent
condition. By the use of strapping for the back, germi-
cidal gargles, and salicylates, the sacroiliac disability rap-
idly disappeared.
Case III. — L. G., female, age twenty-three years. Pa-
tient was unable to walk because of pain and stiffness of
right thigh. This condition had existed for two weeks.
The pain began in the sacral region and was most severe
in the posterior aspect of the thigh, some pain to a lesser
degree below the knee. There was no local condition to
explain this pain. On inquiries tending to bring out his-
tory of a particular strain to the right leg, the patient
rem.embered that, due to a painful condition of the small
toe of the right foot, she had for several months been in
the habit of walking with a peculiar rigidity of the corre-
sponding leg in an effort to protect the toe from full
pressure of the shoe. No undue symptoms were, how-
ever, noticeable imtil an attack of coryza and bronchitis.
About the time of subsidence of this attack, the painful
condition of the extremity came on suddenly in one day.
Cultures of the nose and throat gave pneumococci and
streptococci. There bemg no other demonstrable focus
of infection, the acute respiratory- infection was taken as
the probable cause of the sudden onset of symptoms in
a part previously under strain. Under measures tending
to remove the strain, such as protection of the toes with
absorbent cotton, salicylates, and local antiseptics for the
nasal and pharyngeal mucosa, the disability was largely
removed in about ten days.
Case IV. — R. B., male, age thirty years. Patient com-
plained of pain in right sacroiliac region. This pain had
been noticeable for one week. One week before onset of
pain he had coryza and bronchitis. In consequence of a
recent fracture of the 'pft le<7. h^ had been going about
bearing his entire weight on the right lee. No other me-
chanical reason was found for the disability and no other
area of infection was discovered. On examination there
was tenderness and pain on motion in the right sacroiliac
joint and also some pain in the posterior aspect of the
right thigh near the knee. Cultures of the nose and throat
gave a predominance of streptococci. Marked improve-
ment occurred after a few days of rest and salicvlates,
though it is probable that improvement would have oc-
curred spontaneously under the conditions mentioned in
the history.
M.^NAGEMENT OF CASE.
It is apparent that there are not only two areas
to treat, but that at times e^eneral systemic medica-
tion, perhaps of a tonic character, is needed. The
sites of infection must be removed, dramed, or
actively treated unless they have been temporary
ones, as in acute infections of the respiratory tract.
The secondary lesion, if of an orthoi>edic nature,
had better be seen by an orthopedist. A sacroiliac
joint may require strapping, a flat foot may require
accurate correction by supports or special shoes. At
times it is not possible to eliminate the strain upon
a certain part without change of occupation or
actual rest in bed. Often it is only necessary to
call the attention of the patient to the part played
by certain duties in the production of subsequent
sytnptoms, and he will endeavor to correct these
causes, as a rule with some benefit. The salicylates
are of decided value in the amelioration of pain,
and improvement apparently occurs more quickly
under their administration. Other local symp-
tomatic measures, such as baking, massage, and
liniments are of value in cases tending to become
chronic. Constitutional remedies such as iron,
arsenic, iodides, and the like may be used in cases
with anemia or other underlying causes for debility.
F accines. — The object of the vaccines is to create
a condition of general immunity to the causative
organism. It is preferable to use an autogenous
vaccine. In the isolation of the causative organisms
in the alveolar abscesses and blind dental abscesses,
it is necessary to have the cooperation of a dental
surgeon trained to such work. This is especially
true if the diseased areas are to be treated by
drainage instead of extraction of the tooth. These
teeth are usually ones that have been filled or
capped. The individual tooth is isolated from the
rest of the oral cavity by a sterile rubber dam,
painted with tincture of iodine and bored into to
expose the orifice of the root canals. The scrapings
are carefully blown away by an air bulb and the
area rendered sterile by some germicidal solution,
such as phenol or tincture of iodine, but this must
be wiped dry to avoid the possibility of rendering
the culture sterile. The root canals are then entered
by the fine probes used by the dentists for this
purpose and previously sterilized — the ordinary
bacteriologic platinum wire is too thick for this
purpose. Following this, the tip of the wire after
removal, containing some infective material, is
dipped into tubes of ascites broth or glucose bouil-
lon containing a drop or two of defibrinated blood.
These enrichment medias are necessary because the
organism is usually an attenuated streptococcus
difficult of culture. If the teeth are extracted, the
roots are crushed with a sterile bone or extraction
forceps and after a momentary flaming are dropped
into tubes of culture media. The infective material
usually difl:'uses out into the fluid.
In making cultures from gums, the gingival
border is painted with a weak solution of iodine
and the pus expressed by pressure with a wooden
tongue depressor or similar instrument, or a plati-
num loop is inserted into the pocket. The latter
procedure is rendered possible since the diseased
gums are usually not firmly placed against the teeth.
The details are mentioned in this connection, be-
cause without attention to the niceties of technic,
the streptococci or pneumococci of the mouth will
be found on culture and confused with the causative
q8o
SHEFFIELD: WHOOPING COUGH IN THE NEWBORN.
[New York
Medical Journal.
organisms. Cultures of the crypts of diseased ton-
sils may be made especially if some necrotic mate-
rial can be expelled by pressure and this cultured.
After removal of the tonsils, they can be cut with
a sterile scissors or scalpel after searing the sur-
face. Pockets of pus will at times be found in this
way and cultures made for vaccines or for diag-
nostic data. In the culturing of material from ear,
nose, or sinuses, suction apparatus is advisable
when possible.
In the administration of the vaccine, it is well in
the case of the pneumococcus or streptococcus
group to start with a dose of about 50,000,000 to
75,000,000 cocci to avoid untoward reaction. If no
contraindication due to excessive reaction occurs,
the number of bacteria are increased by about
100,000,000 each dose and injections given about
every five days. It may be necessary to run up to
i,o<X),ooo,ooo to secure a favorable result. To de-
pend largely for results upon the employment of
vaccine therapy without thorough eradication of
causes is disappointing, as a rule. However; by the
recognition of more than one cause for these dis-
abling lesions and by the use of some or all of the
therapeutic measures, the outlook for many dis-
couraging cases becomes considerably brighter.
REFERENCES.
I. B. A. THOMAS: American Journal of Medical Sciences, 1917,
cliii, 701. 2. F. F. REILLY: Ihid., 1917, cliii, 709. 3. G. B.
FOSTER: Journal A. M. A., 1916, Ixvi, 1180.
1819 Chestnut Sreet.
WHOOPING COUGH IN THE NEWLY
BORN.*
By Herman B. Sheffield, M. D.,
New York.
The following remarks are based upon the ob-
servation of eleven cases of pertussis in infants of
from nine to twenty days old. In all of these babies
the source of infection could be traced to members
of the immediate family, although in some of them
the positive history was not immediately apparent.
For example, in one case the source of infection
was traced to a grandfather, sixty-four years old,
who for a few weeks had been suffering from a
paroxysmal loose cough accompanied by semi faint-
ing spells. He had been treated for cardiac asthma.
Four infants contracted the disease from their
mothers who had been suffering from a protracted
cough, supposedly bronchitis, because of the ab-
sence of the characteristic whoop. As these infants
during the first few days after birth were entirely
free from any signs of nasopharyngeal or bronchial
catarrh, there is every reason to believe that the in-
fection took place after birth, and, furthermore, that
immunity was not conferred upon them by their
mothers. In the remaining six babies the source of in-
fection was readily discerned since one or more mem-
bers of the family were afflicted with the disease.
The cases of whooping cough in the newly born
thus far recorded are exceptionally few. Among
them may be cited the classic cases of Bouchut,
Rilliet, Barthez, Currier, Watson, Neurath, and
Holt {Twentieth Century Encyclopedia and
Pfaundler and Schlossman Handbook of Pediat-
•Read before the Yorkville Medical Society, November, 1918.
rics). The meagreness of the literature on the
subject, notwithstanding the extremely high mor-
tality which prevails among these cases, tends to
emphasize the apparent levity with which pertussis
is looked upon even by the profession. Of course,
due allowance must be made for the fact that a great
many infants succumb to the disease before a cor-
rect diagnosis has at all been arrived at. For be
it remembered that the symptomatology of pertus-
sis in the newly born differs greatly from that
observed in older children. Whereas in the latter
we are usually able to distinguish three characteris-
tic stages of the disease, thus, stadium catarrhale,
conviilsivmn, and decrcmenti, in the newly born in-
fants the catarrhal and paroxysmal stages are con-
fluent, while the catarrhal stage is so brief in dura-
tion as to entirely escape observation. Beginning
with occasional mild sneezing or coughing a few
days after birth, it is all at once noticed that the
baby is struggling for air with each fit of coughing,
turns blue and even black in color and after a few
expulsive efforts of expectoration, followed
by gagging and trickling out of frothy mucus
from its mouth, the infant falls back pale
and exhausted, in semicoma as it were. The
paroxysms return at shorter or longer intervals,
as a rule, every five to ten minutes. The attacks
of apnea are almost invariably associated with tem-
porary arrest of the heart's action, and it is not
at all unusual for some delicate infants to succumb
during a paroxysm. I witnessed it in two cases —
twelve and fifteen days old respectively. Of the re-
maining cases under my observation two recovered,
five died from bronchopneumonia, or rather hypo-
static or passive pulmonary congestion, one of cere-
bral hemorrhage and one from inanition. One of
the cases of bronchopneumonia was complicated by
rupture of the alveoli. The latter condition was
manifested by rapidly extending subcutaneous em-
physema, or more correctly pneumohypoderma
{Medical Record, November 25, 1911), distinct
purring or crepitation, readily elicited on palpation,
and in severe cases the distention of the skin gen-
erally imparting to the palpating fingers the sensa-
tion very much akin to that experienced when press-
ing upon a strongly inflated toy balloon. The cere-
bral hemorrhage complicating pertussis is usually
localized, giving rise to mono or hemiplegia, and
when confronted with an infant that has been de-
livered instrumentally and shows distinct signs of
forceps traumatism, the diagnosis is apt to be greatly
obscured. In the absence of a positive history of
whooping cough, and more especially in the early
stage of the disease, it is often also very difficult to
decide whether or not we are dealing with congeni-
tal heart disease or hypertrophy of the thymus
gland, since in both of these affections more or less
marked cyanosis predominates. In the differential
diagnosis it is well to bear in mind that in congeni-
tal vitia cordis, the cj^anosis is either permanent or
becomes apparent only during fits of crying. Fur-
thermore, physical examination usually reveals defi-
nite signs of heart disease, such as murmurs or pro-
nounced anatomical malformations. An enlarged
thymus sufficiently marked to produce grave svmp-
toms usually discloses, on percussion, distinct dullness
or flatness over the upper portion of the sternum,
December 7, 1918.]
JOSEPHSON: PROBLEMS IN OBSTETRICS.
981
particularly to the left as low as the second rib and
often also to the back between the scapulae. Fur-
thermore the paroxysms of asphyxia in thymus hy-
pertrophy are much less marked and less frequent
than in pertussis. Mild cases of whooping cough
may sometimes be mistaken for atelectasis pul-
monum, but this condition is usually preceded by
asphyxia nonatorum and is not accompanied by sud-
den attacks of coughing. Some aid in the diagnosis
may be derived from a careful blood examination
which in pertussis generally shows a pronounced
augmentation in the leucocytes, but, as there is al-
ways a great relative increase in the lymphocytes in
the blood of the newly born, this test is not as de-
cisive in infants as in older children. However, this
test may serve to detect the immediate source of
the infection and should be applied to the other
members of the family who happen to be afflicted
with a recalcitrant cough.
In view of the extreme mortality in pertussis
neonatorum our main therapeutic efforts must be
directed toward prophylaxis. It devolves upon the
obstetrician particularly to guard against transmis-
sion of whooping cough to the newly born, be it by
the mother or any other member of the immediate
family. Even if there is only a suspicion the infant
must be promptly isolated, and with further corrobo-
rative evidence of the existence of the disease, im-
mediately immunized. Judging from personal ob-
servation the administration of prophylactic pertus-
sis vaccine in full doses is absolutely harmless even
in the youngest of infants. If the mother is suf-
fering from whooping cough, we must stop her
nursing of the infant, at least until the infant has
been thoroughly immunized. In a number of cases
owing to the frequency and severity of the parox-
ysms, the infants are totally unable to nurse at the
breast, in which event it will be found advantageous
to feed them on the breast milk by means of Brack's
feeding tube, in small quantities, and at short in-
tervals, in the same manner as practised with
premature babies. The active treatment is very un-
promising. In four of my catees pertussis vaccine
as a therapeutic agent proved useless. Some benefit
may be derived from the early administration of
bromides, to arrest the frequency of the spasm, of
ipecacuanha, to facilitate expectoration and thus to
hasten the termination of the paroxysms and of
strophanthus, to sustain the baby's heart action.
The bromides, either potassium or sodium, should
be given in sufficiently large doses to induce more
or less profound sleep. One grain every three to
six hours in the beginning and less frequently there-
after usually answers the purpose. The ipecac,
preferably the syrup, should be given in from three
to five minim doses until the cough has thoroughly
loosened, and whenever the chest and throat become
choked up the tenacious mucus, it is occasionally
of advantage to increase the dose suf¥iciently to pro-
duce emesis. Vomiting, by the way, is nature's
method of relieving the paroxysms of pertussis. The
dosage of the tincture of strophanthus should vary
with the condition of the infant's heart. Generally
a half to one minim, three times a day, will be found
sufiflcient. Finally, it is most important to remem-
ber that an abundance of fresh air is the sine qua
non in whooping cough, and that, especially in deli-
cate babies, oxygen by inhalation is worthy of
trial.
127 West Eighty-seventh Street.
PROBLEMS IN OBSTETRICS.
By Isidore Josephson, M. D.
New York.
An obstetrical case throws upon the physician a
greater responsibility than any other condition m
which he is called upon to render his services, in
that he has two oatients to take care of at one time.
Either of these is at any time apt to become the
subject of unforeseen complications which must be
promptly attended to, and the mother may during
pregnancy present serious abnormal conditions
which only persistent care and observation on the
part of the attending doctor will determine. The
course pursued when so determined will hold two
lives in the balance.
The general practitioner must of necessity con-
duct the majority of labor cases but many of these
physicians, regrettable as it may be, are not suffi-
ciently trained to recognize abnormalities when they
arise. Even when perceived they lack the proper
knowledge as to the course of procedure. These
conclusions which 1 have drawn in this, as yet, early
stage of my medical career are the results of certain
observations made during my interne days.
It is commonly thought that all doctors can attend
cases of confinement. This is true ; but the fact is
often overlooked that the field of obstetrics includes
the care and treatment of the mother and child
before, during, and after labor, and that the actual
delivery is only a mechanical procedure which any
one with the least degree of manual skill can
acquire, but which is the least important aspect of
the prenatal and postnatal era. Therefore though
most doctors congratulate themselves and boast of
their ability to do a breech extraction, forceps,
version, etc., they forget that it is equally important
to know how to care for and treat pregnant women,
to recognize an abnormality during the prenatal
stage, and to know what course to pursue when
discovered. The following of a case thoroughly,
knowing when to do forceps or version instead of
forceps or the indications for Csesarean section is
the important point.
The maternal or fetal mortality in many instances
is no doubt due to a last minute operative procedure
by the general practitioner, who, confronted by an
unforeseen complication, usually becomes the victim
of miscarried judgment. The mother or child, or
sometimes both, suffer the consequences.
It is not amiss here to say a word about mid-
wives. It is difficult to understand why ignorant
women are permitted by law to conduct labor cases.
The midwife probably still exists as a relic of the
ancient methods of practising medicine when old
women were obstetricians and healers at the same
time. Surely if the average modem doctor who is
supposed to have had years of training is not as yet
thoroughly acquainted with the methods of caring
for a woman in this the most critical period of her
082
JOSEPHSON. PROBLEMS IN OBSTETRICS.
[New York
\ Medical Journal.
life, it stands to reason that an ignorant woman
cannot be taught this important responsibih'ty in h
few months. Fortunately the midwife is gradually
losing her popularity and the specialist in obstetrics
is coming into his own. The burden of my plea is
therefore to encourage the more universal practice
of obstetrics as a specialty and to emphasize the faot
that a woman in this era of her life requires more
expert attention tlian an ignorant woman knows
how or a careless practitioner cares to bestow.
The laity is gradually waking up to the true con-
ditions. Well to do patients are more and more
engaging men who have made their reputations as
obstetricians. At the same time patients of the
poorer classes are at present more commonly en-
gaging to be confined by one or" other of the large
lying in hospitals where each case is followed care-
fully and complications met before it is too late.
But the great mass of patients have not the means
to engage high priced obstetricians and are at the
same time too proud to rely on lying in hospitals for
treatment. It is this class that engages the general
practitioner for confinement and it often finds itself
in inexperienced hands when some radical measures
are necessary.
To illustrate the harm that can be done by im-
proper judgment in such conditions I will cite four
cases occurring in a hospital where I was an interne
at the time. This is a general hospital that conducts
a large obstetrical service supervised by attending
obstetricians who are general practitioners. There
is also a private ward for obstetrical cases and one
of the cases quoted was conducted by an outside
private practitioner.
Case I. — The patient, a primapara, aged twenty years,
was examined at eight months and was found to iiave a
generally contracted pelvis. This was reported to the at-
tending obstetrician, but nothing was done and the woman
was allowed to go into labor at term. Labor lasted about
forty-eight hours with no progress, pains being strong and
severe, the head being finally forced into the pelvis. After
a period of acute suffering forceps were applied, and trac-
tion was made for fully an hour, resulting in the final de-
livery of a much distorted dead fett:s. The maternal parts
were bruised and torn beyond recognition, and after a
month of stormy puerperium the patient was able to be
about. However, she will no doubt remain invalided for
many years to come.
With proper care the procedure in this case
should have been the following : When the diagnosis
of contracted pelvis was made labor should have
been induced somehow before term at the discretion
of the attendant, in this way allowing a smaller
object, the head, to pass through a recognized small
passage. By allowing the patient to go to term the
passenger was allowed to exceed in size the passage
through which it was to go, producing thereby fetal
dystocia. Admitting that the woman was at term
and in labor and knowing that there was a small
passage to deal v/ith, Csesarean section should have
been urgently considered after having given the
woman a sufficient trial of labor. Although this
would have meant subjecting the woman to a major
operation, if due care had been taken to obviate in-
fection the restilt would have been very much better
than delivering a dead baby by forceps and at the
same time making the mother an invalid, perhaps
for life.
Case II. — In the case of this patient, a primipara, aged
twenty-three years, the circumstances were similar to those
in Case I, e.xcc|)t in some minor details. The patient
was found to have a contracted pelvis, and, as in Case
I, no action was taken. After a prolonged labor she
was delivered by means of high forceps, was torn down to
the rectum, developed a hematoma of the vulva, and ran a
stormy puerperium.
A timely Cassarean section would have saved the
infant and would have given the mother a better
chance for the future. In all probability she will
l)ermanently show some elTects of her trying
ordeal.
Case III. — A multipara, age thirty years; previous la-
bors normal. The fact that her previous labors were nor-
mal no doubt accounts for the apparent neglect of proper
observation in this case. The fact that it is perfectly pos-
sible for a woman to have had three normal confinements
and at the fourth time show an abnori-rtality was not con-
sidered. This patient was not examined until she went
into labor. A diagnosis of transverse presentation was
niade and so was reported to the attending physician. Va-
ginal examination showed the patient two fingers dilated
but the presenting part could net be reached. Nothing
was done. Labor continued and, as is the case with most
multiparse, she dilated rapidly when not observed, rup-
tured her membranes spontaneously, allowing a loop of
cord to prolapse and protrude from the vagina. A hasty
version and breech extraction was done but it was then
too late, the cord having ceased to pulsate when delivery
was done. The baby was dead.
The proper procedure should have been as fol-
lows : As soon as the position was recognized the
introduction of Voorhees bags through the partially
dilated cervix ; careful observation as the pains in-
creased ; and the attendant should have been con-
tinually by the patient's side in anticipation of what
was going to happen. As soon as full dilatation was
reached a version and breech extraction v.'as indi-
cated, and there should have been a continuous look-
out for what did happen here, namely a prolapsed
cord.
Case IV'. — This patient, a primipara, age forty years,
was the private case mentioned above. The patient had
norma! measurements but when she went into labor the
attending doctor found both feet presenting. In spite of
his inexperience — I subsequently learned that this doctor
was a life insurance e:faminer and occasionally took con-
finement cases, amoiuiting to about fifteen annually — he
went ahead with the delivery instead of calling in expert
aid. During delivery he became excited and in his effort
to extract the child, without following anv particular
method, he tore her down to the rectum. I subsequently
learned that her rectovoginal wall was torn through, that
sepsis set in and she for a time hovered between life and
death. She recovered from the immediate effects of her
ordeal but subsequently had to undergo operative pro-
cedure.
Each of these cases was supervised by men who
did not know what to do at the important moment,
men who were general practitioners and who at-
tempted to do the work of an expert. No doubt what
occurred here occurs daily in private practice. It is
true that most obstetrical cases are normal and can
be attended by general practitioners. But the gen-
eral practitioner should make an efTort to ascertain
and learn, by a careful study of each case he is
called upon to attend, whether any abnormalities are
present and, when found, to consult sonTe one who
has exerted himself to learn more than he about the
proper methods of treatment. This few men care to
do and the ptiblic suffers accordingly.
789 Dawson Street.
December 7, ig'SJ SCAL: BACK INJURIES AND THE WORKMEN'S COMPENSATION LAW.
BACK INJURIES AND THEIR RELATION
TO THE WORKMEN'S COMPENSATION
LAW.
By Joseph C. Scal, M. D.,
New York.
Of all injuries sustained by workmen none are as
vague and as difificult to diagnose as those to the
back. The malingering workman who is trying to
collect money through the Workmen's Compensa-
tion Law is one of the greatest problems of the
mdustrial world today. This sort of worker con-
siders it more desirable to lie idly in bed and collect
two thirds of his salary than to work and earn his
full pay. The most successful of all malingerers is
the one who claims an injury to the back, because
he knows even better than the physician just how
difficult it is to diagnose correctly any injury in
that region.
Let us consider the anatomy of the back — the
structure of the spine, the muscles, the fascia, and
their relation to the movements of the spinal col-
umn. The spinal column itself is made up of
individual vertebrae, with their component parts,
which when moved, in no way affect the spinal cord.
The anterior muscles of the spine produce flexion;
those situated posteriorly raise it from a stooping
posture, and both acting together steady it. The
fascia of the back separate the various muscles from
each other, and serve as their attachments.
Diagnosis of injuries to the back is a difficult
procedure at best, the physician often having
nothing more definite to guide him than the patient's
history of the accident and the manner in which he
carries himself during the examination. He should
note how the patient undresses and dresses, how he
moves about, and his actions when he believes him-
self unobserved; but all of these are insufficient for
accurate diagnosis, especially in the case of the
malingerer who alleges that he has a sprained back.
It often happens that a patient finds it impossible to
assume a stooping position when asked to do so
during the examination, but quite readily bends to
pick up a pencil which apparently has been dropped
accidentally.
For the examination, the injured man must strip
completely — at least to the waist. All characteristic
attitudes should be carefully noted, since in the
presence of pain nature always demands rest of a
part as well as protection ; so that if a joint is in-
flamed the surrounding nerves are irritated, and the
muscles moving this joint are in constant tension to
keep it quiet. If the vertebras are affected the
muscles of the spine are held rigid, the patient
keeping them as motionless as possible. The ex-
aminer should take into consideration the fact that
slight lateral curvatures of the spine are common.
In the case of the malingerer who attempts to keep
his erector spinae muscles rigid and spine erect,
palpation will in a short while reveal muscular
twitchings in indication that the muscles have been
kept voluntarily inactive, until exhausted ; an effect
that will soon result in the spine assuming its normal
position. Radiography plays a very important part
in exact diagnosis of injuries to the back. It is re-
maikable. however, how often spinal fractures are
present when there is little or no clinical evidence.
Pain in the back may result from various causes,
the most frequent of which is lumbago, which is
commonly defined as pain in the muscles, joints, and
fascia of the back. The pain is often very acute,
and manifests itself upon rising from a stooping
position. We must, therefore, in examining, con-
sider whether this condition is due to disease or
accident, and whether the pain is real or assumed.
It is usually unilateral, relieved by pressure, and
especially acute with movement ; generally yielding
to treatment. Other causes competent to produce
pain — such as kidney conditions, tumors, and
uterine displacements — should be eliminated before
the diagnosis of lumbago is accepted. Usually the
cause of this condition is a tearing of some of the
fibres of the lumbosacral muscles, or a sprain of one
of the vertebral joints. A history of a sudden
sprain or slip while carrying a heavy burden is
usually given, with ])ain, which lasts some timo,
located at a definite spot. We must first ascertain
if the location of the pain coincides with the point
of injury, or whether we are dealing with leflex pain
which occurs in the path of a nerve, and in which
the painful area is not tender to light or deep press-
ure. Local ])ain is usually intensified with increased
pressure. Pain is also intensified by the contraction
of a muscle, actively, passively, or by electricity, as
when the muscle is brought into action.
Another cause of muscular pain is the overtaxa-
!ion of a muscle for a long period of time, especially
when the back is flexed during work. In such cases
there is generally a temporary loss of full contractile
power, for when the muscles become stretched con-
siderable pain results, which lasts until the tone of
the muscles resumes its original condition. Pain
and tenderness are usually the reasons given for not
being able to work, but, being a subjective symptom,
this is always difficult to prove. We must, however,
note that pain is always due to pressure on a nerve,
increase of which will cause exaggeration, and re-
moval will alleviate pain. The complaint of pain is
impossible to disprove, and we must be guided by
the patient's description, which is of great value. A
throbbing pain indicates pus ; a dull, boring pain
means increase in pressure on a deep local part, as
in osteomyelitis. A constant, annoying pain denotes
hyperemic inflammation ; while a burning pain
means that the skin only is involved.
Strain of the muscles of the black (strained back).
— This is defined as violent stretching of the muscu-
lar fibres of the back, and results from overtasking
the muscular tissues beyond its physiological limit —
as evidenced by the presence of sudden pain. It is
generally the result of excessive or too sudden
work, especially when applied to already fatigued
muscles, or to a sudden twist of the body in the
middorsal or doisolumbar region. This condition
gives rise to most trouble from the medicolegal
standpoint, but in considering it we should note that
a painful muscle is painful only when that muscle
is thrown into action. Hence in determining a
•Strained back the injured man should be asked to
place himself in the exact position he occupied at the
time of the accident. This will undoubtedly cause
pain and prove the veracity of the statement. The
984
NOVACK: TREATMENT OF INFLUENZA.
[New York
Medical Journal.
liislory of an honest case will always coincide with
the facts found at the examination as well as the
symptoms and complaint of the injured. Pain in a
strained muscle which has an acute onset should
get well in from two to three weeks, provided no
complicating focus of infection exists in some other
part of the body — as pyorrhea, gingivitis, gonor-
rhea, etc. — in which case the pain diminishes with
rest, only to reappear with exercise until the infec-
tive focus is eradicated. The treatment of a simple
strain of the back has for its aim absorption of the
cflusion and prevention of adhesions and blood
clots, and consists in absolute rest, together with
light massage. Rough massage defeats its purpose
by adding injury to the already existing trauma.
Active motion should be stopped if it causes pain.
The pain i? often alleviated by strapping the affected
part with adhesive plaster strips well above and
below the painful area, the spine being bent back-
ward during its application. This dressing is worn
for two weeks, during which time the back can be
ironed with a heated flatiron, and upon its removal
massage and electricity should be instituted.
Riiptiirc of the muscles. — This is rare, but may
result from the force of opposing muscles suddenly
brought into play.
Contusion of the muscles. — A condition that re-
sults from force or violence applied externally,
especially when the muscles are in action, causing
an effusion of blood into the injured tissue. A
severe form of violence may cause temporary par-
alysis of the muscles, power not being recovered for
a few days. If, however, permanent paralysis
should result, the injury is to the nerve and not to
the muscle.
Straining of ligaments. — An effect produced
when the ligaments are subjected to severe pressure
or mechanical movement that tears or overstretches
the fibres of the ligaments around a joint. It
usually results in an effusion of blood into the joint
or surrounding tissue, and causes overdistention
with resultant pain.
Pain in the bones of the back. — This, if continu-
ous, is generally due to bone disease, such as tumors
or syphilis, in which case the pain is worse at night.
In fractures, when impacted, no pain may be
present — a condition very common in spinal frac-
tures. The only way to ascertain if pain is due to
spinal fracture is to have the patient rise to his
tiptoes and suddenly come down upon his heels.
If the lesion is in the vertebral or intervertebral
joints, pain will result.
Sacroiliac sprains. — These are not very frequent,
owing to the great protection this articulation en-
joys, and are usually due to severe falls or wrench-
ing forms of violence in which other injuries occur.
The symptoms are localized pain on pressure, in-
creased by walking, sitting, or rising. Treatment
should consist at first in absolute rest, obtained by
strapping the pelvis and later by applying an elastic
belt and the use of local remedies, in conjunction
with hot applications, massage, etc.
Back injuries involving the spinal cord. — In cases
where the coverings of the spinal cord are involved,
there is a gradual onset of paralysis from the hem-
orrhage that arises (its severity depending upon
location) and corresponding symptoms which slowly
disappear with the absorption of the blood. If the
cord itself is involved, paralysis is immediate and
more or less permanent.
Fracture of the spine. — In this injury there is
often an absence of symptoms, beyond pain and
some stiffness, provided the cord is not affected. In
dislocating fractures in which the cord is involved
there will be a definite corresponding paralysis of
the nerves which pass through that location.
Railway spine. — In so called "railway spine" no
actual damage exists, the symptoms coming on sev-
eral weeks after the accident, without any clinical
signs, and persisting until litigation is at an end.
I'F eakness of the back. — This is a common com-
plaint, impossible to disprove, being purely a sub-
jective symptom. In such cases, in the absence of
any local nutritional distuibances, it is fair to as-
sume that exercise in the form of light work will be
more beneficial than harmful.
Stiffness of the back. — A term usually employed
by one who experiences difficulty in bending his
back. It may arise from pain in a muscle, ligament,
or bone, or be due to muscular spasm or structural
changes.
In conclusion let me add that in examining al-
leged painful backs in patients suspected of maling-
ering, I have found it advantageous to mark the
spot indicated as painful with a blue pencil. Then,
after distracting the patient's attention, I ask him
to again localize the pain. If he is malingering, the
second spot is generally a few inches away from
the first. Another n^ethod of catching him is to
ask if the side opposite the one alleged painful is
also painful, in the meantime applying deep pressure
to the painful side. The stethoscope may be used to
advantage in this way.
It might be of interest to the public to know that
since the Workmen's Compensation Law has been
in effect more back injuries among workmen have
come to our attention than ever before, and they
require a lonsr course of energetic treatment before
the patient will resume work.
2X3 East Broadway.
THE TREATMENT OF INFLUENZA.
By H. T. Novack, M. D.,
Philadelphia.
During the present influenza epidemic more than
250 cases have come under my care with very grati-
fying results, and as the method of treatment
deviates somewhal in principle from that usually
advised, I feel justified in presenting the same.
In studying the natural course of the disease it
seemed to me that the fever had a direct antitoxic
or germicidal effect, and that any interference in
the way of cool sponging, ice caps, or even draughts
of air when the patient was lightly covered, had a
tendency to prolong the disease, with its usual effect
of weakening the lung tissue and resulting in a
secondary pneumonia. As a result of this theory,
the following is the plan adhered to :
December 7. i9'» ] STALLER: EVOLUTION OF TUBERCLE BACILLUS CAPSULE.
985
The patient is dressed in a loose, flannel night-
gown and put to bed, completely covered up to the
chin with a woolen blanket, and on top of this with
a warm quilt or two. No matter how uncomfort-
able, the hands are not to be taken from under
cover, or chilling will result. The bed is moved
away from direct draughts of air. The window
farthest from the patient is opened from the top,
just sufiicient to allow gentle ventilation.
Absolute rest in bed is essential, using glass tubes
for feeding liquids. No matter how sthenic tho
patient, nor how mild the attack he is not permitted
to leave the bed nor to assume the sitting posture,
the bed pan and urinal being used exclusively, and
with the utmost care, in order not to chill the pa-
tient.
In all cases, whether with or without bronchial
symptoms, the chest is first either cupped or liber-
ally covered with mustard plasters, followed by
repeated applications several times daily of turpen-
tine liniment or other counterirritant. The object
is to prevent congestion of the lungs which seems
to be the usual tendency. The counterirritation is
continued even after the temperature has become
normal.
An initial dose of one mil of mixed influenza
vaccine (Sherman's, No. 38) is given in these
cases ; also ten grains of aspirin or sodium salicylate
followed by one or two teaspoonfuls of sal
hepatica in a glass of cool water — both repeated
every two hours at first and then as the bowels be-
come loose and perspiration profuse, every three or
four hours — no phenacetine, Dover's powder or
quinine is used.
The patient is kept covered during the following
twenty-four or forty-eight hours, wiping the pers-
piration, while under cover. Where there is a
tendency to collapse, a dram or two of aromatic
spirits of ammonia or whiskey is given, or as a
heart tonic in asthenic cases the following, every
four to six hours, is beneficial :
Digalen min. v;
Strychnine sulph gr. i/6o;
Spts. frumenti 3ij ;
Peptonoidi liquidi 3ij.
For the cough, the following, in emulsion every
four to six hours, will give relief :
Creosotal min. xv to xx ;
Codeinae sulph gr. ^ to Ya..
As a result of this treatment, usually withiii
thirty-six to forty-eight hours the fever dropped
and not until then were changes made in bedding
or clothing, care being taken that the room was
sufficiently heated and all windows and doors
closed. Following this the patient was made com-
fortable, covering well but not too heavily, and
windows opened more freely. Where the tempera-
ture failed to drop within two or at most three days,
the entire scheme of treatment was repeated, an;l
if it then persisted, congestion of the lungs or a
mild pneumonia were usually found to be the cause.
In regard to diet, milk and chicken broth are
given exclusively until the temperature remains
normal for two or three successive days, after which
time the patient may be allowed to sit up a little in
bed, and a baked apple, a baked potato, and buttered
toast added to diet. Three or four days later full
diet may be resumed, the patient being confined to
his room and house for four or five days longer, in
order that normal resistance may be regained.
With convalescence a tonic pill of the following,
may be taken, three times daily after meals :
Arsenic t'ioxid gr. 1/40;
Peduced iron gr. ^ ;
Ext. mix vomica gr. 1/5;
Quinine sulph gr. j.
This, together with the creosotal, with or without
the codeine, may be continued for some time until
complete recovery.
The following results have been obtained in over
250 cases of influenza : six patients developed defi-
nite mild lobar pneumonia ; five developed relapses ;
two patients died ; the remainder recovered, the
temperature becoming normal within two to four
days. Of the patients who died, one was a woman
of twenty-eight years of age, who developed pneu-
monia at the start and had an old valvular lesion of
the heart ; the other was a man of thirty-three years
who failed to follow directions and left his bed on
the fourth day to resume work. He also developed
lobar pneumonia and died, although not under my
care.
The six pneumonia cases were all characteristic-
ally mild, and rapidly recovered without complica-
tions, under the fresh air method of treatment.
In a number of patients who, when first seen, had
classic signs of pneumonia — including rusty sputum,
etc. — when treated as outlined, the temperature
dropped within thirty-six or forty-eight hours, fol-
lowed by complete recovery ; so that the author is
oonvinced of the beneficial eft'ect of conserving the
fever to cure the patient.
Thirty-second and Diamond Streets.
EVOLUTION AND DISSOLUTION OF THE
TUBERCLE BACILLUS CAPSULE.
By Max Staller, M. D.,
Philadelphia,
Medical Director. Jewish Consumptive Institute; Visiting Surgeon,
Mount Sinai Hospital, Philadelphia.
All unicellular organisms possess the power of
multiplication, division, feeding, and maintaining a
complete separate life within or without the animal
host. They are not only ready to attack, but they
must always be ready to defend themselves, in
emergencies, against destruction by the host or other
unicellular cells. Each organism defends its exist-
ence by a different mode of warfare. The patho-
genic as well as the pyogenic organisms find the
easiest way to .iccomplish their end is by means of
the circulation, by throwing into it a large amount
of protein poisons, thus destroying the normal
molecular union of the animal's normal protein in
the blood, thereby creating havoc on the leucocytes,
whose duty it is to eliminate those poisons. As
leucocytes rush through the circulatory stream with
their burden of toxins, the stationary cells, possess-
ing the chemical affinity for some of those toxins,
pick up the loose ions, which then begin to interfere
with their function, thus putting out of commission
all associated organs comprising the general makeup
986
STALLER: EVOLUTION OF TUBERCLE BACILLUS CAPSULE.
[New York
Medical Journal.
of the animal and jeopardizing the very hfe of the
host. If in this critical moment the animal is not
able to stop the activity of the organism by neutral-
izing its toxins or destroying the organism, the
animal will succumb, unless the organ involved is
not essential to life.
The poisons, as well as the organisms, possess
certain predilections for certain tissues. The
typhoid bacillus prefers Peyer's patches; toxins of
tetanus, the central nervous system ; the pneumo-
coccus, the lungs ; the meningococcus, the meninges ;
the tubercle bacillus, while ready to attack any pan
or organ of the body, yet prefers the lungs, because,
through this medium — rich in bloodvessels and air
cells — it can best attack its host through the circu-
lation by its toxins, and it is easier to destroy the
hardworking air cells than either the bono or con-
nective tissue cells. It entrenches itself in its posi-
tion and from there throws its arrows into the
circulation in constantly increasing amounts, creat-
ing a condition which the body was not prepared to
meet. Unless the protective mechanism of the body
succeeds in producing enough substances to combine
with the toxins present in the blood, in making
them harmless, the great, powerful host with its
trillions of cells becomes the helpless victim of the
tubercle bacillus.
The ordinary lysins usually present in the blood
are not able to destroy the tubercle bacillus, on ac-
count of its powerful waxy capsule which it has ac-
quired during centuries of parasitic life, because
this capsule is impenetrable by the lysins which
cannot aflfect its inner molecular composition.
An analysis of some unicellular organisms,
whether animal or vegetable, will serve to illustrate
the modus operandi of the development of the
povv^er of defense of the tubercle bacillus. All living
organisms, without exception, have the faculty of
spontaneous movements, in contradistinction to th'i
inertia of unorganized substances. These result in
change of place of particles within the living
cytoplasm, which is the primary result of its own
interior chemical composition ; secondly, by stimula-
tion or irritation from without, according to the
media in which they live, these spontaneous move-
ments result in changes not only of the inner, but
also of the outer constituents of the parasite.
A simple cell, like the foraminifer makes a shell
for its protection out of limestone, leads an inde-
pendent life in the ocean, and lives also in colonies.
These shells gave the cell the advantage in the strug-
gle for existence, otherwise it would have been ex-
terminated. Another species of single cell, deflugia,
also builds around itself a protective armor out of
sand. Another cell known as the arcella, builds for
itself a covering out of material which resembles
wings of insects for the protection of its life.
Another specie, diatoma, covers its body with a
transparent flintlike substance for the protection of
its life. The Noctiluca milliaris, a single cell, pro-
vides itself not only with a covering hard as flint
and transparent as glass, but also with searchlights.
All these elements are produced by this unicellular
organism, to fit itself for the supremacy in the
struggle for life, and in defense against other uni-
cellular organisms with whom they have to compete
for existence.
. If the ameba is thrown into a fluid containing an
acid, it will immediately contract, and if the im-
purity of the acid persists, the ameba proceeds at
once to encase itself, giving off or exuding a
homogeneous exudate, out of which a capsul^ is
formed, and the ameba then assumes a spherical
form.
What is true of those unicellular organisms is also
true of the vegetable parasites. A living parasite
with no power of locomotion would have no chance
in the struggle for existence. Was the waxy capsule
a chance variation beneficial to its being, in order to
fit it for the struggle of existence and perpetuation
of its kind, or was the capsule the primary requisite
of its own life? If the theories of Darwin, Wallace,
and Huxley are to be taken into account, we must
come to the conclusion that the struggle for exist-
ence was the cause for the variation which causes
the change in the animal as well as in the unicellular
organism, to provide weapons for itself, not only
for offense but also of defense.
The tubercle bacillus thrown into a medium com-
posed of unicellular organisms, as the leucocytes in
the circulation, was met first by the lysins in the
blood which were capable of exterminating it in
toto; those organisms whose membrane was tough
and, for that reason less easily penetrated by the
lysins, survived, and undertook the battle with the
leucocytes. Their weapons of offense were the toxins
and endotoxins, and their means of defense was the
tough capsule which, from time to time, developed
more powerfully, until it became perfect. With a
perfect capsule it is in a position to defy the leu-
cocytes, as a permanent barbed wire entanglement.
The lysins, henceforth, met several obstacles',
first, they were not able to penetrate or diffuse into
the tubercle bacillus on account of its capsule ;
secondly, the toxins and endotoxins neutralized the
lysins present, thus making them inert ; thirdly, the
tuberculous poison retarded the multiplication of
the leucocytes, by preventing the lysins stimulating
phagocytosis.
All living organisms, without exception, must be
sensitive, the sensitiveness being influenced by en-
vironments, and nsust react to changes in their own
structures, in accordance with the environments,
heat, moisture, light, gravity, electricity, and chemi-
cal action in the environment. Any of these influ-
ences acting upon the sensitive plasma must cause
changes in the molecular composition of the organ-
ism. The sensitiveness in the organism expresses
itself in the different ways. In the lowest form of
organic life in the Chromacea protophyta and low-
est metaphyte only movements of growth are
recognizable. Some protista, like the unicellular
algse, accomplish a creeping or swimming motion
bv ejecting a slimy substance which gives them the
chance to creep. This is the lowest form of sensi-
tiveness.
Organisms which float in water, like radiolaria,
ascend and descend by altering their specific gravity,
either by osmosis or squeezing out the air. In the
higher unicellular organisms the sensitiveness ex-
presses itself in the power of contraction and expan-
sion, like ameboid movement and ciliary movement.
.•\ny one of those forms of sensation is the response
to the external stimulation. All living protoplasm
December 7. .918.] STALLER: EVOLUTION OF TUBERCLE BACILLUS CAPSULE.
987
possesses power and irritability. Any physical or
chemical change in the environment will call forth
a response, which will develop into, either, expan-
sion or contraction. If useful, it will express itself
in growth or expansion; if harmful it will contract
for protection. Each time the organism contracts
it is for protection ; and so, gradually, it discovers
the best means for defense against those harmful
substances or cells. So it can readily be seen, that the
tubercle bacillus, although only a vegetable parasite,
and not even motile, has a basic cause of origin for
its capsule. The organizing of its capsule was a
necessity for its protection and defense, without
which it could not survive.
The tubercle bacillus, as a primordeal cell, when
its sensitive plasma was irritated, produced an irit-
able spot, at the point of irritation, which in return
coalesced and formed a membrane. In time chemi-
cal changes occurred, taking up substances present
in the host's circulation to improve and strengthen
it, until it became perfected. The law of variation
having reached its limit, the capsule became the
permanent property of the tubercle bacillus.
Infusoria, as well as all unicellular organisms,
whether animal or vegetable, obtained the material
necessary for the formation of the coat of arms, out
of the medium in which they thrived ; they prepared
weapons out of che material at hand, which could be
converted to their best advantage. The tubercle
bacillus must have made its capsule out of the ma-
terial present in the medium of its environments,
and not from outside sources ; therefore, the ma-
terials entering into the composition of the capsule,
are part and parcel of the animal body on which it
thrives. But the basic atom formed primarily into
a molecule was due to irritable substances in the
hosts, which in time completed the molecules
and resulted in the formation of its waxy capsule.
It is, therefore, clear that the destruction of its
capsule could not be accomplished in toto, but in
causing a rearrangement in its primary component
molecules ; and the only way to accomplish this feat,
was either in throwing in a stronger base to displace
the original base, or by adding an excess of the
original base, in order to tear away the loose ions,
thus causing a rearrangement in the famous waxy
capsules.
The destruction of the tubercle bacillus in toto in
the animal body without killing the host, even if
possible, would not be advisable, since the evidence
of many authors as well as my own experimentation
shows that killed tubercle bacilli cause the forma-
tion of tubercles in experimental guineapigs ; and
since tubercles are never found in guineapigs as a
result of toxins and endotoxins, but of direct con-
tart and in the immediate vicinity of the tubercle
bacillus dead or alive, the logical conclusion must
therefore be drawn that the waxy capsule is re-
sponsible for the necrosis of the tissues. There-
fore, if one should succeed in killing the tubercle
bacillus in toto, a fertile field would be prepared
for the pyogenic organisms in the host, already be-
low par. It is evident that the natural enemies of
tubercle bacillus, the leucocytes, must not be taken
away because any substance strong enough to de-
troy the tubercle bacillus would also destroy the
leucocytes, which would result in the disability of
the latter to remove the debris, leaving a free field
for the pyogenic or pathogenic organisms to thrive
on. Our duty is to supply the leucocytes all arma-
mentarium necessary, in the great impending battle,
v/hich consists in weapons with which they are
inadequately supplied, namely amboceptors.
It is a well known fact that if a tubercle bacillus
could, without hindrance, multiply indefinitely, the
whole surface of our planet would be occupied by
them, and since this is not the case, it shows that
many more bacilli are born than survive. Those
that possess in themselves some protective power,
will have a better cliance to survive than those that
are born weak and not able to defend themselves, so
that those naturally selected live to propagate and
form modified species, according to chance environ-
ment. The bovine and human tubercle bacillus are
only one type. The modification of each one of
those types consists of its ability to attack and de-
fend itself best, the bovine in cattle and the human
in man, each one being more dangerous to its
habitat.
In fact there are many other acid fast bacilli, like
the Bacillus lepra, the Bacillus smegmatis, and
others found in hay and grass, which are not so
easy to dififerentiate without stains or modes of
culture media necessary for their growth ; and yet
while all those bacilli may belong to the same
generic species, they do not belong to the same
variety or type as typified by the bovine and human.
But the original generic species dates far, far back,
long before the tubercle bacillus became pathogenic,
so we must look back to those bacilli that were and
still are saprophytic and are performing useful work
in the universe, assisting in the decomposing of
vegetable debris.
The change in such a vegetable parasite as the
tubercle bacillus could only be accomplished by
chemical change, in the organisms from within and
from without. As the waxy capsule is a chemical
product, organized solely for defense, we must,
therefore, use the same means to disorganize it by
chemically allied or alike substances which produced
it ; since no molecule can be formed without a
base, which is capable of attracting the other atoms,
either from the interior of its original plasma, or
of its surrounding capsule, or both, unless it is done
by adding to the medium in which they prosper, of
the original element, in the form of certain leuco-
cytic digestive germs containing the original sub-
stances combined with the cellular substances and
plasma of the animal, acting as the chemical labor-
atory. Thus the substance must be properly pre-
pared for the leucocytes to help them digest and
penetrate the waxy capsule of the tubercle bacillus.
A plant cannot live without carbon, which it
needs for the maintenance of life, but the carbon it
gets must be in the form of carbondioxide gas, and
not in the form of coal or diamonds. Through its ,
chlorophyll in the presence of sunlight it manages
to free the carbon from the oxygen. The latter is
set free, and the carbon is retained. If you should
create a vacuum over a plant, cover it with a glass
bowl, and expose it to the sun, surrounded with coal
or diamonds in the presence of chlorophyll, the
plant will die, although it has its green substance
and sunlight. Plants cannot utilize the carbon
988
STALLER: EVOLUTION OF TUBERCLE BACILLUS CAPSULE.
[Mf.w York
Medical Journal.
present because it differs in form from that which
they have learned to spHt. The same is true of the
leucocytes, they are not able to penetrate the
tubercle bacillus capsule with their lysins unless they
are armed with the original material, the tubercie
bacillus had, to strengthen and form its primordial
capsule.
The serum I produce is a result of years of study
of an allied bacillus, belonging to the generic tree.
Those bacilli, injected into goats, are easily devoured
by the leucocytes, and after a certain period, the
serum of the goat, contains the chemical composi-
tions, of the original germs used, digested by the
enzymes of the animal, mixed with the enzyme of
the original germs, and hence contain tuberculous
antibodies (proved by tests) (i). As a result of
testing out this serum on a large number of bonv
and pulmonary tuberculosis subjects, very favorable
results were obtained. I, therefore, feel justified in
asking the jjrofession to give it a trial.
SUMMARY.
1. The tubercle bacillus is armed with toxins and
endotoxins at birth, all formed to express its power
of life by attacking the enemy cells or lysins —
offense.
2. To repel the attacking lysins of leucocytes of
its hosts, the tubercle bacillus germ has provided
itself with a powerful waxy capsule, making it im-
possible of penetration by ordinary osmosis — de-
fen.'ie.
3. In the primordial state the capsule was entirely
absent because defense was not needed.
4. As all living cytoplasm responds to external
irritation by contraction and results in hardening,
and as those irritations are kept up and the hard-
ening maintained, the capsule begins to form.
5. The original capsule was thin and acted -only
as a temporary protection, those whose capsules
were harder, survived, and taking up material
present in the circulation to strengthen themselves,
until a time came when the capsule became hard
and tough, as we find it today, resulting as a perma-
nent property of the tubercle bacillus.
6. Even today capsules of persons who are not
perfect succumb easily on account of the lysins being
able to penetrate into the interior of its psycho-
plasm and causing a disorganization of its chemical
constituents, and thus preparing them for the leu-
cocytes to be devoured.
7. The toxin and endotoxins weaken the host by
feeding the cells with toxalbumins, thus lowering
their vitality, and therefore lessening the resistance ;
the lysins are neutralized, thus preventing their
function of stimulating leucocytosis, hence leuco-
penia results.
8. With a weakened resistance of leucocytes
themselves with a hard, tough im,penetrabh capsule,
the tubercle bacillus defies its host, and threatens its
extermination.
9. At this stage only two courses arfe possible ;
either the tubercle bacillus wins out, or the leu-
cocytes and lysins have fully recovered their resist-
ance, and begin the gradual destruction of the
tubercle bacillus by digesting them ; and in time the
host is free from tuberculosis.
TO. In order to digest those tubercle bacilli, the
leucocytes as well as the cells provide themselves
with antibodies ; antibodies are produced by an
infected person only in time. If he succeeds, he
wins; if he fails, he dies.
11. I have succeeded in producing a serum com-
posed of tuberculous antibodies, as proven by tests,
the agglutination, precipitation, and complement
with tubercle bacilli.
12. This serum acts by neutralizing the toxins
present, these maintaining the leucocytes and sta-
tionary cells in their normal activities.
13. This I have proved clinically as follows:
a. The larger the area of infection, the more toxic
the patient, the stronger the reaction to the serum.
b. With each succeeding injection the reaction be-
comes milder and finally no reaction is produced.
c. In bone tuberculosis with open sinuses regard-
less of size the reaction is mild, while in close bone
tuberculosis the reaction is stronger, and yet not as
strong as in a case of incipient pulmonary tubercu-
losis.
14. The tubercle bacillus is not destroyed in totn,
but is becoming slowly devitalized with a loss of
power of regeneration, and disorganization of the
capsule.
15. This is accomplished by the primary atom
present in the serum of Bacillus x which tears ofT
free ions from the capsule thus making it possible
for the leucocytes to get after them, proved :
a. In a patient v/ho gained in weighr, with a cessa-
tion of cough, sweat, temperature, and the disap-
pearanc^of all clinical evidences, the tubercle bacilli
were still found in small numbers.
h. Bacilli from a tuberculosis patient injected into
guineapigs prior to treatment with my serum
caused death in guineapigs from two to three weeks,
while pigs receiving the tubercle bacilli from the
same patient, after five injections of serum were
given, lived four months.
c. In patients in whom all evidences of tubercu-
losis were gone, after being ready to discharge only
one or two bacilli found in the sputvtm, this sputum
was washed and injected into guineapigs and up to
the present time, ten months later, no tuberculosis
developed in the guineapigs. Whether or not those
avirulent tubercle bacilli will become virulent in
time under favorable conditions, is impossible for
me to say ; however, the period — ten months — is
worthy of note.
16. The accumulative evidence shows that we
have different types of tubercle bacilli and also of
different varieties. They all must have had one
common origin, resulting in development of tyf>es
according to the media in which they chanced to get
in.
17. It is therefore possible to obtain a bacillus, as
Bacillus X, which when injected into the circulation
of an animal will break it up into its original
atoms, uniting the enzymes, and other substances
present in the blood, and form tuberculosis anti-
bodies. The result obtained in the treatment of fifty
cases of bone and pulmonary tuberculosis justifies
its general use by the profession.
REFERENCE.
I. STALLER: New York Meoical Journal, D-ceniber 22 and
29, 191 7, Report of Experimental Work in the Production of an
Antituberculosis Serum.
1310 South Fifth Stkeet.
Med icine and Surgery in the Army and Navy
CHEMICAL POISONS IN WARFARE.
A Study of Gases and Benzene Derivatives.
By Walter C. Allen, M. D.,
Chicago.
An analysis of the chemicals used in modern war-
fare, including the asphyxiating gases used, respec-
tively, by the Central Allies and the Entente Allies,
to render the enemy hors de combat, the gases gen-
erated by explosives, and the chemicals used in the
manufacture of explosives, yields important data.
The asphyxiating gases available for gas warfare
are chlorine, carbon oxychloride (phosgene), carbon
monoxide, cyanogen, and certain other gases the
chemical composition of which has keen kept, more
or less, a secret. Chlorine and phosgene gases seem
to have been employed very extensively. The
asphyxiating gases are, for the most part, corrosive
in action, coagulating the tissues with which they
come into contact. Some of them act through the
production of methemoglobin in the blood. They
are absorbed through the respiratory organs, cause
acute lobar pneumonia in nonfatal cases, acute ede-
ma of the glottis, larynx or lung in fatal cases and,
if not fatal, leave a stubborn chronic bronchitis,
favoring chronic pulmonary tuberculosis, and ra-
pidly accelerate an existent tuberculosis to a fatal
termination. Most modern high explosives are de-
rived from hydrocarbons, coal tar products, chiefly
nitro and amido substitution chemicals of the ben-
zene series, and produce a clinical entity, in poison-
ing, which may be called the hydrocarbon syndrome.
In studying chemical poisons it is well to deter-
mine upon a classification of their action. Blythe
has offered a simple grouping of poisons into three
classes: i. Those producing quick death, such as
hydrocyanic acid, cyanides, oxalic acid, and strych-
nia. 2. Irritant poisons, such as arsenic, antimony,
phosphorus, cantharides, savin, ergot, digitalis, col-
chicum, and zinc, mercury, lead, copper, silver, iron,
barium, and chromium salts. These produce vom-
iting and purging as prominent symptoms. 3. Irri-
tant or narcotic poisons, acting on the central
nervous system, such as chloral, opium, chloroform,
producing narcosis ; belladonna and camphor, pro-
ducing delirium ; strychnine, producing convulsions ;
and nicotine, producing complex nervous phenomena.
Roberts has made an interesting classification of
poisons, as to their action on the blood: i. Those
interfering, physically, with the circulation, such as
hydrogen peroxide. 2. Those producing methemo-
globin, such as potassium chlorate, hydrazine, nitro-
benzene, aniline, picric acid, carbon disulphide, car-
bon monoxide and nitrous oxide. 3. Those which
dissolve blood corpuscles, such as saponin. 4. Those
acting on blood pigments, such as sulphides of hy-
drogen and cyanides.
Loew. in his studies of synthetic chemistry, has
developed some important principles, relative to the
toxic action of chemical compounds. These prin-
ciples have a broad application, when applied to the
complex chemical compounds used in the manufac-
ture of explosives. Loew claims that the hydroxyl
grou2> (Oil) endows a chemical with toxic proper-
ties, as in the alcohols, and that the more hydroxyl
groups present, the greater the toxicity, e. g.,
phloroglucin (three OH groups) is more toxic than
resorcin (two OH groups), which, in turn, is more
toxic than phenol (one OH group). When hydro-
gen is replaced by a halogen, especially chlorine, in
the fatty acid series, the resultant chemical has nar-
cotic properties, e. g., monochloracetic acid. For
instance, ethyl sulphite is a weak poison, while
monochlorethyl sulphite is very toxic. Toxicity in-
creases as the carbon content increases, as in the
series of ethyl, propyl, butyl, and amyl alcohol. The
triamines of nitrogen are less toxic than the penta-
mines of nitrogen. Alkaloid properties are altered
by the presence of the methyl group, e. g., strych-
nine and brucine cause tetanic reactions, while
methyl strychnine and methyl brucine are without
this property.
Some of Loew's generalizations are as follows:
The presence of the carboxyl and sulpho groups de-
crease toxicity ; chlorination increases the toxicity
of the catalytic poisons, alcohol, ether, chloroform,
carbon tetrachloride, carbon disulphide and the vol-
atile hydrocarbons ; the presence of the hydroxyl
group in the catalytic poisons of the fatty acid
series decreases toxicity ; on the other hand, the
toxicity of the substituting poisons, such as hydrox-
ylamine, hydrazine, phenylhydrazine, hydrocyanic
acid, hydrogen sulphide, aldehydes and phenols, is
enhanced. A three linked nitrogen compound, when
converted into a two linked compound, becomes
more toxic. The presence of a second amino group
increases the toxicity ; the presence of the nitro
group increases the toxicity. It is safe to say that
with the attention of the American medical research
workers concentrated upon the poisons incident to
the manufacture of highly complex hydrocarbons in
our newly created munition and coal tar industries,
these studies of Loew will receive considerable at-
tention.
The four important classes of derivatives of coal
tar, from a medical point of view, are the benzols,
crystalline carbolic acid, naphthalene, and creosote
oils. Pure benzene, toluene, and xylene are benzol
derivatives by distillation. Benzene is used in the
manufacture of nitrobenzene and aniline. The ani-
line dyes are derived from the latter. The trinitro-
toluene (TNT) of modern warfare is produced bv
the nitration of toluene. Crystalline carbolic acid
is antiseptic. By nitration, it gives picric acid. It is
a source of salicylic acid. Naphthaline finds com-
mercial use as a carbureting gas. From it are also
derived the phtfialein, azo, and indigo colors. The
creosote oils are antiseptic, preserve timber, act as
lubricants and are useful in the production of patent
fuels.
Since synthetic chemical derivatives of coal tar
have had a tremendous vogue as drugs and antisep-
tics, e. g., salicylates, acetphenetidin, acetanilide,
phenyl acetamide, phenyl hydrazalon, resorcin,
betanapthol, cresol, creosotes, benzoates, and, since
the literature is rich in case reports of poisoning
990
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
Nitric acid
Nitrobenzol
Nitrocellulose
Nitroglycerine
Nitrogen oxides
Phenol
Potassium chloride
Potassium nitrate
Sodium nitrate
Sulphuric acid
Sulphur dioxide
Tetrachlorethane
Trinitrochlorbenzol
Trinitromethvlanilin
Trinitrophenol
Trinitrotoluene
Toluol
from these coal tar products, it is important to com-
pare these cases with poisoning from hydrocarbon
explosives, such as trinitrotoluene (TNT). The
well known picture of salicism has many points in
common with the evidence of an almost specific
sulphocyanogen poison, as seen in poisoning from
the nitro and amido derivatives of benzene, dinitro-
benzene, triniirotuluene, nitronaphthalene, aniido-
benzene, tctranitromethylanilin, and trinitrophenol,
such as splitting headaches, amblyopias, tinnitus,
and confusion. The blood picture, likewise, shows
many points in common.
It has been stated, with much truth, that the great
European war is a gigantic tournament of chemists,
and this fact will be appreciated when one examines
the list which follows. It will be noted that an
astonishingly large number of the chemicals are
members of the benzene series, obtained chiefly
from coal tar: ,
Amidobenzol
Ammonia
Ammonium nitrate
Amyl acetate
Aniline
Asphyxiating gases
Benzene
Benzol
Carbon monoxide
Carbon oxychloride
Chlorine
Cyanogen
Diamidobenzol
Dinitrobenzol
Dinitronaphthalene
Fluorine
Mercury fulminate
Mononitronaphthalene
Explosives are made, in large part, from organic
compounds, and these compounds consist of the
hydrocarbons, including the paraffins, olefins, acety-
lenes, and benzenes ; alcohols, ethers, ketones, espe-
cially acetone ; phenols, quinones, and carbohy-
drates, those of cellulose series being used in mak-
ing guncotton.
Of the asphyxiating gases, carbon monoxide, CO,
is colorless, almost odorless, divalent, a product of
the incomplete combustion of coal, produced, in
large amounts, in the manufacture of illuminating
gas, and in the distillation of coal tar. It is fatal
to all forms of animal life, and enters into chemical
combination with the hemoglobin of the blood,
forming the stable methemoglobin. Chlorine, CI, is
a greenish yellow gas, over twice as heavy as air,
of a pungent, suffocating odor, exceedingly poison-
ous, corrosive to tissues, and occurs very abundantly
in nature in the form of sodium chloride. Because
of its tendency to hug the ground, chlorine gas is
efl'ective in trench warfare, the gas sinking into the
trenches as it passes over the ground. Carbon oxy-
chloride or phosgene gas, COClg, has been used ex-
tensively and efifectively by the Teutonic armies.
Phosgene gas is also known as carbonyl chloride. It
is divalent, colorless, oflfensive in odor, and is
formed from chlorine and carbon monoxide under
the influence of light. It is sometimes called "stink
gas" by the soldiers. Cyanogen gas is doubly
deadly in war because, in addition to being exceed-
ingly poisonous when inhaled, it is inflammable, and
in combination with carI)on and potash or sodium
may be used in the so called "liquid fire" attacks of
modern trench warfare.
G.\S POISONING SYNDROME.
In this war there have been two main groups of
gas poisoning: one by the asphyxiating gases used
in the trenches ; the other by nitrous oxide fumes
which are present in practically all the processes of
nitration employed in the manufacture of explos-
ives. Tile clinical symptoms of poisoning by any
specific gas massed together, when compared with
those caused by another specific gas, bear a strik-
ing relation and similarity. In fact, poisonings by
all gases exhibit certain symptoms in common, so
that one may, with reason, say that there is a gas
poisoning syndrome. Clinical and laboratory work-
ers in medicine while studying cases of j.oisoning
by chlorine, carbon oxychloride, carbon monoxide,
nitrous oxide, and sulphur dioxide gases have been
inclined to consider each as a separate clinical entity
and have not stressed their correlation with a com-
bined gas poisoning syndrome. Of course, it is true
that poisoning by any specific gas will exhibit cer-
tain idiosyncrasies, dependent upon the chemical
itself.
Gas poisoning, except for small amounts gulped
down and thus absorbed through the gastroin-
testinal tract, is a direct and concentrated attack
upon the parenchyma of the lungs, upon such ad-
jacent tissues as may be affected through continuity,
and upon the constituents of the blood when
brought into contact with the toxic gases during
aeration. The action upon the parenchyma of the
lungs is corrosive and might be likened to a burn or
escaration by nitric, sulphuric, or carbolic acids.
Being, for the most part, members of the halogen
group, they are to be studied as such ; that is, the
chemical phenomena of halogen bodies acting on
living tissue is to be observed. To be sure, the
corrosive action is not characteristic of all gas pois-
oning ; for exainple, in carbon monoxide gas poison-
ing, the classical illuminating gas poisoning, the
primary attack is on the blood, preventing aeration
because of methemoglobin fixation, as exhibited by
the spectroscopic methemoglobin band.
The industrial bearing of these two phenomena is
that thorough physical examination of workers in
munition, dye, and gas producing industries should
be made in order to exclude pretubercular, tuber-
cular, and anemic persons. Because of their low
resistance to tuberculosis, negi-oes and the Irish
present a high mortality rate in these industries.
For similar reasons, where women are employed in
munition work, a blood smear of those appearing
anemic should be taken.
Where the corrosive action of gases is pro-
nounced, if the concentration of the gases is great,
severe pulmonary edema with quick death results,
the subject presenting the agonizing picture of sub-
mersion in his own secretions. Injections of ad-
renalin are ineffective, except in mild cases, where
it has bridged a crisis. If the concentration of the
gas has been less, but still severe poisoning has oc-
curred, an acute lobar pneumonia, with showers of
fine crepitant rales through both lungs develops.
The sputum is copious, bloody, and frothy. Many
December 7, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
991
of the cases in which pneumonia does not develop
show a copious, thin, white, or greenish yellov/
sputum. The pneumonia takes one of the following
courses: Death by acute edema- of the larynx or by
pulmonary edema, gangrene of the lung, relapses ; or
it may develop into a chronic bronchitis or pulmon-
ary tuberculosis. Latency and relapses are striking
features of gas poisoning by corrosives. In many
instances pneumonia has not developed until six to
eighteen weeks after the gas attack. In other cases,
second and third attacks of pneumonia have fol-
lowed in rapid succession at intervals of seven or
ten days after crisis. The pneumonia, in most
cases, has been associated with patches of em-
physema. The corrosive gases produce a capillary
thrombosis. While this has been noted most fre-
quently in the lung, it has also been noted in studies
of sections from other organs, such as the kidney.
Mott, in excellent studies, published in the
Archives of Neurology and Psychiatry, in 1907, and
in the British Medical Journal, in 191 7, reported
punctiform hemorrhages in the cerebrum and basal
ganglia in cases of treach gas poisoning, associated
with hyaline thrombosis of terminal capillaries, such
as are present in the cerebrum and basal ganglia.
It is believed that capillary thrombosis, widely dis-
tributed throughout the body, is characteristic of
gas poisoning. Mott has noted it in carbon mon-
oxide poisoning, too, so that the phenomenon is
probably not limited to any pai*ticular group of gas
poisons. These thrombi may explain some of the
sudden deaths which have occurred in gas poison-
ing. Other cases of sudden death have appeared to
have been due to a more or less specific action on
the respiratory centre, with failure of respiration.
A large percentage of cases of gas poisoning have
shown central nervous system symptoms such as an
aggravating insomnia, night terrors (bad dreams),
and a fine tremor of facial muscles, tongue, and
fingers. These again may bear some relation to the
capillary thrombi mentioned above. These insom-
nias, terrors, and tremors, like the respiratory symp-
toms, have persisted far into the long convalescent
periods. Mild cases of gas poisoning may clear up
in a few days, so that the men return to the
trenches. The mild cases are usually liste<l as cases
of tracheobronchitis, which are greatly relieved by a
few drops of chloroform and aromatic spirits of
ammonia in water. The subacute cases are also re-
lieved considerably by inhalations of stramonium,
nitre and, occasionally, opium.
Blood studies in gas poisoning have shown that a
grave anemia is to be expected. This often takes
the form of aplastic anemia, and has been found so
often that it should be looked for as a routine pro-
cedure. Miller and Rainey, English investigators,
who have directed the treatment of hundreds of
cases of gas poisoning since the European war be-
gan, studied blood smears from a majority of their
cases and found a lymphocytosis of forty to sixty
per cent, in almost all cases. It is interesting to
note that aplastic anemia and lymphocytosis also
occur in all severe cases of poisoning from nitro
and amido derivatives of the benzene series. Clini-
cians were surprised and unable to account for a
temperature of I02°-I04° F. in gas cases. Halli-
burton, in a i)ersonal note to Mott, has offered the
theory that it may be due to the formation of acid
hernatin, similar to the temperature rise noted when
hematin is set free during malarial paroxysms. In
gas poisoning, of course, the abnormal temperature
is continuous in type. A rise in temperature has
been noted in gas cases where there were no com-
plications, such as pneumonia, to account for it.
The corrosive gases destroy dentine, so that a filthy
oral condition due to dental caries is often present.
Fatty degeneration of kidney, spleen, liver, and
heart muscle is noted, especially in chronic cases.
Exudates are profuse.
THE IIYDROC.ARIiON SYNDROME. f
Trinitrotoluene, or TNT, plays a major role as
one of the most extensively used explosives em-
ployed in modern warfare. Medical study has been
concentrated upon cases of TNT poisoning among
munition workers. As a result, the medical liter-
ature of 1 9 16-191 7 teems with references to it.
TNT is a dangerous industrial poison. In its study„
investigators have considered it as a distinct clinical
entity. Comparison with cases of poisoning from
benzene, nitrobenzene, nitronaphthalene, amidoben-
zene (aniline), tetranitroaniline (TNA), tetranitro-
methlaniline (tetryl), trinitrophenol (picric acid),
and the popular headache drugs, acetphenetiden, di-
ethyl barbituric acid (veronal) ,phenylacetamid (acet-
anilide), phenyl pyrazalon (antipyrine), and sul-
phonethylmethanum (trional), show that they have
certain characters in common, which may be called
the hydrocarbon or the benzene syndrome. The
condition is seen in poisoning from coal tar pro-
ducts. The essentia] picture of such poisoning is :
toxic hepatitis, with pathologic changes so closely
resembling acute yellow atrophy of the liver that
sections of liver from a severe TNT case and from
a case of acute yellow atrophy of the liver, placed
side by side, can v/ilh difficulty be distinguished ;
blood showing the methemoglobin band by spectro-
scope; lymphocytosis of forty to sixty per cent, (of
small mononuclear type) and leucopenia reaching
as low as 140, when death usually intervenes ; der-
matoses comparable to moist eczemas ; tendency to
hemorrhagic purpuras and marked central nervous
system sym.ptoms, including peripheral neuritis,
toxic amblyopia, migrainous headaches, and, in fatal
cases, Cheyne-Stokcs respirations, with death by
failure of respiration.
Martland has reported findings in a case of TNT
poisoning which came to autopsy. The kidney
showed fatty degeneration of the epithelial cells of
the convoluted tubules anrl hyaline thrombi of the
arterioles with pigment imbedded in the coagulum.
There was a cloudy swelling of heart muscle and a
fibrosis of the parenchyma of the liver, with irrita-
tive and degenerative changes in the endothelial
cells of capillarie? as shown by mitosis of nuclei,
bile duct proliferation and periportal lymphocytosis.
Pneumonia was also present. The hepatitis is a
grave and striking feature.
As for other chemicals used in the manufacture
of explosives which may give rise to toxic mani-
festations, such as ammonia, nitric acid, nitro-
glycerin, sulphuric acid, carbolic acid, and fulminate
992
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal,
of mercury, their toxicological attributes are well
known and need not be discussed here.
When it is realized that practically every ex-
plosive involves nitration processes with consequent
exposure to nitrous oxide fumes, that after the war
our munition works will be converted into indus-
tries for the manufacture of dyes, explosives,
nitrates, and other chemicals, for agriculture and
commerce, and that more than 100,000 people are
employed in munition work now, and that the
number of employees is expected to increase, rather
than decrease, after the war, these medico'ndustrial
questions become transcendental in importance.
August 4, 1914, found the German empire prac-
tically possessed of a world monopoly of the chemi-
cals derived from coal tar. ^ One may wonder
whether this industry was not but a cog in the
almost perfect German war machine, manufactur-
ing dyes in peace tim.es, and explosives in war time.
The advantage of possessing such a highly organ-
ized industry for the manufacture of explosives has
undoubtedly been a big factor in the notable fight
Germany has staged.
CONCLUSIONS.
Poisoning by gases, may be studied as a clinical
■entity, recognizing that there are chemical charac-
teristics of specific gases.
Poisoning by hydrocarbons, especially those of
the benzene series, have certain features in common
which may be grouped into a clinical syndrome.
Complete bibliography will appear in the author's
reprints.
TYPES OF MEN AS OBSERVED AMONG
RECRUITS.
By J. Madison Taylor, A. B., M. D.,
Philadelphia, Pa.,
Professor of Applied Therapeutics, Temple University, Medical
Department.
Extraordinary opportunities are ofifered by the
examination of the millions of young men candi-
dates for military service to learn significant facts
obtainable in no other way. Among these facts are
types of conformation, of disposition, of tempera-
ment, of character, of capabilities of adaptation, of
endurance, of maintenance of physiological and
psychological poise, of nutritional balance, and the
like. The population of America being exception-
ally varied in its origins, extraordinary opportunities
are thus afforded to get a critical line or purview of
practical problems in anthropology, racial admix-
tures, hybridism, stability of racial strains, suscepti-
bilities to environmental influences, to fatigue and
anxiety stresses, to infections and to recoverability
from infections, to variants in the manifestations of
devolutionary agencies, hereditary and environ-
mental.
Studies should, if possible, embrace those men
selected and those rejected. The difficulties of such
an appraisement need not be so large if a compre-
hensive yet economic system of tabulation is
adopted. However, it is probable that only those
who are accepted could be subjected to such assess-
ment, and only the outstanding i)henomena, till the
importance of the census becomes appreciated. The
primary examiners at recruiting stations could not
be expected to do much of this work, although it is
entirely possible that some facts of inestimable value
could be learned and recorded even here by the use
of special cards. Among those rejected these points
could be followed up, and many facts of greater
practical as well as scientific importance might be
learned than from the more perfect accepted indi-
viduals. Already the special examiners of recruits
are making important observations which could
readily be rendered of yet greater value if amplified
in certain particulars desirable for statistics.
Among these special examiners are those of the
mental status, which could readily include, on blank
forms, associated anomalies of conformation, type,
and functional status of the ductless glands. Those
who examine for evidences of infections, tubercu-
losis, and syphilis, could add to their observations
facts which might lead to amplification of our
knowledge of the susceptibilities to, or capabilities
of, recovery from infections. So also in cardio-
vascular renal disorders ; a few associated or corre-
lated facts added would afford enormous er.lighten-
ment in essential directions.
I'he orthopedic experts could contribute much to
a more comprehensive knowledge of the origins of
deformities, of variants in tissue tone, of suscepti-
bilities in the realm of development, and of meta-
bolic and endocrinologic data. Here we have the
realm indicated by Major Joel E. Goldthwaite as
"the challenge of the chronic patient," the indicia
of anomalies in growth forces, developmental pe-
culiarities, as shown not only in conformation but
in body chemistry. Such matters have by no
means become of common interest or knowledge.
Until they become so, clinical results must be nar-
rowed in essential directions. Much of the data
existing is in such form and place of record as to
escape attention. It is also lacking in systematic
presentation, in symmetry, in comprehensiveness.
Let us have aid from present observers in the prac-
tical field afforded by military opportunities.
1504 Pine Street.
MEDICAL NOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva. Switzerland,
Privat-docent at the University of Geneva: Fellow of the Royal
Society of Medicine of London, etc.
modes of transmission of BACILLUS LEPR^.*
With the present extension of the world war,
involving as it does so many countries with their
peculiar climates and pathology, it may not be out
of place to refer to the various modes of transmis-
sion of the Bacillus lepras, an important point for
prophylaxis that should be known to all army med-
ical officers whose troops may be exposed to con-
tagion of this affection.
The elimination of the bacillus in the nasal secre-
tions is, of course, so well known that it is needless
to more than refer to it here, but in the case of the
•This communication was received September 15, 1918.
December 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
993
buccopharyngeal mucus excreted, not so much is
known- SchaefFer has shown that by coughing,
sneezing, or even during the act of speaking, Han-
sen's bacillus is scattered by thousands to a distance
as far as a yard and a half. He placed some Petri's
plates on a table and placed subjects having tuber-
ous leprosy at the distance of one and one half
yards off and made the droplets. He estimated that
the droplets of mucus projected by these patients
during a ten minute conversation contain anywhere
from 40,000 to 185,000 bacilli.
Mucous" secretions taken from the throats of
twenty-seven leprous patients by Auche were posi-
tive in only seven, while Roemmer arrived at posi-
tive results in the mucus removed from the nose
and pharynx.
In order to explain the presence of the lepra
bacillus in the . buccopharyngeal secretions and
saliva,* it is logical to assume that, when local lesions
do not exist in the pharynx or throat, it is prob-
able that the bacilli contained in the nasal secretions
fall with the latter into the pharynx, and becoming
mixed with the secretions and saliva, are thus elimi-
nated in them.
Begue has found the bacillus in the ocular secre-
tions, and the following notes of a case will no doubt
prove of interest : The patient, twenty-nine years
of age, born in Calcutta, had leprosy for sixteen
years, and ocular lesions for three years, consisting
of a central leucoma of the right eye ; vision almost
entirely destroyed. The left cornea was covered with
whitish striae, conjunctival hyperemia, iris normal.
The eyelashes had disappeared. There was dacryo-
cystitis and there were bacilli in the tears, which
probably explains the lesion of the lacrymal tract.
In eight other cases Begue found Hansen's ba-
cillus in the tears, while Babes has pointed out that
leprous conjunctivitis, frequently secondary, is
hardly ever absent in advanced leprous lesions of
the face ^nd can almost always be found in the con-
junctival secretion.
In almost every case of advanced leprosy, fre-
quently also at the beginning of the disease, the con-
junctival sac contains a large number of bacilli
which is due to the superficial localization of the
conjunctival lesions.
It is needless to refer to other writers who have
found the lepra bacillus in the tears and ocular se-
cretions, and I will now mention the bronchopul-
monary secretions. As you undoubtedly know, pul-
monary leprous lesions are uncommon, and al-
though the sclerous type is most frequently met
with, nevertheless the bacillus has been found in
the sputum in these cases. Out of a total of twen-
ty-four cases Auche found five in which the bacillus
was present.
Ehlers, Bourret, and Witte have shown that the
bacillus may be found in the sweat and piloseba-
ceous secretions. The organism has been found by
Roemmer in the roots of the hair of the eyebrows
and eyelashes, in those of the pubis, in the sweat,
and in the matter excreted by the sebaceous glands.
Touton has demonstrated the presence of the spe-
cific organism in the sudoriparous glomerulse and
admits that the sweat may very well be a source of
contagion. This is of all the more importance be-
cause paroxysms of acute bacillemia in leprosy are
far less rare than was formerly supposed, while
paroxysms of sudoral and sebaceous hypersecretion
are likewise very conmion.
The first to discover Hansen's bacillus in the male
urethra was Jeanselme who, during a trip in Yun-
nan found a leprous urethritis in a Chinese beg-
gar. A drop of pus obtained by expression of the
meatus was literally swarming with bacilli, and only
a year or two ago the same writer had another
typical case of leprous urethritis in his hospital
service at Paris which is of such intense interest
that I will give some brief notes of the patient's
history.
The patient was fifty-five years of age, was born
in Argentina, where he contracted leprosy about fif-
teen years previously. Two years ago he came to
France. The patient's skin was covered with nume-
rous copper colored maculae and large anesthetic
tubercles. Successive crops of lepromata had ren-
dered both corneas opaque. The ulna nerves were
hypertrophied and moniliform. Leprous rhinitis
was very marked.
For the past six months micturition has been
difficult and the stream of urine reduced in size.
When the glans penis was exposed it was found
covered with lepromata. One of them had de-
veloped around the meatus and infiltrated the
urethral walls, to the extent of over a centimetre,
and blended with the fossa navicularis. By expres-
sion some droplets of viscid grayish pus were ob-
tained from the urethra, which microscopically
showed very numerous intact polynuclears, some
macrophage cells, and large epithelial cells with a
large clear nucleus. Many bacilli were found.
The etiological importance of this bacilliferous
urethritis is evident because the patient admitted
that he was still in full sexual activity. These ba-
cillary purulent products washed down with the
sperm and deposited on the vaginal mucosa during
ejaculation may very well be the factor of utmost
importance in propagation of this dire affection. A
female quite free from leprosy, with a healthy va-
ginal mucosa having had intercourse with a subject
with a bacilliferous discharge, is quite capable of
contaminating other men by an inoculation on the
glans or in the urethra.
And this brings me to the question of the vaginal
mucous secretion in leprous women. Nicolas ex-
amined ten leprous females and found the vaginal
secretion bacilliferous in four, negative in five, and
doubtful in one. Thiroux examined the vaginal
secretion of nine leprous females, one being a vir-
gin child of ten years of age, and found it bacilli-
ferous in all, but what is worthy of particular men-
tion is that the cervix and vaginal walls were free
from any leprous lesion in eight, only one present-
ing a cervical metritis and vaginitis.
Now, we know from Cabanesco's experimental
work on the function of microbic autopurification
that is fulfilled by the mononuclears on the various
mucous surfaces and that of the vagina in particu-
lar, that bacteria deposited on the surface remain
there in a saprophytic state and at length are elimi-
nated. Therefore, from the point of view of
prophylaxis, great care should be taken to prevent
994
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
I
troops from sexual contact with women in leprous
countries.
I would once more insist that it should be gener-
ally known among the medical corps of the army
that elimination of bacilli by an intact vaginal or
urethral mucosa in a leprous female or male does
actually occur and, as proof of this statement, I
need only mention the case of the physician, re-
ported by Ehlers, who contracted leprosy during the
labor of a leprous female who did not present any
outward evidence of the disease. He pricked his
finger and the little wound was long in cicatrizing.
Soon afterwards there was very sharp pain in the
finger and at length a leprosy of the anesthetic type
was manifest.
Roemmer has pointed out that the intestinal ulcers
in leprosy dififer from those encountered in tubercu-
losis. The former have distinctly outlined borders ;
the bottom offers a medullary infiltration ; they are
rare, annular, and in the edges numerous bacilli are
found but no miliary nodules. The bacilli can be
demonstrated in the stools. Boeck found the bacil-
lus present in the stools of two patients out of five
that he examined in this respect. This fact should
be recalled from the viewpoint of prophylaxis.
A number of writers have described leprous
lesions of the kidneys with bacilli in the connective
tissue stroma and renal parenchyma. Jeanselme
found in one case numerous clusters of bacilli in the
glomerulse while in the intercanalicular connective
tissue of the cortex there were globi and bacilliferous
cubic cells in very small number.
Babes has met with a few clusters of bacilli in the
mucosa of the bladder, but the first paper especially
relating to the elimination of bacilli by the urine
dates back to as recent a time as 1910, when
Dominguez, Recio, and Martinez, of Havana, un-
dertook this research in one case and obtained posi-
tive results. Following this, a number of other
cases have been recorded. The following are the
notes of a case recently under the observation of
de Beurmann and Gougerot :
The patient was a South American who had mar-
ried a leprous wife. Up to 1910 he offered nothing
abnormal, but in iQii there was a pigmented
er\i:hematous macula with an achromic, anesthetic
centre on the left forearm and leg. In 191 2, the
patient had capricious, painless, total hematuria.
Careful palpation of the kidneys gave a negative
result. The urine was very albuminous ; there was
an intermittent macroscopic hematuria, but histo-
logically blood was always present.
The red blood corpuscles were slightly changed :
there were many polynuclears and mononuclears,
with only a few eosinophiles. There were also cells
from the renal pelvis, ureter, and hematic and gran-
ular casts. No hemoglobinuria. Twice a few
Hansen bacilli could be detected. The writers at-
tribute the bacilluria to bacillemia as occurs in all
other infectious processes.
The conclusion is that leprosy may be transmitted
by the urine.
It is hardly necessary to add that I have merely
outlined the various possible ways in which leprosy
may be contagious ; but given the importance of the
question from the viewpoint of military hygiene it
seemed apropos to call attention to the subject, and
I will briefly outline the supposed channels of
penetration of the Bacillus leprae into the human
body.
I'irstly, it may be said that one hears less and less
of the contagiousness of leprosy. The relation of
cause to effect between Hansen's bacillus and
leprosy is universally acknowledged, but much un-
certainty still exists as to the mechanism of the
inoculation. Does it take place directly from man
to man, or indirectly by the intermediary of an
agent of transmission, for example, an insect ? The
principal hypotheses for explaining the manner of
invasion of the Bacillus leprae are the following:
1. Nasal theory. — The frequent and early locali-
zations of the disease in the nasal mucosa have
given rise to this theory, but too much stress should
not be laid upon it. Hoorda Smit thinks that per-
sons living among lepers may be inoculated with
the disease by scratching the nose, thus infecting
themselves directly with the fingers.
2. The digestive theory. — The lower digestive
tract has also been incriminated as a starting point
of the infection. Some writers suppose that the
infection takes place in early life, remaining latent
up to a time when the influence of some, as yet,
ill defined cause makes the disease appear.
3. The skin theory. — The penetration of the
bacillus in the cutaneous surface is a hypothesis of
some little value, and a number of competent
writers have pointed out that in certain countries
where the inhabitants go about barefooted, the first
manifestations of the disease are often noted on the
lov/er limbs.
Geil saw a case in Java, in which the subject cut
his bare foot on a pointed stone. The wound was
slow in healing and a year later a maculoanesthetic
leprosy developed.
All these data should be recalled, but none of
them offer a satisfactory explanation of the mech-
anism of the infection. The same may be said of
arm to arm vaccination, but as this method is no
longer in use the question need not be discussed.
However, Arning and other observers have found
the Bacillus lepras in the lymph of a vaccinal pustule.
Of the possibility of contracting the disease by
coitus, I have already spoken, and in conclusion,
I will briefly refer to the part played by sucking
insects in the transmission of leprosy.
Some suppose that the mosquito is the agent of
transmission and Noe found an acid resistant bacil-
lus in the digestive tract of this busy insect which
had been fed on leprous infiltrated tissue. Goodhue
says that he has found the Bacillus leprae in the
female mosquito and bedbug, and Borrel supposes
that the demodex may carry the bacillus from one
person to another.
Donal, Curie, and Leboeuf admit from their ex-
periments, that the domestic fly may be a carrier of
the bacillus, as these writers found the organism in
the digestive tract of flies which had been fed on
the surface of ulcerated leprous lesions. The part
played by flies in the contagion of lepra is, there-
fore, limited, if in reality it is effective.
Such is the state of our knowledge of this inter-
esting question at the present day.
December 7, 1918.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
995
THE LABORATORY OF THE PORT OF
EMBARKATION.
Central Clinical Laboratory for Thirteen Hospitals
—Wide Scope of Work — A Training School for
Technicians.
On the roof of the Greenhut Building at Sixth
Avenue between Eighteenth and Nineteenth
Streets, New York, the officers, technicians, hos-
pital corps men and clerical assistants who consti-
tute the personnel of the central laboratory of the
Port of Embarkation have established themselves
in commodious cjuarters. Here they have an animal
house with rabbits, guineapigs, white mice and other
"small deer" for testing controls in their bacterio-
logical work. Here they have their various labora-
tories all high above the din, the dust and the noise
of the street and here they keep a surplus stock of
laboratory supplies and sera of different sorts in re-
serve subject to emergency calls from any one of
the twelve laboratories which form a part of the
elaborate and farreaching system of hospitals under
the command of the Surgeon of the Port of Em-
barkation. That able officer. Colonel J. M. Ken-
nedy, M. C, whose portrait was printed in the New
York Medical Journal for September 28th and the
extent of whose command was also set forth there
in detail, has under his supervision thirteen hospitals
with a bed capacity of about 18,000 and an aggre-
gate of between 4,000 and 5,000 officers, nurses, and
enlisted men to carry on his work.
The first of these tasks was the supervision of
the health of troops embarking for foreign service.
The physical condition of every soldier, every Y. M.
C. A. worker and every civilian who sails for Eu-
rope from any of the ports north of Baltimore must
be favorably reported on by some of Colonel Ken-
nedy's staff before he can set sail. His is the duty
also of receiving all the sick, the maimed and the
wounded returning from overseas. Only five or six
thousand of these have as yet returned, but now
that actual hostilities have ceased the sick and
wounded will be returned as rapidly as they can be
brought over and cared for. Plans have been laid
for providing fifty thousand beds in and around
New York city for the sick and wounded from the
American Expeditionary Forces. The cessation of
hostilities, however, has obviated the necessity of
further expansion and no additional hospitals are
being provided, although those already in course^of
construction will be completed.
At present there are clinical laboratories at two
camp hospitals, five debarkation hospitals, one gen-
eral hospital, one post hospital, and two subsidiary
hospitals under Colonel Kennedy's command. The
work of all of these is coordinated by the Director
of Laboratories, Major E. H. Schorer, M. C, who
has immediate charge of the laboratory of the Port
of Embarkation in the Greenhut Building. Major
Schorer has with him three medical officers, seven
women technicians, one sanitary corps officer, two
contract surgeons, and eleven hospital corps men
besides clerical assistants.
The laboratory in the Greenhut Building acts
primarily as a departmental laboratory, the scope of
which is outlined in Article V of the Manual of the
Medical Department, thus: "Department laborato-
ries are maintained for the purpose of making such
examinations as cannot well be made at the smaller
laboratories of post hospitals. Surgeons may, un-
less otherwise instructed, send specimens for exam-
ination to the nearest department laboratory making
appropriate explanation direct to the officer in
charge of the laboratory."
[n the second place the Laboratory of the Port
acts as a school in army laboratory methods. Its
personnel is constantly being changed, new men and
officers being sent to the laboratory for training in
laboratory methods and in keeping military records.
Laboratory workers who have been thoroughly
trained are detached from time to time, as occasion
may arise, for service in smaller laboratories where
they will be thrown upon their own resources. In
addition to the general work this Port Laboratory
will do all the work of the hospital in the Greenhut
Building, Debarkation Llospital No. 3, which will
provide ample material for gaining experience.
The third function of this laboratory is as a
source of supplies for the other laboratories under
Colonel Kennedy's jurisdiction. Major Schorer not
only has sufficient quantities for his own needs but
also is able to supply promptly therapeutic sera as
well as general laboratory supplies. Laboratory
workers are detached from time to time and as-
signed to other units, and occasionally it is necessary
to send a detachment of technicians or officers and
men to some special command to take a large num-
ber of cultures where there is a suspicion of the
presence of infectious disease.
Not only is all the laboratory work of Debarka-
tion Hospital No. 3 done in the Port Laboratory but
media are prepared for use in the laboratories of
Debarkation Hospital No. 4 at Long Branch, and the
same course is to be pursued regarding Debarkation
Hospital No. 5 in the Grand Central Palace as soon
as it is ready for occupancy.
Finally all the samples of catgut purchased by the
government are tested for sterility in this insti-
tution.
The laboratory occupies floor space of about five
thousand square feet and includes a large store room
which is used as headquarters, a large refrigeration
room, an animal house, a labcyatory store room, a
Wassemiann test room, a large bacteriology room,
a large incubator room, a room for pathology, one
for clinical microscopy, one for chemistry, one for
the preparation of media and two record and offfce
rooms.
The pathological work involves both clinical pa-
thology and examination of specimens from ne-
cropsy.
TYPES OF CHEMICAL ANALYSIS MADE.
Some idea of the scope of the work done in
chemical analysis may be gathered from the follow-
ing memorandum which has been sent to the com-
manding officers of the various hospitals in the Port
of Embarkation for their information as to the
chemical work which this laboratory can undertake :
November 22, 1Q18.
It is requested that yon inform the chi°f of the Labora-
tory Service that the laboratory at the Port of Embarka-
906
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
tion, Sixth Avenue and Eiglueentli Street, New York city,
is now prepared to make the following chemical examina-
tions :
1. Ice cream- -Fat: Reese Gottlieb method, also for
condensed milk, cream, milk, skim milk, buttermilk and
whey.
2. Mill: analysis. — Fat determination, Babcock method ;
calculation of total solids, lactometer method ; test for for-
maldehyde, phenylhydrazen, and ferric chloride.
,3. IVatcr and sewage. — Examination for poisons, heavy
metals, and alkaloids.
Chemical aiialy.:is. — Free ammonia, albuminoid am-
monia, oxygen combinin.g capacity, inorganic solids, ni-
trites, nitrates, chlorines, alkalinity, temporary hardness,
permanent hardness, soap consuming powers, excess
chlorine in water, sulphates, and iron.
4. Alcohol determination in liquids. — Quantitative and
(jualitative.
5. Excinination for poisons in food, water, or tissues,
group and individual tests for. — (a) Volatile poisons,
(b) fix"d org.Tnic poisons, and (c) fixed inorganic poisons.
6. Urine analysis. — Quantitative determinations; Nitro-
gen partition, total nitrogen, urea, uric acid, chlorides,
sulphates, phosphates, titratable acidity, hydrogen ion con-
centration, glucose, total acetone bodies, acetone and dia-
cetic acid, and beta hydrophthalein test for kidney func-
tion.
7. Blond analysis. — Nonprotein nitrogen, urea,, chlo-
rides in blood plasma, and hemoglobin.
8. Stomach contents.
9. Feces. — Fat and fatty acids.
10. Ar:;rnic determination in blood, urine, t^ssu^s, etc.
11. Media. — Hydrogen ion concentration, glucose, and
total nitrogen.
12. Creatiniiie in blood and urine.
1.3 Creatinine.
14. Glucose in blood.
15. Birarbovafe content of blood plasma under constant
carbon dioxide tension.
ifi. Oxygen binning capacity of blood.
The laboratory is also prepared to supply and examine
Dnkin's solution, normal and standard solutions and stand-
ardi7e ap'^aratus.
When anv of these special determinations is required it
is requested that this laboratory be called and the special
precautions and method of obtaining samples ascertained.
MEDICAL NEWS EROM WASHINGTON.
Rear Admiral William C. Braisted, Surgeon General of
the Navy, Before House Naval Committee.
Washington, D. C, December 3. 1918.
When Rear Admiral William C. Braisted, Sur-
freon General of the Navy, was before the House
Naval Committee last week, the subject of cuttincj
naval estimates carrjjs up, and he took occasion to
warn the members of the committee that every man,
woman, and child in this country will demand, and
will have a right I0 demand, that the men remaining
in the service, the sick and wounded, have the very
host of medical attention.
During his hearing, Admiral Braisted stated that
there had been no case reported of lack of medical
supplies, and that the cooperation and coordination
with other bureaus of the navy had been all that
could be desired. He laid particular stress upon the
complex problems to be met with the advent of
peace, and he warned the committee that they must
not reduce the a[)propriations for th'e medical de-
partment if they desired to have it as successful in
the future as it had been during the war.
Admiral Braisted believes that he faces the
heaviest and most important part of the work in-
cident to his bureau in handling the results of the
war. It was shovvn that the men coming home will
not be under the same strict discipline that existed
during the war, anrl they will need very careful
treatment as a reward for heroic service. He as-
sured the committee that everything will be done to
take care of the sick and wounded, and that par-
ticular thought is being given to the question of re-
construction. It is proposed to use army hospitals
for special reconstruction, after men leave the naval
hospitals, to put tlie.m in shape to earn a livelihood.
The navy will pay the upkeep of its men during
the period under physical reconstruction in the
army. When physical reconstruction is complete,
the men will be placed under instruction with the
Federal Vocational Board.
The estimates, as revised by Admiral Braisted,
amount to approximately $9,500,000. or about two
thirds of the original estimate before the armistice
was concluded. Pie pointed out the increasing de-
mands on the Medical Corps in the transportation
of the sick and wounded in both the army and
navy, which largely falls to the navy or to ships
manned by the navy. The work of the navy in
connection with the transport service was particu-
larly praised by Admiral Braisted, who called it one
of the best works of the navy during the war,
which it had been unexpectedly called upon to un-
dertake.
Admiral Braisted stated that the total number of
sick under care of the navy at present is 15,000
men. The total casualties in deaths in the navy
during the war are 1,233 men.
The question of the care of patients was gone
into at great length before the committee, which
was told that all of the present naval hospital fa-
cilities are full, and until the navy is decreased and
the present construction under way is completed,
there will be necessity for securing outside accom-
modations. Admiral Braisted stated that his prin-
cipal worry at the present time was finding places
to put the men returning from abroad, and that he
will be forced to take measures to relieve New
York and Norfolk for sometime to come as the
hospital facilities become inadequate for the re-
({uirements of the navy. He stated that there were
forty-three hospital establishments in use by the
navy during the war. and that all of those abroad
will be demobilized as fast as possible.
Concerning hospital ships. Admiral Braisted said
that there are three in commission, but that the
Solace is not expected to be in use very long after
the present emergency is over. The Mercy and
Comfort are considered very good ships, and they
now are being used to bring back army sick and
wounded. Each has a capacity of 1,000 patients.
The new hospital ship, authorized several years ago,
will have a capacity of between 500 and 800 pa-
tients, and when completed it will take the place of
the Solace.
Members of the committee manifested much in-
terest in provisions for female nurses for the navy,
and were told that there are 290 in the regular es-
tablishment, 500 in the reserve corps, and 625 in the
naval reserve force, or a total of 1,415. The basis
of calculation is one nurse for every ten patients,
and the navy ought to have approximately 1,500
at present.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D-,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, twenty-five cents.
Remittances should be made by New York Exchange,
pest office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, DECEMBER 7, 1918.
THE TUBERCULOSIS WAR PROBLEM.
Probably no other phase of the medical prob-
lems presented by the war has been more carefully
worked out than that of the handling' of tubercu-
losis. Colonel George E. Bushnell, M. C, for
some months acting as assistant surgeon general
of the Army, has devoted himself especially to
the study of tuberculosis, and as commanding
officer of the Army tuberculosis hospital at Fort
Bayard, N. M., he had unusual opportunities to
study this disease.
In the August issue of The Military Surgeon
Colonel Bushnell gives a most informing review
of the work done by the medical department of
the Army during the first year of the war. A
body of nearly 400 examiners for tuberculosis
was organized, all of whom were more or less
expert. Some of these were in the Army, but
many were not, but merely acted as contract sur-
geons. A circular of instruction, for their guid-
ance, was drawn up by Colonel Bushnell to in-
sure uniformity in procedure.
At officers' training camps 53,905 men were ex-
amined and 0.362 per cent, were found to be tuber-
culous. In the aviation corps 38,835 men were
examined, of whom only 0.159 per cent, were
affected. Both of these groups represented a
picked class of men, for an examination of the
entire army, which then numbered 1,406,498, re-
sulted in the discovery of 11,020 cases of tuber-
culosis, or 0.783 per cent. Not all of these were
discharged, as many patients had no clinical
symptoms, and a still larger number were sent to
sanitoria for treatment. In the regular army
190,398 men were examined and 1,144 cases of
tuberculosis were discovered, or 0.758 per cent.,
while in the coast artillery, a part of the regular
Army whose duties confine them to garrison.^
40,396 men were examined, and 297 cases found,
or 0-735 per cent.
Altogether, something like 10,000 men were
excluded from the Army by the tuberculosis sur-
vey, and the great majority of these were found
to have contracted the disease before entering
the service. Consequently they did not become
pensioners when discharged. A conservative
estimate places the average cost of a tuberculosis
soldier at $1,000 for pensions. If, therefore, half
the 10,000 men were prevented from becoming
pensioners on account of disabilities for which
the Government was not responsible, a saving of
•$5,000,000 was made by the tuberculosis survey.
The Canadian Government estimates that each
iuberculous soklier returned from Europe costs
the Government $5,000. If there had been no ex-
amination held, these 10,000 tuberculous patients
would have been sent to Europe and been re-
turned at a cost of $5,000 each, making a total of
$50,000,000.
But the Government has not been content to
attempt to exclude the tuberculous soldiers
from the Army, for it has made ample
provision for the care of those who do
develop the disease in the service, hav-
ing established tuberculosis hospitals at New
Haven, Conn.; at Otisville, N. Y. ; at Markelton,
Pa. ; at Azalea, near Asheville, N. C. ; aj: Waynes-
ville, N. C. ; at Denver, Col. ; and at Whipple Bar-
racks, near Prescott, Ariz., with a total capacity
5>875 beds, besides the big hospital at Fort
Bayard, N.v M. To care for these men will re-
quire the aid of many specialists, and all medical
men who have special skill in the treatment of
tuberculosis are urged to apply for appointment
in this service.
998
EDITORIAL ARTICLES.
[New York
Medical Journal.
RESPONSIBILITY TOWARD VENEREAL
DISEASE AMONG NEGROES.
A state of apathy or indifference toward half
measures has been shaken from us in many ways
during the present prolonged crisis in affairs.
Factors which have been left standing to breed
what disaster and corruption they may, have
been forced upon active attention. Not the least
of these is the question of the health of the negro
in the midst of our population, especially in the
field of venereal diseases. Once more it has been
the imperative importance of attaining and main-
taining the efficiency of our army that has
aroused active interest in a problem that con-
cerns civil life as well.
Spingarn [Arthur B. Spingarn : The War and
Venereal Diseases Among Negroes, Social Hy-
giene, July, 1918] puts before us the lamentable
lack of scientific knowledge of the real incidence
and state of such diseases among the negroes.
This ignorance has been obscured and fostered
by generalizations which are based upon most
meagre facts and largely influenced by prejudice.
The result has been a careless dismissal of the
sanitary questions involved, and any definite at-
tack upon the diseases themselves among the ne-
groes or of unsanitary conditions which further
their spread has been prevented. It has been
left a problem too vague for investigation and
too large for control.
War necessity has, however, brought a more
determined and effective state of mind. The
actual high incidence of venereal diseases among
the negro population serves to emphasize the
lack of moral influences, social restraints, and
sanitary measures, toward which the white race
bears a heavy responsibility. Strangely, the
white race has merely pushed aside the existing
menace, failing to consider its own danger to
health, and this even though the two races are con-
tinually thrown into the closest contact.
The army camps have, however, at last taken
up the question as one, not of race, but, primarily
of health, which, owing to the seriousness of the
problem, admits of no distinction. The colored
troops arriving at camp show a high percentage
of infectidn, mostly of a chronic character vary-
ing from several months to many years in dura-
tion. The contraction of new infections after
arrival compares favorably with that of white
troops. It has been the policy of 'the Surgeon
General that systematic and painstaking effort
should be made, as efficiently and expeditiously
as possible, in the examination and cure of these
troops ; furthermore, every safeguard should be
thrown about them, as in the case of the white
troops, to prevent new infection. There have
been instances of a careless and perfunctory
treatment of these troops which has taken no ac-
count even of separating those who were infect-
ed from those who were not, and therefore sub-
jecting the latter to infection through the use of
unsterilized syringes upon all alike. This, Spin-
garn states, is fortunately not typical, and on the
whole conscientious and intensive treatment has
produced most satisfactory results.
The social agencies of the camp have also had
a large share in the health of these troops, by
surrounding them with the same facilities for
recreation and stimulation of moral and social
interest. This work is only in its initial stage,
but its effect is no less marked than that of med-
ical treatment.
It is not enough that these agencies are at work
at the cantonments ; in order that they shall be
eft'ective there, and that the work begun as a war
measure shall become a part of civil sanitary and
moral protection, it must extend outside these
limits. Here there is particular need that com-
munities shall awaken to the menace that has
been with them and the possibility of combating
it successfully. The recommendations which are
offered, therefore, include both the cantonments
and the civil communities. It is recommended
that in the camps the Surgeon General's policy
be rigidly carried out and that for this purpose
there should be a sufficient number of colored
medical officers and orderlies, should this prove
advisable. There should be instituted some in-
struction in social hygiene, in lectures specially
adapted to the negro's capacity, with an appeal
also to his race pride. It should be remembered
that these troops are in special need of military
discipline before they set out to perform their vari-
ous tasks.
There should be adequate facilities provided
for prophylactic treatment both within and with-
out camp. Those places outside the camp which
endanger colored morals and health should be
cleaned up with the cooperation of the civil com-
munity, while there should be especially drastic
control of extracantonnient zones for repressing
prostitution. It must be remembered that this
pertains to white troops as well as to colored.
With the same consideration in view, colored
women should be submitted to the same regula-
tions in regard to punishment, detention, and
treatment as white women. Public clinics main-
tained by State, city, or public health service
should be accessible to the negro, as to the white.
December 7, 1918.]
EDITORIAL ARTICLES.
999
The importance of recreational diversions should
be recognized for both sexes among the colored
as well as among the white population and ade-
quate provision be made for it. Effort should
extend to the definite improvement of such con-
ditions as tend toward vice and disease. There
should be direct attack upon illiteracy and bad
industrial and housing conditions. Constructive
work also should be undertaken among the civil
negro population as well as in the Army, both in
regard to venereal disease and in matters which
will rouse their pride and interest. An essential
factor to success is the hearty cooperation on the
part of the colored people themselves, among
whom already exist many agencies which might
be utilized.
THE ULTIMATE SIGNIFICANCE OF
PAIN.
Perhaps the most important and time honored
duty of the physician is the alleviation of pain,
no more, however, merely in the abstract, but
concretely in relation to the removal of the cause.
No one believes any longer that pain is an un-
mitigated evil. The importance of pain to the
life of the individual organism is now somewhat
better understood. Pain acts as the harbinger
of evil to the system and warns it of the presence
of pathological conditions before they become
irremediable. Without pain pathological condi-
tions would have free rein in the destruction of
the organism, the organism remaining unaware
of the destructive processes going on. But if
the sole function of pain is to signal danger, one
would expect that the intensity of that signal
of danger would be commensurate with the de-
gree and form of danger. This is not so. The
degree of conscious pain varies with the degree
of development of the particular organism affected.
The defective or those low in the scale of devel-
opment have less sensitiveness to pain than those
more highly developed. It is this fact which
points to a more general evolutionary signifi-
cance of pain.
Moreover, while lower organisms feel pain in
some degree, it is only those of higher develop-
ment who feel it acutely, more particularly pain
other than the purely physical, such as moral
pains — qualms of conscience, pains of apprehen-
sion and imagination. To the refined or highly
specialized individual these pains cause more
sutTering than mere physical pain. The higher
the organism the more sensible to pain and
the greater the variety of pain from which it can
suffer. Every adversity, every problem it meets it
must remove as it would the cause of a pain, for to
such an organism every life problem is a pain until
overcome. The more complex and differentiated
the nervous organization of the individual, the more
acute the pain and the suffering. Differentiation
and specialization bring with them, however, nor
only more pain but also more pleasures. Indeed,
overcoming a pain, or the cause of it, is a source of
conscious pleasure. Those who can enjoy music
are capable of suffering real pain from dishar-
mony, when the same action would cause indi-
viduals not so developed no pain at all. The more
highly specialized the organism becomes in any
endeavor the more occasions of pain arise and
the more sources of pain m.ust it learn to over-
come.
That pain is purposed only for evolution is
proved by the fact that, while we speak of re-
membering pain, a pain dies after its work is fin-
ished, and we only remember having had a pain.
We never refeel the same pain. The pain sur-
vives only in the consciousness of the higher or-
ganisms ; the lower organisms have neither the
consciousness nor the pain when once passed.
The harm of pain inflicted is not merely on the
sensorium, for the pain is a physical part of the
organism as a whole. It is now found in sur-
gical operations that it is not sufficient to rob the
consciousness of the pain, but that the seat of
the infliction of the pain must be insulated or
dissociated from the rest of the organism — annoci-
association. It is the dissociation of the part
where pain is inflicted that anticipates pain.
There is no pain in actions of dissociated organs
or tissues. It is the sympathetic unity of the
organs that appreciates the infliction of pain on
one of them, and it is their combined harmony of
action in avoidance that moves for their higher
development. The action of a lower organism in
apparently shrinking when injury and pain are
inflicted is explained on the ground that such an
organism shrinks from any action that affects its
normal physiological action and leans to those
agents that enhance it. Indeed, it shrinks from
anything that does not excite normal physio-
logical action.
In a broader sense the moral notions that re-
strain single organs or phases of the organism
from indulging in certain individual pleasures are
born of the consciousness in the higher organism
that this individual action, particularly since in-
dividual and not harmoniously united with the
interests of the entire organism, would injure
the whole organism. The moral restraint is in
lOOO
OBITUARY.
[New York
Medical Journal..
effect the pain or danger signal of disease im-
pending to the whole organism because of this
separate and therefore immoral action. And the
moral development of the race is occasioned from
an avoidance of moral or even physical pain or
disease. The defective or the immoral are in-
capable of this consciousness, just as the lower
organisms are incapable of appreciating pain. It
is pain in whatever form that spurs man onward
in development, proximately in mere avoidance
of pain, but remotely in his evolutionary prog-
ress. Without the pain sense or the adversities
or the problems that cause it there would be no
incentive for development to overcome them, and
the organism would remain stationary. What-
ever virtue there is in the alleviation of pain and
suffering, the abolition of pain is neither aimed
at nor desired. It is intended rather to overcome
this pain by developing the organism and to put
it in position to meet the more diversified and
acute pain of higher differentiation and develop-
ment of the organism. Like any ideal, the aboli-
tion of pain is a goal to strive for but not to
attain.
SALICIN IN INFLUENZA.
The subsiding epidemic of influenza will of
course be followed by a barrage of remedies, each
guaranteed to be a specific. Luckily the next
epidemic will probably not occur for so long a
time that most of these will be forgotten. While
they are still apropos, however, let us call an-
other one to the attention of the American pro-
fession. Dr. E. B. Turner, in the British Medical
Journal for August 3d, lauds the use of salicin.
In the epidemic of 1890-1891 and in the few
years following it, Turner says, he treated more
than two thousand cases, with recoveries in an
average of thirty-six hours, with no mortality.
He gives twenty grains an hour ; in two or three
hours the pain is gone, and the fever materially
reduced. Besides this, he believes that the in-
fectivity of the patient is greatly lessened. He
has noted no ill results from the large quantities
of the drug given, and in the present epidemic
recovery has usually occurred in twenty-four
hours.
We mention this specific for influenza for what
it is worth. The value of salicylates in this affec-
tion is well known ; what advantage is obtained
by administering this particular form of the drug
is difficult to see. While borne well by the stom-
ach, salicin is far less prompt and reliable than
salicylic acid itself or the salicylates.
SERVICE AND SACRIFICE.
The Distinguished Service Cross has been
awarded to Major Jackson Stuart Lawrence, Medi-
cal Corps, of the 368th Infantry, for extraordinary
heroism in action at Binarville on September 30th.
Major Lawrence, with two soldiers, voluntarily
left shelter and crossed an open space fifty yards-
wide swept by shell and machine gun fire to rescue
a wounded soldier whom they carried to a place of
safety. Doctor Lawrence was born in 1880, was
graduated from the School of Medicine of the
University of Pennsylvania in 190.S, and was en-
gaged in the practice of medicine at Greensburg, Pa.^
when he entered the army. A number of surgeons
have been killed and wounded ; the first American
officer to be killed in the war was a medical officer.
Lieutenant Fitzsimmons, who was killed by a
bomb dropped by a German airplane on a base hos-
pital in France. Many physicians have given their
sons for the cause. Dr. Herman Vedder, of New
York, has lost two sons within the past three
months. Dr. Herman J. Boldt, Dr. Alexander
Duane, and Dr. Howard Lillienthal, of this city,,
have each lost a son since the American advance
was begun. These are but a few instances in which
the doctor has been called upon to make a sacri-
fice for his country even greater than that of life
itself. To these and all the many doctors who have
suffered such loss, the members of the medical pro-
fession extend their homage and their deepest
sympathy. The medical profession of the United
States may well be proud of the part that it has
played in the great war, both in service and in sac-
rifice.
^
Obituary
MAJOR JOSEPH B. BISSELL, MEDICAL
CORPS, U. S. A.,
of New York.
Major Joseph B. Bissell, who died in Mt. Sinai
Hospital on December ist. was born at Lakeville,
Conn., on September 3, 1859. He graduated from
the Scientific Department of Yale University in
1879 and the Medical Department of Columbia
University in 1883. He studied in Vienna and
Munich and in 1886 was appointed instructor in
surgery at the New York Polyclinic School and
Hospital. In 1889 he became instructor in surgery
at the New York Post Graduate School and Hos-
pital nnd in 1805 he became surgeon to St. Vincent's
Hospital, At the time of his death, he was clinical
professor of surgery at the University and Bellevue
Hospital Medical College, visiting surgeon to the
Bellevue and St. Vincent's Hospital, consulting sur-
geon to the Hospital for Deformities and Joint Dis-
eases and to the German Hospital and Disoensary,
consulting gynecologist to the Ossining Hospital,
consulting radiologist to the House of Calvary, and
surgical director to the Radium Institute of New
York. He was elected president of the American
Radium Society last June. Early in the war, he
was invited by the British authorities to demon-
strate the use of radium in the treatment of septic
sinuses and for that purpose went to England.
December 7,
1918.]
» NEIVS ITEMS.
K)OI
News Items.
Section Meeting Postponed. — The Section in
Otolojjy of the New York Academy of Medicine
will meet on Wednesday, December i8th, the meet-
ing having been postponed from the second to the
third Wednesday.
To Increase Capacity of Naval Tuberculosis
Hospital. — At a hearing before the House Naval
Committee last week, Surgeon General Braistcd
called attention to the importance of rhe Naval
Tuberculosis Hospital at Las Animas, Colo. Thi
hospital has a capacity at present of 500 beds, but
Admiral Braisted believes that this capacity should
be doubled as =?non as possible.
House Naval Committee Compliments Admiral
Braisted. — At a hearing before the House Naval
Committee last week, Rear Admiral Braisted,
Surgeon General, United States Navy, was com-
plimented on the excellent showing of his depart-
ment. He insisted that the praise should be given
to the officers and men under him, and he took
occasion to call attention to the very great support
he had had at all times from the Secretary of the
Navy. He closed the hearing with the earnest
request that the members of the committee give
him the full amount estimated as necessary for the
next fiscal year, as the problems of his department
are greater now, and will be for the next year or
two. than thev were during the war.
Wounded Soldiers Return. — The United States
Hospital Ship N 01 them Pacific reached Pier i.
New York, Monday, December 2d, with 1,100
wounded soldiers from the war zone on board.
The ship had a very stormy voyage and the sufifer-
ings of the wounded men were greatly increased by
the roughness of the weather. Lieutenant Com-
mander R. G. Davis, of the Medical Corps of the
Navy, who was in charge of the patients, said that
most of the severe cases would be cared for at Fox
Hills, base hospital, Staten Island. There were 600
walking patients and 500 severe cases. The sol-
diers came from every battlefield in France. Fifty-
four infantry units, ten units of engineers, six of
field artillery, two of the machine gun battalion,
one of cavalry, one of the Quartermaster's Corps
and two of the nnrines were represented.
Meetings of New York Medical Societies. —
The following medical societies will hold meetings
in New York during the coming week : Monday,
Society of Medical jurisprudence (annual), New
York Ophthalmological Society, Yorkville Medical
Society, Williamsburg Medical Society ; Tuesday,
New York Academy of Medicine (Section in
Neurology and Psychiatry). Manhattan Dermato-
logica! Society, New York Obstetrical Society ;
Wednesday, Medical Society of the Borough of the
Bronx, New York Pathological Society, New York
Surgical Society, Alumni Association of the Nor-
wegian Hospital, Brooklyn (annual) ; Thursday,
New York Academy of Medicine (Section in Pedi-
atrics), West End Clinical Society (annual),
Brooklyn Pathological Society ; Friday, Clinical
Society of the German Hospital and Dispensary,
Eastern Medical Society of the City of New York
(annual), Flatbush Medical Society.
Narcotic Drug Commissioner Appointed. —
Governor Whitman has announced tlie appointment
of Frank Richardson, of Cambridge, N. Y., as com-
missioner of narcotic drug control. The commis-
sion was created by the tqiS legislature.
A Polyglot Ward in an American Red Cross
Hospital. — In an American Red Cross hospital,
in Dunkirk, France, a visitor found ten nationalities
represented. They were Belgian, French, English,
American, German, Chinese, Japanese, Moroccan,
Italian, and Polish.
Anniversary Address at the Academy of Medi-
cine.— Dr. Edwin G. Conklin, professor of biol-
ogy at Princeton University, delivered tlic annual
anniversary address at the New York Academy of
Medicine, Thursday evening, December 5th, his
subject being The Biology of Democracy, with
special reference to the present world crisis.
Few American Soldiers Blinded. — According
to the Aniiv (I'ld Navy Journal for November 30,
igi8, the Office of the Surgeon General of the
Army is authority for the statement that probably
less than fifty American soldiers have suffered total
blindness from wounds received in action. This is
considered a remarkable record considering the
number of men engaged and the intensity of the
fighting in the sectors where Americans were en-
gaged.
Demobilization of Students' Army Training
Corps. — Thirteen New York and Brooklyn col-
leges and universities have begun the demobiliza-
tion of their Students' Armv Training Corps, in
compliance with the War Department's order.
Among the institutions afTected bv this order are
Columbia University, New York University, Cor-
nell University. Medical College, New York College
of Dentistry, College of Dental and Oral Surgery,
and Long Island Medical College.
The Journal of Orthopedic Surgery. — The
American journal of Orthopedic Surgery, which is
the official organ of the American Orthopedic As-
sociation, announces that with the coming of the
new year it will enlarge its .scope by serving also as
the official organ of the newly formed British Or-
thopedic Association. Henceforth the name of the
publication will be The Journal of Orthopedic
Surgery. The journal will be published, as hereto-
fore, by Ernest Gregory, Boston, who assumed th-:
publication in January. 1916, when the journal
made its previous step of progress from a quarterly
io a monthly publication.
Exhibit at Clinic for Reeducation of the Dis-
abled.— The directors of the Clinic for Func-
tional Reeducation of Soldiers, Sailors, and Civil-
ians have issued invitations to an exhibition of the
equipment and a demonstration of the apparatus
of the clinic, to be held on Thursday afternoon,
December 12th. This clinic, which is situated at 5
Livingston Place, New York, is affiliated with
Cornell University Medical College. Dr. W. Gil-
man Thompson is president of the institution. The
stafif consists, in great part, of members of the
faculty of Cornell Medical College, but medical
officers experienced in Canadian and French work
of functional reeducation have been invited to give
instruction.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
POLYVALENT SERUM THERAPY IN
CEREBROSPINAL MENINGITIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
Certain clinical reports on the use of serum in
epidemic cerebrospinal meningitis have been far less
encouraging than might have been expecteil, in view
of current statements concerning the efficacy of
specific treatment in this disease. Thus a mortality
of sixty-one per cent., in spite of serum therapy,
has been reported by Rolleston, of sixty-eight per
cent, by Ellis, and of fifty-five per cent, by Gaskell
and Foster. Of seventeen English clinicians em-
ploying serum, not less than seven deemed it
altogether valueless. In truth, as with all relatively
new therapeutic procedures, even the most valuable,
optimal results from antimeningitis serum could not
be expected from the start, a prolonged period of
trial and modification necessarily elapsing before
complete availability of the measure under all cir-
cumstances can be obtained. Evidence is not lack-
ing that in the case of the serum in question this
period has not yet terminated, or at least, that
unanimity of opinion and procedure has not so far
been attained.
Upon seeking the cause of the irregularity in
clinical results from antimeningitis serum, vari-
ous observers have been led to emphasize the fact
that meningococci of difYerent origin, even though
alike in their cultural and biological characteristics,
may be markedly different in other respects — in
particular their behavior as antigens, including their
response to specific agglutination tests. Studies of
the influence on various samples of meningococci
of monovalent sera obtained by inoculation of ani-
mals enabled Ellis, Dopter, Gordon, Arkwright, and
others to classify rhcse organisms in definite groups,
each group corresponding to a monovalent serum,
toward which was shown specificity, not only in
regard to the agglutination and precipitation tests,
but also in regard to bactericidal power in vitro and
in animal experiments. Most students of the ques-
tion have not regarded this differentiation of dis-
tinct groups as involving a division into separate
species of organisms, but merely as reflecting the
occurrence of meningococci in different strains or
varieties. Among the French observers, however,
Dopter was instrumental in propagating the view
that the organisms of epidemic meningitis should be
divided into two definite species, viz., the meningo-
cocci and the parameningococci. Meningitis due to
the latter form of organism was shown to be amen-
able to that which he terms antiparameningococcic
serum, though refractory to meningococcic serum.
Furthermore, Dopter later found it necessary to
recognize at least three distinct types of paramen-
ingococci, which he designated, respectively, with
the three Greek letters, alpha, beta, and gamma.
Nicolle, Debains, and Jouan, 191 7, who have also
made a careful study of the specific meningitic
organisms, recognize a Type A of organism, corre-
sponding to the true meningococcus of Dopter and
the Type I of Ellis, Arkwright, and Gordon; a
Type B, corresponding to Dopter's alpha paramen-
ingococcus, possibly also to his beta organism, and
likewise to the Type II of Ellis, Arkwright, and
Gordon ; a Type C, corresponding, at least partly,
to the beta parameningococcus, which is aggluti-
nated by C serum, and a Type D, corresponding to
the gamma parameningococcus.
In brief, the multiplicity of meningococcic organ-
isms that may be responsible for cerebrospinal fever
has been rendered clearly evident, whatever the sys-
tem of notation used to distinguish them. Since the
beginning of the war, moreover, as pointed out by
A. Netter, 1918, the ratio of samples of meningo-
cocci diff'ering from the originally recognized type
has proven increasingly large, and this, in view of
the known occurrence of variations in seric spec-
ificity among different samples of organisms be-
longing to a given species, seems likely, even a
priori, to have an important bearing on treatment.
Dopter, believing most cases of meningitis to be
due to the typical meningococcus, at first deemed it
sufficient to begin treatment with an injection of a
monovalent antimeningococcic serum and to turn
to other sera only when that first used had
proven ineffectual or the identity of the invading
organism as a parameningococcus had been ascer-
tained. Experience with this type of treatment
showed, however, that at times a patient treated
with the antimeningococcic serum succumbed before
the parameningococcic infection actually present
and responsible had been identified. Netter was
therefore led to emphasize the fact that in menin-
gitis the earliest possible use of an e^cacious serum
of whatever nature and composition, is the chief
necessity, and that since the employment of a
monovalent serum at times resulted in a fatal
termination that might have been preventable, a
serum efficient against different groups of meningo-
coccic organisms must be given from the start. This
is rendered all the more essential in that where, as
is often the case, laboratory facilities and the ne-
cessary technical skill are not available, recognition
of the type of organism present in a given patient
as basis for a more accurately specific treatment is
out of the question.
At the Rockefeller Institute the advisability of
using several types or strains of organisms in the
preparation of antimeningococcic horse serum was
early recognized. Netter, employing clinically
Plexner serum prepared with a considerable num-
ber of bacterial samples from cases of cerebrospinal
meningitis, obtained better results than he did from
sera supplied by Wassermann, Kolle, and others.
Whereas among the first forty-eight cases he sub-
jected to serum treatment the total mortality was
twenty-seven per cent., among thirty-one cases that
received Flexner serum it was nineteen per cent.
{To be continued.)
December 7, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
1003
Dietetic Treatment of Liver Diseases. — Allen
Eustis {New Orleans Medical and Surgical Jour-
nal, August. 1918) says that the diet should consist
essentially of an abundance of carlx)hydrates, and,
while a transient glycosuria may be produced, this
soon disappears as the liver cells regenerate. This
must be selected according to the gastric function
of the patient, auvl, if vomiting exists, glucose by
drip proctoclysis or by hypodermoclysis must be
lesorted to. Where there is little disturbance \yith
gastric function the following diet list should be
selected from, and the patient maintained on this
diet as long as a positive aldehyde reaction is ob-
tained, or as long as there is an intestinal toxemia.
Diet for Patients with Defective Liver Function.
MAY TAKE.
Soups: All clear soups, vegetable broths, puree of corn,
beans, peas, asparagus, spinach, celery, onions, potatoes and
tomatoes.
Eggs: None.
Fish: None.
Meat, Game or Poultry: None.
Farinaceous: Oatmeal, rice, sago, hominy, grits, cracked
wheat, whole wheat bread or biscuits, corn, rye and graham
bread, rolls, dry and buttered toast, crackers, muffins,
waffles, batter cakes, wafers, grape nuts, macaroni, noodles
and spaghetti.
Vegetables: Potatoes (sweet and Irish), green peas,
string beans, beets, carrots, celery, spinach, artichokes,
alligator pears, eggplants, lettuce and onions. All vege-
tables except cabbage, cauliflower and turnips.
Desserts: Rice and sago with a little cream and sugar,
figs, raisins, nuts and syrup, stewed fruit, preserves, jellies,
jams, marmalades and gelatin; prunes, apples and pears,
either raw or cooked.
Drinks: Tea and coffee (with cream, but not milk),
grape juice, orangeade, lemonade, limeade and Vichy, cocoa.
An abundance of pure water, cold or hot.
MUST NOT TAKE.
Veal, pork, goose, duck ; salted, dry, potted or preserved
fish or meat (except crisp bacon) ; oysters, crabs, salmon,
lobster, shrimp, mackerel, eggs, turtle and ox tail soup,
gumbo, patties, mushrooms, mince pie, cabbage, cauliflower,
turnips and cheese; alcohol.
Negative tests for urobilinogen and indican ex-
tending over a week indicate that either eggs, fish,
or easily digestible meats may be taken in modera-
tion, this being limited to not oftener than once a
day. The author finds that buttermilk, to which
lactose has been added, is the best animal protein
on which to start, and strongly urges a constant
control of the diet by frequent examinations of the
urine.
Gunshot Wounds of the Knee Joint. — H. H.
Hepburn (British Medical Journal, September 28.
1918) discusses only those cases in which the
synovial membrane was penetrated, except to point
out that in the nonpenetrating cases joint suppura-
tion has been strikingly diminished in frequency
since the general adoption of immediate excision
of the wound and j rimar}' surgical cleansing. In
the penetrating cases, as seen at a base hospital,
the first three days constitute the doubtful stage,
during which indications for further surgical inter-
ference are most likely to arise. In cases which
develop suppuration in the joint, repeated aspira-
tion, with or without lavage through a cannula,
does not give results which warrant delaving more
efficient drainage. The joint should be aspirated
once only and if ihe fluid shows evidence of active
infection and the pus recurs, effective drainage
should be instituted immediately. The streptococ-
cus has been the infecting organism in all cases
which have required reopening. The operative
treatment begins with the administration of omno-
pon, and anesthesia is produced by nitrous oxide
or ether. With as little movement of the joint as
possible the skin is scrubbed with soap and water
and washed with eusol. A tourniquet is applied
to secure a dry field. An incision three or four
inches long, centred opposite the upper pole of the
patella, is made along the line of the anteroexter-
nal margin of the femur. This is carried down to
the synovial membrane, but not through it. The
extrasynovial fibrous layer is then sewed to the
skin by a continuous catgut suture through the
whole length of the incision ; this step is repeated
on the inner side of the patella. The synovial cav-
ity is then opened on both sides anrl the anterior
portion of the cavity is irrigated clean with at least
a gallon of warm saline solution, followed by one
or two pints of eusol. With the knee slightly flexed
a small catheter is passed first between and then
along either side of the femoral condyles and these
regions are similarly irrigated, the leg being alter-
nately flexed and extended. When the return flow
is clean the anterior portion of the cavity is again
washed out with eusol and the tourniquet removed.
Two Carrel tubes are passed upward under the
quadriceps and two downward, one on each side
of the joint. The part is then put up in a Thomas
knee splint with about ten degrees of flexion and
no traction is applied, in the hope that the posterior
part of the joint cavity will become shut off from
the anterior and take care of itself. Half an ounce
of eusol is injected into each of the Carrel tubes
every four hours and the joint is thoroughly irri-
gated once daily for three days. Then the tubes
are removed and replaced by two which lie super-
ficially in the two incisions, these being allowed to
close as rapidly as they will. When the synovial
sac has been closed for ten days gentle passive
movement of the joint can be started. Under this
plan there were only two deaths and six amputa-
tions among fifty cases.
Treatment of Empyema. — T. Tuffier (Presse
medicate, September 26, 1918), in pneumococcic
empyema without sinus formation, first makes a
simple intercostal incision in the region of the
posterior axillary line and evacuates the empyema
and false membranes. In nonpneumococcic empy-
ema, costal resection is performed and followed by
a very careful visual examination of the size and
arrangement of the intrapleural purulent focus.
Seven or eight Carrel tubes are then introduced in
all recesses, even the most remote, and in all direc-
tions, and are fastened to the skin with an adhesive
strip or silver wire. The second step in the treat-
ment consists in chemical disinfection by injection
of Dakin's solution through each tube every two
hours. Every other day the exudate is taken from
the superficial tissues, pus tract, and deep recesses,
and bacteriologically examined. In five to thirty
days, the microbiologic curve and nature of the
organisms present show that the pleural cavity is
sterile. The incision is then closed, care being
taken to avoid an effusion of blood, and respiratory
1004
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
exercises instituted to facilitate absorption of the
pneumothorax, hi some cases of empyema with a
sinus already existing, rubber tubes enclosing silver
wire are passed into the cavity and an x ray picture
taken. Where the sinus is to be at once surgically
dealt with, however, this procedure is dispensed
with. A broad opening is made through the wound
and the wound margins widely separated with a
double retractor. Gray membranes over the surface
of the lung are removed by simple rubbing and the
shape of the cavity carefully inspected. Disinfec-
tion with Dakin's solution is then systematically
carried out, with daily pulmonary gymnastics. The
size of the pleural cavity is measured by ascertain-
ing the amount of fluid required to fill it, and the
extent of lung expansion calculated by comparison
of the quantities of fluid injectable during inspira-
tion and expiration. Wlien bacteriological examina-
tions show clinical sterilization — one bacterium in
{our fields or less — the antiseptic treatment is
stopped. If three additional bacteriological ex-
aminations are negative, the case is ready for opera-
tion and suture. The entire sinus tract is removed
and decortication of the lung, as completely as pos-
sible, effected as in Delorme's operation. The
results of this are vastly better than formerly, for
the operation is no longer carried out in a septic
medium. Former surgical principles are now re-
versed, in that the lung is brought to the chest wall
rather than the latter brought to the lung, with
corresponding improvement in the result.
Treatment of Catarrhal Pancreatitis. — Hugh
Morton (Glasgozj Medical Journal. September,
1918) reports th.^ successful treatment of a case
of functional disturbance of the pancreas associ-
ated with achylia gastrica, and counsels against
giving a prognosis in an apparently hopeless diges-
tive disorder until all methods of making an ac-
curate diagnosis have been exhausted. The patient,
an overworked business man, complained at first
of diarrhea, discomfort after meals, and general
apathy ; later, of ,1 dislike for meat, borborygmi,
offensive flatus two hours after taking food, white
and greasy stools, and gradual loss of weight. The
stomach showed no free hydrochloric acid, with
a total acidity of twenty. The Wohlgemuth test
showed a marked deficiency in amylolytic ferments ;
the Wolff-Junghans test suggested a benign rather
than malignant achylia. Rennin and pepsin were
but slightly deficient. The patient was put to bed
in a nursing home, given meals at definite intervals,
and enjoined to eat slowly and masticate well.
Fats, meats, and eggs were restricted, but he was
able to take considerable milk. Carbohydrates were
given in the form of fine farinaceous food. To
promote duodenal antisepsis, one of the following
powders was given morning and evening:
Hj'drarRyri cum cretJE, 3 grains;
Rhei nilveris, ) r 1 . ■
Phenylis salicylatis. j 5 Strains ;
Rismuthi siibsalicylatis, 10 grains.
Fiat pulvis.
Hydrochloric acid was given with the food, at first
in forty minim doses ; later, in diminishing amounts,
as the Ewald test meal showed spontaneous secre-
tion of gastric juice. The acid was given with
pepsin, thus :
R Acidi hydrochlorici diluti,
Pepsini (puri), ) r u j
Tinctiirie nucis vomicje, j ' ' ' ''^ ^ ^''^'^^ •
Glycerini i dram ;
Aquce q. s. ad 6 ounces.
M. Sig. : Two drams thrice daily in water along with
meals.
To assist starch and fat digestion, pancreatin was
given about one hour after food:
R Pancreatin 2 drams;
TincturrR cardomomi compositse 4 drams;
Glycerini i ounce;
Aquje q. s. ad 6 ounces.
M. Sig. :Two drams thrice daily in water one hour after
meals.
The remaining measures used comprised : Gastric
lavage daily for four weeks with sodium chloride
solution, two drams to the pint ; biweekly injections
of five mils of sea water plasma aseptically under
the shoulder blades ; a soap and water enema every
morning, followed by rectal injection of a solution
of urotropin and sodium benzoate, ten grains of
each ; to stimula;:e the liver, a cold compress over
it every night, and removed in the morning. Un-
der this treatment the patient rapidly improved. In
five weeks the free acid and pancreatic secretion
were normal.
Serum Therapy in Gangrene. — J. Mairesse and
J. Regnier (Frcssc medicale, September 9, 1918)
report on four months' experience in the French
Army with an antiperfringens serum supplied by
the Institut Pasteur of Paris. Examining the flora
of wounds in 1,016 cases, the authors found 197
instances of infection with rodlike organisms of the
perfringens type ; in many cases the identity of the
organism was verified by culture. These organisms,
in common with other bacteria, appeared in the
wounds at the seventh or eighth hour after injury.
Each of the 297 positive cases was given at once,
before surgical intervention, an injection of anti-
perfringens serum — twenty mils in 247 cases and
forty mils in fifty cases more heavily infected.
Twenty-five patients developed gangrenous lesions
requiring repetition of seruin treatment, and five
died of gas gangrene. Three of these deaths oc-
curred early in the series, when the amount of
serum given was relatively small, owing to the fear
of serum disease. Both of the other two fatal cases
had penetrating shell wounds of the thigh ; in
neither instance was the entire track of the missile
exposed at the operation. Gangrene appeared sud-
denly on the third day and was followed by death
in ten hours. These cases illustrated the usual
modification of the manifestations of gas gangrene
by serum, showing absence of gas formation and of
odor, ruddy muscles, and preservation of the nor-
mal softness of the superficial tissue layers. Of
the twenty-five cases requiring curative in addition
to the initial prophylactic injections, nearly all re-
ceived but eighty to 100 mils of serum altogether;
most of them showed injury to arterial trunks. The
serum treatment always restricted the gangrenous
involvement below the level of arterial injury, and
likewise prevented centripetal extension of the
disease. Conservative surgical treatment was facili-
tated bv it.
December 7, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
Loss of Achilles Reflexes in Intensive Arseni-
cal Treatment. — Sicard and Roger (Paris medi-
cal, June 29, 1918) call attention to destruction of the
Achilles tendon rt:flexes as an early sisiri of chronic
arsenical poisoning in paretics subjected to intensive
neoarsenobenzol treatment in the daily intravenous
dose of 0.3 gram, up to an aggresjate dose of twelve
to twenty grams. The loss of the reflex indicates a
latent arsenical neuritis of the internal popliteal
nerve, as yet unaccompanied by disturbances of
locomotion, pain or muscular atrophy, yet already
resulting in certain quantitative modifications of the
electric reactions in the involved muscles. Paretics
subjected to such treatment show marked physical
and mental improven;ent, but tliere is no clinical or
humoral cure, the Bordet-Wassermann re;iction in
the cerebrospinal fluid remaining irreducible.
Surgical Closure of Wounds. — Georges De-
hellv {Anvals of Surgery. October, 1918) de-
scribes the precautions to be taken in the surgical
closure of wounds, as follows: i. The closure must
be complete, as far as possible. If the suture is
not complete there is reinfection from the exterior,
generally from the skin. 2. The stitches should
be without exaggerated traction. Tension of the
stitches puts the skin in bad condition of defense
against infection. 3. Under the cutaneous suture no
cavity must be left in which secretions can accumu-
late. The secretions accumulated in the cavity
constitute a very good medium for the culture of
the bacteria. There is, however, a procedure which
banishes complications when suture is not abso-
lutelv complete, or if there is reason to fear a
hematoma, or if there is any oozing whatever. This
happens often in the secondarv closure of stumos
with resection of scar tissue and bone ends.
In these cases cutaneous suture is made as complete
as possible, but one or two instillation tubes are left
under the skin to sterilize the subcutaneous cavity
bv the Carrel-Dakin method, without the necessity
of removing stitches, if there is some inflammation
after the operation.
A Healing Paste for Ulcerated Wounds. —
Morlet (Presse mcdicalc, September 12, 1918), in
view of the favorable results obtained in the trerit-
ment of all forms of ulcerated wounds — except
those due to syphilis — by application of the old
fashioned occlusive dressing with strips of dia-
chylon plaster, was led, in order to eliminate the
attendant copious and malodorous discharge, to use
a paste containing balsam of Peru, which is both
deodorant, antiseptic, and keratoplastic. To render
the paste absorbent and porous after desiccation,
bismuth subnitrate was also included, the complete
formula of the paste being: Balsam of Peru and
bismuth subnitrate, fifteen to twenty grams of
each, according to the extent of infection of the
wound ; fish glue and glycerin, fifty grams of each,
and water, 100 grams. This constitutes a semi-
occlusive dressing which, while tending to dry the
wound, also allows any pus formed to pass out.
Fish glue is employed in preference to any other
form of gelatin in order to obviate all risk of infec-
tion with tetanus. Wounds to be dressed with
the paste are first cleansed with alcohol and their
margins loosened. A bandage impregnated with
the hot paste is then applied, covering the wound.
The dressing is allowed to remain from twelve to
fifteen days. According to the size of the wound
one or two dressings are required, rarely three. To
promote formation of a good new epidermis the
patient is allowed to get up and walk about during
the course of the treatment, the act of locomotion
havinjj the effect of an actual massar^e of the wound.
Organotherapy in Wounds. — Serge Voronoff
and Evelyn Bostwick (Presse mcdicalc, September
9, 1918) report that, after much experimentation
at the College de France, they were able to cause
healing of extensive and deep wounds in a few
days, by applying locally the pulp of sex glands
procured by cas:rating young animals. The cells
of these glands, through the secretion thev contain
and which is absorbed by the wound, exert an in-
tense accelerating action on the process of granula-
tion. The organ found most efifectual in these ex-
periments would, a priori, have been considered
that most suitable, owing to its especial vital energy.
Animals deprived of these organs are known to
accumulate fat at the expense of their muscles and
to become apathetic and passive. In the wounds
treated with this material, its use often had to be
discontinued after a few days in order not to ex-
ceed the results sought and cause projection of new
tissue beyond the level of the wound cavity by
reason of a too intense development of granula-
tions. With the aid of this treatment its sponsors
hope to spare the wounded longr months of sufTer-
insf and considerably shorten their stay in hospitals.
This method is being tried at Carrel's hospital.
Fusion Treatment of Vertebral Tuberculosis.
— Russell A. Hibbs (Journal A. M. A., October 26,
1918) presents the results obtained by the fusion
operation in a series of 210 cases of spinal tuber-
culosis. The operation was performed more than
three and a half vears ago in everv case. The op-
eration consisted in the fusion of the vertebrae over
an area including the afYected vertebrae and at least
two healthy ones at each end. This was accom-
plished bv removal of all nonosseous tissue from
l)etween the lateral articulations, the laminfe, and
the spinous processes, and the securing of bony
contact at all of those places. Of the entire group
of cases nearly seventy-five per cent, have been
cured, about ten per cent, are still doubtful cures,
and about fifteen per cent, have died. In 139 of
the cases there has been no increase in the deform-
ity, while in eighteen there was a definite increase.
Five of the deaths occurred in patients who had
been definitely cured of their Pott's disease. Three
of the patients in the series had had previous bone
graft operations, but in none was there any bony
fusion, and all of the patients had evidences of
active disease still persisting. In only four of the
fusion cases did fusion fail to take place at even
one single point, and in these the failure was prob-
ably due to imperfect technic. The effect of the
fusion in all cases was apparently to hasten cure
of the spinal disease, in spite of the fact that the
average duration of the disease, before the opera-
tion, had been nearly four and a half years. It is
suggested that even better results can be expected
if the operation is performed at an earlier stage.
ioo6
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal,
Serum Treatment of Type I Pneumonia. — Les-
ley II. Spooner, Andrew Watson Sellards, and John
H. Wyman {Journal A. M. A., October 19, 1918)
obtained a mortality of twenty per cent, for Type I
pneumonias when treated with a low titre serum
before the outbreak of influenza in their camp.
After this epidemic had invaded the camp the
mortality of Tyi>e I cases of pneumonia treated
throughout with low titre serum, or with low titre
at first and high titre later, was about double that
recorded before the influenza epidemic. In contrast
to this, the Type I cases occurring during the epi-
demic which were treated throughout with high
titre serum gave a mortality of only seven per cent.
From these observations the use of large amounts
of low titre serum was deemed inadvisable. It was
noted incidentally that the Bacillus influenzje was
established by careful bacteriological investigations
as the causative agent of the influenza epidemic at
the camp.
Treatment of Influenza Pneumonia with Con-
valescent Human Serum. — L. W. McGuire and
W. R. Redden {Journal A. M. A., October 19,
1918) tried the use of serum from convalescent
human cases of influenza as a treatment for influ-
enza pneumonia in thirty-seven consecutive patients.
At the time of writing thirty of the patients were
convalescent, six were still under treatment and one
had died. Of those under treatment two were much
improved, two were not improved, and two had
received only one dose of serum. The serum was
obtained from convalescents within a week to ten
days after their temperature had become normal,
each patient giving about 800 mils of blood in two
bleedings. The serum was tested by the Wasser-
mann test and aLso against the recipient's corpuscles.
The serum was given intravenously in doses of
seventy-five to 125 mils, repeated at intervals of
eight to sixteen hours. The average total amount
given was 300 mils, though two patients received
from 600 to 700 mils each. Diflferent sera were
found to vary widely in potency, some having no
effect whatever. The effects of the serum treat-
ment were usually quite evident within the first
twenty-four hours and the best results were ob-
tained when the treatment was begun within the
first forty-eight hours after the development of the
pneumonic complication. Efforts were made to test
the potency of the human serum by complement
fixation or by agglutination, but no successful
method was found.
Cranioplasty. — L. Dufourmentel {Paris medi-
cal. Tune 29. 1918) believes the use of a metal plate
to be the only procedure affording an assurance of
stout protection of the underlying soft tissues in
extensive wounds of the cranium. The author's
mode of operation is effected in two stages. In the
first, which may be carried out under local an-
esthesia, the opening in the cranium is exposed
either by incising the scar or by making a flap. The
scar in the dura may or may not be incised. The
essential step is to carefully expose the margins of
the bony opening. An impression of the opening is
now secured with a block of wax previously steril-
ized by boihng and allowed to cool until soft — to
about 40° C. The wound is then temporarily closed
with a few tissue clamps. Next the cast is
taken to a dentai or other appropriate laboratory,
where a plate of gold or other chemically resistant
metal is made from it ; for large openings, alum-
inum is best because of its lightness. The plate is
fashioned as an inlay, i. e., must fit precisely in all
the irregularities of contour of the opening. It may
or may not be perforated to facilitate adhesion of
the adjacent tissues. The plate covers the bevelled
bony margins and rests solely upon them. The
second stage, which is very simple, takes but a min-
ute or two, and is carried out a day or two after
the first, consists in removing a few clamps, intro-
ducing the plate under the skin to its proper posi-
tion, replacing the clamps, and applying a sufficiently
firm dressing. The tissues adjacent to the plate
subsequently hold it in place just as they would
fragments of bone or cartilage. Tolerance of the
plate for an indefinite time can be expected. That
osteoperiosteal or bone transplants may lead to
restoration of bony continuity in cranial wounds
remains to be demonstrated ; meanwhile the metallic
plate is the best corrective device.
Treatment of Severe Burns. — Byron N. Linge-
man {Indianapolis Medical Journal, September,
1918) says that the most important things to be con-
sidered are: i. Does it exclude the air in the early
stages? 2. Does it prevent or combat the shock?
3. Does it favor sloughing of the tissues? 4. Does
it maintain the sterility of the tissues? 5. Does it
injure the newly formed granulations? 6. Is it
painless in application? 7. Does it permit the im-
mobilization of the tissues and limbs in the best
possible position ? The combination of the open and
closed treatments might be better than one alone.
The open treatment might be better in the slough-
ing stage, while the closed might be better in the
later stages. The following outline is proposed: i.
Relieve the pain by giving morphine and excluding
the air in early stages either with paraffin or con-
tinuous bath. 2. Prevent or combat the shock by
providing artificial heat, giving alkaline drinks, and
h\ intravenous injection of sodium bicarbonate. 3.
If the wound contains clots or other debris, place
the patient in a continuous tub bath for a few hours,
but do not forcibly remove burned skin. 4. Remove
from the tub, and irrigate according to the Carrel-
Dakin method, together with daily exposure to the
sun, light, and air. Continue this treatment during
the sloughing period, eight or ten days. 5. If only
a second degree burn treat (after sloughing period)
by the paraffin or adhesive strip method, keeping
the limbs in the proper position. If a third degree
burn and wounds are sterile, try skin grafting.
Treatment of Empyema by the Carrel-Dakin
Method. — George A. Stewart {Medical Record,
August 10, 1918) reports forty-five cases of em-
pyema treated by the Carrel-Dakin method at the
Rockefeller Institute, with twelve deaths. At first
spontaneous closure was allowed to go on, but later
secondary suture was done after cultures were
sterile, which, on the average, was fourteen days.
In such cases primary union was obtained in seventy
per cent, of all cases. The hospital stay of these
patients was shorter than the average, and none of
them was discharged from the army for disability.
Miscellany from Home and Foreign Journals
Toxicity of Eucalyptus Oil and Myrtol in Hu-
man Beings and Animals. — Lewellys F. Barker
and Leonard G. Rowntree (Bulletin of the Johns
Hopkins Hospital, October, 1918) in a review of
the literature of myrtol poisoning, found thirty-
four such cases, to which they add one of their
own. Undoubtedly certain people exhibit an idio-
syncrasy, as the symptoms of intoxication occur
after minute or therapeutic doses in some cases. An
analysis of the Htcrnture divides the cases into two
groups, showing different syndromes which follow
as evidences of intoxication with derivatives of
myrtaceous plants — eucalyptus oil, myrtol, cineal,
etc. These the authors call a myrtogenic neurop-
athy and a myrtogenic dermatopathy, and the latter
may in some instances be a specific instance of the
neuropathy. The first twenty-nine cases reviewed
belong to the myrtogenic neuropathy group, while
five cases, including the authors' patient, showed
remarkable cutaneous manifestations. Ihe skin
lesions may be erythematous, urticarial in typ^^ or
an outspoken derm.atitis. In seven of the cases
there was a fatal termination. Experiments on dogs
and cats proved that the symptoms of intoxication
of the nervous system observed in man can be
duplicated by 3ubcutaneous and intraperitoneal
administrations of myrtol. The report of .the au-
thors' case is as follows : The patient, a man of
forty-two years, complained of cough and a large
amount of offensive sputum. After physical and
x ray examinations, the diagnosis was determined
to be bronchiectasis, chronic putrid bronchitis,
fibrous peribronchitis, and chronic pleuritis, right.
In addition to general measures, three minims of
myrtol in capsules to be taken three times a day
weie prescribed to relieve the fetid bronchitis. The
patient had previously taken oil of eucalyptus and
oil of sandalwood, which he continued to use along
with the myrtol. Later the patient wrote that after
takine two capsules three times a dav for eight
days his face became discolored, with puffiness under
the eyes ; his forehead looked as though it was going
to break out with eczema, his left eye was nearly
closed and the right eye partially closed from the
swelling. The drug was stopped, but th^ swelling
lasted a long time. His cough increased markedly,
his heart action became more rapid, and he was
greatly depressed. The discoloration of the skin
and eruption covered the entire chest.
Function of the Gallbladder: An Experimental
Study. — F. C. Mann (Nezv Orleans Medical and
Surgical Journal, August, 1918) finds that the func-
tional significance of the gallbladder seems to be in-
timately connected with the fact that it is mechani-
cally adapted to change the escape of bile into the
intestine from a more or less continuous flow into
an intermittent one. Studies on animals — practi-
cally always dogs — with biliary fistula, show that
the liver secretes bile continuously, although the
rale varies considersbly. In most instances, how-
ever, in which duodenal fistula have been formed,
the escape of bile into the intestine has been inter-
mittent. No studies seem to have been made on
animals without a gallbladder in regard to the flow
of bile into the intestine, but it seems that, in all
probability, it would be continuous with liver secre-
tion. Observations have been made in the rat and
pocket gopher, but the experiments were compli-
cated by the necessary anesthetic. Under such
experimental conditions, the entrance of bile into
the intestine in these two species was continuous,
except for the slight changes produced by respira-
tion. The fact that the sphincter seems to be in-
active in species without a gallbladder would imply
that this was quite the normal condition. A study
of some species of animal without a gallbladder, in
which it i^ possible to make a permanent duodenal
fistula, will be necessary to definitely prove this
point. The action of the gallbladder seems to be as
follows : The liver secretes bile more or less con-
tinuously. Under normal conditions this is secreted
under very low pressure. The sphincter at the
opening of the common bile duct is normally under
tone, which is great enough to increase the intra-
duct pressure above the resistance offered to the
entrance of bile into the gallbladder. At intervals
the sphincter relaxes, allowing bile to flow into the
intestine. The mechanism controlling the action of
the sphincter is not known, but is reported to be
vmder nervous control. The gallbladder not only
acts as an expansile chamber for the accommodation
of the difference in rate of bile secretion and bile
discharge, but it also prevents some of the fluctua-
tions in intraduct pressure which would occur dur-
ing respiration in all instances in which the duodenal
sphincter is active. It should be appreciated that
in all species in which the sphincter is active some
mechanism like the gallbladder is necessary.
Acute Syphilitic Meningitis with Turbid Cere-
brospinal Fluid. — Paillard and Desmouliere
(Presse mcdicalc, September 12, 1918) report the
case of a Chinese laborer who was brought to a
hospital with a meningeal syndrome and subfebrile
temperature of about 38° C. Lumbar punctur."
yielded a frankly turbid fluid, macroscopically
similar to that of cerebrospinal meningitis. Im-
mediate examination of the fluid showed very
pronounced lymphocytosis and mononucleosis,
without any bacterial organi.sm. The Bordet-
Wassermann proved to be strongly positive in the
cerebrospinal fluid and blood, in spite of the ab-
sence of any syphilitic lesion of the skin or mucous
membrane upon careful clinical examination. In-
travenous injections of neosalvarsan, with mer-
curial treatment, rapidly overcame the morbid
manifestations. This case is emphasized as show-
ing that an acute syphilitic meningitis may appear
at such an interval from the secondary stage as to
be entirely unaccompanied by secondarv disease
phenomena ; that the condition may be subfebrile —
a condition existing six days in this instance ; and
that the cerebrospinal fluid in such a case may be
macroscopically turbid and of the type of an
aseptic puriform meningitis.
ioo8
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Effects of Various Systemic Agents on Super-
ficial Hemorrhage. — Paul J. Hanzlik {Journal of
Pharmacology and Experimental Therapeutics,
September, 1918) studied the result on superficial
hemorrhas^e of various drugs administered to dogs
intravenously, intramuscularly, and subcutaneously.
Epinephrin proved to be the most effective hemo-
static agent ; tyramine was less successful, while
pituitary extract was variable in its action. In one
experiment a falal dose of ergot lessened the
bleeding, while a large dose of digitalis completely
arrested it. The effects of the following agents on
bleeding are roughly parallel to the changes in
blood pressure: coagulen (Cila) ; kephalin
(Howell) ; thromboplastin (Squibb) ; horse serum:
stypticin ; gelatin ; saline ; emetine ; and possibly
pejitone. Nitrite and hydrastis increased the bleed-
ing, while the blood pressure fell. The thrombo-
plastic agents might give different results with
prolonged administration, but the investigation was
interrupted before this could be determined.
Morbid Anatomy of Spanish Influenza. — E.
Rivaz Hunt (Lancet, September 28, 1918') outlines
the symptomatologv of the disease and points out
that it is characteristic in most cases Nevertheless
the disease may readily be confused with a number
of other conditions prevalent among the soldiers at
the front, including malaria, colon bacillus baccil-
luria, malignant endocarditis, trench fever, the en-
teric fevers, and cerebrospinal fever. The differen-
tiation between these is verv greatly helped by a
blood count, trench fever usually showing a moderate
leucocytosis : malaria, endocarditis, scarlet fever and
cerebrospinal fever a marked leucocytosis : the en-
teric group a leucopenia ; and influenza a count be-
tv/een 5,000 and 9,000. In influenza there are
evidences of slight myocarditis and, post mortem,
some degree of myocardial involvement was always
found. Other methods of dift'erential diagnosis
than the blood count must be employed, but the
latter gives a defin'tc clue to the probable diagnosis.
Some cases of influenza begin with occipital head-
ache and pain in the neck and even show a doubt-
ful Kernig's sign. In such cases a lumbar puncture
mav be necessary for definite diagnosis.
Studx of the Leucocytes in an Epidemic of In-
fluenza.— Roy P. Forbes and Helen A. Snyder
(Journal of Laboratory and Clinical Medicine,
September, 1918) report a study of the blood count
made on fifty cases, diagnosed as influenza, at
Camp Hancock. The epidemic there was highly
contagious, but was a comparatively mild infection
of the respiratory tract. In only one instance,
which proved to be the only fatal case in the camp,
was the influenza bacillus recovered. The organism
was found in two blood cultures and in post
mortem cultures taken from the lung and spleen.
The present work is in accord with that of other
observers — that the influenza bacillus is rarely
found, and then only in very severe or fatal cases.
A summary of 202 counts in fifty cases showed the
average of leucocyte counts to be as follows: On
the first day of the disease it was 6,166; on the sec-
ond day, 5,378; on the third day, 7,522: on the
fourth day. 8,157; on the fifth day, 8,059,
the sixth day, 7,885. A complicating bronchopneu-
monia seems to decrease rather than increase the
lymphocytes. The authors state that absence of
hyperleucocytosis or actual leucopenia, and relative
lymphocytosis are characteristic of influenza. They
believe that the leucocyte count is of value in the
early diagnosis of influenza, and as a means of
differentiating it from scarlet fever rash.
Fracture of the Spinal Column with and with-
out Cord Injury. — Norman Sharpe {Journal A. M.
A., October 26, 1918) says that we usually think
of fracture of the spine in terms of cord symptoms,
the bony lesion being itself of minor importance.
This is true in the great majority of cases, but there
is a small number in which there is fracture with-
out cord injury, and in these the diagnosis of frac-
ture is frequently not made. Five such cases are
reported by the author and emphasis is laid upon
the fact that in the process of repair of the over-
looked fracture the callus formed may produce
serious cord symptoms which could have been pre-
vented if the diagnosis had been made and proper
immobilization of the spine practised from the first.
It is therefore very necessary to subject all cases
of suspected injury of the spine to careful clinical
and rontgen ray examination to prevent later ill
effects from unsuspected fracture. It is also con-
ceivable that in such cases a sudden movement by
ihc patient might cause displacement with serious
rind permanent injury of the cord.
Occurrence and Significance of Bacillus Wel-
chii in Certain Wounds. — James L. Stoddard
(Journal A. M. A., October 26, 1918) investigated
a consecutive series cf 137 cases of war wounds,
excluding only trivial and clean bullet wounds.
The wounds ranged between one and eleven days
old when first seen and all had been thorouehly
treated in a casualty clearing station. The Bacillus
welchii was found in twenty-three per cent, by
culture, while smears showed the organisms in only
fourteen per cent, of the cases in any appreciable
numbers. Such figures are much lower than for
wounds seen during rush periods or for wounds in
the period before excision was the common practice.
There was definite muscle infection with gas pro-
duction in only three oer cent, of these cases. There
was onlv a very small difference in the results be-
tween the excised and the vmexcised wounds, show-
ing good judgment (;n the part of the surgeons who
first saw the patients. The organisms tended
definitely to persist in greater numbers until the
eighth day in the gas infected than in the nonin-
fected wounds. In the cases without gas infection
the number of the bacilli became very small early
in the history of the wound. The organism did not
flourish well in the surface exudate, or for long
periods. In wounds of the type considered the
presence of large numbers of the organisms was
good evidence of gas infection, and v/as the stronger
the older the wound ; on the other hand their ab-
sence was not conclusive evidence of lack of infec-
tion. The results of smear examinations were of
more value than those of cultures in determining
the likelihood of the occurrence of gas infection.
The presence of large numbers of Bacillus welchii
in smears was a contraindication to suture of the
wounds, but small numbers were not necessarily so.
December 7, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
lOCK)
Antimeningitis Vaccination; Agglutinins in
the Blood of Chronic Meningococcus Carriers. —
Frederick L. Gates (Journal of Experimental Med-
icine, October, 1918) describes the use of a menin-
gococcus vaccine suspended in salt solution which
was given as a prophylactic to about 3.700 volun-
teers at Camp Funston, Kansas. Preliminary trials
were made on a small group of men to establish
the proper dose, :ind the vaccine was finally given
subcutaneously in three injections of 2,000 million,
4,000 million, and 4,000 or 8,000 million cocci at
weekly intervals. The reactions were usually mild.
The i'wst injection appeared to cause less generol
and local reaction than the tyuhoid prophylactic,
and the second injection caused even less discom-
fort than the first. The question of individual sus-
ceptibility is important, ris a few patients suffered
severely from doses whicli caused no general dis-
comfort in the great majority of the men. In such
cases the symptoms were partly those of meningeal
irritation, and sometimes simulated the onset of
meningitis. A study of the blood serum of vac-
cinated men showed that specific meningococcus
agglutinins were demonstrable, as compared with
the serum of normal controls. An interesting point
is the demonstmtion of agglutinins in the blood
serum of chronic meningococcus carriers. Evi-
dence is thus adduced that the relative immunity
of meningococcus carriers to epidemic meningitis
may be owing to the presence of specific antibodies
in the blood stream.
Epidemic Jaundice. — J. Cantacuzene (Bulletin
de r Academic dc medccine, September 17, 1918)
presents data concerning an epidemic of infectious
jaundice which occurred during the summer of
191 7, in Roumania, and was characterized by mild-
ness and widespread extension of the disease. The
epidemic began in May in small separate foci,
spread throughout the army with great rapidity,
matured in August, and subsided in October. The
civil population did not begin to be affected until
July. At the time of the appearance of the epi-
demic the Roumanian army, vaccinated against
typhoid and paratyphoid infections ten months
before, was beginning to lose its immunity. Sys-
tematic revaccination in September was followed
by cessation of the epidemic. The highly com-
municable nature of the disorder was shown in the
frequent spread of an epidemic, following the ar-
rival of a single case in a previously unaffected
village, factory, or company. The incubation
period proved to be four to seven days. In the
first two months of the epidemic the clinical picture
showed pronounced tmiformity, the onset being
marked by slight fever which subsided in a day or
two, followed by nausea, sometimes vomiting, epi-
gastric discomfort, gallbladder tenderness, jaundice,
pronounced asthenia, pains, especially in the lower
extremities, decolorized stools in half the cases,
slow pulse, and bile pigments and urobilin in tht^
urine. The disease ran its course without fever
in one to two weaks. No complications occurred,
and there was practically no mortality. Later,
there appeared a hardly noticeable, attenuated form
of the affection, as well as cases with fever persist-
ing two to three weeks. In pregnant women the
disease was ahnost always fatal ; the pulse rate was
high, the temperature low, jaundice intense, and
coma followed. Abortion occurred in the later
days of the disease. Autopsy in such cases showed
fatty degeneration of the liver and lesions of the
adrenals. Blood culture revealed, in one third of
all cases of the ordinary form, paratyphoid bacilli —
usually of the B variety, but with atypical charac-
teristics. In patients inoculated against typhoid
and paratyphoid seven or eight months before, the
jaundice caused a marked return of the previously
lost agglutinating power in both the typhoid and
the paratyphoid organisms.
Retrograde Movement of Ureteral Calculi. —
Merman L. Kretschmer (Journal /I. M . A , Octo-
ber 26, 1918) reports two cases of ureteral calculus
in which the calculus was shown to have wandered
upward in the ureter. In one its retrograde move-
ment carried the stone from about one inch above
the ureteral orifice in the bladder to opposite the
fourth lumbar vertebra ; in the other the range of
wandering was between approximately similar
points. Such retrograde movement might readily
lead to error in operating unless the stone was
localized just prior to operation. Such was actually
done in one case and the patient was spared a
wholly fruitless and unnecessary operation. Such
retrograde movement of the stones in the ureter
might be accounted for on the basis of marked
dilatation of the iiimen above the stone, permitting
it to fall about with gravity ; or as resulting from
reversed peristalsis in the ureter. Analysis of the
literature and of the results of animal experiments
showed that both explanations might be accepted,
the latter accounling for retrograde movement in
cases without dilatation of the ureter.
Association of Rickettsia Bodies in Lice with
Trench Fever. — J. A. Arkwright, A. Bacot, and
F. Martin Duncan (British Medical Journal,
September 21, 1918) conclude that a very close
correlation exists between the presence of rickettsia
bodies in lice, or their excreta, and trench fever.
They conducted many carefully controlled experi-
ments which show that large numbers of these
bodies can almost invariably be found in the excreta
or the bodies of lice about ten days after the latter
have fed on a trench fever patient. Daily examina-
tion of lice after an infecting meal shows evidence
of these bodies for the first time on the fifth day,
when they are present in small numbers only. Their
numbers rapidly increase during the next three or
four days. When a box of lice has once become in-
fected with these bodies they continue to be present
for periods of two to three weeks, or until all of the
fed lice are dead. Not all the lice from an in-
fected box show the rickettsia bodies, only a small
proportion doing so in the first week, while the
great majority are infected bv the second and third
weeks. The lice can be infected bv trench fever
patients during the fever, between the attacks, or
even several weeks after an attack. Normal lice,
fed on persons who have never had trench fever, do
not show rickettsia bodies. From these and other
experiments, including inoculation tests on volun-
teers, the presence of rickettsia bodies in lice is
shown to be directly associated with trench fever.
Proceedings of National and Local Societies
PHILADELPHL'V COUNTY MEDICAL
SOCIETY.
Meeting Held Wednesday, March 2y, igi8.
T'iie President, Dr. Frank C. Hammond, in the Chair.
SYMPOSIUM ON NEPHRITIS.
Symptoms and Diagnosis of Nephritis. — Dr.
Davijj Riesman called attention to the fact that
there were two diseases which manifest themselves
in most protean ways — hysteria and uremia.
Uremia was so much more common than true
hysteria that it Vv^as important to know its peculiar
habits. The cause of uremic poisoning had not
yet been established, but it was acknowledged that
it exerted itself largely upon the central nervous
system. Every one who had had hospital experi-
ence in a case of coma knew the difficulty of de-
termining the cause. The comas of the various in-
fections had no very definite earmarks attending
them. In a case seen by him recently it was very
difficult to decide between uremic coma and that
attending acute cerebrospinal meningitis. Alcoholic
coma and the coma of brain injuries were often
difficult to dififerentiate from uremic coma. Per-
haps the most important factor liere was the
catheterization of the patient and the examination
of the urine. Enlargement of the heart and hyper-
tension pointed toward uremia, and the eyeground
changes were important in differential diagnosis.
It was difficult to determine the differential diag-
nosis of uremic hemiplegia and uremic aphasia.
Those men who v/ere trained in the Philadelphia
Hospital would remember how often a case diag-
no.sed as apoplexy showed at autopsy no hemor-
rhage in the brain. The condition of uremic
hemiplegia or of monoplegia was transitory in char-
acter, with a tendency to recover. There was near-
ly always hypertension with cardiovascular changes
of chronic Bright's disease. It was not known
whether, in such cases, one was dealing with a
poisoning of the nerve cells or with some vascular
crises in the brain ; the transitory character of the
picture might be compatible with either. Another
nervous condition was that of uremic headache,
which might be the only symptom of which the pa-
tient complained. It might be so intense that brain
tumor was suspected. There were also severe
neuralgias referable to uremic intoxication. Uremic
narcolepsy also ])resented difficulties in diagnosis.
Such a case had been brought into one of the hos-
pitals in a state of sleep exactly like that from t+ie
effect of drugs. The breathing was natural. The
urine contained no albumin, but always granular
casts. Autopsy showed the kidneys to have been
not much larger than a silver dollar. The only
symptom in this case was the continued narcolepsy
during six days. Doctor Riesman thought that gas-
trointestinal symptoms were often very important.
Uremic dysentery, a.= pointed out by an English
writer, was rare, but did occur at times. It seemed
as though the uremic poisoning acting upon the
colon produced a severe colitis. There might be
constant itching of the skin with no other involve-
ment than that of chronic interstitial nephritis. The
so called hemorrhagic diathesis was another mani-
festation of uremia ; a patient would suddenly bleed
from the mouth and nose and perhaps from the
bowel and would show patches of hemorrhage in
the skin. In all cases of this nature which Doctor
Riesman had seen there had been contracted kid-
ney v/ith high blood pressure and injured heart.
Uremic pericarditis might also be seen. In one such
case the man had shortness of breath with symp-
toms of mediastinal tumor; tapping showed hem-
orrhagic fluid in the pericardium. At autopsy
chronic interstitial nephritis only was shown. The
diagnosis of uremia and of Bright's disease in gen-
eral must be made, not upon one element alone, but
after the consideration of many factors. The
urinary analysis tnight be misleading: he had seen
cases of Bright's disease with no albumin. There
might be greatly contracted kidney with low blood
pressure. A most valuable point was that with the
albuminuria of heart disease the urine was nearly
always highly colored and contained a large amount
of urates. The albumin was generally small in
amount and casts v/ere few ; but, it would often try
the best men's skill to determine whether the case
was one of Bright's disease with cardiac failure or
purely a heart condition.
Functional Tests of the Kidney in Diagnosis
and Prognosis. — Dr. O. H. Perry Pepper said
that although the kidney, of all the organs of the
body, lent itself most readily to a study of its func-
tion by functional tests, such testing was difficult
and was complicated by several factors. Three
difficulties to be remembered in this connection
were the complexity of kidney function, lack of
final knowledge regarding the mechanism of urin-
ary secretion, and the importance of extrarenal
factors. In the tests of renal function not only
must the quantitative appearance of the ingested
substance be measured, but the time relation was
equally important, for even a markedly diseased
kidney would alv/ays eliminate the increased
amount of water, salt, or urea, if given time. It
was hardly necessary to refer to the entire useless-
ness of estimations of urinary urea if unaccom-
panied by exact control of the intake of all protein
food and of the nitrogen loss in the feces. The
extrarenal factors v/ere too many for any reliance
to be placed on the test except under extremely
favorable conditions. The separate tests of the
ability of the kidneys to dispose of known amounts
of water, protein, and salts might be combined and
the patient placed on a diet containing known quan-
tities of these substances and the results observed.
This, however, was usually done in conjunction
with .studies on the blood. The determination of
the freezing point and the estimation of urinary
toxicity were other tests, though not widely em-
ployed. The blood sooner or later showed the re-
sults of any depreciation of renal activity. At-
tempts had been made to express the relationship
«
December 7. ipis.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
lOl I
■of the urinary urea and the blood urea in a formula
which would give the functional efificiency of the
kidney in mathematical terms as an index. None,
however, had proved wholly satisfactory and the
plan was scarcely one for general clinical use.
Another group of tests was based upon the intro-
duction into the body of some substance foreign to
the organism but which was eliminated by the kid-
neys and of which it was possible to determine the
rate and quantity of excretion. Of the various
tests, the three of special usefulness were: i, The
testing of the ability of the kidneys to eliminate
water and to dilute or concentrate the urine ; 2, the
estimation of salt test ; 3, estimation of blood urea
nitrogen ; and 4, the phthalein test. Diagnosis by
functional test might be considered from the fol-
lowing points of view: i, The ability of the kidney
to perform a given function ; 2, an estimate of the
degree of renal impairment by nephritis by one or
more tests ; 3, an estimate of the patient's condition
at the time; 4, conclusions concerning the anatom-
ical lesions in the kidneys. This, however, could
not be successfully done with our present knowl-
edge. The test of provoked polyuria was of chief
value in the recognition of acute nephritis, simple
degenerative nephritis, and of passive congestion
of the kidneys. The test of chloride elimination
cften gave the earliest evidence of impaired renal
function. The phthalein test was the best all
round test of renal function, and there were few
renal diseases in which it did not give a fairly true
estimate of the rena! function. Its especial value
was in chronic glomerulonephritis. These tests
aided in prognosis only as they led to a correct
diagnosis ; a zero phthalein might occur in an acute
nephritis and recovery ensue ; or, it might appear
as a warning of imminent fatal uremia. In prog-
nosis and for the control of treatment, the func-
tional tests must be repeated at intervals to obtain
the best results. The importance of carefully ex-
cluding extrarenal factors and of always interpret-
ing the tests in conjunction with routine study of
the urine, the blood pressure, and of the patient
should not be overlooked.
Treatment of Nephritis. — Dr. William E.
Hughes said thrit the picture of Bright's disease
showed a condition due to retention of poisons,
deterioration of the blood, interference with func-
tion of various organs, and changes in the circula-
tory apparatus. The fact must also be taken into con-
sideration that the crippled condition of the kidney
was aggravated by attempts to secrete even a nor-
mal amount of excrementitious material. Treat-
ment must include the attempt to prevent ingestion
of further poiso'.is, to take as much work oflf the
kidneys as possible, to stimulate faulty function of
other organs, to restore the blood condition, to
minimize the injurious effects of circulation, and
possibly to stimulate the faulty kidney to renewed
activity. The methods of treatment we'-e, there-
fore, indirect rather than direct. The matter of
food was the most important in treatment. Of
foods which were the least injurious milk probably
stood at the head. Sweet milk, buttermilk, whole
milk, or skim milk were, in extreme cases of
Bright's disease, the ideal diet. Meat was the most
injurious form of diet, on account of the high
nitrogen content. The nitrogenous foods appar-
ently were those which poisoned most seriously and
permanently. It was necessary, of course, to have
a certain amount cf nitrogenous intake, except for
a short period of time. Eggs, rather than meat,
might be adopted as the nitrogenous constituent of
the food. It had been Doctor Hughes's practical
experience that a moderate amount of salt in the
diet did no harm. In the use of water we were
likely to go to extremes and, by increasing the
waterv content of the blood, raise the blood pressure
and thus produce a secondary danger to the kidney
function. The effervescent beverages contained a
certain element of danger in their stimulative char-
acter. The state of the digestion was a most serious
factor in Bright's disease and one to which treat-
ment should be directed with the closest attention,
because through the absorption of toxins in the
intestinal tract additional irritation in the kidneys
was brought about. Intestinal antiseptics seemed
to offer rather slight reliance, but of these probably
calomel was the best. Colonic irrigation should also
be considered. Among the poisons that were opera-
tive in the production of Bright's disease or in its
aggravation were those produced by fatigue. In no
other class of disease was the wearing apparel so
important as in Bright's disease. Doctor Hughes
believed that woolen underwear of proper weight,
worn all the year round would serve an exceedingly
useful purpose. In the matter of climate, Cali-
fornia probably offered the best in this country
and next to that. Florida. Undoubtedly patients
with Bright's disease had their lives prolonged by
removal to some such climates as these. We all
seemed to be rather fanatical concerning good air
and plenty of it, and not infrequently, an exacerba-
tion of Bright's disease might be traced to too light
bedclothing and too much fresh air at night. The
skin circulation, of vital importance in cases of
kidney conditions, was favorably influenced by
baths and massage to a moderate degree ; hot air
baths also, in all cases of Bright's disease, were
distinctly beneficial. Anemia as one of the ill
effects of nephritis must always be borne in mind.
The drug of most value in treatment was iron and,
with it, pilocarpine in small doses would be found
beneficial. The later stages of cardiac failure were
treated as in other conditions. The dropsy of
Bright's disease was in no way different from any
ether dropsy; there was the condition of diseased
vessels, poor heart power, and wrongly mixed
blood. Of cardiac stimulants digitalis was the best.
It must be borne in mind that many cases of ap-
parent apoplexy "stroke" were really cases of
uremia, and that vigorous treatment must be di-
rected to the kidneys. As far as possible the kid-
neys should be relieved of work and the intestinal
tract cleaned out to prevent further absorption of
poisons. Where there was much hypertension and
the patient was fairly well nourished and not par-
ticularly anemic, he should be bled and bled fre-
quently.
Dr. M. Howard Fussell suggested that the name
Bright's disease should be eliminated, for the reason
that it was applied in many cases of nephritis, and
IOI2
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New 'York
Medical Journal.
tliat, to the mind of the layman, it carried tlie idea
of an absohitely fatal condition. There was no
doubt that many cases of nephritis, if not curable,
did not result fatally in short time. It was there-
fore better, as Doctor Pepper had said, to use the
term nephritis. While in the vas.t majority of the
arteriosclerotic types, uremia, according to Doctor
Ricsman, could be easily recognized by the cardio-
vascular changes, in acute nephritis these changes
v.'cre not present. Hemiplegia sometimes lasted
until death. Docror Fussell remembered a case, in
the Episcopal Hospital, of a woman with a typical
interstitial nephritis, who did not seem very ill but
developed a left sided hemiplegia and died appar-
ently of apoplexy, but at autopsy there was no sign
of thrombus — nothing but the sclerotic arteries.
Doctor Riesman had said that it did not make much
difference whether the arteriosclerotic condition was
recognized as the basis of certain cases of nephritis,
so far as treatment was concerned, but Doctor Fus-
sell had, that very afternoon, seen, in the University
Hospital, a colored man who, it seemed, presented
an excellent example of the condition due to a gen-
eral arteriosclerosis. The man, fifty-five years of
age, had suiTered for some time with dyspnea and
recurring attacks of edema of the legs. His arteries
were like pipe stems ; he had polyuria, with low
phthalein output. From the results of treatment by
rest and elimination, in all probability the case was
one of general arteriosclerosis ; it was not Bright's
disease. It seemed a great mistake, from the stand-
point of treatment, to consider such a case one of
nephritis. Such a patient, given rest and placed in
an old man's home, would live a number of years.
It was true that albuminuria does not mean ne-
phritis ; it was also true, unfortunately, that a great
many physicians believed that albumin. in the urine
meant nephritis. Notwithstanding our disappoint-
ments in the results of the removal of teeth and
tonsils for the elimination of foci of poisons pro-
ducing the nephritis the search for these foci should
' be continued and knowledge concerning the proper
method of dealing with diseased teeth must be in-
creased. In some nephritics, meat, however slight
in amount, seemed to act as an actual poison. In
treatment each case should be a law unto itself. In
acute nephritis diuretics were absolutely harmful.
There should be absolute rest and in cases of heart
failure digitalis ought to be used.
Dr. William Duffield Robinson emphasized the
necessity of study, by every method of research, to
determine the cause of nephritis. In treatment
much could be accomplished by a proper dietary,
and he advocated one day of starvation a week.
The usual quantities of fluid should be given but the
tax of elimination was reduced with the lessened
food intake. Regarding drugs, he stronglv advised
the use, in nephritis, of pilocarpine, which would
result in the greater elimination of solids and the
increase of the specific gravity. The essential point
in the consideration of nephritis was to seek X\v,
cause of the abnormal content in the blood.
Dr. Moses Beiirend said that any disrepute into
which the operative treatment of nephritis may have
fallen was probably due to the fact that most cases
were brought to the surgeon too late and that the
cases were not properly selected. Cases of chronic
interstitial nephritis did very badly as did those of
interstitial nephritis in the aged on account of the
arterial changes and the changes in the kidneys
themselves. The most favorable cases for operation
were those of acute parenchymatous nephritis.
The best results had been obtained by Edebohls and
Lloyd; the former had operated on about no pa-
tients, and the latter twenty-five or thirty. They
pave a mortality or ten per cent, and claimed a cure
in thirty-three per cent, of their cases with improve-
ment in forty-three per cent. ; this was an extremely
good record. Doctor Behrend's own experience was
not at all satisfactory. He had operated on six
patients, three of whom were of the chronic par-
enchymatous type. The last case was that of a
child of six years ; death followed in from twenty-
four to thirty-six hours. It was an extreme case,
and operation was the last resort. He had operated
for bichloride poisoning, stripping the kidneys, but
the patient died, a? these patients usually do in
severe bichloride poisoning. In operation for
eclampsia the best results had occurred after
labor. Before the puerperium the results were
rather fatal. Litchfield's mortality was 1.73 per
cent, in fifty-three cases. Many writers, especially
Lloyd, have said that a fibrous capsule redeveloped
after decapsulation of the kidney and that this
fibrous capsule was just as bad as the original
capsule ; this was denied by another writer. Op-
Dortunity for reoperating on these cases was natur-
ally not very good. E. H. Goodman had noticed a
rapid fall of blood pressure after decapsulation and
this might be of some importance in this operation.
AMERICAN ACADEMY OF POLITICAL AND
SOCIAL SCIENCE.
Meeting Held at Philadelphia, September 20 and
21, ipi8.
Dr. WiLMER Krusen, Director, Department of Public
Health and Charities, Philadelphia, in the Chair.
THE rehabilitation OF THE WOUNDED.
Nature and Scope of the Problem. — Dr. W. W.
Keen, of Philadelphia, said that the fundamental
difference between the surgical conditions during
the Civil War and the present world war was our
ignorance, in 1861, and the enormous increase in
our knowledge since that date. In chemistry and
in physics the chief advances in fifty years had been
made by experimental research. In biology and its
subdivisions of medicine the same was true. The
almost virgin fields of battle during the Civil War
held few bacteria ; hence, while tetanus was not
common, it was deadly, killing nine of every ten
victims. In the early days of the present world
war it exacted a fearful toll of lives, exact figures
of which could be given only after the war was
over. As soon as a sufficient supply of the tetanus
antitoxin for the huge numbers of the wounded was
obtained the ravages of tetanus were checked, and
as a result few died from lockjaw in the later stages
of the war. Every hour of delay, however, in giv-
ing the protective serum meant a life lost. In the
Civil War compound fractures killed two out of
December 7. i9'8.J PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
every three; amputations averaged over fifty per
cent, mortality. Only twenty-five per cent, of the
cases of compound fractures were now fatal com-
pared with sixty-six per cent, in the Civil War.
Our victory over infection was the reason for the
greatly diminished number of amputations done
during this war. Moreover, the mortality from
amputations during this war was low — in some
series every patient recovered. The present war was
waged on densely infected soil, the wounds were
caused by high explosives, and there developed an
unprecedented riot of infection utterly unknown
prior to 1914. If the wounded could be brought to
the surgeon in the few golden hours, two out of
three could be saved. Out of 400 cases in Carrel's
hospital in which primary healing could not be se-
cured because of delay in reaching surgical aid,
only six were failures. This was due to the re-
searches of Dakin and the work of Carrel. While
engineering and chemistry had done much to de-
velop modern sanitation, bacteriology had been the
most important factor in this movement. In 1861
we were wholly ignorant of the fact that the mos-
quito alone spread yellow fever and malaria ; of
the role of the fly in typhoid fever ; of that of
the flea and rat in bubonic plague, and of the fact
that the louse was responsible for the deadly typhus
and the wholly new disease, trench fever. Typhoid
has been banished from our army. The following
are Surgeon General Gorgas's figures : "In the en-
tire army, numbering over 1,500,000 men at the end
of December, 1917, there had been, during the year,
242 admissions of typhoid fever patients to hos-
pitals, with eighteen deaths. During the corre-
sponding period in 1861 when the Northern Army
was being mobilized, there were about 9,500 cases
of typhoid fever, with less than one quarter of the
strength of the present army, with about 1,800
deaths." In the British Army ninety-nine per cent,
of the soldiers were vaccinated voluntarily. Dur-
ing the past year there had been but one death as-
cribed to antityphoid vaccination in our more than
1.500,000 men. This would seem to be an over-
whelming testimony to the value of the method and
to the fact that making it compulsory was essential
to our winning the war. "The road to the heart is
only a little over an inch in a direct line," said Pro-
fessor F. S. Lee, "but it has taken surgery nearly
2,400 years to travel it." The heart was first laid
bare and sewed up for a stab wound twenty-one
years ago (1897). The operation has now been
done hundreds of times and has saved the lives of
about half of those operated upon. In the present
war missiles have been removed from the interior
of the heart and even from the large bloodvessels.
A striking instance of the value of experimental re-
search compared with observational and clinical re-
search was given in our present knowledge concern-
ing the treatment of syphilis. Since 1903 we have
learned more and accomplished more for the hu-
man race than in the preceding four centuries of
intense clinical study. Ehrlich's discovery of a
cure for syphilis was one of the most beneficent
ever made. Research will never cease to give us
better and better methods of coping with disease
and death so long as they afflict the human race.
Reclamation of the Maimed in the Industries.
Lieutenant Colonel Harry E. Mock, M. C, U. S.
A., in presenting his views on this subject, said that
in warfare a number were bound to become dis-
abled, but very few need remain so. A handicap
was bound to put more fight in a man and often
resulted in his making good. To be disabled was only
a temporary state, to be crippled, a permanent one.
A man living in Kansas City confined to bed for
four years by paralysis had become the owner and
supennlcndent of a large publishing house. Asked
to tell iiow he accomplished such a result he said,
"I am not an invalid; I am a business man." His
advice was to keep the mind alert an'i active.
The medical department of the army began at the
earliest moment to plan for the reclamation of the
soldiers, and it was desired to make closer the co-
operation between the medical department and the
general public in the reconstruction and rehabilita-
tion of the soldiers and sailors. During the past
decade a new specialty had been developed in indus-
trial medicine and surgery. In order to prevent
waste, deformity, and inefficiency many industries
had developed a staff of physicians for men in the
first line trenches of the industrial army, and one
tenth of the workers of the nation were receiving
the benefits of this work. Too often men injured
in the industries were given positions without con-
sideration of theii fitness ; if trained they could fill
a gainful position. The most unfortunate among
the injured and disabled in the industries were those
not employed by the firm for which they worked.
They must be not only cured, but trained for and
given suitable positions affording them equal in-
come to that received before their disability.
Rehabilitation of the Wounded. — James Phin-
NF.Y MuxRCE, vice-chairman, Federal Board for Vo-
cational Education, said that we were in the midst
of the greatest v/aste and the greatest saving in all
history. It was not extravagant to believe that the
colossal outpourings of wealth which the orgy of
war had forced would possibly be redeemed in one
generation by the spirit of saving which, with many
other hard and salutary lessons, war had taught.
The work of the Federal Government in the re-
habilitation of the soldier had its essential comple-
ment in the Vocational Rehabilitation Act passed by
Congress in June of this year. This act placed upon
a federal board the responsibility for the retraining
and placement of injured soldiers and sailors. Under
the Vocational Rehabilitation Act, the Federal
Board for Vocational Education made up, ex offi-
ciis, of the secretaries of agriculture, commerce, and
labor, and the commissioner of education, and of
three other mem.bers appointed by the President,
was charged with responsibility for the placing back
in economic life ?nd, if need be, for'the training, of
every soldier and sailor so far disabled in military
service as to have become a beneficiary under the
War Risk Insurance Law. So long as that soldier
or sailor needed daily hospital care or so long as he
was adjudged fit to return to full or limited mili-
tary service, he was the sole ward, of course, of the
medical military authorities ; but from the moment
he was discharged from military service, either be-
cause his disabilities were such as to preclude fur-
I0I4
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
ther army service, or because he was relieved from
such duty by the coming of peace, he became auto-
matically a ward of the Federal Board for Voca-
tional Education. v.nA as such ward, had established
rights which he alone and by his own free choice
could surrender. Having elected to receive train-
ing, the board, together with the War Risk Insur-
ance Bureau, assumed not only his support and that
of his dependents, should he have any, during the
process of training, but undertook to follow him up
after placement, and to give him reasonable oppor-
tunity for further training should the first venture
prove not to be suited to his capacities. The jobs
which these men undertook would be theirs because
they were fitted to take them. In this placement
the board had the specific right under this law to
ask the cooperation of the Department of Labor ; it
had the general right, in consideration of the debt
which we owed to these disabled men, to seek the
cooperation of every employer in every line of ac-
tivity. The Government would fulfill its sacred ob-
ligation to make these men as efficient as possible
physically, also vocationally, in the widest possible
field of effective economic service.
Role of the American Red Cross in the Na-
tional Program for the Rehabilitation of the
Wounded. —Curtis B. Lakeman, assistant to the
director general of Civilian Rehef, American Red
Cross, said that in this, as in all its work, the Red
Cross would subordinate itself to government lead-
ership and bend all its enthusiasm and resources to
the promotion of the official plans and to tlie filling
of such supplemental needs as might arise. The Red
Cross had assumed obligation of military service
reaching to every soldier and sailor and to his de-
pendents whenever they indicated a need that the
Red Cross could fill. This service continued
through that indeterminate but critical interval
in which the man awaited the application of the
government's plan to his individual needs. Such
endeavor naturally fell to the Department of Civ-
ilian Relief of the Red Cross as a phase of Home
Service work and organization. The Red Cross had
already in operation a special piece of war service
machinery peculiarly adapted to assist in the after-
care of the disabled soldier. Under the Department
of Military Relief of the Red Cross there had been
conducted also the pioneering research and educa-
tional work of the Red Cross Institute for Crippled
and Disabled Men in New York, and the more re-
cently established Red Cross Institute for the Blind
supplementing the work of the Army Hospital at
Baltimore.
Reconstruction and Rehabilitation of the Re-
turning Soldier. — Frederic C. Howe, commis-
sioner of immigration at the port of New York,
stated that the i)roblcm of reconstruction and the
redistribution of millions of men and women in
immediate profitable employment at the termination
of the war was as colossal a problem as the mobili-
zation of the army. The United States Employ-
ment Service was a proper agency for carrying
through the work of demobihzation. All of the
warring countries were emphasizing the necessity
of returning the soldier to the land, and in England.
Australia, and Canada the farm colony was being
developed. Experts had submitted the statement
that the soldier would not take up an unbroken
piece of land isolated from his fellows. Official
commissions in England and Australia were devel-
oping plans by which the state would sell to the
returning soldiers ready made farms of from three
to thirty acres which one man could cultivate.
Farms were grouped as a community with educa-
tional, recreational, and cooperative agencies for
marketing and buying. Farms with a house and
barn were sold to men, and they were provided
with sufficient capital on easy terms, the state ad-
vancing nine tenths of the capital to be repaid on
long term installments. The experience of Au-
stralia and of Denmark demonstrated the success
of this plan. In the United States such colonies
should be located in New England, the southern,
central, and western states, each adjusted to a
special kind of farming. Tractors and farm
machinery should be owned in common. Such a
program involved no permanent burden to the
nation. Such a comprehensive agricultural pro-
gram was demanded by the drift of population to
the cities, the growth of tenancy, and the exhaustion
of the soil.
Training of the Blind in the Rehabilitation of
Soldiers and Sailors. — Lieutenant Colonel James
Bordley, expresssd the opinion that in no phase of
reconstruction were there more difficulties to over-
come than in connection with the blind. The public
had made up its mind that the blind were indus-
trially useless, forgetting the long list of dis-
tinguished blind men, statesmen, musicians, poets,
warriors, merchants, and inventors. A blind man
could perform any operation except where judgment
must be based on sight. To concretely translate this
definition the Surgeon General of the Army work-
ing in conjunction with the Surgeon General of the
Navy had established, on a beautiful estate, in Balti-
more, tendered the Government for that purpose by
Mrs. T. Harrison Garrett, a hospital training school
for the blind sailors, soldiers, and marines, and
Congress had endowed the Federal Board for Vo-
cational Education with money and power to supple-
ment whatever was necessary for training and to
provide the opportunity for employment. The
American Red Cross had caused to be organized the
Red Cross Institute for the Blind to supply such
economic and social supervision as might be found
necessary after the discharge of the blind by the
various governmental departments. Vocationally
the courses were classified as professional, agricul-
tural, commercial, industrial, housework and blind
shop work. Only through individual study of the
men could any plans be formulated and any de-
cisions made in regard to placing them in proper
classes. It was hoped to hold to the lowest possible
proportion the home and blind shop worker. A
talented and experienced industrial engineer was
making an analytic industrial survey to determine
the occupations suited to the blind. The significance
of the work was reflected in the hearty cooperation
of every industry studied. If the blind man failed
to make good the employer would be relieved of all
embarrassment by removing the blind man and re-
educating him for another trade.
December 7, 19:8.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
IOI5
Opportunities for Emplo5rnient. — Gertrude R.
Stein, employment secretary, Red Cross Institute
for Crippled and Disabled Men, New York, said
that in initiating an employment bureau for the
handicapped it was of advantage to have the
bureau a small one. No organization of this
kind was truly valuable unless it was flexible.
She felt that employment work did not mean the
mere securing of positions, but the securing of the
chance to make a livelihood at congenial work with
the opportunity to make use of the best powers of
the man. In New Vork was an effective clearing
house which was invaluable in widening the oppor-
tunities open to cri]jpled men. A placement bureau
for the handicapped must be more efficient than the
average bureau or it would not hve ; it must have
a file of satisfied employers who could be called
upon when the applicant seemed suited for his
particular job. An industrial survey of the oppor-
tunities for cripples in the city must be carried on
m conjunction with the employment work. The
whole system of placement was valueless unless it
was properly followed up.
T. B. Kinder, vocational secretary, Invalided
Soldiers' Commission of Canada, on duty with the
Vocational Educational Rehabilitation Division of
Washington, said that the United States went fur-
ther than any other country in the care of its fight-
ing men in that it provided that any man entitled to
compensation as a result of his injuries would be pro-
vided after his discharge from service with a course
of training at the expense of the Government. In
Canada every case is studied individually in the
light of every factor with a possible bearing. This
plan had been adopted also by the Federal Board
at Washington in dealing with American soldiers.
One of the most important factors in this connec-
tion was the man's educational history ; his indus-
trial history was also of great importance. The
disabled man must have the will to succeed with his
reeducation and successful placement. The man
elected his course, but he must be assisted to select
wisely and in the light of all the information with
which his vocational advisers could provide him. A
careful medical examination was made to determine
the man's abilities, and medical and technical ex-
perts were consulted. In Canada 1,347 men had
completed courses of reeducation for new occupa-
tions; 1,868 were at present taking courses. Over
2,000 men were taking courses during convales-
cence ; many of the men receiving active treatment
in bed were being trained vocationally. The large
majority of men completing courses were in posi-
tions as good as were held before their service and
many were vastly better off. They were selfsup-
porting, capable members of the community fulfill-
ing their duties in peace as they did in war. This
was one of the big things we were learning from
the war, the lesson from which would be carried
over into the industrial life. Congress was con-
sidering a bill to provide for vocational rehabilita-
tion for the injured in the industries and their re-
turn to employment. Of the men returned to
Canada unfit for further military service only about
ten per cent, required reeducation for other occupa-
tions. An interesting fact also was that up to June
1st last, out of nearly 30,000 disabled men returned
to Canada, less than 1,500 had suffered a major
amputation. The commission had proved the value
of occupation for mind and body of the men. It
was disciplinary for the disabled man in that it pre-
vented the moral and social deterioration always the
result of prolonged idleness in an institution.
Lew R. Palmer, acting commissioner of the State
Department of Labor and Industry, called attention
to the fact that 50,000 jobs were open and wait-
ing in Pennsylvania for disabled soldiers return-
ing from France. Industrial accidents in that state,
in the two and a half years ending July ist, had
crippled more men than were crippled in the Cana-
dian army in four years of war. Pennsylvania was
the first state in the Union to take steps toward
providing employment for the blind and the crippled
after the war. Seven months before Congress
adopted the rehabilitation act Pennsylvania, through
the Department of Labor and Industry, submitted
questionnaires to 900 industrial plants to ascertain in
what capacity each plant could employ the disabled
war veterans. Forty-seven thousand of the 50,000
jobs awaiting the crippled heroes were in industrial
work ; 900 were clerical ; sixteen were in agricul-
tural lines, and 1.200 were miscellaneous. The
number of amputations due to industrial accidents
in this state were 3,798 in two and a half years,
while in the four years of war Canada's army had
only 1,200 amputations. As the result of industrial
accidents in Pennsylvania 1,157 eyes were lost, while
up to last spring only thirty-four Canadian soldiers
had been blinded.
Employment of Disabled Service Men. — Fred-
eric W. Keough, of the National Association of
Manufacturers, said that in putting disabled men
back into industry there was no room for the spec-
tacular. Our soldiers would go the limit in their
military life, and we would go the limit in appre-
ciation and care of the injured. Bringing the
physically unfit and disabled men to an irreducible
minimum was a national obligation. If disabilities
made it inadvisable for a man to follow his former
occupation he should be fitted for a new occupation
by appropriate training. The greatest number of
openings were undoubtedly in the clerical fields. In
France blind soldiers had been trained to take dic-
tation on a special machine and to transcribe their
notes rapidly and accurately. Among the indus-
tries open to disabled men were the plate glass, ma-
chinery building, boiler making and printing. In
the underwear industry many firms had offered to
take disabled men, one firm even oft'ering to employ
them up to one sixth of the operating force. For
men who had suffered the loss of their arms the
chemical industry was particularly inviting. The
large number of processes which required little
manual labor but careful watching made it possible
to employ men lacking both arms. Many and
varied industrial opportunities had been offered,
proving that no industry was entirely closed to
these workers. It had been the experience of firms
already employing disabled men that the latter were
so keenly appreciative of the opportunity offered
that their spirit of willingness more than compen-
sated for their disabihty.
ioi6
BOOK REVIEWS.— BIRTHS, MARRIAGES. AND DEATHS.
[New York
Medical Journal.
Book Reviews.
[We publish full lists of hooks received, but we acknowl-
edge no obligation to reviciv them all. Nevertheless, so
far as space permits, 7Ve rerneiv those in zvhich we think
our readers are likely tu he it'.lcrested.]
lutcrnatioual Medical Animal. A Year Book of Treat-
ment and Practitioners' Index. Contributions bv
Twenty-seven Doctors. New York: William Wood &
Co., 1918. Pp. xxiii-666. (Price, $4.)
This sort of thing, a distillation of the year's
work by a group of practical authorities, has an im-
portant place in medical literature, and bridges the
gap between current periodical material, some of ii
quite ephemeral, and permanent scientific contribu-
tions. This particular annual, now in its thirty-
sixth year, is an excellent one. "The great war,"
the first three words of the editor's introduction,
runs through this number, even as it has over-
shadowed all human activity. War experience is
fully reported, but no undue insistence upon it is
noted. Judicious selection and careful editing have
produced a well balanced and interesting volume,
and it would seem to be of value alike to the man
of medicomilitary interests and to the man who is
looking for the application of the war's lessons to
civil practice. Part I is entitled The Dictionarv of
Materia Medica and Therapeutics ; Part II, The
Dictionary of Treatment ; and Part III, Miscellane-
ous. Including ^ledicolegal and Forensic Medicine
and State Medicine. As the old friends of the
International Medical Annual may know, the ma-
terial is arranged alphabetically according to topic,
with careful cross references. This system is fur-
ther supplemented and the material made the more
easily available by a good general index which em-
phasizes the more important articles. Signed arti-
cles give a brief, concise review of important work
and the pith of significant contributions with com-
ment and the conclusion of the author. la the case
of work which has attracted attention and presented
new concepts, but whose conclusions are not ap-
proved, the editor or contributor quotes to condemn,
but the case is fairly put and the reader has the
reference to verify or reverse judgment. The in-
clusion of such material is. we take it, as important
as the approved work. After careful reading, it can
be said in general, that this International Medical
Annual can be depended upon to present the sig-
nificant work of the year. The references appended
to each item constitute a good bibliography for one
who must have the literature sifted.
The Doctor's Part. What Happens to the Wounded in
the War. By James Robb Church, .^.M.. M.D., Col-
onel, Medical Corps. U. S. Army. With Foreword by
Major General William C. Gorgas, Surgeon General.
U. S. Army. Illustrated. New York and London: D.
Appleton & Co., 1918. Pp. 284. (Price, $1.50.)
Colonel James Robb Church had the good fortune
to be sent to France as a military observer in No-
vember, 191 5. He remained there until America
had passed from the category of friendly neutrals
to that of active allies. In this book he tells in
simple, nontechnical terms, just what happens to
the sick and the wounded in the war. He first de-
scribes the organization of the sanitary service in
the French Army, an omission no doubt due to the
fact that in the French Army the medical supply
service is in the hands of pharmacists, not physi-
cians. He describes the hospitals of the interior,
the medical work in the zone of the armies, the
transportation, and the work of the surgeon in the
front lines. He does this in a most interesting and
human manner, making altogether a very readable
and informing book.
S'ruvi'lle methode dc vaccination antxtyphoidiquc le L'ipo-
Vaccin T. A. B. Par E. Le Moignic, medecin de ire
classe de la Marine, et A. Sezary, ancien chef de clin-
ique a la Faculte de Medecine de Paris. Paris : Li-
brairie J. B. Bailliere et Fils, 1918. Pp. 75. (Price, two
francs.)
The new method of antityphoid vaccination which
is described in this monograph is being tried in our
own medical service and so far with satisfactory
results. The essential feature is that the mixed
bacteria of typhoid and of the two forms A and B
of paratyphoid fever are killed, the water drawn
oflF by sedimentation, centrufigation, and aspiration
under reduced pressure. The residual mass of bac-
teria is then taken up by an oleaginous medium.
This oily emulsion of bacteria is then adjusted so
that one injection suffices to immtmize the patient.
The reaction is no greater in this more concen-
trated dose than it is in the divided dose which has
heretofore been used. The method certainly offers
great advantages in the celerity with which im-
munization is conferred, but sufficient clinical data
have not yet been accumulated to warrant an un-
qualifie-d endorsement of the mixed lipovaccine.
^
Births, Marriages, and Deaths.
Died.
BissELi.. — In New York, on Monday, December 2d, Dr.
Joseph B. Bissell, Major, Medical "Corps, U. S. Army,
aged fifty-nine years.
Bull. — In France, on Friday, November 15th, Dr. Will-
iam S. Bull, of Cranbury, N. J., aged thirty-two years.
HoRTON. — In Providence, R. I., on Friday, November
22d, Dr. William D. Horton, aged fifty-one years.
HuxTER. — In New York, on Wednesday, November 27th,
Dr. Linnaeus Jones Hunter, aged fifty-five years.
L.'^\"ERTy. — In Middletown, Pa., on Friday, November
22d, Dr. Dewitt C. Laverty, aged sixty-two years.
Mead. — At La Catelet, France, on Thursday, October
30th, Captain Theodore Douglas Mead. Medical Corps,
U. S. Army, of New York, aged thirty-three years.
Peck. — In Caldwell, N. J., on Friday, November 22d,
Dr. Edward D. Peck, aged sixty-four years.
Ross. — In Brooklyn, N. Y., on Friday, November 29th,
Dr. Henry William Ross, aged sixty-nine years.
Rowan. — In Brooklyn, N. Y., on Wednesday, November
27th, Dr. John P. Rowan, aged forty-one years.
RuBiNO. — In Paterson, N. J., on Thursday, November
2ist, Dr. Antonio Rubino.
ScHLAPPi. — In Fulton, N. Y., on Thursday, November
2ist, Dr. Herman W. Schlappi, aged forty years.
Wasson. — In Waterbury, Vt., on Sundaj^ November
24th, Dr. Watson L. Wasson, aged forty-four years. '
WiNKELMAN. — In Brooklyn, N. Y., on Sunday, Novem-
ber 24th, Dr. John G. Winkelman, aged sixty-two years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
.4 TIvt'iA' Rez/e-j.- of Medici?ie, Established 1843.
Vol. CVIII No
NEW YORK, SATURDAY, DECE.MBER 14, 191:
Whole
2089.
Original Communications
MILITARY TRAINING AS A FACTOR IN
PUBLIC HEALTH.
By Ch.\rles O. Lixder. M. D.,
Spokane, W ash.,
Member of Health and Sanitation Committee, Spokane Chamber of
Commerce.
I.
The statement has been made that an average of
eighty-one per cent, of the men in the draft have
been found to be physically defective. The record
for the five years before the war shows that the re-
jected applications for enlistments averaged eight}--
one per cent, plus, which was higher than those in
the draft. Most of these defects could and prob-
ably would have been corrected in early infancy
had they been discovered.
It is universally conceded that physical education
and training, especially as a preventive against
the high percentage of defectives, should begin in
early school days. Attention should be given to
habits, hygiene, teeth, ears, eyes, nose, throat, feet,
etc. Modem school boards are doing much to
correct many defects pertaining to the throats anl
eyes of school children, but in earher days such mat-
ters were considered absolutely no business of the
school authorities.
Eight)--one per cent, defectives does not mean
that this percentage had been rejected under the
present draft system. Relaxed war standards have
caused to be accepted many who have minor defects.
There are on record examinations bv the Life
Extension Institute of large groups of supposedly
healthy persons, busy at their work, of which prac-
tically all show some form of impairment, more
than fift)- per cent, being in need of medical atten-
tion. These findings led to the forecast, before the
draft examinations took place, that among the popu-
lation of militan,- age (from nineteen to forty-five)
at least fift>- per cent, would be found unfit for mili-
tary ser\-ice even under relaxed war conditions,
which are, as stated before, less rigid than those
for maintenance of a small and select peace armv.
Figures collected from local boards of diflFerent
types may be accepted as fairly representing the
conditions in the age group covered by the present
draft. The total number of men called in Detroit,
New York, and Brookhn was 8,875 • the total num-
ber examined 7,611; the total number rejected
2.232, giving a rejection rate, for physical reasons,
of twent}'-nine per cent. The rejections at the can-
tonments of those passed by the local boards have
varied from two to eleven per cent. Therefore, it
is safe to say that the total rejection rate, for physi-
cal reasons, lies between thirty and forty per cent.,
and this in the group of most favorable ages —
twent}--one to thirty-one years.
Of the defects in registrants above referred to
and which caused rejection, defective eyesight was
at the top of the list with 462 cases : defective teeth
came next, with 366 cases ; underweight, 350 cases ;
hernia, 223 cases ; heart, eight}--four cases ; feet,
eight}- ; and so on down the list. It may be said that
some of these defects are purely structural and iii
a sense, anatomical, and do not reflect substandard
general health ; but when we find such a hea^y per-
centage of eye defects, for example, to a degree that
disqualifies for military' service, then we are justi-
fied in regarding such a degenerative tendenc}' as
reflecting some fault in the care of the body or in
nutrition, or in the use of the eyes, and as showing
the failure of securing proper correction of refrac-
tive errors. As to the teeth, there can be no doubt.
Mouth infection is a menace to health, and missing
teeth indicate probable past impairment. Bad mouth
infection is liable to develop into actual organic
disease. Mutilation is a physical defect, not neces-
sarily indicatmg ill health. Most other impairment
causes for rejection evidence ill health. Flatfoot
and deformities are mostly reflections of muscular
iir-pairment or fault}- footgear and improper posture.
Let us remember that sixt\- per cent, of this sub-
standard condition is preventable : that thirty per
cent, is due to poor general physical conditions re-
medial by proper nutrition and physical training and
hygiene : that thirty per cent, is due to defective
eyes and bad mo-ath conditions ; and that ten per
cent, is due to neglected surgen,-.
The digest of ttie Provost Marshal General's re-
port early this year gives the rejection rate, for
physical reasons, as 29.11 per cent, of all those ex-
amined in all local boards. In addition toJ:his it
must be remembered that an average of 5.8 per cent,
will be further rejected before the troops are in-
ducted into active ser\-ice. These figures are com-
piled as a result of the examination of men of the
most favorable age group, from twent}'-one to
thirt\--one years.
The Provost Marshal General's ref>ort is as fol-
lows :
Total number called 3,082.996
Men examined by local boards 2.510,706
Coprright, 1918, by A. R. Elliott Publish ing Company
ioi8
FARNELL: PSYCHANALVSIS.
[New York
Medical Journal.
Number of men rejected by local boards for
physical reasons 730,756
Percentage rejected of those examined. .29.11%
Add 5.8% as further rejection (estimated
at cantonments) -. . 5.8%
34.91%
The intense interest in the findings of the draft
examinations can be utiHzed to arouse the people
to their need of physical development. There can
be no doubt, with the figures facing us, of the need
of child hygiene, of the tremendous importance of
universal physical training and of standardized peri-
odical jjhysical examination. Entirely apart from
the actual reclamation of registrants, an immense
stinmlus can be given to the popular movement for
physical reform and for higher ideals of health
and hygiene.
Under proper military training where discipline
is supreme, proper habits of cleanliness are formed.
Training in accuracy and in precision of thought
and action, regular hours and regular meals, regular
nine o'clock retiring and early rising, learning to
obey and to devote spare time to selfimproveinent
in various ways, will have its efifect upon the men
thus trained and enable them to carry on their vo-
cations more efficiently when this war is over.
By proper modern military training the soldier
boy, instead of being a weakling, becomes a strong
and healthy man. Every day drilling develops the
muscles, builds up and strengthens the body. He
learns to do his duties during each and every day.
The instruction in health habits will have a lasting
efifect and make him as nearly as possible immune
to sickness.
The result of military training, discipline, and in-
struction in health habits are clearly shown in a
report from one of the training camps in the Middle
West which did not have one death among its 50,000
men for one week — in August of this year — a very
different and gratifying record from that which
terrified the American people during the Spanish
American War twenty years ago, when the death
rate at concentration camps was twenty-five out of
every thousand soldiers. Even at the time of Amer-
ica's entrance into the present conflict the death
rj.tc at the concentration camps was rather on the
increase, but marked improvement in health condi-
tions have taken place within the last few months.
The nation has found a scientific, dependable way
to gather its young manhood in concentration camps,
cure their minor aliments, build up their physical
strength and constitutional vigor, discipline and
train them for better service in civilian pursuits, and
in various other ways make them efificient, patriotic,
and intelligent citizens. We have done this fine
work under the whip and spur of a terrific war, but
the benefits thus conferred upon the country's youth
are no less valuable in time of peace than in stress
of war. The lessons which have been taught to boys
to avoid preventable diseases and their being brought
to a state of physical wellbeing as a result of military
training, will result in lasting benefit to the com-
munity, whether the boys are in or out of the army.
When the public has been convinced of what
modern military training can accomplish with our
youth, the question of universal physical training
will have taken a long step forward.
PSYCHANALYSIS.
By Frederic J. Farnell, M. D.,
Providence, R. I.
It has been said recently of one of our American
heroes who died in battle while still a youth, that,
"he was entirely at ease within his own moral
code." Nothing can be more pregnant with sug-
gestion to the new psychologist, if only he is a
morahst as well, than this statement, which arrests
one's attention and compels one to think just what
it may mean. The physician who works through
psychology, if it is his wish to reach a cure for his
patient, must, first and foremost, make that patient
"entirely at ease within his own moral code." Never
was the conflict depicted in the New Testament of
serving both God and Mammon, or, the larger, more
comprehensive conflict between the flesh and the
spirit so well understood, as now — ^the conflict so
often unrecognized by the person who is engaged
in it, and having, not only moral results, as em-
phasized by all religions, but oftentimes far reach-
ing physical results baffling the skill of the most
clever and conscientious physicians, and only just
beginning to be understood by specialists in the
study of mental conflicts.
The object which the psychiatrist sets before him-
self is the discovery of the conflicting personalities
of the patient, and then the adjustment of these
personalities to each other, whether these personali-
ties are conscious, or, as is more often the case, one
is conscious and the other subconscious — assuming
that there are but two in conflict. .Fortunately, the
majority of neuroses, even of psychoses, if a recov-
ery is reached at all, as in many instances, are cured
spontaneously, without the interference of physician
or friend who directly and purposely influences the
thinking life; one set of ideas eventually adjusts
itself to the conflicting set of ideas. The person
whose world is so different from ours is usually
adjusted gradually, sometimes suddenly, not always
to life as it is, but to life as he feels it to be, and
the conflict paving closed, the adjustment having
taken place, the ills both of mind and body disap-
pear.
It is not, however, a problem of this class on
which the psychiatrist must needs ponder, but on
what he personally must do to bring a patient into
normal relations with himself and the world. In
this transformation it may or may not be a hard,
persistent, and painstaking task to find the con-
flict and adjust the man to himself. But, besides
that, a second problem m.ay arise. It may be not
only necessary to adjust the patient to himself, thus
restoring health, but also it 'may be best to change
both the conscious and the subconscious personali-
ties to conform to other standards of living; that
is, to change his character into something better.
'Hypnotism has always been thought to be a pos-
sible great menance to society, a treatment calling
for a different sort of skill from that of the physi-
cian who may even employ a dangerous drug, or the
surgeon who uses the knife. For the hypnotist not
only knows that his suggestion will make a man
do this, rather than that, but he has a greater choice
in the results to be accomplished than the physician
who aims at a normal — as that normal is generally
December 14, 191 fs.]
FARNELL: PSYCHANALYSIS.
1019
understood. And so the warnings against the hyp-
notist have been many, lest one become the victim
of an unwise influence, or even an unwiUing tool of
an evil man. Today, the man who heals through
the medium of suggestion does not often resort to
hypnotism, for long ago it was found that the sub-
conscious mind could be reached through the con-
scious with no show of magic. But no less re-
sponsible is the task of him who changes the per-
sonality of his patient, though the patient is under
no hypnotic spell. The work of the psychopatholo-
gist is in a great measure a destructive process, and
so far as it is, the problem is a comparatively simple
one. A patient has this idea, and that, and again
another, all of which are, in the eyes of the expert,
radically wrong. So far the object may be clearly
seen and stated, though it may not be easy to attain.
These ideas are wrong, they do not express what the
experience of more nearly normal people have
found to be true ; therefore these ideas must be re-
moved to be substituted by others.
To make the case clearer, assume the abnormality
to be anxiety hysteria as understood by the abnor-
mal psychologist and as treated by the psych-
analyst. The mechanism of hysteria, the repression
of natural emotions, or the repression of the natural
outlets of these emotions has been aptly described
by a layman, Mr. James Lane Allen, ^ in his A
Summer in Arcady. "Take a cannon ball of the
best metal that m.ay be cast ; hollow it out ; fill it
with water ; plug it tight : put it under the corner of
a house so that the weight of the house will rest
on the ping. Then let nature come along in a
freezing mood and one of two things will happen :
the water will force the plug and lift the house, or
the ball will burst. And if she requires so much
room in which to freeze, think of the space that she
needs for heat. Nature quietly asks room for the
operation of her laws; if it is not given, she takes
it, and you take the consequences."
The psychanalyst deals again and again with such
cases as are here figuratively described. "Nature
quietly asks room for the operation of her laws ;
if it is not given she takes it and you take the con-
sequences," and theti the physician is called in to
make all things calm and normal again, after the
explosion. In effect, the physician, if he under-
stands these psychophysical or psychosexual mani-
festations, finds, if possible, what it is in his patient
that is explosive, and then what the inhibitions are.
The course to be taken is evident : either do away
with the explosive, do away with the inhibitions, or
compromise.
Now, this having been effected, conditions are
changed until conflicts cease, the patient may be de-
clared cured, and the analyst may leave him to do
what he will with his own life, feeling that up to
this point and no further he is his brother's keeper.
The patient is cured of his mental or physical dis-
turbance which mcapacitated him from doing a
man's work in the v;orld. But is this the sole aim
of the analyst? In many cases, yes; it is all that
needs be done. In others, no ; and here lies the peril
'Discussion of the emotional activities and their psj-chanalytic
value, in several of the aforesaid author's works, will form the
basis of a theme soon to be compiled by the writer and L. A. Y.
of psychanalysis as it is understood at least by the
layman.
As has been said before, a part of the work of
the analyst is destructive, and certain ideas and
feelings having been done away with, 'the patient
becomes not only v/cll, as understood by the physi-
cian, but in a condition quite satisfying to himself
and to his friends. But, as in the case of most de-
structive work that has been going on among our
old ideals and ideas, a corresponding constructive
work is often necessary, that we, like ships that have
been deprived of an old rudder or anchor, may not
drift aimlessly but m.ay have some new steering gear
or some new anchor far better than the old. All
through the ages the rebound from destruction of
old systems of thought has too often been disastrous
to the individual or the race ; and then, from too
great freedom and license have arisen new systems
called out by man's inner needs.
Psychanalysis is generally understood as having
to do with some unsteadiness or abnormality in
the attitude toward the sexual relations of life —
the word sexual being used in so broad a sense that
even the most Puritan minded need not be startled.
It has to do with the relation of the infant to either
parent ; of brother to sister or brother to brother,
or sister to sister; of boy to boy friend or girl
friend, and girl to boy friend or girl friend, and
later of man to man or woman, and woman to
woman or man, and so on ; and all this without any
implication necessarily of any moral unfitness or
physical grossness. In looking fairly and squarely
at this new science of psychanalysis, one must not
shrink before the words sexual, bisexual, homo-
sexual, heterosexual, for these words scientifically
used, do not necessarily imply what is commonly
understood by them, but only that all mankind is
divided into several classes described by these
words, as their chief interests, admirations, and
affections centre in themselves, or others of the
same sex, or of the opposite sex. And just here
one would like to suggest to the psychanalyst that
if this could be tactfully explained at the outset to
some patients, it might save them the shock of feel-
ing that they are being unjustly and ruthlessly ac-
cused of some feelings or acts of which they are
confident they Icnow nothing. A barrier is too
often raised between patient and physician because
of the fact that the content of a word or phrase is
quite different in the minds of the two. Whatever
the difficulty of the patient along these lines may be,
the work of the physician must in some measure be
constructive. The wrong ideas, the wrong attitude
to life as it really is, have, we will assume, been re-
moved. Not often can the patient find for himself
the satisfactory new ideas, the new attitude, and
so he looks to the one who has destroyed his old
standards for help in taking a new and definite
attitude toward certain basic facts of all human
relations. The analyst therefore becomes in a very
great degree his brother's keeper, and the problem
is one to call out all that there is of fineness and
wisdom in a man whose profession requires that he
should himself be essentially fine and wise. '
We may roughly classify the cases of a psych-
analyst as follows, according to their moral codes
T020
FA RNELL : PS YCHA NA L YSJS.
[New York
Medical Journal.
and their attitudes toward the same. First there
are those whose moral code is already a high one,
quite unimpeachable even in their most secret think-
ing life. They havi definite and worthy ideals and
the will to" pursue them. A physician helps them
out of some conditions of maladjustment which
have been thwarting their full development, and
then his work is satisfactorily done. There are
those whose moral code has never been high, but
who would like to live on a higher plane, who
realize there is something better than their own
level, and have the will to attain could they but be
shown the way. They are not content to remain at
ease within their own moral code which they have
heretofore followed, and they naturally look to the
one who best knoAvs their struggle, and whose
suggestion has removed many of their difficulties,
to make clear the higher plane of living, and once
more by suggestion help them to attain it. They
want a new moral code and they want to live at
ease within it. Will the analyst meet their needs?
Unfortunately there is another kind of patient
w-liose moral code has been inferior, and this class
is not a small one. There are those who are not
only content with their present ideals, but will have
no other. They cannot conceive of any pleasure for
them in a life on a higher plane of moral standards.
Their wills are strong to follow their own devices.
They have through some obscure conflict of their
personalities, through some unnatural thought or
feeling, fallen into an uncomfortable condition of
mind and body or both. They wish these discom-
forts removed, which are inhibitions to the full en-
joyment of life according to their own moral code.
They seek the psychiatrist to have their discomforts
removed, but they will not allow any tampering with
their moral code. It is somewhat similar to the
burglar who enjoys the fascination and gamble of
that life, who is eager for all the advice and help he
can get to shorten his term of imprisonment, or to
prevent detection and arrest, but who would re-
sent any attempt to make a better man of him,
that is, to change his moral code. The work of the
physician with these is not ideal. Perhaps it is this
class more than any other which causes most dis-
satisfaction with this new science of psych^nalysis
— still in a very experimental stage. Surely this is a
hard problem for the physician who cares. No law
of nature or society is more true than that we are
known and j'udged by our fruits and, in these cases,
the fruits of neitlier patient nor ])hysician seem
worthy.
In the last class may be put all those whose ideals*
are most unformed and whose minds are most
suggestible ; who have gone the way of least re-
sistance, but meeting the resistance can as easily
turn and go another way. These may be children
in years or children in their mental attitudes. With
this larger class the physician is indeed his brother's
keeper. No hypnotist with all his seeming magic
power can so surely control, for better or worse,
the destiny of a subject than the analyst a patient
of this class. He can not only put the conflicting
personalities into harmony, but from the beginning
of his treatment of those patients he can persistent-
ly, subtly, instill a definite moral code, if he will.
Indeed, whether he wills it or not, he must leave
them on some moral level, be it a moral height or a
moral abyss, influenced in a large measure by his
own teaching. It is not strange that there is great
skepticism today as to the worth to mankind of this
new science ; not strange that there is strong con-
viction that the analyst may do infinite harm. Such
possibilities lie in the hollow of his hand !
To sum up — what shall be the attitude of the
physician toward those he can most control?
Many a criminal would choose the better way, if
the way could be discerned and there were stretched
out to him a guiding hand. And many a patient,
whatever his standards of living may be, would rise
to greater heights could he be shown the way and
lielped a little. And so there is this great class of
patients who should rouse the physician to his great-
est and finest efifort. The responsibility is great, for
the stake is one of ideals.
If it is the province of the psychanalyst to deal
with the most insistent and enduring emotions of
the human race; if he can by a suggestion or a
series of suggestions change the thinking Hfe, and
therefore, the whole life of his patient; if he may
alter the character of a grown person who becomes
a child again in his teachableness, affecting the rest
of a life already partly spent ; if he can more easily
and more thoroughly alter the character of a child
whose days are hardly begun, and whose long un-
spent life will ever be different because of the way
he has been changed at this critical time, different
in itself and different in the influence it in turn ex-
erts on many others ; then, indeed, the psychiatrist,
should be chosen with no less caution than the much
feared hypnotist is avoided ; and the psychiatrist,
if he would do all that he should, must keep his
own ideals high. It may be possible to teach a child
to be all that one is not one's self ; to teach him to
hold to ideals which one can conceive of for others,
l)ut cannot attain one's self, but this way is far from
secure. Unless the teacher lives close to worthy
ideals, the pupil who sees sharply and thinks in-
telligently will be affected not only by what he says.
l)Ut what he is. It is not enough for either patient
or physician that the patient shall be made ''entirely
at ease within his own moral code." For his own
good, for that of society in which he lives, and for
the sake of his own deathless influence, which no
man can measure, on generations to come, that in-
fluence with its never ending ramifications, which
is in itself an immortality, necessarily indicates that
his moral code must be made the best possible. If
the psychanalyst will not fail, let him look to him-
self and keep ideals lofty and untarnished. He
too must be "entirely at ease within his own moral
code," and that moral code must be unimpeachable.
Does one ask too much of this new science?
Tennyson says, "Have patience, ourselves are full
of social wrong; And maybe wildest dreams are
but the needful preludes of the truth"
Thready Pulse in Typhoid Perforation. — G.
Giacobini {La Semana Medico, May g, 1918) con-
siders that a thready or filiform pulse is a pathogno-
monic sign of perforation in typhoid fever. Other
signs may be present, but this is the one decisive
feature.
December 14, 191 8.]
PISKO: SYPHILIS AND MATRIMONY.
I02I
SYPHILIS AND MATRIMONY.
By Edward Pisko, M. D.,
New York.
In choosing this subject, I was guided, in the
main, by the frequency with which a physician, who
possesses the confidence of a family, is asked advice
as to whether a person who has had syphihs ought
to marry, and if so how long a period ought to
elapse between the infection and the marriage ; also,
whether, and to what extent, the children would
suffer.
Syphilis is a disease that has been well known
for centuries and thoroughly studied with the result
that there can be no doubt it is a factor to be con-
sidered in contracting marriage. While there are
still many people who firmly believe that syphilis is
incurable, we know better because thousands and
thousands of those afflicted have married, enjoyed
perfect health and old age ; did not infect their
wives, and had healthy children and grandchildren.
Well, then, their syphilis must have been cured.
Still there are many, not only lay people but also
medical men, who do not believe that syphilis can
be cured. Hebra, Sigmund, Zeissl, Kaposi, Neu-
mann and Finger, of the Vienna school ; Lesser, of
Berlin ; Neisser, of Breslau ; Fournier, Brocq and
Ricord, of the French school, and Hutchinson and
Hunter, of the English school, may be quoted at
the outset as authorities that a syphilitic person may
marry.
The question is, how long after the infection?
Although I do not consider syphilis to be infectious
like the rest of the well known infectious diseases,
it is not within the scope of this paper to discuss
these points nor to differentiate between ordinary
infection and constitutional disease, but I would like
to state right here that I believe that syphilis is con-
stitutional with the most peculiar initial lesion — the
Hunterian chancre — a unique lesion never show-
ing up again on the body no matter how long
the patient exhibits any lesions. In the very regu-
lar course that syphilis takes we meet the sclerosis
only at the very onset and it is my belief that the
disease at that point is already constitutional.
That a person with florid lesions is forbidden to
marry is a matter of course, but how about it if
there is no active syphilis after four or five years
of routine treatment during that period? The an-
swer to this question must be given first. Up to the
beginning of this century it was left entirely to the
discretion of the clinician whose sole guidance was
his clinical experience, there being no other means.
Then almost simultaneously came the discovery of
Spirochaeta pallida, salvarsan, and the Wassermann
reaction, almost revolutionizing all previous teach-
ings.
It is a well established fact that a virus has a
limited life, just like any other life, whether it be
animal or vegetable ; we are not able to correct
nature and so lengthen life or preserve it. There is
no such thing. If the Spirochreta palHda is con-
cerned in the causation. of syphilis, isn't it more
than likely that in fighting it, we may do more harm
to the finer structures such as nerves, vessels, etc. ?
There was a time when every surgeon followed
Lord Lister's theory of antisepsis ; even now car-
bolic acid and the bichloride are used for cleaning
and cleansing utensils and instruments, but not in
the operation field ; sterilized water and saline solu-
tions are used exclusively and asepsis is preached
and practised, whereby the finer tissues are not
destroyed.
I wish specifically to emphasize that up to date
it must be admitted that those of us who see thou-
sands of syphilis cases have comparatively few
cases of neurosyphilis, syphilis of the brain, of the
medulla, tabes dorsalis, and paresis. To me, per-
sonally, it is clear that we have jogged along
quite comfortably on old lines of the recognized
schools, but I am more than convinced that when
the time comes, say after fifteen or twenty-five
years, that we shall see results of salvarsan
treatment, especially after the energetic and heroic
attitude that some authors have adopted of late, and
I am very much afraid that the proportion will be
increased materially — our bodies and systems are in
the habit of forming their own antibodies, and those
brought m from without must necessarily act as
foreign l)odies and consequently must have a de-
structive effect.
Nursing is another important point in syphilis
and matrimony. We all know that there are many
instances where artificial feeding is contraindicated.
and in the case of the mother being unable to nurse
her baby, it is imperative to order a wetnurse.
Here the Wassermann reaction is a godsend, in the
truest sense of the word. While we had to go by
data collected before the time of the Wassermann
test, today we simply and offhandedly reject a per-
son with a positive Wassermann, and in this way
we save the child from infection. The four plus
speaks for itself, and so there are many more
noints that I could enumerate, but it is of course
impossible to include everything in this short paper.
For the last few years, syphilis has been listed
as a communicable disease by the Health Department
of New York, and is to be reported ; also before a
marriage license is granted both parties are asked
v/hether they ever have had syphilis. Now, what does
that mean and what kind of a protection is it? How
many practitioners report their private cases in or-
der to help the health authorities to look up these
records and refuse the license? How many men will
admit to the officer that they have had syphilis and
how many men are there who have had it and did
not know it ? Is there one single woman who would
make a positive statement ? How will this problem
be handled after the war, when these thousands of
men will come home infected in the same or similar
proportions to those quoted in the Hospital World?
The British army, up to April 23, 1917, had
71,000 cases of gonorrhea, 21,000 cases of syphilis
and 6,000 cases of soft chancre! In the Canadian
army, up to March 31, 1917, there were 18,335
cases of venereal disease. Several of the Canadian
camps visited showed 90 per cent, of the returning
soldiers infected with syphilis — two thirds of one
division infected with syphilis before it had been
six months in England ! Two Australian regiments
completely incapacitated by venereal disease before
reaching the trenches !
1022 BUERGER: GONORRHEAL INFECTION OF KIDNEY AND' URETER. . [New York
ivf EDICAL JOURNAL.
I believe every man returning to this country
ought to undergo a rigid test and with a positive
Wassermann ; he must be told of the danger of
infection and also his family — be it a single man
or a married man — or else we will have to fight a
greater war against venereal diseases than the great
world war. These figures lead us to the only solu-
tion, dealing with the stamping out the root of the
evil of venereal diseases : licensed prostitution.
Coming back to and concluding our subject —
syphilis and matrimony : A negative Wassermann
reaction does not mean anything at all and does not
amount or lead to anything. But what about a
positive reaction, taking it for granted that we do
not deal with leprosy, tuberculosis, cancer, scarlet
fever, etc., that also give a positive Wassermann
reaction ? The question is whether this indicates
that there is an active process of syphilis going on
somewhere and why are we not able to locate the
focus? My idea is that after four or five years
of routine treatment there is no need of further,
treatment if we cannot ascertain cluiically — and ]
emphasize the word clinically — the seat of the
process.
When it comes to the question of marriage, I be-
lieve it is the duty of the family physician to send
such persons to a syphilographer and it should
be left to him to decide whether such persons had
enough antiluetic treatment during the past four or
five years. Here, too, there is a hitch, because
some of the so called specialists are so mercenary
that they do not discriminate enough. Another great
drawback with these unfortunate patients is the
secrecy ; it is not like a hip disease or a pneumonia.
Shame or fear or ignorance — in most cases the three
factors combined — land these unfortunates at the
offices of 'the advertising quacks.
To get down to bed rock: after four or five years
of treatment I deem it imperative to wait another
year with a positive Wassermann reaction ; the out -
line of treatment is four months of active treatment,
about seven or eight of salvarsan or its equivalent,
and routine injections of salicylate of mercury, then
about two or two and one half months of mixed
treatment by the mouth, no treatment whatsoever
for the second half year, and then again a Wasser-
mann blood test taken at the end of the year — of
course the patient is to be watched and seen at least
once a month, but no treatment given, and I am con-
vinced that it matters very little whether the Was-
sermann has remained positive, because after all we
are guided by the clinical findings, and if there were
none during the past year, we may safely allow the
parties to contract matrimony.
Hepatic Form of Spirochetosis. — Manine
{Prcsse mcdicalc, September 19, 1918) states that
spirochetosis, as met with in an epidemic form at
Lorient, in 1917, proved to be an infection with
variable course and manifestations, with a rather
high mortality — five per cent, of marked gravity in
its meningeal and typhoid forms, and justified a
guarded prognosis on account of the frequent per-
sistence of visceral sequelae. The disease probably
occurs everywhere sporadically.
RENAL AND URETERAL INFECTION
WITH THE GONOCOCCUS.*
By Leo Buerger, M. D.,
New York.
Although the literature contains a fair number of
observations on the effects of invasion of the kid-
ney, ureter, and bladder by the gonococcus, the
practical lessons that can be deduced from a study
of recorded cases are insufficiently defined to enable
the clinician, cystoscopist, or surgeon to formulate
a clear picture of the pathological processes peculiar
to this form of infection, when it involves the
upper urinary tract. What the cystoscopist is par-
ticularly desirous of knowing is the configuration or
even the general appearance of the lesions of the
bladder, especially about the ureteral orifices, if any
such are characteristic in this affection. From a
perusal of the literature he would like to obtain, in
succinct form, a well defined picture of what he is
to expect when he examines the bladder in which
gonorrheal infection plays the most prominent part.
This, strange to say, he cannot glean from a review
of the recorded cases, for most of the descriptions
of the bladder lesions, as well as the circum-
ureteral changes — if such exist — are so vague as
to be of no practical value.
In our own experience, two cases of undoubted
gonorrheal infection of the bladder, ureter, and
pelvis of the kidney, the vesical and circumureteral
lesions were sufficiently characteristic to warrant
being brought to your attention, for if our observa-
tions are confirmed by other observers, true diagnos-
tic points will have been discovered. From our own
limited number of cases, however, these can be re-
garded merely as suggestive and in no sense as
pathognomonic.
In recounting the case histories, cystoscopic find-
ings, and pathological changes found in two cases
of gonorrheal infection of the bladder, ureter, and
kidney, I feel that I am bringing to your attention
lesions sufficiently characteristic to warrant future
investigation. In one instance, the alterations were
confined to the bladder ; in the other, they were so
striking and well developed about one ureteral ori-
fice, so confusing in their simulation of tuberculous
lesions, so complexingly associated with stricture of
the ureter, that we felt that we were confronted
with pictures worthy of the application of more re-
fined diagnostic methods.
Case I. — Gonorrheal infection of the bladder and
the lower portion of a kidney with separated pelves
and ureters ; hydropyonephrosis ; and gonorrheal
stricture of the corresponding member of the dupli-
cated ureters.
B. G., male, age twenty-one years (referred by
Dr. S. Rose) ; consulted me on February 28, 1918,
because of the persistence of a gonorrhea, which he
had incurred about one year previously, and because
of pyuria. There had been the usual complications,
namely, a rightsided epididymitis some nine months
previously, pain in the ankle, and aches in the tarsal
joints, off and on for almost eight months. The
*A lecture delivered at the New York Polyclinic Medical School
and Hospital, March 14, 1918.
December 14. .9'S.] BUERGER: GONORRHEAL INFECTION OF KIDNEY AND URETER.
1023
urethral discharge had subsided about six months
ago, only to reappear again from time to time.
More recently a leftsided epididymitis had devel-
oped (five weeks ago), but this seemed to have
cleared up entirely, whereas the lesion of the right
epididym.is seemed not to have disappeared al-
together. More recently the patient complained of
a pain in the right lumbar region, particularly near
the vertebral column, a constant dull ache, which on
only one occasion was accompanied by colic. Tn
short, a history of gonorrheal infection lasting for
about one year, with bilateral epididymitis, joint
symptoms, recurring urethral dischaige, recent dull
continuous lumbar pain, with one attack of renal
colic, and a persistent pyuria. The family physician
wished to know the reason, first for the continued
pyuria, and, secondly, for the refractory nature of
the gonorrhea in this case.
Phvsical examination. — Disclosed a fairly well
nourished, but not robust young man, presenting
nothing worthy of note outside of the genitourinary
tract.
Urine. — Turbid, amber, acid, a trace of albumin,
sugar negative ; macroscopically and microscopically
showed abundant pus, but no red blood cells. Ex-
amination of spreads of urinary sediment showed
tubercle bacilli negative ; a moderate number of in-
tracellular and extracellular gram negative diplo-
cocci, morphologically gonococci.
Cultures. — Gonococci in pure culture.
Abdominal c.vamination. — Some tenderness in
the right costovertebral angle ; right kidney some-
what enlarged ; distinctly palpable. Both epi-
didymes somewhat enlarged and tender. Prostate
very slightly enlarged ; prostatic fluid on two occa-
sions showed a very few pus cells ; but no gonococci.
In short, gonococci present in the bladder urine and
absent in the prostatic secretion.
Cystoscopic examination (March 4, 1918). — Af-
ter thoroughly irrigating the anterior urethra, the
cystoscope was introduced and the bladder fluid
collected in a sterile tube. This bladder urine con-
tained numerous gram negative diplococci (gono-
cocci).
The bladder picture was unusually interesting,
both because of the presence of an anomaly in th^^
shape of two ureteral orifices on the right side, and
also because of most unusual lesions about one of
the ureteral orifices, namely, that which drained the
infected portion of a double kidney with duplicated
ureter.
The two orifices on the right side will be de-
scribed in Fig. I as the right upper (in reality
posteroexternal), and the right lower (or distal).
At first glance the lesions about the right upper
ureter could be mistaken for those associated with
renal tuberculosis. The inner lip of this orifice is
raised, has a crenated or scalloped edge, so that the
orifice itself marks the outlet of a sort of a tunnel,
which is roofed by the swollen inner lip. This
whole region, as well as the trigone, is edematous
and hyperemic. Grouped about the right upper
orifice, as depicted in Fig. i, are polypoid ed-
ematous protuberances, not unlike those seen and
regarded as edema bullosum in tuberculosis. Just
beyond the right upper ureter, except for the loca-
tion of a small patch of exudate hanging or attached
to the floor of the orifice itself, is a whitened area,
which is suggestive of cicatrization subsequent to a
previous inflammatory process. The lower right
ureter shows none of these lesions, presenting only
that slight hyperemia and edema common to the
general trigonal inflammation.
Ureteral catheterisation. — The ureteral catheter
meets an obstruction at ten cm. (that is from the
bladder orifice) in the right ureter; no urine could
be obtained over a period of some twenty minutes.
From the right lower ureter and from the left
ureter, a good flow of perfectly clear urine was
obtained, the renal function as estimated roughly
by the excretion of indigo carmine showing good
excretion from both the right lower ureter and the
left ureter. Shadowgraph catheters were then in-
serted into the two right ureters and a radiogram
taken.
Summary. — Peculiar lesions suggestive of renal
tuberculosis about the upper of the duplicated right
Fig. I. — Cystoscopic picture of circumureteral lesions in Case i;
note edematous and polypoid lesions about upper right ureter, and
normal lower ureter.
ureteral orifices ; general edema and evidences of
inflammation about the trigone, with evidences of
cicatrization just beyond the right upper ureteral
orifice ; ureteral stenosis at ten cm. in the right
upper ureter ; clear urine, free of any abnormal
elements, and suggesting fairly normal function of
both the left kidney and of the upper separated
portion of the right kidney.
Examination of specimens. — The specimens from
the right lower ureter (namely, from the upper por-
tion of the right kidney) and from the left kidney
contained no gonococci, no pus cells, the urine being
otherwise negative. The bladder urine contained
numerotis gonococci. No urine was obtained from
the right upper ureter.
Tentative diagnosis. — Ureteral stricture involving
that one of the duplicated ureters on the right side
which leads into the lower pelvis ; infected hydro-
nephrosis of the lower portion of a double kidney
on the right side (probably infected with gono-
cocci) ; intermittent evacuation of some of the con-
tents of this hydropyonephrosis when the tension is
1024
BUERGER: GONORRHEAL INFECTION OF KIDNEY AND URETER. „ [N^w York
Medical Journal.
great; a noninfected upper portion of the right kid-
ney; and a noninfected left kidney.
X ray examination (March 4, 1918). — Negative
as far as calculus is concerned. Left kidney normal
in size and position ; right kidney outline not suffi-
ciently definite to warrant any statement regarding
its size.
Plates were also taken with shadowgraph cathe-
FlG. 2. — Radiogram showing shadowgraph catheter in lower right
ureter passing into normal upper pole; another meeting obstruction
in infected ureter.
ters in situ, these having been placed in the two
ureters on the right side, immediately after the
cystoscopy described above had been completed.
The ureter leading from the upper right ureteral
orifice is seen to be discrete, completely separated
from its neighbor as far as the catheter goes,
namely for a distance of some ten cm. (Figs. 2 and
3), whereas the catheter in the lower ureter is seen
to pass into the kidney.
.Examination of the urine for tuberculosis was
again made on March 6th, and found negative. In
spite of the presence of gonococci, it was thought
advisable to rule out tuberculosis with certainty by
the application of intravesical biopsy practised ac-
cording to the method which I suggested some years
ago. Pieces of the inflamed edematous ureteral Hp
are excised through the author's operating cysto-
scope and submitted to the pathologist for micro-
scopical examination. Miliary tubercles are usually
found where macroscopic ureteral lesions are pres-
ent. Unfortunately the patient was recalcitrant and
refused to submit to this procedure, so that we were
forced to relinc[uish the hope of absolute substantia-
tion of our tentative diagnosis of gonorrheal in-
fection of bladder, ureter, and kidney by a positive
exclusion of tuberculosis. However, the finding of
pure cultures of gonococci in the bladder specimen
on two occasions, the absence of tubercle bacilli af-
ter careful search in two catheterized specimens,
the presence of considerable pus in the bladder,
which was doubtless derived to a considerable ex-
tent from the infected right lower pelvis — all these
data seem to justify the assumption that we were
dealing with a gonorrheal infection of the bladder,
a gonorrheal stricture of one of the duplicated
ureters leading to the right kidney, and a gonor-
rheal pyohydronephrosis of the lower portion of a
double kidney with separated pelves. The anatomi-
cal rule that the upper or proximal ureter leads into
the lower portion of the kidney, the distal ureter
draining the upper pole, was confirmed and shown
to obtain in this case by the shadowgraph catheter
(Figs. 2 and 3), as well as by the findings at opera-
tion.
Operation.— h nephrotomy was performed March
7, 1918. It was seen that the upper portion of the
kidney comprised at least two thirds of the total
mass, and was fairly normal in appearance ; that the
lower portion of the kidney was flaccid and very ad-
herent. The upper pole was easily delivered. And,
in order better to expose the lower pole, and get an
idea whether a horseshoe kidney or evidence of
fusion was present, it was deemed advisable to sever
the vessels of the upper portion first. When this was
done, a very thorough inspection of the lower half
of the kidney was possible, its adherent ureter and
enlarged pelvis being easily brought to view.
While the diseased portion was being attacked, it
was found to be very adherent, the lower pole
flaccid (hydronephrotic), and giving rise to a pyri-
form extrarenal pelvis, just as large as the lower
pole itself (Fig. 4), the latter being separated from
the normal kidney by a distinct furrow. From
this point downward the extrarenal pelvis of the
lower part of the kidney and the normal ureter were
fused together in an inflammatory mass, which
could be traced downward. The two ureters were
then separated by dissection, the small or normal
ureter first cut through and then the thickened one,
the latter being indurated and enlarged to the size
of a man's little finger. Then the kidney was re-
moved, the stump being carboHzed. Closure was
done in the usual fashion, with a rubber tube for
drainage.
Pathological specimen. — The kidney measured
five and one half inches in length, presenting an
upper portion, which measured about two thirds of
the renal mass (exclusive of the pelvis), and a
lower portion, made up of dilated parenchyma and
a fusiform, very much dilated prolongation, name-
ly, the dilated pelvis (Figs. 4 and 5). The total
kidney mass measured five and one half inches in
length and might be divided into a larger upper por-
tion, about three and one half inches in length, sep-
arated by a furrow from a flaccid hydronephrotic
smaller lower pole, which fused into a larger pyri-
form mass, the dilated sacculated lower pelvis and
ureter (Fig. 5). Externally the upper portion of
the kidney, that which corresponded to the normal
two thirds of the renal parenchyma, showed prac-
tically no abnormalities, no external adhesions ex-
cept near the furrow, which separated it from the
lower hydronephrotic part. Its ureter emerged
from a separate hilus or indentation in the inner
December 14, 1918.] BUERGER: GONORRHEAL INFECTION OF KIDNEY AND URETER.
1025
border, was of normal size and coursed almost ver-
tically downward, being bound by adhesions to the
pyriform sacculated distended pelvis referred to
above (Figs. 5 and 6). The external appearance of
the lower hydronephrotic and infected portion witli
completely separated renal parenchyma, pelvis, and
ureter, was, in main, that of a typical infected
hydronephrosis, except for the small size of the
area of renal cortex that capped the much larger
distended pelvis. This indicated that the lower por-
tion of the separated renal parenchyma must have
comprised only one third or less of the total func-
tionating tissue. The pelvis of this part of the kid-
ney is enormously dilated, pyriform, very much
thickened, edematous externally, covered by thin
adhesions, and leads into a much thickened and
dilated ureter. On section (Fig. 5) the upper renal
mass was seen to be perfectly normal with a normal
pelvis, drained by a practically normal ureter. The
lower portion of the kidney was converted into a
pear shaped sac, a portion of whose wall is made
up of very much attenuated parenchyma, which
showed the , usual appearance of atrophy. It was
impossible to detect any tubercles, although a num-
ber of incisions and a careful search were made
throughout the limited area of cortex. Some of
the flattened papillae (Fig. 5), nowhere occupied
by ulcerations, present here and there pinkish
elevations that are suggestive of tubeicles (pseudo-
tubercles), which, however, did not show any tuber-
culous lesions in microscopic sections. Most inter-
esting, however, was the interior of the dilated
pelvis and ureter, which had a rosy red, and in
places angry red, granular, strawberrylike appear-
ance, having in practically every respect the typical
earmarks of the .strav/berry gallbladder, and would
be easily mistaken for such if its origin was not
known. The fluid content of this sac was a turbid
bloody urine. Cultures were made from this fluid
and found sterile. Histological examination of a
number of sections removed from the attenuated
parenchyma, particularly where pseudotubercles
were to be seen, failed to show any of the lesions
of tuberculosis, nor were there any tuberculous
lesions found in the pelvis.
Summary of the pathological lesions. — In short,
we were dealing here with a kidney with separated
pelves and ureters, divided into an upper normal
portion, free from infection, provided with a prac-
tically normal ureter, and a lower hydronephrotic
and infected portion with dilated pelvis and thick-
ened ureter, with peculiar lesions simulating those
of the strawberry gallbladder, lesions produced by
the effects of inflammation and ureteral stenosis,
due undoubtedly to the gonococcus, and altogether
different from anything that we usually encounter
as the result of the action of the usual pyogenic
organisms, including the colon bacillus. The small
size of the anomalous lower dilated and infected
portion of the kidney, the situation and conforma-
tion of the pelvis, would suggest that exceptional
anatomical conditions obtained in this part of the
kidney before the superadded lesions of inflamma-
tory ureteral stricture had supervened to bring
about the finished pathological product.
Clinical courses. — The patient made an uneventful
recovery after ihe nephrectomy, although a sinus
remained for .some three weeks before the wound
was completely closed.
Epicrisis. — We were dealing, then, in this case,
with an unusual instance of gonorrheal infection
of the bladder, ureter and kidney, with bladder
lesions that were suggestive of tuberculosis, with
stenotic, indurative, and periindurative lesions of
the meter, with intensive periureteritis, with corre-
sponding dilatation of the ureter and pelvis of the
kidney beyond the coarctation, with the production
of unusual lesions in the involved portion of the
kidney, the pathological pictures encountered being
sufficiently striking and exceptional to be regarded
as possibly characteristic of gonococcus infectiojri.
Worthy of discussion are the following observa-
tions :
1. The bladder lesions suggestive of tubercu-
losis.
2. The ureteral stricture.
3. The periureteritis.
4. The lesions in the pelvis and kidney, with
the absence of gonococci in culture.
I. Bladder lesions. — How closely the circumu-
reteral lesions simulate those of tuberculosis can
be readily appreciated by a glance at the illustration
(Fig. l). Such extensive proliferative and edema-
tous changes about one ureteral orifice, however,
when they are the expression of a tuberculous pro-
cess, are most frequently associated with other blad-
FiG. 3. — Radiogram showing pelvic course of the two right uretersj
der lesions suggestive of this process. Here none
such could be detected. When tubercle bacilli are
absent the most reliable method of diagnosis (when
permitted by the patient) would be the removal of
portions of the edematous tissue by means of a
punch forceps through the author's operating cystO'-
1026
BUERGER: GONORRHEAL INFECTION OF KIDNEY AND URETER. [New York
Medical Journal.
Fig. 4. — Drawing of the patho-
logical specimen showing exteinal
view, the upper normal portion
separated from the lower hydro-
nephrotic by a furrow.
scope, and the histological examination of such
tissue for miliary tubercles. Although the histolo-
gical changes of tuberculosis cannot always be
demonstrated, when the tuberculous lesions about
a ureteral orifice are minimal in extent, they would,
in our experience, be very apt to exist and be easily
discoverable where the
lesions are as extensive
as in this case. The ab-
sence of tubercle bacilli,
therefore, in the bladder
specimens, the absence
of miliary tubercles in
excised tissue about the
ureteral orifice, with the
presence of gonococci in
sufficiently large num-
bers in the bladder speci-
men, would speak for the
gonococcus as the causa-
tive agent.
2. Ureteral stricture.
— The presence of a ure-
teral stricture at 10 cm.
from the bladder orifice
of the ureter was ascer-
tained first by the intro-
duction of an ordinary
ureteral catheter, and
then again when the
shadowgraph c a t h e ter
was inserted for the demonstration of the double
ureters. Its existence, therefore, could be accepted
without hesitation, all the more so since no urine
could be collected through the ureteral catheter, and
since the operation disclosed an enormous amount
of periureteritis, a dilated ureter above and a hy-
dronephrosis. Just how much this coarctation of the
ureter contributed to the impediment of the urinary
flow and how much the periureteral indurative pro-
cess was responsible therefor it is difficult to say.
Interesting, however, from the standpoint of diag-
nosis, and in so far as it adds to our knowledge of
the pathology of gonococcus inflammation of the
ureter, is the fact that the ureteral lumen is prone
and subject to the same stenotic influences that
obtain when the gonococcus invades the urethra.
3. Periureteritis. — So extensive was the periu-
reteral inflammation about the lower ureter (that
is, with the upper or posterior vesical orifice) that
it offered no little difficulty in the removal of the
kidney. It involved the larger portion of the ureter
as far as could be discovered with the limited ex-
posure afforded by the operative field. In the ab-
sence of any calculus, and in the absence of any
tuberculous lesions, this periureteral inflammation,
coupled with the narrowing of the ureteral lumen
seems noteworthy from both the pathological and
therapeutic view^point. For from the standpoint
of treatment it would suggest the advisability of
early injection of the ureter with the silver salts,
lest the process be allowed to progress so far as
not only to jeopardize the integrity of the ureteral
wall, but to implicate the tissues about the ureter
as well. A comparison of the ureteral and periure-
teral lesions of this case and those of the second
will show how alterations destructive of both ureter
and kidneys were prevented in our second case by
the timely introduction of the ureteral catheter and
the injection of argyrol solution.
4. Lesions oj the kidney, its pelvis and the ab-
sence of gonocucci in culture. — As for the changes
in the kidney and pelvis, there are two points
worthy of consideration : First, the peculiar straw-
berry appearance of the interior of the hydrone-
phrotic sac and its pelvis, giving the general appear-
ance of a "strawberry gallbladder" ; and, secondly,
the presence of pseudotubercles, without any de-
monstrable lesions of tuberculosis either in the
])arenchyma or anywhere in the pelvis, a sufficient
number of sections having been made to discover
the existence of any tuberculous lesions, had such
been present. As for the absence of gonococci in
culture, this fact cannot be accepted as precluding
the existence of a gonococcus inflammation, since
the exclusion of a hydronephrotic sac, for some
time at least, as a consequence of the ureteral stric-
ture, had doubtlessly resulted in the gradual dis-
appearance and death of most of the organisms, an
analogous phenomenon in the case of infected Fal-
loppian tube being rather the rule that the excep-
tion. Possibly cultures from the lower stenosed
portion of the ureter would have been positive.
Summary. — We have learned, therefore, from
this most unusual case, first, that gonorrheal lesion;
in the bladder and about a ureteral orifice may simu-
late those of tuberculosis; secondly, that extensive
stricture of the ureter may ensue; thirdly, that
marked thickening of the ureter, with periureteral
mflanmiation, can exist as the result of gonorrheal
inflammation, without the presence of calculus or
any other specific type of infection ; fourthly, that
such ureteral coarctation
may result in attenua-
tion of the renal paren-
chyma and its destruc-
tion; fifthly, that the
lesions of such an
infected hydronephrotic
kidney and its pelvis
may be unique, dififering
essentially from those
produced by other pyo-
genic organism ; and,
sixthly, that our case is
unusual in that only one
ureter, pelvis, and its
corresponding renal
pelvic tissue were in-
volved, the other portion
of the separated kidney
and ureter remaining
free.
Case II. Gonorrheal
infection of the blad-
der ; gonorrheal ure-
teritis with stricture formation ; gonorrheal pye-
litis and ureteritis cured by lavage v. ith argyrol.
Past history. — L. B., male, thirty years of age
(■referred to me by Dr. Jos. A. Herb, January 4,
1916). said that he had "an infection" (presumably
gonorrhea) about one year previously. Although
Fig. 5. — Section of the patho-
logical specimen showing hydro-
nephrotic sac.
December 14. .9.S.] BUERGER: GONORRHEAL INFECTION OF KIDNEY AND URETER.
1027
the usual source of infection was denied there
seemed to have been no doubt regarding the diag-
nosis, because he had had a severe infection of the
conjunctiva, that was attributed by the eye spe-
ciaHst to the urethral discharge. Over a period of
a year he had sought the advice of numerous phy-
sicians ; had received bladder irrigations almost
daily for a period of more than seven months, and,
on July 27, 1915, was said to have had a very severe
cystitis with considerable pus in the urine. Latterly
he gave up all treatment because of the persistence
of his symptoms, the pyuria, the vesical symptoms,
bladder irritability continuing, in spite of the vigor-
ous treatment he had received during the past year.
Present compla'mt. — Of late he thinks that the
pain on voiding has diminished, so as to be very
slight • but the pus in the urine is present as before,
and he is anxious to know whether he is able to
get married or not.
Physical examination (January 4, 1916).— Pros-
tate was slightly enlarged ; the right epididymis was
indurated ; the kidneys were not palpable ; the urine
was very turbid, containing mascroscopic pus.
Cystoscopic examination (January 7, 1916). —
Showed rather unusual lesions, which may possibly
be characteristic of gonorrheal inflammation of the
bladder. The floor of the bladder showed a con-
siderable amount of inflammation, particularly
about the left ureter, where the edema, the thicken-
ing and velvety condition of the mucosa extended
somewhat over the paratrigonal regions and distally
well into the sphincter. There were numerous
strawberry like papular lesions, more angry red than
the follicular lesions seen so frequently in the cys-
titis of females, and in the posterior wall of the
bladder there were numerous minute bodies, some
of which seemed to be lymphoid follicles, others
cystic (cystitis follicularis et cystica). The speci-
mens obtained from the right kidney showed that
indigo carmine appeared in good concentration after
a lapse of fourteen minutes, the urine being per-
fectly clear. From the left kidney, however, the
urine was turbid. From this side, on introduction
of the catheter, a fairly copious flow of very turbid
urine was at once obtained, the urine being slightly
blood tinged (specimen i). Then, after the catheter
was pushed further upward to a point of about
twenty cm., meeting and overcoming an obstruction
in its passage, an even more copious flow of urine
followed (specimens 2 and 3), as if the ureter was
dilated with retamed urine. The catheter was then
drawn outward again to a point between ten and
fifteen cm., and, again, slightly turbid and bloody
urine was collected, whereas the specimens ob-
tained from a point higher up were much more
watery and less cloudy.
From this examination it appeared that there
were evidences of retention of urine in the left
ureter; that there was an obstruction in the lower
ureter that could be overcome with manipulation ;
that there were evidences of ureteritis, and possibly
pyelitis, the involvement of the lower ureter being
indicated by the fact that more turbid urine was
obtained from the lower ureter than from the upper.
In short, a tentative diagnosis of gonorrheal ure-
teritis with a tendency to stricture formation, and
of gonorrheal pyelitis was made. For confirmation
of these suppositions the following specimens were
sent to the laboratory for examination of spreads,
cultures and the usual routine. Five specimens in
all were collected from the left ureter, two from
the right and one from the bladder.
The following is a copy of the urine report re-
ceived from the bacteriologist, Dr. E. P. Bernstein,
on January 10, 1916:
Right. Left 4 and 5. Bladder.
Reaction Alkaline Alkaline .Alkaline
Albumin Trace Trace Trace
Sugar Negative
Urea 0.8 per cent. 0.4 per cent. 0.6 per cent.
Microscopical Few epithe-
Hal cells
Few red Many red
blood cells blood cells
No pus M an y pus Many pus
cells cells cells
No casts No casts No casts
Spreads for
gonococci
Culture for
gonococci
Negative
Negative
Positive
Positive
Left I.
Positive
Positive
Positive
Positive
Left 2 and 3.
Positive
Positive
Spreads for gonococci
Culture for gonococci
From this it can be seen that no gonococci could
be found in either the spreads or cultures from the
right kidney urine. Gon-
ococci were found in
culture and the spreads
from all the five speci-
mens collected from the
left kidney, a fact which
practically rules out con-
tamination with the
catheter. Positive find-
ings were also reported
in the specimens obtained
from the bladder. The
presence of pus cells in
the left specimens fur-
ther corroborated the
diagnosis of infection of
the ureter and pelvis of
the kidney with the gon-
ococcus. An x ray ex-
amination on January
8th was negative. On
January 13th cystoscopy
was again done, and the
pelvis of the kidney and
ureter were washed out
with fifteen c. c. of a twenty per cent, argyrol solu-
tion, about five c. c. being allowed to remain in the
reral pelvis, the pelvis and ureters being irrigated
with the rest of the solution. In short, a case of un-
doubted gonorrheal infection of the left ureter and
left renal pelvis and bladder wall, the patient having
been given treatment of the pelvis and ureter
with twenty per cent, argyrol. The improvement
was most remarkable after this treatment, so that
on January 26th another cystoscopy showed
that the bladder was very much improved, the
granular appearance having almost disappeared.
There was still evidence, however, of stricture of
the ureter at about ten cm. from the bladder, but
Fig. 6. — Diagram depicting
various lesions of the specimen.
I
1028 MILLER: COMPOUND FRACTURE OF LONG BONES.
this was easih' dilated and passed. Argyrol was
again injected in ten per cent, strength, some of the
soUition returning alongside of the catheter. On
the 1st of February the urine was practically clear,
and from this date on the patient made an unevent-
ful recovery. It is true that in addition to the two
ureter and renal pelvic lavages the usual through
and through irrigations of the bladder were given
together with massage of the prostate, but the strik-
mg improvement immediately following the cysto-
scopic treatment was so definite as to be unmistak-
able evidence of the influence of the argyrol injec-
tion on the infection.
Epicrists. — We have here a very definite case, in
which pyuria persisted for about one year, undoubt-
edly due to the localization of the gonorrheal pro-
cess in the left ureter and left kidney. Further,
the interesting observation was made that the in-
flammatory process induced by the gonococcus in
the ureter has a tendency to produce a stricture of
this passage just as in the urethra and that reten-
tion of urine above such stricture can be demon-
strated to occur.
The peculiar bladder lesions are, it seems to me,
worthy of being sought for in cases that may come
under the observation of others. Although none
of the circumureteral edematous changes which
were present in the first case reported by me could
be detected here it seems not imlikely that a con-
tinuance of the ureteral inflammation over a longer
period of time might have resulted in an extension
of the edema to the vesical ureteral orifice. The
disappearance of the peculiar papular lesions after
the treatment seems rather significant and would
suggest that they are characteristic of the gonorrheal
process. The operative findings in Case I, demon-
strated the occurrence of a hydronephrosis after a
gonorrheal ureteritis. Here, too, in Case II, such
hydronephrosis might have been produced had we
not been able to bring about a cessation of the
gonorrheal lesions, and a subsidence of the reten-
tion of urine bv timelv therapeutic intervention.
Hence the importance of pelvix and ureteral lavage
as soon as the diagnosis of renal and ureteral
gonorrheal infection is established, not only in
bringing about a cure of the gonorrheal process and
preventing a reinfection of the distal genitourinary
tract, bladder, prostate and vesicles, but also in ab-
orting the destructive renal lesions.
1000 P.vRK Avenue.
Urinary Calculi in Childhood. — R. Puech and
G. P. Souza {Aimalcs Paulistas dc Mcdicina c
Chugia, Aprd. 1Q18) report thirty-five cases of
urinary calculi in children, with the following con-
clusions ; The condition is fairly common in Brazil ;
the vesical variety is much more common than the
renal; fifty per cent, of their cases were in Italians
or persons of Italian descent : the condition is
much more frequent in males than in females
(thirty-four males and one female) ; and the com-
mon age is from, three to five years. Ninety per
cent, of the calculi were phosphatic, while seventy
per cent, of the children had phimosis, which is
apparently a contributory cause. There were no
recurrences after operation.
[New York
Medical Journal.
A NEW TREATMENT FOR COMPOUND
FRACTURE OF THE LONG BONES.
By Julius Asher Miller, M. D.,
Sunderland, Engrland,
Lieutenant, Medical Corps, U. S. Army, Attached to the Royal
Army Medical Corps War Hospital, Sunderland.
(Published by prrniission of the Royal Army Medical
Corps.)
The treatment of compound fracture of limbs
varies as to the time after injury. Very good re-
sults have been obtained by various methods of
immobilization of the injured limbs applied soon
after the injury was sustained. I am, however,
not going to deal with the treatment of a compound
fracture immediately after injury. My deductions
and experience with this common injury date only
from the time the wounded man has reached the
permanent base hospital ; usually from three days
to a week after having been wounded.
These men as they arrive usually are found put
up in the following manner : either in skeleton iron
extension splints, or in hinged splints of wood.
These splints are excellent for the purposes they are
made to serve, namely rapid immobilization, con-
venience of application, and for ease in the dressing
Fig. 1. — Showing how plaster splints are made.
of wounds, but to my mind these apparatus cease
to be useful when anything more permanent, more
reliable, and more comfortable can be substituted.
Besides, there are decided objections, from the pa-
tient's point of view, to these rudimentary splints ;
for example, a skeleton extension splint of the arm
or forearm usually confines a man to bed. The back
splints in lower extremity cases permit no turning /
in bed. The hinge splints loosen and go awry, and
dressing is painful.
All these objections are eliminated in the im-
mobilization of a compound fracture in the manner
described below. Pain is even greatly lessened, in
the dressing and manipulating of the injured parts ;
absolute rest is given to the part and the setting of
the fracture is permanent.
Many of these men can scarcely be touched with-
out giving them the greatest pain, and the posi-
tion of the limb must be changed frequently for
comfort, while on the other hand, many men who
would otherwise have been confined to bed, have,
in a comparatively short time, been up and about
after the molded plaster splints have been applied.
These plaster splints, being made at the time of ap-
December 14, igis.] MILLER: COMPOUND FRACTURE OF LONG BONES.
1029
plication, can be of any strength or shape desired.
For the arm one or two spHnts may be made,
usually two, anterior, posterior or bilateral. These
are easily applied and as easily removed after the
plaster has hardened, and the arm or forearm is
never out of immobilization. If the patient has but
Fig. 2. — Showing the posterior splint being applied to the forearm.
one wound, one of the splints may be bandaged on
permanently, and the other removed at will. If
there are wounds on opposite sides, first one splint
may be removed, wound dressed, splint reapplied
and held, while the other is being removed and
wound dressed. This prevents absolutely the mov-
ing of the injured part, actively or passively. For
the lower limb, two splints are also made. One
posterior splint turns up at the heel, and is
molded into the shape of the foot ; the second
splint is bilateral and goes round the foot like a
stirrup up either side of the limb, internally and
externally. The latter splint, when dry and hard,
sHdes off quite easily, and the entire limb can be
dressed on three sides, the posterior splint keeping
the limb in position. If the wound is in the calf,
the lateral splint can be made the permanent one,
and the posterior splint the removable one; or, if
necessary, the splints can be removed in turn, and
likewise reapplied. The splints for the lower limbs
have been of the greatest value, as the ordinary
Fig. 3. — Treatment of compound fracture with plaster splints.
splints have sometimes been very trying to the pa-
tient as well as to the surgeon. It has often been
difficult to make them fit accurately, and give the
proper support at all desired points, without great
discomfort to the patient. They have often to be
padded, and this padding occasionally gives way,
causing pressure sores, no matter how much atten-
tion is given to its careful adjustment.
In many cases of multiple wounds, one of which
being a compound fracture of the bones of the
lower limbs, it is most difficult, if not impossible, to
dress all the wounds without turning tlic patient on
his side. This cannot be done in the ordinary way
by putting up compound fractures of bones of the
lower limbs. Again I wish to say all these objec-
tions are eliminated by the molded plaster splints.
The patient can be turned about in any manner
without pain or disturbance to the injured limb.
The method of procedure is as follows: The
wound in the limb is dressed, and the entire limb
is bandaged with one thickness of flannel bandage.
The limb is measured for the desired length of the
splint, then a piece of flannel or muslin bandage,
the required length, is moistened and stretched out
on a smooth, long table. The plaster bandages are
soaked in warm water, to which salt in the propor-
tions are eliminated by the molded plaster splints.
This adding of salt makes the plaster harden more
rapidly. Now starting at one end of the piece of
flannel, the plaster bandages are laid down on this
flannel (or muslin) from left to right, and back
Fig. 4. — Treatment of compound fracture.
from right to left until the entire bandage has
been used, and another is now used, if necessary,
until the desired thickness is obtained. The plaster
splint is now made; it is soft and pliabif.. and is
put on the limb lengthwise, the limb being held m
position. The splint is bandaged onto the limb by
means of gauze bandage, being molded at same
time. The second splint is now made and applied
in the same manner. The limb is held in position
by means of sand bags until the splints are dry,
usually about fifteen minutes. The making of both
splints and their application takes rarely longer
than ten minutes. It is only a question of unrolling
a moist plaster bandage, folding it in layers, and
bandaging it on to a limb. Three inch bandages
are most useful. For forearm, three such band-
ages are usually sufficient for both splints, made
long enough to immobilize elbow, and going down
well onto hand. About seven are necessary for
the splints in cases of fracture of the tibia and
fibula, immobilizing both knee and ankle.
I am certain these splints can be used in nearly
all cases of compound fractures of bones of the
limbs. Carrel-Dakin treatment may be carried out,
the tubes being b.'"ought out between the splints. The
WILDER: YALE'S MEDICAL
ACTIVITIES IN CHANGSHA.
[New York
Medical Journal.
moisture will not materially injure the splints, or
even if they are injured, it is no great inconvenience
to apply a new set. Again in the latter stages of
the fracture these splints facilitate massage of the
limb, being so easily removed and reapplied. These
splints have worked with the greatest satisfac-
Fig. 5. — Showing results of treatment with plaster splints.
tion to both patients and surgeons in the Sunder-
land War Hospital. They have been used in many
hospitals in New York in the treatment of simple
fractures and have proved highly valuable. I make
no claim for originality in the making of them. I
should also like to bring to attention the fact that
these splints are great labor savers, and should
they be adopted, would not only be a great comfort
to the patients but also would permit the men to
go into a convalescent home much sooner, and thus
relieve congestion to some extent in the emergency
hospitals. Transportation of these patients is also
facilitated.
The accompanying photographs illustrate splen-
didly, by contrast, the conditions dealt with.
Figure i shows the making of the splints. Figure
2 shows the posterior splint being put on a limb,
the tibia and fibula of which were fractured by a
gunshot wound. Figures 3 and 4 show the manner
in which compound fractures are treated up to the
time these men have been sent to the Sunderland
War Hospital. They show better than words can
describe the helplessness and discomfort of the
patients. Figure 5 shows these same patients
some time after they have been put up in molded
plaster splints. They are both about to be dressed.
Both these men have been out of bed two days
after the splints had been applied.
In conclusion I wish to report a few cases treated
as described above :
Case I. — Private K. Compound fracture of tibia, and
simple fracture of fibula (right leg). On admission was
on a posterior frame splint. One wound four inches in
length on anterior surface of leg, and about two inches
of the upper fragment of the tibia exposed ; another wound
on calf of leg; both wounds infected. Dressing of the
wounds was most painful, due to the manipulation. The
discharge was profuse, and necessitated frequent dress-
ings. Patient was forced to lie on back, and could not
turn in any direction. When molded plaster splints were
applied, patient was able to be allowed out of bed in a
chair. Dressings were not painful. Patient could support
his own limb and turn in any direction without the slight-
est pain. The bilateral side splint was the permanent one.
Carrel-Dakin treatment was carried out, and there was
no damage done to the splints. Patient was shortly after-
wards sent to a convalescent hospital.
Cask II. — Sergeant S. Compound practure of ulna and
radius, upper third of left forearm. On arriving at Sun-
derland War Hospital was in a skeleton extension splint, ^
similar to the one shown in Fig. 3. There were two
wounds each about three inches in length, one anterior and
one posterior. Dressing was most inconvenient and pain-
ful. Patient was confined to bed and turning about in
bed was impossible. Two days after the molded plaster
splints were applied patient was out of bed. The splints
were kept on for one month. Wounds are now all healed
and patient is ready for return to his unit.
C.ASt III. — Private B. Compound fracture of surgical
neck of humerus, compound fracture in elbow, compound
fracture of ulna and radius, and compound fracture of lit-
tle finger, all on the right arm, forearm, and hand. On
admission to this hospital he had an iron skeleton splint
on arm and forearm. Heavy walking near his bed would
jar him so that he winced with pain. He was decidedly
septic and exhausted, his wounds demanded frequent
dressing. He was operated upon. All the wounds were
cleaned out and treated with Bipp except the wound of
the surgical neck of the humerus, which was treated by
the Carrel-Dakin method. While still under anesthetic
the molded plaster splints were applied. When sepsis had
subsided the man was allowed out of bed. He has since
been transferred to a hospital in London, still wearing the
splint. The wounds were healed and union between the
hragments had taken place in all the fractures.
I wish to thank Lieutenant Colonel J. W. Alex-
ander, D. S. O., M. D., administrator of War
Hospital, Sunderland, for kind permission to pub-
lish this paper.
YALE'S MEDICAL ACTIVITIES AT
CHANGSHA, CHINA.
By Amos P. Wilder,
New Haven, Conn.,
Secretary -Treasurer of Yale-in-China.
Enthusiastic young men of Yale University thir-
teen years ago started at Changsha, the capital city
of Hunan Province, what they supposed would be a
centre of higher education on a missionary basis.
This early ideal has been well sustained, some fiftv
men and women having gone out for a longer or
shorter service as teachers. However, the medical
Dr. Branch, of the Yale Mission, Changsha, China, celebrated
the opening of the new $200,000 hospital in January, 1918, by
performing an abdominal operation. A doctor from an interior
mission has come in to see an expert operate. An American nurse
at foot. Chinese pupil nurses at left.
opportunity was so great, and the doctors and
nurses sent out were so well equipped and keen in
December 14, 1918.] WILDER: YALE'S MEDICAL
their work that the medical side of "Ya-H," as tho
Chinese call it, has developed beyond all expecta-
tions. Hunan Province has 22,000,000 people, and
while the foreigner was an object of aversion, to
put it mildly, before the Boxer year (1900), the
Yale doctors made themselves so useful that the
Chinese saw an opportunity and for once native
conservatism was overcome.
The gentry and litterati made overtures for :i
medical school, which is now in operation under
the joint supervision of Chinese and Yale teachers
with sixty pupils. A nurses' training school has
been developed under Miss Nina D. Gage, who
served during the past summer at the Vassar
School ; and the hospital, a $200,000 building, the
gift (if a niemhcr of the Harkness family, has
An old powder magazine converted into an emergency hospital
at the Yale Medical Mission, Changsha, China.
proved very useful during the recent revolutionary
troubles, which largely centred in Hunan. The
China Medical Board makes a liberal grant to the
medical activities for a period of years ; and the
provincial government does the same and — which
does not always follow in that country of shifting
administrations— has actually paid the money for a
period of years. While the preparatory school and
college are staffed exclusively by men with Yale
degrees, among the seven doctors are men of other
training; and the hopes of expansion after the war
are so great that cooperation from a number of
quarters is proposed. The medical students at
Changsha represent six or seven provinces. The
school has the advantage of a college on the same
campus from which to draw largely for its pupils. .
ACTIVITIES IN CHANGSHA. 1031
As soon as conditions are favorable, the construc-
tion of a laboratory, for which the China Medical
Board has appropriated $38,000, will begin. Here
the young men will get their biology, physics, and
chemistry.
In the Yale school instruction is given in the
h'nglish language. Just what the scope of the
school will be, compared with the more ambitious
})lants of the China Medical Board at Peking and
A street scene in Changsha, China, showing the "office" of _ a
native doctor who for a cent and a half will put on a plaster while
vou wait warranted to "cure major and minor infirmities."
.Shanghai, remains to be seen. It will depend to
some extent on how heartily the Yale alumni body
respond to what is undoubtedly a great opportunity.
Whether the Changsha school shall become a highly
equipped plant, with all that means of departmental
development at great cost, for the supreme training
of leaders in medicine in China ; or whether it must
be content to do substantial work on a more modest
basis in the training of many merely good physi-
cians remains to be seen. There is a Medical Ad-
Civilian victims of bandift and soldiers of North and South fac-
tions lirought in to be treated at the Yale Medical School at
Changsha, China.
visory Board of Yale graduates in this cotintry, of
which the members are Dr. William H. Welch, Dr.
Walter B. James, Dr. Samuel W. Lambert, Dr.
Harvey Cushing, Dr. Richard P. Strong, Dr. Fred
T. Murphy, Dr. George Blumer, and Dr. John
Howland.
5 White Hail.
I032
ROVINSKY: CELLULITIS DUE TO A FOREIGN BODY.
[New York
Medical Journai,.
CELLULITIS OF THE UPPER LID DUE TO
A FOREIGN BODY
Report of a Case
By Alexander Rovinsky, M. D.,
New York.
The patient, eight years of age, was brought by
his mother, to the eye clinic of the Post Graduaf.e
Hospital, with a history of having had a piece of
wood "shoved" into his eye by a playmate some
eight weeks previous to his presentation for ex-
amination. The day following the mishap the eye
became swollen and has practically remained so
until the present time, notwithstanding treatment
afforded it by private and dispensary physicians.
The patient is a boy of average physique, for his
age and station in life. The right eye is enormously
swollen and entirely closed by mechanical ptosis
due to the weight of the edematous lid. The swell-
ing is rather uniformly soft to touch, but conveys
no impression of fluctuation. The boy evinces no
particular pain or tenderness on manipulation, ex-
cept when an effort is made to separate the lids.
Eversion of the upper lid is of course out of the
question, but on forcibly separating the lids the
globe proper seems to be untouched, the cornea is
perfectly transparent and the pupillary reaction
normal. There is, however, considerable chemosis
at the nasal portion of the conjunctiva, and a slight
protosis outward ; the eye performs its excursions
more or less freely, except inward, where its mo-
tion is rather limited.
The history of the case and the general appear-
ance of the eye suggested, at first glance, the possi-
bility of d traumatic orbital cellutitis ; however, the
fact that the condition was practically stationary,
having persisted for two months without any in-
vasion of the eyeball and the circumorbital tissues,
to judge by the mother's statement, and, what was
most important, the behavior of the boy, who
seemed not to suffer any pain except as above
stated, spoke decidedly against cellulitis of the orbit.
To be sure this latter, generally a very serious and
often dangerous inflammation of the retrobulbar
tissue, while usually accompanied by constitutional
symptoms such as chills, fever, headache, general
malaise, etc., may sometimes appear in a compara-
tively light form, run a more or less severe course,
and pass without leaving any trace behind. To ex-
clude the possibility of extension of an inflamma-
tory process from any of the neighboring sinuses
— hardly probable in one of that age in whom the
sinuses are as yet anatomically undeveloped — we
look an x ray, tlie report showing a frontal sinus
small and infantile in character, but with outlines
and septal markings well defined, and the ethmoid
and maxillary apparently clear. The absence of
thickening and pain at the margin of the orbit, as
fai as it could be palpated through the swollen tis-
sue, excluded the possibility of a marginal or orbital
periostitis.
He was given some Burow's solution for external
application, and the mother was instructed in or-
dinary eye toilet. The boy failed to report for two
weeks, and when he appeared again I found the
swelling had gone down somewhat, his condition
otherwise unchanged. On palpating the swelling
I detected a firm elongated foreign body immedi-
ately under the lid, its proximal extremity toward
the inner canthus. A slight pull with the forceps
brought to light a sliver of wood about an inch long
and one quarter inch wide in its widest portion.
The removal of the body was unaccompanied by
any reaction, the chemosis disappeared entirely in
a couple of days, ophthalmoscopic examination
'showed the media clear and the fundus normal, with
normal vision. There was a slight mechanical ptosis
which gradually improved, until at the time of writ-
ing, three weeks after extraction of the body, the
lid has taken on its normal shape and motility.
The interest in reporting the case lies in the rather
unusual size of the foreign body that lay deeply im-
bedded in the palpebral tissue for ten weeks with-
out seriously injuring either the lid or the eyeball.
In dealing with any lid injury, whether a contused
or lacerated wound, a burn, an imbedded foreign
body or what not, the fact should be constantly
kept in mind -that, thanks to the considerable elas-
ticity of the skin covering the lids and their loose
attachment to the subjacent parts, the edema and
ecchymosis resulting from any trauma is much
greater than one would expect to find from the
nature of the injury, in fact greater than would be
found in any other part of the body after a similar
injury — comparatively slight contusions are apt to
be followed by enormous edema and extensive dis-
coloration. With this in view a thorough examina-
tion is called for to determine whether, in addition
to the swelling and discoloration, there is also an
open wound in the lid, and an involvement of the
orbit and the eyeball. It would appear in this case
that the edema was so extensive that the foreign
body was successfully hidden in the tissues so that
a perfunctory palpation failed to elicit its presence.
Later on, evidently, when the swelling subsided to
some extent it came so much nearer to the surface
that it was removed without difficulty.
1340 Madison Avenue.
The So Called Lucid Interval in Manic Depres-
sive Psychoses. Its Medicolegal Value. — Alfred
Gordon (Americaft Journal of Insanity, April,
1918) thinks that the attitude of the community
towards the manic depressive in the intervals be-
tween his attacks is very important. Should he be
left at large, and. if so. should he be allowed free
control of his affairs? Doctor Gordon relates two
cases from his own practice in which the patients,
although appearing absolutely normal to the world,
showed decided defects of judgment and transvalua-
tion of emotional values. He believes that the
length of time elapsing between attacks is some in-
dex to the degree of recovery, inasmuch as when
attacks occur every year or every few years the
subject is less likely to be normal during the inter-
vening period than when many years go by without
an attack. In any case this author thinks that such
a patient should always be provided with admin-
istrators or counsel to protect his affairs.
December 14, 1918.]
ABSTRACTS AND REVIEWS.
1033
Abstracts and Reviews.
THE ANNIVERSARY ADDRESS OF THE
NEW YORK ACADEMY OF MEDICINE.
Thursday Evening, December 5, ipiS.
The President, Dr. Walter B. James, in the Chair.
Dr. Walter B. James opened the meeting and
introduced the speaker of the evening in a short
address in which he said that all through the war,
which had so happily come to a close, the most valu-
able information to the world had been accumulat-
ing and the need for its propagation was becoming
more urgent. Constantly through the horrors and
terrors of the conflict, certain features which the
war seemed to have brought out had attracted
marked attention throughout the world. This had
been especially true in the direction of biology and
the relation of the other natural sciences to the ordi-
nary aftairs of human life. The explanation of the
various phenomena of life by the laws of chemistry,
physiology, biology, and so on, were of great value
and interest to mankind. Tonight Professor Edwin
G. Conklin, professor of biology in Princeton Uni-
versity, had kindly consented to deliver to the Acad-
emy the anniversary address in which he would ex-
plain the relation of the laws of biology to true de-
mocracy.
THE BIOLOGY OF DEMOCRACY. WITH ESPECIAL REFER-
ENCE TO THE PRESENT WORLD CRISIS.
Professor Edwin G. Conklin, of the depart-
ment of biology, Princeton University, maintained
that the outcome of the recent war was in perfect
accord with the established laws of biology. The
whole course of evolution from ameba to man had
been marked by increasing specialization or limita-
tion of constituent parts of an organism and their
integration and cooperation in the organism as a
whole. Nature invariably sacrificed the individual,
if necessary, for the good of the colony or race or
species. Many German scientists as well as mili-
tary men had claimed the sanction of science, and
especially of biology, for the beneficial effects of
war. for a militarized state and for a hereditary
aristocracy. Nevertheless, the war had ended with
the victory of the forces fighting for democracy,
and it would appear that not only was the world
now safe for democracy but that it was unsafe for
anything else. If democracy was to endure, how-
ever, it must rest upon science as well as sentiment,
and it might be profitable on this occasion, in ad-
dressing members of the greatest of the biological
professions, to examine certain aspects of democ-
racy in the light of biology, for the principles of
biology applied to man and his institutions no less
than to other organisms.
In looking for the biological bases of democracy,
one found many kinds of democracies in many fields
of human activity, for example in government, in-
dustry, commerce, education, etc., and it was difificuit
to define the exact meaning of the term. But it
would be admitted that democracy in its widest sense
meant the ultimate control of all matters of common
interest by the people as a whole rather than by any
person or class. The rights of man as man have
ever been the foundation stones of democracies.
The American Declaration of Independence and
also the motto of France, "Liberty, Fraternity,
Equality," represent in many respects the funda-
mental ideals of democracy.
Questions of great biological and social import-
ance were these : How could there be individual lib-
erty together with social organization and harmony,
universal fraternity in spite of national and class
antagonism, democratic equality in spite of in-
herited inequalities ? Was the ideal state one in
which the social bond was as loose as possible
and individual freedom was the chief aim, or
was it one in which the bond was as close as pos-
sible and the good of the nation or race or species
was the supreme object? There could be no ques-
tion as to the biological answer ; sacrifice of the in-
dividual was to be made, if necessary, for the good
of the nation.
If democracy meant decreasing specialization and
greater personal freedom it meant disintegration
and extinction. Democracy, however, did not neces-
sarily mean this. It was only the early experience
of this country as a pioneer society, where it was
possible for every person to be a self sustaining
unit, that led to this conclusion. As the country
became more populous greater specialization and
limitation of individuals and greater cooperation
and harmony among them were essential. The free-
dom of the individual merged necessarily more and
more in the larger freedom of society. Democratic
freedom of necessity meant the freedom of society
rather than that of the individual.
There then remained the problem of overcoming,
by the ideal of universal fraternity, the known facts
of national and class hostility. It was highly prob-
able that all people of English, French or German
stock were descended from the ancestors of a thou-
sand years ago, and therefore it was a biological
fact that, if not brothers, they were all at least
cousins. If the number of one's ancestors doubled
in each ascending generation, as would be the case
except for the marriage of cousins of various de-
gree, every one would have had more than one
billion ancestors one thousand years ago, and every
one was literally descended from royalty and from
any and every other person of one thousand years
ago who left many descendants, including nonentities
or worse. People hunted up their noble ancestors but
they carefully overlooked the others. In length of
descent all were equal, and in community of descent
all were cousins if not brothers. As a result of this
common descent human resemblances were vastly
more numerous and important than the differences.
Racial and varietal differences represented a natural
classification based chiefly upon physical character-
istics and these differences tended to cause a natural
and desirable segregation of races, but they did not
justify racial antagonisms. The fundamental in-
stincts of all races were so essentially similar that
all might and often did live together in harmony ;
and the cooperation of all types of men in organ-
ized society was so much a matter of education and
environment that the most distinct races might work
together in mutual helpfulness.
I034
ABSTRACTS AND REVIEWS.
[New York
Medical Journal.
Coming to those minor subdivisions represented
by various European stocks, the distinctions were
usually so slight that they formed no natural bar-
rier to the most intimate association and coopera-
tion, as had been abundantly demonstrated in this
country. The inherent antagonisms between these
stocks that agitacors and designing politicians talked
so much about were really not inherent at all, but
were largely created, cultivated and magnified for
factional and selfish purposes. The biologist would
look with concern upon the breaking up of Eu-
ropean nations hito minor independent units, just
as the intelligent American would deprecate the
breaking up of his own country along similar lines.
Such a process represented disintegration and devo-
lution rather than progress and evolution.
The most artificial and unnatural classification of
all minor class distinctions were those relating to
wealth and social position. This did not mean that
persons should not prefer association in congenial
groups which had common interests and ideals ; but
when attempts were made to array one group
against another and to make these classes perma-
nent and hereditary, an artificial disharmony was
introduced into society which could work only dis-
astrously. Autocratic personal or class rule was
always bad, for no person or class was wise or good
enough to rule other persons or classes without their
consent. The strength and stability of governments
were proportional to their all inclusiveness, their
breadth of base ; whereas autocracies were inverted
pyramids. Equal universal suffrage and majority
rule were the only selfpreserving mechanisms yet
discovered for harmonizing conflicting elements in a
population ; they were the safety valves of society.
Majority rule would level society down to gen-
eral mediocrity we're it not for the instinct of the
people to follow leaders. Neither in a democracy
nor in an aristocracy did the people make the plans
for the form of government, for war or peace, or
for anything else. These plans were always made
by leaders, but in the one case they were laid before
the people for approval or disapproval and in the
other they were not. The greatest danger that con-
fronted democracy was not in its slowness and in-
efficiency, but was plainly represented by the fact
that unscrupulous leaders might pervert and
misdirect the normal social instincts of the people
in order to accomplish selfish and partisan purposes.
The only remedy for this great danger was to edu-
cate the people as a whole to appreciate the differ-
ence between emotional and rational appeals.
The democratic creed of the United States was
that "all men are created equal," and yet nothing
was more evident than that all men were unequal
in personality, intellect, and influence, and biology
showed that many of these inequalities were in-
herited. How should one harmonize the teaching?
of biology with those of democracy? Hereditary
aristocracy was founded upon an obsolete idea of
natural inheritance, namely the law of entail. It
confused social and biological heredity. A son
might inherit the property of his father in entirety,
but not his personality ; his titles and privileges, but
not his intellect and character. "From yon blue
heavens above us bent, the gardener Adam and his
wife smile at the claims of long descent." In bio-
logical heredity the qualities of the parents were
separated and distributed to the offspring so that the
latter were mosaics of ancestral traits. The best
traits might appear in parents and be lost in their
children. This was the great law of heredity dis-
covered by Mendel and it differed fundamentally
from the law of entail. The law of entail was
aristocratic but the law of Mendel was democratic.
No family had a monopoly of good or bad traits
and no social system tould afford to ignore the great
personahties that might appear in obscure families
or to exalt nonentities to leadership because they
belonged to great families.
Democracy did not mean that all men were equal
in personality. It was not a denial of personal in-
equalities, but only the genuine recognition of them.
Rigid class and family distinctions, on the other
hand, were denials of individual distinctions. It
did mean equality before the law, no special priv-
ileges due merely to birth, freedom to find one's
own work and place in society. In short it meant
that every man was to be measured by his own
merits and not by the merits of some ancestor
whose good qualities might have passed to a col-
lateral line. Democracy alone permitted a natural
classification of men with respect to social value,
and it contributed more than any other system of
government to the contentment, peace and stabilitv
of the peoples of the world.
"Who breaks his birth's invidious bar,
And grasps the skirts of happv chance.
And breasts the blows of circumstance.
And grapples with his evil star ;
And moving up from high to higher.
Becomes on Fortune's crowning slope
The pillar of a people's hope,
The centre of a world's desire."
Canada's Reconstruction Work for Her Sol-
diers.— Mr. T. B. Kidner, vocational secretary
of the Invalided Soldiers' Commission of Canada,
tells in The Modern Hospital for November, 191S.
the steps taken by his country in the important work
of reconstruction of the returned soldier. Begin-
ning with improvised and altered structures for ten-
dering hospital service to disabled soldiers. Canada
later devised and erected special types of buildings
at various points throughout the country, which,
although of substantial type, are not permanent in
their nature. After a time, steps were taken to
provide for the placement in civil employment of
men who had been discharged, after their rehabili-
tation was complete, and early in 1916 vocational
reeducation was undertaken. Simple workshops
were established, followed later by a wide variety
of opportunities which enabled every man, under-
proper hospital supervision, to undertake some form
of activity, mental or phvsical. which would be help-
ful to him. Public, semipublic. and private agencies
have all cooperated in the great problem of the re-
absorption of the disabled men into civil life, and
Canada's unusual success in this work of greatest
importance is well worth the attention and study
of America today.
Medicine and Surgery in the Army and Navy
RECEIVING WOUNDED FROM OVERSEAS.
First Patients Arrive at Debarkation Hospital No.
J. — How the Grecnhnt Building IV as Recon-
structed.— Largest Kitchen in the City. — Cafe-
teria Service on a Large Scale.
A single policeman on a motorcycle turned into
the almost empty street from Fifth Avenue at slow
speed and stopped just beyond the canopy of the
Eight eenth
Street en-
trance. A
long line of
khaki colored
-m^ balances
followed.
Two women
in leather
coats sat on
the driver's
seat of each.
As the first
a m b u 1 a nee
drew along-
side the curb
a tall, pale
young man of
twenty - five,
with whitened
hair, stepped
slowly down
with his roll
of blankets,
h i s colored
"ditty bag,"
and his mess-
kit in h i s
hands and
passed into
the open
door.
The first
patient had
come to U. S.
D e barkation
Hospital No.
3- This first
patient, Pri-
vate M u i r,
was fro m
Maiden.
Mass., and
was recover-
i n g from
p n e u m onia
followed
by empyema.
The second to
square browed
was a messenger attached to battalion headquarters
and formed part of the second wave. A sniper
hidden in a tree shot him through the right arm.
He fell, rose, tied up his arm and walked back
through a rain of bullets to a first aid station. Since
then he had passed through one hospital after an-
other, French, Jiritish and American, all good, all
well managed, but the American best of all. "You
are with your own folks."
pa-
filed
MAJOR W. J. MONAGHAN, M.
Commanding Officer U. S. Debarkation Hospital No. 3.
step out was from Mississippi. A
Celt whose upstanding shock of
black hair, fair skin and deep blue eyes proclaimed
his origin even before one learned that his name
was Murphy.
Murphy "got his" at Soissons on July 20th. He
T h e
t i e n t s
into a room
fitted with
plain benches,
for all the
world like the
waiting room
in an out-pa-
tient depart-
ment. Every
patient had
personal be-
longings o f
some kind in
awkward, un-
gainly pack-
ages or can-
vas bags.
Many used
crutches, and
a few were
on litters.
These, of
course, were
carried.
Across the
rear of the
room ran a
barrier be-
h i n d which
sat ten hos-
pital corps
men at type-
writing ma-
chines. Each
patient
stepped up to
the barrier.
A typist
filled out a
clinical brief,
form 55A, in
tri p 1 i c a t e.
Taking a
copy, the pa-
tient passed
down the
counter where an officer and an orderly listed
his valuables, placed them in a numbered envelope,
pinned it up and gave the patient a receipt
signed by the officer, the patient signing a car-
bon duplicate. The patient then passed into an
undressing room with a bench along one side. Here
Copyright International Film.
In the conservatory.
1036
MEDICINE AMD SURGERY IN THE ARMY AND NAVY.
Medical Journal.
[New York
an orderly helped him undress and carried the cloth-
ing to the next room where the naked patient and
his underclothing were carefully examined for ver-
min and evidences of contagious diseases by one of
ten medical officers standing there. If vermin were
found, that fact was noted by the surgeon's orderly.
The patient with his attendant orderly passed into
a clothing room of which there were two, one for
infected and one for "clean" men. The clothin:^
was deposited in three piles, in one the underwear,
which went into the laundry chute without identifi-
cation marks, in another the outer clothing, which
had no leather attached to it, and in the third the
leather equipment. A bin number tag was at-
same ward, returned to each his papers and con-
ducted the group to the elevator and then to the
proper ward. Here the ward surgeon and ward
nurse met the group and assigned the men to their
cots. This was journey's end — for a while.
The first patient arrived at 12:20 noon on No-
vember 23d. In just forty minutes he was seated
by his cot writing a letter home on a pad of paper
handed him by Major Lamond, the American Red
Cross representative.
Presently the patients were led to the dining room
on the second floor. This room can seat 2,000. The
tables are of unpainted pine. The tops are re-
movable and each board of the top is washed on all
Copyright International Film.
PART OF THE ADMINISTRATIVE STAFF OF U. S. EMBARKATION HOSPITAL NO. 3.
Seated, left to right: Lieutenant I. S. Tassman, registrar; Captain W. W. Osgood, sanitary inspector; Lieutenant A. F. Anderson,
Adjutant; Major W. J. Monaghan, commanding officer; Captain Ralph H. Jones, S. C, medical supply and property officer; Lieutenant
William Baylies, Q. M. C.
Standing, left to right: Lieutenant F. J. Quist, commanding officer, detachment of patients; Lieutenant A. E. Anderson, chaplain;
Captain B. R. McClellan, chief of surgical service; Captain Dennis C. O'Neil, chief of medical service; Captain D. E. Eraser, dispo-
sition officer; Lieutenant W. C. Swartout, personnel adjutant; Captain C. H. Haas, mess officer; Lieutenant W. G. Nichols, assistant
adjutant.
tached to the outer clothing and the equipment, a
duplicate of which was handed the ])atient. This
clothing was later sterilized, the leather goods by
formaldehyde, the other by steam, and returned to
the patient. The patient then stepped into the
shower room where two orderlies scrubbed him
down thoroughly with soap, under a warm shower,
the temperature of which was governed by thermo-
stat. Two other orderlies dried him with big bath
towels and the linen man then handed him a suit of
pajamas, a pair of slippers, and a flannel dressing
gown. An orderly then collected the patients in
groups of five, all of whom had been assigned to the
four surfaces every day. A railed-oflf passageway,
eight feet wide, leads from the door to the serving
counter at the opposite end of the room. On each
side other railings divide oft' the passage for out-
going patients. At the door the mess officer, Cap-
tain C. H. Haas, M. C, directed all the maimed
who seemed unable to carry a tray to tables already
set, where they could be waited on. "Say, but I'm
glad to wait on those fellows," said one orderly as
he passed with a heaped-up tray. "Just think what
they've been through ! We can't do enough for
them." And this spirit seemed to animate every
man in the hospital from the commanding officer,
December 14. 1918.] MEDICINE AND SURGERY IN THE ARMY AND NAVY.
Major W. J. Monaghan, M. C, to the smallest runt
of a rookie in the ranks of the medical detachment.
The patients able to wait on themselves, passed
on to the cafeteria counter. Here each picked up
a tray, knife, fork, etc., and passing down the line
received his helping of bread, butter, steak, beans,
potatoes, gravy, macaroni and coffee, and found a
seat where, between mouth fuls he discussed with his
fellows the possibilities of early shipment home.
"After a
little experi-
ence we can
handle incom-
ing patients at
the rate of 200
an hour," said
Major Mona-
ghan.
They are
lucky patients
who are as-
signed to Em-
barkation Hos-
pital No. 3. It
is in the heart
of the city oc-
c u p y i n g the
Greenhut and
the C 1 u e 1 1
buildings,
which extend
from Eigh-
teenth to Nine-
teenth Streets
on the east
side of Sixth
Avenue. The
Greenhut
Building
has a total
floor space of
300,000 square
feet, or fift~een
acres. The
building is one
of the best
lighted of its
size in the city,
for it has
52,198 square
feet of outside
windows ,some
of which have
a single pane
of glass twenty
feet wide by
fifteen feet
high-
The Cluett building, eleven stories high, is used as
barracks for the enlisted men, the Greenhut building
being devoted to the hospital proper. The main
floor of the Greenhut building, on the Sixth Avenue
side, is occupied by a Red Cross theatre seating
nearly a thousand. Around this auditorium are
booths giving some privacy for patients in meeting
their visitors.
U, S. DEBARKATION HOSPITAL NO. 3.
The Greenhut Building, on Sixth Avenue from Eighteenth to Nineteenth
New York. The hospital has a capacity of 3,400 beds.
The main floor also furnishes the receiving rooms
already described and a garage for twelve automo-
biles. ,
On the roof is a conservatory with over 4,000
square feet of floor space and with glass walls and
roof which is fitted up as a lounging room. This
has been supplied with palms, ferns, a piano and a
victrola through the kindness of friends.
On the mezzanine floor arc the offices of the com-
manding officer
and his staff.
The western
portion of the
second floor is
devoted to
three surgical
wards and the
southern por-
tion to one of-
ficers' ward.
T h e eastern
portion houses
the diningroom
and kitchen.
This kitchen is
the largest in
the city of
New York and
is fitted up
with the very
latest and best
equipment.
Every utensil
used is of alu-
minum, this
metal being
used even for
the six big
steam jacketed
kettles for
boiling soup,
and six coffee
urns, each with
a capacity of
sixty gallons.
The kitchen
equipment in-
eludes 140
running feet of
heavy duty gas
ranges, eight
steam cookers
which carry
350 pounds
pressure and
four low pres-
sure steam
cookers, and an
electrically driven kitchen machine with attachments
for mixing dough, grinding meat, whipping cream,
mashing vegetables, etc. There is also an electrically
driven potato peeler which peels twelve barrels of
potatoes in an hour and which does it with such
great econom}' of potatoes that when the hospital is
running at full capacity it will save its own cost,
$640, from this economy alone in six weeks.
Streets,
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Joi-rnal.
The cafeteria idea is applied in a modified form
to the service for bedridden patients, the cafeteria
going to the patient instead of the patient going to
the cafeteria. This rolhng cafeteria consists of a
service wagon on four wheels fitted to receive four
covered food containers each twenty-two inches
long, fourteen inches wide and eighteen inches deep.
Some of these are subdivided. They also fit into
the steam tables of the cafeteria in the main dining-
room. The nurses will supply each bed patient with
a tray, plate, etc. Two of these mobile cafeterias
are wheeled to the bedside and the patient served
with food and drink direct from the big containers.
These dififer materiallv from the service wagons
The dental surgeons. Captain H. B. Reilly, D. C~,
Lieutenant F. S. Adams, D. C, and Lieutenant
H. West, D. C, have two dental chairs, with the
latest equipment of dental engines, etc., adjoining
the surgical rooms.
The X ray rooms are also on the fourth floor and
art equipped with three fixed and three portable
X ray outfits beside a special fluoroscope apparatus
with a screen measuring twenty-four by eighteen
inches. The portables can be attached to any
electric light outlet and by their use x ray photo-
graphs can be taken of a patient in bed in any part
of the building.
The dispensary occupies a central position on the
Copyright Underwood & Underwood.
MESS HALL OF U. S. DEBARKATION HOSPITAL NO. 3.
The (lining room has a seating capacity of 2,000, and the cafeteria can serve 800 meals an hour.
usually found in hospitals in that they are built on
the principle of a fireless cooker and will carry
regular diet for 160 men. They are so geared that
one man can push them, and so narrow that they
can pass between the cots.
The operating rooms, including the dental office,
X ray room, and dressing rooms, are on the fourth
floor. The operating room faces south with win-
dows reaching from floor to ceiling. Suspended
from the ceiling is a cluster of electric lights in
circular form which provides ample illumination
devoid of shadows.
fourth floor and keeps four enlisted men busy dis-
pensing prescriptions. Two of these are graduates
of the Brooklyn College of Pharmacy and one a
graduate of the Rhode Island College of Pharmacy.
When the hospital is running at full capacity more
help will be required.
Three isolation wards, each of which has fifty
beds, are provided in a space on the eastern side of
the Greenhut building, completely walled ofT from
the remainder of the building, though communicat-
ing doors are cut in the walls.
The clinical laboratory of the Port of Embarka-
December 14, 191S.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
1039
tion, under the command of Major E. H. Schorer,
M. C, which was described in the New York Medi-
cal Journal for December 7, 1918, is quartered on
the roof of the Greenhut building and does all the
laboratory work required for this hospital as well
as acting as a department laboratory for all the
laboratories in the thirteen difi'erent hospitals under
the supervision of Coionel J. M. Kennedy, the sur-
geon of the Port of Embarkation.
One corner of the basement is occupied by the
Post Exchange. When detailed as Post Exchange
officer, Lieutenant C. C. Rogers, M. C, an eye
specialist from Allentown, Pa., asked for funds to
purchase supplies, but none were available. The
next day he reported to Major Monaghan that he
had purchased 100 quarts of ice cream, fifty dozen
soft drinks, and $200 worth of tobacco and cigars.
"But where did you get the money?" asked the
major. "I didn't get it," said the lieutenant. "I
will pay when I sell the goods." And he has been
selling them! One hundred quarts of ice cream
When run at full capacity the boilers consume 350
tons of coal a week.
RECEIVING VISITORS.
Visitors are a source of never ending worry in
every military hospital. Anxious parents come in
droves to see their hero sons and their rights must
be recognized though their presence is sadly sub-
versive of discipline unless carefully regulated. The
American Red Cross is furnishing valuable aid in
handling this problem. An entrance on Sixth Ave-
nue has been designated for visitors. On entering
the visitor confronts a desk where Red Cross rep-
resentatives supply a blank on which the visitor
writes the name, rank and command of the patient,
and the visitor's relation, whether parent, relative or
friend. The whereabouts of the patient, learned
from a card index, is inscribed on the blank and a
Red Cross messenger dispatched to find him.
The task of converting the former department
store into a hospital was placed in the hands of
Copyright Underwood & Undcrivood.
KITCHEN OF U. S. DEBARKATION HOSPITAL NO. 3.
Said to be the largest kitchen in the city of New York. It is fitted with the most modern and efficient equipment.
went in the first twenty-two hours. Lieutenant
Rogers also has a barber shop with five chairs which
took in $60 a day during the first week, netting a
profit for the exchange of $9 a day. He has also
installed a tailor shop where the men can have their
clothes pressed at rates as reasonable as those
cliarged in the barber shop — fifteen cents a shave
and twenty five cents for a haircut, with absolutely
no tipping allowed.
The roomy and numerous elevators, there are
twenty-six in the Greenhut building alone, greatly
facilitate the transportation of the patients. These
are for the most part grouped around a circular space
in the center of the building which has a diameter
of seventy-five feet. This central hall furnishes an
/deal place for parking litters and affords the space
needed in handling the patients in large numbers.
The building has its own heating and lighting
plant, including ten boilers and eight dynamos.
Major S. F. Voorhees, S. C, a New York architect ;
Captain Walter E. Lang, M. C, and Lieutenant
Russell H. Kettell, S. C, who prepared the plans
for the reconstruction. These plans were executed
under the direction of Major Charles W. Noble,
construction quartermaster. When the building was
taken over it was an empty shell. The plans origi-
nally made provided for division into small treat-
ment wards of about twenty-five beds. These plans
were changed on the ground that the institution was
to be primarily an evacuation hospital and not for
treatment and the wards were consequently changed
to hold from eighty to 125 beds. Each ward is pro-
vided with a nurses' room, a linen room, a service
room, bathrooms and toilets, so that a patient does
not have to go off the floor under any circumstances
except for food. When working at full capacity
the hospital can accommodate 3,400 patients, whose
care will require the services of sixty-five officers.
104P
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
300 nurses and 900 enlisted men. There will also
be attached to the hospital for escort duty sixty
officers and 400 enlisted men.
The nurses are quartered at the Trowmart Inn on
Abingdon Square, which has been chartered for that
purpose by the Government. While this is in walk-
ing distance of the hospital, the nurses are carried
to and from duty in ambulances, if it is so desired.
The personnel of the staff of a hospital as large
as Debarkation Hospital No. 3 changes frequently.
When the first patients arrived there were forty-
nine commissioned officers and 400 enlisted men on
duty. This number was increased on the next day
by the addition of 300 enlisted men sent over by
Colonel Hughes, personnel officer of the office of
the Surgeon of the Port of Embarkation. New
officers and men have been added pari passu with
the arrival of additional patients. On December
5th the roster showed the following officers on duty :
Administrative staff. — Major W. J. Monaghan,
commanding officer; Captain W. E. Lang, assistant
to the commanding officer ; First Lieutenant A. F.
Anderson, adjutant ; Second Lieutenant W. G.
Nichols, S. C, assistant adjutant ; Captain D. E.
Eraser, disposition officer ; Captain C. H. Haas,
mess officer ; Captain R. H. Jones, S. C, medical
supply and property officer ; Captain W. W. Osgood,
sanitary inspector; Captain H. G. Walker, assistant
mess officer ; Captain W. C. W^ilHams, receiving of-
ficer; Eirst Lieutenant E. Anderson and Eirst Lieu-
tenant E. E. Davis, chaplains ; Eirst Lieutenant C.
H. Doty, detachment commander ; Eirst Lieutenant
R. M. Hall, assistant commanding officer of the
detachment of jjatients ; Eirst Lieutenant E. J
Quist, commandmg officer of the detachment of
patients ; First Lieutenant C. C. Rogers, exchange
officer ; Eirst Lieutenant W. C. Swartout, personnel
adjutant ; Eirst Lieutenant L S. Tassman, registrar :
Eirst Lieutenant W. S. Wallace, assistant com-
manding officer of the detachment.
Surgical service. — Captain B. H. McClellan, chief
surgical service ; Captain L. H. Beals, assistant to
chief : Captain T. B. Bond, general ; Captain
John Cook, surgical ; Captain H. S. Dowell,
eye. ear, nose and throat ; Captain W. Gauch, gen-
eral; Captain EI. J. Herrick, eye, ear, nose, and
throat ; Captain George L. McKee, assistant chief
surgical service ; Captain C. H. O'Crowley, genito-
urinary; Captain Charles Whelan, x ray; Eirst
Lieutenant T. McG. Brennock, assistant to chief ;
Eirst Lieutenant T. P. Govan, assistant to chief ;
Eirst Lieutenant C. H. Johnson, assistant to chief ;
First Lieutenant T. B. King, x ray ; Eirst Lieuten-
ant J. P. Mayer, assistant to chief ; Eirst Lieutenant
F. E. Montgomery, anesthesia; Eirst Lieutenant M.
S. Nelson, surgical, and Eirst Lieutenant Morris
Rosenfeld, assistant to chief.
Medical service. — Captain D. C. O'Neill, chief
medical service ; Captain J. B. Campbell, assistant to
chief ; Captain J. P. Comegys, assistant to chief ;
Captain M. M. Denlinger, internal ; Captain W. H.
Enders, assistant to chief ; Captain H. L. Hayes, as-
sistant to chief medical service; Captain R. R. Hos-
kins, medical ; Captain T. P. Martin, general ; Cap-
tain EI. C. Mowery, general ; Captain J. Steffens,
internal ; Eirst Lieutenant J. F. Ahern, assistant to
chief ; First Lieutenant M. M. Andrews, medical ;
First Lieutenant R. Callaghan, internal ; Eirst Lieu-
tenant C. V. Calvin, internal ; First Lieutenant J. G.
Cottrell, internal ; First Lieutenant W. J. Davidson,
internal ; First Lieutenant J. A. Earrell, neurology ;
Eirst Lieutenant F. A. Glass, medical ; Eirst Lieu-
tenant W. D. Maccobee, internal ; First Lieutenant E.
A. Miller, assistant to chief ; Eirst Lieutenant H. W.
Patton, assistant to chief ; Eirst Lieutenant N. L,
Reynolds, internal ; First Lieutenant C. W. Ruther-
ford, assistant to chief ; First Lieutenant E. W.
Schlemmer, internal, and First Lieutenant D. S.
Strong, assistant to chief.
Dental service. — Captain H. B. Reiley, D. C. ;
Lieutenant E. S. Adams, D. C, and Lieutenant C.
H. West, D. C.
There are at present also 660 enlisted men at-
tached to the habitat. In addition to the personnel
attached to the hospital there is an escort detach-
ment quartered at the hospital which takes charge of
the transference of patients to other hospitals.
When a patient leaves the building Major Mona-
ghan's responsibility for him ceases. He turns him
over at the outer door to the escort detachment,
under Major C. M. Thomas, M. C, who has fifty-
three officers and 27.4 enlisted men at his disposal to
accompany patients who need escorts when they are
transferred. These men' are specially trained for
the purpose and know how to meet such emergen-
cies as might arise in the train or steamer. When
necessary, patients will be accompanied by surgeons.
All this is but one of the thirteen hospitals under
the supervision of Colonel J. M. Kennedy, surgeon
of the Port of Embarkation, who from his office in
Hoboken keeps tab on the health of the men and
women going to and coming from Europe. Now
that the tide of travel has turned he has converted
his embarkation hospitals into hospi-tals for debarka-
tion and all of them will soon have every bed filled.
WAR HELMETS.
Doctor Bonnette, of the Medical Corps of the
French Army, writes in Ld Presse Medicale for Sep-
tember 23, 1918, that the belligerent armies have all
adopted the metal helmet for troops holding the
trenches and making attacks. At the resting can-
tonments they use a soft, Hght headgear, such as a
kepi, or cap, a felt hat, a Tarn o' Shanter, etc.
In a general way, the helmet has an almost hemi-
spheric shape, like that of the head, which it pro-
tects against shrapnel bullets, ricocheting balls, and
against the small shell fragments, called grenaillons,
that rain over a battlefield on the day of an attack.
Thanks to this protection, cranial traumatisms have
diminished in frequency and gravity ; the bone ero-
sions and small fissures that are so frequently fol-
lowed by the bursting of the vitreous lamina, have
become rarer and the necessity for trephining less
common.
Previous to the adoption of the helmet, the sur-
geon was recommended to explore all cranial sores,
even the minutest and .mildest, lest grievous acci-
dents ensue. These explorations were made under
anesthesia, by opening the wound, examining di-
rectly the bony surface, and making ready to
December 14, i9'8.] MEDICINE AND SURGERY IN THE ARMY AND NAVY-
1041
trephine, in case it was deemed necessary (Koech-
lin's thesis).
At present there exists three types of helmet:
I. The Anglo- American helmet. — This steel hel-
met, very low and rather widened, is cast in a single
block, both crown and brim The metal is sonorous
when struck with a metallic object. Outwardly it
has no military insignia ; inwardly, three rivets are
seen which adjust to the hollow and the side walls
the throat strap and the inner gear. This strap, to-
ward the base of the crown, holds an oval ring
which is composed of felt, or leather, made up like
black rubber, covering and encircling the head.
This ring carries a crown of twelve cushions 0.025 cm.
thick 0.025 cm. long and 0.015 cm. wide, separated
by 0.03 cm. spaces, which favors ventilation. This
clastic cushion crown deadens the cranial shocks and
this slight mobility favors the deflection of project-
iles. Its weight varies between 1,000 and 1,080
grams, being therefore somewhat heavier than the
French helmet (which averages 800 grams) and
lighter than the German lielmet (which averages
1,400 grams). The fore and after brim is 0.03 cm.
wide and the side brim 0.05 cm. This defensive
weapon is rather unesthetic, but as a practical prop-
TYPES OF HEADWEAR USED IN THE WAR.
1. German helmet. 2 French helmet. 3. Anglo-American helmet.
4. German helmet for advance troops. 5. German sharp shooters'
helmet with removable visor. 6. Soft fatigue cap of Germans.
osition it stands the test of experience. In short, the
secret of its efficacy rests on the resistance of the
metal and also on its light mobilitv under shock.
2. The French helmet. — The Adrian helmet, used
by the French, is composed of a crown of plated
steel and a metallic border, with a steep slope that,
unlike the American helmet, has a five cm. fore and
after brim and only a two cm. brim at the sides on
the level with the ears. It weighs between 700 and
800 grains, according to height. It is horizon blue
for the metropolitan troops and khaki for the co-
lonials. On its front it shows the militarv insignia
of the dififerent army services.
On the middle upper posterior part there runs a
small metallic headpiece that covers a depression of
the hollow, ending in two air holes. Interiorly,
there is a black leather coif, terminating in seven
little strips which can be more or less tightened,
thus regulating the fitting of the helmet. At the
base of the crown and under the coif are found four
corrugated metallic thongs that give access to the
air around the skull and let the air out through the
upper holes of the headpiece. The Adrian helmet is
esthetical, the lightest of all, and affords good pro-
tection against shrapnel and small metallic frag-
ments.
3. The German helmet. — This steel casque is the
newest born, its adoption dating back to no more
than two years. It is molded in a single block, as
is the Anglo-American head piece. However, in-
stead of being very low and widened like the latter,
the walls of the crown are almost vertical. Only
the visor is a little raised. The lateral walls cover
the nape and the ears. It is seventeen cm. high,
and at the base, thirty-one cm. long and twenty-three
cm. wide. It weighs between 1,350 and 1,400
grams. Its color matches the field gray uniform of
the German soldier.
Outwardly, the crown shows five metallic rivets,
three for adjusting the inner coif and two for the
throat strap. Besides, on the lateral surfaces of the
crown there are two rounded metallic projections,
perforated with a central channel for aeration.
These projections serve as the pivots for holding a
shield, which is attached to the helmets of the scout
sentries or sharpshooters. The German helmet
bears no military insignia. Inwardly, at the lower
edge of the crown a flexible leather ring is found
which carries three wide cushions, a frontal and
two latteral ones (parietooccipital^) that adjust the
helmet and distribute the weight evenly. Through
the interstices of these cushions the ventilating air
is filtered. The German helmet is heavy and not
esthetic, but very resistant.
Shields or bullet protectors. — For the scout sen-
tries the Germans have devised a steel shield, four
millimetres thick, that embraces the frontal region
of the helmet above the visor. The posterior bor-
ders of this cuirass carry a notch that enables it to
be joined and fixed at a level with the two lateral
metallic pivots of the helmet. This bullet stopper
weights 2,500 kilograms. It is attached to the hel-
met at the rear by a leather band, which in a case of
surprise permits its being removed quickly. Accord-
ing to German medical testimony, this frontal cover
is very efficient, even against bullets with a flat tra-
jectory.
The leather pointed helmet. — These legendary hel-
mets are no longer tolerated at the front, but are
still used at the rear. This headwear has as a dis-
tinctive sign the heraldic emblem of the original
country and the national cockade on the left side.
The cap. — -The German soldier continues to wear
the ancestral and ridiculous round cap, made of field
gray stuff, as a headgear when in repose. The two
cockades, the color of the filet, and of the piping,
permit one to recognize the nationality and the prov-
ince of the wearer. The upper cockade (black,
white, and red) is that of the empi'-e and is borne
by men of all organizations ; the lower cockade,
placed over the filet, denotes the country of origin
(Prussia, Bavaria, Saxony, Wiirttemberg, Baden,
etc.) The regiments of the guard have a cockade
with two black circles embracing a white circle.
All the belligerent armies have felt the necessity
of adopting a steel helmet for their front line troops.
Thanks to this efficacious protection, the cranial
wounds have notably diminished both in frequency
and in gravity.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, twenty-five cents.
Remittances should be made by New York Exchange,
pest office or express money order, payable to the
A. R. ElHott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Medjour, New York.
NEW YORK, SATURDAY, DECEMBER 14, 1918.
THE WOUNDED COME HOME.
Almost every day for the past week transports aiii
liners have arrived at New York bringing back sol-
diers from overseas. Every ship brings some sick
and wounded and the two naval hospital ships Com-
fort and Mercy have brought patients only, and, for
the most part, those who were seriously wounded.
They come from every section of the Western front
and present almost every phase of disability. As
they arrive these patients are sent to some one of the
three debarkation hospitals now in commission, Ellis
Island, Fox Hill, Staten Island, and Debarkation
Hospital No. 3, in the Greenhut Building, which is
described at some length in this issue. These insti-
tutions are being used as evacuation hospitals, where
the patients are sorted as to their complaints and
needs, and forwarded for treatment to that hospital
best adapted to their requirements. The arrange-
ments made for forwarding the patients to treat-
ment hospitals includes the organization of an escort
detachment, composed of officers and men of the
medical department who accompany the patients.
collected in groups, to the respective hospitals to
which they are forwarded, giving them any needed
attention en route.
While these evacuation hospitals are not intended
primarily for treatment, they are provided with an
adequate stafif of surgeons and with a complete
equipment, including operating rooms and x ray
and clinical laboratories, so that the treatment of the
patient is not interrupted while in these hospitals.
The patients are under constant supervision and the
development of any morbid characteristic or un-
toward symptom is immediately noted and followed
up with proper treatment. Where a tuberculous
patient develops unfavorable symptoms, an x ray
is at once taken, and in several cases where the
presence of large quantities of pus was shown op-
erations were performed, immediately giving relief.
In several cases of cranial injury x rays have shown
the presence of foreign bodies or of suppuration,
and the patients have been promptly relieved by
operation. Where indicated by the condition of the
patient routine treatment is also given.
The location of one of these debarkation hospitals
in the heart of tlie city has awakened the public to a
better realization of the work being done by the med-
ical department, and volunteers of all sorts, both
organized and unorganized, have oflfered their serv-
ices in many directions. The patients have been lion-
ized to an extent calculated to turn the head of the
most matter of fact man. They have been deluged
with invitations to entertainments, to dinners, and to
automobile rides. The hospital in the Greenhut
Building is provided with a large auditorium and a
stage, where Broadway favorites have volunteered
to present their plays. In fact, the hospitality and
hero worship of the general public have imposed a
considerable burden on the administrative stafif of
this particular hospital. In view, however, of the sal-
utary effect of these attentions on the morale of the
patients, such attentions have a distinct therapeutic
value. This enthusiasm will probably wane as the
novelty wears off and will cease to be embarrassing.
There is no question, however, that back of the ex-
citement of the moment there exists in the hearts
of our citizens a feeling of gratitude toward the
yoimg men who have made such sacrifices for our
country and that the public will continue to extend
a cordial and a heartfelt welcome to all the wounded
as they come back, even though that welcome may be
a shade less demon.strative than that accorded to the
first contingent which landed after the signing of
the armistice.
December 14, 1918.]
EDITORIAL ARTICLES.
1043
CANCER OF THE CLITORIS.
Of secondary malignant growths of the clitoris
little need be said, as they are devoid of interest,
but the same does not apply to primary ciancer of
the organ.
The etiology of the primary type is obscure
and the process is of great infrequency as well.
Out of a total of 3,349 cases of malignant diseases
of the genitalia, Gurlt was able to find only
eighty-one cases concerning the vulva, and only
ten instances of primary cancer of the clitoris.
However, forty cases of primary cancer of this
organ have been found scattered through the lit-
erature by Bjorquist and Jacoby, but many of the
case reports were incomplete.
Cancer of the clitoris is more prone to occur at
the time of the menopause or later in life, but
there are exceptions to this rule. Thus, Launois
met with an instance in a little girl five years of
age, and it would appear from statistics that it is
less common before the age of fifty years than
after that of seventy.
As to the etiological factors, properly speak-
ing, there is much divergence of opinion, and al-
though in most reported cases the patients were
multiparae, it is difficult to affirm that labor had
anything to do with the development of the neo-
plasm. Masturbation and repeated traumatism
have likewise been invoked, and the late Sir J.
Hutchinson, who certainly possessed a keen di-
agnostic acumen, maintained that syphilis was an
etiological factor, stating that luetic ulcerative
processes can degenerate into cancer in such a
gradual and imperceptible manner that it is im-
possible to say where one process begins and the
other ceases. A number of French observers are
of the same opinion.
Ordinary pruritus has been invoked as a causa-
tive factor of malignant disease of the clitoris,
and it is quite true that many patients complain
of pruritus, not as a symptom at the onset of the
process but before papillomatous growths of the
organ have been known to undergo malignant
transformation, as in other regions of the body.
Buccal psoriasis is an aflfection which, par ex-
cellence, predisposes to the development of can-
cer; the same applies to leucoplasia of the vulva
in the case of primary malignant disease of this
structure. The histologic structure of epitheli-
oma developing on a leucoplasic spot has been
described in a masterly way by Le Dentu, Piche-
vin, and A. Pettit. They noted the presence of
epidermic globes and caught the transformation
of the leucoplasia into cancer in the act, so to
speak, and they conclude that the epithelioma is
not merely an accident resulting from mechanical
changes of the horny plaque, but rather an ulti-
mate evolutive phase of leucokeratosis ; while P.
Petit, from his studies, concludes that from leuco-
keratosis to cancer is but one step, if even leuco-
keratosis is not in reality the early stage of
cancer.
It is, therefore, fair to assume that most, if not
all, cases of vulva leucoplasia end in cancer, and
the logical conclusion would be that the same ap-
plies to cancer of the clitoris, thus attributing the
most important place to leucoplasia as an etio-
logical factor of primary malignant growths of
the clitoris.
HIGH HEELS IN MEN.
It has been for so many years the custom of the
trousered sex to ridicule the foibles of the restless
sex that it is with rather a wry laugh that we find
the tables turned nowadays in some particulars.
For example, the tightness of women's shoes and
the height of their heels have been a stock joke,
but any one who has spent much time'in examining
the feet of prospective recruits will wonder why
the female sex was singled out in this regard. Such
a quantity of corns, bunions, hammertoes, and flat
feet certainly were never seen in any other age.
A recent writer [Sylvester D. Fairweather, M. B.,
Ch. B., Aberd. : Boot Heels as a Cause of Flat Feet,
Soldier's Heart, Myalgia, etc., British Medical
Journal, September 21, 1918] has told how heels of
even moderate height may cause not only flat foot,
but such other afifections as myalgia, soldier's heart,
asthma, varicose veins, and scoliosis. He calls at-
tention to the fact that in a barefoot man standing
erect, the weight rests on the heels and the balls of
the feet, not on the arch or the inner sides of the
feet. If, however, heels of even one quarter of an
inch m height are used the body weight is thrown
on the arch ; if in a man of average height three
quarter inch heels are worn the head is thrown nine
inches ofif the vertical, and the muscles of the back,
thigh, and foot must come into action. Three
things combine to flatten the arch : the weight of
the body, the action of the peroneus longus and
brevis, and the loss of support of the tibialis anticus.
The muscles most concerned in preserving the erect
position against these odds become strained, and
myalgia results.
A soldier of average height and weight, wearing
a heel three quarters of an inch in height, has to
exert strength equal to that employed in constantly
lifting fifty-six pounds from the ground to retain
his balance. Fairweather believes that this con-
stant strain is one of the causes of soldier's heart.
1044
EDITORIAL ARTICLES.
[New York
Medical Journal,
He thinks that the sole and heel should be of the
same thickness s6 that, even if flat foot is present,
it need be no handicap.
The writer adds that if heelless shoes were worn
by women there would be no need of corsets. The
war may bring about a great many changes for the
better in our social organism, but it will not bring
about the millenium nor will it introduce us to the
spectacle of women without heels and without
corsets.
AN OLD ENEMY OF PUBLIC HEALTH.
This is a time of rapid advance toward national
prohibition of the public sale of alcoholic bever-
ages, and, consequently, of a phenomenal ad-
vance toward public sanity.
Russia, that backward, benighted, but none the
less vast and important realm, has set a most
enlightened and advanced example in prohibiting
the public sale of vodka and allied poisons, and
the United States has come near seconding her
example in giving at least a majority vote in the
House in favor of national prohibition. It is
true that the edict for prohibition promulgated
by the Czar was for war purposes, but its results
in advancing human efficiency in all lines are
proving so beneficial that it is likely that the ban
upon this public poison will never be removed.
What is beneficial in war times, will, in this case,
prove even more so in times of peace.
Since the discovery of the process of making
fermented drinks, those who have had private or
public welfare at heart have fought to suppress
intemperance; but it was not until the thirteenth
century, w^hen distilled liquors came into exist-
ence, that very vigorous opposition to the use of
alcohol as a beverage was aroused. Alcohol, even
for medicinal purposes, has proven anything but
the "water of life" its early users fancied it to
be, and the nations which gave it a place in their
midst have suffered enormously under its de-
pressing influence.
The first temperance organization in the world
was founded in New York, in 1808, and it was
not until a decade later that a similar society
sprang into existence abroad. New York was
also the leader in the state prohibition move-
ment, passing in 1845 — a- bold step for those
groggy day!5 — a law forbidding the sale of liquor.
Since that time the tide of prohibition sentiment
has been steadily gaining within recent years,
through the recognition of economic gain ac-
companying temperance.
The antialcohol movement has been and is
more than ever a movement for public health,
physical and psychical ; these, of course, always
go together. Though it has become so common-
place and lacks the spectacularity of efforts along
other lines of sanitation, it none the less needs
and deserves the vigorous support of the medical
profession. We make much of the suffering and
economic waste from tuberculosis and typhoid,
and we take pains to check the use of morphine
and cocaine, but the abuse — and we might as
well say the use — of alcohol is still a greater
source of sickness, crime, and poverty, of a dis-
eased body politic, than any of the above causes.
We take infinite pains to round up and segregate
the typhoid carrier, but we leave wide open at
all hours the door of the public drinking house.
It is difficult to obtain an opium dream, but de-
lirium tremens can be had without the least diffi-
culty whatever. It is always the unusual phe-
nomenon that stirs both the private and public
imagination, and if alcohol were a less familiar
cause of disease and death it would have been
long since abolished amidst a general burst of
enthusiasm over the "triumph of modern sci-
ence."
PSYCHIC INFLUENCE UPON
TUBERCULOSIS.
The vagueness and the constant emotional flux
of the psychical life make difficult the explana-
tion of its influence in comprehensible terms,
therefore the intellect welcomes a concrete ex-
pression of this in the language of physiology.
Indeed, the physiological activity is in itself a
definite and pointed expression of the mental im-
pulse which has in the last analysis no other
means of speech. Motor activity of the vocal
organs and other voluntary muscles, and the
somewhat less voluntary facial expressions, are
familiar language. The language of involuntarily
controlled organs, of inner secretory glands, is
also becoming familiar through the physiological
experimental laboratory, as well as through clin-
ical observation.
Doctor Ishigami has presented the result of
his observations and experimental work on the
opsonic index in tuberculosis to determine the
influence of psychic states upon this disease
[Tohru Ishigami: The Influence of Psychic Acts
on the Progress of Pulmonary Tuberculosis,
American Review of Tuberculosis, October, 1918].
He calls attention to the several spheres in which
experimentation has already proved an unmis-
takable relationship between psychic states and
their varying conditions and physiological func-
December 14, 1918.J
ED IT OKI AL ARTICLES.
1045
tioning-. This was first noted by certain observers
and then more definitely confirmed by such work-
ers as Pawlow in the case of gastric secretion,
Cannon and his fellow workers in reo^ard to the
adrenal secretion and the movement of blood
sugar, and others who have demonstrated these
effects and the innervation through which they
are accomplished.
Ishigami himself has worked for a number of
years to determine first the relationsliip of the
opsonic index to the progress of tuberculosis
and the influence of psychic states upon the op-
sonic factor. He has found that in advanced
tuberculosis this index is lower than in the less
advanced stages of the disease and that treatment
raises the index. In untreated cases a higher
index is shown where the prognosis is favorable ;
a fluctuating index accompanies an unfavorable
prognosis. He finds, further, that change in the
index is to a great extent dependent upon the
mental condition, anything that causes anxiety or
depression at once lowering the opsonic index
which again rises when the mental depression
has passed. If the cause of worry is prolonged,
a "cumulative negative phase" persists. More-
over, certain patients, in spite of extensive local
manifestations and the presence of many micro-
organisms, show a comparatively high opsonic
index and proceed' favorably. These are an op-
timistic type of patients who do not easily yield
to worry. In chronic cases progressing fairly
well, the opsonic index may be suddenly lowered
by sudden misfortune and the disease will at once
take an unfavorable turn.
In order to place these observations upon a
more exact basis the author performed a number
of experiments, supplementing uranalyses made
regularly upon the patients, to determine the
physiological pathway by which psychic events
produced this definite efifect. It was shown that
glycosuria was frequently present in advanced
cases, particularly in nervous subjects. It was
demonstrated also that glucose and adrenalin
have an inhibitory action upon phagocytosis in
general, this being particularly confirmed in the
case of consumptive patients, and that in the less
severe cases the phagocytosis was still present
to a more marked degree than in the more ad-
vanced ones. The writer believes that this rep-
resents the overstimulation through psychic con-
ditions of a normal compensatory mechanism
which Cannon has described, whereby through
an increase of adrenalin output and increase in
blood sugar the individual is prepared for sudden
emergency. Here the stimulation, set in motion
by the psychic reasons playing upon the patient,
cause an increase in these products in the blood,
for which there is no adequate opportunity for
utilization, and they therefore remain to aflfect
the lowering of the opsonic index, of which they
liave been proved capable. Other disturbances
of physiological processes, such as interference
with the digestive function, are at the same time
psychically initiated, wliich aid in the deteriora-
tion process.
It is interestingly noted that in Japan, from
which this report comes, tuberculosis is espe-
cially prevalent among those of school age and
among primary school teachers. This fact the
author attributes to the inadequacy of prophylac-
tic measures during the school age, the peculiarly
heavy strain attendant upon linguistic difficulties
and the didactic method of teaching, and the se-
verity of examinations, beside the severe living
conditions for which only low teaching salaries
are provided. Mental strain on the part of both
teachers and pupils favors the spread of infection
from one to the other.
This report of these very important observa-
tions and studies has maintained itself on the
strictly conscious levels of the more obvious play
of psychic factors upon these essential physio-
logical processes. It is only from these as a
starting point that the intimate relation of
psychic and physiological processes can first be
established, but it should awaken medical
thought to the fact that this, after all, is the ap-
proach to a larger field of much responsibility
and much fruitful result for the future, pro-
I)hylactic as well as curative, as the author sug-
gests it from the more obvious point of view.
There are unfathomable depths of psychic activ-
ity where unconscious psychic factors are oper-
ative, with a force that has scarcely begun to be
measured, in the lives of each individual. The
avenues that are being opened into their recogni-
tion and study present a fascinating possibility
of approach to the treatment of tuberculosis on
the psychic side as well as toward a prophylaxis
through a strengthening of psychic health and
resistance. The value of this can be estimated
only through the patient and determined cooper-
ation of future physiologists and psychologists.
MANUAL TRAINING IN SHELL SHOCK.
In one of the American hospitals in the Toul
sector interesting work is being carried out in the
use of a manual training in shell shock. At this hos-
pital is a young woman. Miss De Zeller, who had
conducted special classes for mentally defective chil-
1046
NEJVS ITEMS.
[New York
Medical Jhurnai..
dren in the public schools of New York. She had
received special training for the work at Columbia
University and ":he results obtained with these chil-
dren suggested the possibility of applying similar
methods with soldiers whose nerves had broken
down under the strain of battle. The results have
been most encouraging. Men and officers in all
stages of mental unbalance have gradually regained
their selfcontrol and it is expected that this hospi-
tal will be maintained for months, so long as there
are patients to supply it. Various kinds of handi-
work are taught, but carpentry furnishes employ-
ment for most of the patients, even for some who
are unable to walk. The teacher is generally re-
ferred to as the "lady carpenter" and her vv'ork has
been commended by many high officials both French
and American. It is found that even the most
melancholy and depressed patients can gradually be
won back to a normal condition by being given
something to do vvith their hands.
Officers and privates work alongside each other
and soon become interested and frequently develop
great ingenuity and skill in some sort of handicraft.
While no formal leport has been published on the
subject private letters show that this method of
reclaiming the shell shocked contains great promise.
The ordinary therapeutic methods including special
baths are, of course, made use of at the same time.
«^
News Items.
Demobilization of the Army Medical Corps. —
Of the 649,000 men who have been designated for
demobilization in the United States, 2,000 are in the
medical corps. These men will be returned to civil
life as fast as the army can return them.
$10,000,000 for Medical Research. — The will of
Captain Joseph Raphael De Lamar, who died in
New York on December ist, leaves nearly half of
his estate, estimated at about $25,000,000, to the
Harvard University Medical School, the medical
department of Columbia University, and Johns
Hopkins University, to be used for research into
the causes of disease and the principles of correct
living.
Meetings o'f Medical Societies to Be Held in
New York Next Week. — Monday, New York
Academy of Medicine (Section in Ophthalmology),
Medical Association of the Greater City of New
York, Psychiatric Society of Ward's Island, York-
ville Medical Society ; Tuesday, New York Academy
of Aledicine (Section in Medicine), Federation of
Medical Economic Leagues of New York ; Wednes-
day, New York Academy of Medicine (Section in
Genitourinary Diseases), Geriatric Society, Medico-
legal .Society (annua!). Northwestern Medical and
.Surgical Society of New York (annual). Alumni
Association of City Hospital : Thursday, New York
Academy of Medicine (stated meeting), New York
Celtic Medical Society ; Friday, New York Acad-
emy of Medicine (Section in Orthopedic Society),
Clinical Society of New York Post Graduate Medi-
cal School and Hospital (annual). New York
Microscopical Society, Brooklyn Medical Society.
Government Returns Properties to Owners. —
Llotel Nassau, at Long Beach, N. Y., which was
taken over by the government to be turned into -i
war hospital, has been returned to its owners. It
was to have been Debarkation Hospital No. 4. Sea-
view Hospital, Staten Island, and North Brother
Island have also been returned by the government.
Influenza in Army Camps. — An official sum-
mary of the results of the influenza epidemic in
army camps and military centres in the United
States, made puljlic by the War Department o.'i
December loth, shows that there were 338,257 cases
of the disease up to December ist, with approxi-
mately 17,000 deaths. Because deaths resulting
from influenza and pneumonia were not separatelv
grouped only approximate figures were given for
those due to the epidemic. From September 13th
the date of the outbreak, to December ist, 19,694
deaths from all causes were reported by military
stations in the L^nited States. Army medical au-
thorities estimate that about 2,000 of these were due
to causes other than influenza and pneumonia.
Influenza and Pneumonia Increasing. — New
cases of influenza and pneumonia reported to the
Department of Health of the city of New York
for December 8th and 9th show that the extent of
the two diseases has neither grown nor diminished
in comparison with the figures of the last few
weeks. The new cases of influenza for the two
days were 227, and those of pneumonia amounted to
eightv-seven. There were thirty-eight deaths from
influenza for the two days and seventy-eight pneu-
monia deaths. In Boston thousands of new influenza
cases were reported throughout greater Boston last
week, and many fear a return of the ravages of the
recent epidemic. Cities and towns fifty to
100 miles away report increases during the last few
'lays. Two hundred new cases were reported in
Boston proper on December 8th and 9th, with a
score of deaths. Framingham, fifteen miles from
Boston, reports more than r,ooo cases. Authorities
gain hope from the fact that the proportion of
deaths is much smaller than before.
Medical Organization of the Army. — In the
annual report of the Secretary of War, it is stated
that on November 11, 1918, we had eighty fully
equipped hospitals in this country with a capacity
of 120,000 patients, while there were 104 base hos-
pitals and thirty-one evacuation hospitals in the
A. E. F., and one evacuation hospitals in Siberia,
with ten other auxiliary units operating abroad. The
army hospitals in the United States cared for
1,407,191 patients dtiring the war, while those with
the A. E. F. cared for 755,354, a total of 2,162,545.
In addition 931 medical officers of the army were
detailed to serve with the British forces and 169
for service in base hospitals turned over to the Brit-
ish. Several ambulance sections have been operat-
ing with the Italian army. On November ti, 1918,
there were 4.429 dentists in the army and 5,372 in
the reserve corps not yet called to active duty. The
growth of the medical department is shown by the
fact that at the beginning of the war there were 750
officers, 393 nurses, and 6,619 enlisted men in the
department, while in November there were 39,393
officers, 2T,344 "tirses, and 245,652 enlisted men.
Dec;iiibtr 14 191S.I
NEWS ITEMS.
1047
The Health of the Army. — The annual report
of the Secretary of War slates that for the year
ending August 30, 1918, die death rate from disease
among troops in the United States was 6.4 in a
thousand ; in the A. E. F. it was 4.7 ; for the com-
bined forces it was 5.9. Pneumonia, either primary
or secondary to measles, caused 56 per cent, of all
deaths among troops, and 63 per cent, of the deaths
from disease.
British War Casualties. — The British War
Office has issued a correction of its recent state-
ment that the British losses during the war totaled
658.704. It is now announced that this number di;i
not include the men who were reported missing and
who actually lost their lives but of whom there was
no trace, nor did it account for the men who had
died at the front of sickness. The corrected num-
ber is nearly 1,000.000, killed or dead through
various causes.
The Return of the Wounded. — The hospital
ship Comfort reached New York Monday morning,
December 7th, two days late, with 401 woundecl
soldiers on board. The American transport Sierra
which also arrived in port on Monday, had thirty-
five officers and 1,581 men from Brest, practically
all wounded at the western front. On Tuesday the
Empress of Britain brought 406 wounded men and
on Wednesday the hospital ship Mercy, with 398
men from the American Hospital at Bordeaux, ar-
rived in port. The British steamship Siamese
Prince, sailing from Liverpool, also reached New
York on Wednesday with 398 men on board, all
surgical cases, and the Kroonland brought 704 sick
and wounded, and the Tenadores 882, the latter
being medical cases not requiring special attention.
The sailing of other ships from European ports
bringing home the sick and wounded is being an-
nounced almost daily.
Dr. Joseph B. Bissell. — The executive commit-
tee of the medical board of Bellevue Hospital
records, with profound sorrow, the death of their
esteemed colleague, Dr. Joseph Bidleman Bissell,
major, Medica' Corps, United States Army, chief of
the .surgical service at Fort McHenry, Md., and
visiting surgeon and surgical director of the fourth
division of Bellevue Hospital.
His selfsacrificing devotion and unflagging
energy were always given to the sick poor of this
hospital. In his death Bellevue Hospital has lost a
skillful surgeon, the community has lost a useful
and patriotic citizen, and his colleagues have lost an
amiable and lovable personality.
. At a time of life when most men of his age might
reasonably expect that the defense of our nation's
right might safely be left to younger men, he vol-
unteered for active duty in the service of his
country. He died in that service as a result of the
strenuous life incident to camp duty, and his death
is no less glorious than if it had occurred in the face
of the enemy and on the field of battle.
Signed, George D. Stewart, M. D., president,
Charles E. Nammack, M. D., secretary,
Executive Committee, Medical Board, Bellevue
Hospital.
Medical Association of the Greater City of
New York. — A stated meeting of the association
will be held in Du Bois Hall, New York Academy
of Medicine, Monday evening, December i6th, un-
der the presidency of Dr. Edward E. Cornwall, of
Brooklyn. The topic chosen for discussion is Pneu-
monia Complicating Influenza. Dr. M. Goldberg,
Dr. H. E. Smith, first lieutenants, Medical Corps,
U. S. Army, will present the bacterial findings in
500 cases of influenza pneumonia at Camp Mills.
Dr. Thomas F. Reilly will read a paper on Clinical
Varieties of Pneumonia Observed in the Recent
Epidemic of Influenza. There will be an open dis-
cussion of the pneumonias in the recent epidemic
of influenza, each speaker being limited to five
minutes.
Personal. — Lieutenant Colonel Rafaele Bastia-
nelli. professor of surgery in the University of
Rome and consulting surgeon to the Italian Army,
has been granted an honorary fellowship in the
New York Academy of Medicine by a unanimous
vote. Colonel Bastianelli recently delivered before
an enthusiastic audience at the academy a remark-
able lecture on lung surgery at the ItaHan front.
Colonel C. F. Craig, Medical Corps, U. S. Army,
who is now on duty at Yale University, met with
a serious accident recently which will incapacitate
him from duty for some time. He fell down an
elevator shaft in one of the university buildings and
broke both legs.
Dr. Colin Foulkrod, of Philadelphia, has been
elected by the board of governors of the Maternity
Hospital to fill the vacancy on the staff caused by
the death of Dr. Clarence H. Gray.
Dr. William V. P. Garretson was recently ap-
pointed consulting neurologist to the Hospital for
Functional Reeducation of Disabled Soldiers and
Sailors, which is affiliated with Cornell LTniversity
Medical College, New York.
Major General Robert E. Noble (lieutenant colo-
nel, Regular Army) and Colonel Walter D. McCaw,
Medical Corps, iJ'nited States Army, who have been
serving with the American Expeditionary Force in
France, were nominated on December 3d for the
rank of brigadier general m the Medical Corps of
the Regidar Army.
Dr. Anthony Bassler has been appointed pro-
fessor of gastroenterology at Fordham University
Medical School, New York.
Dr. William T. Shoemaker, of Philadelphia, has
been appointed ophthalmologist to all the American
hospitals in England and recently left France to
enter upon his new duties. Doctor Shoemaker went
to France in May, 1917, as ophthalmologist to the
Pennsylvania Flospital unit. Two of his sons are
in the service, one with the engineers in France and
the other with the Naval Reserves.
Dr. Joseph S. Diamond has been appointed chief
rontgenologist to Beth Israel Hospital, New York.
Captain Ethelbert Talbot Smith, son of the late
Dr. E. Franklin Smith, of New York, has been
recommended for decoration for special bravery in
the face of the enemy. During two days of terrific
fighting at the Italian front in the latter part of
October with only twelve ambulances under his
command, he rescued 2.000 wounded.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
POLYVALENT SERUM THERAPY IN CERE-
BROSPINAL MENINGITIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
(Continued from page 1002.)
Clinical and other observations indicating the ad-
visability of using a polyvalent serum in cerebro-
spinal maningitis, instead of a serum prepared by
injection of the typical meningococcus alone, were
referred to in the preceding issue. Netter's com-
parative trials with monovalent serum and the Flex-
ner serum, prepared with a number of different bac-
terial samples from clinical cases, were mentioned,
and the perceptibly lower mortality following treat-
ment with the latter serum emphasized.
The superiority of the polyvalent serum, among
Netter's observations, was shown even more strik-
ingly by its effect in cases already treated without
apparent benefit for a number of days by monova-
lent serum prepared at the "institut Pasteur, of
Paris. Thus in the case of a child treated ineffect-
ually with three injections of Dopter's serum — 100,
120, and sixty mils, respectively — fifteen mils of
Flexner serum brought about a permanent reduc-
tion of temperature to normal. The difficulties ap-
prehended by some in inducing active minimization
of a single animal to various types of meningococcic
organism have been definitely shown to be non-
existent, Flexner and Amoss, after inoculating iden-
tical horses with cultures of fifteen typical meningo-
cocci and fifteen parameningococci, having obtained
a uniformly high agglutinating power against each
of the organisms employed.
Netter's results since igii have shown, however,
a progressive improvement in spite of the substitu-
tion of differently constituted sera for the Flex-
ner product. In 191 1 and 1912 the average mor-
tality under treatment consisting nearly always of
Dopter serum was thirty- four per cent., or with
omission of patients dying within twenty-four hours
and cases in which death could not be ascribed to
the meningococcic infection, 24.5 per cent. In 1913
and 1914, during which Netter used a mixture of
antimeningococcic and antiparameningococcic sera,
the corresponding mortality rates were reduced to
twenty-five and fourteen per cent., respectively.
Again, in the vear 191 5, in which the same mixture
of sera was largely used, but also the Flexner
serum in some instances, with sixty-eight as the
total number of cases treated, the mortality rates
were 20.6 per cent, and 8.6 per cent., respectively.
The procedure followed in this mode of treatment
was to inject the mixed serum at the outset but
also to isolate at once the causative organism in the
individual case and ascertain its nature by agglutina-
tion tests, thereafter employing the corresponding
serum alone in the treatment.
In this procedure one notes, in the adaptation of
the treatment to the precise nature of the cause in
the individual case, beginning recognition of the fact
that the type of organism causing meningitis varies
greatly under varying circumstances and in dif-
ferent epidemics. Syk, 1917, has emphasized the
variability of meningococci at different seasons, and
Paleani, 1917, the advisability of using serum made
from the strains of meningococci prevalent in each
individual epidemic. Whereas Dopter states that
before the war the true meningococcus was found
in ninety-six per cent, of all cases of cerebrospinal
meningitis, during the conflict a striking deviation
from this state of affairs was observed, the cases
dependent upon the true meningococcus often con-
stituting only a minority in the reported series of
cases. Thus, among thirty-six cases in which satis-
factory cultures were obtained by NicoUe and his
coworkers, 1917, only twelve yielded NicoUe's true
meningococcus or Type A, while twenty-four showed
organisms belonging to the Type B — a group corre-
sponding to Gordon's Types II and IV. Similar ob-
servations were made by Ellis, Gordon, Bloch and
Hebert, and others. The authors last named, 1917,
describe parameningococci as having often been
found in cases of epidemic meningitis on the Eastern
firing line. According to Amoss, an American
worker, eighty per cent, of cases of meningitis are
due to the normal strain of meningococcus or to the
parameningococcus, and almost all of the remaining
twenty per cent, to two intermediate strains, A
and B.
Along with these variations in the type of organ-
ism present under different circumstances is to be
considered the possibility of a distinction between
the several types in regard to their changes in viru-
lence and their effects ttpon the human system. An-
drews, from researches recently conducted in Eng-
land at St. Bartholomew's Hospital, was led to con-
clude that under ordinary circumstances the bulk of
the saprophytic meningococci of the pharynx are
of primitive type and low pathogenic power, for the
most part falling into that which he terms Group
II or the parameningococcic group, some, however,
still remaining indeterminate. In nonepidemic times
certain strains in this group nevertheless possess
sufficient virulence to attack the very young, causing
sporadic instances of cerebrospinal meningitis.
When, for reasons as yet unknown, certain strains
increase in virulence, they show at the same time
an increased complexity in the structure of their
antigenic component. This increase of virulence
may occur in either Group I or Group II, but in
general is seen more markedly in Group I ; thus,
whereas in the less virulent form of the disease or-
ganisms of Group II are the commoner, in the more
virulent forms the organisms of the two groups be-
come more nearly equal in number. According to
Netter, the organisms included in Nicolle's Type B
are especially concerned in cases of generalized
meningococcic infection in which purpuric manifes-
tations and extranieningeal involvements are rela-
tively common.
December 14, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
1049
On the whole, recent studies of meningococci
plainly indicate marked variations in the nature and
behavior of the virus. Consequently, the serum
treatment of meningococcic meningitis should, it
would seem, not only take into account mainly
those varieties of the meningococcus which are most
often pathogenic, but also make provision for di-
versity in the constitution of the virus at different
times.
{To be continued.)
Caesarean Section in Eclampsia and Placenta
Praevia. — George L. Brodhead {Neiv York State
Journal of Medicine, October, 1918) believes that
in a large proportion of cases of eclampsia and
placenta prjevia Ca-sarean section is unwarranted
and unjustifiable. This is true where the fetus is
dead or not viable, when the patient is in active
labor with the cervix partially dilated or readily
dilatable, and when the advantages of a well
equipped hospital and the services of a competent
surgeon are not available to the patient. On the
other hand, the operation appears to be nearly the
ideal method of treatment in cases of eclampsia
when the patient is a primipara at or near term and
bas had but one or few seizures. Caesarean section
for eclampsia, performed by various surgeons, gave
a maternal mortality of slightly over twelve per
cent, and a fetal mortality of about nineteen per
cent, in a series of 174 cases. A later series of
cases, all but two being in primiparas, gave a ma-
ternal mortality of a little over fifteen per cent.,
several of the patients having had many seizures
prior to operation, and a fetal mortality of less than
six per cent, In a collected series of cases of
placenta pra;via Caesarean section gave a maternal
mortality of six to eight per cent, and a fetal
mortality of slightly over three per cent. The
operation was followed in practically all cases by
strikingly little morbidity on the part of the
mothers, and its results are certainly to be regarded
as brilliant. Caesarean section seems to be of the
utmost value in all patients near term in whom
there is a central placenta praevia, and in primiparas
at or near term in whom there is partial placenta
praevia with no cervical dilatation.
Conservative Treatment of Eclampsia. — Ross
McPherson {Nezv York State Journal of Medicine,
October, 1918) bases his opinions upon two and a
balf years' experience with the method to be de-
scribed and the comparison of the results yielded
by it with those obtained with other methods. In
a series of sixty-seven patients, every one of whom
bad had at least one convulsion before treatment
began, the maternal mortality from conservative
treatment was a little over seven per cent, and the
fetal mortality 28.5 per cent. The method of treat-
ment which was followed consisted in taking the
patient's systolic blood pressure and securing a
catheter specimen of urine immediately upon en-
trance into the hospital. The woman was then put
into a darkened isolation room where it was as
quiet as possible. Thirty milligrams (half grain) of
morphine sulphate were then given hypodermically,
the stomach washed, and two ounces of castor oil
left in it when the tube was withdrawn, and the
colon was irrigated with five gallons of five per
cent, solution of glucose. If the blood pressure was
above 175, blood was removed by phlebotomy to
bring it down to 150. No bleeding was done in
cases with pressures lower than 175 because of the
danger that might arise from further loss of blood
during delivery. Veratrum viride was not given
because of the danger of excessive lowering of
blood pressure if hemorrhage should be profuse at
delivery. I'he patient was thereafter kept quiet and
given fifteen milligrams (one quarter grain) of
morphine every hour hypodermically until the res-
pirations were brought down to eight per minute.
By that time the convulsions usually ceased and
labor had begun. This was terminated riormally or
by an easy low forceps operation. Convalescence
was then treated in the usual manner^ depending
upon the symptoms, and was generally strikingly
free from complications.
Immediate Fixation in Fracture of Femur. —
F. B. Chavasse {British Medical Journal, October
5, 1918) describes a most efficient plan for the im-
mediate immobilization of the whole lower ex-
tremity, combined with powerful extension, which
can be applied on the battlefield by the stretcher
bearers. All that is needed is a stretcher and two
slings, and as each of the four bearers in a squad
has one sling, two are always available, while two
are left for purposes of carrying. The first step
IS to expose and dress the wound. Then the ad-
justable loop of one sling is enlarged to its max-
imum, slipped over the foot on the injured side, and
passed up into the groin. The ankles and knees arc
next tied together firmly with bandages, the
stretcher is opened and a small pillow (the rolled
waterproof sheet will do) is placed on it where the
patient's knees will come. The patient is then put
on the stretcher so that his heels project a couple of
inches beyond the canvas, the heel on the injured
side being a little lower than that on the sound side.
The loop of the second sling is adjusted to be
equal in length to the distance between the poles and
is slipped over one of the handles. The sling is
then passed across the soles of both feet, up across
both insteps, behind both ankles, down across both
insteps, through the loop and across the soles of the
feet to the opposite handle. All this winding about
the feet is made very tight. The end is then se-
cured tightly to the end of the opposite pole bv
means of the small strap and buckle. The foot of
the stretcher is then raised gently, almost to the
perpendicular, and the patient is drawn downward
head first. It may be necessary to maintain this
position for a few minutes to tire the muscles and
secure their relaxation. When extension is good
the back part of the sling loop should be well be-
hind the buttock and the loop adjusted so that the
grip plate will lie almost on the surface of the
stretcher when strain is taken. This tends to cor-
rect flexion, abduction, and external rotation of the
upper fragment. Very heavy tension is then put
upon the groin sling and it is secured round the
upper pole handle. The stretcher is then levelled
again, a bandage is tied about the stretcher and the
patient's pelvis, and a rifle is bandaged along the
outer side of the extremity.
1050
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New Vokk
Medical Journal.
Infantile Scurvy. — J. Comby (Presse medicate,
September 19, 1918) maintains that any child arti-
ficially fed with sterilized food — milk or milk sub-
stitutes— for several successive months, to the ex-
clusion of fresh, living food, is threatened with
scurvy. The proper procedure under such condi-
tions is, therefore, to. administer prophylactically,
every day, from a teaspoonful to a tablespoonful of
orange juice or, if this is not available, of grape or
diluted lemon juice. Of fifty-five cases of infantile
scurvy that have come into the author's hands,
forty-five had previously been wrongly diagnosed
and treated as rheumatism, acute poliomyelitis,
syphilis, acute osteomyelitis, coxalgia. Pott's disease,
etc. To avoid overdosing infantile scurvy, the fol-
lowing four diagnostic features must be constantly
borne in mind: i. The patients are infants from
six to eighteen months old, artificially fed with
sterilized or otherwise devitalized milk. 2. All ex-
hibit more or less prominently a painful pseudo-
paralysis of the lower extremities. 3. Some show
swelling of the shaft of the femur or tibia, due to
subperiosteal hematoma. 4. Most of the children
that have teeth exhibit red, swollen, ecchymotic,
and sometimes bleeding gums ; when the child cries,
its mouth fills with blood. As regards treatment,
the mother should be instructed to leave the child
in its cradle and avoid moving, rubbing, bathing,
and dressing it for a few days. Whatever devital-
ized milk preparation is being used must be at once
and permanently discontinued, and fresh boiled milk
substituted. A teaspoonful of grape or orange
juice should be given twice a day, and in slightly
older children, a few spoonfuls of potato puree may
be added. Under these measures recovery is likely
to occur in a week.
Suppurative Gingivitis with Alveolar Involve-
ment.— Arthur Zentler (Journal A. M. A., Novem-
ber 9, 1918) employs this term to include the more
advanced cases commonly called pyorrhea alveolaris
and holds that the condition is purely a surgical one.
The condition is of such a nature that nothing short
of the radical removal of all of the diseased soft
and bony tissues will suffice for cure. The most
satisfactory operation is a modification of Robit-
zeck's, in which the diseased tissues are completely
excised. Under procaine-epinephrin conductive an-
esthesia the parts to be operated upon are swabbed
with tincture of iodine and a flap is reflected
over the afifected teeth by means of parallel lateral
incisions extending from the cervical free border
of the gum to the apex of the tooth and a horizontal
incision along the festooned edge of the gum. The
incisions pass through the periosteum and this, to-
gether with the overlying structures, is retracted
until the diseased bone is completely exposed. All
the inflamed, infected, granulomatous tissue be-
tween and about the roots of the teeth is removed
with curettes and knives. Next all infected bone is
chiseled of¥ with delicate chisels, the roots of the
teeth are well curetted, and the remaining free edges
of alveolar bone are smoothed ofif evenly. The inner
surface of the flap is inspected for adherent diseased
tissue, which is thoroughly removed with the mini-
mum of disturbance to the healthy periosteum. The
parts are washed with normal saline solution.
swabbed with half strength tincture of iodine, the
wound surfaces freshened, and the flap is replacd
and sutured. The sutures are taken at each end
of each lateral incision and at points on the free
margin between these two, when more than three
or four teeth have been exposed. Finally the parts
are again swabbed with tincture of iodine and cov-
ered with a strip of iodoform gauze, which is
changed once or twice at intervals of twenty-four
hours. The sutures are removed on the fourth or
fifth day. The loose teeth usually become firm and
the periosteum becomes completely reattached, ex-
cept in cases with very extensive necrosis and re-
moval of some of the teeth. The operation is not
usually followed by any discomfort, and the slight
swelling and pain, which sometimes come on after
the efifect of the procaine has gone, can be relieved
promptly by the application of an ice bag for fifteen
minutes every hour, for two or three hours. The
operation can be performed in any area of the
mouth, but wheie there are devitalized teeth in the
areas to be operated upon these must first be treated
and root canals must be thoroughly and aseptically
filled. Apicoectomies can be performed at the time
of the operation, but nonvital multirooted teeth
with apical abscesses had better be extracted.
Electrothermic Treatment of Cancer of the
Oral Cavity, Jaws, and Throat. — William L.
Clark {Journal A. M. A., October 26, 1918) be-
lieves that these methods are peculiarly adapted
to the treatment of malignant disease in these loca-
tions. Electrodesiccation by the Oudin type of cur-
rent is especially suitable for the removal of small
or moderate sized growths when localized and a
good cosmetic result is desired. The desiccation
can be so well controlled in both depth and area
that even a small corneal lesion can be removed
without injury to vision, or a growth on the vocal
cord destroyed without impairing phonation. It pro-
duces very slight trauma and no secondary inflam-
mation, and hence no scarring. Electrocoagula-
tion by the d'Arsonval type of current is more
penetrating and intense than the desiccation method
and is useful for the destruction of large growtl^s,
including those involving bone. Both electrical
methods are specially suited for growths in any
part of the oral cavity, since the tumor can readily
be attacked without the need of surgical measures
to expose it. In the case of growths in inaccessible
locations, such as the antrum, or when normal
tissue? cover the giowth, the tumor should be ex-
posed or the gross mass even removed by surgical
operation before the application of the electro-
thermic treatment. Both of the electrical methods
have the great advantage over surgical removal in
the avoidance of opening of blood and lymph chan-
nels, these being, on the contrary, completely sealed
by the coagulation. When the cervical glands are
involved they should be removed surgically, fol-
lowed by deep crossfire rontgen treatment. When
the glands are not involved they should be treated
by the deep rontgen rays after electrothermic treat-
ment of the primary lesion. A section should never
be removed for diagnosis until immediately before
operation, since such removal leads to rapid exten-
sion and metastasis of the growth.
December 14, 1918.] MODERN TREATMENT AN
Dichloramine-T Chlorcosane Solution in
Treatment of Infections of the Upper Air Pas-
sages.— D. Bryson Delavan (Medical Record, July
20, 1 91 8) reports excellent results with a two per
cent, solution of dichloramine-T chlorcosane, tak-
ing care to first expose the recesses of the tonsils,
the nasal chambers, and pharynx by washing with
an alkaline solution and then applying adrenalin.
The oil solution must be sprayed under pressure to
all recesses, and better results will be obtained with
a condenser than with an ordinary hand bulb.
Superior Longitudinal Sinus in Children: Its
Value in Transfusion and for Rapid Medication.
— Louis Fischer (Medical Record, September 7,
1918) considers that the superior longitudinal sinus
in infants is the ideal vessel, from its accessibility,
for transfusion, administration of alkaline and
other medicinal solutions, removal of blood for
Wassermann and other tests. It is readily entered
at the posterior angle of the anterior fontanelle, and
the risk of trauma is negligible even when the punc-
ture of the sinus is repeatedly done. Salvarsan in-
jections are conveniently given by this route as well
as antitoxin in diphtheria.
Sensitization to Ipecac by Emetine Injections.
— Billard and Blatin (Prcsse niedicalc, September
12, 1918) resorted tentatively to ipecac medication
in twelve cases of severe amebic dysentery in which
emetine hydrochloride had lost its efifect. Ingestion
of but 0.05 gram of powdered ipecac in all cases
brought on pallor, nausea, vomiting, and diarrhea
within a few minutes. In four instances cardio-
vascular depression to the point of temporary syn-
cope was observed, and in one an actual narcolepsy
persisted for over eight hours. Whether these dis-
turbances were due to anaphylaxis or simply to
sensitization by the emetine the authors have not
as yet been able to ascertain.
Primary Depression and Secondary Rise in
Blood Pressure Caused by Epinephrine. — Hugh
McGuigan and Emory G. Hyatt (Joiintal of Phar-
macology and Experimental Therapeutics, Septem-
ber, 1918) find that a quick rise in the blood press-
ure of dogs is followed by a rapid fall and a sec-
ondary rise when adequate doses of epinephrine in
the form of adrenalin are administered intraven-
ously (0.5 to one c. c. of i :io,ooo). After studying
various hypotheses to account for this, they con-
clude that the primary rise is due entirely to
peripheral action, and the secondary rise is appar-
ently due to a central action of the epinephrine
acting through the sympathetic ganglions. This
central action can be prevented by pithing of the
brain or removal of the head. Section of the vagi
or atropine does not prevent it, and in many cases,
section of the vagi accentuates the secondary rise.
Nicotine, given until the ganglia are paralyzed, will
prevent the phenomenon. Changing the intra-
cranial pressure with a water manometer through a
trephine hole in the skull will modify the blood
pressure to give a typical secondary rise, while a
greater increase in the presure may again prevent
the secondarv rise. Changes within the cerebro-
spinal fluid also modify the blood pressure tracing
of epinephrine.
) PREVENTIVE MEDICINE. 1051
The Capproni Method in the Treatment of
Pleurisy with Effusion. — Al. Maurizi (Rifonna
Medico, June 27, 1918) reports seven cases of
pleurisy with efifusion treated by this method of in-
jection into the pleural cavity, with two to four
grams of iodoform in ten to twenty c. c. of glycerin.
His results were excellent and he warmly advo-
cates this procedure as simple, harmless, and easily
carried out in any surroundings.
Radical Cure of Sciatica by Lumbar Anesthesia.
— C. Mancini [Rifonna Mcdica, June 1, 1918)
describes a method employed by him for many years
in the treatment of sciatica. He injects twelve to
fifteen c. c. of a five per cent, novocaine solution
into the third or fourth lumbar interspace, thus pro-
ducing an anesthesia lasting from three quarters of
an hour to two hours. The injection may be re-
peated every seven days but repetition is not usually
necessary. The advantages claimed for the method
are direct contact with the diseased nerve fibres,
simplicity and innocuousness.
Treatment of Shock. — J. Regnault (Presse
mcdicale, August 8, 1918) conceives of shock as a
nervous inhibition which upsets the equilibrium be-
tween the tonic actions of the vagus and sympa-
thetic nerves. In severe, painful wounds, early
operation may forestall or lessen shock by elimi-
nating afferent nervous stimuli which, if kept up,
would have brought on hypotonia of the vagus, the
latter, in turn, resulting in congestion, and later in
cellular changes in the viscera. Study of the
reflexes is in itself partly sufficient to suggest a
proper line of treatment for inhibitory states, in-
cluding shock.
Treatment of Chronic Prostatitis. — Oswald S.
Towsley (Annals of Surgery, October, 1918) says
that the treatment of this condition consists, for
the most part, of prostatic massage followed by a
cleansing of the urethra, either by irrigation with
silver nitrate or potassium permanganate solutions
or by the passage of urine followed by instillations
of argyrol, silver nitrate, or other antiseptic solu-
tions into the prostatic urethra. Every two or
three weeks the urethra is dilated with sounds or,
preferably, by the Kollman dilator. Thomas, of
Philadelphia, in a recent publication has concluded
that: I. Chronic prostatitis may be and is at times
a surgical disease requiring prostatectomy for its
efficient treatment. 2. Chronic prostatitis is not
infrequently associated with hyperplastic polypoid,
papillary, or nodular formations of the mucosa of
the prostatic urethra and vesical orifice demanding
removal by treatment coincident with that directed
to the prostate. 3. Fulgu ration or the high fre-
quency spark promises to oflFer the best method
of intraurethral treatment for this purpose. 4.
In the protracted cases of chronic prostatitis cysto-
urethroscopy is always indicated and may be obli-
gatory for proper diagnosis and treatment. Rarely
will a case fail to respond to the palliative methods
described above, provided the treatment is con-
tinued for sufficient length of time ; hence, surgery
of the chronically inflamed prostate should be a
very rare outcome, although there are cases in
which it would appear to be justifiable.
4
Miscellany from Home and Foreign Journals
Purulent Bronchitis Complicating Measles and
Rubella.— W. M. Macdonald, T. R. Ritcliie, J. C.
Fox, and P. Bruce White (British Medical Journal,
November 2, 1918) record the observation of an
epidemic of these two diseases involving 418 men
from New Zeaktnd. They believe that the measles
was contracted when the ship carrying the men
stopped at an American port. In a large majority
of the cases in this epidemic the exanthems were
complicated by severe purulent bronchitis, or
copious mucopurulent bronchorrhea. At the same
time as this epidemic was prevailing among these
men there was an epidemic of measles and rubella
which involved 146 British troops resident in the
same district, but among these there was only one
case of purulent bronchitis and this was in a motor
driver who had been engaged in the transport of the
New Zealand troops. In the early stages of the
bronchitis the most striking feature was the pres-
ence of the copious purulent expectoration along
with absence of physical signs of marked involve-
ment of the lungs. Later, in the more severe cases,
the physical signs became more marked and evident
bronchopneumonia was present in many. Pleural
effusion was rare and there were no cases ot
empyema. One or more varieties of streptococci
were found in the smears and cultures of all but
two of the cases examined, the varieties apparently
being the hemolytic and viridans types. The
Staphylococcus aureus was also found in large num-
bers in practically all of the cases. Of forty cases
examined the Bacillus influenzae was found in
smears or cultures, or both, in twenty-nine. Blood
cultures, when positive, almost invariably yielded
only the streptococcus. Pathologically the fatal
cases showed the constant presence of petechias or
larger hemorrhages on the surface of the lungs,
especially toward the base and in the interlobar
fissures. Otherwise the findings varied, according
to the severity of the case, from typical purulent
bronchitis through bronchopneumonia to complete
lobar consolidation. Serofibrinous pericarditis was
found in six of fourteen cases examined.
Unrecognized Forms of Septicemia. — De Gau-
lejac and Nathan (Bulletin de I'Acadeinie dc mede-
cine, September 24, 1918) point out that, aside from
the well known febrile type of septicemia, there has
been revealed in war surgery a whole class of
afebrile, latent, monosymptomatic septicemias. The
most perfect type of these is the septicemia that
follows attrition of cancellous bone tissue. Such an
injury, even when extensive, is at first nearly al-
ways painless and apyretic, pain and functional dis-
ability appearing only about the tenth day, when
the compact bone tissue and neighboring joint have
become involved. Throughout the initial period but
one sign of the septicemia exists, viz., tachycardia,
the pulse remaining at ninety to no in the presence
of temperature of but 37.5° C. There are no con-
stitutional disturbances nor any other physical
signs. That a septicemia actually exists is shown in
that in nearly all instances blood culture reveals a
microorganism — almost invariably the enterococcus,
rarely the pneumobacillus of Friedlander. Cultures
from the injured bone tissue likewise nearly always
reveal these organisms. Where the contused bone
tissue has been completely removed, the septicemia
is forestalled or remains insignificant in its exter-
nal manifestations. If removal has been incom-
plete, chronic osteoarthritis, with a tendency to
ankylosis, sets in ; the patient becomes pale and
cachectic. In several such cases a positive blood
culture was obtained months after the injury.
Apart from these war septicemias the authors have
observed a number of afebrile and latent septice-
mias, often due to the tetragenus organism, which,
after fatigue or an ordinary contusion, becomes
localized in the osteoarticular system, causing osteo-
myelitis in a child, an attack of arthritis in a subject
with congenital coxa vara, and in other instances a
spondylitis or an involvement of the knee joint with
a tendency to extend. The latent septicemias are
linked with the grave septicemias through a series
of intermediate forms. In making the blood cul-
tures, both aerobic and anaerobic media should be
used.
Application of a Colorimetric Scale to the Bor-
det-Wassermann Reaction. — A. Bergeron and E.
Normand (Presse medicale, September 12, 1918)
use as primary color standard, 0.2 mil of a one in
ten dilution of sheep erythrocytes. For the colori-
metric tests this is further diluted, one in five, by
the addition of saline solution. In a series of hemo-
lysis tubes, numbered one to ten, are introduced in
succession o.i, 0.2, 0.3, etc., of the resulting fluid.
Enough hemolysin and alexin are then added to
induce complete hemolysis, and the amount of so-
lution made up with saline to 2.5 mils in each tube.
The tubes are then placed in the incubator until
hemolysis has occurred. The tint in the first, or
0.1 mil tube, corresponds to that produced by a ten
per cent, hemolysis of red cells employed in the
Wassermann reactic^n ; that in the 0.2 mil tube to
twenty per cent, hemolysis, etc. To offset the addi-
tional coloration imparted in the actual reaction by
the patient's serum and the antigen, 0.2 mil of any
human serum and 0.3 mil of antigen are added in
each tube, thus bringing the total volume of solu-
tion to three mils. In carrying out a colorimetric
determination, the centrifugated Bordet- Wasser-
mann tubes are compared in turn with the ten tubes
of the color scale. If the tube containing the least
amount of antigen shows the same tint as tube three
of the scale, it is known that enough free alexin has
remained to hemolyze thirty per cent, of the ery-
throcytes in the firsl instance and ten per cent, in
the second, and the reaction is put down as positive
at 30-10. If the eighth and sixth tubes are matched,
the reaction is negative at 80-60, and if the sixth
and fifth, it is suspiciously negative at 60-50. This
precise method permits of ready comparison of the
successive findings of a single observer as well as
of the results obtained in different laboratories.
The scale is independent of the procedure used.
December 14, 1918.]
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
1053
Mitral Stenosis and Raynaud's Disease. — J.
Chalier (Prcssc >neJicalc, September 12. 1918) lays
stress upon the in.mifold etiology of Raynaud's
disease and the importance of cardiac disorders,
especially mitral stenosis, among its several causes.
He reports no h3s than six cases, personally ob-
served, which occurred in association with mitral
stenosis. In all the cardiac condition, judging from
the physical examination or the anamnesis and the
time of appearance of the functional disturbances,
preceded the Raynaud condition. As mitral sten-
osis is rather easily overlooked, it should be exam-
ined for carefully and repeatedly in cases of Ray-
naud's disease. That both the heart defect and the
Raynaud condition may result from acute rheu-
matism is not probable, a considerable interval gen-
erally elapsing between the last rheumatic attack
and the involvement of the extremities. In three
of the six cases no rheumatic manifestation was
elicited. Tuberculosis as a cause of Raynaud's dis-
ease deserves greater attention, and its role in some
instances is gradually being accepted. Roque has
emphasized the marked similarity of Raynaud's
syndrome with a series of skin manifestations of
the extremities, belonging to the group of the tuber-
culides of Darier, rmd believes that the tuberculous
toxins, acting upon the vasomotor centres, play the
chief etiological role, while the concomitant heart
disorder exerts an adjuvant influence. Among the
author's cases three had manifest tuberculous dis-
ease, to which the heart condition is ascribed. The
strictly nervous, vasomotor theory of Raynaud's
disease does not appeal to the author, though he
recognizes vasomotor change as an exciting factor
where there are underlying pathological conditions,
cardiac or vascular, which reduce peripheral blood
flow and blood pressure and predispose to gangrene.
Military Aspects of Status Lymphaticus. —
James Ewing {Journal A. M. A., November 9,
1918) says that during the past thirty years patho-
logists have come to believe that the fate of the
human body is in general controlled by certain con-
genital intrinsic physical tendencies. This conclu-
sion is cjuite in line with the doctrine of a constitu-
tional predisposition to disease, the importance of
which has been largely submerged by the advent of
the germ theory, so that clinical observers have not
been much impressed with the importance of the
constitutional factors. The recent experience of
the Army Medical Department has shown that
many factors in physical makeup which escape
ordinary physical examination soon become most
emphatically evident under the stress and strain of
military life. Since these constitutional defects are
not amenable to remedy their discovery at the earli-
est possible time is of the greatest importance to the
army. Among these defects that of status lympha-
ticus ranks as one of the most important and is
also one which should be recognized clinically in
the majority of cases, when attention is directed to
its detection. The clinical features and the physical
stigmata of this constitutional defect are set forth
in detail by the author and the military importance
of the condition is shown in many ways. Cardiac
and arterial hypoplasia dominate the picture in
adults and the small and feeble heart renders the
subjects victims of early fatigue, palpitation,
dyspnea, irritable heart, deficient muscular energy,
lack of stamina, and low blood pressure. Many
such persons also die most suddenly after trivial
exertions. Many also seem to respond most un-
favorably to the injection of foreign proteins,
arsphenamine, antiserums, and vaccines. They also
provide the cases of precocious apoplexy in young
adults. When they fall victims to the infectious
diseases they usually do so very badly ; they seem
to provide all of the fulminant cases of meningitis,
a large proportion of those of pneumonia, the
rapidly fatal cases of typhoid fever, and over a
fourth of the fatal cases of diphtheria. Many cases
with exophthalmic goitre show evidences of status
lymphaticus and such cases seem to give a high mor-
tality under operations. Other susceptibilities and
defects associated with the occurrence of this con-
stitutional anomaly might be mentioned, but suffi-
cient has been presented to indicate the great mili-
tary importance of its early recognition among re-
cruits and the discharge of its victims from the
military forces.
Syphilitic Peritonitis. — M. Letulle (Presse medi-
calc, September 19, 1918) believes syphilis of the
peritoneum far more frequent than is generally
thought. Ordinarily it occurs in conjunction with
hepatic cirrhosis of the so called alcoholic type. Out
of 154 instances of "alcoholic" cirrhosis in which
the Bordet-Wassermann reaction was carried out,
no less than seventy-four gave a positive result.
Furthermore, antisyphilitic medication in such cases,
in the form of intravenous injections of biniodide
of mercury, potassium iodide in large and ascending
doses, arsenobenzol, and many other preparations
of arsenic, sulphur, or mercury, in some instances
yielded surprising results. Pathologically, the
syphilitic peritoneuriT is characterized by thickening,
a washed out appearance, a milky white coloration,
and even an enamelled aspect. The loops of the
small bowel may appear less numerous than nor-
mally, and are of increased size, thick, whitish, and
hard. The jejunoileum may have tindergone an
actual .shortening of one to four metres, counter-
balanced by the increase in thickness. The large
bowel may exhibit obliteration of all its normal
irregularities of surface by a thick "icing" of
sclerous chronic peritonitis. Kinks of the colon,
leading to obstruction and necessitating operative
intervention, may exist. Histologically, the syphi-
litic process is characterized by hyperemia, lympho-
cytic infiltration, follicular formations or miliary
gummas, and in particular, by destruction of the
elastic coat and an overgrowth of connective and
vascular tissue — the latter two peculiarities espe-
cially differentiating it from tuberculosis of the
same structures. Ascites occurs and often returns
with disconcerting regularity and rapidity after
puncture, as much as a litre of fluid collecting in
twenty-four hours. At times, however, spontaneous
absorption of the ascites occurs, or the syphilitic
peritoneum may remain dry throughout. Any
hepatic cirrhosis causing ascites should bring to
mind syphilitic infection. Again, in any hepatic
cirrhosis it is worth while to try systematic and
prolonged antisyphilitic treatment.
J 0=4
MISCELLAXY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Production of Meningococcus Antiendotoxin.
— M. H. Gordon {British Medical Journal. Septem-
ber 2S. 1918) obtained a highly toxic endotoxin
from young cultures of meningococci of the two
commonest types, and in testing these endotoxins
against various samples of antimeningococcus
serum found that several sera were very deficient
in neutralizing the endotoxin although they were
high in agglutinins and opsonins. Two samples of
serum proved very active in neutralizing the endo-
toxin, and one of these w^as one which had given
the best results in the clinical treatment of menin-
gitis. Efforts were then made to determine a
method for the preparation of serum of high anti-
endotoxic value against the two commonest strains
of meningococci. The rabbit was found capable of
elaborating such a scrum, but to secure it of a high
degree of potency it was found necessary to avoid
overdosage of the antigen in the case of Type I
meningococcus. The most satisfactory antigens for
the production of highl)^ potent antiendotoxic serum
were suspensions of the dried coccus or the sensi-
tized raw coccus.
Death from Influenza. — Henry A. Christian
(Journal A. M. A., November 9, 1918) brings
forth evidence and offers strong arguments in sup-
port of the idea that practically all fatal cases of
epidemic influenza are complicated by a pneumonic
involvement before the fatal issue. Thus not a
single patient out of 126 consecutive fatal cases
failed to show physical signs justifying a clinical
antemortem diagnosis of bronchopneumonia. Every
one of twenty-two consecutive necropsy cases
of influenza showed bronchopneumonia. In the
necropsy cases the pulmonary changes were gener-
all)^ more extensive than the clinical findings dur-
ing life had indicated. Careful clinical study of
nonfatal cases indicated that practically all fairly
severe to sewre cases had bronchopneumonia. The
author does not deny the possibility of fatal results
to influenza patients from an overwhelming toxemia
without pulmonary involvement, or from meningitis
or encephalitis, but such cases did not occur in his
large experience. As a corollary it would seem both
unjustifiable and misleading to classify deaths as
due to influenza and pneumonia separately, as
was done by many boards of health.
Dakin's Solution and Dakin's Oil in the Nor-
mal Peritoneal Cavity of the Dog. — Ernest G.
Grey (Bulletin of the Johns Hopkins Hospital,
October, 1918) describes experimental work on
dogs in order to draw attention to the fact that
the indiscriminate use of the chlorine antiseptics is
not entirely devoid of danger. Injections into the
normal peritoneal cavity of a dog of the neutral
solution of chlorinated soda (Dakin's solution) or
dichloramine-T in chlorinated paraffin (Dakin's
oil) lead to an inflammatory reaction which varies
in direct proportion to the amount of chlorine anti-
septic used. When injected in a sufficient amount
(less of the oil suffices) death ensues. Injection of
either of the chlorine antiseptics into the gallbladder
of a dog caused no abnormal symptoms, but the
gallbladder does become thickened and shrunken,
while the remainder of the biliary tract shows no
change. An injection of Dakin's oil into the normal
pleural cavity was performed without anesthesia.
There was an immediate and marked reaction : rest-
lessness, evacuations of the bladder and rectum,
muscular spasm of the abdomen, and some degree
of extensor rigidity of the legs, and finally death.
The clinical course is comparable to the pleural re-
flex deaths described by the French. Grey con-
cludes by saying that since Dakin's oil has been
used without recognizable ill eflects in some infec-
tions of the abdominal cavity, his work suggests
that the wall of an abscess cavity, or sinus, must
play an important part in protecting the peritoneum
in general from the efliects of free chlorine. It also
suggests that the maintenance of an adequate drain-
age tract is an indispensable part of the technic for
using antiseptics of this nature within the abdomen.
The use of the chlorine antiseptics in intraabdominal
nifections should be undertaken with caution.
Psychiatric Family Studies. — Abraham Myer-
son {American Journal of Insanity, April, 1918)
has made a study of the psychoses of brothers and
sisters in seventy-four families to find out whether
there is a tendency toward likeness or unlike-
ness ; he is also interested in the relation be-
tween two great groups of dementia prjecox
and manic depressive to each other. Although he
regards his studies as based on too little data for
generalization, Myerson is inclined to the followine
opinions : True paranoia is closely allied to dementia
precox, while true epilepsy belongs fundamentally
to a dififerent class from either dementia prsecox or
manic depressive. These last two psychoses do not
occur, as a rule, in the same family group. He be-
lieves that in the causation of psychoses predisposi-
tion plays the greatest part. He expresses it in the
following way : "Difficulties in synthesis due to dis-
harmonious development and action of the various
emotions and desires break down the personality."
The Rat and Poliomyelitis.^ — Harold L. Amoss
and Peter Haselbauer {Journal of Experimental
Medicine, October, 1918), in order to test Richard-
son's theory that the rat and its parasite, the flea,
are active agents in the transmission of poliomye-
litis, tried to transmit this disease to monkeys by
inoculating the central nervous and visceral organs
of rats caught in Brooklyn, where the epidemic pre-
vailed in the summer of 191 6. Such material was
injected into monkevs under conditions sufficient to
incite infection, if the poliomyelitic virus had been
present in the internal organs of the rat in any con-
siderable amount, and of any real virulence. The
monkeys failed to respond to two large inocula-
tions, made two weeks apart, so it appears that none
of the rats tested carried demonstrable amounts of
poliomyelitis. Experiments to show the power of
survival of an active virus of poliomyelitis, when
injected into the brain of rats, proved that it does
not survive there as long as four days in a form
or in amounts sufficient to cause infection when
inoculated intracerebrally into monkeys. This was
not due to the quantity introduced, as at the end of
one and a half hours after the injection, the excised
inoculation site when injected into the monkey
caused typical experimental poliomvclitis. It does
not seem probable that the rat acts as a natural
reservoir of the virus of poliomyelitis.
Proceedings of National and Local Societies
THIRD RESUSCITATION COMMISSION.
Meeting Held at the Rockefeller Institute, New
York, Friday, May 17, 1918.
Under the Auspices of the Committee on Safety
Rules and Accident Prevention of the Na-
tional Electric Light Association.
Dr. S. J. Meltzer, of New York, in the Chair.
There were present at the meeting Passed As-
sistant Surgeon E. F. DuBois, U. S. Naval Reserve
Force of the Bureau of Medicine and Surgery,
Navy Department; Dr. D. L. Edsall, professor of
medicine and dean, Harvard Medical School ; Mr.
W. C. L. Eglin, chairman of Committee on Safety
Rules and Accident Prevention of the National
Electric Light Association ; Dr. Yandell Henderson,
professor of physiology, Yale University, and con-
sulting physiologist of the Bureau of Mines; Dr.
William H. Howell, professor of physiology and
assistant director of the School of Hygiene and
Public Health, Johns Hopkins University, member
of the National Academy of Sciences ; Dr. Reid
Hunt, professor of pharmacology, Harvard jSIedi-
cal School, secretary of the Commission; Professor
A. E. Kennelly, professor of electrical engineering,
Harvard University and the Massachusetts Insti-
tute of Technology ; Dr. Charles A. Lauffer, medical
director of the Westinghouse Electric Company,
Pittsburgh, Pa. ; Dr. S. J. Meltzer, Rockefeller In-
stitute, chairman of the Commission, member of the
National Academy of Sciences ; Dr. Joseph Schere-
schewsky, assistant surgeon general, U. S. Public
Health Service ; Dr. G. N. Stewart, professor of
experimental medicine, Western Reserve Univer-
sity, Cleveland ; Professor Elihu Thomson, General
Electric Company, West Lynn, iNIass., member of
the National Academy of Sciences ; Lieutenant Col-
onel Edward B. Vedder, Army Medical School ;
Major Frank G. Young, ordnance division of the
War Department.
A telegram was received from Surgeon General
Gorgas that Dr. Charles H. Frazier, professor of
surgery, University of Pennsylvania, was to repre-
sent his office. (In a subsequent communication
Major Frazier accepted his appointment.) Con-
ferees: Mr. P. H. Bartlett, Philadelphia Electric
Company ; Mr. Wills Maclachlan, Electrical Em-
ployers' Association, Toronto, Canada; Mr. C. B.
Scott, chairman of the subcommittee on accident
prevention, National Electric Light Association ;
Dr. F. E. Schubmehl, General Electric Company,
West Lynn, Mass.
The chairman stated that the object of the Com-
mission was to consider efficient methods of arti-
ficial respiration in emergency cases, as they were
met with in peace as well as in war. For more
than a century England has had several lifesaving
societies, and many special commissions have been
appointed to investigate the methods employed in
resuscitation. In this country, about six years ago,
a Commission on Resuscitation from Electric Shock
was created for the first time, through the initiative
of the National Electric Light Association. It was
now generally recognized that efficient artificial
respiration was for such conditions the best and
practically the only means available for resuscita-
tion. It required but little consideration to realize
that the need for an efficient means of artificial
respiration was very widespread. It would be of
value in such emergencies as injuries to the head
which stop respiration ; injuries to the chest —
especially double pneumothorax ; in laparotomies,
during which the respiration ceases occasionally ; in
cases of shock which occur in peace and more so in
the present war; in poliomyelitis with stoppage of
respiration ; in postdiphtheritic paralysis ; in poison-
ing by opiates, by volatile gases, ether, chloroform,
etc. ; by mine and fuel gases ; poisoning by rnag-
nesium salts, in electric shock, and in drowning.
The Committee on Safety Rules and Accident Pre-
vention of the National Electric Light Association,
of which Mr. Eglin was the chairman, agreed that
the Third Resuscitation Commission should con-
sider its problems from a general point of view.
Mechanical Methods. — Doctor Meltzer dem-
onstrated, in the laboratory for physiology and
pharmacology, the efficiency of the method of
pharyngeal insufflation in an etherized dog, after
complete removal of the anterior wall of the thorax,
in which the lungs and heart were exposed to full
view. This was followed by a demonstration by
Doctor Rossiter, of the Carnegie Steel Company,
who exhibited the latest device of the Pulmotor
Company, which is not identical with the original
pulmotor. He also showed the original pulmotor.
He stated that he had resuscitated eight gas cases
in which the respiration had stopped. This was
done by the original pulmotor, in which he had
more confidence. Dr. James M. Booher, medical
director of the Life Saving Devices Company, dem-
onstrated the lungmotor. He showed a number of
bloodpressure tracings taken from animals which
had received artificial respiration by means of this
apparatus. In reply to a question Doctor Booher
stated that in these experiments the lungmotor was
connected with the animal by means of a tracheal
cannula. In human cases the lungmotor was applied
by means of a face mask. Doctor Booher left
with the Commission histories of a number of cases
in which the lungmotor had been used. The Com-
mission found no time to examine these written
histories, but Doctor Booher mentioned especially
two cases. One of these cases was subsequently
investigated by the chairman. It was in connection
v/ith a poliomyelitis patient, with complete paralysis
of the respiration, whose life was maintained for
thirty-six hours by means of the lungmotor.
In introducing Mr. Foregger the chairman ex-
plained that unfortunately the physician most com-
petent to present the details of the apparatus of the
Foregger Company could not be present, as he was
in France. He explained that the apparatus con-
sisted in modifications of the insufflation apparatus
of Meltzer. Among other changes, the apparatus
carried an oxygen generator tank. In reply to a
1056
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
question Mr. Foregger stated that the oxygen thus
generated might last eight or ten minutes.
Manual Methods. — Mr. Eglin read a letter
from Mr. M. W. Alexander, of the General Electric
Company, stating that he hoped the "Commission
would be very definite in recommending the prone-
pressure method, as experience has proved its
value."
Mr. C. B. Scott stated that the Accident Preven-
tion Committee of the National Electric Light As-
sociation had reached the point in its investigation
where it felt that the prone-pressure method was
best to recommend, bearing in mind that machines
were not always available in emergencies. His own
company had had nine successful cases of resusci-
tation by the prone method and three unsuccessful
cases in which mechanical means were used. Dr.
Schubmehl stated that the prone-pressure method
had been most successfully applied by their 225
first aid men. Mr. Maclachlan stated that it was
his duty to train, possibly, 3,000 men in the
prone method. Their system required the men to
practise this method at least once a month. The
men were instructed not to desist in less than three
and a half hours, and not until then should they
listen to advice from a physician who might tell
the operator that the patient was dead.
The secretary read the following parts of a letter
from Professor Schafer, of Edinburgh, to the chair-
man: "The prone method has been adopted exclu-
sively for about twelve years by the Royal Life
Saving Society, the only important organization in
the British Empire whose object is the resuscitation
of the apparently drowned. It has also been
adopted for several years by the London and other
police forces, by the Board of Trade, by the Army
and the Navy." "The most important thing is, in
cases of drowning, to have something ready which
any man can use, which will efifect respiratory ex-
change— whether exactly as much as normal, mat-
ters very little."
RESOLUTIONS ADOPTED BY THE COMMISSION.
In the discussion following the presentation of
methods and evidence to the Commission, the fol-
lowing important facts were emphasized: i. That
in most accident cases no resuscitation apparatus
was at hand for immediate use. 2. That reliance
upon the use of special apparatus diminished
greatly the tendency to train persons in the manual
methods and discouraged the prompt and persever-
ing use of such methods. 3. That police officers or
physicians often interfered with the proper execu-
tion of manual methods, in that they directed that
the patient be removed in an ambulance to some
hospital, thus interrupting the continuance of arti-
ficial respiration. . 4. That in many hospitals the
members of the staff were not all acquainted with
the methods of artificial respiration. 5. That in
medical schools instruction was not properly pro-
vided for students in the manual methods of arti-
ficial respiration.
In view of these facts the following resolutions
were adopted by the Commission :
I. The prone-pressure or Schafer method of re-
suscitation is preferable to any of the other manual
methods.
2. Medical schools, hospitals, fire and police de-
partments, the Army and Navy, first aid associa-
tions, and industrial establishments in general,
should be urged to give instruction in the use of
the prone-pressure method of resuscitation.
3. Individuals who, from accident or any other
cause, are in need of artificial respiration, should
be given manual treatment by the prone-pressure
method immediately, on the spot where they are
found. It is all important that this aid be rendered
at once. The delay incident to removal to a hospital
or elsewhere may be fatal, and is justifiable only
where there is no one at hand competent to give
artificial respiration. If complications exist or
arise which require hospital treatment artificial
respiration should be maintained in transit and after
arrival at the hospital, until spontaneous respira-
tions begin.
4. Persons receiving artificial respiration should,
as much as possible, be kept warm and the arti-
ficial respiration should be maintained till spontan-
eous breathing has been permanently restored, or
as long as signs of life are present. Even in cases
where there is no sign of returning animation arti-
ficial respiration should be kept up for an hour or
more.
5. A brief return of spontaneous respiration is
not a certain indication for terminating the treat-
ment. Not infrequently the patient, after a tem-
porary recovery of respiration, stops breathing
again. The patient must be watched, and if normal
breathing stops the artificial respiration should be
resumed at once.
6. Artificial respiration is required only when
natural respiration has ceased. In cases of simple
unconsciousness, from any cause, in which natural
respiration continues, artificial respiration should
not be employed without medical advice.
7. The Commission recommends that in cases of
gas asphyxiation, artificial respiration, whether
given by a manual method or by special apparatus,
should be combined when possible with the inhala-
tion of oxygen from properly constructed apparatus.
8. With regard to the employment of mechanical
devices for artificial respiration the Commission
feels that it ought not at present to take a definite
stand, either for or against any particular form of
apparatus. However, the Commission recommends
that the use and installation of apparatus should be
confined, for the present, to properly equipped in-
stitutions under medical direction. The Commis-
sion recognizes the great need of simple devices
capable of performing artificial respiration reliably
and efficiently. It therefore recommends a careful
study of the problem, directed toward the develop-
ment of a reliable method appropriate for general
adoption.^ Such studies can best be carried on in
properly equipped hospitals and laboratories which
offer opportunities and facilities for critical observa-
tion and experimentation.
In view of the importance which the knowledge
of proper methods of resuscitation possessed for
'See Appendix.
December 14, i9i».] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
1057
public health and safety, and considering the fact
that many practitioners, members of hospital staffs
and graduates of medicine were not thoroughly fa-
miliar with the methods of resuscitation, especially
that of the prone-pressure method, the Commission
recommended: a, That medical journals and other
scientific and practical journals which were inter-
ested in the problem of resuscitation be asked to
publish the resolutions adopted by the Commission ;
b, that a copy of these resolutions be sent to the
medical colleges with a request that proper instruc-
tion in this subject shall be arranged for in the col-
lege schedules ; c, that these resolutions be sent to
as many hospitals as possible, with the recommenda-
tions that members of the house staff familiarize
themselves with the methods of resuscitation ;
d, in order that the resolutions of the Commission
may be brought to the attention of interested
circles (fire and police departments, industrial
plants, etc.) it was agreed that they be communi-
cated to the Associated Press (by the National
Electric Light Association).
It was voted that the Third Resuscitation Com-
mission should be properly organized and continue
its existence, ready to respond when requirements
arise. The following officers were elected : Presi-
dent, Dr. S. J. Meltzer ; vice-president, Dr. Yandell
Henderson ; secretary, Dr. Reid Hunt ; treasurer,
Mr. W. C. L. Eglin. It was voted to appoint a
committee for the collection of verifiable data relat-
ing to resuscitation. The following members were
appointed to this committee: Dr. D. Edsall, chair-
man ; Dr. Reid Hunt, secretary ; Professor Elihu
Thomson, and the president, exofficio.
APPENDIX.
The Commission consisted of fifteen members.
Fourteen members approved the foregoing report
without qualifications. The fifteenth member. Dr.
Yandell Henderson, qualified his support of the
resolutions by the following statement: "While I
concur in a considerable part of the report of the
Resuscitation Commission I dissent from the state-
ment in Resolution 8, recognizing 'the great need
of simple devices capable of performing artificial
respiration reliably and efficiently.' Devices which
are excellent from the mechanical standpoint are
now available and widely sold ; but the evidence re-
garding them indicates clearly, I believe, that even
if these devices were on the spot where several
gassings or electrocutions occurred, and if all the
victims were treated with them, except one who was
given manual (prone-pressure) treatment, this one
would have much the best chance of recovery. In
actual practice the apparatus is seldom right on
the spot adjusted and ready. Critical time is lost,
and thus in the above supposititious cases, as they
actually occur, the only victim with any consider-
able chance of resuscitation (aside from those who
recover spontaneously and are credited to the appar-
atus) is the one treated manually. Even more im-
portant is the fact, demonstrated now by universal
experience, that when apparatus is known to be
obtainable, it is sent for and the manual method
neglected. Thus today the apparatus in public use
is, on the whole, contributing very materially to
decrease the saving of life."
AMERICAN LARYNGOLOGICAL
ASSOCIATION.
Fortieth Annual Meeting Held in Atlantic City,
N. J., May 2'j-2<), igi8.
The President, Dr. Thomas H. Halsted, of Syracuse, in
♦he Chair.
A Diagnostic Clinic for Pay Patients: The
President's Address. — Doctor Halsted in open-
ing his address said that while the organization of
hospitals for the care of ward cases and dispensa-
ries for free ambulatory cases had been well
organized, there had been no combing arrange-
ment for the care of private patients ; hence it
frequently happened that a diagnosis could not be
made because of the expense involved in calling m
as many physicians as the case really demanded.
Ofttimes the patient sought relief by consulting
various physicians of his own volition, with disap>-
pointing results. It sometimes happened that the
right physician was accidentally consulted, and the
cause of the obscure symptoms found, with a re-
sulting cure. It was for the profession to devise
the means of correcting this very grave fault. As a
result there had arisen many institutions in which
the medical staff was comprised largely of special-
ists in different branches. While some of these
institutions were excellent in every way, the great
majority were not, and as long as they remained
purely commercial organizations they never would
be. The scheme devised, worked out and practised
for nearly three years by the Clinical Club of St.
Luke's Hospital, San Francisco, offered the best
foundation from which to build a diagnostic clinic.
The medical staff of this hospital consisted of
twenty-four full staff members, four consultants
and ten assistants, with an excellent clinical labora-
tory and complete x ray department. In a hospital
with which he was connected, Doctor Halsted said
that the first choice was given the regular staff,
after which the assistants were given an opportunity
when vacancies arose. The staff was divided into
two groups serving on alternate months, with a third
group known as the auxiliary group, made up of
those specialists whose services would not be required
in every case. The latter became available in any case
in which the group chairman considered such
service desirable. The chairman was responsible
for the history of the case, and after making his
examination arranged for the visits of the other
members of the group together with such members
of the auxiliary group as he may desire. Records
were kept by a supervising nurse whose duty it was
to attend to the financial end of the work, see that
specimens were furnished the laboratory, arrange
the details of the physician's visits, to be present at
all examinations, typewrite the notes and attend the
general consultations, taking the minutes and tran-
scribing them. After all examinations, clinical and
laboratory, have been completed, a general consulta-
tion of all who have had to do with the case was
held, and every possible diagnosis arrived at, the
physician who referred the case being present and
participating in the consultation. A satisfactory
conclusion having been reached, a report was sent
to the referring physician, a second copy to the
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES
[New York
Medical Journal.
patient or his responsible relative — whenever this
seems desirable, and a third retained in the files of
the clinic. Only cases that were obscure and com-
plicated and apparently could not be diagnosed
by the average physician, were accepted by the
clinic. A minimum fee of $50 and graded up-
ward, according to the patient's financial situation,
was charged. Such fee included the services of the
medical man and of the laboratory and x ray de-
partments, as well as of the supervising nurse. In
addition, the hospital charged regular room rates
for time occupied. The portion of the fee remain-
ing would finally be divided equally among those
who had examined the case, to be received by them
individually or be voted by them for the purchase
of new equipment for improving the service of the
clinic of the hospital, the latter being expected to
be the disposition of the funds for some time to
come. In rendering this service they would them-
selves receive much knowledge and should benefit
greatly through these examinations and consulta-
tions, adding materially to their diagnostic ability.
The hospital would benefit by the steadily increas-
ing efficiency of its staff.
Finally, Doctor Halsted called attention to the
work of its committee in the National Council of
War Defense, and requested a quick response to
the appeal of the surgeon general for voluntary
medical service to meet the demands of the drafted
army. Each man must weigh the matter for him-
self and, putting aside all argument and questions of
personal advantage, reach a decision that he would
be willing to submit to the scrutiny of his fellows
and abide by their decision. Those who could go
were to be congratulated ; they were to be envied,
as they were the favored ones of the profession.
' A doctor who in this emergency could conscientious-
ly go and failed to respond to his conscience and
his country's call, putting a selfish profit first, was
to be pitied.
Report of Interesting Cases of Vincent's An-
gina.— Dr. Clement F. Theisen, of Albany, said
that there were two distinct clinical types of the dis-
ease, one form to be dififerentiated from diphtheria
and other pseudomembranous anginas occurring al-
most exclusively in young people, while the other
form had a localized ulceration simulating syphilis
occurring mainly in adults, usually, in his experi-
ence associated with carious teeth, especially in
those whose mouths were not well cared for. The
odor was distinctive and characteristic, and if not
promptly treated, extensive ulceration of the fauces
occurred with fatal ending. There had been, in the
speaker's experience, two fatal cases : one previously
reported in 1912, and the other a recent case in a
man thirty-two years of age. The uvula and part
of the soft palate had been practically destroyed,
and there was deep ulceration of both tonsillar sur-
faces and of the gums around the last molars. The
ulcerated surfaces were covered with a tenacious
pseudoniembrane. The molar teeth were badly de-
cayed, and the gums bled easily when touched with
a probe. The odor was so bad that it required a
good deal of courage to examine him. The patient
said the condition had been going on for several
weeks, but he had received no treatment. He had
been using a mouth wash of peroxide and water.
He was in an extremely weakened condition, be-
cause the pain in swallowing was so severe that he
had not been able to take much nourishment. No
history of syphilis could be obtained. Smears from
throat swabs verified the diagnosis of Vincent's
angina. He was given a strong solution of potas-
sium chlorate, powdered alum, carbolic acid, gly-
cerin and water, to be used as a gargle, and locally
the ulcerated surfaces after cleaning were swabbed
with a saturated solution of methylene blue in alco-
hol. Potassium iodide was given in large doses. This
was always administered in Doctor Theisen's cases,
whether a history of syphilis was obtained or not.
Blood count showed a moderate leucocytosis. The
patient failed steadily in spite of all efforts, and died
about two weeks after he was first seen. The larynx
was not involved in this case. Salvarsan was used
both locally and intravenously without any appre-
ciable effect. There was no autopsy.
Pure alcohol swabbed on the ulcerated surfaces
was also extremely valuable in these cases. The
greatest difficulty was in having the severe cases get
enough nourishment, because the pain in swallowing
was often so great. A solution of orthoform in
olive oil, swabbed on the ulcerated surfaces before
meals, afforded a certain amount of relief. A spray
of carbolic cocaine in the worst cases gave more re-
lief than anything else, if used a few minutes before
meals. In some of the adult cases of the ulcerative
type we were probably dealing with a combination
of syphilis and Vincent's angina, even when we
failed to obtain a history of syphilis. That might
be one reason why salvarsan acted so promptly in
some cases, although the consensus of opinion
seemed to prove that the arsenic preparations had
a specific action. Doctor Theisen had known cases
of this kind in which there was a positive Wasser-
mann (with no syphilitic history), with the typical
clinical and microscopic evidence of Vincent's
angina.
Discussion. — Dr. Christian R. Holmes, of
Cincinnati, inquired as to the temperature of the
patients; whether blood cultures had been made in
the two severe cases, and whether the alcohol treat-
ment has been applied locally or not. In Camp
Sherman there had been quite a run of Vincent's
angina among the soldiers, but none had been
seriously ill. All were the kind of cases that yield
readily to treatment. This consisted of the nitrate
of silver bead applied in the crypt, using it on a
heavy silver wire ; also of permanganate of potash
and peroxide of hydrogen used as a gargle. Gar-
gling with vinegar diluted with equal parts of water
had been tried lately and appeared very effective.
Dr. Lewis A. Coffin, of New York, said that
from the papers on this subject, it was evident that
patients have gotten well under various forms of
treatment. He thought that if these patients were
seen early, recovery might be looked for, if any of
the various methods were applied vigorously. The
speaker referred to a case which he had treated
twice daily for about a week, at the end of which
time he told the patient that he was practically well
and need not return for forty-eight hours. That
same afternoon, after sitting out during a ball game.
December 14, 1918.]
BOOK REVIEWS.
1059
the patient was seized with a chill, which was the
ushering in symptom of a typical attack of follicu-
lar tonsillitis.
Colonel Herbert S. Birkett, M. D., Montreal,
Canada, said that perhaps there was no condition
which was more prevalent than Vincent's angina
among British troops. He had seldom seen it in
any of the colonial troops, and this he thought was
due to the fact that the mouth conditions were very
well cared for among the Canadians. The condi-
tion was found not only on the tonsils but also on
the gums, even as far forward as the incisor teeth ;
it seemed as if this was due rather to direct infec-
tion. His experience with this condition was that
it yielded rapidly to treatment, consisting of an ap-
plication of hydrogen peroxide, liquor arsenicalis,
and vin ipecac. ^
Dr. Emil Mayer, of New York, expressed the
opinion that it was relatively easy to make a diag-
nosis of Vincent's angina when there was an ex-
udate and it was possible to make a smear, but he
had recently seen an instance in which the diagnosis
had been a great surprise. A woman of much re-
finement who took good care of her teeth, had con-
sulted him on account of a spasmodic cough. She
had a skin aflFection for which she was being
treated. There was a simple, mild exudate on her
soft palate, which seemed to be an evidence of the
skin infection on her mucous membrane. Doctor
Mayer felt that .she had a similar condition on her
trachea, because of the negative result of all of the
examinations. Her sputum was really more saliva
than anything else, and he was intensely surprised
at the report that it was full of the fusiform bacilli.
There was an absence of anything like a membrane,
yet the condition occurred, and in a person not
neglectful of her teeth or general condition. It
probably occurred much more frequently than was
generally believed in this class of cases.
The treatment that had answered best in Doctor
Mayer's experience was the local application of
salvarsan, together with the iodine and glycerin,
which he had recommended at the time he had re-
ported the first case in the English literature. He
had never seen the severe fatal cases. Arrowsmith
reported a case in which the patient nearly died. It
was important to be on watch, for cases would prob-
ably be discovered where least expected. .
Dr. Greenfield Sluder, of St. Louis, referred
to the solution of methylene blue in alcohol alone,
of wliich Doctor Theisen spoke. He was glad to
know of that. Doctor Sluder had also used the
rnethylene blue, but in powder and in aqueous solu-
tion, and likewise found it to answer the purpose.
Dr. Clement F. Theisen, of Albany, replied to
Doctor Holmes's question regarding blood cultures.
Blood cultures had not been taken iDut blood counts
had been made and the leucocytes in both cases
were increased. There was an increase in the poly-
nuclears. The method of treatment was a combi-
nation of old drugs, practically a specific, either as
a gargle or in the spray form. This combination
consisted of potassium chlorate, powdered alum,
glycerin, and water. The results were excellent.
Alcohol was used locally.
{To be continued.)
Book Reviews.
[We publish full lists of hooks received, but we acknowl-
edge no obligation to reviezv them all. Nevertheless, so
far as space permits, we reviezv those in which we think
our readers are likely to be interested.]
The Pretty Lady. By ARNni.n Bennktt. Illustrated.
New York: George H. Doran Compsiiy, iqi8.
Men and women — even so righteous and well in-
tentioned a body of citizens as the Antivice Com-
mittee of Fourteen — may stand of¥ at a distance and
•say what ought to be done. The only difficulty is,
and it is a serious one. that beacuse of the aloofness
with which they are able to form judgments, mak'^
reports, and agitate legal reform, they are too prone
to draw a veil before the real issue that lies in the
lives of the men and women whose actions they
place under surveillance but whose inner psychic
impulsion they fail to reckon with. Their duty as
guardians of the outer decorum of society places
them in a false superficial position. Their work is
a necessary one as far as it makes it easier for men
and women to find the fuller, more constructive,
therefore the higher exercise of their impulses and
powers. It will nevertheless fail of such a deep and
lasting end if it does not more sincerely know the
individuals and the conditions with which it has to
do. in the most profound psychical significance.
It takes courage and human sympathy, as re-
vealed in this book, The Pretty Ladv, to discover
that prostitutes, "clerks," and profiteers under the
Raines law have certain inner reasons for their
course of life, which are far more profound, more
complex, more universally human, than the mere
seeking of material advantage of the plying of a trade
into which outw.ird circumstances or the following
of some single impulse forces them. Until society
and the representatives it sets to aid it in its pro-
gress upward through reforms comprehend thi.s
with more than an intellectual acquiescence or that
of a superior self righteous "sympathy," real aid will
not come. In this story of Bennett the prostitute
is one because of a very human course of events
combined with a special mental makeup on the
part of the mother and of the Prettv Lady herself,
which had gradually worked together to set the
daughter's life in this particular sphere. Here she
proved herself a sincere, consistent heroine in her
own way. It was a limited one and made her com-
placently accept her career and fulfill it. Her
sincerity and consistency were greater than of the
man who deserted her when he came, as he thought,
upon some episode in her history which proved her
unworthiness and baseness. He had a psychology
too limited and too dependent upon the conventions
and advantages of his upper social world to admit
that there might be further explanation for her
apparent defection and unexplained behavior. The
instance was the seeking by the Pretty Lady of the
soldier to whom a hallucinatory mystic faith had di-
rected her, and toward whom it imposed a sacred
duty. This revealed in her not a baseness and im-
possibility of comprehension and acceptance of a
higher position, as her lover thought, but rather the
fact that there is also a psychology which is often
a pathological one behind such a social career as
BIRTHS. MARRIAGES. AND DEATHS.
[New York
Medical Journal.
hers. This again gives added reason for thoroughly
imbuing a scientifically symphathetic psychology into
reformers and moral advocates. The book is one
wliich such workers should take to heart that they
may know that they deal not first with social prob-
lems but first with individual psychic facts in each
man and woman. It is the physician who should
first adopt such a standard insisting upon a knowl-
edge of individual psychology and of its relation to
social disease of any sort, that is to be compre-
hended and dealt with. From this point of ap-
proach alone can institutions which work for social
harm or the individuals who maintain such insti-
tutions or make use of them be understood and be
enlisted for good rather than for destructiveness
and evil. Such a book as this humbles the critic
who attempts to judge as he stands apart. In
recognizing the living factors in such a character
as the Pretty Lady, he comes to ask whether, after
all, there is not a revelation of humanity here which
his merely conventional attitude, unconsciously
protective against such self knowledge, has pre-
vented him from, recognizing in himself.
T echnik dcr P critnncalen ]VitndcrbchandJunq des Weib-
lichen Bcckcns. By Oskar Beuttner, M. D., Professor
at the University of Geneva. Illustrated. Zurich : Art
Institut Orel! Fiissli, 1918. Pp. 488. (Price, $15.00.)
We are glad to have this work before us,- coming
as it does from a conscientious gynecologist who
sincerely desires to offer to the surgical world what
he supposes to be worthy of attention. But in point
of fact, the Geneva professor has not accomplished
much from the viewpoint of American surgery.
In 1895, Segond of Paris and Jacobs of Brussels
came to the United States to teach the method of
vaginal hysterectomy and they returned to their re-
spective cities imbued with our methods of abdomi-
nal hysterectomy with peritonization, a method
which has held its place since the above date. Amer-
ican surgeons were developing peritonization to
quite an extent at that time. Soon after their
return, both Segond and Jacobs published papers
on the American methods, as done by Kelly, Ernest
Gushing, Baldy, the regretted Pryor, and a host of
others, which the Germans rapidly adopted, not for-
getful at the same time to give their names to these
technical procedures. The result, therefore, has
been that Beuttner in his innocence — or rather
ignorance of the American and EngHsh medical
literature of the past twenty years — has offered
matter that to the American profession is an old
story, and although it must be admitted that the per-
sonal technic described by the author is certainly
ingenious, it could hardly be considered impor-
tant by any practical Anglo-Saxon operator. Even
when Beuttner describes uterine suspension he de-
picts Baldy's and Thomson's operations, which
have, we believe, been discarded for others, such as
the Webster-Baldy technic, etc. Pryor originated
his technic of total hysterectomy before IQOO, if we
are not mistaken, and about 1906 Wertheim gave
to the surgical world his copy of Pryor's operation,
although of course without mentioning the Ameri-
can surgeon's name.
Beuttner passes in review the various i^echnics of
Wertheim, Doderlein, Bumm, Veit, Kiistner and all
the German school of gynecology, revealing the fact
that their methods were founded on what had pre-
viously been done in the United States.
The press work and illustrations are of the very
best and a credit to the well known publishers.
Deinils of Military Medical Administration. By Joseph
H. Ford, B.S., A.M., M.D., Colonel, Medical Corps, U.
S. Army. With thirty Illustrations. Published with
the Approval of the Surgeon General, U. S. Army.
Philadelphia : P. Blakiston's Son •& Co., 1918. Pp. xi-741.
(Price $5.)
Colonel Ford has given in this book a work which
will prove invaluable to military medical officers.
It is a large volume, admirably printed, and pre-
sents in a concise, interesting, and readily available
form, just that kind of information which the
civilian surgeon needs on taking up military work.
Unfortunately, the constant change in the forms
used in the service soon render obsolete any set of
forms which may be published, but one who fa-
miliarizes himself with the forms laid down in Colo-
nel Ford's admirable work will have little difificulty
in adjusting himself to any modifications which may
be made by the medical department. We have al-
ready made editorial reference to this excellent and
informing volume.
<$>
Births, Marriages, and Deaths.
Died.
Bradford. — In Philadelphia, Pa., on Tuesday, December
3d, Dr. Thomas L. Bradford, aged seventy-one years.
Collins. — In Parishville, N. Y., on Tuesday, November
19th, Dr. William E. Collins, of Massena, N. Y.
CoRRiGAN.— In St. Leo, Fla., on Thursday, November
28th, Dr. Joseph F. Corrigan, of New York, aged seventy-
four years.
Erdman. — In Macungie, Pa., on Sunday, December ist,
Dr. William B. Erdman, aged eighty-one years.
Gloninger. — In Lebanon, Pa., on Tuesday, December
3d, Dr Andrew B. Gloninger, aged fifty-seven years.
Gravatt. — In Troj, N. Y., on Monday, December 2d,
Dr. Edwin J. Gravatt, aged forty-eight years.
Gray. — In Shreveport, La., on Monday, November 25th,
Dr. Robert A. Gray, of Frankfort, Ky., aged eighty-eight
years.
Grekn.— In Boston, Mass., on Thursday, December sth,
Dr. Samuel Abbott Green, aged eighty-nine years.
Griffin. — In New York, N. Y., on Saturday, November
30th, Dr. Carlton L. Griffin, aged sixty-eight years.
Hamblen. — In Bedford, Mass., on Wednesday, Novem-
ber 20lh, Dr. Edward J. Hamblen.
MacFarland. — In France, on Thursday, October 24th,
Dr. James MacFarland, Captain, Medical Corps, U. S. A.,
of Burlington, N. J., aged thirty-one years.
Millard. — In Cheyenne, Wyo., on Tuesday, November
19th, Dr. Hugh R. Millard, of Dundee, N. Y., aged thirty-
two years.
Parsons. — In Palmer, Mass., on Saturday, November
30th. Dr. William Turner Parsons, aged thirty-seven years.
Pettingill. — In Philadelphia, Pa., on Monday, Decem-
ber 2d, Dr. Eliza F. Pettingill.
Robinson. — In Bluffton, Ind., on Wednesday, November
i8th, Dr. Homer E. Robinson, aged forty-one years.
Rose. — In Brooklyn, N. Y., on Friday, November 29th,
Dr. Henry William Rose, aged sixty-nine years.
RuPiROSA. — In New York, N. Y., on Thursday, Decem-
ber .sth, Dr. Rafael Rubirosa, of the Dominican Republic,
aged thirty-three years.
Smith. — In Baltimore, Md., on Friday, December 6th,
Dr. Kirby Flower Smith, aged fifty-six years.
Soltan. — In London, Eng., on Saturday, November 2d,
Dr. Harry B. Soltan, of New York City.
White.— In France, on Saturday, November 2d, Dr.
Clarence H. White, First Lieutenant, Medical Corps, U. S.
Army, of Cohoes, N. Y., aged thirty years.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843
Vol. CVIII, No. 25.
NEW YORK, SATURDAY, DECEMBER 21, 1918.
Whole No. 2090.
Original Communications
A BOLSHEVIK BOLUS.
By William P. Cunningham, M. D.,
New York,
Visiting Dermatologist to the Misericordia Hospital; Associate
Visiting Dermatologist to the Children's Hospital and
Schools, Randall's Island.
The civilized world has stood aghast at the spec-
tacle in Russia. Under the domination of the so-
cialistic cult, bedlam has broken loose ! Disorder
runs riot ! Violence and crime released from the
restraint of established authority have swept abroad
like a pestilence ! The bulwarks of society having
broken down, the dregs of society have seethed to
the top. Envy, hatred, greed, and vengeance are
running amuck! Perched on the back of the so
called doctrine of equal rights ; of the brotherhood
of man ; of the just title of the laborer to the full
product of his labor; of the elimination of capital
and the distribution of wealth among those only
who create it ; the most detestable qualities of our
imperfect nature have galloped roughshod over the
principles and safeguards of our social organiza-
tion and laid them shattered in the dust. SociaHsm
has had its day in court or rather at court, for it
has supplanted a more or less objectionable tyranny
with a thoroughly vicious one! Human rights un-
der its ruthless terrorism have vanished into
tWn air. They were much better recognized under
the Czar! Brutish, brainless, blind rapacity,
raging in insensate fury against everything of worth
or consequence, has constituted itself the apogee
of economic freedom, and the be-all and the end-all
of socialistic achievement ! Here was socialism
acted out to the life: here it was in all its naked
beauty! Here amid the fires and the thefts, and
the murders, and the nameless outrages of mob
supremacy, it wrought a perfectly consistent demon-
stration of destruction and decay! The world with-
out saw and shuddered! Men of reason deter-
mined that the lesson was su^^^cient and that the
hideous hydra-headed devil of socialism should
never get another chance. It had cut its own throat
with the sword of its own forging ! But these wise
men seem to ignore the power of hydra to regrow
the head that is cut off. They seem to think that
glaring at Russia and framing resolutions are suffi-
cient deterrent to the reappearance of the evil else-
where.
Note the ominous signs from Germany! But
even where disorder has not given it favorable op-
portunity, the cunning of the reptile insinuates its
slimy carcass by a hundred devious ways into th^
forum of legislation. We are tricked by some hu-
manitarian project into accepting a principle of
action whose logical consequence can be only Bo! -
shevikism. Specious reasoning by clever ergoteiirs
and interested exploiters, who see salaries or profits
in the uplift propaganda, blind us as to the real
character of the step we are taking. Before we are
aware of whither we are going we are treading the
path of the Bolsheviki. While the administration
of the socialistic state has been a wretched fiasco,
because of the absence of truth and justice from
the fabric of its dreams, nevertheless in the pres-
entation of the case for our suffrages the socialistic
orator has a certain facility of expression and a
certain speciousness of appeal which are very allur-
ing and deceptive. So that if we are not "armed
so strong in honesty" that we are proof against all
seduction, we are apt to be entrapped into accepting
some .shred of his argument and thereby committing
ourselves to the propagation of his toxic tenets.
These temptations unfortunately do not always pro-
ceed from the avowed socialist whose identity
would arouse our antagonism at once. They fre-
quently proceed from quarters whence we should
expect anything but socialism ! They are often ad-
vanced by individuals and societies who would shud-
der at the imputation of socialism! and yet they are
socialism nevertheless but so disguised as to be
especially dangerous. We may guard ourselves
against the open enemy, but the false friend or the
smiling traitor or the deluded zealot is hard to
unmask ; whence it comes that we are encompassed
round about today by socialistic stratagems in the
hands of nonsocialistic sponsors. To the intense
delight of the Marxian doctrinaire, they play the
game with perfect artlessness and childlike incom-
prehension of the damage they are doing! It is
certain that these heedless social service marplots
gain a wider hearing for unadultered socialism and
put its teaching on a more acceptable footing than
all its undisguised exponents put together! Thev
appeal to people whose hard common sense would
revolt from the vaporings of the professional pro-
pagandist. They get to the susceptibilities of the
man of aft"airs, and the woman of thought, and
under the guise of pure Christian altruism lead
them in the direction of Bolshevikism.
Thus it is that we have the amazing spectacle of
our Rockefellers and our Lamberts and our Gold-
waters striving with the infatuation of the veriest
Copyright, 1918, by A. R. Elliott Publishing Company.
io62
CUNNINGHAM: A BOLSHEVIK BOLUS.
[New
Medical
York
Journal.
soap box orator to advance the standard of red
fla£j internationalism. In so far as they can, they
urge the adoption of certain specious features of
that abhorrent doctrine under the pretense of ame-
h'orating the condition of the masses ! As class con-
scious as the wildest social revolutionists, they
would legislate for the "laboring class" ! They
acknowledge the principle on which the meddling
interference rests. They admit that the State must
do for part of its citizens what it is not called upon
to do for all ! They admit that the State has the
right to do this. They contend that it h3s the
correlative duty to do it. This involves, of course,
the confession that society has been cheating these
particular units of its organization. This makes the
case for socialism.
* So true is this that in speaking of one particu-
larly objectionable proposal in the way of med-
ical legislation they actually use the term "socializ-
ing medicine." They not ony accept the fact but
glory in the brand ! There can be but one logical
consequence of this deplorable surrender of legi-
timate democracy and sturdy Americanism, and that
is the eventual bolting of the whole loathsome Bol-
shevik Bolus! These half informed enthusiasts will
not concede the inevitability of that dread disaster,
but in so far as they are instrumental in the forcing
of bits of the doctrine upon a dull witted electorate,
they are bringing nearer the acceptance of the
whole. The class distinction that underlies the
whole argimient of socialism, the granting of special
privileges and immunities to certain elements of
society, irrespective of their fruitful utilization of
the opportunities common to all, is the foundation
on which the conception of the destructive philos-
ophy rests. The socialist simply pushes it further
than his respectable confederates care to do at
present ! He claims for a particular class not only
distinct concessions, unwarranted in law or nature,
but actually the investiture of that class with the
title to all the wealth of the world ! No one pro-
duces but the hand laborer! No one but the hand
laborer is entitled to reap the rewards. So in un-
fortunate Russia where this midsummer madness
has got the upper hand by a curious whirl of the
wheel of fate the producing ( ?) class proceeded
to appropriate what had been accumulated by the
professional and trading classes, and the whole
social system fell into clamorous chaos ! And curi-
ous to relate, the "oppressed and exploited laboring
class," imputed to have all the virtue and real worth
of the community, no sooner got a taste of the "flesh
pots of Egypt" than it promptly threw aside all pre-
tense of the brotherhood of man and set up a
tyranny of its own more execrable than any that
had preceded it ; a tyranny utterly oblivious of the
rights of others, and more heartlessly coercive and
embruting! The world should have learned its
lesson from the martyrdom of Russia; everything
savoring of "socialism" should be instantly repudi-
ated. The very beginnings of the hateful scourge
should be stamped out. Nothing flavored with it
should be aught but a stench in the nostrils of
decent men ; yet with this example still fresh before
us, we are utterly unimpressed and heading straight
for the adoption of ideas emanating from the
mephitic whirlpool. Health insurance seems to
have gone into a trance, at least under that designa-
tion. The war perhaps has brought about sjich a
dearth of available doctors, that it is momentarily
impracticable, but it is dear to the heart of its Bol-
shevik sponsors, botli in the camp of the blatant
socialist and his "social service" accessory. It will
crop out again, possibly under its own title, possibly
camouflaged with a more deceptive one. But mean-
while, as the devil never sleeps, the program of the
compulsory health insurers is still offered for ap-
proval with its auxiliary features brought into the
prominence of the discreetly retired pivotal project.
One of the innovations planned was the estab-
lishment of clinics for the exploitation of the
specialties in the interest of the poorer "classes" —
fee, one dollar. These were to be held at night so
that the people employed all day could take advan-
tage of them. As already stated, they were orig-
inally to be tagged on to the compulsory health in-
surance program. Now for reasons of weight they
are coming first. And imagine what influence is
now supporting this dangerous and confiscatory in-
novation ! The United States Government !
Of course, the United States Government is act-
ing in this instance at the behest of the Medical
Department of the Army, Navy, and Public Health
Service. The ostensible purpose is to provide
clinics for the treatment of venereal diseases among
enlisted men. But these clinics, either at once or
eventually, are to embrace the general public.
It may be remarked in passing that the amount
of solicitude expended on the victim of his own
libidinous excursions by the various medical boards
aforesaid is touching in the extreme. To protect
the man from the reward of his folly, he is pro-
vided with a prophylactic ointment and wash and if
he contracts disease despite this godly precaution,
he is handled as if he had sufifered in the most
meritorious cause in the world. If he goes upon
his amorous adventure without notifying the au-
thorities of his commendable and edifying inten-
tion and he brings back a chaste memento, he is ppt
in the -guard house for an extended period and de-
prived of the various privileges dear to the heart of
the soldier.
When the public has been included in the clinen-
tele of these venereal clinics the entering wedge of
Bolshevik medicine will have been firmly driven in.
The specialties will have come under the fire of the
reformers who seek the subjugation of medicine to
the dictation of salaried institutionalists. We shall
have specialists working set hours for a salary or
on percentage and treating large numbers of pa-
tients. The net result, upon the specialist, will be
the dampening of his professional ardor and the
blunting of his diagnostic acuity. We all know
what the incentive to investigation and improve-
ment is in workers in our hospitals and clinics. It
IS certainly not the mere love of the work in hand.
If there were nothing beyond but the abstract re-
wards of intellectual achievement, enthusiasm
would quickly fade into apathetic routinism and the
dull application of an unprogressive formulary.
The drudge in the dispensary is fitting himself for
the remunerative employment in other fields of the
December 21, 1918.]
CUNNINGHAM: A BOLSHEVIK BOLUS.
knowledge he has thus painfully acquired. The
public pays for its advantage in furnishing clinical
material for the doctor's education; that is just.
Everything in this world that is worth having costs
an effort ; we all pay. Nothing for nothing is the
rule of justice, since we are all under the primal
curse of laboring for our needs.
Oh ! we all anticipate the protest arising from the
throat of sweet charity against this cold blooded
proposition. Great services are constantly rendered
for nothing in the name of the greatest of the
virtues. But this is a faulty apprehension of
motives. The .service under the impulse of charity
is compensated by the knowledge of a huntanitarian
or religious duty faithfully performed. Attached to
this, in the minds of most of the performers, and
in no way detracting from the merit of their con-
duct, is the hope of a great reward in heaven ! They
ca.st their bread upon the waters in the expectation
of a manifold return. This has been promised and
is a perfectly legitimate incentive to selfsacrifice.
But when it conies to a question of the monetary
payment of special medical skill no one who ex-
pects or demands this at a cut rate (at the rate of
a few cents a case or consultation) need reasonably
anticipate anything more than he pays for. If he
does he is flying in the face of human experience
since society was organized. If he invests thirty-
three and a third cents in a medical opinion he is
strangely deluded if he looks for five dollars' worth.
He will get thirty-three and a third cents' worth
exactly. The dollar paid by the patient is to be
divided into three parts, of which the hospital is to
get one third, the drug department one third, and
the doctor one third. The expert opinion is figured
by the institution as no more valuable than the cost
of the medication. This knowledge, to be sure,
tends to raise the selfappreciation of the vendor of
that opinion. His enthusiasm for humanity is mar-
velously increased by the realization of what
humanity thinks of him ; his desire to help the
aforesaid humanity is augmented by its evident
desire to swindle him. What a wonderful rap-
prochement between the patient and his adviser ;
what mutual esteem and admiration will be created
by a system whereby the parties working under it
are either practising or resenting extortion. When
a man gives away his services he retains his self-
respect ; when a man sells them at a ruinous reduc-
tion he feels that he has become a bargain counter
remnant of his professional self. He is doing his
share in the depravation of his profession. The
motives actuating the institutionalists and their
Bolshevik confederates are sinister enough, but
they have the merit of virility compared to those
of the weakkneed Esaus who fall for the beggarly
mess of pottage.
Compulsory health insurance or health insurance
by the State or government, has been temporarily
sidetracked as we have seen, for reasons best known
to its supporters. The evil features of this utterly
unconscionable interference of the State in the af-
fairs of private life have been shouted from the
housetops by earnest men of prescient mind. But
it is to be feared that the medical men most liable
to the pressure of that iniquitous proposal, have not
been awakened to the meaning of it. They have
been so accustomed to legislative raids upon their
means of subsistence that they give but scant at-
tention to the warning now going forth. They
have seen the qualifications for the practice oi
medicine rigidly enforced in their case and felon-
iously relaxed in the case of Christian science,
chiropractic, and every other irregular and bizarre
design upon the pockets of the credulous. The
proponents of any fool scheme with a friend at
Albany could obtain the privilege of preying upon
the public after a few months nondescript instruc-
tion in a mythical "college" : whereas the student
in a standard school of medicine is compelled to
study four hard years and pass gruelling examina-
tions both at the hands of his own professors and a
State board of regents before he is allowed to
compete with the charlatan for the business of
curing the sick. This discrimination was unfair
and unjust and indefensible, but the patient doctor
stood it. Now it is proposed under health insurance
to reduce him to a condition of practical serfdom by
sweeping away his professional independence, and
compelling him to work fof a beggarly yearly
stipend apportioned to the number of patients he
has in his "section." It is proposed to extend the
"lodge" system of practice to the profession at
large and the community in general. Everybody
who works for a certain wage is to be forced to take
health insurance; if he does not do so he will not
be employed anywhere. His family is also insured.
His wife is insured against the expense of her con-
finements ; he pays so much a year for the privilege
of the doctor whenever he wants him. The sum
is ridiculous. Let us say about five dollars a year
or ten cents a week. For this magnificent recom-
pense the doctor must respond to any amount of
work that may be laid upon him by that man. He
is to be at his beck and call, and he cannot refuse
to comply. He cannot escape the agreement. He
is a contract laborer for the term specified. No
matter how distasteful or objectionable the patient
may become the doctor must put up with him till
the time expires You will say that the doctor has
freedom of choice and need not undertake the
service. He has certainly great freedom of choice;
with the State compelling its citizens to assume this
insurance, and thereby forcing the great fiiajority
of people to resort to the physicians assigned to
their districts, the physicians who do not sign up
for the work will find themselves without any
patients at all. A fine freedom of choice, to accept
the terms offered or go into some other occupation.
The comi^etition of the State is too powerful to
be resisted; the knell of independent practice will
be struck among physicians of moderate incomes.
There will not be patients enough to keep all oc-
cupied when they are herded in sections under the
block system, and there will not be remuneration
enough, at the figures charged, to maintain all the
physicians who might be driven to accept the
humiliating situation. Thus many men will be
forced to the wall who are now maintaining a
modest but respectable establishment. Where the
patients, as at present distributed, are suffcient to
support many doctors in comparative comfort.
1064
CUNNINGHAM: A BOLSHEVIK BOLUS.
[New York
Medical Journal.
under the proposed revolutionary alteration they
would be compacted into the care of fewer men
who, themselves receiving less for their labor than
before, would be the instruments of extinguishing
the incomes of their brethren.
It is strange indeed that the average physician
cannot be brought to see the deplorable position in
which this will place him. It is strange also that
many physicians of prominence are urging the
adoption of this scheme of practice for their pro-
fessional compeers of more modest pretensions.
The point of view of the average physician is dulled
by his inaptitude for resentful resistance. The point
of view of the other sort is that of the complacent
commiserator of the "common people" ; this person
is a myopic prig ; a mischievous meddler ; a consti-
tutional marplot. The poor are so much in need
of advice, protection, and patronage, that fairness
and common honesty are ruthlessly sacrificed to
provide them. To coddle the poor a selfsustaining
element of the community is to be reduced to
beggary.
But the most menacing part of the whole
w^retched business i§ the partnership between this
so called uplift element and the out and out so-
cialist. They are both heading straight for the
same object. They both acknowledge it. There
is absolutely no dif¥erence in their arguments or
phraseology. They are both set upon the "so-
cializing" of medicine. The language is identical
with the smug uplifter and the ranting soap box
reformer. Naturally advocating the same thing,
for the same reasons, they fall into the same
forms of speech. With your eyes shut you could
not distinguish in the smooth utterances of Lam-
bert, or Goldwater, and the raucous ravings of
the Russian Reds any essential difference in their
sentiments and intentions on this particular
topic ! They are for the socializing of medicine !
The doctor is to work for the State ; the State is
to dictate the terms on which he shall work ; the
State is to compel the people to accept the doctor
and the doctor to accept the remuneration fixed.
Both parties to the arrangement are deprived of
their character as free agents. Other members
of the community, who have no direct interest in
the welfare of either party, are to be taxed to
help to defray the expense of the project, which
also includes sick and death benefits.
The State is the whole actuating force. It com-
pels the debasing of one of its constituent bodies
for the alleged betterment of another. It dis-
cards equity and decides upon the frankly so-
cialistic principle of the right of the "masses" to
what they can appropriate. Vested rights are
ignored ; the rights of property are cooly abrogated ;
the right of a man to the product of his laho;' is per-
verted into the right of a man to the product of
other men's labor. Given the pernicious doctrine
that physicians may be fairly reduced to such a
servitude on the principle advanced by both avowed
and camouflaged socialists, and the whole case
against socialism falls to pieces. Admit that men
may be forced to work for the State in one in-
dustry, and you admit that they may be forced to
do so in every industry. Admit that the State has
the right to fix the rate which its citizens may
charge for their services in one industry and you
admit its right to fix the rate in every industry.
Admit these two contentions and State socialism
becomes only a matter of expediency. Its ethical
aspect is no longer in controversy. It is the sup-
port, endorsement and impetus thus given to State
socialism by the advocates of health insurance
which constitute the most reprehensible feature of
the programme. The way is made ready for the
facilitation of the whole confiscatory and demoraliz-
ing movement. And when the inevitable attack is
made upon some other better buttressed economic
factor, the howl of disapproval from these one time
associates cannot fail to astonish the whole hog
socialist. He will retort, and fairly, that when it
was a question of applying the principles of social-
ism to the invertebrate medical profession, no more
ardent socialists ever frothed at the mouth than
these now recalcitrant reformers. They sustained
the demand for health insurance and upon the very
grounds on which the larger inroads are now pro-
jected. Perhaps the partners in the socialistic sub-
jugation of the medical profession will now be at
odds over the common ownership of land. But
surely if the State may coerce the doctor to sur-
render his income it may coerce the landlord to sur-
render his rent. If it may organize and socialize
the treatment of the poor, it may also organize and
socialize the housing of the poor. It may dictate
the prices landlords may charge or compel them to
turn over their incomes to the common treasury.
If a corporation has the control of the manufacture
of a certain commodity the State may rightfully
appropriate the plant and run it for the benefit of
all the people. The feeding of the people is as
much the concern of the State as their health.
In fact, the two considerations are in some aspects
indistinguishable. Health depends as much on food
and dwelling as it does on medication. If for the
good of the public health the State may dragoon
the doctors into unwilling servitude, then for the
good of the public health it may dragoon the own-
ers of the natural opportunities into providing the
nutriment and the shelter which are requisite for its
preservation.
It may compel makers of shoes to turn over
their factories or products to the authorities for the
better protection of the public and therefore the
better conservation of the public health. There is
no extension of the socialistic teaching which can-
not be justified by the acceptance of the principle
of compulsory health insurance. The yielding of
a principle for the perpetration of injustice brings
its retribution in the form of graver injustice. Those
who, in order to reduce the doctors to subservience
to their designs, adopt the formulas of the social-
ists will find themselves a party to the unpalatable
application of those formulas to institutions which
they wish to uphold. By their cooperation on a
former occasion they will have justified the larger
demands of their whilom partners. The law of
gravitation is operative not only on the massive
boulder but on the grain of sand. It is deducible
from the fall of a sparrow as well as from the
fall of an eagle.
December 21, 1918.]
CUNNINGHAM: A BOLSHEVIK BOLUS.
1005
The principle of socialism is as firmly established
by compulsory health insurance as it would be by
the acceptance of the whole Marxian system ; and
it is this stealthy invasion of the thing that has de-
stroyed Russia, which we must oppose with all our
power. We must not permit the evil beginnings of
the economic disease. The smallest seed planted
under the cleverest subterfuge may be the origin of
a upas tree of great growth and malignancy. It is
at the inception of an epidemic that the greatest
caution is necessary to prevent its taking hold. It
is at the inception that the completest repulse can
be administered. The safest course for society is
the rejection of all those sweetly worded "social
reforms" whereby it is sought to break down the
barrier, insurmountable in an honest frontal attack,
between socialism and the rights of property. The
wrongs of man may be many. But they are reme-
diable by the slow and sure evolution of enlightened
public opinion. They are not remediable by the per-
petration of other wrongs. The advance to perfect
justice is not along the road of confiscation. The
happiness of all the people cannot be secured by the
ill usage of any. It is a contradiction in terms !
Cheating and browbeating the doctors in the inter-
est of the laboring "classes" will rebound to the in-
jury of the latter. There is no profit in dishonesty.
Even he who seems to thrive upon it makes tenfold
atonement in the loss of selfrespect. And society
will the sooner go into convulsions, for the sur-
render of the smallest safeguards against dishonest
exploitations. The doctors wronged will mean the
speedier wronging of some other class and the ex-
pediting of the coming of the day of Russian mad-
ness !
The defeat of the insidious socialistic infiltration
is the gravest duty of the thinking man today. The
great war is won. It is no longer in doubt ; but
the sleepless activity of the socialistic propaganda,
which had all but lost the war for us by the catas-
trophe in Russia, is ever moving upon the works of
real democracy and by trick and device seeking to
find the weak places in its defences. These are
often revealed by more or less conscientious idiots
Avho are seduced to give a helping hand to the in-
vader. Under the disguise of patronizing "uplift"
of the needy, concessions are made to the less pro-
nounced demands of the internationalists, and the
whole case against them is thereby given away. If
principle is surrendered details are a matter of little
consequence. The energetic apostle will not fail to
push them relentlesslv, upon the incautious relaxa-
tion of that eternal vigilance which is the price of
safety. These social service triflers with the funda-
mental ideas of real democracy admit that some of
the conceptions of the socialist are just. This ad-
mission was inevitable since they were bent upon
the same "reforms." But as the socialistic doctrine
is erected upon the hypothesis that the production
of wealth is all effected by the proletarian and that
in the distribution of wealth he is the only one to
be regarded ; that capital being the accumulation of
wealth thus produced belongs to the laborer ; that
everyone able to work is entitled to the same reward
in the shape of food, shelter, clothing, and recrea-
tion, irrespective of his individual productive
capacity; it will be seen that in accepting any of
the deductions from this hypothesis, its correctness
is inferentially acknowledged. Herein lies the fatal
blunder of the zealous "uplifter": he wants to be a
bit of a socialist without admitting it. He wants
to run with the hare and hunt with the hounds.
The consequence of that course is proverbial. He
wants to have a foot in both camps, forgetting that
he will be mired by the foot in the socialistic camp.
New communities never run to socialism. It is
only when the pressure of population increases that
the demands of the less industrious or more im-
provident for an unearned share in the general
accumulation take the socialistic form of special
legislation for the poorer "classes."
W hat other men have fought for, striven for, and
worked for is to be handed over in part, or in whole,
to these less energetic or capable contenders on the
ground of "the public good." That is the open
sesame of State socialism, "the public good" ! The
substance of those who have had the brains, the
prudence, the capacity to acquire a competence is
to be taxed away to make up the deficiencies of
those who have neglected natural endowments and
equal opportunities. All in response to the shibbo-
leth "for the public good." That cry will justify
the infliction of any injustice. It justified the
wholesale murders of the French Revolution. It
has justified the assassination of individual rulers
and philosophers. It is used to justify today the
appalling excesses of the Russian socialists. To be
sure, society has the right to determine in some
measure the conduct of its members. People are
to be protected m the exercise of their right to life
and property. Disease that threatens to spread by
contagion may be lawfully subjected to quarantine
and other measures of control ; but these are in-
stances of action in selfdefence and not "class"
legislation in favor of any particular part of the
community.
The segregating of the people by salarv limi-
tations and the enactment of special rules of medical
practice for those who are on one side of an arbi-
trary line, and the taxation of the rest of the people
for their behoof and benefit is vicious and undemo-
cratic. It is an acknowledgement of the tenet that
the communit}' is bound to make good the defi-
ciencies of its members- not only in the matter of ill
health, but also in the matter of ill fortune — of
whatsoever character. It is an acknowledgement
that the community owes this to its members.
What is owed, the creditor has a right to collect.
From whatever angle this proposition is viewed it
leads straight back to State socialism ! And that is
why we witness the extraordinary spectacle of the
settlement workers and uplifters and social service
zealots receiving the support and commendation of
the cunning Bolsheviki. Every effort put forth by
the former is activating the cause of the latter.
They are a band of brethren for a piece of the road.
W hen they come to the parting of the ways the
Bolsheviki can truly thank their unwitting confed-
erates for the great assistance afforded in making
socialistic doctrine pass current in so many re-
spectable quarters.
{To he concluded.)
io66
FRIEDLANDER BACILLUS THE CAUSA-
TIVE FACTOR IN BRONCHOPNEUMONIA
FOLLOWING INFLUENZA*
James B. Rucker, Jr., M. D.,
Philadelphia,
Director of Laboratories, Pennsylvania Department of Health,
AND John J. Wenner, Ph. D.,
Philadelphia,
Pennsylvania Department of Health.
(From the Laboratories of the Pennsylvania Department of Health.)
During the recent pandemic of influenza instruc-
tions by the acting commissioner of health were
given to the director of laboratories to proceed to
Pottsville, Schuylkill County, Pa., where the epi-
demic seemed to be ravaging almost the whole com-
munity of some 30,000 inhabitants in the heart of
the anthracite region of Pennsylvania, the respira-
tory disease assuming, in that portion of the state,
a particularly malignant form. Hundreds stricken
with the so called influenza had died from a super-
vening pneumonia, and the city and its immediate
environs were well nigh panic stricken as a result
of the epidemic. About half the physicians of the
county had entered the military service and almost
half of those remaining were ill of the disease and
those who were left had been working night and
day, giving medical aid to as many of the stricken
as possible. Several emergency hospitals were es-
tablished in Pottsville, Frackville, and Minersville,
so that those who could not be given medical atten-
tion in their homes could be more easily attended
to by the overworked doctors and nurses.
The patients coming to the Pottsville City Hos-
pital and to the emergency hospital were usually des-
perately ill. They had been taken down with the
influenza upon which had been engrafted a pneu-
monia, and v/hen they were admitted to the hospitals
had been up and about with a pneumonia of frotn
two to four days' duration. These patients were in
a large majority of cases foreigners, and in many
instances especially among the men, were heavy
drinkers. Naturally, among these hospital patients
the mortality was quite high. Autopsies, however,
v/ere rather difficult to obtain, the Pottsville Hos-
pital in over three weeks having been able to get
only some sixteen in hundreds who had died.
Through the kindness of Dr. J. B. Rogers, presi-
dent of the Pottsville Board of Health, arrange-
ments were made with the Pottsville Hospital to
carry on our work there and Doctor Shafer, patho-
logist to the hospital, very generously extended to
us the use of his laboratory and its facilities, for the
necessary securing of material, animal inoculations,
and isolations in our researches while in Pottsville.
The immediate stimulus to the investigation as
to the etiological factor causing such a malignant
form of pneumonia, was that it had been reported in
Pottsville and the report came to the ears of the
acting commissioner, that the bronchopneumonias
were being caused by the Bacillus pestis, and that thrt
disease was really the pneumonic type of the plague ;
and to prove or disprove this theory the director of
the laboratories was detailed to make the necessary
investigations.
•Published by p<"rmission of Dr. B. Franklin Royer, Acting Com
missioner of Health. ^
41
[New York
Medical Journal.
We were fortunate enough to secure, through the
courtesy of Doctor Burke, chief resident physician
ol the Pottsville Hospital, autopsies on the bodies of
two persons who had had most typical cases of this
very malignant form of acute respiratory disease
which we had been detailed to investigate. The
first autopsy disclosed the following:
The body was that of a well nourished male,
native of Poland, about thirty years of age, weigh-
mg around 180 pounds, height seventy inches.
When the autopsy was performed he had been dead
about six hours. The skin was pale with a yellow-
ish tinge. There was a great deal of postmortem
lividity over the back of the chest, trunk, arms, and
lego. On opening the thorax, no free fluid was
found. Lungs on right side showed almost com-
plete consolidation of the lower lobe, the middle and
upper lobes containing large numbers of broncho-
pneumonic consolidations. The left lung presented
many areas of bronchopneumonia in both lobes.
The consolidated areas were distinctly lobular in type
as opposed tn the lobar consolidation in the right
lung, lower lobe. On section they appeared dark
red in color and exuded a dark red, bloody fluid.
There were dense adhesions of the right pleura.
There was no enlargement of bronchial or mediasti-
nal glands. The heart was full, no excess of fluid in
pericardial cavity. The liver was enlarged, con-
gSiSted, and had the appearance of a passive con-
gestion ; the cut section was slightly bile stained.
The gallbladder seemed normal ; spleen was en-
larged, dark red and soft. Kidneys: capsules tense,
stripped easily ; organs themselves were enlarged and
reddened ; cut sections indicated an acute parenchy-
matous nephritis. The small intestines showed an
enteritis, especially marked throughout the ileum.
No ulcers were observed. Appendix showed ca-
tarrhal appendicitis. Cultures were made in as
sterile a manner as possible from incisions into the
bronchopneumonic areas of the lungs, on blood agar
slants. Smears on glass slides were also made from
these incisions, and a guineapig was inoculated in-
traperitoneally with a portion of a section of bron-
chopneumonic area, emulsified in physiological salt
solution. Cultures, smears, and inoculation of a
guineapig were made in the same manner from an
incision, with a sterile knife, into the spleen. Smears
from lung showed streptococci, a few pneumococci,
short thin gram negative rods and short thick, coc-
coid gram negative rods ; no short thick bacteria
with polar staining appeared. Smears from spleen
showed streptococci with a few pneumococci, and
short, thick, coccoid, gram negative rods and short,
thin, gram negative rods ; no short thick polar
stained rods observed. Slants from lung on blood
agar show thick coccoid gram negative rods in large
numbers and a few streptococci and staphylocci.
Slants from the spleen gave us the same thing ex-
cept that there were also present a few colonies of
pneumococci. From the slants made from these
two organs were isolated on blood agar plates the
bacillus of Friedlander, streptococci and staphylo-
cocci. The colonies of the Friedlander bacillus far
outnumbered the colonies of the other microor-
ganisms.
Guineapig No. i, inoculated with a portion of the
spleen, died in eighteen hours. Autopsy showed
RUCKER AND WENNER: FHE FRIEDLANDER BACILLUS.
December 21, 1918.] KUCKER AND WENNER: THE FRIEDLANDER BACILLUS.
1067
subcutaneous edema at point of inoculation; abdo-
men contained a clear straw colored fluid with
whitii-h mucilaginous flakes here and there on the
parietal and visceral peritoneum ; intestines showed
an enteritis ; liver and spleen enlarged and con-
gested ; lungs normal. No enlargement of lymphatic
nodules except in the inguinal region nearest the
point of inoculation, which were only slightly en-
larged. Smears on glass slides made of the sub-
cutaneous exudate at the point of inoculation, the
peritoneal exudate, the splenic pulp and from the in-
side of the liver showed almost pure cultures of
short capsulated rods. Slants on blood agar made
from these sites gave practically pure cultures of
Friedlander's bacillus with here and there a colony
of streptococcus.
Guineapig No. 2, inoculated with portions of
pneumonic patches in the lung, died in sixteen
hours. Autopsy showed no enlargement of in-
guinal lymph nodes ; small amount of serous ex-
udate at site of inoculation ; peritoneal cavity full of
clear, straw colored fluid ; marked enteritis ; liver
and spleen enlarged and congested, spleen soft;
right lung congested, left normal ; heart full. No
'vinlargement of bronchial or mediastinal lymph
nodes. Smears of peritoneal exudate showed al-
most a pure culture of short, capsulated organisms,
among which were a few streptococci. Agar slants
from the peritoneal exudate and from liver and
splenic pulp showed this capsulated organism in
almost pure culture, though a few chains of strepto-
cocci were seen. Pure cultures were, obtained by
plating.
The second autopsy was performed on the body
of a Polish woman, twenty-five years of age, who
had been stricken with influenza followed by pneu-
monia. She had been in the hospital for about
forty-eight hours and had been delivered of twins
(dead) twenty- four hours before her death. Au-
topsy revealed a well nourished female, blonde,
weight about 150 pounds, height sixty-two inches.
Death occurred five hours previous to autopsy.
Postmortem lividity w^as marked on back and sides
of chest, trunk, and arms, and somewhat less on
legs. Chest cavity filled with blood tinged fluid
exudate. Lungs congested and showed broncho-
pneumonic patches throughout both organs, while
the lower lobes of both lungs were nearly solid
with them. Pleura on the right was tightly adherent
to lung. The pleura on left was adherent at the
left base to the thoracic wall. There was no en-
largement of the bronchial or mediastinal lymph
nodes. Heart full ; no excess of straw colored fluid
in pericardial cavity. Liver enlarged and congested,
yellowish brown on section ; spleen enlarged, dark
red on section and mushy. Enteritis was evident
throughout, most marked in the ileum. Kidneys
were swollen and capsule tense. On section, organs
were very red, with thickened cortex, the mal-
pighian bodies standing out as little red dots.
Abdominal cavity contained no excess fluid. Ap-
pendix was normal. There was no enlargement of
lymph nodules anywhere. Smears were made of the
exudate in the thoracic cavity, pneumonic patches
in the lung, liver and splenic pulp, and blood agar
slants made from them.
Inoculation of guineapig No. 3 was made from a
portion of the splenic pulp and guineapig No. 4
with a portion of a pneumonic patch in the lung.
A portion of the spleen and of the pneumonic areas
in the lung were preserved in four per cent, formal-
dehyde for histological examination. The same
technic was carried out in the isolation, recovery,
and identification of the microorganisms from the
slants made at the mortuary table and from guinea-
pig inoculations as in the first autopsy, and practi-
cally the same organisms were found. The encap-
sulated, gram negative, short, thick rod was found
in great preponderance in the cultures from the
iung and spleen.
Guineapig No. 3, inoculated with the spleen, died
in • ninety-two hours after inoculation intraperi-
toneally, showing a serous blood tinged fluid in the
abdominal cavity, enteritis, enlarged liver and
spleen ; lungs not afifected. No enlargement of
lymph nodes. Cultures made from peritoneal ex-
udate, heart's blood, liver, and spleen were practi-
cally pure cultures of Friedlander's bacillus.
Guineapig No. 4, inoculated with a portion of the
jMieumonic patches in the lung, died in about eighty-
nine hours, showing a large amount of peritoneal
exudate of a sticky, heavy white, mucilaginous
character. Enteritis was marked ; liver and spleen
enlarged and congested; no affection of the lungs;
lymph nodes, not enlarged. Smears and slants were
macle of the peritoneal exudate, heart's blood,
spleen, and liver. A short, thick, encapsulated,
gram negative rod was seen in all the smears, while
the cultures made from the same showed very large
numbers of this encapsulated organism, practically
pure, though on isolation by the plate method, a few
colonies of streptococci were obtained. Sputa from
six cases of pneumonia with a preceding influenza,
were cultured on blood agar plates and smears of
these same specimens of sputum made on glass
slides. The comparative findings were as follows :
Isolation from plates.
Streptococci, staphylococci.
B. influenza.
Staphylococci, streptococci.
B. influenzae.
Pneumococci, streptococci,
Friedlander's bacillus.
Pn
Smears on slides.
Sputum A:
B. influenzse — a few.
Streptococci — many.
Pneumococci — many.
.Sputum B:
B. influenzae — few.
Streptococci — many.
Pneumococci — few.
Staphylococci — few.
Sputum C:
Pneumococci — very many.
.Streptococci — a few.
B. influenzE — many.
Coccoid, gram negative rod
— few.
Sputum D:
Pneumococci — very many,
B. influenzae — a few.
Sputum E:
Pneumococci — very many.
Streptococci — many.
B. influenzae — few.
Sputum F:
■ Pneumococci
Streptococci.
B. influenzae.
Coccoid, gram negative rod.
Pneumococci — very many.
The microorganism (a gram negative, encapsul-
ated, coccoid rod), mentioned throughout this re-
port as having been found so universally and in
great predominance in the smears and cultures from
the pneumonic patches in the lungs and in the spleen?
at the two autopsies at the Pottsville Hospital, in
the cultures from the spleen, liver, peritoneal exu-
eumococci, streptococci.
Streptococci.
Streptococci.
Friedlander's bacillus.
io68
RUCKER AND WENNER: THE FRIEDLANDER BACILLUS.
[New York
Medical Journal.
date and heart's blood of the guineapigs inoculated
with this material from the human autopsies and
its isolation from the sputum of two of the six
hospital patients ill of the same type of pneumonia,
as evidenced by the same train of symptoms and
objective findings as those who died and at whose
autopsies we obtained the material as the basis of
this report, was to our minds the etiological factor
in the causation of the malignant type of broncho-
pneumonia so generally observed as following on
the heels of the infection with the bacillus of in-
fluenza now epidemic, and has been identified by
us as the bacillus of Friedlander, otherwise known
as the B. mucosus capsulatus. Why it should fol-
low so closely upon infection with the Bacillus influ-
enzcT, we have been unable to determine. The mor-
phological, biological, and biochemical characteris-
tics of this microorganism as worked out by us, from
the material described in this report, are as follows :
Short, thick, rod, sometimes appearing almost
coccoid, nonmotile, flagella not observed, negative
to the gram staining method, capsules easily demon-
strated in smears from the organs and the exudates
and in milk; heavy, thick, white mucilaginous
growth on agar ; gelatin not liquefied, litmus milk,
acidified and showing a soft coagulum ; bouillon
showing a dense turbidity and a heavy" stringy sedi-
ment, and frequently a very slight surface growth
or a ring at the surface of the medium on the glass
wall of the test tube. On potato, growth was heavy
and dark gray. Colonies on agar were from 0.5
to i.o mm. in diameter, circular, entire, grayish
w^hite, elevated, and mucilaginous in consistency.
\\'hen fished with a platinum needle long strings of
a mucoid character cling to the colony as the needle
is withdrawn from it. Gas is formed abundantly in
dextrose, lactose, and saccharose. No indol is
formed. It is pathogenic to guineapigs in from
sixteen to ninety-two hours.
As our primary object in making this investiga-
tion was to determine whether this epidemic of
bronchopneumonia was caused by the B. pestis or
plague bacillus, it might be well here to give the
main points wherein the bacillus of Friedlander dif-
fers from B. pestis ; B. Friedlander is nonmotile and
more irregular in morphology ; B. pestis is motile,
having flagella, and evidences bipolar staining.
B. Friedlander grows abundantly on agar and potato
and its colonies are large and sticky. It coagulates
milk, it produces turbidity in bouillon with a heavy
stringy sediment and does not form a pellicle. It
forms gas abundantly in all the sugars. It is not
so rapidly pathogenic to guineapigs as is B. pestis.
B. pestis grows slowly on agar in small colonies
which are not mucilaginous in character. In bouil-
lon, pestis produces no turbidity but forms a heavy
pellicle ; it does not coagulate milk, nor form gas
in the sugars. It is highly pathogenic to guinea-
pigs, producing death on inoculation in from two
to five hours.
As to the type of cases from which our autopsy
material was obtained, we have this to say, that
Doctor Burke, chief resident physician at the Potts-
ville Hospital, stated to us that he had performed
autopsies on fourteen bodies of those who in life
had suffered from this type of bronchopneumonia,
our two autopsies making the fifteenth and six-
teenth, and in every one he had found the same
conditions pathologically as were found in the two
at which we were present and from which we ob-
tained our material for research. In order further
to demonstrate that it is the Friedlander bacillus
that causes the large number of deaths from bron-
chopneumonia and not the influenza bacillus, we
inoculated one guineapig with a pure culture of
B. Friedlander obtained from the lung in the first
autopsy, and its death occurred in about eighteen
hours. A guineapig inoculated with pure culture
of B. influenzae, obtained from the sputum of a
patient very ill of pneumonia, is still alive though
he became ill after the inoculation and is now
recovering.
A third autopsy, on the body of a man who had
died in less than a week after admission to the hos-
pital from an influenza upon which during the last
two days of his Hfe had been engrafted a severe
bronchopneumonia and seemed to be of much the
same malignant type of disease as that seen in
Pottsville, was performed at the Hospital of the
University of Pennsylvania on October i8th. The
body was that of a man weighing 115 lbs., height
sixty-five inches, thirty-three years of age, dead
about eight hours. Skin over whole body was of a
yellowish tinge. Postmortem lividity on back of
chest, neck, and arms was marked. Thorax con-
tained a moderate amount of blood tinged fluid.
The lower lobe of the left lung was solid, the upper
lobe contained many small patches of pneumonic
consolidations, as did the two lower lobes and the
lower half of the upper lobe of the right lung. On
section they exuded a dark bloody fluid. No en-
largement of mediastinal or bronchial lymph nodes.
Adhesions binding the left base to the parietes were
observed. Heart full, no excess of pericardial fluid.
Liver enlarged, passively congested, and on section
bile stained. Gallbladder normal and common duct
patulous. Acute inflammatory reddening of the
mucosa of the small intestine especially marked in
the duodenum and ileum. Colon was normal in
appearance. Spleen enlarged, congested and soft.
Kidneys showed cloudv swelling. Portions of the
pneumonic patches in the lungs and small portion
of the splenic pulp respectively were emulsified in
physiological salt solution and two c.c. injected in-
traperitoneally into two guineapigs. The guineapig
injected with the material from the pneumonic
patches in the lung died within sixty hours. Au-
topsy showed normal lungs ; heart full ; liver and
spleen enlarged and congested ; and a marked en-
teritis was observed. The abdominal cavity was
filled with a large amount of serous straw colored
fluid. Cultures made from the heart's blood, peri-
toneal exudate, liver, parenchyma, and splenic -pulp
yielded pure cultures of the Friedlander bacillus,
identified by its well known morphology of nonmo-
tility, capsule formation, and its gram negative stain-
ing, and by its characteristic growth on artificial
media as well as by its biochemical reactions. The
guineapig inoculated with an emulsion of the splenic
pulp of the case at autopsy became ill for a time,
but is now well and in good condition.
In conclusion, as a result of our investigation of
December 21, 1918.]
BRAUN: DIAGNOSIS OF SINUS THROMBOSIS.
1069
the sputum and of autopsy material from a small
number, but of typical cases of the malignant type of
influenzal pneumonia, we feel that we are justified
in saying that the B. influenzae is the etiological
factor in the causation of the primary infectious
influenza ; that the secondary pneumonia and fatal
terminations are due to the production of areas of
bronchopneumonia caused by the B. mucosus cap-
sulatus, otherwise known as the bacillus of Fried-
lander, and not by the B. influenzae ; and that
B. pestis was not a factor in the etiology of the
recent epidemic of influenza.
THE DIAGNOSIS OF SINUS THROMBOSIS.
By Alfred Braun, M. D.,
New York.
■ Cerebral sinus thromboses may be either nonin-
fectious or infectious. The former are rare. They
are usually due to exhausting diseases and do not
concern the otologist. Infectious sinus thrombosis
is usually otitic in origin. The sinus which is most
often involved as the result of suppurative disease
of the middle ear nnd mastoid is the sigmoid sinus.
The thrombus may extend from the sigmoid sinus
to the jugular bulb, the petrosal sinuses, the cav-
ernous or the superior longitudinal sinus. A
primary thrombosis of the jugular bulb sometimes
occurs with middle ear disease.
The symptoms of infectious sinus thrombosis
may be divided into those which are due to the gen-
eral systemic poisoning and those which are due to
the local inflammatory lesion in the af¥ected sinus.
The former symptoms are common to all cases of
sinus thrombosis; the latter symptoms diflfer ac-
cording to the sinus or sinuses involved. The
symptoms due to the local lesion in the sinus may
be divided into those which are caused by the
inflammation in the sinus wall, and those which are
the result of obstruction to the venous circulation,
caused by the thrombus.
A. In infectious thrombosis of the lateral sinus,
the symptoms which are due to the inflammation
of the sinus wall are the following:
I. Pain. — The pain of sinus thrombosis varies
within wide hmits. When it is very slight, it is
often impossible to distinguish it from the pain due
to the accompanying mastoiditis. When it is very
severe, it is usually due to the fact that the inflam-
mation has extended from the sinus wall to the
adjacent meninges, and has caused either meningeal
irritation, or a serous meningitis. In most cases of
sinus thrombosis, there is little or no pain. In fact,
euphoria is rather characteristic of sinus thromb-
osis. In cases, in which, after a mastoid operation,
the temperature is very high, and the patient says
he feels very well, one should suspect sinus
thrombosis. When pain does occur, it may be in
any part of the head. It is not necessarily localized
about the region of the lateral sinus. It is apt to
be sharp and occur suddenly, and disappear just as
suddenly.
When the inflammation extends from the sinus
wall to the meninges and causes a serous meningitis,
it sometimes gives rise to inflammation of the optic
nerve and of the sixth nerve.
2. Optic nerve changes. — These occur in only a
moderate number of cases of sinus thrombosis.
In thirty-four cases of sinus thrombosis reported
by Jansen, twenty of the patients were examined
ophthalmoscopically. Ten of these had normal
discs, seven had well marked chaiiges in the disc,
and in three, there were doubtful changes. This is
a much higher proportion of optic nerve changes
than is reported by most observers. The pathologi-
cal lesion in the nerve is usually a neuritis, or a
hyj)eremia. Choked disc occurs very rarely. In
many cases, the optic nerve changes do not come
on until after the sinus has been opened and the
jugular vein ligatod. For this reason, it is believed
by some otologists that the optic nerve changes are
due to circulatory disturbances within the skull.
However, it is much more likely that they are due
to the meningitis which accompanies the sinus
thrombosis, because the changes in the nerve are
usually inflammatory rather than circulatory in
nature. The optic nerve changes are usually uni-
lateral, but they may be bilateral. When unilateral,
they are ordinarily on the side of the afifected sinus.
Marked visual disturbance is uncommon. Recovery
from the nerve condition usually takes place, if the
patient gets well of the sinus thrombosis. Optic
atrophy is rare.
3. Paralysis of the sixth nerve. — This sometimes
occurs with sinus thrombosis. This, in all proba-
bility, is also due to the accompanying meningitis.
It is usually unilateral, occurring on the side of the
affected sinus. It causes convergent strabismus,
diplopia, and inability to move the eye outward.
Paralysis of the sixth nerve sometimes occurs in
uncomplicated mastoiditis and even with acute
middle ear suppuration. A sixth nerve paralysis
occurring with a middle ear suppuration, with or
without mastoiditis constitutes the so called
Gradenigo syndrome.
4. Perijugiilitis. — The inflammation may extend
to the perijugular connective tissue and the lymph
glands surrounding the vein. When this occurs, a
tender cordlike mass can be felt at the side of the
neck, along the course of the internal jugular vein.
Movements of the head are painful, and there may
be some pain on swallowing. The inflammation
may extend from the jugular bulb to the nerves
which pass through the jugular foramen, i. e., the
glossopharyngeal, pneumogastric and spinal acces-
sory nerves.
5. Involvement of the glossopharynegeal nerve. —
This may cause paralysis of the soft palate and
difificulty in swallov/ing. Difficulty in swallowing
may also be caused by the inflammation of the
tissues around the internal jugular vein in the neck.
6. Involvement of the vagus nerve may give rise
to hoarseness and slowing of the pulse rate.
7. Involvement of the spinal accessory nerve may
cause spasmodic contractions or paralysis of the
sternomastoid and trapezius muscles.
B. The symptoms of infectious thrombosis of the
lateral sinus which are due to interference with the
venous circulation are the following:
I. Griesinger's sign. — This is a painful swelling
1070
BRAUN: DIAGNOSIS OF SINUS THROMBOSIS.
[New York
Medical Journal.
at the point of exit of tlie mastoid emissary vein
from the skull, i. c, at about the middle of the
posterior margin of the mastoid process. This
sign is due to an extension of the thrombotic pro-
cess from the lateral sinus into the mastoid emis-
sary. The swelling is caused partly by edema from
interference with the circulation in this region, and
partly by the inflammatory process in the vein and
the perivascular tissues. In some cases it is due to
the fact that the pus from a perisinus abscess has
leaked out of the skull through the space between
the wall of the emissary and the margin of the
mastoid foramen. In such cases, there need be no
thrombus within the emissary, nor within the sinus.
The sign is not diagnostic of sinus thrombosis.
2. A painful szvcUing in the posterior triangle of
the neck occurs sometimes, when the thrombotic
process extends from the lateral sinus into the
posterior condyloid vein. The posterior condyloid
\-ein empties into the vertebral plexus, which is sit-
uated in the posterior triangle of the neck. The
swelling is due to interference with the venous
circulation in this region. A swelling may also oc-
cur in this location when the pus from a perisinus
abscess passes out of the skull through the posterior
condyloid foramen, alongside of the condyloid vein.
This sign is not diagnostic of sinus thrombosis.
3. Gerhardt's sign. — This is an unequal fullness
of the external jugular veins on the two sides.
Gerhardt found that in some cases of thrombosis
of the lateral sinus, the external jugular vein on the
affected side was partly collapsed, as a result of the
diminished blood supply on that side. However,
this is not a very reliable sign.
If the lateral sinus is exposed during a mastoid
operation, the appearance of the outer wall of the
sinus may or may not give information as to the
presence of a thrombus. When a perisinus abscess
is present, the outer surface of the sinus wall is
usually covered with granulation tissue. This in-
creases the difficulty of determining the contents of
the sinus. Usually, when a perisinus abscess is
present, there is no sinus thrombosis. The thicken-
ing of the sinus wall which occurs with perisinus
abscess is an indication of a defensive process
against the infection. In the majority of cases, the
infection is controlled before the interior of the
sinus is reached. However, this is by no means
always the case.
In many cases of sinus thrombosis, especially
where there is only a partial thrombus, the outer
wall of the sinus is perfectly normal in appearance.
A normal sinus wall has a slightly bluish tinge and
is semitranslucent. In some cases of sinus throm-
bosis, the wall of the sinus becomes white and
opaque, or yellowish, or a dirty gray in color. Some-
times it takes on a blackish discoloration. Occa-
sionally there is a hole in the outer sinus wall. This
occurs in cases where the clot has broken down in
the centre, and the ends have organized. The
abscess which has thus formed within the sinus
breaks through the outer wall of the sinus, and a
perisinus abscess is formed.
In cases where there is a mural clot, palpation of
the sinus wall does not give us any information as
to its contents. The presence or absence of pulsa-
tion in the sinus is of no diagnostic value. The
pulsation is transmitted from the brain through the
sinus whether the latter contains or does not con-
tain a clot. A normal sinus wall is elastic. When
the sinus is completely filled J)y a thrombus, it has
a doughy feel under the finger. In older organized
thrombi, the sinus has a firm resistant feel. In
some cases of sinus thrombosis, the sinus appears to
be collapsed and the outer sinus wall falls away
from the sinus groove.
When there is a primary thrombosis of the jugu-
lar bulb, no changes are found in the appearance or
feel of the lateral sinus. In such cases, a test de-
scribed by Whiting is of value ; after the sinus is
freely exposed, he places the left index finger just
above the jugular bulb, with sufficient pressure to
obliterate it. The right index finger is placed above
the left, and with the former, the sinus is milked
out as far as the knee, and the finger left there. An
assistant presses on the jugular vein in the neck.
The lower finger is now removed. If the sinus
does not refill, there is a thrombus in the bulb. If
the clot is below the bulb, blood from the inferior
petrosal sinus or the posterior condyloid vein would
fill the sinus, and mislead the operator. This
method of examination is not entirely without dan-
ger. The manipulation may result in breaking off
a portion of the clot, and carrying it into the general
circulation. Another method of determining
whether there is a thrombus in the bulb is the
following: After the sinus is exposed, a plug is
placed across its upper end with sufficient pressure
to obliterate it. If the sinus is emptied by the as-
piratory action of inspiration, there is no thrombus
in the bulb.
There are no local symptoms which are charac-
teristic of thrombosis of the superior or inferior
petrosal sinuses. There may be an optic neuritis,
or a paralysis of the sixth nerve, due to the same
causes as in thrombosis of the lateral sinus. Throm-
boses in the petrosal sinuses are usually extensions
of thromboses either in the lateral sinus, or in the
cavernous sinus. The condition is usually discov-
ered only at operation. If a thrombus in the lateral
sinus extends up above the knee, the following test
will show whether the thrombus extends into the
superior petrosal sinus: The sinus is packed off by
means of a plug above the knee, and by another
plug below, near the bulb. The outer wall of the
sinus is incised and the thrombus removed. As the
superior petrosal sinus enters the lateral sinus at the
knee of the latter, there will be bleeding from the
lateral sinus at the knee, unless the thrombus extends
into the superior petrosal. It is more difficult to de-
termine whether the inferior petrosal is thrombosed.
The inferior petrosal sinus enters the jugular bulb,
or the internal jugular vein, just below the bulb. If
the lateral sinus is incised, and there is no bleeding
from its lower end, there may be a thrombus in the
bulb, or in the bulb and the inferior petrosal sinus.
Occasionally it is possible to drag a clot out of the
bulb and get a flow of blood from the lower end of
the sinus. When this occurs, one cannot be sure
whether the stream of blood h coming from the
internal jugular vein, or from the inferior petrosal
sinus. For it is possible to dislodge sufficient of the
December 21, 1918.]
BRAUN: DIAGNOSIS OF SINUS THROMBOSIS.
clot in the bulb to lay bare the orifice of the inferior
petrosal sinus, and yet leave some of the clot in the
lowermost portion of the bulb and the ui)per end
of the internal jugular vein. When this occurs, the
bleeding is from the inferior petrosal sinus. On
the other hand, the extraction of the clot may cause
the bulb and jugular vein to become free, and the
bleeding may come from the jugular vein, while a
clot remains in the inferior petrosal sinus. One
can only be sure of the presence of a clot in the
inferior petrosal sinus, if the jugular bulb itself is
opened, as in the Grunert operation. If the bulb is
completely freed of the clot, and there is no bleed-
ing from the orifice of the inferior petrosal sinus,
we can be sure that there is a clot in the latter. A
thrombus in the posterior condyloid vein can be
determined in the same way.
In infectious thrombosis of the superior longi-
tudinal sinus the local signs are similar to those
occurring in noninfectious thrombosis of this sinus,
i. e., edema of the soft tissues in the frontal, parietal,
and temporal regions. Focal brain symptoms are
not as likely to occur in the infectious cases as in
tha noninfectious cases, because tlie thrombotic
process is usually not as extensive in the former
class of cases.
In thrombosis of the cavernous sinus, the symp-
toms due to the local inflammation in the sinus are
the following:
1. Pain. — The pain of cavernous sinus thrombosis
may be due to one of two causes, and varies in
character according to the cause. When the in-
flammatory process extends from the cavernous
sinus to the adjacent menmges there results a gen-
eralized headache. When the inflammatory process
involves the first division of the fifth nerve (which
passes through the cavernous sinus), there is neu-
ralgic pain in the area of distribution of this nerve,
i. e., in the supraorbital and infraorbital regions.
In a large number of cases of cavernous sinus
thrombosis, there is no pain whatever.
2. Optic nerve changes. — One would assume that
changes in the optic nerve are quite frequent in
cavernous sinus thrombosis, as the central retinal
vein empties into the ophthalmic vein, v/hich, in
turn, empties into the cavernous sinus. As a mat-
ter of fact, optic nerve changes are comparatively
infrequent in this condition. The writer has seen an
optic neuritis in only one case of cavernous sinus
thrombosis, and this was a case in which the cav-
ernous sinus thrombosis was secondary to a throm-
bosis of the lateral sinus. When changes do occur,
they may follow one of two types, an optic neuritis
or a choked disc. When there is an optic neuritis,
it is probably due to an accompanying meningitis.
When there is a choked disc, it is probably due to
an extension of the thrombus from the cavernous
sinus to the ophthalmic and central retinal veins.
The changes in the optic nerve do not usually go
on to atrophy, as the patient usually dies before
this occurs.
3. Paralysis of the third, fourth, first division of
the fifth and sixth nerves. — Paralysis of the third
nerve is present in almost every case of cavernous
sinus thrombosis. It comes on fairly early in the
disease, usually within a day or two of the onset
of the exophthalmos. As a result of the third nerve
paralysis, there is ptosis, divergent strabismus,
inability to move the eye inward beyond the median
line, limitation of movement of the eye upward,
inability to move the eye downward, and dilatation
of the pupil. When there is involvement of the
fourth and sixth nerves in addition to the third
nerve, there is ptosis, the eye is fixed in the median
line, with inability to move in any direction, and
there is dilatation of the pupil. When the first
division of the fifth nerve is involved, there is
neuralgic pain or anesthesia in the area of distribu-
tion of this nerve, i. e., in the supraorbital and in-
fraorbital regions.
The obstructive symptoms in thrombosis of the
cavernous sinus are the following :
1. Exophthalmos. — Exophthalmos occurs in
every case of cavernous sinus thrombosis, and is a
very early symptom. The exophthalmos is usually
very marked, but is usually masked by the ptosis
and swelling of the lids, and can only be determined
when the lids are forcibly separated. It is due to
edema of the orbital cellular tissue and engorge-
ment of the orbital veins. It is dififerentiated from
orbital cellulitis or orbital abscess by the fact that
in the latter condition pressure upon the eyeball is
very painful, whereas in cavernous sinus throm-
bosis, pressure upon the eye is painless. Another
point of dififerential diagnosis is the fact that
orbital abscess is usually unilateral, whereas cav-
ernous sinus thrombosis almost always becomes
bilateral after a few days, the thrombus rapidly
extending across from one cavernous sinus through
the circular sinus to the opposite cavernous sinus.
2. Chcmosis or edema of the ocular conjunctiva
occurs in every case of cavernous sinus thrombosis,
and is due to the same causes as the exophthalmos.
It is sometimes so marked that the conjunctiva ap-
pears as an irregular gelatinous mass in the pal-
pebral fissure.
3. Edema of the lids occurs in every case of cav-
ernous sinus thrombosis and is due to the same
causes as the exophthalmos. It is usually very
marked, so that the eyeball cannot be seen unless the
lids are forcibly separated. It involves both the
upper and the lower lids. When edema of the lid
is marked, it masks the ptosis which is present. The
ptosis can only be determined if the patient is seen
before marked edema of the lid appears.
The eye symptoms of cavernous sinus thrombosis
are sometimes mistaken for orbital abscess or cellu-
litis, ethmoiditis, or acute conjunctivitis. Cavernous
sinus thrombosis can be differentiated from all of
these conditions by the fact that only in the former
conditions are there paralyses of the ocular muscles.
The symptoms become bilateral in a few days in
cavernous sinus thrombosis, whereas in orbital
cellulitis, or ethmoiditis, they are usually unilateral.
Pressure backward upon the eyeball is painful in
orbital cellulitis and ethmoiditis and is painless in
cavernous sinus thrombosis. In ethmoiditis pus
may be seen in the middle meatus of the nose, and
an X ray picture of the head may show disease in
the ethmoidal cells. In acute conjunctivitis, the
conjunctiva is reddened and there is purulent secre-
tion in the conjunctival sac, whereas, in cavernous
1072
BRAUN: DIAGNOSIS OF SINUS THROMBOSIS.
[New York
Medical Journal.
sinus thrombosis, although the ocular conjunctiva
is swollen, it is pale, and there is no secretion.
4. Edematous swelling in the pharynx. — An
edematous swelling in the lateral pharyngeal fossa,
about the tonsil and in the soft palate occurs occa-
sionally in cases of cavernous sinus thrombosis,
when the thrombus extends from the cavernous
sinus into the pterygoid plexus. It does not usually
give rise to subjective symptoms, except a feeling
of fullness in the throat. Usually it is found only
in the course of a routine examination of the
throat. It should not be mistaken for a peritonsillar
abscess, as in the latter condition there is severe
pain and the swelling is very sensitive to pressure.
The general symptoms due to thrombosis of the
venous sinuses of the, dura mater are the same,
irrespective of the location of the thrombus. They
are as follows :
1. Temperature. — The vast majority of cases of
sinus thrombosis have very high temperatures.
Temperatures of 105° F. are very common, and in
children they sometimes reach 106° F. In many
cases, the temperature curve is of the remittent
type, the remissions being to nearly normal, or nor-
mal. Occasionally the temperature is subnormal.
There may be a rise and fall every day, or there
may be several rises in one day. The rise of tem-
perature usually occurs when there is a fresh bac-
terial invasion of the circulation. In a fairly large
proportion of cases, there are no remissions. The
temperature remains steadily high. In these cases,
the temperature curve is of no assistance in making
a diagnosis. A temperature curve of this type is
especially apt to occur in severe cases, where there
is marked toxemia, and no pyemic manifestations.
Occasionally a case of sinus thrombosis runs its
course with very little or no elevation of tempera-
ture. In these cases thrombosis is not suspected
before operation. The writer operated on two such
cases, in which the clinical course was that of a
simple uncomplicated mastoiditis. At operation, a
defect was found in the sinus plate, leading to a
perisinus abscess. The sinus was covered with
granulations, in the midst of which was found a
fistula leading into the interior of the sinus. The
thrombus was organized at both ends, and broken
down in the centre. The abscess thus formed
within the sinus had perforated through the outer
sinus wall and was draining into the perisinus
abscess. In these cases there is no general sepsis.
2. Chills. — When the temperature is of the remit-
tent type, a chill may accompany each rise of
temperature. There may be a chill only with the
first rise of temperature, or the chills may be pres-
ent only during the latter part of the disease ; there
may be no chills at any time in the course of the
disease ; the chill may last anywhere from a few
seconds to an hour. The chill generally occurs
when there is a fresh invasion of the circulation by
bacteria. There may be one chill every day, or two
chills every day, or one chill every two or three
days. The chills sometimes keep on for many
weeks. The chills sometimes continue after the
primary focus in the sinus has been eliminated,
when there are metastases.
3. Sweats. — When a chill occurs, it is usually fol-
lowed by profuse sweating, which may last for sev-
eral hours. Sweating may occur without chills.
4. Rapid pulse. — The pulse is usually rapid, small,
and toward the end of the disease, feeble. In the
intervals, when the temperature is approximately
normal, the pulse is not so rapid.
5. Gastrointestinal symptoms. — The tongue is
usually heavily coated. There may be fetor ex ore.
There is anorexia. There may be constipation or
diarrhea. Vomiting occurs in some cases. When
the gastrointestinal symptoms are very prominent,
the condition may be mistaken for typhoid. Icterus
occurs occasionally.
6. Vertigo occurs in some cases of sinus throm-
bosis, but is not very common.
7. Disturbances of the sensorium are rare in sinus
thrombosis — except shortly before death. When
there is delirium or coma, the sinus thrombosis is
usually complicated by meningitis.
8. Metastases. — In the fulminating cases of sinus
thrombosis there are usually no metastases. The
patients die before metastases occur. When the
course is more prolonged, metastases are more apt
to occur. Metastases may occur in any part of the
body. They are most common in the lung. They
are next most common in the joints. They may
occur in the muscles, subcutaneous tissues, men-
inges, brain, or abdominal organs.
It was believed by Leutert and many other otolo-
gists that metastases in the lungs occurred in cases
of chronic otitis, and metastases in the joints oc-
curred with acute otitis. They base their belief on
the fact that solid particles of thrombotic material
are broken ofif from the clot in the sinus, in cases
of chronic otitis, whereas there are free bacteria in
the circulation in acute otitis. The thrombotic par-
ticles pass from the lateral sinus through the right
heart and are caught in the small pulmonary vessels,
where they produce metastases. When bacteria are
free in the circulation, they pass through the pul-
monary capillaries and enter the systemic circula-
tion, where they may be deposited in the joints,
muscles and subcutaneous tissues. But as a matter
of fact, we know that either thrombotic particles,
or free bacteria, may be present in the circulation
in sinus thrombosis due to chronic or acute otitis.
Consequently the duration of the otitis has no in-
fluence on the location of the metastases. Some
metastases run a mild course, and some a severe
course. The severity depends upon whether the
embolus contains few or many bacteria, and upon
the virulence of the bacteria. In some cases the
infarct does not break down; there is a local in-
flammatory reaction with hemorrhage into the lung
tissue, and finally cicatrization. When the infarct
breaks down and forms an abscess, it may perforate
through the pleura and form a pyopneumothorax,
or it may perforate into a bronchus. The symp-
toms of metastases in the lungs are sometimes ob-
scured by the general septic symptoms. When an
infarct of some size occurs in the lung, there is
usually a sudden sharp pain in the chest, which
disappears in a few hours and is followed by cough
and bloodtinged expectoration. The pain is due
to the fact that the infarct usually occurs close to
the surface of the lung and involves the overlying
December 21, 1918.]
BRAUN: DIAGNOSIS OF SINUS THROMBOSIS.
1073
pleura. The expectoration becomes purulent after
a time and finally acquires a vile odor. Pieces of
necrotic lung tissue may be coughed up. At first
the physical signs may be negative; later there are
numerous moist rales in the affected area. If the
abscess is large enough, physical signs of a cavity
may eventually be elicited. An x ray picture of
the chest will usually determine the presence of the
abscess. According to Ganter, most of the otogenic
lung metastases occur in the lower left lobe.
Metastases in the joints may be located either
within the joint capsule or in the periarticular
tissues. There may be a collection of pus within
or about the joint, or there may be merely a swollen
tender joint, which subsides after a few days with-
out breaking down. Metastases may involve any
joint in the body. Metastases in the muscles or
subcutaneous tissues may occur in any part of the
body and may, or may not, break down. Meta-
stases in the liver, spleen, or intestines are rare.
Metastases may occur in the brain or meninges.
In addition to resulting from metastases, meningitis
and brain abscess may result from direct extension
of the inflammatory process from the visceral sinus
wall to the pia and brain, or from extension of the
thrombus into the pial veins. Congestion of the
meningeal veins due to obstruction to the circula-
tion in sinus thrombosis causes symptoms of serous
meningitis and paralyses of the ocular muscles. It
may also cause changes in the eyegrounds. In these
cases, lumbar puncture is apt to show a normal
cerebrospinal fluid under increased pressure. Men-
ingeal symptoms in sinus thrombosis can only be
considered an expression of a purulent meningitis,
when lumbar puncture shows a turbid cerebro-
spinal fluid which contains bacteria. Cerebellar ab-
scess occurs rather frequently with sinus throm-
bosis. In most cases the abscess is not metastatic,
but is due to extension of the infection through the
inner sinus wall. The symptoms of the cerebellar
abscess may be masked by those of the sinus throm-
bosis. Often the cerebellar abscess gives no symp-
toms whatever. When the abscess becomes mani-
fest, there is slowing of the pulse, vertigo, vomiting,
nystagmus, past-pointing, loss of the pointing re-
action, and a tendency to fall.
The diagnosis of sinus thrombosis is sometimes
very easy and sometimes very difficult. A typical
case is one in which there is a discharging ear, with
well marked mastoid symptoms, high temperatures
with marked remissions every day, chills and sweats
and metastatic abscesses in various parts of the
body. But in many cases the picture is very atyp-
ical. The ear symptoms may be very slight or may
be overlooked altogether. The patient may be un-
aware of a slight discharge from the ear. The tem-
perature, instead of being remittent, may be con-
tinuously high, or there may be no rise of tempera-
ture. Cases with a continuous high temperature,
especially for the first week, are fairly- common.
These cases are apt to be mistaken for typhoid
fever. In many cases the remissions are only mod-
crate (one or two degrees Fahrenheit). Ihere may
be a middle ear suppuration complicating typhoid
fever or pneumonia with or without mastoid symp-
toms, in which there are high temperatures, with or
without remissions, chills, and sweats. In such a
case, it is very easy to make a mistaken diagnosis of
sinus thrombosis. In some cases of erysipelas com-
plicating mastoiditis, there is a very high tempera-
ture for five or six days before the rash appears.
Such cases may be mistaken for sinus thrombosis.
One of the most valuable diagnostic aids for the
determination of the presence of sinus thrombosis
is an examination of a blood culture The blood
is drawn from one of the arm veins under the
strictest aseptic precautions. In young children,
where it is very difficult to enter the arm veins, it
may be necessary to use the external jugular. The
method described by Libman is as follows : "Ten
to twenty-five c. c. of blood are drawn from the vein,
and incubated on agar, glucose agar, serum agar,
bouillon, and glucose bouillon, with and without
the addition of ascitic serum. Preference is given
to media containing glucose and serum. Plates and
flasks are incubated for five days, subinoculations
being made daily from flasks (after shaking), in
glucose bouillon and on glucose serum agar." In
cases of sinus thrombosis, a growth of bacteria will
be found sometimes in eight or ten hours. Occa-
sionally it takes two or three days before a growth
appears. If the first culture is negative, another
culture should be taken the following day. It is
not at all uncommon to get a negative culture the
first time, and a positive culture the second, or
third time. It is best to draw the blood for the
culture during or immediately after the chill or rise
of temperature, as the circulation contains the
largest quantities of bacteria at that time.
A negative blood culture does not exclude sinus
thrombosis. A positive blood culture with suppura-
tive middle ear disease or mastoiditis usually means
sinus thrombosis. Meningitis may also give a posi-
tive blood culture, but this can be differentiated by
an examination of the cerebrospinal fluid. In men-
ingitis, the cerebrospinal fluid contains bacteria.
The organism which is usually found in the blood
in sinus thrombosis is a streptococcus ; either Strep-
tococcus hsemolyticus or Streptococcus mucosus.
Rarely some other organism is found. If an or-
ganism other than the streptococcus is found in the
blood, a careful review of the case should be made,
to determine whether soriie condition other than
sinus thrombosis is present. The presence of sta-
phylococci in the culture should lead one to suspect
a faulty technic in the taking of the blood culture,
with contamination. However, it is possible for a
stai)hylococcus to occur in sinus thrombosis. The
presence of pneumococci in the blood should lead
one to look for pneumonia. Pneumococci are
rarely found in the blood in sinus thrombosis.
The presence of typhoid bacilli in the blood makes
the diagnosis of typhoid fever. A bacteriemia is
always found in acute bacterial endocarditis. The
physical signs in the heart will serve to differentiate
this condition. Bacteriemia is 'also occasionally
found in tonsillar infections, accessory sinus inflam-
mation, scarlet fever, and erysipelas. These con-
ditions should always be looked for and excluded
in making a diagnosis of sinus thrombosis.
In doubtful cases, where there is a positive blood
culture, Leutert suggested taking blood from an
BRAUN: DIAGNOSIS OF SINUS THROMBOSIS.
arm vein, and from the lateral sinus, and comparing
the number of colonies in the two cultures. If
there are more colonies in the sinus culture than in
the culture from the arm vein, the diagnosis of
sinus thrombosis is very probable. However, the
likelihood of contaminating the sinus culture from
the outer side of the sinus wall is very great, as
was pointed out by Libman. This method might
have some value in cases of suspected sinus
thrombosis with bilateral mastoiditis, to determine
which side to explore. Both sinuses should be ex-
posed and blood aspirated from each sinus, and the
cultures compared. The side that has the greater
number of colonies is likely to be the side that has
the thrombus.
Aspiration of the sinus may give some informa-
tion as to the contents of the sinus. When there is
a completely obturating thrombus, aspiration is
negative. However, if the outer wall of the sinus
is very much thickened by granulations, one cannot
always be sure that the end of the needle is within
the lumen of the sinus. When there is a broken-
down thrombus present, aspiration may reveal pus.
When there is a mural thrombus present, the aspir-
ating needle will draw blood just as in a normal
sinus. If the thrombus is located in some portion
of the sinus other than the point aspirated, the
needle will draw blood. The dangers from the use
of aspiration are very slight. It is possible to carry
infection into the interior of the sinus from with-
out by the needle, but this is very rare. If a few
bacteria are carried into the sinus, they are rapidly
destroyed by the bactericidal action of the blood. If
there is an obturating thrombus in the sinus, the
needle may pass through the thrombus and through
the inner wall of the sinus into the subdural space,
and infect the m.eninges. Such an accident is only
likely to happen if the thrombus is very thin, and the
inner and outer walls of the sinus are almost in ap-
position. If there is a perisinus abscess, and the sinus
and surrounding dura are covered by thick granu-
lations, it is not always possible to distinguish be-
tween sinus and cerebellar dura, and the needle may
be passed through the cerebellar dura instead of
the sinus, and thus infect the meninges or the
cerebellum. Much more reliable information can
be obtained from incision of the sinus than from
aspiration. In order to get reliable information
from incision of the sinus, the incision must be of
sufficient extent to give a good view of the interior
of the sinus. It is not sufficient to simply make a
small incision in the sinus wall, to see whether any
bleeding occurs. One may get free bleeding from
a sinus which contains a mural clot of considerabki
size. Furthermore, an incision made in this way
exposes the patient to the danger of air embolism.
During inspiration, the negative pressure within the
chest produces suction on the column of blood in
the internal jugular vein, and this is transmitted to
a lesser degree to the blood in the sigmoid sinus.
If an incision is made in the sigmoid sinus during
inspiration, without any precautions being taken,
air may be drawn into the sinus and into the right
heart, with possibly fatal results.
The proper method of incising the sinus is as
follows : The bony covering is removed from the
[New York
Medical Journal.
sinus to a point well behind the knee and down as
close to the jugular bulb as possible. The area of
bone removed must be sufficiently broad so that the
entire width of the sinus is uncovered. A plug of
iodoform gauze is now placed across the upper and
lower ends of the sinus, between the outer siijus
wall and the overlying edge of bone, in such a way
that the lumen of the sinus is completely obliterated.
If the portion of bone removed is not as wide as
the sinus, it will be impossible to compress the sinus
in its entire width, and the bleeding will not be com-
pletely controlled. If there has been sufficient bone
removal, and the plugs are properly placed, there
cannot possibly be any bleeding from the sinus,
when it is incised. A longitudinal incision is now
made in the outer wall of the sinus, at least three-
quarters of an inch long, and the edges of the
wound pulled back with forceps, so that the interior
of the sinus can be plainly seen. Care must be
taken in making the incision not to wound the inner
or visceral wall of the sinus. The lower plug pre-
vents air being drawn into the circulation by the
aspiratory effect of inspiration.
Another possible danger in incising the sinus for
diagnosis is the danger of infecting the sinus. A
number of cases of sinus thrombosis have been re-
ported following accidental injury to the sinus dur-
ing operation, and even after iniury to the emissary
vein. It is not unlikely, therefore, that infection
may follow exploratory incision of the sinus. How-
ever, the danger of infection is far less from ex-
ploratory incision than from accidental injury. In
the latter case, the mastoid cavity is likely to con-
tain purulent material at the time of injury, and
infected bone may be left in contact with the sinus.
Before an exploratory incision of the sinus is made,
all the bone overlying the sinus is removed, and the
wound cavity is cleaned out and disinfected as thor-
oughly as possible. As a matter of fact, sinus
thrombosis resulting from exploratory incision is
very uncommon. It is difficult to prove that a
thrombosis which occurs after an exploratory in-
cision was due to the incision, for a mural thrombus
may have been present before operation, and been
overlooked.
If no thrombus is seen in the portion of the sinus
which is incised, the upper plug is removed. If
there is no bleeding, there is a thrombus at the
torcular end of the sinus. However, there may
be bleeding from the torcular end in spite of the
presence of a thrombus in this region. For the
thrombus may not be an occluding thrombus. Or,
even with an occluding thrombus, the bleeding may
come from the superior petrosal sinus. In order to
obviate the possibility of a mistake from the latter
source, the incision in the sinus wall should be car-
ried up past the knee, so as to bring into view the
entrance of the superior petrosal sinus into the
lateral sinus.
If there is no bleeding from the sinus on remov-
ing the lower plug, there is a clot in the lower part
of the sinus, or the jugular bulb. But there may
be a clot in the bulb, in spite of bleeding from the
lower end of the sinus. The bleeding may come
from the inferior petrosal sinus. A much more
reliable method of determining the presence of an
December 21, 19.8.] BRAUN: DIAGNOSIS OF SINUS THROMBOSIS. IO75
obturating thrombus in the bulb is that described
above, namely, before incising the sinus, to com-
press its upper end, and note whether the sinus is
emptied during inspiration. If it is, there cannot
be an obturating thrombus in the bulb. If the sinus
is not emptied during inspiration, and on incising
the sinus we get bleeding from its lower end, we
can be assured that the bleeding is from the in-
ferior petrosal sinus. When the sinus is incised, in
addition to determining the presence of a clot, the
visceral wall of the sinus can be examined to de-
termine the possible presence of a fistula leading
to a cerebellar abscess. Sinus thrombosis may be
mistaken for malaria, typhoid, pneumonia, ery-
sipelas, septic endocarditis, meningitis, grippe, ton-
sillitis or cervical adenitis.
In malaria, as in sinus thrombosis, there are sharp
rises and remissions of temperature, with chills and
sweats. But in sinus thrombosis, there is no regu-
larity in the intervals between the rises of tempera-
ture. In malaria, except in the estivoautumnal
form, the rises occur with regularity every day or
every other day. Examination of the blood in
malaria will show the plasmodia. In sinus throm-
bosis, a blood culture is apt to show a bacteriemia.
The middle ear suppuration which is the cause of
the sinus thrombosis may be so slight as to be over-
looked by the doctor as well as by the patient.
In typhoid fever the rise of temperature is usually
gradual, and when it reaches 104° or 105° F., re-
mains high. In sinus thrombosis, the rise of tem-
perature is usually sudden, and there are apt to be
marked remissions. However, in -^any cases of
sinus thrombosis, the temperature remains persist-
ently high. In typhoid fever there is enlargement
of the spleen and there are rose spots on the body.
In sinus thrombosis there may also be some enlarge-
ment of the spleen. The blood culture gi^es the
most valuable information for differentiating these
two conditions. In typhoid fever, typhoid bacilli
will be found in the blood, whereas, in sinus throm-
bosis, streptococci are usually found. A bacteri-
emia is found in typhoid fever long before a positive
Widal reaction can be obtained.
In pneumonia there are physical signs of con-
solidation in the chest. However, in cases of cen-
tral pneumonia, the physical signs may be very dififi-
cult to elicit. On the other hand, in sinus throm-
bosis, with metastases in the lung, the physical signs
in the chest may resemble those of a pneumonia.
In some cases of pneumonia, a blood culture will
show the presence of pneumococci in the blood.
Pneumococci are rarely found in the blood in un-
complicated sinus thrombosis.
In erysipelas, the temperature curve may re-
semble that of sinus thrombosis, but the temperature
is more apt to be persistently high in the former
condition. In cases where the redness appears about
the wound, within a short time after the rise of
temperature, the diagnosis of erysipelas is very
easy to make. But it is not so very uncommon for
the temperature to remain high for four, five, or
even six days before the redness appears. Such
cases are very puzzling, and a number of them have
been operated upon for sinus thrombosis. It is very
humiliating for the surgeon to operate and find a
normal sinus, and for erysipelas to appear a dav
or two after operation. Blood culture is a valuable
diagnostic aid being usually negative in erysipelas.
In .septic endocarditis there may be physical signs
over the heart, and petechiae in the skin and con-
junctiva. The organism which is usually found in
the blood in septic endocarditis is the Streptococcus
viridans. The blood culture is not of much value in
difterentiating between sinus thrombosis and menin-
gitis, for there is often a bacteriemia in the latter
condition. However, the rigid neck — Kernig and
Babinski signs — and the changes in the cerebro-
spinal fluid serve to make the diagnosis in menin-
gitis. Sinus thrombosis may be associated with a
meningitis. In such cases, the diagnosis of sinus
thrombosis is usually made at operation.
In grippe, the temperature is not apt to go as high
as in sinus thrombosis, nor is it common to have
chills with sharp remissions in the former condition.
It may be possible to isolate the bacillus of influenza
from the nasal secretions or the expectoration. The
blood culture is negative in grippe. Streptococci
are occasionally found in the blood in acute follicu-
lar tonsiUitis. Such cases may be very difficult to
difl'erentiate from sinus thrombosis, if there hap-
pens to be a concomitant ear infection. But a bac-
teriemia due to tonsillitis usually disappears in a
few days. It is, therefore, advisable, in cases of
suspected sinus thrombosis, when a tonsillitis is
present, to delay operative intervention until the
tonsillitis has subsided, in order to eliminate the
possibility of diagnostic error from this source.
The occurrence of cervical adenitis, complicating
middle ear suppuration and mastoiditis, is often
the source of confusion in diagnosis. Adenitis is
an especially common complication in children ; it
often gives rise to a high temperature, 104° to
106° F., which may last for several days, or even
weeks. The temperature may be continuously high,
or it may be remittent, and very closely resemble
the temperature of a sinus thrombosis. The fact
that in sinus thrombosis the glands along the inter-
nal jugular vein are often swollen and inflamed,
adds to the difficulties in diagnosis. The blood cul-
ture is a valuable diagnostic aid. It is negative in
adenitis. The glands which are involved in these
cases are usually the superficial glands at the angle
of the jaw, whereas in the perijugulitis, which
.sometimes accompanies sinus thrombosis, the deeo
glands under the anterior border of the sternomas-
toid are involved. In perijugulitis, the glands do
not usually reach the large size that they do in ordi-
nary cervical adenitis in children. Occasionally
thrombosis in the internal jugular vein is secondary
to cervical adenitis. Such cases are very puzzling.
616 Madison Avenue.
Menstrual Fistula of the Abdomen. — N. Taglia-
vacche (Revista dc la Asociacion Mcdica Argentina,
June, 1918) reports two cases of this extremely
rare condition, only one other case being found in
the literature, and that also in Argentina. A fistu-
lous opening existed in these cases through the
external abdominal wall into the cavity of the
uterus, through which the menstrual flow escaped.
1076
CORNWALL: CONSTIPATION TREATMENT OF PNEUMONIA.
[New York
Medical Journal.
THE CONSTIPATION TREATMENT OF
PNEUMONIA.
By Edwari) E. Cornwall, M. D., F. A. C. P., '
Brooklyn, N. Y.
During the past six years the writer has used a
plan of treatment for pneumonia which might be
called, if a label is required, the constipation treat-
ment, from what, in the face of contrary custom,
would appear to be its most striking feature, al-
though a negative one, viz., avoidance of artificial
evacuations of the bowels except in extraordinary
conditions. The writer has already published de-
scriptions of this plan of treatment (i), and his
excuse for calling further attention to it is that
accumulated experience and the testimony of others
have strengthened his belief in its practical value.
This plan of treatment is flexible enough for uni-
versal application, and does not conflict with the
use of true biological specifics, when such are dis-
covered, being exclusive only of therapeutic pro-
cedures which belong in the category of meddlesome
medicine.
\\ hile regular avoidance of artificial evacuations
is perhaps the most striking feature of this plan, it
is by no means its only distinctive feature, and the
writer wishes to safeguard against any such assump-
tion being made. This plan essentially requires, be-
sides letting the bowels alone, that certain things be
done and thac certain things be not done ; and with-
out the concurrent doing and not doing of these
things avoidance of artificial evacuations is not
recommended. To treat a patient according to this
plan one must not only let the bowels alone, but
must live up to it; and living up to it involves some
finely adjusted procedures.
The rationale of the constipation feature of this
plan is suggested by the following facts: i. If
artificial evacuants are withheld and a fluid diet of
a character which makes for inhibition of injurious
bacterial activity in the alimentary tract is given,
the bowels usually show a tendency to remain more
or less constipated ; and this natural inactivity of
the bowels may be looked on as essentially helpful
rather than the opposite, since habitual procedures
of nature in the presence of disease can regularly
be interpreted as constructive rather than destruc-
tive. 2. The increased fluidity of the feces regularly
produced by artificial evacuants facilitates the mul-
tiplication of the intestinal bacteria, which in the
colon are largely of the more injurious varieties. 3.
Bowel movements, particularly artificially induced
ones, have a disturbing efifect on the heart, which
in pneumonia is rendered more or less unstable by
the regular conditions of the disease.
Dogmatic and routine purgation is condemned by
the Father of Medicine. In his Second Aphorism
Hippocrates says: "Artificial evacuations, if they
consist of such matters as should be evacuated, do
good and are well borne ; but if not, the contrary."
The truth of this aphorism is well shown in pneu-
monia. The memories of most of us, if searched,
would probably be found to contain suggestive clin-
ical pictures of cases of pneumonia in which tym-
panites developed after free purgation, and of cases
in which the patient promptly went into cardiac
collapse when a purge or enema was given near the
expected time of the crisis.
Special conditions may arise which legitimately
call for the use of artificial evacuants, and this plan
of treatment provides for their use in such emerg-
encies. If no bowel movement has taken place
within twenty-four hours of the time when the
patient first comes under observation, and the dis-
ease is in its early stage, and the heart is in good
condition, a mild laxative or an enema is usually
given; and if tympanites of marked degree devel-
ops during the course of the disease, which the
writer has observed to happen much less frequently
since adopting this plan of treatment than before, a
simple, or soapsuds or fel bovis enema, or possibly
a colonic irrigation, is given; and if the patient com-
plains of an unpleasant sense of fullness in the rec-
tum, which does not often happen, a simple, or soap-
suds, or olive oil enema is allowed, if he is other-
wise in good condition ; and two days after defer-
vescence, if the bowels have not already moved
naturally, an enema is regularly given.
Intimately connected with the constipation feature
of this plan of treatment is regulation of the diet.
It is evident, if the bowels are not to be moved for
a week or more, unless they do so spontaneously,
which often happens, that the diet must be regu-
lated both as to quantity and quality so as to prevent
bad consequences arising from such inactivity ;
which means, in particular, that the food must be
reduced in quantity below the health ration, which
the short course of the disease renders a safe pro-
cedure, and that it must be made up of articles-
which bring about a change of the intestinal flora
from the more malign to the more benign types.
Articles of food which constitute culture media
favorable to the development of the swallowed
pneumQCocci and the indigenous saprophytic bac-
teria, must be excluded from the diet, and those
which constitute culture media favorable to the
growth of the benign acidophilic bacteria, whose
predominance in the alimentary canal makes against
putrefaction, must be included. The saline bal-
ance in the diet also must be preserved, and
especially must the calcium deficiency which is
regularly present be provided against; the en-
croachment on the alkaline reserves of the body,
which fevers regularly produce, must be ofiFset
by proper rations of alkahes ; and the necessary
vitamines and water must be supplied. The
food, in general, must be of a character which
will leave little undigested residue ; if it is of such a
character, and also of a character to discourage
activity of the saprophytic bacteria, whose dead
bodies form a large portion of the ordinary stool,
large fecal accumulations can not well take place.
The following dietetic prescription, to be taken
during the febrile period and for two or three days
after, is arranged to meet the indications suggested
above :
DIETETIC PRESCRIPTION FOR PNEUMONIA.
7 a. m. — Give 7.5 ounces of a two to one mixture of milk
with barley water, other cereal decoction, or lime water,
to which has been added five strains of sodium chloride
and five grains of sodium bicarbonate.
8 a. m. — Five ounces of water in which has been dis-
solved ten grains of calcium chloride.
December 21, .918.] CORNWALL: CONSTIPATION TREATMENT OF PNEUMONIA.
1077
9 a. m. — The same as at 7 a. m.
10 a. m. — 7.5 ounces of a mixture made of the strained
juice of one orange, or an equivalent amount of the
strained juice of grapefruit or pineapple, three fourths of
an ounce of lactose, and water.
11 a. m. — The same as at 7 a. m.
12 m. — The same as at 8 a. m.
1 p. m. — The same as at 7 a. m.
2 p. m. — The same as at 10 a. m.
2 p. m. — The same as at 7 a- m.
4 p. m. — The same as at 8 a. m.
5 p. m. — The same as at 7 a. m.
6 p. m — The same as at 10 a. m.
7 p. m. — The same as at 7 a. m.
Everything is to be taken through a tube, the patient
retaining the horizontal position.
This prescription supplies daily about thirty-eight
grams of protein, fuel of a value of about i,2CK)
calories, thirty-five grains of sodium chloride, thirty-
five grains of sodium bicarbonate and thirty grains
of calcium chloride, in addition to the salts naturally
present in the articles of food given, and ninety
ounces of water. It is a maximum diet except as
regards vi^ater, which may be given freely as desired.
This prescription may be modified to meet special
indications by substituting peptonized milk, butter-
milk, or lactacidized milk for all the feedings of the
milk mixture or for a specified number of them;
or by substituting barley water or other cereal de-
coction, or water alone for the feedings of the milk
mixture, or by substituting other specified physiolog-
ically equivalent salt solutions for the solution of
calcium chloride ; or by omitting all food for a time
except water.
Another feature of this plan of treatment is
stimulation of the heart according to a definite pro-
gram, which is flexible in prescribed ways to meet
special indications. This stimulation is not begun
until there is reason to believe that it is necessary,
or is likely to become so very soon ; and care is .
taken to avoid overstimulation. The heart stimu-
lant drugs regularly used are strychnine, strophan-
thus and caffeine. Digitalis is used as a substitute
for strophanthus when for any reason, such, for
instance, as idiosyncrasy, the latter drug is not well
taken. Other drugs for modifying cardiovascular
functions are rarely called for, but there is nothing
in this plan of treatment to forbid their use if the
indications for them are clear. Of the drugs regu-
larly employed, the dose is prescribed as definitely
as it is possible to do so in a general statement.
Strychnine sulphate, in doses of 1/60 grain every
four hours, is the first drug given, and this may
be sufficient. If more stimulation is needed, tincture
of strophanthus, in doses of one and a half to three
minims, every four hours, is added; cr, if the tinc-
ture is not well borne, or a more positive and pow-
erful efifect is required, strophanthin is given by
intramuscular injection, in doses of 1/1,000 to
1/500 grain every four hours. If still more stimu-
lation is required, caffeine citrate or cafifeine and
sodium benzoate, the latter being adapted for hypo-
dermic use, is also given every four hours, and per-
haps the dose of the strychnine increased to 1/30
grain. It is not often that the amount of stimula-
tion supplied by these three drugs, in the range of
doses mentioned, need be exceeded, but if it should
be, then the dose of strophanthin is temporarily in-
creased to 1/250 grain every four hours; and in
sudden and severe cardiac failure i/ioo grain of
strophanthin is given intramuscularly or intraven-
ously, but after such a dose no more strophanthin
is given for twenty-four hours, although the strych-
nine and caffeine may be kept up. Alcohol, which is
not conceded to be an effective heart stimulant, al-
though it sometimes seems to act like one, is usually
given to patients who have been alcoholic addicts,
and occasionally to those who are advanced in years.
Another feature of this plan of treatment is a
conservative attitude toward the relief of symptoms.
The fact is recognized that symptoms do not neces-
sarily call for suppression, being not so much mani-
festations of disease as evidences of nature's repara-
tive activity ; but the fact is also recognized that
some symptoms may be so severe, or may persist so
long, that they become harmful, and for that reason
require modification ; and also that some symptoms
which are distressing can be relieved, at least to a
certain extent, without endangering the patient.
This plan of treatment permits, in a definite and
prescribed manner, the relief or modification of
certain symptoms in certain conditions. Pain,
cough, restlessness, and insomnia, occurring in the
early stages of the disease and depriving the patient
of much needed sleep, are relieved by the applica-
tion of hot poultices to the chest and, perhaps, by
the administration of small doses of morphine or
codeine ; but opiates are strictly forbidden in the
latter stages of the disease and at any time if the
respiration is embarrassed. Diarrhea is treated by
lestriction of the diet to barley water, rice water,
or water alone. Vomiting is treated by stopping all
food for a time, and perhaps, if it occurs in an early
stage of the disease, by small doses of morphine
given under the skin. Tympanites, which is not of
common occurrence in patients treated according
to this plan, is treated by exclusion of milk from
the diet and, perhaps, restriction of the diet to barley
water or rice water; and if extensive, by the intro-
duction of the rectal tube or the administration of
enemas as previously described. Delirium is treated
by constant watchfulness and, perhaps, physical re-
straint; very rarely by sedative drugs.
A negative feature of this plan of treatment, and
by no means its least important feature, consists
in not doing certain things which are sanctioned by
tradition and prevailing fashion, and even by emi-
nent authority. One of these negative things has
already been mentioned, viz., avoidance of routine
catharsis, and the writer cannot refrain from re-
ferring to it again, being strongly convinced of its
importance. Particularly to be condemned, in his
opinion, is the routine administration of calomel
and magnesium sulphate. Magnesium sulphate, in
addition to possessing the other disadvantages of a
cathartic in this disease, is a cardiac depressant and
kidney irritant after absorption, which takes place in
direct proportion to the strength of the solution and
the length of time it remains in the bowel ; and
calomel possesses the additional disadvantage of
being an irritant to the intestinal mucosa and the
hepatic tissues. Other things which are not done
are the follov/ing: Antipyretics are not given, fever
being respected as a constructive or defensive
process, except when there is hyperpyrexia, in
BRAV: INTERSTITIAL KERATITIS.
[New York
Medical Journal.
which case antipyretic hydrotherapy is allowed.
Diuretic and expectorant drugs are not given.
Drugs for the purpose of producing intestinal anti-
sepsis are not given, reliance being placed on diet
for modifying the intestinal flora. And none of
those drugs are given which have been recommended
for a specific or quasi specific effect, such as cresote
carbonate, salicylic acid, quinine and urotropin.
As an illustration of the practical working of this
plan of treatment, two series of cases are cited
which occurred in the writer's service in the Nor-
wegian Hospital, Brooklyn. In one the patients
were treated without the regular use of artificial
evacuants, and in the other with it, the treatment in
other respects being not markedly dissimilar, al-
though in the series treated without the regular use
of artificial evacuants the diet was more precisely
regulated than in the other. These two series are
similar in that they were continuous, that is, they
included all the cases which came into the writer's
service in that hospital during stated periods, which
were diagnosticated as primary lobar pneumonia
and pneumonia of influenza ; not only those patients
whom the v/riter saw and treated, but also those
who were moribund on admission or died before
the writer saw them. These two series also may
be assumed to correspond in general character as
regards social and intellectual status and ma-
terial environment, being brought in mostly by
an ambulance service which covered a definite
section of the city. The two series also ex-
tended over considerable and nearly equal periods
of time, the first covering six and two third years,
from May i, 1906, to January i, 1913, and the
second, five and a half years, from January i, 1913,
to July I, 1918. In the first series, in which artifi-
cial evacuants were more or less regularly used, in a
total of 124 cases, there were thirty-eight deaths,
giving a mortality of 30.6 per cent. In the second
series, in which artificial evacuants were not regu-
larly used, in 218 cases there were forty-one deaths,
giving a mortality of 18.8 per cent.
References.
I. E. E. Cornwall, Observations and Suggestions
on the Treatment of Lobar Pneumonia, Medical
Record, August 2, 1913; Report of Fifty-four
Cases of Pneumonia Treated by a Special Method,
New York Medical Journal, May 30, 1914; A
Rational Method of Treating Lobar Pneumonia,
With a Report of 133 Cases in Which It Was Used,
Medical Record, August 28, 191 5; Remarks on the
Treatment of Lobar Pneumonia, Interstate Medical
Journal, July, 1915; How to Treat Pneumonia,
Medical Times, January, 1917.
Effect of Physical Labor on Arterial Tension.
- — M. Banuelos and S. V. Portella {Revista de Medi-
cina y Cirugia Practicas, September 7, 191 8) con-
clude, as a result of extensive experimental work,
that moderate exercise diminishes arterial pressure,
which is more marked in those who are in poor con-
dition ; violent exercise, on the other hand, raises
arterial pressure. The mechanism involved in this
process is probably nervous, hormonal, and chem-
ical.
VARIATIONS IN THE CLINICAL PICTURE
OF INTERSTITIAL KERATITIS.
By Aaron Bray, M. D.,
Philadelphia,
Ophthalraologist to the Jewish Hospital, Philadelphia.
Interstitial keratitis is an important disease of the
eye, not only because of its frequency ; nor because
of the serious changes in the integrity of the ocular
tissues ; nor because it jeopardizes the visual acuity
of the sufiferer and often disables him for months,
not infrequently for years, but because of the con-
stitutional nature of the disease. It is generally
accepted today that interstitial keratitis is a consti-
tutional disease of a specific nature, although the
exciting cause may be of a local character.
Interstitial keratitis is a manifestation of a hered-
itary syphilis in the first, second, or third genera-
tion. It is an attenuated form of syphilis. It is
usually associated with other clinical manifestations,
so well described by Hutchinson, and known to
every ophthalmic surgeon but not infrequently it is
the only clinical sign that leads to the recognition of
a constitutional disease that has been transmitted
from parent to offspring. In the great majority of
cases the specific nature of the disease can be defi-
nitely demonstrated by serologic tests. Brinkerhof
found in 107 cases sixty-six positive Wassermann
reactions (i), Leber found a positive reaction in
ninety-four per cent., Ingersheimer and Fozit found
it in practically 100 per cent. (2). With reference
to the etiological nature of interstitial keratitis, J
am a Unitarian, firmly believing that they are
always the result of hereditary syphilis. Carpenter
has seen three cases of interstitial keratitis in ac-
quired syphilis (3V In fact several cases attributed
to acquired syphilis have been recorded in foreign
literature. It must however be remembered that an
individual with congenital taint may have a super-
added acquired syphilitic lesion (4). Interstitial
keratitis is pathognomonic of hereditary lues. I
prefer to look upon it as a metasyphilitic disease
caused by the toxic product of the spirochetes cir-
culating in the blood. I am in accord with Fournier
who looks upon this disease as a syphilitic dyscrasia
(5). It is, however, of considerable interest to
note the variations in the clinical picture of the
disease that is admittedly caused by one primary
constitutional element. One is at a loss to account
for these variations. In a general way we must fall
back upon the only plausible explanation, namely,
the diflference in the constitutional makeup of the
individual, i. e., his resisting power to the syphilitic
liemotogenous toxin, and the variance in the virus
itself as a result of its passing from one host to
another; the change in the culture media influences
the development of the spirochetes and their toxic
products. The disease occurs in both sexes in
childhood and adult life and not infrequently even
in middle age. In my own limited experience fifty
per cent, of the cases occurred in adults between
the ages of seventeen and twenty-six years.
Clinically speaking the following variations are
usually seen: i. Variations in the objective manifes-
tations of the disease ; 2, variations in the subjective
symptoms; 3, variations in the onset of the disease;
December 21, 1918.]
BRAV: INTERSTITIAL KERATITIS.
1079
4, variations in the course and complications of the
disease; 5, variations in the ultimate outcon-.e of the
disease.
VAKIATIONS :N THE OBJECTIVE SYMPTOMS.
All cases of interstitial keratitis manifest them-
selves by an infiltration into the lamellar tissues of
the cornea, but the extent and the density of the
infiltration varies in different cases. In some, the
infiltration is slight, the cornea is seen studded with
small whitish gray foci which become partly conflu-
ent, appearing as a whitish gray patch. In some
cases the infiltration begins at the margin, in others
at the centre of the cornea. The transparency of
the cornea suiters only at the point of infiltration,
the rest of the cornea retains its lustre. As the
disease progresses the entire cornea becomes infil-
trated. The loss of the corneal transparency is in
direct proportion to the density of the infiltration,
wliich is usually most marked at the centre. The
cornea in some cases is so densely infiltrated that
neither iris nor pupil can be seen, and in other cases,
as a result of a densely central infiltration, the cornea
becomes conical. There is, however, no ulceration,
although a fluorescin test will show that the corneal
epithelium has suffered some destruction. No ves-
sels are visible to the naked eye in this type of the
disease and it is thus spoken of as the nonvascular
type.
VARIATIONS IN THE VASCULARIZATION OF THE CORNEA
There is a vascular type of this disease where the
bloodvessels can be seen with the naked eye, but
here too the variations are well marked. In some
cases very small vessels enter the corneal stroma
from the linibus appearing to the naked eye as
delicate red streaks. I look at this vascular
l^henomena as nature's method of therapeutics, in
bringing into the cornea an abundance of blood sup-
ply. In fact, clinical observation leads us to the
conclusion that all cases of interstitial keratitis are
accompanied by this process of bloodvessel forma-
tion. In the nonvascular type however, these ves-
sels can only be discerned with the aid of the
ophthalmoscope. In some cases the vascularization
of the cornea reaches such a high degree that it
covers the entire cornea, completely hiding the
corneal tissue, and giving it a red velvety appear-
ance. I recall a case of a young man, twenty-one
years of age, where the vascularity was so marked
that the entire cornea appeared as an aggregation of
bloodvessels with a vivid red velvety color. There
was no light projection. The patient recovered
completely, and retained useful vision. It seems to
me that the deep vascularization is also nature's
method to protect the cornea during the dangerous
period, as these vessels practically disappear after
the disease has run its course, and only some fibrous
streaks remain which may be observed with the
ophthalmoscope. In this connection it is well to
mention also the variations in the corneal contour.
In some cases it appears normal, in others the
cornea is considerably flattened, while not infre-
quently the cornea bulges forward in the centre,
giving the appearance of a conical cornea. The
cornea usually returns to its normal condition,
although a change in the refractive status is alwavs
to be expected. Not infrequently the corneal bulg-
ing is associated with some rise in the intraocular
tension, I ain inclined to believe however that the
bulging of the cornea is not caused by the high
tension but by the greater infiltration and vasculari-
zation in the central part of the cornea. It is also
well to recall that tliere is a milder type of inter-
stitial keratitis where the infiltration appears to be
confined to a triangular area leaving the rest of the
cornea unaffected. 1 his runs a milder course and
yields more readily to treatment.
V.\RIATI0NS IN THE SUBJECTIVE SYMPTOMS.
The subjective symptoms also show a marked
degree of variation. While pain is one of the com-
mon symptoms of the disease, it is interesting to see
how some patients are altogether free from pain ;
others have pain to a moderate degree, and a con-
siderable ntimber suffer severely and rec|uire active
meastires for relief. Apparently the pain has
nothing to do with the degree of infiltration, but is
probably caused by an associated iritis or cyclitis.
The same variations may be observed with regard
to photophobia. Of course, pain and photophobia
go together. In some cases there is no photophobia ;
in others the patient feels some inconvenience and
has to keep out of the light. Sometimes this symp-
tom is so severe that the patient has to.be kept in a
dark room and children bury their faces in the
pillow seeking relief. The asthenic type of this
disease runs its course without pain and without
photophobia.
VISUAL DISTURBANCES.
One of the principal symptoms of the disease is
a reduction in the acuity of vision. Some patients
are totally blind when the acme of the disease has
been reached. The variations in the reduction of
vision can always be accounted for by the degree
of corneal infiltration, the density and extent of the
infiltrated area, and the vascularization thereof.
The severity of the case has no direct relation to
the visual disturbance. I have seen patients who
were blind during the acme of the disease, which
ran its course practically free from pain. On the
other hand in some very severe cases there is some
degree of vision even at the height of the disease.
VARIATIONS IN THE ONSET OF THE DISEASE.
Interstitial keratitis is often very insidious in its
outset, the patient noticing only a slight dimness in
vision which gradually increases. There may be no
inflammatory symptoms present. Some cases, on
the other hand, begin with very severe inflammatory
symptoms ustially associated with acute keratitis.
Quite often these patients come to the office with
the complaint that some foreign body has got into
the eye, which they wish to have removed. This
happens so often that one cannot look upon it as
merely accidental. A foreign body in the eye often
constitutes the local exciting element in the develop-
ment of this disease. Trauma, however slight, must
be considered a potent factor in the causation of
this disease in individuals predisposed. Mohr, out
of 670 cases found trauma as the probable cause in
.all except two (6). This is probably out of pro-
portion with the findings of ophthalmic surgeons.
Some cases begin v/ith a marked conjunctivitis. I
have recently seen two cases, one in a colored boy,
io8o
BRAV: INTERSTITIAL KERATITIS.
[New York
Medical Journal.
aged nine years, the other in an Italian girl, aged
six years, that I treated for a week as a severe case
of conjunctivitis before I could make the diagnosis
of interstitial keratitis. The little girl showed signs
of trachoma while the little boy had a marked
blepharoconjunctivitis which persisted after the
keratitis yielded to treatment. Some cases begin
with an iritis or hyperemia of the iris. I recall the
case of a wife of a physician who consulted me in
TQ16, in which I diagnosed an iritis. The instillation
of atropine corroborated my diagnosis, yet within
ten days she had a fully developed interstitial
keratitis. The entire cornea became infiltrated but
cleared up completely after a year's vigorous treat-
ment, leaving practically no opacities and vision re-
stored to 5/6.
It is worthy of notice that the clearing process
always begins at the periphery, while the infiltration
process may begin either in the centre or at the
margin of the cornea. Occasionally interstital
keratitis follows a herpes zoster and it is difficult in
the early stage to differentiate it from a disciform
keratitis which also follows a herpes zoster.
VARIATIONS IN THE COURSE AND COMPLICATIONS 01'
THE DISEASE.
Some cases run their course free from any com-
plications. This is especially true of those cases
that are free from inflammatory symptoms. Quite
often however complications are observed, the most
frequent of which is iritis. These cases usually
give rise to severe pain and require energetic treat-
ment. In a large majority of cases either part or
all of the uveal tract is involved. On^ of the rarer
complications is cataract. I saw one case in 1917, a
little girl, aged twelve years, who developed a
cataract as I was about ready to discharge her as
cured. She was imder my care for one year. She
had the triangular form of the disease. I have also
seen a case of divergent strabismus complicating this
disease. I suppose that muscular deviations are not
very commonly seen. As to the duration and course
of the disease, we can only say that while in the
majority of cases ihe disease is bilateral, in a con-
siderable number of cases the disease runs its course
without involving the second eye. Some cases, espe-
cially the unilateral cases, run their course in from
five to twelve months. Tlie bilateral cases usually
require a longer period. Not infrequently the sec-
ond eye is in the process of healing while the first
eye is still in the stage of inflammation. The second
eyes in some cases gets well before the first eye, but
^■he result is not necessarilv better. Some cases re-
quire two or three years of treatment. I have a pa-
tient at present under my care who after three years
of treatment still has a very marked conjunctival in-
fection, but is free from any pain. I cannot explain
the persistence of this redness.
VARIATIONS IN THE ULTIMATE OUTCOME OF THE
DISEASE.
Prognosis in a general way must be considered
good. I have never seen a case of total blindness
resulting from this disease. I have seen several
cases with a very low visual acuity. We have all
seen variations in the ultimate outcome of the dis-
ease. In some cases vision is restored to almost
normal, in others ii is markedly reduced. The re-
duction in vision depends upon the extent, site, and
density of the corneal opacity. It should be remem-
bered that the healing process in this disease, as in
corneal ulcers, is associated with the process of
absorption and the process of cicatrization. The cica-
trization however is interstitial in character, as the
cellular organization takes place within the corneal
lamellae. In the majority of cases useful vision is
obtained. We must also note here the marked
changes in the refraction status of the healed eye.
We find cases that were emmetropic have become
myopic. In myopic cases the myopia increases.
High degrees of astigmatism are very commonly ob-
served. In one case recently under my care, the pa-
tient who wore a minus 4 Sph. lens had to be given
a minus 12 cylinder in the right and a minus 8 cylin-
der in the left eye, and strange to say, with nearly
normal vision, i. e., 5/ 6. In the beginning he suflfered
from diplopia but after persevering for a week or
two the diplo])ia disappeared and the patient is per-
fectly comfortable attending to his occupation — cler-
ical work. These observations I have made in both
the unilateral as well as the bilateral cases.
TREATMENT.
I cannot share the opinion of Fuchs that, paren-
chymatous keratitis in many cases even under the
most careful treatment, runs a course that is not
essentially different from what would have been the
case without any treatment (7). He probably meant
to emphasize our relative helplessness in shortening
the course of the disease. I think treatment of the
utmost value in combating the noxious elements of
the disease. Atropin is, of course, indispensable as
a local agent. In the painful cases hot compresses,
and often bandaging the eye, is a very useful pro-
cedure. Internally, mercury, iodides, arsenic, iron,
and thyroid extract are all very useful remedies. In
children codliver oil and hynophosphites are ex-
cellent remedies to remember. For the removal of
the corneal opacity dionin and adrenalin are to be
employed. The best result is to be obtained from
the alternate use of dionin and adrenalin I use
adrenalin during the day and dionin at night in thf
form of an ointment or in solution.
I do not think salvarsan is of great value in this
disease ; it may however be useful in the very severe
cases where the pain is very marked. I have not
used salvarsan in my cases. I have used tuberculin
in several cases. I am not convinced of its thera-
peutic value even in those cases that gave a positive
tuberculin reaction. Neither am I convinced of the
therapeutic value of electricity. In both electricity
and tuberculin treatment I think "time" is the prin-
cipal agent. In conclusion I wish to say that I am
not unmindful of the views of Doctor Risley that
interstitial keratitis is occasionally caused by met-
abolic changes. I willingly accept this view, adding,
however, that the metabolic changes are secondary
to an attenuated syphilitic infection in the second,
third, or fourth generation.
REFERENCES.
I. American Journal of Ophthalmology. May, iqi8. 2. Arch. V.
Graefe, Ixxiii and Ixxxiii. 3. Annals of Ophthalmology, 1918. 4.
MENDEL; Centralblatt fiir practische Augcnheilkunde , xxv, p. 10.
5. Traite dcs maladies des Yeux, vol. 1, p. 245. 6. American Ency-
clopedia of Ophthalmology, cix, 6795. 7. Fuchs's Ophthalmology,
p. 20s.
December 21, 191S.]
KATZOFF: KNIFELESS TREATMENT OF FILES.
1081
KNIFELESS TREATMENT OF PILES.
By Simon L. Katzoff, M. D., Ph. G., LL. B.,
Bridgeport, Conn.
First and foremost, regard the usual surgical op-
erations for hemorrhoids, as barbarous, unscientific,
and unnecessary.
A hemorrhoid is a mass of varicose or dilated
and sacculated veins at the anus and lower rectum,
the usual situation being almost always the muco-
cutaneous surface which joins these two structures.
Hemorrhoids are internal or external, depending
upon whether they are developed within the
sphincter ani or outside this muscle. Piles are
called open or bleeding as they give rise to hemor-
rhage, and blind when they do not bleed.
The external pile is a small circumscribed tumor.
Commonly there is more than one of these. They
may be so numerous as to form a more or less com-
plete circle around the anus. The color varies from
dark red to purple ; the surface is smooth or lobu-
lated, and the consistence may be soft, hard, or
elastic, corresponding to the degree of vascular
turgescence.
The predisposing causes are sedentary and indo-
lent habits ; luxurious living, especially the use of
highly seasoned foods, wines, and spirits ; tight
lacing, pregnancy, constipated bowels, and diseases
of the liver. Overexcitement of the sexual organs
may be classified among the predisposing causes.
Vaccination may also pave the way for it. The
exciting causes include anything which irritate the
lower bowel, such as straining at stool, hard riding,
and the use of strong purgatives, especially ex-
cessive use of aloes and rhubarb.
A sensation of fullness, heat, and perhaps itching,
felt about the anus, is generally the first symptom.
The swelling increases until small tumors form,
which are sore and painful. These may be external
and visible, or internal, and are often of a bluish
color, and, when inHamed, are very painful.
The diagnosis of hemorrhoids is usually easy. It
is very common for the laity, however, to mistake
a variety of disease, including simple pruritis, ec-
zema, prolapsus ani, polypus of the rectum, con-
dylomata, and even fistula in ano, for hemorrhoids.
The prognosis is usually favorable, particularly
if the treatment is instituted early.
There are many ways of treating piles. The
hygienic, dietetic, occupational, and other environ-
ments of the patients should be studied and cor-
rected as may be found necessary. The patient should
as a rule, avoid cof¥ee, spices, and highly seasoned
foods, and ihe habitual use of beer, wines, and
spirits. The less meat eaten, the better. Sedentary
habits and much standing on the one hand, and ex-
treme fatigue on the other, are harmful, as is also
the use of cushions and feather beds. A laxative
diet including bran bread or muffins, buttermilk,
prunes, baked or raw apples, should be adopted. A
little fasting (twenty-four hours) once in a while,
will do no harm.
The pile itself should be carefully reduced and
returned within the sphincter, an ointment being
used in the manipulation as well as subsequently
applied and properly retained by dressing. In cases
in which the inflammation is very decided nothing
can be accomplished until cold applications, such as
ice water, or ice itself, are made to the part and re-
tained there. Satisfactory results are greatly fav-
ored by the patient going to bed. If the inflamma-
tion has been reduced and the astringent ointment
is insufficient, good results may be frequently ob-
tained by applications of Monsel's solution of per-
sulphate of iron applied with a brush once or twice
daily. Applications of collodion to external hemor-
rhoids will support the pile and stimulate its con-
traction. It may be dropped on a few fibres of
cotton wool, which are spread over the pile each
mornmg after defecation. Gradually increased dila-
tation of the rectum will sometimes bring about the
desired result, and will be helpful in almost every
case.
The injection methods consist in shaving the hair
around the anus, cleansing the parts thoroughly ;
then, after having the pile in firm position, injecting
with a hypodermic syringe, one or two drops of a
mixture of carbolic acid, one part, and glycerin,
two parts, in each pile, beginning with the smaller
ones. I have personally employed the following
formula at least 200 times :
Carbolic acid, ) aa 3i •
Salicylic acid, i '
Sodium biborate, 5j ;
Glycerin (sterilized), sufficient to make ^i.
One or two drops of this mixture in each pile,
will suffice to begin favorable results.
After the injection almost any usual ointment
such as tannic acid ointment, belladonna ointment,
stramonium ointment, and the like, may be smeared
around the parts, and the usual reduction within the
sphincter, retention, and dressing may follow.
A few other simple methods employed are: I.
Make a thin paste of raw linseed oil and pure white
lead that shall be as thin as cream in consistency ;
anoint the parts, when protruding, twice daily, c.
Equal parts by weight of tannin and glycerin.
Anoint once, and in severe cases twice daily. 3.
The simple remedy, common table salt, is one that is
unsurpassed for bleeding biles. 4. Heat a table-
spoonful of lard to the consistency of ordinary
cream, and to this add about half a teaspoonful of
calomel ; mix thoroughly and apply twice daily.
The Pathological Uterus at the Menopause. —
Charles R. Robins (Medical Press and Circidar,
May 29, 191 8) considers a pathological uterus a
potentially malignant one, and that even if cancer
is not present it may develop later. In the effort to
make an exact diagnosis there is liability to lose
the advantage of early operation in an effort to
secure tissue for examination, so disseminating cells
and stimulating vicious growth. The procedure
should be total extirpation of the pelvic organs, and
the pathological investigation made after the organs
have been removed. In his own cases, cancer was
found in two out of twenty-six. Moreover, the
organs have fulfilled their usefulness and it is
only anticipating nature in removing them. His
experience was that the aftereffects generally
meant improved health and a cheerful existence
instead of one of semiinvalidism. The hysterectomy
technic should be clean and devoid of trauma, and
the parts supported by attachment of ligaments.
Medicine and Surgery in the Army and Navy
MEDICAL NOTES FROM THE FRONT.*
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-docent at the University of Geneva, Fellow of the Royal
Society of Medicine of London, etc.
PATHOGENICITY OF CIMEX LECTUL.XRIUS.
The present happy results obtained for immunity
against the development of infectious diseases
among troops has been in a great measure due to
the research work done in the domain of parasi-
tology. The mosquito, the domestic fly, and the
body louse have been thoroughly studied from this
viewpoint but not much has been said about the bed-
bug— Cimex lectularius — and although this insect
does not appear to be as dangerous to man as the
others, nevertheless, it has not been proven that it is
entirely free from danger. For this reason I shall
attempt to sum up the question as it stands today.
Cimex lectularius and other types of the same
family feed exclusively on the blood that they draw
from the skin of their victim. Since they only
attack living animals it is quite likely that they may
play an important part in the propagation of para-
sitic diseases whose infectious agents are either
present in the blood or skin. But the results ob-
tained so far leave us in uncertainty as to the
pathogenic activity of the Cimex lectularius.
Andre, wishing to discover the fate of bacilli and
trypanosoma in the body of this insect fed bedbugs
on microbic cultures or allowed them to bite animals
aftiicted with experimental diseases, after which he
ascertained what became of the ingested rnicrobes.
The following conclusions have been arrived at:
The streptococcus promptly disappears from the in-
sect's intestine, while the anthrax bacillus, although
present in great quantities, loses its staining prop-
erties within three to four days. The organism is
then pale, appears as if tumefied, and has lost jts
spore producing facuUies. It disappears from the
intestine on the fifth or sixth day. The Trypan-
osoma lewisi of the mouse stains normally during
the first three to four days, after which time it
stains less distinctly and disappears from the in-
testine on the fifth day. The bacteria taken in the
blood by the bedbug die more or less quickly in the
insect's intestine ; then they progressively disinter-
grate as the blood undergoes digestion. This would
seem to show that the bedbug is a poor agent of
propagation, at least for the organisms experi-
mented w^ith. and therefore explains the negative re-
sults of Andre's inoculation experiments. Bedbugs
having sucked blood loaded with streptococci, pneu-
niococci, or anthrax bacilli, were quite incapable of
inoculating healthy animals with these bacteria,
when bitten by the insects on the third and eighth
day after they had ingested the injected blood. The
same result was obtained in the case of the Trypan-
osoma lewisi.
In normal circumstances the cimex swallows the
various parasites circulating in the blood, but it
•This article was wriKen in September, 1918.
progressively digests them because a certain number
of days are required to digest and assimilate all the
blood with which they are gorged. When hunger
presses them again, the destruction of the bacteria
previously ingested has had ample time to take
place. P'or that matter, it seems likely that the di-
gestive tube of the cimex is normally endowed with
bactericidal and paraciticidal properties, and in
point of fact Andre has been able to demonstrate,
by serial sections made before experiments were
done, that the digestive tube of the insects was per-
fectly free from all microbes. Therefore, it may
be taken as a fact that the digestive tube of the cimex
is normally aseptic and that it accomplishes its di-
gestive function without the help of bacteria, as is
likewise the case with caterpillars studied by Por-
tier. But I would point out that this is not sufficient
reason for refusing to credit the cimex with any
part in the transmission of disease. If insufficiently
gorged at one feeding the insect will soon start out
on the search for a second repast, and therefore it
seems logical to suppose that it can then inoculate
the bacteria still in a virulent state. It is thus pos-
sible, I might even say probable, that the insect, for
this reason, plays a part in the transmission of
disease.
The bacillus of the plague is inoculated by rat
fleas as we know, but is this the only agent of trans-
mission? Nuttall and Wierzbitzky fed the cimex
on pestiferous patients and found the specific
bacillus in the digestive tube of the insect. Others
repeated this experiment and obtained identical re-
sults. Jordansky and Klodnitzky succeeded in in-
oculating mice by having them bitten by infected
bedbugs. The cimex was in no way disturbed by
the Bacillus pestis, in spite of the fact that in nor-
mal circumstances their digestive tubes are ami-
crobic, as I have already pointed out. In another
series of experiments the same writers caused thir-
teen bedbugs to bite a pestiferous mouse three hours
before its death. On the nineteenth, and again on
the thirty-first day following, two bedbugs were
still alive and they were allowed to bite guineapigs.
Five days later one bedbug was killed and a large
number of plague bacilli were found in its digestive
tube. On the evening of the fifth day the second
bedbug died and its digestive tube contained only
a few bacilli.
In India, Walker attributes an important role to
the bedbug in the transmission of the plague, and
the insects collected from the huts of the natives
afflicted with the disease were found infected to
the extent of twenty-two per cent. He was able
to transmit the disease to a rat by a bedbug that
had bitten a pestiferous subject. It would seem,
therefore, that the bedbug plays an undoubted part,
although perhaps very limited, in the transmission
of the plague.
As to the transmission of tuberculosis by the
Cimex lectularius nothing definite has been estab-
lished, but the same cannot be said of leprosy.
Professor Blanchard, of Paris, has shown conclu-
sively, I think, that leprosy is not hereditary or
December 21, 191S.]
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
congenital, but that it can be inoculated. And what
is more, he has shown convincingly that the disease
can only be inoculated by the bite of a noctural in-
sect, and he consequently concludes that the insect
is the mosquito. However, it is not my purpose
to discuss the part played by the mosquito, and I
shall confine myself to the question of transmission
of leprosy by the bedbug as revealed in a number
of observations.
The commission sent to the West Indies, in 1909,
by the Danish government, under the direction of
Professor Ehlers, found the Bacillus leprae only
in small numbers in the digestive tube of the bed-
bug or in other insects which were examined shortly
after having gorged themselves on the blood of
leprous patients. This can be readily understood
because the specific organism of the disease is al-
ways rare in the blood. It would, therefore, seem
that inoculation of leprosy by insects and the bed-
bug in particul.nr must be very uncommon, even
under the best conditions.
At the leper hospital at Robben Island, South
Africa, Lindsay Sanders undertook these re-
searches with various insects. He placed them in
test tubes for several days, so as to starve them,
and afterwards put them, with all due precaution,
on indurated lepromata and allowed them to gorge
themselves with blood. Results were negative in
the case of the domestic fly, mosquito, and flea, but
quite otherwise with the bedbug. Out of a total
of seventy-five bedbugs, twenty contained an acid
resistant bacillus, in all respects similar to the Ba-
cillus leprae. These bacilli were found in large
numbers, while they were completely absent in bed-
bugs that had not bitten leper patients. They were
found in the proboscis up to the fifth day, and in
the digestive tube up to the sixteenth day, and were
eliminated in the insects' dejections. They re-
tained their acid resistant power and offered all
the characteristics of living bacilli. It may be sup-
posed, therefore, that the bedbug may inoculate
leprosy by its bite, and this opinion has been con-
firmed by Long at Basutoland. Goodhue has also
seen the bacillus in the digestive tube of bedbugs
after they had bitten leprous subjects.
It is a popular belief in Russia that recurrent
fever or European spirochetosis is transmitted by
the bite of the bedbug, and Fliigge was of this
opinion. Tictin, of Odessa, has likewise accepted
this theory and submitted it to an experimental
test. During an epidemic in that city he collected
bedbugs from the bedclothes of patients and after
having crushed the insects he was able to detect
the spirochetes microscopically. The contents of
eight bedbugs that had just bitten a patient were
inoculated into a monkey who soon developed the
disease. An inoculation, performed forty-eight
hours after the bedbug had bitten the patient, re-
mained negative.
During the epidemic of 1902, Karlinski found liv-
ing spirochetes in the digestive tube of the cimex
and Schaudinn made a similar observation. In
England, Nuttall has successfully transmitted the
disease from mouse to mouse by the intermediary
of the cimex and Sikul, of Odessa, has obtained
an identical result. It is, therefore, not impossible
that this spirochetosis can be inoculated by the bed-
bug, on the condition that the insect bites a healthy
subject within a few hours after having bitten a
patient afflicted with the disease.
As far back as 1898, Gimaud slated that the
bedbug was capable of inoculating leishnianioses.
rhe oriental boil, caused by Leishmania furunculosa,
has been the object of experimental work by Pat-
ton. He observed that the parasite multiplied in
the intestine of the Cimex hemipterus in the flagel-
lated form and even in the postflagcllated form,
but he was unable to inoculate the disease from the
insect's bite. Patton, in the case of kala azar,
caused by Leishmania donovani, experimented
with the same insect and was able to detect the
flagellated forms in the intestine of the insect, but
he could not get beyond this phase. Quite recently,
Mackie has taken up the question and his experi-
ments are well worth summarizing. He first ex-
perimented in order to determine if bedbugs caught
in the bed linen of persons afflicted with kala azar
contained microscopically recognizable bacilli in
their digestive tube. A total of 1,513 bedbugs were
dissected and examined in a fresh state and also
after staining as follows : 398, in Bengal, from
June to October ; 469, at Nowgong, from February
to August ; 646, at Salona, from June to August.
Mackie next carried out experiments to determine
if the contents of these bedbugs could produce the
disease in the monkey, when introduced subcutane-
ously. In Bengal, from June to October, 131 young
bedbugs were fed on subjects suffering from the
disease once or several times and were dissected at
varying intervals and examined microscopically.
At Nowgong, from February to August, 191 bed-
bugs were treated in the same way. He then ex-
perimented to determine if the young bedbugs
nourished in these conditions could produce the dis-
ease when injected into monkeys. At Nowgong,
from February to August, 191 bedbugs were in-
jected into a monkey, while a second monkey re-
ceived 397 young bedbugs subcutaneously. In these
experiments only a negative result was obtained. In
the third, the leishmania was found in only two
bedbugs, still recognizable at the end of twenty-
four hours. To sum up, it can be said that it is
hardly probable that the cimex can inoculate the
leishmanioses. The recent experiments of Gachet,
in Persia, show serious evidence in favor of their
transmission by diptera in conformity with the
generally accepted beHef.
Sangiorgi observed that living trypanosoma in
the digestive tube of the bedbug retained their entire
virulence at the end of three to four days. Brumpt,
experimenting with the Trypanosoma cruzi, observed
that this parasite underwent its evolution easily in
the digestive tube of the Cimex lectularius and
Leptocimex boueti. These insects became infected
in the proportion of one hundred per cent. The evo-
lution of the parasites takes place much more
rapidly than in the conorhinus, which in America
are the normal hosts and the ordinary agents of in-
oculation in man. The evolution of the parasite
takes place especially in the terminal portion of the
intestine and nearly in the state of a pure culture.
The dejections of bedbugs of all ages, kept fast-
1084
MEDICINE AND SURGERY IN THE ARMY AND NAVY.
[New York
Medical Journal.
ing in an oven at a temperature of 25° C, contain
the trypanosoma for at least ten to fifteen days.
Injected into young rats the organism produces ex-
perimental infection.
epilation, or Chagas's disease, which is caused by
Trypanosoma cruzi, subsequently may be inocu-
lated by the cimex as agent.
Typhus fever and the bedbug no longer are re-
lated, because since the important researches of
Nicolle and his associates at the Pasteur Institute
at Tunis this disease has been proven to result from
the bites of the Pediculus vestimenti.
It will, therefore, be seen that for the time being,
at least, the Cimex lectalarius does not occupy any
place in the spread of infectious disease and conse-
quently this detestable insect need not be considered
as a pathogenic agent.
HANDLING THE WOUNDED IN BATTLE.
Captain R. J. Manion, of the Canadian Army
Medical Corps, is a Canadian physician who has put
into type his experiences during more than two
years of service as a physician on the fighting line.
The book (A Surgeon in Arms, by Captain R. J.
Manion, M. D., M. C. : D. Appleton & Co.) is one
of human interest, not a scientific work. It tells
just what happens to the surgeon in arms, what he
sees, hears, feels. Only in a general way does it tell
what he does. The manner in which the wounded
are handled in battle is told, however, clearly and
succintly as follows :
Suppose a soldier is hit by a piece of shell or
sniper's bullet while he is in a trench which his
battalion is holding. He is first attended by the
stretcher bearer nearest to him at the time, who
should use the man's own aseptic dressing which
each soldier is compelled to carry in the lining of
his coat or tunic. The injured man is then taken to
the dugout of the medical officer, if necessary on a
stretcher, where the medical officer rearranges the
dressing, gives a dose of morphine if pain is severe,
and after seeing that all hemorrhage is stopped and
the man is comfortable, he hands the case over to
the field ambulance stretcher bearers who always
serve him and live in an adjoining dugout. This
squad carries the case back — through the trenches
if there is no hurry, but overland if haste is im-
portant— to the advanced dressing station of the
field hospital. If this should be a particularly hard
trip it may be done in relays, for there relay post
dugouts are established with other bearer squads.
The advanced dressing station is usually situated
a mile or so in the rear of the trenches, preferably
in a large cellar, but at any rate in a fairly well
sheltered area where cots are ready to receive fifty
or more patients. At the advanced dressing station
one or two of the medical officers of the field hospi-
tal are stationed with a large staff of men. The
patient is here made comfortable ; given coffee or
cocoa ; name, number and battalion recorded ; and
finally he is inoculated with antitetanic serum. This
has practically wiped out tetanus, or lockjaw, which
was very prevalent at the beginning of the war. He
is kept here till a convenient time, which may be
after dark, when he and any others who may have
come in are put into ambulances and taken to the
main dressing station of the field hospital, another
two or three miles behind.
The main dressing station may be in some old
chateau, or in a group of huts, or, if the v/eather is
mild, in tents. Here a light case, or slightly
wounded man, may be kept for a few days and then
sent back to the line or to a rest station to recover
his stamina and quiet his nerves. But if the case
should be a serious one, such as a shattered leg or
arm or a large flesh wound that will take a consid-
erable time to heal, he is again transferred by am-
bulance to the casualty clearing station (in the
American Army evacuation hospital) another two
to four miles back.
The casualty clearing station, usually in huts or
tents, is the first j-eal hospital behind the firing zone.
It may have accommodation for a couple of hun-
dred patients ; is supplied with x ray equipment, a
well arranged operating room with expert surgical
assistance, and is the nearest place to the line that
trained nurses are sent. Here for the first time
since he left the line the patient gets all those little
motherly attentions that only a woman can give.
The injured man may be kept here days, weeks, or
even months if he happens to be a case that would
be endangered by moving. All immediately neces-
sary operations are at once performed, and often a
seriously wounded man from the firing line may be
lying anesthetized on the operating table of a
casualty clearing station, being operated upon by
expert surgeons within two or three hours of re-
ceiving his injur)' — practically as good attention as
this type of injury would receive in civil life.
This is particularly the case where a man has
been wounded in the abdomen, from which wound
he may quickly develop peritonitis and reach the
valley of the shadow of death in a few hours if
prompt attention is not given. It is also done in
cases of head or lung injuries, or in any wound
causing uncontrollable hemorrhage. In any of these
emergencies, after the medical officer in the line has
given all immediately necessary attention, the pa-
tient is ticketed "serious" by him, and he is rushed
with all speed to the advanced dressing station,
perhaps at great personal risk to the stretcher
bearers. Here he is quickly transferred to an am-
bulance which may have to rush him over heavily
shelled roads, missing the main dressing station
altogether, and taking him direct to the casualty
clearing station for his life saving operation.
After varying periods in the casualty clearing
stations the patients are sent by ambulance trains,
which run almost to their doors, to base hospitals at
the rear. From here they are retransferred to
hospital centres in England and Scotland.
So much for the methods used in caring for the
wounded in the lines during stationary periods.
The same principles and methods are employed dur-
ing big advances, but of course on a larger and
more thorough scale. All the arrangements are
mjide during the weeks preceding a push; extra
stretcher bearers are trained ; the field ambulances
increase their staffs, particularly just behind the
firing lines, in order that the field may be cleared of
wounded at the first lull in the fightitig. The whole
December 21, 1918.] MEDICINE AND SURGERY IN THE ARMY AND NAVY.
intricate system is so complete and so well arranged
that hundreds of cases may be rushed through in
a few hours, some of them being comfortably in
bed in English hospitals the evening of the day on
which they received their "Blighty."
It must be remembered that in actions of a severe
nature, such as great advances, the first object of
the advancing troops is to obtain their objective and
to hold it. Therefore care of the wounded may not
be possible till the action is over. But during these
hours the wounded are by no means without atten-
tion. It is here that the battalion stretcher bearers
do their finest and most self sacrificing work. They
go "over the top" with the fighting troops, and as the
men are hit it is their duty to give them first aid,
while the fight 'jtill goes on, with machine gun bul-
lets whistling by their ears and shells bursting all
about them. Their duty it is, and nobly they per-
form it, to dress the wounded, stop bleeding if pos-
sible, and temporarily set fractures. Then they
place the wounded men in the most protected side
of a shell hole, or in any other sheltered spot, and
pass on to the next needy one, after placing any bit
of available rag on a stick or old bayonet to attract
the attention of the field clearing parties who come
over that area. In the meantime the wounded who
can walk — walking cases — make their way to the
point at which the medical officer is caring for the
injured. After getting the required attention, they
walk on back to the advanced dressing station of
the field hospital.
At the first lull in the fighting it is the duty of the
medical officer to see to the clearing of the field of
those wounded v/ho cannot walk. Any men going
to the rear for supplies, and any German prisoners,
are commandeered by the medical officer as stretcher
parties. In big actions his own trained stretcher
bearers are employed only as dressers. In the battle
of Vimy Ridge which began at 5 130 a. m., it was
twelve hours later ere all the wounded on our front
were evacuated to the field hospitals. That was
quick work when one considers that some battalions,
mcluding my own, had thirty-five per cent, of their
men hit. One hundred German prisoners were
sent up under escort to act as stretcher bearers, and
gradually the field was cleared.
Location of Chief Surgeons at Close of War. —
When the armistice was signed the United
States had in France the First and Second Army,
the First, Second, Third, Fourth, Fifth, and Sixth
.Army Corps and forty-two complete divisions.
To each army corps and to each division was as-
signed a surgeon general, following the classification
of the British Army. The following is a complete
list of these surgeon generals :
First Army, chief surgeon. Colonel Alexander
N. Stark ; Second Army, chief surgeon, Colonel C.
R. Reynolds; Third Army Corps, surgeon general,
Colonel James L. Bevans ; Fourth Army Corps,
surgeon general. Colonel George H. Gosman ; Fifth
Army Corps, surgeon general. Colonel William R.
Eastman, and Sixth Army Corps, surgeon general,
Colonel Bailey K. Ashford.
Following is a list of the names of the division
■surgeons of the respective divisions:
First division, Lt. Col. Flerbert B. Shaw; second,
Col. John W. Hanncr; third, Lt. Col. William H.
Eastman ; fourth, Lt. Col. Robert L. Carswell ;
fifth, Lt. Col. Robert H. Fierson ; sixth, Lt. Col.
Paul L. Freeman ; seventh, Lt. Col. AUie W. Wil-
liams ; eighth, Lt. Col. Lloyd L. Smith ; twenty-
sixth, Lt. Col.' Ralph C. Porter ; twenty-seventh,
Lt. Col. Edward R. Malony ; twenty-eighth, Wil-
liam J. Brookston ; twenty-ninth, Lt. Col. John B.
Muggins; thirtieth, Lt. Col. Arthur W. Whaley ;
thirty-first, Lt. Col. Charles W. Decker ; thirty-sec-
ond, Lt. Col. Gilbert E. Seaman ; thirty-third. Col. L.
M. Hathaway; thirty-four, Col. Jacob M. Coffin;
thirty-fifth, Lt. Col. W. T. Davidson; thirty-sixth,
Lt. Col. A. T. Metcalf ; thirty-seventh, Lt. Col. Joseph
A. Hall ; thirty-eighth, Lt. Col. Robert M. Blanchard ;
thirty-ninth, Lt. Col. Larus D. Carter; fortieth, Lt.
Col. Alexander Murray ; forty-first, Lt. Col. Orvill
G. Brown; forty-second, Lt. Col. D. S. Fairchild;
seventy-sixth, Lt. Col. William A. Powell ; seventy-
seventh, Lt. Col. Chas. R. Reynolds ; seventy-eighth,
Col. George M. Ekv/urzel ; seventy-ninth, Lt. Col.
P. W. Huntington ; eightieth. Col. Thomas L.
Rhodes ; eighty-first, Col. Kent Nelson ; eighty-sec-
ond. Col. Conrad E. Koerper ; eighty-third. Col.
Wallace De Witt; eighty-fourth. Col. John H.
Allen; eighty-fifth, Lt. Col. Cosam J. Bartletts ;
eighty-sixth. Lt. Col. Jos. W. Phalen ; eighty-
seventh. Col. Robert M. Thornbury ; eighty-eighth.
Col. Ray R. Shook; eighty-ninth, Lt. Col. John L.
Shepherd; ninetieth, Lt. Col. Paul S. Halloran ;
ninety-first, Col. Peter C. Field ; ninety-second, Lt.
Col. Perry L. Boyer.
The Civilian War Ration.— Dr. Paul Roth, of
Battle Creek, Mich., read a paper at the June meet-
ing of the American Medical Association in Chicago
in which lie presented a very exhaustive study of
the efl.'ects of a reduced daily food allowance made
on twenty-five students of the Y. M. C. A. College
at Springfield, Mass. The research was conducted
under the auspices of the Carnegie Institution of
Washington, under the supervision of Dr. F. G.
Benedict, director of the Nutrition Laboratory of
Boston and the collaboration of Dr. Walter R. Miles
and Dr. H. Monmouth Smith, of Boston, and Doctor
Roth. Prior to the reduction of the food allowance,
the normal demand of the subjects ranged from
3,200 to 3.600 calories a day ; by a radical reduc-
tion in the food allowance a ten to twelve per cent,
tall of body weight was obtained in from three to
ten weeks. At this lowered metabolic level, the
subject required, on the average, 2,300 calories a
day to maintain the lowered body weight at a
constant level. This represents a reduction of over
thirty per cent, in food reqtiirement. Diverse ob-
servations on the energy expenditures of the sub-
jects likewise show a decided alteration, indicating
clearly that they were able to maintain their
usual physical and mental activities with an econ-
omy of both the food requirements and of the cor-
resjwnding expenditure of energy of approximately
twenty to thirty-three per cent. Twelve subjects
maintained their usual activities for a period of
three weeks on an allowance of only 1,400 calories
a day. These results should have a practical bear-
ing on the present economic situation.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. ne M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT FUBLISHING COMPANY,
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Cable Address, Medjour, New York.
NEW YORK, SATURDAY, DECEMBER 21, 1918.
MEDIUMS AND HYSTERIA.
War always brings with it a wave of renewed
interest in spiritualism, that is, commtinications,
real or supposed, with the spirits of the departed.
We are in the midst of such a wave at the pres-
ent time, and it is well to recall that in the past a
good many of the exposures of so called mediums
have been made by physicians. It would seem
to be a distinct professional duty not to permit
poor, suffering people to be imposed upon, whose
profound sense of loss and deep mourning for
their departed so often make them the easy vic-
tims of designing persons.
There may be a modicum of something inex-
plicable in spiritualism, but it has surely a very
slight degree of seriousness. Sir Oliver Lodge's
recent book is a pathetic demonstration of how
little it takes to convince a man who wants to
believe certain mysterious things. Sir Arthur
Conan Doyle's book is, without doubt, amusing;
what he accepts as the New Revelation and the
evidence for it is a proof of his credulity, but not
at all of the propositions which he advances. Ver-
ily, trifles light as air become proofs as strong as
gospel for those who want to believe in them.
The recent death of Madame Palladino brings
to mind the number of times she had been ex-
posed. In spite of these exposures, scientific
men still continued to believe — because they
could not explain some of the things that hap-
pened in seances with her — that they were inex-
plicable on any but supernatural grounds. What
is needed to catch a tricky mediimi, however, is
not a scientist, whose expectant attitude of mind
is the wrong one for these experiments, but a
conjuror who knows how easily people may be
misled, and with what simple means it can be
done, if only the conditions are favorable.
We would not stamp all mediums as conscious
and deliberate tricksters, however. There is un-
doubtedly another extremely important element
\vhich often enters into these cases and which
makes them of particular interest to the physi-
cian, ^lany so called mediums present distinct
stigmata of hysteria, and not a few of them can
be readily recognized as presenting that charac-
teristic emotional makeup from which hysteri-
cal manifestations so often proceed. This is the
element the physician can best understand. Bet-
ter than any one else does he realize how far hys-
terical patients will go in order to secure for
themselves the publicity usually accorded the
successful medium. There is quite literally no limit
to which persons of this character will not venture,
if thereby they can secure the reputation of having
supernatural powers. To have it announced that
they are channels of communication with the
other world gives them a sense of satisfaction for
which no amount of trouble would be too great
to compensate. To be the very focus of at-
tention and the subject of an investigation on the
part of men of science would appeal so strongly
to their morbid inclinations as to push them to
the fullest extent of their ingenuity, in order to
maintain it. This element in mediumship has
never been properly exploited. Now that the
war is making neuroses of many kinds so much
more interesting — one third of all the discharges
from the British army, apart from wounds, have
been for shell shock, and a considerably larger
proportion of officers than of men in the ranks
have been taken by it — the study of this phase of
the subject of spiritualism well deserves the atten-
tion of scientists.
Medical history is full of examples of hysteri-
cal patients who have deceived their relatives.
December 21, 1918.]
EDITORIAL ARTICLES.
friends, neighbors, and even their physicians.
The older medical literature abounds in cir-
cumstantial details, for instance, of the vomiting
of live mice and of otlier interesting zoological
specimens, usually not counted in the fauna of
the digestive tract. Indeed, the number of living
things that were supposed, for a time, at least, to
have had their habitat somewrhere on the inside
of hysterical women is rather large. As for skin
lesions, physicians have described the most bi-
zarre conditions as occurring in hysterical cases,
until it seemed as though the mind could pro<fuce
almost any kind of pathological effect on the
skin. After a time it was of course discovered
that, in these cases, ammonia, or some mineral
acid or other strong escharotic, was the active
agent at work. Just imagine for a moment some
one, with hysterical tendencies similar to those
of these patients, being selected as a medium.
What a riot of selfsatisfaction would she not
have in producing all sorts of manifestations!
How she would gloat over the notoriety thus
given her! How she would plan and scheme to
produce other and more startling effects, and yet
all the while she would be doing something for
which, according to our present view of these
cases, she would be not quite responsible. While
so ingeniously and deliberately deceiving others,
she would in a certain sense be deceiving herself
also ; besides there would be no special fear of dis-
covery nor any nervousness on her part which
would facilitate detection, for she would have no
scruples about the matter at all.
Here is a phase of spiritualism that in the pres-
ent renewal of interest in it should have a special
appeal to the physician. A good many of the
mediums are proper subjects for treatment rather
than for such admiration and attentive investiga-
tion as will pander to their morbid tendencies
and make them exercise their ingenuity until
they become more and more adept in deception.
The tendency to pseudologia hysterica, or con-
fabulatio phatitastica is well known in the recent
development of our knowledge of hysteria, but it
is under dramatic circumstances particularly that
these patients like to play an important role. The
reports of young girls found gagged and tied in
their homes every year are so frequent that,
through a little investigation, it is made clear
that they are the victims of their own romancing
imagination only.
One of the difficulties with regard to the
rejection of a great deal of evidence for spiritual-
ism has been that it could only be done by assum-
ing that many mediums were conscious trick-
sters. The physician who knows how many
hysterical people there are in the world will have
little difficulty in understanding this. They are
not all merely sordid counterfeiters who are taken
up entirely with the money that there may be in
it for them ; a great many of them are neurotic
persons, seeking an outlet for their dramatic hys-
terical instincts. They would not play their part
so well nor carry ofif their deception so success-
fully if conscious trickery was the only element
in it. Many after a time come to believe in them-
selves and their manifestations. It is, above all,
the person who deludes himself or herself, as the
case may be, and thoroughly believes in himself,
who most successfully deludes others.
SOME NOTES ON RUPTURED SPLEEN.
We shall not take up space here reviewing our
knowledge of the anatomy, physiology, and path-
ology of the spleen ; what little is known of these
subjects is sufficiently well known. But a recent
contribution to the literature tells us something
about a condition, rare in peace times — rupture of
the spleen. In the British Medical Journal for
September 14th, Captain R. Jamison, of the Royal
Army Medical Corps, reports six such cases. In all
these cases considerable trauma had occurred ; in-
deed, in half of them the injury had been caused by
the kick of a mule, than which, according to cavalry
tradition, there is nothing more powerful.
The condition of these patients becomes quite
serious immediately following the accident ; there
is severe pain and collapse. About an hour later
there is a temporary improvement, followed by an
increase in pain and the symptoms of internal
hemorrhage. The diagnosis may ordinarily be
made by the history of the injury, the location of
the bruise, and the site of the pain. It cannot al-
ways be told whether it is the spleen or omentum
which is affected, but an operation is indicated in
either case, so that it is not a matter of great mo-
ment.
The oj>eration is conducted through a vertical
tliree inch incision about one inch to the left of the
middle line, its lower end being at the level of the
umbilicus, and if the spleen is found ruptured this
incision is extended upward. The spleen is de-
livered through this opening. After tearing the
ileorenal ligament this pedicle is ligated and the
whole organ removed. Nearly all of these rup-
tured spleens were found to be larger than normal.
The effects on the patient of complete removal
of this organ, as recorded, were particularly inter-
esting. As far as information could be obtained no
bad results were noted. A very high leucocytosis
io88
EDITORIAL ARTICLES.
[New York
Medical Journal^
occurred rapidly, the count varying from 12,000 to
45,000. Late hemorrhage may occur, in one case
of the series profuse bleeding developed ten days
after the operation. This was easily checked by
ordinary methods.
While rupture of the spleen is not likely to hap-
pen under peace conditions, except in malarial sub-
jects, all the information bearing on the function
of this organ -wt can obtain is welcome, and it is
hoped that the six soldiers who ofYered up their
spleens on the altar of democracy will report from
time to time for examination into their general
health.
VACCINE AND SERUM THERAPY.
Vaccine and serum therapy have reached the stage
of reaction from that enthusiasm with which new
remedies and new methods are always welcomed.
Human nature has not changed materially since
Paul upbraided the Romans for their love of nov-
elty. Every new remedy is welcomed with an en-
thusiasm which stimulates expectation beyond the
bounds of possibility. The passage of time and
cooler observation prove the fallacy of the extrava-
gant hopes raised and in the reaction there is danger
that some really valuable method or substance
may be discarded ; not because it is valueless but
because it does not accomplish all that its too
sanguine proponents had expected of it. Really
valuable remedies are apt to outlive this period of
reaction and eventually win a just valuation.
Captain A. Geoffrey Shera, of the Royal Army
Medical Corps, comes forward {Vaccines and Sera
— Oxford War Primers] with a plea for the just
appreciation of the real value of vaccines and sera
as therapeutic agents as well as for prophylaxis.
The definite results achieved with diphtheria anti-
toxine both in prophylaxis and therapeutically and
by antityphoid vaccination in prophylaxis gives hope
that equally favorable results may be produced by
vaccine and serum therapy in other fields. But
many practitioners have been so badly disappointed
that they have foresv/orn all other vaccines and sera.
Captain Shera is convinced that the failures
noted are due to lack of appreciation of the high
degree of specificity of bacterial infection. He urges
the advantages of autogenous vaccines and of the
use of mixed rather than of pure strains of such
vaccines. That is, he condemns the practice of
isolating the strains of infecting bacteria found and
the use of such isolated strains. He acknowledges
the need for resorting to stock vaccines in certain
circumstances but even then advises that local stock
vaccines be used. For instance when boils become
epidemic in a hospital prophylactic inoculations
against them are helpful. But the stock vaccines
used should be prepared from the strains of bacteria
found in that particular hospital at that particular
time. *
The choice of the agent to be used, whether
vaccine or serum, requires a very clear understand-
ing of the nature of the infecting agent and of its
reactions. In some circumstances a serum, which
contains antibodies, should be used ; in others a
vaccine which contains toxines but no antibodies is
preferable. In any case nature must not be hurried.
Th^ organism must be given ample time between
each injection to elaborate defensive antibodies.
All this means that the administration of vaccines
and sera offers hope in many conditions which are
otherwise hopeless, but they must be prepared and
used with a wide and accurate knowledge of
pathology and bacteriology and they cannot be relied
on for mere rule of thumb administration.
TREATMENT OF CHRONIC RHEUMA-
TISM BY INTRAVENOUS INJECTIONS
OF COLLOIDAL SULPHUR.
Drugs and therapeutic measures in use at pres-
ent for the cure of chronic rheumatism offer un-
questionable relief, but improvement is merely
temporary and the progressive march of the dis-
ease continues. A substance that has for a long
time been studied by Robin and Maillard, and
most deserving of attention in chronic rheuma-
tism, is sulphur, a substance found in consider-
able quantities in the body elements in company
with other substances.
Although the respective proportion of each of
these substances in the organism is very unequal,
as to its mass, the progress made in physiologi-
cal chemistry demands recognition of the essen-
tial nature of all, because those which appear in
lesser amount are not always the least inactive
or least important for the ensemble of the
reactions constituting life. Sulphur is contained
in the human body in greater amount than iodine
and is much more generally diffused throughout
the tissues. The trophic importance of this met-
alloid lies in the fact that it forms an integral and
necessary part of all albuminoid matter of the
hitman organism. There is not a cell or a protein
molecule which can exist without sulphur, and
the majority of proteins contain from one per
cent, to two per cent, of the metalloid.
Sulphur is present in the acids which partici-
pate in the structure of the most active glands as
well as in the most delicate structures of the
nervous system. The metalloid is found in the
cartilaginous tissue in the form of sulphuric
December 2:,
EDITORIAL ARTICLES.
chondroitin, while its presence gives to the con-
nective tissue special properties which character-
ize the cartilage and explain the important part
played by sulphur in maintaining the normal con-
dition of the joints. Beside the minute quantity
of sulphocyanate contained in the saliva, it should
be recalled that there is a large amount of sul-
phur in the hepatic secretion. The bile contains
this metalloid in the form of divers taurins, re-
sulting from the oxidation of cysteiu, and these
circulate in the liver and intestine combined in
the state of sodium taurocholate. Its part as an
antitoxic agent of the body is of the utmost im-
portance because it arrests, in the liver, a series
of toxic products coming from the intestine, such,
for example, as aromatic substances, with which
it forms sulphuric ethers eliminated by the kid-
ney. Urochrome, the normal yellow substance
of the urine which belongs to the group of oxi-
proteic acids, is also rich in sulphur.
Given these data and knowing that chronic
rheumatism is a disease of the nutrition with a
more or less marked organic decay, it may be
logical to assume that sulphur is wanting in the
protein substances composing the tissues and
parenchymata. It is probably for this reason that
the treatment of this affection at sulphur baths
has been fairly successful for ages past. Of late,
thanks to the progress made in chemical science,
sulphur has been exhibited in the form of col-
loidal sulphur. The preparation may be given
by mouth or subcutaneously, but both these have
given indefinite results, and it is for this reason
that the intravenous route has been resorted to
by Maillard and others, with excellent results.
The solution of colloidal sulphur employed is
an opaque whitish fluid, and when allowed to rest
offers a slight deposit which disappears on shak-
ing. The solution contains 33/100 of a milli-
gram of active principle per cubic centimetre.
The injections are given daily in the dose of one
c. c. on the first day, on the second one and a half
c. c, on the third two c. c, and this dose is con-
tinued until the tenth injection is reached. An in-
terval of ten days is allowed and then a second
series of injections is given. Colloidal sulphur elim-
inates the pain, but does not appear to have any ac-
tion on existing deformities of the joints. It causes
a temporary leucocytosis and raises the arterial
tension, and it acts rapidly in cases where other
medication has failed. Colloidal sulphur is ad-
vised by Maillard and others because the metal-
loid is more assimilable in this form, and it is
given intravenously because the medicament is
more completely and rapidly absorbed and its
action more rapid.
It should be pointed out that a more or less in-
tense chill will occur about fifteen minutes after
the injection, but without any elevation of the
temperature. The patient should not take any
food for two hours before the injection, other-
wise vomiting is likely to occur.
THE UNCONSCIOUS PATIENT.
In the presence of two kinds of patients the
physician does well to be cautious of his speech,
namely, the supposedly moribund and the pre-
sumably anesthetized. Because the patient seems
unconscious it is by no means certain that he is
not aware of much that is taking place about him
and that he does not know what is being said in
his presence.
We think most physicians of experience are,
sooner or later, surprised by the keenness of
hearing of the patient who is being anesthetized,
when to all appearance he has become quite un-
conscious. This sharpness of sense seems akin
to that of the partially deaf whose organs of
hearing seem dull enough to the sounds we would
have him hear, but are, someliow, exceedingly
acute for impressions which we do not anticipate
will reach his seat of consciousness. A victim
of cerebral disturbance, though incapable of
speech or of motion, will sometimes understand
everything that is said in his presence. A pa-
tient of our acquaintance, apparently unconscious
in a seeming fatal attack of cardiac asthma, re-
covered to reproach the two physicians in attend-
ance with some remarks which they would gladly
have unsaid. The tongue is an unruly member
and until a patient is actually dead the tongues
of those about him would better be kept under
HEROES ON PARADE.
While the sincerity of the gratitude of the citizens
of the United States for the sacrifices made by our
soldiers is unquestioned, the restrictions placed
upon the troops returning from abroad make the
expression of that gratitude somewhat difficult. We
had pictured, and letters from the soldiers overseas
evidently indicated that they too had pictured, Fifth
xA. venue alive with banners and resonant with cheers
when the boys came marching home. Instead of
ihis we find that the returning heroes are cut off
from communication with their friends and rela-
tives, hurried out to Camp Merritt, Camp Mills, or
Camp Dix for demobilization, and there given their
discharges, and allowed to drift homeward unhon-
ored and unsung. We fail to see any good sanitary
reason why these men should not be given the priv-
ilege of marching up Fifth Avenue before being dis-
banded. It is true, of course, many of them come
over in small detachments and that any parade that
might be arranged for without too great loss of time
I090
NEIVS ITEMS.
[New York
Medical Journal.
would consist of a number of isolated detachments
not previously trained together. While such a
parade might be less impressive from a military
point of view than would a parade of a complete
division or complete regiments, it would be even
more interesting to the public and would be much
appreciated by the citizens of New York, who are
anxious to see and do honor to the men who have
served their countrj;- so gallantly. It is not yet
too late for the military authorities to adopt some
such plan and thus give the men who have marched
so bravely through Flanders fields and Argonne
forests amid a storm of bullets, the gratification of
marching up Fifth Avenue amid the plaudits of
iheir grateful and admiring countrymen.
APPROBATION FROM SIR HUBERT.
In a summary of the operations of the United
States forces in France, made public by the Secre-
tary of War in his annual report, General Pershing
takes occasion to praise the work of the Medical
Corps of the Army in the following terms : "Our
Medical Corps is especially entitled to praise for the
general efifectiveness of its work, both in hospitals
and at the front. Embracing men of high profes-
sional attainments, and splendid women devoted to
their calling and untiring in their efitorts, this de-
partment has made a new record for medical and
sanitary proficiency." It is impossible of course to
give at this early date accurate statistics regarding
the incidence of disease throughout the war, but the
statistics so far available show that the proportion
of recoveries after wounds is much higher than ever
iDefore in the history of the world. Of the
wounded who reach the first aid stations, ninety
per cent, recover, and of those who reach the base
hospital ninety-five per cent, recover. During the
Napoleonic wars fully sixty per cent, of the
wounded died, and during the Civil War from
twenty to forty per cent, of the wounded died. The
incidence of disease has been lowered to such an
-extent that life in the army is safer than among
civilians, so far as disease itself is concerned ; and
even including deaths from wounds, the death rale
in the army is lower than the general death rate
among civilians sixty years ago. In view of these
facts, General Pershing's praise of the work of the
Medical Corps is well deserved.
^
News Items.
Section in Obstetrics and Gynecology Post-
pones Meeting. — There will be no meeting of this
section in December, but the January meeting
will be held as usual on the fourth Tuesday of the
month.
A Directory of Health Authorities. — The
United States Public Health Service has published
a directory of State and insular health authorities
giving the names and addresses of the principal
officials and the sums which are annually appro-
priated for the expenditure of each particular board
or organization. Copies may be obtained by ap-
plying to the superintendent of public documents at
Washington, D. C.
Change of Address. — Dr. Matthias Lanckton
Foster, of New Rochelle, N. Y., has returned from
active service with the Medical Corps of the United
States Army and has resumed practice at a new
address, 48 Centre Avenue.
Health Cartoons. — The Illinois State Depart-
ment of Health is issuing a series of public health
cartoons, a loan exhibit of which will be sent
throughout the State. Electrotypes of a size suit-
able for the use of periodicals will be supplied
without charge to newspapers, medical journals,
and similar publications, bv the assistant director
of the department, whose oflices are in Springfield.
Forty-one Years After. — On October i, 1918,
Colonel Louis M. Maus, Medical Corps, United
States Army, retired, was awarded the Distin-
guished Service Cross for specially meritorious
service rendered on the Belle Fourche River, N. D.,
on November 5, 1877. While a first lieutenant and
assistant surgeon, serving with a detachment sud-
denly surrounded bv an overwhelming force of
hostile Sioux Indians, he succeeded in extricating
the party from a most perilous position.
Distinguished Service Cross. — The Distin-
guished Service Cross has been awarded to three
pharmacists' mates in the navy. These are Chief
Pharmacists' Mate Robert S. Cochrane, of Hich-
burg, S. C. ; Pharmacists' Mate, Third Class,
George Douglas Witt, of Harrington, Wash. ; and
Pharmacists' Mate, Third Class, Frank R. Yates,
of Alturas, Cal. All three of these men were at-
tached to the Sixth Machine Gun Battalion, United
States Marine Corps.
Regional Secretaries for the Tuberculosis As-
sociation.— The National Tuberculosis Associa-
tion has announced that it will put into the field
regional secretaries to open branch offices in differ-
ent sections. As soon as possible secretaries will be
appointed for the Central or Mississippi Valley
States, with headquarters at Chicago ; for the
Northwestern States, with headquarters at Spokane,
Wash. ; for the Southern States, with headquarters
at Birmingham or Atlanta, and for the New Eng-
land or North Atlantic States, with headquarters at
New York. The primary function of these secre-
taries will be to bring the antituberculosis agencies
in the various districts into closer harmony with
each other.
More State Hospitals Needed. — The State
Charities Aid Association has published a report
directing attention to the serious overcrowding of
the State hospitals for mental diseases. The thir-
teen hospitals have a normal capacity of 28,997
patients, but at the end of the fiscal year, had 35,462
patients, or 22.3 per cent, more than the normal
capacity. There have been approximately 6,000
more than the normal accommodations provided,
for a number of years. Building operations have
been held up on account of shortage of labor and
materials due to the war. Hospitals at the follow-
mg points have already been provided for, but their
construction is awaiting the resumption of normal
conditions : Creedmoor ; Marcy, near Utica ; an in-
stitution in the metropolitan district to take the
place of the iVIohansic institution, and a psycho-
pathic hospital in New York.
December 21, 1918.]
NEWS ITEMS.
Women Bacteriologists. — It is said that there
are thirty-nine women bacteriological hospital aids
in various public health institutions throughout the
United States. Manj' of these women are work-
ing in mditary hospitals.
Medical Society of the County of New York. —
Dr. Charles H. Peck was elected president of this
society at the annual meeting held on Monday even-
ing, November 25th, and other officers were elected
as follows : Dr. Charles H. Chetwood, first vice-
president ; Dr. George Gray Ward, Jr., second vice-
president ; Dr. Samuel S. Dougherty, secretary ; Dr.
J. Milton Mabbott, assistant secretary ; Dr. James
Peterson, treasurer.
Medical Problems in Aviation. — At a stated
meeting of the New York Academy of Medicine,
held Thursday, December 19th, the evening was de-
voted to a discussion of some of the medical
problems involved in aviation. Lieutenant Colonel
E. G. Siebert delivered an address on the Field of
the Medical Research Laboratory at Mineola,
Major Lewis Fisher spoke on the Practical Value
of Ear Studies and Captain H. W. Lyman spoke on
the Ear and the Aviator. Moving pictures illus-
trated all three addresses.
New Army Hospitals Planned — Assistant Sur-
geon General Stimson, of the United States Public
Health Service, has requested appropriations
amounting to $26,000,000 for hospitals providing
13,000 beds for discharged sick and disabled sol-
diers. Preliminary appropriations amounting to
$10,000,000 providing for 5,000 beds have been re-
quested of the present Congress. It has been de-
cided to establish one of these hospitals at Norfolk,
Va., and one at Seattle, Wash. Others have been
planned for Massachusetts and North Carolina.
Additions also are to be provided for at the marine
hospitals at Boston, Chicago, Cleveland, Detroit,
Evansville, Louisville, New Orleans, San Francisco,
St. Louis, and Wilmington, N. C, and at the Fort
Stanton, New Mexico, Sanatorium. Their construc-
tion would cost $10,000,000 and provide 5,000 beds.
The Annual Report of the Surgeon General. —
The annual report of the surgeon general for 1918,
has just been issued. It contains a comparative
study of the health of the army, 1820-1917; an ac-
count of the health of the mobilization camps and
of the army by countries ; a consideration of the
principal epidemics in the camps ; and a discussion
of fractures and operations. Nearly 200 pages are
devoted to the special activities of the medical de-
partment : with the American Expeditionary Forces,
and in the divisions of sanitation, hospitals, supplies,
laboratories and infectious diseases, internal medi-
cine, general surgery, orthopedics, head surgery,
neurology and psychiatry, psychology, food and the
Dental and Veterinary Corps. In addition to the
usual tables of illness, discharge for disability and
death, there are given tables of battle wounds and
operations ; of complications of various diseases and
of case mortality. The text is illustrated by sev-
enty-three charts. Altogether the report is a study
of health and morbidity in an army of over l,-
500,000 men, for the m.ost part yet in the period of
training. It should be of interest to epidemiologists,
vital statisticians and army medical men.
New Officers of the Academy of Medicine. — At
the annual meeting of the New York Academy of
Medicine, held Thursday evening, December 5th,
Dr. George David Stewart was elected president, to
succeed Dr. Walter B. James, who was made a
trustee. Dr. Reginald H. Sayre and Dr. Charles H.
Peck were elected vice-presidents ; Dr. Royal S.
Haynes, recording secretary.
Medical Society of the District of Columbia. —
At the annual meeting of this society, held in Wash-
ington on December 4th, the following officers were
elected to serve for the year 1919: President, Dr.
William Gerry Morgan ; first vice-president. Dr.
Ada R. Thomas ; second vice-president. Dr. A. R.
Shands ; recording secretary, Dr. H. C. Macatee :
corresponding secretary, Dr. J. Russell Verbrycke.
Jr. ; treasurer. Dr. C. W. Franzoni. Dr. A. W.
Boswell, Dr. Philip S. Roy, and Dr. Charles S.
White were elected members of the executive com-
mittee for a term of three years.
Medical Society Meetings to Be Held in New
York. — Meetings of medical societies will be held in
New York during the coming week as follows : Tues-
day, December 24th, New York Academy of Medi-
cine (Section in Obstetrics and Gynecology), New
York Dermatological Society, New York Medical
Union, Metropolitan Medical Society of New York
(annual), New York Psychoanalytic Society, River-
side Practitioners' Society, Therapeutic Club Valen-
tine Mott Society, Washington Heights Medical So-
ciety, and the Woman's Hospital Society ; Thursday,
December 26th, Hospital Graduates' Club, New
York, New York Physicians' Association (annual),
Extern Society of Methodist Episcopal Hospital,
Brooklyn ; Friday, December 27th, Academy of
Pathological Society (annual) ; Audubon Medical
Society, New York Clinical Society, Brooklyn So-
ciety of Internal Medicine (annual). Hospital
Graduates' Club, Brooklyn ; Saturday, December
28th, Harvard Medical Society, Lenox Medical and
Surgical Society, New York Medical and Surgical
Society, and the West End Medical Society (an-
nual).
A Diagnosis Hospital in New York. — The New
York Diagnostic Society, organized over a year ago,
announces that plans have been completed for the
erection at 125 West Seventy-second Street, of a
hospital for diagnosis, the first of its kind to be
established in New York. It will be known as the
West Side Branch of the Diagnostic Clinics of the
Academy of Diagnosis. The site and building rep-
resent an investment of $250,000. The building will
consist of six stories and a basement, and will be
provided with the most modern equipment required
for diagnostic investigations and tests, and no pains
will be spared to make it a model for hospitals of
this character. The institution will be selfsupport-
ing and as the work progresses the society hopes to
erect similar institutions not only in other parts of
the city but in other cities throughout the country.
The society was organized largely through the ef-
forts of Dr. M. Joseph Mandelbaum, who is its
president. Other officers are Dr. Monroe Bradford
Kunstler, vice-president ; Dr. Lesser B. Goreschel,
secretary ; Dr. J. Maxwell Van Dyk, treasurer. The
offices of the society are at 330 West 145th Street.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
POLYVALENT SERUM THERAPY IN
CEREBROSPINAL MENINGITIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
(Continued from page 104^.)
Among the most striking clinical observations
that have directed attention to the advisability of
employing polyvalent serum in the treatment of
cerebrospinal meningitis are those of Netter, 1918,
bearing on 347 cases, and some of the details of
which have already been mentioned.
In trying out, in the course of several years,
Flexner's serum, Dopter's serum, and mixtures of
antimeningococcic and antiparameningococcic se-
rums, Netter secured increasingly favorable results,
and controverted, through proper care in adapting
the serums used to the types of meningococcus
pathogenically responsible, the assertions of certain
other clinicians whose results from serum treatment
in cerebrospinal meningitis had been disappointing.
In the year 1916, during which a mixture of mono-
valent serums — each antagonizing a certain type of
meningococcic organisms — was employed in a series
of forty-two cases, the total mortality was at the
rate of 30.9 per cent, but the corrected mortality,
after exclusion of cases where death had occurred
within twenty-four hours or from causes uncon-
nected with the meningococcic infection, was re-
duced to 9.4 per cent. This represented a consider-
able improvement over the results from 1909 to
1914, in which period the corrected mortality had
ranged from ii.i to 28.5 per cent. Again, in 191 7,
thirty-one cases were treated with a mixture of
serums prepared from NicoUe's Types A and B of
meningococcus. Immediate identification of the
type of organism present in each case was under-
taken, and upon receipt of the results of the labora-
tory tests the treatment was limited to the serum
particularly corresponding to the type of organism
identified. In this series of cases there were eight
deaths. Eliminating three deaths which occurred
on the day of the first serum injection, as well as
two deaths due to superadded infection, the mor-
lality was reduced to two cases, or eight per cent.,
practically the same percentage as in the 1916 series
already referred to. A striking feature of the 191 7
series was that, among the eighteen cases in which
the precise type of meningococcus present could be
identified, only four showed an organism of Nicolle's
Type A, i. e., constituting the true meningococcus,
while fourteen belonged to Type B, corresponding
to Dopter's parameningococcus. In eleven addi-
tional cases the meningococci present could not be
identified in spite of actual laboratory investigation,
while in the remaining two no cultures could be
made. The relatively high ratio of vmidentifiable
organisms is emphasized by Netter as in itself show-
ing the necessity of treating every new case with a
polyvalent serum, since definite knowledge of the
kind of meningococcus responsible may be difficult
to obtain.
On the basis of favorable results with mixed
serums, such as those recorded by Netter, the anti-
meningitis serum now prepared at the Institut
Pasteur of Paris for the current use of the French
medical profession consists of a mixture in equal
parts of an anti-A and anti-B serums. Serums
for certain forms of parameningococci, constituting
Nicolle's Types C and D, are also available, but
cases due to these organisms have been very ex-
ceptional in Nicolle's experience, and none are com-
prised in Netter's recent series of patients.
The most recent improvement in the preparation
of antimeningococcic serum, applied by Nicolle and
tested clinically by Netter, consists in the injection
of different types of organisms into the same horse.
A single serum antagonistic to several forms of
meningococci is thus obtained, and the employment
of such a serum in place of a mixture of serums
from difl'erent animals minimized against the vari-
ous meningococcic organisms individually is ad-
vantageous in that the amount of serum injected
therapeutically can be reduced, with a correspond-
ing lessening of the likelihood of serum sickness or
anaphylactic manifestations. Amoss and Flexner
had already succeeded in obtaining, by alternate in-
jection of meningococci and parameningococci into
individual horses, a serum exhibiting marked ag-
glutinating power toward both types of organisms.
Nicolle prepared for Netter's use a serum made by
simultaneous immunization of horses against the A
and B types of organisms.
(To be continued.)
Agglutinating Properties of Sera in Vaccinated
Subjects. — ^Thomas T. O'Farrell (Lancet, No-
vember 9, 1918) draws his conclusions from the
careful analysis of sera from 496 soldiers. In so
far as agglutinins can be taken as a measure of
immunity to infection, immunity is high during the
first three months after inoculation, is moderate be-
tween the fourth and fifteenth months, and is poor
or wanting after the fifteenth month. Reinoculation
should, therefore, be practised after the expiration
of fifteen months. Multiple inoculation has the
effect of yielding a smaller proportion of men who
do not develop immunity, of causing a lesser degree
of immmiity than single inoculation, and of render-
ing the immunity more prolonged. Reinoculation
with mixed T. A. B. vaccine causes a greater rise in
typhoid agglutinins than follows reinoculation with
simple typhoid vaccine, the difference being due to
the presence of the other organisms. Agglutinins
to the paratyphoid A and B organisms are lower
than to typhoid, but follow about the same types of
curves of rise and fall. "This being the case, it is
suggested that the mixed vaccine should be made to
contain one part of typhoid, one of paratyphoid A
and two of paratyphoid B.
December 21, igiS.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
Antiseptic and Cytophylactic Properties of
Iodized Mineral Waters. — G. Billard {Presse
medicak, October 7, 1918) points out that iodine is
not only germicidal, but through its oxidizing power
io capable of attenuating or destroying the toxicity
of toxalbumins such as snake venom and the toxins
of diphtheria and tetanus. As an antiseptic for
mucous membranes he strongly recommends a so-
lution made by adding one teaspoon ful of the official
French tincture of iodine to one litre of Vichy water.
This alkaline water takes up twice as much iodine
as pure water or normal saline solution. Chemical
reactions take place as a result of which there occur
in the solution not only sodium chloride and unde-
stroyed sodium bicarbonate, but also iodates,
alcohol, iodoform, sodium iodide, free iodine,
and dissolved carbon dioxide. Upon wounds a wet
dressing of the solution exerts a marked sedative
and analgesic action ; from the antiseptic standpoint
the solution seems to give, in most instances, results
equal to those obtained with any other agent. In
four or five days healthy granulations appear, and
after this the iodine should not be further used.
Broussegouttes, using the solution in balanoposthitis
with phimosis and with or without chancroid, ob-
served immediate cessation of pain and practical
cessation of discharge in four or five days ; in
sluggish, open buboes, it also proved valuable.
Billard employed the solution with marked success
in the prophylaxis and treatment of contagious dis-
eases, especially diphtheria. The throat is first
painted with iodized glycerin, then irrigated freely
with the iodized solution. This is repeated four or
■more times a day. In about one third of all cases
the false membrane disappears in two or three days
imder this treatment, without the use of diphtheria
ajititoxin. In fact, if the disease is taken at the
start and the solution reaches all tissues covered
-with membrane, recovery will occur nearly always
without the antitoxin ; but the latter should be reg-
ularly used nevertheless. The solution is also rec-
ommended for ordinary throat inflammations and
the sore throats of scarlet fever, measles, grippe,
and even typhoid ; in the last named disease the so-
lution may be taken internally. A silver spoon
should not be used to measure the iodine. The so-
lution should preferably be used fresh; if not, the
bottle containing it should be tightly stoppered.
The Pharmacology of Alcohol. — Robert B.
Wild (Lancet, November 9, 1918) says that the ex-
ternal actions of this drug depend upon its volatility,
its affinity for water, its power of coagulating al-
bumin and its antiseptic properties. It is useful,
therefore, for cooling applications, as a counterirri-
tant when confined or rubbed into the skin, as a
mild antiseptic in dilutions of forty to seventy per
cent., and to harden the skin. By its irritant action
it exerts reflex effects when applied to the mucous
membranes, stimulating the respiration and heart
and arousing consciousness in fainting, etc. These
effects are very transitory and the drug is therefore
of temporary value only in respect of these actions.
It influences digestion in several ways, depending
upon its amount and concentration. In dilute solu-
tion, up to five per cent, it acts as a mild Jjritant in
the mouth and stomach, promoting the flow of
saliva and the gastric juice and increasing the vascu-
larity of the gastric mucosa. Part of the effects of
such dilute solutions in the stomach come from the
volatilization of the alcohol. In concentrations
above five per cent, alcohol delays and interferes
with digestion by disturbing the action of the fer-
ments, hardening the proteins and causing catarrhal
infianimation of the stomach. After absorption
alcohol acts chiefly on the central nervous system
and its action is predominantly one of depression.
The apparent stimulation is due to the depression of
the inhibitory function, the depressant action of
alcohol being manifest in inverse order to the de-
velopment of the nervous functions. In very large
doses all nervous structures are depressed or par-
alyzed. Its depressant action may be of some value
in therapeutics to allay excitation and give a sense
of wellbeing and for this purpose the drug should
be given in the form of fifty per cent, grain alcohol,
disguised by the addition of various bitter sub-
stances and should be prescribed as a medicine.
Systemically, alcohol has no stimulant action on the
heart or bloodvessels, but it tends to dilate the pe-
ripheral vessels and cause a sensation of warmth, in-
creased loss of heat, and some reduction of blood
pressure. There is some evidence that it may act
as a direct food for the exhausted heart, and its
comparatively ready combustion in the body in
amounts up to 100 grams per day makes it available
as a substitute for fats and carbohydrates. As 0
food it is of some value in a very limited number
of cases, especially those in which the digestive
functions are largely in abeyance.
Ocular Lesions Produced by Dichlorethylsul-
phide (Mustard Gas).— Alfred S. Warthin, C. V.
Weller and G. R. Herrm.ann (Journal of Labora-
tory and Clinical Medicine, October, 1918) have
made an extensive study of the experimental di-
chlorethylsulphide lesions of the eye in rabbits and
dogs. Thirteen clinical cases are included in their
report. The action of mustard gas is essentially
the same on the cornea and conjunctiva as on the
skin, but the conjunctiva is less susceptible or better
protected, as the necrosis here is not so marked as
in the cornea or epidermis. The practical clinical
value of the fluorescein test for the determination
of corneal ulceration is apparent. A two per cent,
alkaline watery solution is used to demonstrate ne-
crosis of the corneal epithelium, which can be shown
within ten to fifteen minutes after exposure to
gassing. The degree of degeneration of the corneal
and conjunctival epithelium is in proportion to the
strength of the vapor, the stronger concentrations
producing a more or less complete necrosis of the
corneal vertex, extending throughout the entire
depth of the cornea. Some of the changes noted
are purulent exudation into the anterior chamber ;
congestion and edema only in the posterior chamber
or optic nerve in the noninfected cases ; iridocyclitis
and iritis without secondary infection ; necrosis of
the conjunctival epithelium ; marked edema of the
subconjunctival tissues, with congestion, multiple
hemorrhages, leucocytic infiltration, and often sec-
ondary liquefaction necrosis. The process of heal-
ing in the more severe cases results in vasculariza-
tion and cicatrization of the cornea. There is
1094
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journal.
serious disturbance of eyesight, even in the milder
forms, with refractive errors and reduction of
vision, so that the patient should be referred to a
competent specialist for the correction of these dis-
turbances. Attemps to verify the statement of Vic-
tor Meyer that subcutaneous injections of dichlore-
thy] sulphide determine the occurrence of a con-
junctivitis met with no success. Metastatic lesions
of the eye could not be produced by applications of
mustard gas to other regions of the body, or by
subcutaneous or intraperitoneal injections. As the
methods of treatment reported in the literature
seemed unsatisfactory to the authors, they carried
out an experimental investigation in the hope of
finding an improved method which could be applied
to human cases. They advise against the use of
any method of treatment which brings pressure on
the lids and eyeball, such as tight bandaging, or
heavy compresses ; Hkewise cocaine and the col-
loidal silver preparations are not considered desira-
ble. It is essential to prevent the gluing together
of the eyelids by accumulation of the exudate. In
the severe cases the use of the chlorcosane of di-
chlcramine-T in a strength of 0.5 to one per cent,
is advocated. It is also advised that this solution
be used in all cases of exposure to mustard gas as
an immediate irrigant for its prophylactic ■efTects.
In the milder forms, irrigation w-ith the saturated
boracic acid, the application of light weight boracic
acid presses, hot vapor baths, and protection of the
eyes from light are recommended.
Ether as a Surgical Dressing. — P. Descomps
and A. Richard {Paris medical, September 21, 1918)
note that sulphuric ether now holds an important
place in surgery independent of its use as an
anesthetic, having proven, during the war, a choice
agent in the antiseptic dressing of wounds. The
drug greatly assists in the removal of organic debris,
has proven more reliable as antiseptec in vitro than
any other agent, is of great service through its power
to dissolve oflf fats and many alkaloids, and by caus-
ing hemolysis of red corpuscles enables the polynu-
clear leucocytes in a wound to devote their phagocy-
tic capacity exclusively to the germs present. It un-
questionably favors wound sterilization. In closed
inflammatory conditions, such as lymphangitis,
adenitis, boils, glandular inflammations of the paro-
tid or breast, etc., application of a few dressings of
ether often results in rapid disappearance of the
lesions. In the more severe instances, they limit the
extent of the inflammatory area and induce collec-
tion of pus, which may be then evacuated through a
small incision or even a puncture, thus shortening
the period of repair. The authors first apply two or
three gauze compresses over the inflamed region,
then pour on ether till the gauze is soaked, apply a
covering of some impermeable tissue and cotton, and
complete the dressing with a bandage, only mod-
erately tight in the centre but more closely fitting at
the margins in order to prevent evaporation of the
ether. Ether is reapplied three times a day through
a tube slipped between the gauze layers. In dressing
open wounds, the authors first carefully removed
foreign material and devitalized tissue and asepticize
the skin surface surrounding the wound to prevent
reinfection. In both primary and secondary closure
of wounds ether constitutes the dressing of choice,
irrigation with it before closure having always ap-
peared superior to alcohol, magnesium chloride solu-
tion, or formaldehyde. Rubber drains are passed in
between the gauze compresses and ether introduced
every three hours in amounts varying from ten to
forty mils. That the compresses have been well
moistened with ether is shown by a s^sation of cold
experienced by the patient at the moment of intro-
duction. In the intervals the drains are kept closed
with screw clamps.
Treatment of Lobar Pneumonia with an Anti-
pneumococcus Serum. — P. Kyes {Journal of
Medical Research, July, 1918) reports 115 cases of
acute lobar pneumonia treated with an antipneumo-
coccus serum, and compares the mortality of these
cases with the mortahty among 538 similar cases
occurring in the same institution, and within the
same period of time, but not receiving serum treat-
ment. The series of cases is sufficiently large to
make such a comparison interesting. The death
rate in the 538 untreated cases was 45.3 per cent.,
and in the 115 treated cases it was 20.8 per cent.,
so that in the cases treated with serum it was less
than one half the untreated cases. The antipneu-
mococcus serum was produced by injecting massive
doses of virulent pneumococci into domestic fowls.
Etiology and Treatment of Pruritus Ani. —
Dwight H. Murray {Journal A. M. A., November
2, 1918) presents evidence that true pruritus ani is
due to infection of the skin with the Streptococcus
f;ecahs, and that in cases of pruritus this organism
cannot only be cultivated as the preponderant one
from the afifected region, but also the patient's
blood shows a marked reduction in its content of
opsonins toward the organism. The same etiology
holds for pruritus vulvse and scroti, as well as for
the anal variety. Further support of this concep-
tion of the etiology of the pruritus is found in the
fact that there is no relationship between the oc-
currence of pruritis and the various rectal patho-
logical conditions. The discovery of the etiological
factor gives a logical basis for the treatment of the
condition. Since the infection is not merely a
surface one. but is one which involves the deeper
portions of the skin, it is not possible to attack it
by external local applications. As is to be expected,
the various surgical methods advocated have usually
failed in the cure of pruritus, at best giving but
temporary relief. Further, the cure of associated
rectal affections does not relieve pruritus. The most
satisfactory treatment, and one which is quite ra-
tional, is by the administration of an autogenous
vaccine, made from the Streptococcus fsecalis. This
vaccine contains 2,000,000,000 organisms per mil,
killed by one half per cent, phenol or one third per
cent, tricresol. The initial dose is about 0.2 mil
subcutaneously. The doses are rapidly increased in
size until a good reaction is produced, the number
given varying with the individual case. Along with
this treatment prophylactic measures to prevent re-
infection should be taken, such, as bathing the anal
skin after each defecation. The treatment will not
cure every case, but ic is far more successful than
any other so far employed by the author.
December 21, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
Ambulatory Treatment of Gastric and Duode-
nal Ulcer. — E. B. Freeman {Virginia Medical
Monthly, October, 1918) believes ambulatory treat-
ment justified in a large number of cases, especially
in those where, for pecuniary reasons the patients
are unable to submit to a systematic rest cure in a
hospital. His study embraces 169 cases, comprising
ninety-six of gastric and seventy-three of duodenal
ulcer. No cases with marked gastric deformity or
callous ulcer with pyloric obstruction were included.
The treatment applied consists, in the first place, of
removing all focal infections, especially those about
the teeth and sinuses. Alcoholic stimulants, tobacco,
tea, and coflfee are forbidden. A mixed diet of
carbohj-drate, protein, and fat is administered, but
preference is given to carbohydrate food, which
leaves the stom.ach more quickly than protein or
fats. When possible, the following diet is prescribed
for the first Iv/o weeks : Six ounces of milk at 7 a. m.
and 5 and 9 p. m.. ; egg albumen at 9 a. m. and 3 and
7 p. m. ; a cup of bouillon with one egg at 11 a. m.,
and rice cooked in milk at i p. m. Most patients, how-
ever, being unable to take food every two hours,
tHey are at first put on soft food three times a day,
with a glass of milk or other liquid food between
meals and at bedtime. After two months, light
meats such as chicken and lamb, and fish, are
allowed once a day, and the diet then gradually in-
creased to include thoroughly cooked vegetables.
All patients employ hot moist applications to the
abdomen for fort}'-five minutes before retirinjj.
Medicinally, tincture of belladonna is givers before
and an alkali after meals,' the former in doses of
three drops, increased one drop per dose per day to
tolerance — up to twenty-five drops or more. Bis-
miith subcarbonate, twenty to thirty grains, and
calcined magnesia are given half an hour after
meals. Good results are obtained only with those
who can tolerate belladonna in verv large doses.
Treatment of Pleural Adhesions in the Course
of Intrathoracic Operations. — Le Fort {Presse
medic ale, June 27, 1918) maintains that pleural ad-
hesions surrounding a septic area, which encloses a
foreign body are, essentially, useful protective struc-
tures which should not, as a routine, be destroyed.
On the other hand, adhesions of the lung to the peri-
cardium should be broken up. as they are highly bur-
densome to the heart. Adhesions should also be
broken up where additional working space for opera-
tive treatment is required ; likewise, costodiaphrag-
matic adhesions which hinder free play of the dia-
phragm and bands, spontaneous elongation and soft-
ening of v;hich appears improbable. Broad, surface
adhesions may be loosened where there exists in the
pleura no septic focus capable of inoculating the re-
sulting raw surfaces. Pulmonary adhesions limited
to the extreme inferior border of the lung should be
allowed to remain, as they prevent a diseased lung
from retracting to its hilum and facilitate its respira-
tory expansion. In total pleural symphysis com-
plete liberation of the lung is a deplorable proce-
dure : the lung is. under these conditions, generally
in such a state of collapse that as soon as it is de-
tached from the parietes it shrivels to such an extent
that it could be inclosed in one hand, and that at-
tempts to expand it witlf the glottis closed are fruit-
less. If, in such a case, it is necessary to reach from
the anterior aspect a foreign body situated behind
the hilum and the greater part of the lung surface
has to be freed, at least there should be spared a
band of adhesions which will maintain the vertical
dimensions of the organ and prevent it from col-
lapsing. Pleural adhesions are not always responsi-
ble for the untoward manifestations ascribed to
them ; some constitute a means of defense on the
part of the organism.
Treatment of Uremia in Major Wounds. — I. M.
Reynrs -.Bulletin dc I' Academie de mcdecine, Octo-
ber 8, 1918 ) presents a report based on thirty wound
cases and 210 separate uranalyses. In all major
wounds, even in the absence of infection, the urea
output at once rises to forty or even sevent)' grams
a day, and the urinary urea concentration to from
thirty to forty-five grams a litre. Beyond this the
kidneys fail and uremia results. Serial uranalyses
permit of forestalling uremia by appropriate treat-
ment, viz., hot, sweetened drinks ; glucose enemas
and injections of glucose solution; theobromine and
lactose ; abstention from nitrogenous foods, includ-
ing milk ; ingestion of cooked fruits and purees ; re-
peated saline purgation ; friction ; cotton wrappings,
and external heat. In developed uremia : Venesec-
tion ; lumbar puncture ; glucose solution intraven-
ously, and appropriate local treatment of the wound.
Subsidence of the uremic tendency is marked by an
outburst of polyuria lasting several days.
Intravenous Injections of Quinine Collobiase
in the Treatment of Malaria. — F. Roux {Presse
niedicalc, June 27, 1918; writes that quinine admin-
istered by mouth causes vomiting, subcutaneous in-
jections cause pain and other complications, and in-
tramuscular injections cause persistent nodules and
sometimes the formation of abscesses. In long
standing cases with enlarged spleens, moreover, qui-
nine is not only ineffectual as a rule, but often causes
untoward manifestations, including even hemoglo-
binuria. Intravenous use of quinine collobiase is
free from these objections. The preparation is
without effect when administered by any other route.
The amount of pure quinine introduced with each
injection is from two and a half to five milligrams.
The best time for the injection is within the few
hours preceding a paroxysm ; but practically, it may
be made at any desired time — preferably with the
stomach empty. The injections are given on suc-
ceeding or alternate days, according to the case. The
author never gives more than four injections. The
injection is generally followed by a reaction, mani-
fested in var}-ing symptoms such as a chill, fever,
vomiting, headache, and deep sleep. No serious ef-
fect was ever observed. The therapeutic effect was
found to vary with the degree of reaction. Tried
out for three years in the French colonies, the treat-
ment gave excellent results in the very cases in
which quinine as ordinarily administered proves use-
less and dangerous. The frequency of failures did
not exceed three per cent., and even in the few cases
where recovery did not occur marked improvement
always resulted. The appetite and ability to sleep
returned almost at once and the spleen underwent a
rapid reduction in size. The amount of quinine used
was so small that it caused no unpleasant effect.
Miscellany from Home and Foreign Journals
The Normal Heart in the Navy. — G. F. Free-
man (Boston Medical and Surgical Journal, Octo-
ber ID, 1918), in answering the question as to
what constitutes a normal heart as far as the
standards of the navy are concerned, says that
the normal heart in the navy corresponds, as
far as physical examination is concerned, to the
usual descriptions as to size, sounds, rhythm,
etc. He states that: i. The apex beat, which
is the most miportant guide in determining the
size of the heart, should always be defined. In
a series of 200 cases it was found in the fifth
space in eighty-nine per cent., in the sixth space
in eight per cent., and in the fourth space in three
per cent. The apex beat can be felt in all but four
per cent, of cases before exercise, and in all but
one half per cent, after exercise. In examining re-
cruits and persons in the service, the size of the
heart can be defined much better than in the usual
clinic, because the subjects are all muscular young
men, not obese, and have a vigorous heart action.
2. The apex is, on the average, 9.165 cm. from the
midsternal line, and the nipple is 10.28 cm. from
the midsternal line. On account of the class of
case examined — muscular men — the nipple is a
landmark of much greater importance than it is in
a mixed city clinic. The apex averages one cm.
inside the nipple line, but there is a normal varia-
tion to outside the nipple line. 3. In 67.5 per cent,
of cases the apex is inside the nipple line. In 10.5
per cent, the apex is in the nipple line. In twelve
per cent, the apex is outside the nipple line. 4. In
recording the location of the heart's apex, owing
to the dififerent shape of chests, it is best to give
the distance in centimetres from the midsternal line.
These measurements are best obtained by marking
on the chest and then measuring between the lines
marked by the usual measuring tape laid on the
chest, and not by trying to estimate the distance be-
tween the fingers holding the tape, between the
points determined. In like manner a measuring
rule may be used, but the first method has been
more satisfactory, as the tape is always at hand in
the examining room. 5. The right border of the
heart is best determined by light percussion. In the
cases taken the measurement was from the midster-
nal line at the lower border of the second right in-
terspace, measuring from markings on the chest,
the point mentioned being very easily determined.
It averaged 2.6 cm., or practically one inch from
the midsternal line. With a sternum of average
width, the right border will be found about 0.7 cm.
(or about one third inch) from the right border of
the .sternum, and as this distance is rather too small
to estimate by the usual percussion on a finger, it is
best to assume that the right border of the heart
extends at this point to just outside the sternal mar-
gin. The location of the right side of the heart may
vary slightly with different observers, as its estima-
tion depends somewhat on individual equation, as
does the gejieral outline of the heart if determined
by percussion. On the other hand, when the mus-
cular type of a man to be dealt with is considered.
Freeman cannot agree that the attempt to locate the
right side by percussion is of no value, and that the
only sure way is the x ray. He feels certain that
in these cases the left border can be accurately per-
cussed because there we have a check on our per-
cussion, viz., the location of the apex beat. Then if
the left side can be accurately located, why cannot
the right side also be located by the same methods ?
The method used was to percuss with the eyes shut
and have an assist&nt mark the point found. 6. The
rate of the pulse on the physical examination of the
Navy personnel is accelerated by the excitement
which seems to affect the men on reenlistment as
well as recruits. The pulse is also increased by
exercise (ten sweeps from the erect position and
sweeping down to or near the floor), about ten
beats per minute in recruits, and seven beats in
the reenlistments. A minute's rest is allowed after
the exercise, before the pulse is recorded. The
average rate of pulse in recruits was eighty-four
sitting, ninety standing, and ninety-three after ex-
amination. This high pulse rate is due to the ex-
citement of being in the examining room. Men
who had been in the service from four to twenty
years also had a high pulse rate, the average being
eighty-seven standing, eighty-seven sitting, and
ninety-four after the exercise. 7. Most of the mur-
murs heard meant neither an abnormal heart nor
heart disease. What could be called a murmur was
found in forty-two per cent, of the recruits who,
after passing the recruiting office, were examined
for final acceptance. In the reenlistments of re-
cruits, nineteen per cent, were found with heart
murmurs.
In the verification for final acceptance, four
per cent, were found to be not physically quali-
fied on account of some heart condition, and this
condition was verified by a board of three medical
officers, and thus it was not the opinion of the single
examiner. These men were not allowed to con-
tinue in the service. In the men rejected, out
of 100 recruits who previously had been ac-
cepted, the following conditions were found: i,
mitral regurgitation ; poor physique ; 2, mitral re-
gurgitation in a recruit for fireman. As the fire-
men have to be of a very high physical standard,
any doubtful symptom would stand in the way of
acceptance ; 3, tachycardia, constant rate 124, poor
physique, bronchitis ; 4, probable mitral stenosis, re-
gurgitation. In the reenlistments there were one
half per cent, rejections on account of heart condi-
tion. The most common murmur found was a sys-
tolic one at the second or third left interspace or the
apex, and fairly common at the right of the ster-
num. The systolic murmur at the apex, also accom-
panied by some heart enlargement and an ac-
centuated pulmonic second, is often found in chance
examinations in men in the naval service and can-
not, therefore, necessarily mean heart disease, as
these men never had and do not, under observation,
have any symptoms. It is well to record all these
murmurs on the health record simply as murmurs,
and not to apply to them the name of a heart lesion.
The mitral systolic murmur cannot be diagnosed as
mitral regurgitation unless there are real symptoms.
December 21, 1918.] MISCELLANY FROM HOME AND FOREIGN JOURNALS. IO97
Pulmonary Fat Embolism in Relation to Trau-
matic Shock. — George E. Sutton (British Medical
Journal, October 5, 191 8) says that he was im-
pressed by the similarity between many of the cases
classed as shock at the base hospitals and cases of
pulmonary fat embolism seen in civil life. These
cases are characterized by cyanosis of moderate to
deep grade; small, easily compressible pulse of in-
creased frequency ; increased rate of respiration a.nd
sometimes labored breathing ; cold extremities ; and
a varying degree of delirium. In such cases there
is no appreciable or sustained response to measures
of resuscitation and the patient dies usually within
a few hours. Investigation of a number of such
cases post mortem shows the presence of gross
pulmonary fat embolism almost invariably, or, if
this is not grossly evident, it can be demonstrated
microscopically in specimens stained to bring out
the fat. From the post mortem examination of a
series of cases of shock seen at a ba.se hospital the
figures reveal that about ten per cent, are cases of
pulmonary fat embolism, as shown by gross ex-
amination, and the proportion would probably be
higher if microscopical examinations were made.
The cases in which fat emboli are most frequently
found are: Fractures of the long bones, skull, and
ribs; wotmds involving fatty tissues, including the
abdomen, trunk, and buttocks ; and penetrating
wounds of the abdomen involving the liver.
Acidosis is now much discussed in relation to shock,
and in fat embolism all of the factors productive of
acidosis are present. The main field of treatment
lies in prophylaxis by immediate fixation of frac-
tures and ligature of the proximal ends of veins as
well as their bleeding distal ends.
Residuals of Cerebrospinal Meningitis. — Aaron
J. Rosanoflf (Journal A. M. A., November 2, 1918)
"from the study of twenty-six cases showing the
■ residual effects of epidemic cerebrospinal meningitis
occurring among soldiers from various canton-
ments, reports as follows : The cases presented a
striking uniformity in the syndrome of manifesta-
tions, including limitation of flexion of the spine ;
undue fatigability ; pains in back, legs and head ;
dizziness and faintness ; muscular weakness ; blurr-
ing of vision and photophobia ; and impairment of
appetite and sleep, associated with undernutrition.
^ The Hmitation in flexion of the spine was shown by
inability to stoop over normally and by inability to
touch the sternum with the point of the chin. The
undue fatigability varied in degree in diflFerent
patients, but was present in all. Pains in the back,
legs, and head were present in all the cases, varying
in intensity and sometimes only observed when
some movement was made. In order of their fre-
quency they were found in the small of the back,
back of the head and neck, behind the knees, and
between the shoulderblades. There was tenderness
to deep pressure in some cases. The tendency to
dizziness and faintness was sometimes so great that
slight exertions would cause the patient to become
faint, lose consciousness, and fall. These symptoms
were most frequently aggravated or brought on by
stooping or getting up rapidly from bed, and when
the patient was exposed to unshaded sunlight.
Muscular weakness was shown especially by the
feebleness of the grip. The blurring of vision
usually became manifest when the patients read a
little or indulged in close application, and where the
blurring tendency was most pronounced there was
also some photophobia. The patients showed con-
siderable variations in severity of the several symp-
toms and in the degree of their disablement, and the
quantitative variations seemed to depend partly
upon the severity of the original infection and
partly on the length of convalescence. Apparently
the condition would tend to remain stationary under
rest, while graded hikes and exercises seemed to
bring about some improvement.
Pandemic Influenza and Pneumonia in a Large
Civil Hospital. — John W. Nuzum, Isadore Pilot,
F. H. Stangl, and B. E. Bonar (Journal A. M. A.,
November 9, 1918) studied the epidemic from
various angles and investigated its bacteriology in
a large proportion of cases. They report that the
predominating organism in the washed bronchial
sputum was the pneumococcus, occurring in seventy
per cent, of the samples examined. The Strepto-
coccus hemolyticus was found in that secretion in
twenty per cent, of the cases. Lung punctures were
made in thirty-six cases and twenty-one of them
were sterile. The eleven which showed infection
yielded the pneumococcus in pure culture in nearly
seventy-three per cent, of the cases and hemolytic
streptococci in about twenty per cent. Cultures
taken from the lungs at necropsy again gave the
pneumococcus as the predominant organism,
seventy-five per cent, of the lungs yielding it,
types II and IV being the most frequent.
Hemolytic streptococci were isolated from the lungs
in forty-three per cent, of the cases. The latter
appeared to be late secondary invaders. In the ma-
jority of the cases the pneumococci were of unusual
virulence. The influenza bacillus was isolated in
only 8.7 per cent, of all the cases studied.
Thyroid Hormone and Its Relation to Other
Ductless Glands. — E. C. Kendall (Endocrinology,
April-June, 191 8) describes how the active sub-
stance of the thyroid has been isolated and analyzed,
its empirical and structural formula determined, its
synthesis completed, and its physiological action
studied in a large number of patients at the Mayo
Clinic. In considering the role of the other ductless
glands of the body, Kendall states that they assume
positions secondary in importance to the thyroid,
and that their part may be preparing the various
metabolites for their final action with thyroxin (the
active constituent of the thyroid), with the produc-
tion of energy. In addition to this duty the task
of taking care of byproducts and elaborating other
substances must be accomplished by some agent in
the body, possibly the parathyroids and others of
the ductless glands. A detailed description of the
structural formula of thyroxin is given. It contains
an indol grouj> with the iodines attached to the ben-
zene ring, and on the carbon atom adjacent to the
amino group of the indol ring there is an oxygen
atom. The physiological activity of the substance is
produced by the CO.NH groups. In explaining the
action of iodine in the compound the theory is pre-
sented that it renders the active groups more re-
active.
1098
MISCELLANY FROM HOME AND FOREIGN JOURNALS.
[New York
Medical Journal.
Experimental Parotiditis. — Martha WoUstein
{Journal of Experimental Medicine, October, 1918)
continued tlie work done two years ago, injecting
filtered sterile salivary secretions from soldiers suf-
fering from acute parotiditis for one to twelve days,
into the parotid glands and testes of healthy cats.
The "virus" was detected most readily in the saliva
during the first few days; the period of infectivity
is apparently short, covering about a week, and cor-
responding with the swelling of the parotid. The
saliva from inoculated cats was used for further
injection and produced swelling not only of the
parotid glands, but of the submaxillary, sublingual,
and adjacent lymph nodes, while the lymph nodes
on the uninoculated side were sometimes swollen
and moist. Probably the involvement resulted from
salivary and lymphatic infection. Defibrinated blood
taken from the arm vein of patients suffering
from parotiditis, especially those with severe con-
stitutional symptoms w^as infective for cats. Con-
firmatory evidence of the filterable nature of the
etiological agent of mumps is obtained in this work.
The virus was detected in a case of recurrent paro-
tiditis at the periods of enlargement of the glands,
but not two weeks after the swelling had subsided.
It was not detected in the cerebrospinal fluid.
The Influenza Epidemic of igi8. — A. Netter
(Bulletin de I' Academic de medecine, October i.
1918) asserts that no one observing the sudden
onset of the epidemic disease of 1918, the general
pains and high temperature, the at first relatively
slight involvement of the respiratory and digestive
tracts, the sudden termination after two or three
days, and the distinctly epidemic and even con-
tagious nature of the disease, can fail to identify
this affection with the influenza epidemic of 1889
and 1890. As the epidemic ran its course there ap-
peared numerous instances of tracheobronchitis,
acute bronchitis, suffocative catarrh, bronchopneu-
monia with multiple foci, lobar or rather pseudo-
lobar pneumonia, and pleurisy with bloody or
seropurulent effusions. There were also gastroin-
testinal cases with diarrhea, and mucoid, blood
stained stools, sometimes presenting all the charac-
teristics of typical dysentery. A few of the author's
patients showed marked meningeal symptoms. In
all former great epidemics, influenza exhibited the
same protean nature, the same sudden beginning
with purely nervous and febrile forms, and later
the same visceral involvements, especially of the
respiratory tract. The contagious nature of the
1918 epidemic was exhibited also in 1889. Return -
ing in that year from Egj'pt, to which influenza had
not yet penetrated, the author contracted the dis-
ease in a railway compartment in which an influenza
l^atient had sat for half an hour ; the incubation
period w^as eighteen hours. From bacteriological
studies Netter is a firm believer in the Pfeiffer
, coccobacillus as playing the essential pathogenic
role in the 1918 epidemic. Inability to find the
organism in a certain proportion of instances by no
means proves their absence. From most patients,
sputum for examination is obtained but once ; but
in two of the author's cases a positive result was
secured only in the second specimen, and in one in-
stance only in the third.
An Improvement in Stereoscopic Radiography.
— Henri Beclere {Presse medicalc, Qctober 7, 1918)
notes that the chief aim sought in stereoscopic
radiography is to secure a record of the various
planes of the structures radiographed, in order that
as much relief as possible may be imparted. The
marked difficulty of properly understanding the
stereoscopic negatives results from the fact that
cutaneous landmarks indicating the precise situation
of the various portions of the skeleton are lacking.
JNIetallic rings have already been proposed as in-
dicators of the skin surface, but the following pro-
cedure is much better and simpler : The part to be
taken, lightly covered with petrolatum or wool fat,
is rubbed with a salt opaque to the x rays, such as
bismuth subnitrate 01 subcarbonate. The powder
penetrates into the smallest depressions in the skin,
and on the x ray negative all these depressions ap-
pear in detail. In stereoscopy the effect is striking.
The skin, now rendered clearly visible, exhibits its
form and all its folds. The bony framework ap-
pears in precisely its actual relations to the skin sur-
face. The skin gives the impression of a fine, filmy
envelope which in no way impairs the distinctness
of the details of the bony skeleton. Application of
the procedure to the study of proper padding of am-
putation stumps, with a view to the use of appro-
priate apparatus, has given excellent results. Bone
fragments embedded in the tissues can be easily lo-
cated, thus affording surgical indications of value in
the prevention of untoward complications.
Interesting Reaction to Louse Bites. — William
Aloore (Journal A. M. A., November 2, 1918) says
that he is not aware of any published evidence that
the clothes louse may produce an illness due to a
toxin or toxins introduced by its bite. After one
of his associates had been feeding successive gener-
ations of lice on her arm for a number of months,
with no disturbance other than slight local irrita-
tion, which was easily controlled by the prompt
application of alcohol followed by equal parts of
glycerin and ammonia, the more intensive feeding
of the insects — twice daily instead of only once —
was soon followed by a feeling of being generally
tired and a nearly continuous dull headache at the
base of the skull. Later, chills and fever with
symptoms very like grippe developed, the fever
lasting for three days. At this time a rash like that
of German measles appeared and many small blis-
ters came out on the a-rm where the lice were fed.
Moore then began to feed from 700 to 800 lice on
his own arms twice daily, and almost immediately
developed symptoms quite similar to those described
as having been suffered by his associate. After
recovery from this attack the feeding of large
numbers of the lice was twice repeated by Moore
with the same train of symptoms developing each
time. The feeding of small numbers on several
persons had previously not given rise to any symp-
toms. The observations suggested that when the
clothes louse was present in large numbers it might
produce an illness due to toxins introduced by its
bite. Symptoms encountered in cases of trench
fever were so like those described here that it
seemed possible they might have been due to louse
poison rather than to the trench fever.
Proceedings of National and Local Societies
AMERICAN LARYNGOLOGICAL
ASSOCIATION.
Fortieth Annual Meeting Held in Atlantic City,
N. J., May 2^-2^, Ipi8.
The President, Dr. Thomas H. Halsted, of Syracuse,
in the Chair.
[Continued front page lo^p.)
Serious Damage to Nose and Accessory Sinuses
Operated upon Externally. — Dr. John R. Wins-
low, of Baltimore, reported a number of cases of
operative cure after serious injury to the face:
I. Extensive traumatism of the nose, face, and
frontal sinuses due to a fall from a height ; qptra-
tive cure with exceptional result.
2. Frontal empyema with extensive bone necrosis
rmd external fistula, operated upon externally in
several sittings ; cure of condition with excellent
cosmetic result. Several interesting points were
presented by this case: a. Lack of intranasal patho-
logical conditions. A virulent infection (erysipe-
las?) seemed to have attacked the frontal sinus and
uppermost portion of the bony framework of the
nose without involvement of other nasal sinuses,
b. The posterior (cerebral) sinus wall was denuded,
but was hard and seemed devitalized rather than
necrotic. It took a long time for it to regenerate
(twenty-six months), but his own judgment and
the advice of colleagues was that it was better to
delay than to assume the risk of removal, c.
Marked anesthesia of the operative field, the pack-
ing being for a long time painless, doubtless due to
the devitalized bone. d. Excellent cosmetic results.
3. Fracture of the external bony framework of
the nose and the nasal septum by the kick of a mule,
causing depression of the tip of the nose and great
disfiguration. Restoration of appearance and func-
tion by operation.
4. Fracture of the right nasal bone and nasal pro-
cess and a portion of the orbital process, by an iron
rod ; formation of sequestra and abscess, with sec-
ondary infection of the right antrum. Operation
and cure, with good cosmetic result. Photographs
showing their excellent results were presented.
Doctor WiNSLOw said he would like to hear
from Doctor Coakley or some of the other experts,
as to the proper plan of treatment under such con-
ditions as he had described, where there was
necrosis of the cerebral wall of the frontal sinus.
He wanted to hear their opinions as to how long one
was justified in waiting for nature and wondered
whether he had waited too long.
Dr. Cornelius Coakley, of New York, said that
when he had operated on the frontal sinus he had
never found actual necrosis of the wall unless there
had been syphilis. He had found that in patients who
had been operated upon previously, there had been a
temporary cessation of the discharge with fistula
formation. On opening up the frontal sinus he had
frequently found areas of very marked softening in
the bone, such as one finds in a mastoid operation at
the borders, in back of the large cells, and on ap-
proaching the cells just between these and the cancel-
lous bone. He thought the bone should be regarded
as infected bone, as in the mastoid region, and felt
that neglect to clean out this diseased bone and get
down to healthy bone, whether in the anterior wail
or anywhere else, was not good surgery. One
should get to good bone, even if one had to expose
the dura in the frontal region. In one instance he
found such a degree of softening of the posterior
wall that he felt sure that he should find exposure
of the dura and epidural abscess. Fortunately,
however, that was not the case. He had gone
through an area of three eighths of an inch of
vascular soft bone before coming to what must have
been a very thin area of good bone at the posterior
wall of the frontal sinus. The soft bone was all
cleared out. A drain was placed in the wound for
a short time, leading to the nose. The wound was
sewed up, as in the ordinary Killian operation, and
the patient made — temporarily at least — a good
recovery. The operation had been performed three
months ago, and up to the present time there had
been no recurrence, although there had been two or
three before that. Soft or diseased bone should be
treated as are the same kind of bone in the mastoid
or any other region.
Dr. Lewis A. Coffin, of New York, said he was
less afraid of a curette than of leaving diseased
bone in a patient. He doubted that the posterior
wall, necrotic and perforated, was an invariable
sign of syphiHs. He had seen this condition in com-
paratively few cases. One case was in a child of
six years who had healthy parents ; in another pa-
tient, previously seen, the anterior wall was so soft
that Doctor Cofifin had removed it with a spoon
curette and did not see why the posterior wall
should not be affected bv the same pathological pro-
cess as the anterior wall. A similar case was that
of a young woman who was riding in an automobile
when the shaft of a wagon to which a horse was
attached entered the antrum through the middle of
her cheek, fracturing the floor of the orbit and the
anteronasal wall. She had been under treatment
for some time when seen by Doctor Cofifin. Re-
moving a pad of gauze from her face a stream of
pus poured from the open wound in her cheek. An
incision was made over the eyebrow down over the
ridge of the nose and the centre of the skin covering
the columnar cartilage and dividing the upper lip in
the median line. Turning the flap well back gave
a good exposure of all the diseased parts, which
were thoroughly cleared out. In this case there was
practically no scarring except where the shaft of the
wagon pierced the cheek.
Dr. George L. Richards, of Fall River, Mass..
expressed the opinion that the ability of the face to
heal was remarkable. Some vears ago a patient
was riding a bicycle down a hillside when the chain
broke, and he was pitched suddenly forward in
such a way that he tore off the front of the fare
from the nose to the chin, and in addition got
the dirt of the street into his wounds. A number
of operations were necessary, but in the end a fairly
good looking face resulted.
I lOO
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
Dr. T. Passmoke Berens, of New York, thought
this was the same condition that was found in the
mastoid of bone that is not syphiHtic, but is simply
an unusually firm hard bone. A number of years
ago he had mentioned the mild pressure that was
needed in these cases, such as would come from a
pince nez with long horns pressing the nasal bones
together. It seemed to Doctor Berens that if a
slight constant pressure, such as one gets from a
pince nez, had been exerted, that broadening of the
nose would have been overcome. This was men-
tioned to accentuate the benefit of constant mild
oressure.
Dr. Bryson Delavan, of New York, said that in
suppurative conditions of the nasal sinuses if any
question of the existence of syphilis arose, operative
work should be undertaken with caution, since un-
der antisyphilitic treatment many cases had been
cured or had satisfactorily improved without opera-
tive interference. Many cases could be quoted to
prove this. It was his opinion that where there was
a positive Wassermann reaction it was best to wait,
if possible, until a course of specific treatment had
either cured the sinus disease or made the necessity
for operation clear.
Dr. John R. Winslow, in closing the discussion,
said that he had evidently been misunderstood:
and did not want to leave any one under the impres-
sion that he had left soft bone and closed it in the
wound. It was not soft, but hard as steel, and he
had curetted it three times as much as he thought
was safe. He had acted not only on his own best
judgment, but also on the advice of several friends.
Carpet Tack in the Right Bronchial Tube for
Two Years with No Pathological Symptoms. —
Dr. Dunbar Roy, of Atlanta, described the case of
a young woman, aged twenty-eight years. X ray
showed the tack in the right bronchus between the
seventh and eighth ribs. Its removal was at once
attempted by upper bronchoscopy and failed.
Tracheotomy was performed the next day ; the
bronchoscope passed, but he was unable to grasp
and dislodge the tack, and the tracheotomy wound
was allowed to heal. Five months later a broncho-
scope was easily introduced by upper bronchoscopy
by Dr. R. C. Lynch. The tube was too short and
the foreign body could not be removed. The patient
had been entirely well since then, now two years,
increasing in weight. X ray photographs showed
the tack still in situ.
Dr. T. H. Halsted reported, in connection with
Doctor Roy's case the recent removal of a foreign
body from the right bronchus, in a girl of ten years.
This child, while playing, inhaled a metal clip, shaped
somewhat like a fish hook. There was an immedi-
ate attack of dyspnea. A physician saw her within
ten minutes, at which time all symptoms had dis-
appeared, beyond the pricking sensation. He as-
sured her that she must either have expectorated
or swallowed it. She had no trouble that night, but
the next morning, the sticking sensation referred to
the neck continuing, she consulted another physi-
cian, Doctor Swift, who had an x ray made which
disclosed a foreign body in the right bronchus. Pa-
ti*ent was referred to Doctor Halsted for operation.
Under general anesthesia he soon located the
metallic object by upper bronchoscopy and made re-
peated but unsuccessful efforts at removal. The
x ray failed to tell whether the- sharp point was di-
rected up or down, and it could not be determined
by direct inspection. The next morning steroscopic
plates were made, and showed the foreign body to
be in the right bronchus, the sharp point upward.
Under ether, the trachea was opened, and under
lower bronchoscopy the foreign body was, after two
hours' work, removed. It was in the second divi-
sion of the bronchus, firmly wedged, but by manipu-
lation it was finally removed by a long alligator
forceps with but little damage to the bronchioles.
The foreign body was a flexible steel clip used in
clothing stores for holding cardboard price marks,
shaped like a sharply bent fish hook, the shaft being
three fourths of an inch long and the pin portion
half .an inch. The. tracheal wound was at once
closed ; the child made an uneventful recovery, leav-
ing the hospital in eight days. Doctor Halsted
considered it the most difficult case of its kind he
had met with.
Atrophic Rhinitis and Ozena: With Report of
Case Referred to Last Year. — Dr. Lewis A.
Coffin, of New York, said he believed that he had
been the first to suggest that the foul odor which so
frequently accompanied atrophic rhinitis and con-
stituted the disease known as ozena had its origin
and was caused by a chronically diseased and poorly
drained antrum. Since making this statement
others had reported to him that they had treated
several cases in this manner with the same excellent
results. In one of his cases there had been no
improvement whatever, although operations had
been performed on both antra. He was unable to
account for the failure in this instance.
Dr. Cornelius G. Coakley thought that all the
odor should not be attributed to disease of the
maxillary sinus. If the patient had pansinuitis he
did not see why it should have been cured by wash-
ing out the maxillary and leaving the same patho-
logical process m the ethmoid and frontal. Of
course there would not be much odor from them,
but it was his opinion that they should be cleared
up as well as the maxillary, and he suggested that as
the cause of the continuation of the odor.
Dr. George L. Richards, of Fall River, said that
he had derived excellent results from the use of
chlorinated oil in the type of case that Doctor
Coffin had been speaking of. It had been purely
empirical. He had used it thinking that it would
do some good to place it on the surface and hold it-
there. It was done with the swab or spray, and not
after opening the antrum. Doctor Richards had
not been converted to the belief that all or even the
majority of cases of atrophic rhinitis were due to
antrum disease.
Doctor Halsted said that after seeing Doctor
Coffin's cases last year, he had treated a case with
the foulest odor he had ever encountered. He per-
formed a double antrum (simple Mikulicz) opera-
tion on the patient. The odor was simply unbear-
able and unendurable. Nothing further was done.
The saline douche that she was using was kept up.
He did not see her after she went home, for a
December 21, 1918.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
IIOI
year, at which time the odor had entirely disap-
peared. There was no odor from the nose what-
ever, and no other treatment had been carried out
during this time, with the exception of the washing
out. In three of five other cases there was com-
plete cessation of all odor. It was one of the most
satisfactory operations of any that he had done.
In the other two of these five operations the odor
was greatly lessened. There was a marked diminu-
tion in the amount of crusting in the nose. Doctor
Halsted thought the odor came more from the gas
from the antral secretion than from the nasal scabs,
though doubtless some came also from the other
sinuses, the frontal, ethmoid, and sphenoid, when
they were involved, and their treatment by ventila-
tion through operation would be required in such
cases.
Dr. Greenfield Sluder, of St. Louis, called at-
tention to the fact that if Doctor Coffin had estab-
lished the opening of the antrum for the cure of
ozena and the stench of an atrophic rhinitis, it
seemed to him that it was one of the greatest ad-
vances presented in a long time. He wanted to
repeat the following question, which he asked last
year, but which was not answered, "What happens
in a case of atrophic rhinitis when the olfactory
fissure is crusted all around?" Although the an-
trum was open, the atrophic process was as active
and destructive there as elsewhere.
Dr. Hanau W. Loeb, of St. Louis, said that it
was obvious that if there was any process of this
nature in the antrum, by securing good drainage
there would naturally be improvement in the odor,
just as he had found that by clearing out the
ethmoids a particular odor that may accompany the
process will improve or disappear. He felt that
Doctor Coffin's contribution in this respect consti-
tuted simply calling attention to the fact that th?.
antrum, being the largest cavity connected with the
nose and most intimately associated with its func-
tion, the greatest opportunity for the development
of these crusts was offered by it whenever it was
subjected to the action of the putrefactive bacteria.
He did not see why it should be affected in all the
cases, or even in more than a fair number of the
cases, because, according to his information and ob-
servation, the antrum was not more often affected
than other sinuses.
Dr. Henry L. Swain, of New Haven, expressed
the opinion that if people would take pains to cleanse
the nose properly most of them would remain in-
offensive to their immediate environment. That
would not be the case if the odor depended entirely
on the condition of the interior of the antrum.
Although particularly friendly to Doctor Coffin's
suggestion, he was sure that all cases were not
going to be cured by opening the antrum, because
all cases were not due to that condition. In one
antrum into which he could look pretty well
through a large natural opening between the an-
trum and the nose, where there was an atrophic
process in the nose it could be seen in the antrum
that the mucous membrane lining had the same
process going on in it as in the nose, that is, there
were masses of atrophic material lining the entire
cavity of the antrum. If that could exist once, it
could many times, and would explain why in some
of these cases in which, as Doctor Halsted had dis-
covered, there was no darkness imder transillumina-
tion, the same process would be going on as in the
nose, which could be relieved by opening the sinus,
and only by doing so.
Dr. T. Halsted thought the improvement as evi-
denced by his five cases was remarkable. He felt
that, in a general way, there was a diminution in the
am.ount of crusting, and did not believe that all the
odor came from the crusting, but that it would be
proved that it came from the maxillary sinus as
well as the ethmoid and frontal.
Doctor Coffin, in closing this discussion, said
that Doctor Sluder had given a proper definition of
ozena as the odor accompanying atrophic rhinitis,
but he referred to seeing scabs about the olfactory
fissure, and did not state that there was any odor or
ozena from these particular scabs. The subject
ui'ider discussion was not scabs but an odor known
as ozena. He said that the antrum was practically
the only sinus he had ever opened from which a
foul odor was emitted. This occurred frequently
and was due to the anatomic structure of the an-
trum. Drainage was at the top, while in most other
sinuses drainage was from the bottom. He recalled
the case of a young lady who had extreme atrophy,
no inferior or middle turbinates in sight, nose much
bescabbed ; who, when she first came, emitted a
foul and offensive odor. Her antra having been
opened and cleansed, the odor (ozena) had entirely
disappeared, while imdoubted disease of many of
the other sinuses persisted, as does scabbing, al-
though not to the same degree as before the treat-
ment of the antra. She was one of the patients seen
by Doctor Halsted. Another case was that of a
young boy about twelve years of age. Apparently
he had not only marked disease of the antrum of
one side, but marked ethmoiditis as well — nose full
of crusts and ozena. Doctor Coffin had opened and
treated the antrum, purposely leaving the ethmoids
untouched. The odor disappeared.
As to the value of the x ray in diagnosis, it was
a help, by no means infallible. Personally, he
cared little for another's reading of the negative.
The points which he wished to especially bring out
were the following: First, that the odor of ozena
frequently was due to disease of the antrum, and
was relieved by the treatment of the antrum. Sec-
ond, he had today reported a case not so reheved.
He hoped that the treatment would be tried by
others, as Doctor Halsted had tried it, and that it
would be borne in mind that lOO per cent, cures
were not to be expected.
Three Unusual Nasal (Sphenopalatine) Gang-
lion Cases. — Dr. Greenfield Sluder described the
usual neuralgic picture in the following way :
Pain in and about the eyes and the upper jaw, the
teeth, extending backward about the temple under
the zygoma into the ear, causing earache ; and then
backward into the mastoid, and severest usually at
a point two inches back of the mastoid, extending
into the occiput, the neck, the shoulder into the
shoulder blade, and sometimes the axilla and breast,
and frequently down into the arm, forearm, hand,
and even to the finger tips. Added to this symp-
1 102
I'h'OCEEDlNGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
toni complex, a sneezing and watery secretion was
frequently found, more marked probably in the
morning, frequently extending through the day; a
red external nose, with tearing eyes, photophobia,
and a sense of discomfort in the eyes difficult for
the patient to describe. Occasionally, however, un-
usual features were added to this clinical complex,
for which he could find no explanation.
The first case was relieved of the dizziness and
the headache after cocainization of the ganglion, the
headaches returning in six hours. The patient
passed from further observation. In the second
case headache ceased, but as an eftect of cocainiza-
tion the right eyelid drooped very perceptibly to ob-
scure probably half of the blepharospasm, and the
pupil contracted to one half of its fellow of the op-
posite side. The third case was one of a right sided
blepharospasm of great severity, and was a post-
ethmoid sphenoid suppuration with polyps on the
right side. Cocainization of the right nasal gang-
lion relieved the blepharospasm for a period of three
hours, and injection of the same ganglion was fol-
lowed by relief of the spasm for three to six hours.
Operating on the ethmoids and sphenoids did not
relieve the spasm. The left side was then operated
upon without relieving the spasm, although the right
eyelid opened after injection of the left ganglion.
Dr. Emil Mayer of New York, thought that we
were greatly indebted to Doctor Sluder for calling
attention to these nasal ganglion cases and what
might be done for them. He recalled the case of a
young woman whom he had successfully treated for
dysmenorrhea by intranasal treatment. When seen
later, she was suflfering with headache, and Doctor
Mayer cocainized the nasal ganglion on the side of
the headache. An hour afterward her headache had
ceased. This patient remained well for some
months and then had a recurrence, at which time an
application was made to the ganglion on that side,
and it has remained well ever since. Though it was
difficult at present to explain why such wonderful
results in dysmenorrhea cases could be obtained by
a treatment which must perforce be called empiric,
it was hoped that some explanation would soon
be found.
Doctor SwAXN said that he had tried to cocainize
in the ganglion neuralgic cases, and wanted to con-
firm what Doctor Sluder had observed on the ques-
tion of dizziness, which he also had been unable to
explain. One of the patients whom he had cocain-
ized for headache also suffered from vertigo, and it
was relieved entirely during the period of her cessa-
tion from pain, which was only two or three weeks.
He made another application of adrenalin and co-
caine in combination, which relieved her for so long
that she did not think it necessary to have any fur-
ther treatrhent of that kind ; that was a year ago.
Doctor Swain had not seen her since, and did not
know whether she was still well or not.
Regarding the question of pain in these sinus
cases. Doctor Swain said that he had a number of
cases of severe pain with disease in which he had an
X ray picture taken to learn the exact state of things.
In five instances the neuralgia had ceased imme-
diately after taking the picture, so that there must
have been something in the exposure to the x ray
that broke up the nerve complex in some way and
caused the pain to stop. Previously he had been
treating the cases without seeming relief. This oc-
curred in several instances in persons whom he saw
every day, the pain ceasing thereafter entirely. He
wondered whether this fact could be of some thera-
peutic value. Should patients with this type of neu-
ralgia be exposed to the x ray? He did not think
that the occurrence was accidental in all five cases
in which there was no sinus disease but neuralgia,
and in which, following the x ray exposure, the
pain disappeared entirely.
Doctor Sluder thought that the case Doctor
Mayer had described was one of those in which the
ganglion lay particularly close to the surface. That
sometimes happened, and such a case might be ex-
ploded into the most violent lower half headache by
an ordinary coryza. Cocainization, in that case, was
curative, not merely palliative.
Cyst of the Thyroglossal Duct. A Report of
Tw^o Cases. — Dr. Otto T. Freer, of Chicago, de-
scribed the anatomic origin of these cysts and re-
ported the following cases :
Case I. — The patient, male, began to have dif-
ficulty in swallowing, and at the same time noticed
a swelling in the region of the thyrohyoid space.
When first seen, on April 19, 191 5, the swelling had
increased and there was great difficulty in swallow-
ing. Examination showed a normal nose, pharynx,
larynx, and esophagus. In the thyrohyoid space a
cyst was felt seemingly lying underneath the sterno-
hyoid muscles. It was of walnut size and could be
felt to interefere with the ascent of the thyroid
cartilage to the hyoid bone when the patient swal-
lowed— that is, the cyst became pinched between
the two structures. Operation on June 17, 191 5.
After dissecting off the superficial fascia and
platysma muscle from a vertical median incision, a
strong, tendinous layer of fascia was exposed that
was attached to the lower border of the hyoid bone
above and to the border of the thyroid notch below,
so firmly binding down the cyst between itself in
front, the median thyrohyoid ligament behind, and
the thyrohyoid membrane laterally, that the cyst
was unable to escape from the compartment in
which it was confined when pinched during swal-
lowing. When exposed by removing the fascia
described, the wall of the semitransparent cyst was
found to be so frail that it could not be seized lest
it tear. This made the dissection tedious, as only
the tissue surrounding the cyst could be held with
tissue forceps, the cyst being held aside with dull
retractors. The cyst was removed unhurt from its
bed and was found to end above in a fibrous pedicle
that lay against the posterior surface of the body
of the hyoid bone and could be followed as high up
as its superior border at the level of the hyoepi-
glottic ligament. Removal of the cyst exposed the
median thyrohyoid ligament to view, this ligament
forming the posterior wall of the compartment in
which the cyst had been confined. Microscopic
section of a part of the cyst wall showed it to be
composed of fibrous tissue lined with a layer of
leucocytes intermingled with numerous, evenly dis-
tributed giant cells. There was no epithelium. The
December 21, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
1 103
cyst contained a clear fluid. The removal of the
cyst enahled the patient to swallow normally.
Case II. — The second patient was a woman of
thirty-two years, first seen on November 8, 1916.
She had a swelling over the larynx since her tenth
vear. Iodine was injected into this swelling during
the summer, and since this was done the swelling
had gradually increased in size. Examination
showed a spindle shaped cystic tumor of the size
of a walnut in the prelaryngeal region. The upper
pole of the cyst could be felt to dive under the
centre of the body of the hyoid bone ; its lower pole
dwindled to a cord that could be felt to reach the
region of the thyroid isthmus. Operation under
cocaine on November 17, 1916. It took two hours
to dissect out the cyst, as only the most delicate
handling could prevent its rupture, and inflam-
matory changes caused by the iodine injection had
made the cyst wall grow to its surroundings, so that
ihe thyrohyoid and sternohyoid muscles were firmly
joined to it in front. The upper end of the cyst
ended in a cord that extended upward under the
body of the hyoid bone to its upper border, where
It was lost in the hyoepiglottic ligament. Below,
the cyst ended in a similar cord that joined the
isthmus of the thyroid gland. When freed from
its bed just before removal, the cyst ruptured and
thick pus escaped, a cold abscess probably having
been caused by the iodine injection. After the cyst
was removed, the thyroid and cricoid cartilages,
upon which it had lain, were bared to view.
In the first case the possibility of the cyst being
derived from a subhyoid bursa might come into
question. However, the pedicle which formed a
cord passing up under the body of the hyoid bone
in the location of the thyroglossal duct showed the
thyroid origin of the cyst. In the second case the
entire thyroglossal duct, expanded to a cyst in its
middle, was present to prove the correctness of
the diagnosis.
( To be coiitiiuicd.)
PHILADELPHIA COUNTY MEDICAL
SOCIETY.
Joint Meeting zvith the Babies' Welfare
Association.
Wednesday, November Jj, igi8.
The President, Dr. John W. West, in the Chair.
WHAT THE AMERICAN RED CROSS IS DOING FOR THE
FRENCH CHILDREN.
Dr. J. H. Mason Knox, of Baltimore, assistant
director, Children's Bureau, American Red Cross in
Erance, said that the situation in France was criti-
cal. While the death rate was not enormously
high, in one or two provinces being under ten per
cent., the birth rate averaged something less than
fifteen per thousand. The birth rate had fallen
slowly before the war, and with the withdrawal of
so many of the men for military service, and the
women for munition work the rapidly falling birth
rate was a natural result. The problem in Erance,
therefore, was twofold, increase of the birth rate
and decrease of infant mortahty. The low birth
rate of Erance was probably due to the inborn de-
sire of the French people to live comfortably. The
laws of Erance requiring equal inheritance among
children might be a factor ; for example, the farm
might be large enough for but one. Since families
were small, it was very important to save a French
baby. The work of the Children's Bureau in Erance
was divided into two departments; i, that made up
of remedial agencies for meeting present distressing
circumstances ; 2, that dealing vvith constructive
work. In the first department were the things done
for the babies of the soldiers, the city population,
and the children of the refugee families. In a small
village near the (jcrman front a large number of
children had been subjected to gas attacks. These,
of course, were too small to wear masks. They
were placed in large military barracks and Doctor
Lucas, of San Francisco, was asked to take the
medical care of them. For these 500 or more chil-
dren a hospital was provided, at first of thirty beds
and afterwards of fifty and 100 beds. There had
been developed also a chain of rural dispensaries
illustrating to the poor people of the small villages
the method of caring for children. Small hospitals
were established, and automobile dispensaries with
the personnel of a doctor, a nurse or one or two
nurses' aids made two visits a week in each town.
In case of need the nurse or nurses' aid would be
left in a village. A clinic was held twice a week.
Tv;o or four automobiles covered the whole area of
country of thirty or forty miles in the vicinity of
Toul and Nancy. A number of tuberculosis camps
were also established.
Doctor Park, of the Johns Hopkins Hospital,
opened a clinic for children in Belgium. These
children with their splendid spirit gave one
much encouragement for the future of Belgium.
The Refugee Bureau cooperated with the French
officials in finding homes for the people and
supplying them with furniture and other needed
articles. Every child under twelve years of age
coming through with the convoys of refugees
was examined to detect infectious disease, or
other condition which might be a menace. Forty
per cent, of the convoys were children. Twentv
miles from Lyons is a large chateau with
200 acres of ground where convalescent patients
were sent by the Children's Bureau, where they
were kept until they were able to go on to their
destination. The German consulate was taken over
by the Children's Bureau and made into a hospital.
Two other buildings in the vicinity of Lyons were
converted into hospitals for the children.
Paris is the centre of things. Here the Children's
Bu:eau opened twenty dispensaries, but always aftc
thf most careful examination to see that they did
not conflict with French organizations, and always
with the support and encouragement of the French
physicians. The nose and throat work was exceed-
ingly important in Erance. The complete removal
of tonsils was not done as often as some thought
it ought to have been done. A small private
hospital was secured for nose and throat work and
here perhaps a hundred cases were treated each
week. It was found that many of the children
needed food and not drugs, that the principal meal
of the day was given at the school and that this meal
II04
BOOK REVIEWS.— BIRTHS, MARRIAGES, AND DEATHS.
[New York
Medical Journal.
had to be largely curtailed. The members of the
Children's Bureau supplemented the food so that
the children might have the same as before the war.
In one section sweetened bread and chocolate were
given on behalf of the children of America to the
children of France, and they were told that the
children of America were sharing their bread with
the children of France. The Children's Bureau also
took care of the orphans supported by the American
soldiers ; the bureau supplied the orphans and the
care, while the soldiers supplied the money.
There was a great opportunity for constructive
work in France. One form of educational propa-
ganda was carried out by the use of automQbiles
equipped to demonstrate infant welfare and tubercu-
losis work. Under the Rockefeller Foundation a
large amount of work was being done in the matter
of tuberculosis. As a result of bringing together vari-
ous agencies there Vv'as always a personnel ready for
follow up work after interest was aroused. Crowds
of people attended the exhibits. Trained nurses
were greatly needed, and the bureau believed that
the training of French nurses was one of the most
important phases of its constructive work. Inten-
sive work designed to reach every baby had been
organized under the French officials. Infant wel-
fare work is the same the world over. It shouM
be taught in our schools, but until that time it must
be taught in the homes, and the nurse is the instru-
mentality by which this shall be done.
^fc
Book Reviews.
[We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we re7iiezt< those in zvhich we think
our readers are likely to be interested.]
Mammalian Dentition By T. Wingate Todd, M. D., Ch.
B., F. R. C. S., Eng., Captain, Canadian Army Medical
Corps. Illustrated. St. Louis : C. V. Mosby Company,
1918. Pp. 280. (Price, $3.)
This volume presents a most complete and satis-
factory study of mammalian dentition. More than
100 pages are devoted to a consideration of the en-
vironment, evolution, and dentition of the lower
vertebrates; the ancestry of the mammalia; the rela-
tion between life habits and dentition; and a chap-
ter each on the insectivora and the primates. There
are also several chapters given to the study in evo-
lution of herbiverous types, one devoted to the eden-
tata showing retrogression in evolution, and one
chapter on the carnivora, illustrating evolutional
divergence. The chapters dealing with human
dentition including the deciduous, with their anoma-
lies, are of great interest, dealing with the subject
from a paleontological viewpoint. In studying
other families of the primates, the author traces
the line of evolution progressively from some early
or primitive form. In the case of man this has
been found to be impossible since no human or pre-
human type has been discovered which can, with
certainty, be assigned to a period more remote than
the early glacial epoch. The earliest authentic ex-
ample of the human race, known as the Heidelberg
man, is known only from the mandible. A detailed
description is given of this and other early examples
of dentition. In the chapter on anomalies of hu-
man dentition the author deprecates the fact that
dentists have not made a more careful investigation
into the causes of variations in number, position,
and form of the human teeth, as too often the valu-
able data to be obtained only by him are lost or de-
stroyed in consequence of the tendency to consider
these anomalies merely as freaks. The statement is
made that variation in position of normal teeth are
always of pathological origin. Unfortunately noth-
ing is said in support of this statement, which, if
true, is of great practical significance and especially
so to the orthodontist Chapter XX is devoted to
a study of the roots of teeth, which are said to be
less subject to environmental changes than are the
crowns, though even here changes are noted, the
bicuspids in the anthropoid having three roots, in-
stead of one, as in man. The relative shortness of
the roots in human teeth is also the exact opposite
of that found in the orangoutang. The volume
closes with an interesting chapter on the evolution
of types, in which the author concludes that modi-
fications in dentition are in part the expression of
hereditary constitutional factors, concerning which
nothing is at present known.
The volume contains 100 illustrations and a com-
plete and very satisfactory index. For the student
of mammalian dentition the book can be highly
recommended; for the busy practitioner it could
have been made more valuable by a brief summary
at the end of each chapter.
^
Births, Marriages, and Deaths.
Died.
Ada MS. — In Rochester, N. Y., on Monday, December
Qth, Dr. Reuben A. Adams, aged seventy-seven years.
Beyer. — In Washington, D. C, on Sunday, December
6th, Dr. Henry G. Beyer, Medical Director, XJ. S. N., re-
tired, aged sixty-eight years.
BowEN. — In Springfield Mass., on Thursday, December
5th, Dr. David D. Bowen, aged eighty years.
Brumm. — In Kansas City, Mo., on Tuesday, December
.3d, Dr. William Brumm, aged fifty-three years.
Carr. — In New York. N. Y., on Saturday, December
7th, Dr. David Cole Carr, aged seventy-four years.
Case. — In Hamilton, Canada, on Thursday, December
5th, Dr. Alfred John Case, aged eighty-seven years.
Fitch. — In Crawfordsville, Ind., on Friday, December
6th, Dr. Alexander P. Fitch, aged seventy years.
FiTZGiBBON. — In Racine, Wis., on Wednesday, December
4th, Dr. James Fitzgibbon, aged fifty-four years.
Ford. — In Loomis, N. Y., on Sunday, December ist, Dr.
James S. Ford, aged thirty-three years.
HiMES. — In Baltimore, Md., on Friday, December 6th,
Dr. Charles Francis Himes, of Carlisle, Pa., aged eighty-
one years.
Kelly. — In Manajmnk, Pa., on Friday, December 6th,
Dr. Joseph Vincent Kelly, aged seventy-four years.
Miller. — In Denver, Colo., on Saturday, November 30th,
Dr. William A. Miller, aged seventy-one years.
Nolan. — In France, in November, 1918, Dr. Martin
Francis Nolan, Lieutenant, Medical Corps, U. S. A., of
North Tonawanda, N. Y., aged thirty-four years.
Perkins. — In Cliftondale Mass., on Friday, December
6th, Dr. Thomas T. Perkins, aged forty-four years.
Wallace.— In New York, N. Y., on Monday, December
Qth, Dr. Guy Halifax Wallace, aged thirty-two years.
Weyant. — In Pleasantville, N. Y., on Thursday, Decem-
ber I2th, Dr. Charles C. Weyant.
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal Medical News
A Weekly Review of Medicine, Established 1 843.
Vol. CVIII, No 26.
NEW YORK, SATURDAY, DECEMBER 28, 1918.
Whole Nt>. 2091.
Original Communications
PREVENTIVE MEDICINE AND THE RE-
CONSTRUCTION OF THE RACE.*
By Frederick Peterson, M. D.,
New York.
I take particular pleasure in coming before this
distinguished body of medical men in Buffalo, hav-
ing once lived and practised here. In looking over
the list of your presidents I note that most of them
were old and dear friends of mine. I used to read
medical papers, such as they were, to the patient,
long suffering profession in Buffalo some years be-
fore this academy was founded. Indeed, it is
thirty-five years since I left you, and I feel it is a
duty to make some report to you, to say something
of interest, even if it is only a record of more or
less failure and a somewhat misspent life. There
is no harm in being personal among my oldest
friends. If one cannot be a shining example, one
can at least be a glaring one.
You see I have spent most of these thirty-five
years in repairs, relief, and consolation. Repairs,
relief, and consolation are very good in their way,
very good if well done, but I have awakened to
the fact that these things are not enough. The
awakening should have come long ago — before the
war which has shaken up the general conscience
and made a test of our efficiency in all fields of hu-
man enterprise and conduct.
In the old days we had a good many abstract
ideas in regard to preventive medicine, we had
some very particular ones in relation to communi-
cable diseases, to be sure, but outside of these oui
ideas were abstract, divorced from actual practice
where they concerned neurotic and inferior chil-
dren, the feebleminded, the epileptic, the insane, and
such questions as heredity, ill assorted marriage,
alcoholism, venereal diseases, pauperism, and crime.
Well, war came and in the first selective draft of
young men between twenty-one and thirty-one
years of age, of over 2,500,000 examined, thirty-
eight per cent, were rejected for physical and men-
tal defects. Nearly a million men rejected in the
best and healthiest period of their lives!
Such figures as these have led many to inquire
what the matter is with the young men who have
just come from the schools in this condition. They
were the school children of yesterday. Is there any-
thing wrong with the training in the schools? The
•Address delivered before the Buffalo Academy of Medicine,
October 9, 1918.
answer is found on investigation of the physical
condition of the school children of the present time.
Very careful studies have been made for some
years past, and the best authorities declare that
seventy-five per cent, of our present 22,000,000
school children show physical defects, most of them
preventable and remediable, such as heart and lung
diseases, disorders of sight and hearing, diseased
adenoids and tonsils, flat feet, weak spines, imper-
fect teeth and malnutrition, and among them one
per cent, of mental defect. The children in the
country schools are worse off than in city schools.
There is little or no adequate supervision of the
bodies of children in the schools and no education
in health worthy of mention.
Now if we are to have a strong healthy race it
is necessary to begin with the children at once.
Doctor Holmes once said the education of a child
should begin a hundred years before it was born.
We should begin now the education physical and
mental of the race that is to be. Children are our
greatest national asset ! They are the nation that is
to be. It is twenty-four centuries since a great
philosopher (Mencius) said, "The root of the em-
pire is in the State. The root of the State is in the
family. The root of the family is in the individual.
As for the people — encourage them ; lead them on ;
rectify them ; straighten them ; help them ; give
them wings !"
We have been unconsciously led to look upon
these human assets as negligible, compared with
property. When human beings were slaves they
were property and as such as carefully fostered as
other live stock. You may be sure there were
plenty of good veterinarians to look after them.
But as freemen they are no longer property. As
far as the law can fix a value it has been standard-
ized at between one and two thousand dollars
apiece in various States. Many domestic animals
have commanded a larger figure as property. Most
of our laws are made by lawyers. Their interests
lie wholly in property and their profession leads
them out of touch with humanity except in the
matter of quarrels, crimes, and divorces. They be-
come our statesmen and lawgivers, but too often
without the broad vision that statesmen should
have. A true statesman, one like Doctor Clemen-
ceau, for instance, knows that children are the
State's best property, outranking lands, produce,
mines, water power, live stock, forests, railways.
Billions of dollars are spent upon these purely sec-
Copyright, 1918, by A. R. Elliott Publishing Company.
iio6
PETERSON: RECONSTRUCTION OF THE RACE.
[New York
Medical Journal.
ondary interests, but it is a hard road in our legisla-
ture to do away with the ruin of children in fac-
tories and mines. It is almost impossible to get
two or three cent lunches established in schools to
be paid for by the children themselves. It is very
difficult to secure the smallest health measure de-
manded for the children's welfare.
It is not easy to get official figures as to expendi-
tures by the federal government and the various
States in the relation to matters which would be of
special interest here, but the Public Education
Association of Buffalo has kindly furnished me the
following statistics which in themselves speak
volumes :
TOTAL EXPENDITURES BY THE FEDERAL GOVERNMENT
rOR THE FOUR YEARS, I914-I917.
Plant industry (experiments) $8,301,903.27
.A.nimal industry (experiments) 7,169,664.40
Foot and mouth disease 4,436,640.86
Hog cholera and durine (investigation) 522,273.07
Children's bureau 496,413.05
We might add here one more item out of dozens :
Improving rivers $81,331,454.94
This last item is usually part of what is called
the annual "pork barrel," immense sums spent
foolishly each year on post offices in small towns
and unnavigable creeks, etc., as sops to our law-
givers' constituents.
PREPOTENCE OF INFERIORITY.
We are sending the best we have to the battle-
fields of France and Flanders ; we are retaining
the thirty-eight per cent, of imperfect citizens to
leaven the race of tomorrow. We are doing as
far as I know nothing remedial for these thirty-
eight per cent, of rejected boys already grown and
nothing for the 16,500,000 defective school chil-
dren. There is such a thing as the prepotence of
inferiority. Perhaps this prepotence of inferioritj'
has been going on for centuries in many of the
world states. Among autocracies we have a record
of insane and imbecile kings and emperors. It has
been possible in a democracy like ours for a moron
to be elected as mayor of a city and an imbecile as
governor of a great State; and it may easily be
imagined that the smaller offices in our legislatures,
county boards, and city councils, overflow with the
inferior and the unfit. Thus we get perhaps what
we deserve in the way of government, laws, and
customs.
Let us come back for a moment to the grown up
people. You have heard of the Life Extension In-
stitute. They examined a large number of business
men of the average age of thirty years, connected
with banks and commercial houses, a group char-
acterized as orderly, temperate, and well nourished,
a preferred class as regards health insurance. The
results were as follows: Three in 100 were normal,
eight in 100 were seriously impaired, thirty-eight
in 100 had minor remediable ailments, fifty-one in
100 had semiserious ailments in the curable stage.
Over ninety per cent, of those ill with minor and
semiserious disorders did not know they were ill.
Thinking of all these things has led me to feel
that I have not done my whole duty in keeping
busy all these years at repairs, relief, and consola-
tion. If one may be allowed the paradox, the prac-
titioner should treat his patients before they come
to him as patients. There is something to be said
in favor of the reputed Chinese method of practis-
ing medicine, the family paying the doctor as long
as they are well. If any one gets sick the doctor
pays him. If the patient dies a lantern is hung
before the doctor's door. This system has its
nierits in view of the facts. Now the question
arises how are we to get over the matter of health
to every man, woman, and child in the country?
It seems to me a very long road to try to accom-
plish this by occasional health lectures and by occa-
sional health exhibits at fairs and conferences. The
matter is too pressing, too imminent for sporadic
health meetings and our usual methods of propa-
ganda. The people are awake now to reform and
progress, ready to change their wornout old ideas
for new and better ones. The time is ripe for this
revolution and I think it can be brought about
through the doctors and through the children in the
schools.
Suppose every doctor should confess to himself
that he had left preventive medicine too much to
the health department of his community and been
too well satisfied with his work in, let us say, the
fire department. He has rushed in helpfully to
put out the fires of fever when they were well
started. But the fires should never have been al-
lowed to start and gain headway. Let him say to
all his friends and to the relatives of his patients :
Every adult citizen of the State, man or woman,
has three patriotic duties in his country's service
in the matter of health. These are: i. To take
care of his own health by periodical examinations ;
2, to insist on proper health conditions in his own
home, in the schools which his children attend and
in the places where he works ; 3, to safeguard and
cultivate the health of his children. The doctor
should explain the rudiments of personal hygiene,
how the delicate machinery of the body should have
at least as much attention as a man's watch, sewing
machine, typewriter, or automobile ; then the rudi-
ments of public health in the matter of the con-
tagious diseases, which mean little more than the
destruction of germs that come from the mouth and
intestines of the sick and get into the air, food,
milk, and water supply ; and thirdly, the health of
the children. He could intimate too that damages
might be collected from a community whose water
supply had been the cause of typhoid fever in a
family ! Recently in one of the largest Middle
\\'est cities there were 4,000 cases of smallpox
due to the fact that there was no- compulsory vac-
cination because the wife of the mayor was a Chris-
tian scientist ! Four thousand suits for damages
against the city might well succeed in a case like
this where the city government is responsible for
the outbreak and where we have a disease whose
absolute prevention is the chief triumph of medi-
cine in the history of communicable diseases. The
filing of four thousand suits for damages would
rouse the community.
CHILD HEALTH PROGRAM.
Now we come to the child health program. We
can regenerate the nation through the children in
the schools, and by ten minutes daily of proper
December 28, 1918.]
PETERSON: RECONSTRUCTION OF THE RACE.
1 107
health education introduced into the curriculum of
the schools, we can carry over the whole idea of
good health as patriotic service not only to the chil-
dren in the schools, but through them to the parents,
and to the younger children of preschool age. You
may be interested, possibly amused or troubled, by
a conversation that I had the other day in Washing-
ton with — well, I will not mention his name, but one
of the supreme federal public health officers. I
said : "The covmtry seems alive to betterment in
health and it is a wonderful opportunity to launch
a national health program." He was enthusiastic
and said, "It certainly is and we are going to do
a big concrete thing. See what we have done for
our armies in the way of typhoid prevention. Why
should we not do that for the whole civic popula-
tion?" 1 asked what he meant by that, and he
answered, "We are going to get an appropriation to
inoculate 25,000,000 citizens with antityphoid se-
rum." I was aghast, and said : "Do you mean that
in New York, for instance, where we have annually
eight deaths in 100,000 from typhoid that you woul.l
inoculate the entire 5,000,000 population of the city
with typhoid serum? This typhoid is brought
mainly from infected water supplies in towns and
villages remote from New York, and inoculation
would be preventive only for a limited time. Would
not the expense be unduly large for what would be
accomplished? Perhaps a part of the huge sums
spent on improving rivers could be used for getting
rid of typhoid germs at their source in the waters
of the country, instead of inoculating our 100,-
ooo.O(X) population."
He saw no force in this argument, but kept in-
sisting that what the congressmen want is some-
thmg concrete and distinctly visible. He said the
child health program which I explained to him, and
will now explain to you, was too abstract, vague, and
distant. I confess I was paralyzed by the bureau-
cratic outlook, and did not call attention to the
monies spent by various government bureaus on the
following more or less abstract, vague, and distant
objectives :
FEDERAL EXPtNDITUEES FOR THf: FOUR YEARS I914-I917.
Tmproving harbors $73,698,473.89
Improving rivers 81,331,454.94
Special funds for rivers and harbors 4,663,438.94
Acquisition of lands for protection of water-
sheds, navigable streams 5,449,099.22
Experiments in animal industry 7,169,644.40
Experiments in plant industry 8,301,903.27
Foot and mouth disease 4,436,640.86
Seeds 1,025,738.80
Meat inspection 13,033,180.34
Reclamation fund 30,684,923.60
Forest service 13,591,024.46
Public buildings, sites, construction, equip-
ment 48,074,768.69
Public buildings, maintenance 21,347,436.27
The child health program is a scheme of organ-
ized care of children from before birth to their
vocational graduation at twenty or twenty-one.
One would like to see coordinated to this end all the
organizations now at work for the conservation of
our citizens — the maternity classes, the baby saving
societies, the mothers' committees, the kindergartens,
the child welfare leagues, the physical training
bodies, the seaside, countryside, and sunshine
associations, all that have to do with preschool wel-
fare, then the public schools, tht.. child labor commit-
tee, the mental hygiene association, vocational trahi-
ing bureaus, the boards of education and the boards
of health. I have told you of the physical defects
in the seventy-five per cent, of the 22,000,000 school
children of the country. It is probably the truth
that the greater part of this physical disorder is
malnutrition, depending to some extent upon insuf-
ficent food, to a very large extent upon improper
food, and also in a measure upon certain remediable
defects and unhygienic habits. Now the child is a
growing animal and we have established normal
averages in his rate of growth and in the relation of
his weight to height. Improper food or insufficient
food affects these normal averages. Physical dis-
orders also affect the rate of growth and the ratio
of weight to height. Hence in children we have a
standard scale of ration of weight to height and
relative monthly growth from year to year which
can be tested by parent, teacher, or physician. If a
child is under weight and does not show the normal
monthly gain for his age, the amount and quality of
his food can be regulated by parent or teacher. If
it is simply malnutrition this remedies it. If no
gain follows there is some physical cause or unhy-
gienic habit at work needing investigation by a
physician. Thus a very practical step can be taken
at once by the introduction of the scale and meas-
uring rod into every school and following that, the
introduction of the school lunch system everywhere,
so that the children may buy at wholesale prices the
900 to 1,200 calories they require for a noon day
meal, instead of squandering their pennies and
health on pickles and hoky-poky ice cream.
Some of you may have heard of the demonstra-
tion we had in New York last winter. Public
School 40 has several thousand pupils. Twenty-five
undernourished boys between nine and twelve years
volunteered to eat a luncheon that was given to
them for three months, in order to show other boys
that it is a patriotic duty of every child to grow
strong and healthy for his country's sake. They
were called food scouts. Their diet at home con-
sisted mainly of tea, coffee, bread, macaroni and a
soup with little food value. The luncheon given was
intended to supply the 900 to 1,200 calories required
and to teach to the children and their mothers the
superior value of milk, cereals, fruits, and vege-
tables, and of pea and bean purees in the place ot
thin meat soups. Fifteen of the boys gained from
one to four pounds more than the average gain of
normal children in the three months. Seven gained,
but less than the average (of these four failed to
gain because of colds, sore throats, and other minor
illnesses). Three did not make any gain. The
chief value of this experiment lay in the facts, that
in addition to a gain in weight by most of them,
on one improved meal a day, they learned to coop-
erate as a group for a patriotic purpose, they
learned to eat new and unaccustomed foods, their
mothers came to the school to find out what these
new foods were on which their children became
stronger and healthier, and the children learned
about food values and food habits. It was not only
an experiment in malnutrition, it was one in Ameri-
canization.
iio8
LA ROQUE. TREATMENT OF APPENDICITIS.
[New York
Mei>ical Journal.
The large program \vc have is to break into the
curriculum of the schools and establish education in
health, especially in food knowledge and food habits
as a vital and essential part of teaching. From the
schools the health instruction will be carried home
to the parents and younger children, and soon the
whole movement of reconstruction will permeate the
State.
This is a summary of the program: i. That the
teachers themselves be given better conditions for
their own health and fuller instruction in all that
has to do with the laws of health.
2. That every city and country school be made
sanitary and kept so and the school and its grounds
should be as beautiful as possible, not only for the
benefit of the teachers and the pupils but as an ex-
ample to all other citizens who are beginning to use
the school more and more as a community centre.
3. Every child should be regularly weighed,
measured and examined and a health record kept,
\yhich should accompany him throughout his school
life. It should be the duty of the authorities to see
that the defects of our young citizens are corrected,
disorders of growth and nutrition remedied. As
malnutrition is one of the most serious conditions, a
hot luncheon should be made available for every
child and every teacher. The health examination
should include dental inspection and treatment.
4. Each school should have adequate provision for
physical training, gj-mnasiums, athletic fields, play-
grounds, gardens, and shops together with especially
qualified instructors in physical training and voca-
tional fields.
5, Finally, with the foundations outlined above, a
thorough system of instruction in all matters per-
taining to health with special emphasis upon health
problems rather than upon disease, in physical and
mental habits, in personal hygiene, in public health
and sanitation, in methods to avoid communicable
diseases, in the responsibilities of parenthood, and
in all that relates to nutrition and growth, including
foods and food values and food habits.
PLACE OF THE FEDERAL GOVERNMENT.
This scheme is one that should be undertaken by
the federal government, much as has been done
with plant and animal culture and protection. It
is too important to be left to uncertain initiative of
the various States. We ought in truth to have a
children's administrator with power to coordinate
and direct all the various child welfare agencies and
to compel the introduction in the schools of a sound
and complete health program, a Herbert Hoover for
the children of the United States.
With all this in view and after months of careful
planning the National Child Health Organization
has been formed whose literature is now being dis-
tributed. Do the first practical thing for a begin-
ning. The teachers can place scales and a measur-
ing rod at once in every school and with the height
and weight and age charts that will be sent on re-
quest the campaign can be immediately started
against one of the chief evils, namely malnutrition.
The Child Health Organization has some of the best
teachers and organizers in the country as members,
and counts on its board the foremost medical
specialists on children and public health. Its publi-
cations will be supplied on request to all who desire
them. The office of the Child Health Organization
is at 156 Fifth Avenue, New York; Dr. L. Em-
mctt Holt is chairman. Some of the other medical
members are : Dr. S. McC. Hamill, Dr. G. R. Pisek,
Dr. Victor G. Heiser, Dr. Thomas D. Wood, Dr.
Bernard Sachs. Dr. Hermann M. Biggs, Dr. H. D.
Chapin, Dr. Simon Flexner, and Dr. William H.
Welch. Among the educators are Charles W.
Eliot, Cambridge, Mass. ; President Thomas, Bryn
Mawr, Pa. ; Albert Shiels, Los Angeles ; William
Wirt, Gary, Ind. ; and Dr. John H. Finley, Albany,
N. Y.
20 West Fiftieth Street,
RESULTS OF TREATMENT IN SIX HUN-
DRED CASES OF APPENDICITIS.
Standardiaation of the Surgeon.
By G. Paul LaRoque, M. D., F. A. C. S.,
Richmond, Va.
The efficiency on the part of individual surgeons
in the management of appendicitis can be standard-
ized, provided the results of all the patients oper-
ated upon by each surgeon are truthfully reported.
The standard of efficiency will be set up by the one
whose products show the lowest mortality, the few-
est complications, the smoothest and speediest con-
valescence, the greatest number of complete cures,
and the fewest sequelae. By the.se standards the
results of others may be measured.
The treatment of various types of the disease,
the stage at which it is best to perform the opera-
tion, the best technic to be employed, whether to
drain or not to drain the particular case, whether
to remove or not to remove the appendix in certain
cases of abscess, the treatment after operation, the
length of time patients should remain in bed after
the operation; these and other questions of judg-
ment can with more convincing reasons be standard-
ized upon the basis of an intelligent study of the
results shown by published reports of actual cases
treated by dififerent methods, than by discussions
of theories, preformed opinions, or even the asser-
tion of some textbook or journal authority unless
substantiated by demonstrable results, in the crucible
of experience.
- Standardized beliefs as to the patholog}' of ap-
pendicitis, based upon observation of the structure
in the belly, suggests classification into at least two
types: i, Pure appendicitis; 2, appendicitis with
local peritonitis. When the progress of the disease
is unchecked, the inflammation spreads to the perito-
neum beyond the appendix, to the region about the
cecum and small bowel or omentum in the iliac
fossa, constituting another type ; 3, appendicitis with
regional peritonitis with or without walled of? ab-
scess. In yet later or more vicious cases, perito-
nitis beyond the iliac fossa in more remote areas
constitutes still another type : 4, appendicitis with
difTuse or spreading peritonitis. These four types
of appendicitis and its peritoneal complications are
recognized daily by surgeons the world over, and
should be quite acceptable as a standard classifica-
tion of the disease yielding the highest percentage
December 28, 1918.]
LA ROQUE: TREATMENT OF APPENDICITIS.
1 109
of correct estimations of the pathology present and
the fewest errors of judgment upon which treatment
may be based.
There are other classifications in common usage.
Some of them have yielded and will continue to
yield, even to the most expert clinicians, many errors
of diagnosis and of judgment. If we classify
patients we may say they are sick, acutely or chron-
ically, severely or slightly, temporarily or perma-
nently, with appendicitis ; or that the symptoms are
fulminating, advancing, subsiding, recurring and so
on, in terms limited only by one's vocabulary, de-
scriptive of symptoms and clinical course, but not
acceptable by the scientific minds of trained pathol-
ogists as standard nomenclature for pathology.
Such terms are altogether relative and so apparent-
ly dependent upon the point of view that the ele-
ment of personal equation may cause us to be mis-
led into embarrassing surprise when we discover
a rotten, ruptured appendix with spreading perito-
nitis in a stoical person with a bold smile, no fever,
and slight leucocytosis, who has often had "similar
attacks" before ; or into disgusting chagrin when we
remove a slightly thickened, perhaps strictured, al-
most normal appendix at midnight from a young
fellow who says he is writhing in agony, tossing
with the belly ache, ^cannot stand being touched, and
in whose blood an inexperienced blood examiner
finds "polys" and leucocytes galore. Such mistaken
diagnoses are quite as often of the patient as of the
disease. The definition of the terms acute and
chronic are altogether inexact. To say a patient is
slightly or severely sick means little to the fellow
who is not sufifering. The margin of possible error
in interpreting pathology upon the basis of terms
referring to the clinical course and severity of
symptoms is too great to rival for purposes of
standardization a classification based upon the
pathology of the appendix and its peritoneal exten-
sions. For the disease, therefore, let us abandon
its classification into acute and chronic though we
may continue to use these terms in thinking of the
severity and duration of the patient's illness and
symptoms, provided we guard very cautiously
against any effort to judge the pathological findings
in a given case by the duration of the disease as
estimated by the clock or calendar, or the severity
of symptoms as estimated by the toleration or in-
toleration on the part of the patient to pain or by
the number of leucocytes and "polys" found by an
amateur hematologist at a single hastily made ex-
amination of a speck of blood.
In the present series of 600 cases, thirty per cent.
(180 cases) were pure appendicitis; forty-two per
cent. (253 cases) appendicitis with local peritonitis;
twenty-four per cent. (142 cases) appendicitis with
regional peritonitis; and four per cent, (twenty-
five cases) appendicitis with diffuse spreading peri-
tonitis. There were loi cases of abscess — over six-
teen per cent, of all cases of appendicitis and over
seventy per cent, of those of regional peritonitis.
Considering the incidence of the disease with ref-
erence to sex and age, sixty per cent, of the present
series were in females and forty per cent, in males ;
seven per cent, (forty-two cases) were in children,
and two per cent, (twelve cases) in people beyond
fifty years old. While the disease is tberefore
slightly more common in females than in males,
and much more common in the ages between pu-
berty and the fifth decade, the type of the disease
is much more apt to be complicated by peritonitis
in men and in children, and by gallbladder and
stomach disease in old people. Thus of the 147
cases of regional and diffuse peritonitis over two
thirds were in males ; and of the 142 cases in
children, approximately three fourths of them re-
quired drainage for peritonitis. While these ob-
servations, with reference to age anrl sex incidence
of suppurative peritonitis are recorded as interest-
ing and of practical importance let us not be too
hasty in attributing the cause of suppuration to age
and sex. There remain one third of the cases of
appendix peritonitis in children and in females ; and
in one fourth of the cases of appendicitis in children
pus formation beyond the appendix had not oc-
curred at the time of operation. Daily observations
of almost indisputable proof have caused the writer
to believe that even in children the most potent
factor in the production of pus is peristalsis pro-
duced by purgatives.
In the men of this series ninety per cent, were
operated upon solely for appendicitis and its peri-
toneal complications. In approximately 150 women
m the present series of 600 cases of appendicitis
(fifty per cent, of those between puberty and fifty
years old) pelvic disease was present; and in ninety
per cent, of these the pelvic disease was operated
upon at the time the appendectomy was performed.
In the more recent cases we have succeeded in
ninety-nine per cent, of cases of coincident appen-
dix and pelvic disease in women in curing all the
pathology at one operation. At this point it is in-
teresting to note that in nearly 300 women in this
series of appendicitis, sixteen cases, or approxi-
mately five per cent., had been operated upon pre-
viously by other surgeons for pelvic disease and
their appendices allowed to remain, and they sub-
sequently had to be operated upon by the writer
for pelvic disease. Conversely, of 500 women op-
erated upon for pelvic disease, twenty-five (five per
cent.) had been operated upon previously by other
surgeons for appendicitis and their pelvic disease
allowed to remain for a second operation. This
gives a ten per cent, error of judgment (resulting
in a second operation) on the part of those surgeons
who, on the one hand, are rather timid about taking
out normal appendices when operating primarily
for pelvic disease and, on the other hand, rather
quick in performing emergency operations upon
women for appendicitis. A standard practice
should be to cure all pathology at one sitting. This
statement does not imply that there are not excep-
tions to this practice, but upon the surgeon who
makes the exception should be placed the burden
of defense of his position.
Of approximately 250 women between the ages
of puberty and the menopause, six (2.5 per cent.)
were operated upon for appendicitis while pregnant.
All were clean cases, all performed through muscle
splitting incisions, and all went through normal
pregnancy labor and puerperium without compli-
cation.
1 1 10
LA ROQUE: TREATMENT OF APPENDICITIS.
[New York
Medical Journal.
Four per cent, of the 600 cases were also operated
upon for hernia and two per cent, for gallbladder
and stomach disease. More diligent search, better
surgical judgment, and less haste in emergmg upon
patients would add to our efficiency in Demg able
to cure, at one operation, a greater number of
patients with hernias and gallbladder disease exist-
ing coincidentally with appendicitis.
Concerning the duration of symptoms before op-
eration, they varied from a few hours to several
years. We have frequently seen a ruptured appen-
dix and regional peritonitis within twelve hours
after the initial pain and have equally as often seen
a very slightly diseased appendix in patients who
had been sick for several days or weeks. I am
therefore convinced that the pathology is not guided
by the hands of the clock, and have long ago deter-
mined that the urgency for operation is less depend-
ent upon the duration of the illness than upon the
clinical picture presented. Careful observation of
several thousands of cases has aroused in me a
strong suspicion that the most dangerous operation
a patient can have for abdominal pain is the "opera-
tion of the bowels" from the administration of
cathartics. It is no longer open to doubt that the
severity of appendicitis is much more intensified by
the administration of cathartics than by the passing
of time. Applying this principle to the treatment
of the disease, many surgeons have become convert-
ed to the belief that when peristalsis is perfectly
pacified by the withdrawal of all food and the ad-
ministration of ample doses of morphine, it is fre-
quently proper and sometimes wise to postpone op-
eration until the patient can be placed in a proper
hospital under the care of an experienced surgeon.
The results obtained by this method of procedure
are so greatly superior to results obtained by occa-
sional operators doing emergency operations upon
patients in their homes or improperly equipped hos-
pitals as to justify the belief that emergency opera-
tions by unskilled surgeons upon patients in their
homes or improperly equipped hospitals is mis-
chievous in its efYect upon mortality and morbidity.
As a matter of fact, in the patients in this series of
600 cases the clinical history and the appearance of
pathology presented strong evidence that at least
fifty per cent., and probably seventy-five per cent.,
of the patients operated upon had had the disease
for from three days to several weeks before opera-
tion and some had had many recurrences of acute
symptoms during months and years.
Between forty and fifty per cent, of patients op-
erated upon came to Richmond from other parts
of the state and from neighboring states, and
many came from remote country areas, traveling
in trains, automobiles, and horse drawn vehicles.
In no case has travel seemed to influence the sever-
ity of the disease and in most patients the avoidance
of purgation, withholding of food, and the admin-
istration of morphine during the period necessary
to wait, has seemed to produce genuine benefit.
COMPLICATIONS AND RESULTS.
A few cases of malaria characterized by a single
paroxysm of chill, fever, and sweat occurring five
to ten days after operation, in patients coming from
malarial districts, have been promptly relieved by
quinine. One patient had typhoid fever.
Postoperative bronchitis of mild grade has been
recognized in approximately two per cent, of the
total series and in perhaps ten per cent, of the cases
of Types 3 and 4. Between fifty and seventy-five
per cent, of the abscess cases had bronchitis previous
to the operation, and in two cases of subdiaphrag-
matic extension of appendiceal abscess right basic
pneumonia and pleurisy were recognized before op-
eration and promptly subsided after loosening
of the lung and bronchial disease by the best ex-
pectorant, ether, and removing the cause of the
respiratory disease by drainage of the appendiceal
abscess. There have doubtless been many cases of
localized pneumonia overlooked, but we have had
no serious trouble from this source, and regard
bronchial and pulmonary infections when second-
ary to appendicitis as urgently calling for operation.
In the entire series of 600 cases there have been
two cases of postoperative acidosis recognizable by
stupor and unmistakable urinary findings. They
were both in large abscess cases of many days' dura-
tion before operation in children.
One case of postoperative acute chorea developed
in a child seven days after operation. This case
was exceedingly interesting. Three days before
appendicitis she had tonsillitis, appendectomy was
performed promptly before suppuration occurred ;
seven days after operation she showed violent
chorea ; two weeks later, malignant endocarditis ; a
week later, cerebral embolism.
There have beeri two cases of femoral phlebitis
in the 600 cases, both of the right thigh, both in
men, and both following operation in abscess cases
— practically two per cent, of abscess cases.
Excessive vomiting is largely dependent upon the
point of view and definition of excessive. Vomit-
ing has been rare after twelve hours. Bilious
vomiting has uniformly been relieved in the dozen
cases of this series by a single washing of the
stomach, by drinking warm water, or through the
tube. There hnve been four or five cases of suf-
ficient epigastric distention to be designated dilated
stomach, all but two promptly relieved by tube
lavage. There was one case of severe stomatitis,
two cases of fecal impaction, two cases of hematuria
due to hexamethylenamin.
In approximately three per cent, of cases there
was retention of urine after operation, necessitating
catheterization from one to three times. Most of
the "necessity" for catheterization is not necessary.
There is a trick about emptying the bladder which
])atients have to learn, and if sixty to 100 grains of
hexamethylenamin are in the first quart of water they
drink after operation, the bladder irritation of this
drug usually teaches them the trick. By constantly
teaching nurses and house doctors that the catheter
should not be used according to the clock but ac-
cording to the bladder, it is exceedingly rare for a
patient to have to be catheterized.
Wound infections and hematomas in clean cases
occurred in about one per cent. In no case has this
ever been serious, though it has caused the patient
to have to stay in bed from two to five days longer.
Careful study of wound infection has convinced me
that fully ninety-nine per cent, of them are not in-
December 28, 1918.]
LA ROQUE: TREATMENT OF APPENDICITIS.
1 1 1 1
fections per se, but are the result of the breaking
down of small collections of blood beneath the skin.
There have been no wound infections which in my
opinion could be attributed to lack of asepsis in the
technic. For some curious reason one almost never
sees wound infection in drainage cases.
Three of the 600 cases developed fecal fistula
after operation. All three were large abscess cases,
two in patients with obvious tuberculosis of the
bowel and advanced disease of the lungs, one in a
boy with large abscess of two weeks' duration com-
plicated by gangrene of the cecum. The latter case
healed in three weeks. The two in tuberculous
bowel cases never healed, both patients dying of
tuberculosis six months and eighteen months re-
spectively after operation.
One large abscess case was followed by annoying
sinuses of the abdominal wall which I attribute to
infection of a blood clot beneath the aponeurosis of
the external oblifjue muscle.
Of the total 600 patients operated upon, there
were four deaths — a mortality of three fourths of
one per cent. One was the case of a woman seven
day? following operation for a case of appendicitis
and peritonitis of erysipeloid appearance ; one, a
man with appendicitis with gangrene and large hole
rupture of the appendix and diffuse cathartic peri-
tonitis seven days following operation ; and two
boys almost moribund with diffuse cathartic peri-
tonitis, one dying in three hours and the other in
thirty-six hours following operation. For these
deaths I offer no excuse, save that I was not suf-
ficiently skillful to save them.
Ninety-eight cases of abscess, including twenty-
two cases of diffuse peritonitis, were saved. In
these prompt drainage, and in ninety-four of the
ninety-eight cases appendectomy at the same opera-
tion resulted in saving life and eliminating the
dangers, the anxiety, and time required to carry out
the morphine saline stomach tube and cold storage
treatment before operation and the prevention of
long draining sinus, the recurrent symptoms and
dangers of recurrent illness and second operation
due to appendicitis of the stump after simple drain-
age of an abscess. There have been no postopera-
tive obstructions, no hemorrhage, no peritonitis or
secondary abscess, no anesthetic disasters, no
cardiac or pulmonary embolism, no catastrophes.
The duration of the patient's stay in bed follow-
ing operation depends upon the incision employed
and whether or not drainage is employed. After
the muscle splitting incision closes completely, pa-
tients are out of bed in from three to seven days,
fifty per cent, in five days. Median and groin in-
cisions necessitate confinement to bed for from ten
to sixteen days ; ninety per cent, of these are out of
bed in twelve days. Cases requiring drainage are
in bed from twelve to sixteen days.
In all cases of uncomplicated appendicitis, in
which only appendectomy is called for by the needs
of the patient, operation is performed through a
muscle splitting incision, following which the patient
is out of bed in from three to seven days.
After making careful observations of several
hundreds of cases of healthy patients who sat up
on the third to the fifth day following an easy ap-
pendectomy through a small muscle splitting in-
cision in the extreme southeast corner of the abdo-
men, my surgical judgment convinces me that long
confinement to bed is not necessary for wound
healing. I seriously challenge the belief that any
case of postoperative hernia has ever occurred as a
result of a patient sitting up that would not have
occurred as a result of vomiting, coughing, or
sneezing while in bed. Our own experience is that
no hernia has developed and no ill effects have oc-
curred after early rising.
Concerning postoperative hernia, I consider every
case which has to be drained as having a rupture
of the abdominal wall as soon as the operation is
performed. I have always instructed every patient
to report if a hernia should occur, but since only
one has so reported, I am satisfied that patients are
a little timid about reporting unpleasant sequelae.
The opportunity to reexamine, at the end of three
to six months, a large proportion of the cases which
had to be drained, and failure to find but one case,
leads me to believe that postoperative hernia is ex-
ceedingly rare following the muscle splitting incision
even if drainage has to be employed, provided we
use small instead of large drainage tubes and care-
fully place sutures between the tubes when more
than one is employed. Two or three small holes
would seem less apt to be followed by hernia than
one large one. I feel, however, that some of the
patients drained may have developed hernia later
and reported the fact to their doctor and friends
rather than to me.
The follov/ing questions can be answered by the
experience gained from the present series of 600
cases.
1. Can the disease be cured without operation?
No. If it could have been the present 600 cases
would not have been operated upon. All of them
had appendicitis and its results. Approximately
ninety per cent, had had repeated attacks of illness
from the disease and had been treated by non-
operative measures for many attacks before coming
to operation. In about ten per cent, of the 600 cases
the attacks for which they were operated upon were
the first, and in over a half of these nonoperative
measures were employed for from one day to sev-
eral weeks without relief of symptoms. A diseased
appendix cannot be restored to normal. The only
curative treatment of the disease is appendectomy.
2. Is immediate operation necessary? No. This
statement does not imply that the experience derived
from these 600 cases favors delay in performing the
operation, it is only intended to state that while it is
wise, if a good surgeon and a good hospital are
available, to perform the operation as soon after the
onset of the disease as is practicable, yet it is safe
to wait a reasonable length of time before operating,
so that the patient can be placed in a properly
equipped hospital under the care of an experienced
surgeon. The avoidance of cathartics, the with-
holding of food, and the administration of mor-
phme hypodermically in doses sufficiently large and
sufficiently often to pacify peristalsis and relieve
pain, have permitted 100 cases recently observed to
be properly made ready for operation during the
period of delay necessary to transmit the patients
III2
LA ROQUE: TREATMENT OF APPENDICITIS.
[New York
Medical Journal.
to a good hospital, and has yielded lOO per cent,
cures.
3. Should operation ever be deliberately post-
poned? In the majority of cases, no. In excep-
tional cases, yes. There are times when, for one
reason or another, it is actually wise to postpone
operation for a reasonable length of time; more-
over a large percentage of patients — especially
women — with appendicitis, have also other pathol-
ogy in the abdomen which of itself needs to be
cured and in which it is both good surgical judg-
ment and good common sense to place the patient
in the proper place to have all the pathology cured
at one time. Such patients should not be "emerged
upon" for appendicitis and allowed to continue to
suffer with the other abdominal disease until a sub-
sequent operation. In a series of 500 patients upon
whom I have operated for pelvic disease, five
per cent, of the women had had their appendices
removed previously by other surgeons, as emergency
operations. In a number of the cases of appendi-
citis in the present group, in women who also had
disease of the pelvic organs, I "emerged" upon them
for appendicitis and did not cure the pelvic pathol-
ogy, and the women still suffer with pelvic disease.
Some of them have had to be operated upon the
second time. In a goodly number of cases during
the past few years, I have deliberately carried pa-
tients through an acute illness of appendicitis on
morphine and starvation during a few days, wait-
ing so that they could be operated upon for pelvic
disease at the same time. The same applies to cases
of appendicitis complicated by gallbladder and
stomach disease. In many cases of this character I
have deliberately postponed operation for several
weeks so that we were able to operate successfully
on all the pathology at one time.
It must be borne in mind, however, that there
will still remain a few cases — approximately fifteen
per cent. — in which, instead of subsiding, the ap-
pendix disease will go on to abscess formation and
necessitate drainage. This need not be dishearten-
ing, for ninery-seven per cent, of abscess cases are
cured ; and the surgeon who argues that every case
should be immediately "emerged upon" under im-
perfect facilities must show a superior efficiency in
his personal results of such practice, or his argu-
ment is nonconvincing and open to challenge. The
fact remains, however, that whenever operation is
postponed the burden of proof of the wisdom of
the delay is upon the doctor who advises it, and
while it is generally safe and sometimes wise to
postpone operation until the patient can be placed
under efficient care, it is imperative that ample mor-
phine be administered, all food withheld, and all
cathartic remedies as scrupulously avoided as if
they were the poisoned water and treacherous ex-
plosives left in the land evacuated by a retreating
German army.
Under these circumstances not only will life be
saved, but frequently a long subsidence of symp-
toms will ensue. If, as is so often the case, cathar-
tics are administered by friends and relatives, and
morphine is not given, even yet the patient's life
can be saved in all but a small percentage of cases,
though drainage may have to be employed and con-
valescence will be tedious and stormy.
4. Which is the best incision ? In all cases in
which it is contemplated that appendicitis is the only
pathology needing treatment, a muscle splitting in-
cision is our standard. This has been employed in
ninety per cent, of the cases in men and in fifty
per cent, of those in women in this series of 600
cases. Muscle fibres were cut in one case only, and
this was many years ago, before we had learned
how to enlarge the muscle splitting incision. We
have succeeded quite satisfactorily by placing this
incision low, in exploring the pelvic organs of
women and repairing hernia and by placing it high,
in palpating the gallbladder and right kidney. In
a few cases of error of diagnosis we have removed
ovarian cysts and right tubes ruptured by tubal
pregnancy through this incision, though in cases of
appendicitis in which we found pathology in the pel-
vic organs, we have employed standard median
incision. We detest the incision through the
right edge of the sheath of the rectus muscle. The
difficulties in closing it, the pain following opera-
tion, the liability to hematoma formation, the adher-
ent omentum which is seen in the scar when re-
operating upon patients upon whom the right rectus
incision had been made by other surgeons, have
caused us to think that for appendicitis the right
rectus incision is vicious and I prefer the median
incision when I am forced to penalize my patients
for my lack of ability to diagnose their troubles.
Of this series of 600 cases five and one half per
cent, (thirty-two cases) required incision through
the middle of the upper portion of the right rectus
muscle for exploratory and therapeutic purposes
upon the stomach and gallbladder. In a few of
these more recently we have employed a high muscle
splitting incision (and much prefer it) for gall-
bladder drainage.
5. Shall the appendix always be removed in cases
of abscess? It would seem that the opinion of all
intelligent men would be that the ideal thing to do
is to remove the cause, namely, the appendix. In
the individual case there is a difference in the judg-
ment of the operating surgeon. It is so obviously
unwise to risk the patient's life that the question
hangs upon the decision of how much additional
risk is taken by a reasonable and skillful search for
the appendix. In abscess cases we have removed
the appendix in ninety-four per cent, at the first
operation. Three of the four deaths in this series
of 600 cases followed operation in abscess cases. In
two of these the appendix was seen without search,
and removed ; in the third it was not seen and not
searched for. I know other surgeons of good judg-
ment who consider it wise to make no search or
little search for the appendix at the primary opera-
tion, being content merely to open and drain the
abscess. I would plead with those who have adopted
this practice to publish their results as to the saving
of life, the duration of the patient's stay in the
hospital, and the necessity for secondary operation.
Surely we are not easily convinced that a patient
does not still suffer from appendicitis if the appen-
dix has not been removed. I have operated upon
six patients for appendicitis of the stump remaining
after the abscess had been merely drained. In one
of my own cases after draining an abscess, the sinus
continued to discharge pus until the second opera-
December 28. 1918.] CUNNINGHAM: A
tion was performed three weeks later, at which the
appendix was removed. In four cases in which I
merely drained the abscess, making no search for
the appendix, the wounds closed completely and
promptly, and I heard from the patients from three
to twelve months following operation, during which
time they said they were not sick. I believe, how-
ever, that they still suffer with appendicitis if they
have not been operated upon by some other surgeon.
In one of the three deaths following operation for
abscess, the appendix was not removed nor sought
for. I am anxious to compare my own results in
removing the appendix in ninety-four per cent, of
cases of abscess with the results of a number of
others who more or less, in a routine fashion, con-
tent themselves with incision and drainage of ab-
scess. We have also been favorably impressed with
the value of careful inspection of the omentum and
cecum in suppurating cases for localized collec-
tions of pus and gangrene of the omentum and ce-
cum. In many cases we have excised pieces of
omentum oil this account and in several have tucked
in or excised areas of gangrene of the cecum.
6. When and how shall drainage be employed?
In those cases in which all the pus is removed and
the stump turned in, drainage is unnecessary and
pernicious. Walled off abscesses should obviously
be drained. In cases of regional peritonitis in
which, even though the appendix is gangrenous,
there is no fecal matter in the cavity, and when a
"cloak" effusion characterized by beef broth con-
sistency and color or slightly tinged with yellow is
found, the incision may safely be closed after the re-
moval of the appendix and mopping up the fluid. The
old maxim, "When in doubt drain," has about been
changed to "When in doubt do not drain." The
best surgeon is he who is less often in doubt. Per-
sonal judgment must always enter into the practice
of surgery, and the best judgment is characterized
by the best results.
A BOLSHEVIK BOLUS.
By William P. Cunningham, M. D.,
New York,
Visiting Dermatologist to the Misericordia Hospital; Associate
Visiting Dermatologist to the Children's Hospital and
Schools, Randall's Island.
{Concluded from page io6j.)
Now the rational beings in this world have had
enough of the experiment tried in Russia ; they have
no desire to repeat it anywhere. The bubble of the
brotherhood of man under socialistic auspices has
blown up in a burst of terrorism and crime. Hav-
ing witnessed the climax of that orgy of lunacy and
hate they are rightly suspicious of every move indi-
cative of a tendency in that direction. It does not
matter in what syrupy diction the soidisant "uplift"
is couched, if it smells at all of "socialization" its
whfllesomeness is to be suspected, and as a matter
of precaution its adoption is to be rejected. We
must build a wall of iron wills against this insistent
and insidious assailant. In this wall no little rift
of carelessness or apathy must permit the insinua-
tion of the small end of the wedge. Mobilizing
doctors for the war needs of the army or the navy
is indispensable and proper. Mobilizing doctors for
BOLSHEVIK BOLUS. 1113
the care of civilians is unnecessary and demoraliz-
ing; even in war times, when the aforesaid civilians
are earning such increased remuneration for their
accustomed labor as to put them entirely beyond the
calls of charity. There may be situations where
the available supply of medical men for country dis-
tricts is inadequate because of the enrollment of so
many of them in the medical reserve corps ; but
the remedy for that is obviously not to take men
from such regions, but rather from the big cities,
where those remaining will adjust themselves auto-
matically to the augmented pressure. It has long
been the cry of the public that there were too many
doctors. Overlooking the inconsistency of adding
to the number by the authorization of any sort of
quack practice, if it had a strong enough lobby to
influence the legislature it would appear that the
emergencies of the present conflict have rather dis-
credited the general opinion. If we had not over-
stocked we should be badly off at present. If we
had limited the supply to the needs of peace we
should be utterly unprepared for the demands of
war. But if we had too many in the time of peace
we ought to be about rightly apportioned now.
This paper might seem more of an onslaught on
socialism than a screed befitting the nonpolitical
subject of medicine. Art is supposed to have no
sex ; medicine is supposed to have no politics. The
mind of the artist is as pure as the driven snow
and takes no account of the sex attributes of his
naked model ; the mind of the physician is free from
all considerations except that of curing the sick.
We are all convinced of the truth of the aphorism
as applied to art. The most upright, chaste, and
edifying lives have been those of' painters and
sculptors, and as a sort of corollary to this the most
wonderful examples of virgin purity (utterly un-
conscious of the least possible incitation to salacity)
have been the careers of the aforesaid naked
models. We all know this. The minute man or
woman takes to "Art" sexual attraction loses every
bit of its alleged seductiveness and it is no longer
necessary to mitigate it by the conventional safe-
guards of customary raiment. We all know also
the moment man or woman takes to medicine all
rational comprehension of the other affairs of life
is automatically lost and lambs led to the slaughter
are marvels of worldly wisdom in comparison.
Anything may be done to the doctor ; any impo-
sition may be loaded upon him. He does not know
it and obediently bends his neck to the yoke. That
is why he has been selected as the victim in the
initial offensive of State socialism ; that is why this
paper has been written, to show him wherein he is
a fool for his own interest, and also wherein he is
a fool for the interest of the community of which
he is so valuable, and so little valued, a constituent.
Through his spineless acquiescence in every "re-
form" involving his own material interests he has
been selected as the medium for opening a breach in
the opposition to State socialism ! His own income
will be cut and his independence will be wrecked
while he is used to illustrate the "socializing" pro-
cess, which it is hoped to apply eventually to all
branches of industry. There is no disguise about
the project ; we have already seen how the term
"socialization" is brazenly applied to it, not only by
1 1 14
CUNNINGHAM: A BOLSHEVIK BOLUS.
[Xew York
Medical Journal.
tlie avowed socialist, but also by him whom we
might properly term the "occult socialist" : your
professional uplilter, who is busy throwing the balls
made by skilful but concealed conspirators.
The doctor apprised of the plot afoot owes it,
not only to himself, but to his country, to resist it
to the utmost ! Entitled to the protection of the
State in the prosecution of a profession to w^iich
it has licensed him, he should fight tooth and nail
the threatened abrogation of that protection and
the institution of unfair and ruinous competition.
If, by dint of earnest effort and agreeable personal
qualities he has built up a business yielding a com-
fortable income, the State has no right to intervene
and so materially alter the conditions of practice
that he is utterlv impoverished and his career de-
stroyed. And, above all, the State has iio right to
do this evil thing under the pretence of helping
another "class" of the community ; for then it is
perfectly plain that it has deliberately ruined one
■'class" for the benefit of another. This is class
legislation in a doublv nefarious sense ! It cannot
even oft'er the lame excuse of the greatest good of
the greatest number, for it is a measure not calcu-
lated to produce that result. It is compelling cer-
tain members of the community to surrender the
means accumulated in salutary labor to other mem-
bers who have been less advantageously employed.
It is confiscation and extortion; it is flagrantly dis-
honest ; it is plain unvarnished Bolshevikism, no
matter whether it is backed up by demands of the
red flag brigade or the combined exhortations of
all the settlement workers in the slums ! The an-
guish of the settlement worker for her proteges
should not blind her to the fact that the Decalogue
is still in force and that it contains a sfern injunc-
tion against stealing; she would be horrified at the
suggestion that her charges should go forth and
satisf}' their hunger at the expense of the grocer
at the corner, or that laws should be enacted com-
pelling him to yield his substance at a loss ! She
would resist determinedly the proposal to legislate
the earnings of anv other individual, or class, into
the pockets of her pampered constituents. That is
to say, any other individual, or class, than the med-
ical. When this class is involved all laws of right
and wrong are suspended ; the Decalogue goes into
the discard ; they boldly pick up the red flag and
yell "Bolsheviki" !
There is not a word of exaggeration or intemper-
ance in these strictures. The assault on the doc-
tors going on for years at Albanv in the attempt
to pass the health insurance measure has been
made by the apparently incongruous elements linked
as partners in this indictment. The socialists and
the various welfare bodies have stood shoulder to
shoulder and fought for its enactment. They have
fought for it on the same grounds and almost in
the same language. The opposition of the more
enlightened doctors, A'oiced bv spirited delegates,
has been persistently disregarded and the pressure
relentlessly maintained. The saner members of the
tabor unions, uninfluenced by the socialistic leaven,
have denounced the project in unmeasured terms.
Various business concerns of great scope and in-
fluence have sent tlieir eminent financial men and
attorneys to protest agaii.r.^ this invasion of personal
rights and established usage. Tremendous forces
were felt to be directing the drive. It was evident
that all the vigor displayed in the repeated attacks
was not due to the unorganized efforts of misguided
welfare workers and the organized efforts of com-
paratively uninfluential socialists. There was a
common impelling purpose — and monev behind it.
There was definite cohesion In the units engaged
and a well determined and executed plan of action
Failure was due to the obstinacy of the resistance
and the fortunate support of the labor unions (non-
socialistic) and the big insurance companies. If
the doctors had been left to themselves they would
have been swamped ; as it was the contest was so
close on the last occasion that consideration of the
plan was entrusted to a committee to report back
at the reconvening of the legislature last winter.
No further action was taken probably because our
entering into the great war disarranged the details
of the contemplated raid. But it was not killed,
it was only scotched ; it will reappear when condi-
tions have become normal in civil life. The strength
of the coordinated, if ill assorted, forces displayed
on the last occasion, presages a renewal of the at-
tempt and reveals the welding influence of large
monetary interests. Enthusiasm for humanity
never aroused such fighting qualities as character-
ized the efforts of all contenders for the bill.
The doctors have got a breathing spell. Well,
ladies and gentlemen of the profession, breathe as
deeply as } 0u like, but do not go to sleep ! ^^'atch
jealously not only the advertised movements of this
determined clique, but also the cunning circumven-
tions by which they -will seek to accomplish their
purpose under other pretences. Keep a sharp eye
out for all "welfare" legislation. Keep one eye on
Albany and the other on Washington. Be sure that
the United States Public Health Service does not
execute the maneuvre that will give these gentry the
opening they arc after. No word of protest is in-
tended against the devoted solicitude of the country
for its warriors at home or abroad. Nothing is
too good for the American soldier ; nothing should
be denied him that gratitude and admiration can
suggest. But in our panting eagerness to show our
appreciation of his noble qualities let us not shut
our eyes to the possibility of the harm that may
be done to the profession of medicine under the
guise of emergency legislation on his behalf. Some
of the present war measures would be intolerable
and ruinous in times of peace. We understand that
conditions render imperative grave concessions of
private right. In order to uphold the hands of our
President we are willing to surrender, for the time
being, the liberties that we so jealously guard
against intrusion. But when the war is over we
do not wish anv of these emergency concessions to
be retained as permanent. We do not wisTi the
unusual circumstances of the hour to establish
precedents for the practice of medicine in the days
to come. In short, under the excuse of war
measures we do not wish the enactment of any Bol-
shevikism which may stick after life has resumed
its even tenor. The heated minds of exasperated
patriots, planning ever for the victory of our arms.
December 28, 191S.]
CUNNINGHAM: A BOLSHEVIK BOLUS.
may i:ot so cautiously scan all the changes proposed
in the comparatively unimportant domain of civics.
Much may be sneaked across without full apprecia-
tion of its import ; principles may be violated which
will open the door to the inrush of grave departures
from equity and justice. No matter what the com-
pany which the socialist is keeping for the nonce,
distrust it as you do him. Birds of a feather flock
together.
It is deplorable that so many well intentioned
people do not see the error of advocating certain
concepts of the red flag cult. They do not associate
the humane impulses of their own hearts with the
skirmish line of the socialistic propaganda. They
rather flatter themselves that if the socialists think-
as they do on the question, let us say, of the reform
of medical practice, it is because they have been
influenced by the ideas that have filtered dowii from
the element of superior virtue. They would be
horrified to learn that the sequence of events is the
other way ; that the party of superior wisdom and
virtue has imbibed these ideas from the clever in-
doctrinian of the tireless socialist. The insinua-
tion of the '"class conscious" distinction into the
social organization has produced in the minds of
the charitable well to do an obsessing desire to help
the lower class along in the gruelling struggle for
existence. The American idea of equal opportuni-
ties for all, and no favoritism before the law, which
is the foundation of our independence and strength,
is opposed to this legislating for any "class." Laws
are made for all to observe. Laws should never be
made to give any class an advantage. The people
collectively may give in charity to the helpless and
the sick ; but that is a very different thing from tax-
ing all the citizens for the benefit of a class which is
simply, in a relative degree of poverty, compared
with the rest of the community. It is able to satisfy
its wants and keep its selfrespect if only shielded
from the meddling of the welfare workers. It can-
not save, perhaps ; it is always on the edge of debt ;
but it manages to pull through, in the vast majority
of instances, in the stalwart American way of keep-
ing its head up. For this "class" no concessions are
needed. Regular employment and fair wages are
the only requisites for normal maintenance.
Just at this time most of the members of this
"class" who are not in the army are drawing wages
of a highly remunerative volume. There is no
question whatever that the condition of the so called
laboring "class" is steadily improving. Combina-
tions have rendered laborers formidable ; wages
must be kept at an acceptable figure or strikes are
resorted to. To talk of enacting special eleemosy-
nary legislation for a "class" like that is nonsense ;
it can very well look out for itself.
Curious to relate, the "class" about which all
this pother is to do, seems largely unconscious of its
grievance and indifiPerent to the remedy. The labor-
ing people as a rule know nothing of the attempt
to save them from the rapacity of the doctors.
Health insurance conveys no idea to them and
arouses no aspirations. In point of fact where the
better informed members of labor unions have
taken a hand in the fight it has been to prevent the
forcing of this great blessing upon them. Whether
it is just plain ingratitude or American independ-
ence, or fear of the unwarranted interference of
the State in their i)rivate concerns, it is neverthe-
less most lamentably true that they will have none
of it. They smell the aroma of the red ! They
realize that health insurance is only a prelude to
some other "compulsions" to follow if this is ac-
complished. The word "compulsory" is hateful to
the American free man. He shies at everything
qualified with it. His instincts are in the main
correct. Vox populi, vox Dei. When the people
speak there speaks Wisdom. In their soul the
people grasp the full significance of the meddle-
some Bolshevikism of the professional or dilettante
uplifter. They understand the attitude of the
avowed red perfectly, because he does not hide his
light under a bushel. They distrust both. The
average man is honest ; his intuitions scent hypoc-
risy and fraud. The red he has discounted ; ho
regards him derisively. The wealthy amateur up-
lifter, or the paid professional, he views with dis-
trust ; he understands well enough that all he re-
quires to look after himself is plenty to do and
wages of sorts. All substitutes for these are in-
tended to blufl:' him from the main consideration.
Those who ofifer him cheap doctors make no efifort
to increase his income ; sagely enough he reasons
that cheapening his medical attention is not going
to better it, and the saving in that regard is so
episodal that it is no material oft'set to low wages.
Making him special rates at the clinic because he is
"poor" wounds his susceptibilities, which are as
acute as any. The implied condescension is hateful.
To recapitulate, there we have a situation where
a public which does not want it is to be forcibly
endued with an advantage wrung from the income
of the underpaid doctors ; where nonsocialistic
social servers unite heartily with frankly socialistic
propagandists for the furtherance of an indubi-
table socialistic programme ; where the element least
inclined to socialism is busy carrying out socialistic
strategy ; where the injury done to the doctors,
while grave and indefensible, is the least part of
the destruction contemplated ; where Bolshevikism
held up to the scorn of all right thinking people is
coming upon us, through the connivance of the
soidisant better classes, who, dabbling in the wel-
fare game from fad, fancy, or fatuity, are wrecking
the safeguards of the American Republic. Ladies
and gentlemen of the American medical profession,
your duty in the premises is, not only to yourselves,
but to your country. If you supinely submit to the
plans projected for your subjugation you will lay
the foundation of that monstrous system which has
all but wrecked the Allied cau^e in JEurope by the
betrayal of Russia. You will, by cooperating in
this measure of health insurance or special pay
clinics, bring the danger of dominant Bolshevikism
very much closer. You will by apathetic acqui-
escence do the very same thing. It is your duty to
combat this menace. You have been unhappily
placed in the forefront of the conflict waging
against our free institutions at the instigation of the
internationalists and you must resist to the last
extremity.
r 1 16
B REIVER: CONTROL OF COMMUNICABLE DISEASES IN ARMY.
[New York
Medical Journal.
It is typical of these enemies of rational liberty
that their initial assault is to be made ijpon the
profession which has slaved without compensation
in the cause of humanitarianism and whose charities
surpass those of all other orders of society com-
bined. This brutal indifiference of the socialistic
cult is of a piece with its character everywhere. It
cares nothing except for the furtherance of its
schemes, ostensibly in the interest of all the prole-
tariat; actually in the interest of the exploiters of
a misguided mob of envious incompetents. When
the socialistic orator, or writer, begins to get a
hearing he no longer labo'-s except with his wits.
The proletariat to him is an organ on which to play
his maddening diapason of greed and hate. He
works not, neither does he spin, but he eats well
and dresses well and is not concerned as to the
wherewithal while he has his gullible adherents !
In a former paper I urged the members of the
threatened medical profession to strike back with
their own weapons at the politicians who were play-
ing into the hands of the welfare — socialistic con-
federacy— and make them understand that organ-
ized reprisal would be made upon every legislator
who gave it support. The average politician is not
a guide ; he is a species of dictaphone ; he does not
form opinions ; he registers opinions which rebound
to his political advantage. With his ear to the
ground, or the wall of the board room, he gathers
an idea of the momentum of certain suggestions and
cimningly figuring out his own profit in the event
he takes sides for or against the people. Such
characters are readily amenable to the influence of
fright. If assured that determined opposition to
their reelection will be the consequence of premedi-
tated action their meditations are apt to take an-
other tinge. If the medical men and women would
but follow out the proposal made in that paper and
write to the senators and assemblymen and politi-
cal leaders of their districts, and solemnly acquaint
them with their disapproval of compulsory health
insurance, and their resolve to oppose the election
of every candidate committed to it, the project
would speedily fall into disrepute at Albany. If
they would also write to the same persons their
disapproval of the establishment of pay clinics as
foreign to the purpose of the charters of the
public hospitals, and their conviction that these
institutions should conduct all these services en-
tirely without charge as a public charity in return
for the remission of taxation, this insidious flank
movement of compulsory health insurance would be
promptly sidetracked also. The law making power
has authority to re.gulate the hospitals through the
medium of the taxing function. Hospitals which
are attempting to convert the public clinic into a
moneymaking scheme, in defiance of the original
conception of its purpose, may be brought to book
by deprivation of their privileges as eleemosy-
nary institutions. The pretence of benefiting the
public by a routine perfunctory and apathetic sys-
tem of examination and treatment is too transparent
to be worth a moment's consideration. Note the
quality of service in the free clinics of today and
draw the inevitable parallel.
Let me repeat the injunction to every practitioner
of medicine who is not biased by a salaried or insti-
tutional point of view to write to the politicians who
represent ( ?) him at Albany protesting vigorously
against compulsory health insurance in its proper
guise, or variously disguised and boldly promising
retaliation for the infliction of injury. Let him
write to the congressman representing him at
Washington protesting against the installation of
any analogous system under pretence of emergency
war measures ; and in in all of these communica-
tions let it be made perfectly plain that his atti-
tude is not purely selfish but is dictated by the con-
viction that these innovations, dear to the heart of
the wily welfare worker, and inveterate institution-
alists are indirect assaults upon the principles upon
which this republic was founded, and apertures for
the instillation of those poisonous doctrines which
have brought about the horrors of the Russian
cataclysm. We want no socialism overt or occult ;
we want nothing of the philosophy which has linked
the socialists all over the world in open sympathy
with German purposes. It does not seem to matter
where the internationalist is found, he is striving
for the triumph of the German arms either boldly as
in Russia, or artfully as a pacifist in the lands
allied for freedom ! The German despotism would
appear to appeal to him because of his avowed in-
tention to establish an economic despotism. Indi-
vidual socialists, here and there, contest this indict-
ment but the action of their representative bodies
everywhere sustains it. The exceptions are anomal-
ous and repudiated by their party !
If we might be permitted reverently to para-
phrase the immortal words of Marco Bozarris we
should exclaim :
".Strike till the last Red Flag retires !
Strike for your altars and your fires !
Strike for the freedom of your Sires
P'or God and your native land !"
323 West Fourteenth Street.
(Ptiblished by Authority of the Surgeon General,
United States Army.)
SUGGESTIONS FOR THE USE OF CERTIFI-
CATES SHOWING PREVIOUS INFEC-
TIONS IN THE CONTROL OF
COMMUNICABLE DISEASES.
By Lieutenant Colonel Isaac W. Brewer, M.C,
Camp A. A. Humphreys, Va.
During the past winter the principal cause of
sickness in the army, excluding venereal diseases,
has been measles. A large number of these cases
were followed by pneumonia, and a considerable
number of the patients died. The problem before
the military sanitarian has been to prevent
measles, and at the same time not prevent the train-
ing of the men.
In October, 1917, before the American Public
Health Association, I read a paper outlining a plan
for preventing measles which has been successfully
followed at the concentration camp at Fort Ethen
Allen, Vt. When this plan was applied to a large
organization it was found to be impracticable, be-
cause of the lack of statistics showing whether the
men had had measles or not. If a measles census
December 28. 1918.] STEINDLER: RECONSTRUCTION WORK ON HAND AND FOREARM.
1117
is taken in the presence of an epidemic of measles,
a large number of men who desire to avoid quaran-
tine will state that they have had the disease. The
census immediately becomes of no value. It has
been suggested, and I believe it to be a valuable
suggestion, that at the time a man joins the service
he should be questioned regarding the various com-
municable diseases he has had. This would at once
give us data regarding the men who are susceptible
to measles and also those who have had typhoid and
are possible carriers. That there will be errors in
these statistics is not denied, but I believe in a
large measure they will be of great value. The
importance of having correct statistics regarding
those who have had communicable diseases is ap-
parent to any who have had to deal with the pre-
vention of those diseases. It seems to me that a
very important advance in the prevention of diseases
will be made if the various departments of health
would furnish a certificate in card form to every
child who has had a communicable disease. This
form could be made out on a printed card, to be
filled in by the attending physician at the time he
reports the disease. It would then only be neces-
sary for the State or city department to stamp it
with the official seal. In a short time each child
would be provided with the data showing each dis-
ease it has had. This in a large measure would
prevent unnecessary work in case a disease should
break out at school. Later on it w'ould be of value
in connection with epidemics that may occur in fac-
tories, or in the army or navy.
SUGGESTED FORM.
State of New York, City (or town) of
This certifies that age years,
Residing at street, is suffering
from measles (scarlet fever, mumps, whooping cough,
diphtheria, tyhoid fever).
Date
Attending Physician.
(Not official unless it bears the seal of the State
Department of Health.)
ORTHOPEDIC RECONSTRUCTION WORK
ON HAND AND FOREARM.
By a. Steindler, M. D., F. A. C. S..
Iowa City, la..
Professor of Orthopedic Surgery, University of Iowa.
This is a report of a series of sixty cases, details
of which, partly at least, have appeared in previous
papers. I am well aware that the series is not
large, nor is it exhaustive in any of its details ; but
it has, by reason of careful clinical analysis and ex-
perimental investigation, oflfered an opportunity to
establish some of the fundamental points by which
the surgical procedure should be guided. The cases
are grouped according to the principles involved
and not strictly according to the pathological nature.
FLEXION CONTRACTURE AND FLEXION ANKYLOSIS OF
THE WRIST.
A simple flexion contraction of the wrist joint
rapidly decreases the flexion power of the fingers
by reason of relaxation and loss of tension of the
flexors. At full flexion of the wrist the power of
the fingers is more than three quarters exhausted.
Furthermore, fmger flexion is also impeded by in-
creased tension of the extensors of the wrist and
fingers. The indication in flexion contraction of the
wrist is to release this contraction and reestablish
the equilibrium between the flexors and extensors.
In eleven cases examined three patients had con-
genital club hand deformities without lateral devia-
tion and were treated conservatively. Eight patients
were operated upon. The correction was good in
all the eight cases, function was good in three cases,
doubtful in one case, and poor in four cases.
The technic of tenoplasty, applied in five cases,
consisted of i)lastic lengthening of the flexor tendon
frcin a median incision on the volar side of the
forearm, running from the wrist upward. One of
the reasons for the poor functional result in the
spastic cases was the failure to stabilize the wrist
joint, relying upon the extensor muscles to carr\
out the extensor movement of the wrist. The dis-
appointment in these cases led us to adopt other
methods, which are described below. In two cases
a bloodless correction was done under anesthesia ;
in one case Stoft'el's operation of partial resection
of the median nerve v.as performed with good cor-
rection, but poor functional result.
FLEXION CONTRACTURE OF THE WRIST AND FINGERS.
Continued contraction of the flexors of the fingers
results in the flexion of the phalangeal joint. The
metacarpophalangeal joints yield to the increased
tension of the extensors of the fingers by being
forced into hyperextension (claw hand). In Volk-
mann's contracture the sequence of contractures, in
our series, began invariably with contraction of the
wrist, simultaneously with, or soon followed by.
contraction in the phalangeal joint, and later, hyper-
extension in the metacarpophalangeal joints.
The indication here is to release the contracture
of the flexors by tenoplasty. This usually takes care
of the wrist and finger joints in cases of contrac-
tures following nerve lesions and Volkmann's con-
tracture. The tenoplasty is also usually found suf-
ficient to release the hyperextension in the meta-
carpophalangeal joint in the absence of secondary
changes in the structures of the dorsum of the hand
and Avrist. Tenoplasty was performed by length-
ening each individual flexor tendon from a long
median incision on the volar side of the forearm,
with subsequent dressing in Robert Jones' cock-up
splint in overcorrected position. Mechanical and
muscle educational aftertreatment. In six cases
of Volkmann's contracture, average age of patients
eight years, average duration thirteen months, aver-
age observation after operation eight months, the
correction was good in six cases ; the function' was
good in two cases, and fair in four cases. In two
cases of traumatic and inflammatory contractions,
average age thirty-two years, average duration one
year, average observation, after operation, nineteen
months, the correction was fair and the function
good.
ARTHRODESIS OF THE WRIST.
While correction of the flexion contraction of the
wrist and fingers may in this way be obtained and
the proper position of the wrist reestablished, it is
iiiS
STEINDLER: RECONSTRUCTION WORK ON HAND AND FOREARM [New York
Medical Journal.
equally important for the function of the hand that
such a position be actively maintained. This may
be taken care of by the power of the extensors, if
they are sufficiently preserved. But if they are in-
capable of actively extending the wrist, they must
be reenforced, by tendon transference from the
flexors, if sufficient material is available from that
source, or the wrist joint must be stabilized by
arthrodesis. If it is doubtful that tendon trans-
ference will establish a reliable wrist, one should
make use of the arthrodesis rather than to allow a
flail and unstable wrist joint to persist. In six
cases, average age of patient thirteen years, average
duration ten years, average observation ten months,
the correction was good in all, function was good
in two cases, fair in two cases, and poor in two.
TECHNIC OF ARTHRODESIS OF THE WRIST.
Incision is made at the dorsum of the hand be-
tween the tendon of the extensor pollicis longus and
of the extensor indicis, opening the ligamentum
carpi dorsale and entering the wrist joint at the
notch of the distal end of the radius, between the
grooves for the extensor pollicis longus and the
common extensor of the fingers. A wedge is re-
sected from radius and scaphoid. Capsule and liga-
ment are sutured. Fixation in dorsiflexion. By en-
tering between the sheath of the extensor pollicis
longus and the extensor communis digitorum, the
dorsal tendon sheath may be avoided.
INTEROSSEOUS TENDON TRANSPLANTATION.
By arthrodesis the loose wrist joint is stabilized
in a favorable position and in this way one of the
fundamental requirements for the function of the
hand is met. In addition to this, possibilities are
opened up for the reconstruction of the finger
action. Owing to the fact that, after arthrodesis,
the flexors of the wrist become available for trans-
ference to the extensors of the fingers, active ex-
tension of the fingers may thus be obtained. Both
surgically and mechanically it is perfectly sound
to aim for active extension action after the wrist
joint has been properly stabilized. But to do this
on the basis of a flail and uncontrolled wrist joint,
as has been done so often, is a decided mistake,
which naturally invites failure.
The muscles available for transference are the
flexor carpi ulnaris and radialis. Of these two I
have used the flexor carpi ulnaris for tendon trans-
ference. Though this tendon is short, since the
muscle reaches within two inches of the insertion,
yet it is possible to liberate the tendon for a consid-
erable distance upward without interfering with its
nutrition. In devising the plan of operation we
were careful to secure a straight and direct course
for the transplanted tendon and for this reason the
route through the interosseus space was adopted.
Prior to the use of this method we swung the tendon
around the bones of the forearm in the usual man-
ner but found this procedure not satisfactory on
account of the mechanical disadvantage which is
involved in slanting of the tendon around the bone.
In five cases, average age fifteen years, average
duration six and a half years, average observation
four months. Four cases of arthrodesis plus inter-
osseus tendon transplantation : correction, good
three cases ; function, good three cases, fair one
case ; one case died of intercurrent disease.
The one case of interosseus tendon transplanta-
tion without previous arthrodesis showed only fair
correction and function. In this case, we again
placed reliance upon the extensors to be sufficent
to control the wrist, but the tension of the flexors
proved too great, even after tendon transplantation,
to quite overcome the flexion tendency.
TENDON TRANSPLANTATION THROUGH THE
INTEROSSEUS SPACE.
Incision is made on the volar side of the forearm
over the flexor carpi ulnaris from pisiform bone
upward, five inches. Dissection of the flexor carpi
ulnaris to the insertion at the pisiform bone. Free-
ing of the entire tendon through the whole length
of the incision. The fascial compartment, under-
neath the flexor carpi ulnaris, is then opened and the
ulnar nerve and artery carefully dissected and re-
tracted to the radial side. The superficial and deep
flexor muscles are retracted radially. Then the up-
per border of the pronator quadratus is looked up
and proximal to it an opening is made in the inter-
osseus membrane wide enough to receive the tendon
of the flexor carpi ulnaris. By keeping close to the
outer border of the ulna the interosseus nerve and
artery are avoided.
A second incision is made in the midline on the
dorsum of the forearm over the wrist reaching to
the base of the metacarpals. The tendon of the
flexor carpi ulnaris is then passed from the volar
side, through the incision in the interosseus mem-
brane, then out through the dorsal incision. The
hand is then put in dorsiflexion and the free end of
the flexor carpi ulnaris is placed between the four
tendons of the common extensors of the fingers,
two being on the outside and two on the inside of
the flexor ulnaris tendon. Then for a distance of
two inches and with the hand in dorsi flexion, a
side to side suture is laid between the flexor ulnaris
tendon and the tendons for the extensors of the
fingers, lying on both sides of the former. The
sheath of the extensor muscle and the ligamentum
carpi dorsalis is restored by suture. Fasciae and
skin closed. The hand is put up in dorsiflexion.
In all cases this method has given satisfactory re-
sults. Active extension of the fingers was noticed
within a very few days after the operation ; but the
hand should be kept completely immobilized for four
to six weeks, and later carefully supported by a splint,
to be removed only for massage and exercises. Ten-
don transference from the extensors to the flexors
of the fingers was carried out in two cases in which
active flexion of the wrist was lost ; in the first case
the extensor carpi ulnaris and extensor poUicis
longus was swung around the radius and ulnar re-
spectively and fastened to the flexor digitorum com-
munis ; in the second case the extensor carpi radialis
was used to transplant the flexor carpi radialis. The
functional result, however, was only moderate in
both cases.
In some instances of clawhand deformity it was
found impossible to release the hyperextension in
the metacarpophalangeal joint, .either by tenoplasty
or by forcible manipulation. Considering that the
December 28, 191S.] STEIN DLER: RECONSTRUCTION WORK ON HAND AND FOREARM.
II19
motion in this joint is indispensable for the play of
the fingers, and that operative interference at the
joint proper therefore could not be done, a method
was applied which consisted in osteotomy proximal
to the joint with subsequent kinking of the frag-
ment. In two cases correction and function were
good. In these cases a small longitudinal incision was
made from the head of the metacarpal upward.
Osteotomy was performed on the metacarpal bones
three quarters inch proximal to the joint, and the
fragments were kinked forward. The result of the
operation is a much better approachment of the fin-
gers to the thumb, which considerably improves the
grip of the hand.
Reconstruction work on the thumb was carried
out in a number of instances. The cases may be
grouped in two classes. Lack of apposition of
the thumb arising from paralysis of the thenar
muscles. Lack of action of the opponens pollicis
is most noticeable since it cannot be replaced by
any of the long muscles of the thumb. Good func-
tional result in four cases.
PLASTIC SUBSTITUTION OF THE OPPONENS ACTION OF
THE THUMB.
Incision along the flexor pollicis longus from the
interphalangeal joint downward to the middle of
the thenar. Avoid carefully the upper half of the
thenar so as not to injure the motor branch of the
median nerve to the thenar muscle. The sheath of
the tendon of the flexor poUicis longus is split, the
tendon divided longitudinally and the outer half
is separated at the upper end. The sheath is closed
over the inner half. The outer half is then placed
upon the outer side of the base of the first phalanx
and is here sutured to the periosteum. This half
of the tendon is now running in the direction of
the paralyzed opponens pollicis, and each flexor
movement of the thumb will be accompanied by
an opposition movement of the thumb against the
fingers.
The other group comprises some spastic cases
in which the flexion tendency of the thumb is so
great that it is thrown under the fingers with a
snapping motion, whenever the hand closes for the
grip. In these cases the procedure consisted in
tenoplastic reenforcement of the long extensors of
the thumb, acting as a check upon the tendon. Re-
sult : good function four cases ; fair in two cases.
INCISION OVER THE EXTENSOR INDICIS.
Here the tendon is severed, drawn forward to the
thumb and brought out through an incision over
the extensor pollicis longus. To the latter tendon
the tendon of the extensor indicis is then united,
the thumb being held in hyperextension (Technic
of Biesalski and Mayer).
From the viewpoint of function of the hand, two
conditions involving the forearm had to be taken
up in a number of cases and are consequently in-
cluded in this series. One, the pronation contrac-
ture of the forearm, was found in cases of Volk-
mann's contracture and in cases of spastic paralysis.
Simple tenotomy of the pronator radii teres does not
accomplish its object. I have observed several re-
currences after tenotomies. The operation chosen
was that of resection of the pronator teres, from an
incision running from the internal epicondyle of the
liumerus slightly downward and outward in the
direction of the pronator teres. Result: correction,
good two cases ; fair in one ; function, good in two
cases, fair in one. •
FOREARM PLASTY OF THE ELEOW.
To this group belong the cases of flail elbows.
The paralysis of the flexors of the elbows was re-
lieved by a muscle plasty of the forearm muscles,
which were transposed upward upon the humerus,
to act as flexors of the elbow ; in most cases the
condition was associated with paralysis of the hand
or shoulder. Good result in five cases ; in observa-
tion two cases ; died one case ; poor one case.
Incision is made around the internal condyle of
the humerus. The lower end of the incision slants
downward and outward in the direction of the
pronator teres. The ulnar muscle group is care-
fully dissected and its origin from the internal con-
dyle is separated for two inches. Then this muscle
bundle is drawn upward to be inserted into the
intermuscular septum on the inner side of the
humerus two inches above the internal epicondyle.
Two points must be carefully observed: i. Lesion
of the ulnar nerve will best be avoided by carefully
dissecting the nerve in its course behind the epi-
condyle and by retracting it backward. 2. In
preparing the muscles, from their origin, great care
must be taken not to damage the nerve supply. The
flexor muscles of the hand should be in fair condi-
tion, if the operation is to be successful. Our un-
satisfactory results were due entirely to the fact
that impairment of the flexor of the forearm was
more extensive than anticipated. As the operation
attempts to make the flexors of the forearm act as
flexors of the elbow under difficult mechanical con-
ditions, these muscles should be either intact or only
very slightly involved in the paralysis.
Clubhand deformity with lateral deviation was
observed in three cases. One of these cases was a
double congenital clubhand deformity, the other
two were acquired. Following osteomyelitis of the
forearm, there was almost total loss of the radius
in one case and loss of the lower epiphysis of the
radius of the entire thumb in the other. Three
cases : osteotomy one case, correction good ; bone
graft one case, correction fair; osteotomy and
thumb plasty one case, correction good.
In the last case a plasty of the thumb was made
in two steps. The new thumb was made from the
seventh rib.
Four cases of skin contracture of the hand were
treated according to ordinary methods of skin
plasty. Result : good in two cases, fair in one.
Nerve resection for scar contracture, one case. Re-
sult, good.
Relative Digestibility of Maize and Cottonseed
Oils and Lard. — Elbert W. Rockwood and P. B.
Sivickes (Journal A. M. A., November i6, 1918)
studied the utilization of these oils on dogs in vary-
ing states of health and nutrition and found that all
three were readily and very completely digested, and
that corn oil could well be substituted for cottonseed
oil or lard. The same probably would apply to
man.
1 120
HANSELL: EXTRACTION OF CRYSTALLINE LENS.
[New York
Medical Journal.
SUCCESSFUL EXTRACTION OF AN
OPAQUE AND DISLOCATED
CRYSTALLINE L£NS.*
By Howard F. Hansell, M. D.,
Philadelphia.
Mrs. W., aged forty-five, came to the Jei¥erson
Hospital complaining of increasing loss of vision.
She stated that for twelve years she had been unable
to read. She had consulted several well known
oculists in England who had given an unfavorable
prognosis and had declined to undertake treatment
except to give myopic glass of lo D. I could obtain
no authentic history that the lenses were congeni-
tally dislocated ; on the contrary she stated that
until twelve years of age her sight had been unusu-
ally acute both for distance and for near vision
and that she had made no earlier complaint con-
cerning her eyes. As she was an intelligent and
educated woman I accepted her statements as ac-
curate.
At my first examination I found diffuse uniform
opacity involving the entire lens in each eye. The
opacity was not dense but permitted no detailed
examination of the vitreous or eyegrounds. I ad-
vised preliminary iridectomy on each eye. During
the performance of this operation a slight amount
of vitreous, of aoparently normal consistence, oozed
out of the wounds. This was the first intimation
that the lenses were not in their normal situation.
On my first examination I had failed to discover
the dislocation. There had been no trembhng of the
iris, no history of an accident or other indication
pointing to dislocation. The wounds healed without
imusual delay, the eyes recovering slowly. Several
weeks later, after fully advising the patient as to
the danger incurred by operation, I extracted the
lens of the left eye.^ Before making the limbus in-
cision I prepared a large conjunctival flap, and in-
troduced and loosely tied the sutures so that im-
mediately after the extraction operation proper was
concluded I might draw the flap over the entire
incision. The incision was made in the limbus. An
insignificant amount of vitreous was lost. After
waiting a few minutes in the hope that the lens
might move forward, and finding that it retained its
original situation, I introduced the wire loop be-
hind the lens which I then removed in its capsule
without encountering any obstacle or losing any
more vitreous. The flap was brought down and
sutured. It covered the upper two thirds of the
cornea including both ends of the incision. The
anterior chamber was reformed in forty-eight
hours, the first inspection after operation, and the
sutures removed the following day. Healing was
uneventful. Three weeks later with -\- lo — -\-
1.50 cyl. ax. 120° V. — 6/6pt.
The feature which contributed largely to the suc-
cess of the operation in this case was the conjuncti-
val flap. In order to be assured of the efficacy of a
flap one must dissect the conjunctiva far back,
quite up to the fornix, and before determining that
*Read before the Section in Ophthalmology, College of Physi-
cians, Philadelphia, November 21, 1918.
1 At a subsequent operation, the right lens, also dislocated, has
been extracted by precisely the same method, with recovery of full
acuity of vision.
he has completed this step of the operation he
should draw the membrane over the cornea by
forceps grasping each of its sides. Only by doing
this will he be able to make up his mind that the
flap will be sufficiently large. The operator, inex-
perienced in making a conjunctival flap, will be
surprised when he learns how extensive the dissec-
tion must be. The silk sutures must be in place.,
loosely tied, and thus ready to be drawn taut and
knotted immediately after the flap has been drawn
over the entire incision, involving the covering of
at least the upper third if not the upper one half of
the cornea.
So important did the late Professor Stanculeanu,
of Bucharest, consider the conjunctival flap that he
always made it the first step of his cataract extrac-
tion operations. This practice is, in my opinion, un-
wise because it complicates the operation by adding
another step to the extraction ; moreover, unless the
flap is brought exactly into position and is really a
protection of the wound it may increase the danger
of operation by slipping upward and forcing the
corneal flap outward, so that union of the edges of
the wound will be prevented.
Seventkenth and Walnut Streets.
MEDICAL NOTES FROM THE FRONT.
By Charles Greene Cumston, M. D.,
Geneva, Switzerland,
Privat-docent at the University of Geneva; Fellow of the Royal
Society of Medicine of London, etc.
LESIONS OF THE PERIPHERAL NERVES.*
The important and interesting question of lesions
of the peripheral nerves of the upper limb as met
with in warfare offers two very different aspects:
Sometimes they occur as motor disturbances or true
paralysis ; at others they represent the sensitive,
painful type.
While each nerve of the arm may be paralyzed, it
is most extraordinary that although the paralysis of
the median and ulnar are frequently incomplete and
dissociated, the radial is usually paralyzed in its
entire extent below the lesion, even when the latter
is very slight. The hand drops, and deprived of
an)' extension, the condition is very characteristic.
In other words, paralysis of the radial is an exten-
tive one.
In the sensitive, painful types the radial nerve
reacts especially by motor disturbances ; it is only
slightly or not at all painful ; and it never is the seat
of a neuritis. Cutaneous anesthesia is, so to speak,
absent, and only hypesthesia is met with over a less
extensive area than the topography of the cutaneous
sensitiveness of this nerve would indicate.
From the viewpoint of sensitiveness, the ulnar
represents a means between the radial and median
nerves. It reacts less painfully than the median
but, nevertheless, lancinating pain and electric con-
cussion are frequently complained of in lesions of
the ulnar. From the objective viewpoint, anesthesia
is usually distinct over the internal border of the
•This article was written in September, 1918.
December 28, 1918.]
CUMSTON: MEDICAL NOTES FROM THE FRONT.
II2I
hands, and particularly over the auricular. Clonic
shocks of the forearm can be obtained when an at-
tempt is made to straighten out the ulnar claw. In
lesions of the median nerve, besides the classic type
of motor paralysis, one frequently meets with a
painful type, recently described by Pierre Marie.
The motor disturbances are of a secondary nature
in the painful type. The patient remains in bed,
holding the hand with precaution in the axis of the
forearm. The fingers are near together at their
base and separated at their distal ends, while the
thumb and ring finger approach each other, giving
the hand the appearance of being narrowed trans-
versely in contrast to the large, flat hand of median
nerve paralysis. The three first fingers are often the
seat of a fine, irregular tremor, very different from
the clonic shocks that are sometimes seen in the
last two fingers in lesions of the ulnar nerve. The
patient suffers from paroxysms of pain. Pressure
reveals pain over the median nerve below the lesion,
rarely above. Very severe pain is complained of
at the fingertips, on the internal aspect of the thenar
eminence, in the interosseous spaces and metacarpo-
metatarsal joints. The pain is compared to violent
burning or crushing. Insomnia is the rule, because
the slightest touch on the hand or the sound of foot-
steps starts the pain. Marie, however, states that
the pain has a tendency to disappear in about five or
six months. I may add that cold applications relieve
the pain and that heat has the contrary effect. The
reflexes are not changed. The trophic disturbances
are rather characteristic, while amyotrophy is moder-
ate. The hand is thin, the fingers pointed, the nails
smooth. The skin is white and smooth but not
shiny as in glossy skin. The palmar aspect des-
quamates constantly, the hand is rather cold with a
hyperhydrosis. In the painful variety the skin is
dry and the hand very hot, and in the case of lesion
of the median nerve there is absence of stereognos-
tic sense in the painful type.
In lesions of the peripheral nerves various clinical
syndromes are noted which may be conveniently in-
cluded under three headings, namely, the syndrome
of dissociation, the syndrome of interruption, and
the syndrome of progressive constriction or com-
pression.
The syndrome of dissociation is frequently met
with when the paralysis only involves a part of the
muscles innervated by the injured trunk below the
lesion, which of necessity can only be a partial divi-
sion. Direct excitation of the nerve trunks in the
operative wound, by Marie, showed that in each one
the nerve fibres which went to a given muscular
group formed absolutely distinct fasciculi.
The syndrome of complete interruption is char-
acterized by the absence of all functions of the
nerve, and its clinical elements are principally motor
symptoms. There is first complete paralysis and es-
pecially disappearance of muscular tonicity, the
muscles ofi^ering a flaccidity much more marked
than in simple muscular atrophy. This disappear-
ance of the tonus is particularly well marked in
paralysis of the radial from complete division of the
nerve. The hand drops in flexion at a right angle
on the forearm and dangles when the limb is shaken.
Absence of the sensation of pain when the muscles
are pinched likewise belongs to this syndrome and
this muscular analgesia is not encountered in cases
of compression of a nerve trunk. There is complete
loss of faradic and galvanic excitability of nerves
and muscjes. What characterizes this syndrome is
the total paralysis, absence of tonus, and the com-
plete and definitive character of the sensory and
motor disturbances.
The syndrome of progressive compression is
made manifest by its progressive evolution and
electrodiagnosis. At the time of the injury the pain
is less intense than in complete division of the
nerve. The trauma provokes a paralysis and an-
esthesia from the start, sometimes of the entire
limb, but at all events usually extending beyond the
limits of the nerve involved and is due to nervous
commotion. But in a fortnight or three weeks
afterwards, the clinical aspect of the lesion becomes
clearer. The motricity and sensibility slowly re-
turn, usually only in part, but sometimes completely.
Soon, however, spontaneous pain occurs of a lan-
cinating kind with nocturnal paroxysms produced
by pressure or movement of the arm. From the
objective viewpoint there is a short phase of hyper-
esthesia of the involved nerve, soon followed by
anesthesia. Before the latter occurs paresis arises,
finally ending in true paralysis. Vasomotor disturb-
ances are never absent. The extremity of the limb
is cold, more or less cyanotic and there is hyper-
hydrosis. Trophic disturbances and amyotrophy in
particular are rarely wanting. Faradic and galvanic
excitability quickly diminish and finally disappear.
The reaction of degeneration, partial at the begin-
ning, becomes total, and then if the compression
continues to increase until physiological section of
the nerve has taken place, galvanic excitability in
turn disappears.
In considering the diagnosis the question arises as
to whether the case is one of a nerve lesion, a pseu-
doparalysis, or a psychic paralysis. On the other
hand, supposing that a hysterical paralysis has been
demonstrated to exist, this fact does not eliminate
the possibility that the nerve has been injured. Is
the functional impotency due to a nerve lesion or
is it of psychic origin? If the motricity is carefully
studied, it will be noted when there is an organic
lesion that the only muscles paralyzed are those
below the site of the injury and whose innervation
depends upon the involved nerve. In psychic
paralysis, the paralysis extends to a segment of the
limb, often to the entire member involved or to all
the muscles associated in a given movement. The
objective disturbances have a known topography,
but there is never a segmented anesthesia, such as
is met with in hysterotraumatism. In case of nerve
lesion the trophic disturbances are more or less
intense, according to whether neuritis exists or not,
but at all events amyotrophy is rarely missing.
Causalgia is not uncommon. The vasomotor dis-
turbances, hyperhydrosis, and cutaneous cyanosis
are frequent. In hysterical paralyses trophic dis-
turbances are not apparent and, while organic
paralysis causes an absence of the reflexes, hystero-
traumatism offers no disturbances of reflectivity.
In the special neurological services of Claude and
Vigouroux, the frequency of neuropathic accidents
I 122
CUMSTON: MEDICAL NOTES FROM THE FRONT.
[New
Medical
York
JoURNAl
among wounded soldiers is estimated at about ten
per cent.
A nerve lesion having been diagnosed, it remains
to determine its degree. Generally speaking, if the
paralysis occurs immediately after receipt of the
injury it may be assumed, according to the disturb-
ances present, that the nerve is partially or totally
divided. If the accidents arise progressively, it may
be concluded that the nerve trunk is being com-
pressed with increasing intensity as the production
of cicatricial tissue or a callus is increasing, embed-
ding the nerve in the neoformed tissue.
Electrodiagnosis is of great importance. In com-
plete division the electric excitability of the nerve
progressively diminishes and will have entirely dis-
appeared at the end of a fortnight. In incurable
cases the reaction of degeneration at length disap-
pears, and it is only then that one can be sure that
the nerve has been completely divided. In com-
pression of a nerve there will be diminution of both
faradic and galvanic excitability, but this decrease
is slow in taking place and follows the progress of
ihe paralysis. It must never be forgotten that ex-
citation of the nerve above the lesion will be trans-
mitted below it as long as the compression is not
absolute. When an operation for the repair of the
nerve is done the electrodiagnosis in situ will de-
termine exactly to which muscles the injured nerve
fibres correspond.
In regard to the prognosis, nerve compression,
generally speaking, is the most favorable. The
less the compression, the more quickly will the
nerve recover its functions. It goes without saying
that if with the compression there is also a partial
lesion of the nerve, recovery is longer in taking
place. The same cannot be said in complete division
of a nerve, because even now, after four years of
extensive experience, the operative results of nerve
suture are still uncertain.
Electrodiagnosis possesses a prognostic value ox
the highest order. The prognosis is good when the
excitability of the nerve retrogresses instead of
progressing. It is likewise favorable when the de-
crease of the excitability of the nerve progresses
with the reaction of degeneration, and in this case
surgical interference may save the situation. It is
only when the absence of electric excitability in the
injured nerve and muscles persists, after having
afil'ered the reaction of degeneration, and ceases to
react to any elective excitation that the prognosis is
very serious and the case considered as incurable.
In closing I would say that in the painful neuritic
forms occurring in the median nerve, Marie is of
the opinion that the prognosis is relatively good,
even without surgical interference.
HELIOTHERAPY IN SURGICAL DISEASES.
Heliotherapy, as employed by Rollier, of Leysin,
Switzerland, and which I have seen applied to some
very remarkable surgical afflictions, unquestionably
represents a very high specialization of orthopedics
and conservative surgery. By employing this
method irreparable mutilations are avoided and the
functions of the joints are protected to the highest
degree. Considering the splendid results obtained
by Rollier in the treatment of surgical tuberculosis
by the use of sunlight and fresh air therapy, it is
quite natural that this method should give favorable
results in nontubercular lesions resulting from war
wounds. Cazin has had some remarkable results,
in the use of heliotherapy alone, in wounds where
suppuration had continued for months, and where
there had been no manifestations of tissue repair.
Lea was one of the early users of heliotherapy in
the treatment of war wounds. He applied the treat-
ment at Evreux, Hospital No. 4, in September,
1914. Reinbold, of Lausanne, Switzerland, has also
systematically used heliotherapy in the hospital
which was under his direction in France, since the
beginning of the war, while Grangee, in the hospital
at Evian has resorted to the treatment since 191 5.
The rapid and uniformly successful results ob-
tained by these and other surgeons should encour-
age the American military surgeons to adopt this
method of treatment. There is no doubt that it de-
serves all the praise that it has received.
BRUTALITY OK GERMAN MEDICAL MEN TO WOUNDED
PRISONERS.
The Huns appear to be pretty well done up at
present and their miserable underlings, Austria and
Turkey, even more so, but we can still recall some
of the atrocities which have been committed by the
German medical profession on the British and otlier
war prisoners. Aside from the fact that the Ger-
mans have proved themselves vastly inferior to the
Allies in the field of medicine and surgery they
have subjected some of their prisoner patients to
barbarous treatment, as I will show by the following
authentic cases.
A British officer with a paralysis of the hand tells
the story of a Hun surgeon who while dressing his
arm, touched it in a certain region remarking, "That
is the nerve," the British officer understood and
speaking German replied, ''Yes, that is the nerve."
The German surgeon then said to his assistant,
"Here is an Englishman who understands German.
Now you shall see how an Englishman can scream."
He then had the prisoner's arm placed over the
assistant's shoulder and bound to his back, and
gave the nerve six jabs with an instrument. This
beastly performance occurred in a hospital near
Metz about the first week in June. 191 8. Just one
more example. At Wevelghem, last May, a sergeant
in charge of a ward hit a delirious patient in the
mouth, knocking his teeth in, because the unfortun-
ate patient had placed his hand under his bandage
during his delirium, displacing it. The German
sergeant had been a priest in civil life.
Will the American medical profession receive
these miserable thieving braggarts with open arms
after peace has been concluded? Members of the
German medical profession have stolen discoveries
made in other countries right and left. In a letter
dated September 11, 1018, one of America's most
prominent medical journalists wrote me, "about the
last thing I saw (in a Hun medical journal) before
the war began was an elaborate article on surgery
of the nose, in which the author had stolen bodily
the work of Cuter of New York, without mention-
ing his name." This wholesale thieving by the Hun
medical profession has been going on for years and
it is now high time to expo.se it.
Editorial Notes and Comments
NEW YORK MEDICAL JOURNAL
INCORPORATING THE
Philadelphia Medical Journal
and the Medical News
A Weekly Review of Medicine
EDITORS
CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D.,
Philadelphia,
SMITH ELY JELLIFFE, A.M., M.D., Ph.D.
New York.
Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers,
66 West Broadway, New York.
Subscription Price :
Under Domestic Postage, $5 ; Foreign Postage, $7 ; Single
copies, twenty-five cents.
Remittances should be made by New York Exchange,
pest office or express money order, payable to the
A. R. Elliott Publishing Company, or by registered mail, as
the publishers are not responsible for money sent by
unregistered mail.
-Entered at the Post Office at New York and admitted for transpor-
tation through the mail as second class matter.
Cable Address, Med jour. New York.
NEW YORK, SATURDAY, DECEMBER 28, 1918.
VIVISECTION IN ENGLAND DURING 1917
A place for discussing- the merits of vivisection
is no longer justified in a medical journal. Those
publications whose mission it is to make the
world laugh are frequently led, through sheer
dearth of other material, into accomplishing this
end by attacks on vivisection and vaccination.
Serious students of the progress of medicine,
however, have always realized that they must
turn to experiments on animals for information
regarding the action of drugs or the ravages of
disease in man. To such the recently issued re-
port on the number and nature of experiments
performed on living animals in England, during
1917, is of particular value. Of the 671 persons
who were licensed, 392 performed no experiments.
It is noteworthy that the experiments which
were performed without anesthesia consisted of pro-
cedures such as inoculation, hypodermic injec-
tions, and the like. Of these slightly over 55,000
experiments, more than 12,000 were made in the
course of cancer investigation, some 19,000 in the
course of government research, and between
22,000 and 23,000 for preparing, testing, and
standardizing sera, vaccines and drugs.
The government inspectors visited the regis-
tered places frequently, usually without notice,
and found the animals well cared for and well
treated. In over a thousand visits only two
irregularities were found.
Unfortunately, in view of the possibly well in-
tentioned agitation, no details are given in regard
to the exact results accomplished. One reason
for this is, of course, that such results usually do
not become apparent until several years after the
performance of experiments, for, following ani-
mal experimentation, a remedy must naturally
be tried out in the human body, and its status
does not then become fixed until sufficient time
has elapsed to prove whether or not first suc-
cesses are to be permanent.
No physician at all acquainted with the his-
tory of his profession, however, doubts the value
of animal experimentation. This question arises
only in quarters in which snake oil for rheuma-
tism, the blood of a black cat for shingles, and
such remedies, are still a matter of belief.
DIAGNOSIS OF THE PYLORIC SYN-
DROME IN NURSING INFANTS.
When all the signs of the pyloric syndrome in
infants are present, they are so distinctly charac-
teristic that the diagnosis is an easy matter.
A^omiting occurring during the first few weeks
after birth and persisting, regardless of change
of feeding or hydric diet ; a more or less marked
constipation, the small amount of feces passed
being composed of greenish mucus containing
some caseiform curds ; a progressive emaciation
with a flat belly, occasionally permitting the
peristaltic gastric movements to be perceived;
■more rarely the existence of a pyloric mass felt
by palpation ; these are signs which, when pres-
ent together, impose the diagnosis upon the med-
ical man.
But there are cases where the peristaltic move-
ments cannot be perceived under the abdominal
parietes and where no pyloric tumor is per-
ceivable. In such cases the problem becomes
complex and hesitation permissible. It is diffi-
cult to mistake regurgitations of an overfed in-
fant with vomiting due to pyloric spasm, but the
question becomes more delicate in certain forms
EDITORIAL ARTICLES.
[New York
Medical Journal.
of gastrointestinal dyspepsia of nursing infants.
Reference is not here made to the frank types
where vomiting is accompanied with diarrhea,
with stools containing curds, but to the type de-
scribed by Marfan with predominance of gastric
phenomena. In this type vomiting overshadows
all other symptoms, and hesitation is quite per-
missible between a mild pyloric syndrome and
this particular form of dyspepsia. The quick
cessation of vomiting as soon as the infant has
been put upon a hydric diet, likewise of the diar-
rhea, indicate tliat the case is one of dyspepsia.
In the types of chronic dyspepsia met with in
infants not breast fed, there is constipation, but
this constipation is often interrupted by attacks
of diarrhea. The spells of vomiting are less fre-
quent, the belly becomes lax and large on account
of elongation of the intestine — all of which signs
dififerentiate it from the pyloric syndrome.
Exceptionally, one may be obliged to differen-
tiate the symptoms engendered by a pyloric
stricture due to a congenital malformation of the
digestive tract with the pyloric syndrome. These
cases, which are rare, are characterized by phe-
nomena much more precocious and with a more
serious onset than those of the pyloric syndrome.
They even occasionally offer particular signs
which allow one to locate the site of the lesion.
Congenital stricture of the esophagus is made
evident by regurgitation rather than by vomit-
ing. The milk is ejected almost immediately
after ingestion, without having undergone the
slightest trace of change from contact with the
gastric juice. Occasionally the infant assumes
a cyanotic tint after feeding, and the esophageal
culdesac filled by the food acts by compression
on the pulmonary hilum. .Stenosis from mal-
formation of the pylorus is characterized by ear-
lier symptoms and which, from the beginning,
are much more serious than those of pyloric
spasm. Constipation is absolute and after the
meconium has been voided no more stools come
away. The effect on the general health of the
little patient is rapid and intense, death usually -
occurring within the first week after birth, while
in the most serious forms of the pyloric syn-
drome death is not apt to take place before the
end of the first month. Congenital stricture of
the intestine is likewise characterized by obsti-
nate vomiting and constipation, the meconium is
not always voided, but the principal symptom is
a rapidly developing abdominal distention, wliile
bile is found in the vomitus.
This picture of acute intestinal occlusion may be
met with in various processes, as in intestinal in-
vagination or in rare cases of neoplasms, but can
hardly be mistaken for pyloric spasm. The vomit-
ing in acute peritonitis of infants offers abdominal
distention, a more or less intense diarrhea, and a
rise in temperature — all symptoms which distin-
guish it from the vomiting of the pyloric syndrome.
The vomiting of meningitis is too well known to re-
quire mention.
PSYCHOPATHY AND CRIMINALITY.
From objective to subjective might well be
called the watchword of the newer psycopath-
ology and psychiatry. The emphasis has been
shifted from external causes and merely indi-
rectly contributing factors in psychic disturb-
ance, to internal ones finding origin in the per-
sonality and expressing themselves through this.
Mental diagnosis has lost its generalized formu-
laristic character and become a matter for re-
search and investigation in each individual. No-
where has this received greater emphasis nor
been presented with greater convincingness than
in the report of the psychopathic laboratory of
the Municipal Court of Chicago by the director.
Dr. William J. Hickson. It is in fact the attitude
and the message of the tenth and eleventh annual
reports of the Municipal Court of Chicago, re-
cently issued. 'J'he interest of the larger report,
however, concentrates largely upon that of the
psychopathic laboratory, and such is the nature
of the work of the Municipal Court and its
spirit of progress that the two cannot be sepa-
rated. The more intensive report incorporated
within the broader one may therefore speak for
the whole.
Doctor Hickson's urgent message is that those
who come under the surveillance of the Munici-
pal Court should be examined to determine
whether they are not subjects for medical treat-
ment, to be looked upon and treated first of all
as sick and incapable and only secondly as crim-
inals. He makes no vain and ill advised plea for
the offender against society. He speaks rather
in the interests of a true protection of society
itself against the evils from which it suffers in the
character and behavior of these subjects. He
urges that the old classic methods of treatment
take no account of these individual factors, but
merely leave them to work their way unaffected
by a limited period of confinement or other pun-
ishment which only perhaps precipitates further
offense. It does nothing really to prevent this
or to save these subjects from their inherent ten-
dencies nor society from the fruits of them.
December 28, 1918.]
EDITORIAL ARTICLES.
These persons young and old are in fact for the
most part mentally diseased, a fact which the
carefully acquired records of the laboratory fully
attest. Moreover, the disease and disability ex-
ist for the most part constitutionally and are
therefore latent, at least from the earliest years.
Intellectual defect is largely apparent, but a still
more prevalent menace, less apparent and there-
fore more insidious in its workings upon society,
is the emotional defective condition, chiefly that
comprehended under dementia praecox.
The old objective methods of trying to sup-
press vice by measures which do not reach into
individual psychology, do not take into account
the motives and impulses which lie there, and do
not recognize the constitutional inability of the
individual to control and direct them, have
proved themselves fruitless. The efficacy of
"law and more law" as a remedy for these things
is arraigned at its own bar. Such negative testi-
mony is furthermore overwhelmed by the abun-
dance of positive testimony which arises from
the facts which present themselves to a scientific
mode of approach and attack, such as that which
this laboratory has proved efficacious. The re-
sults of its several years of work, given statis-
tically, should convince the most sceptical. The
writer is first of all the practical worker, the
psychiatrist who speaks of that with which he has
had such efifective experience, and he attacks his
problems theoretically as well as from the broad-
est, which is at the same time the most individu-
alistic, point of view. He brings to bear the
thought and experience of leaders in practical
psychiatrical affairs, chiefly in the clinics and
psychopathological fields abroad. Then he adopts
the attitude of the most penetrating and, progres-
sive of these in refusing to recognize a general-
izing and obscuring classification or description
of the difficulties presented or of the cases in
which such things appear. Here the individual-
istic point of view is paramount, as it is in the
attempt to reach and deal with each case.
The study is a very intensive one as it is pre-
sented in this formal report. It is well worth the
attention of physicians and members of the legal
profession first of all, and of every thinking man
and woman who is interested in the preservation
of society from the increasing menace of those
unfortunate in intellectual and emotional non-
adaptability, who are therefore drifting into
crime. The writer has purposely gone deeply
into the technical psychiatrical side in order to
present the background of understanding upon
which alone these individuals can be appraised
and their defective attitude toward the social order
effectually controlled. Against this he presents
the number and extent of such actual mental
illness and defect among those who pass through
the Municipal Court and its psychopathological
laboratory. On these two broad bases of fact
stands out in clear relief the only means by which
control can be secured and exercised : regard
for these unfortunates as needing medical diag-
nosis first, then medical treatment and care. By
this alone can society be saved from the effect of
their uncontrolled behavior and the continuous
propagation and extension of the evils existent.
Medical care and treatment mean such in the
widest sense of the word, as they extend to the
broadest social policies, medical and legal first,
for the detection and guardianship of such help-
less individuals and their segregation at some
suitable farm colony or wherever they can be
thus cared for and the dangerous forces turned
into healthful and, as far as possible, effective,
constructive channels.
TO IMPROVE HEALTH CONDITIONS IN
RURAL COMMUNITIES.
Impressed by the backward state of health condi-
tions in rural communities and by the importance of
promptly raising and maintaining the health of the
rural population. Representative Lever, of South
Carolina, has introduced a bill embodying the prin-
ciple of federal aid, whereby effective cooperation
between federal, state, and local authorities is as-
sured. The bill, as introduced, provides an appro-
priation of $250,000 for the first fiscal year, to be
allotted for work in the various states on the half
and half plan, and an appropriation of an additional
$250,000 each, fiscal year thereafter, until a continual
annual appropriation of $1,000,000 is reached.
Some idea of the conditions prevailing in a large
part of the rural districts in this country is given in
Public Health Bulletin No. 94, just published, em-
bodying the result of sanitary surveys and health
demonstrations conducted by the Public Health
Service in various states throughout the country.
In this survey over 50,000 farm houses were
visited in fifteen different counties. Of these less
than two per cent, were equipped for the sanitary
disposal of human excreta. Over two thirds, sixty-
eight per cent., used a water supply which was ob-
viously exposed to potentially dangerous contamina-
tion from privy contents on from promiscuous de-
posits of human excreta. In the majority of these
the water was also exposed to pollution from stable
yards and pig sties. Only one third of the dwell-
ings were effectively screened during the summer
1 126
NEWS ITEMS.
[New York
Medical Journal.
season, to prevent flies, which had free access to
nearby deposits of human and other filth, from en-
tering dining rooms and kitchens and contaminating
foods intended for human consumption.
Taking the prevalence of typhoid fever as the
most reliable single measure of the efifectiveness of
proper health measures, the bulletin shows that
wherever a sanitary survey and health demonstra-
tion was carried on, the number of cases of typhoid
fever promptly fell to one quarter, or even less, of
what they had been during previous years. That
this was the logical outcome of well planned health
activities is clearly shown by the fact that practi-
cally the same result was obtained in all the demon-
strations, although these demonstrations were con-
ducted in the widely scattered states of Maryland,
Virginia, North Carolina, South Carolina, Kentucky,
Tennessee, Georgia, Alabama, Mississippi, Iowa,
Missouri, Nebraska, Oklahoma, Texas, and Wash-
ington.
It is conservatively estimated that there has been
an annual average in the last decade, in- the United
States, of about 2,000,000 cases of hookworm ; 350,-
000 cases of typhoid fever, of which 30,000 were
fatal ; and approximately 9,000,000 cases of malaria,
of which 3,000 were fatal. These diseases result
largely from insanitary conditions in our rural dis-
tricts. They are preventable diseases. The eco-
nomic loss to the nation each year from malaria and
typhoid fever has been estimated at $9,000,000. The
prevention of typhoid fever, hookworm disease, and
malaria has a profound influence in the prevention
of many other diseases including tuberculosis. Ex-
perience has shown that by carrying out sanitary
measures which efifect a reduction in typhoid fever,
there is a prevention of about three deaths from
other causes for each death from typhoid fever pre-
vented.
It has become more and more clear that health
conditions throughout the country are largely de-
pendent on health conditions in the rural districts.
Health ofificers throughout the United States have
time and again shown that the prevalence of typhoid
fever, scarlet fever, diphtheria, tuberculosis, and
other communicable diseases, cannot be successfully
controlled without dealing eflfectively with insanitary
conditions in the rural districts, to which, in many
instances, these diseases are directly traceable; •
Under these circumstances it is reasonable and
proper that any plan for improving rural sanitary
conditions should enlist the cooperation of federal,
state, and local health authorities, a principle recog-
nized in the bill now under consideration. The adop-
tion of this principle by Congress cannot but be re-
garded as a great step toward improving the health
of the nation.
THE LAST KICK.
If the nonmedical healers in the province of
Ontario do not get any concessions now, they are
not likely to get any when the Ontario legislature
opens its session, early in 191 9. The government,
only a few days ago, called representatives of the
various bodies concerned, including representatives
of the Ontario Medical Council, the Ontario Medical
Association, and the Academy of Medicine, Toronto,
Their object in doing so was to go over the report
of the commissioner, Mr. Justice Hodgins, on medi-
cal education and practice in that province, to find
out just where each of the bodies aforesaid stood re-
garding the report. The medical representatives of
the profession stated they were satisfied with the
report, but suggested the following as a definition
of the practice of medicine : "The practice of medi-
cine shall mean and include diagnosing, healing, *
alleviating, or attempting to diagnose, heal, or alle-
viate any ailment, defect, or mental condition, di-
rectly or indirectly by advice, assistance, or any
action whatever, with or without the use of drugs
or any other means."
Numerous objections to the report were made, of
course, .by the representatives of the unlicensed
bodies.
Colonel A. Primrose, C. M. G., president of the
Academy of Medicine, possibly gave as good advice
to the government as could be given. He told the
law makers of the new Ontario Medical Practice
Act that no irregular practitioner of any cult what-
soever had been permitted to enter either the Royal
Army Medical Corps, or the Canadian Army Medi-
cal Corps, and advised that the government inquire
into his statement before it even thought of allowing
these cults into practice in a regular way. The
reason for this lay in the fact that both the Royal
Army ]Medical Corps and the Canadian Army Medi-
cal Corps had trained members of the profession
both in England and in Canada to specially perform
all manipulative surgery required, and to do it effi-
ciently.
^
News Items.
The Health of the Navy. — The Bureau of
Medicine and Surgery of the United States Navy
announces that the sick rate for men in the service
is rapidlv changing to normal after the epidemic.
Medical Officers to Retain Temporary Rank. —
]\[r. Dyer has introduced a bill in the House of
Representatives known as H. R. 13345, providing
that officers of the ]\Iedical Corps of the regular
army who have received temporary promotions
shall retain their advanced grade to the conclusion
of the war as extra numbers in the permanent es-
tablishment until promoted to the next higher
grade.
December 28, 1918.]
NEIVS ITEMS.
1 127
Archives of Neurology and Psychiatry. — The
American Medical Association announces that it
has established and will issue, beginning on Janu-
ary I St, a monthly journal to be known as the
Archives of Neurology and Psychiatry.
Blind Pensioners in Illinois. — The quarterly
report of the lUinois State Department of Public
Welfare states that 2,000 blind adults are supported
by county pensions in Illinois. Of these, 350 are
in the southern part of the State. Trachoma is de-
clared to be the cause of the high rate of blindness
in this section.
Effects of Demobilization. — Colonel Deane C.
Howard, Director of Sanitation of the Army, is
quoted in a recent issue of The Army and Navy
Joxirnal as predicting an increase in the death rate
and the sick rate of the army as the process of de-
mobilization proceeds. This condition will arise
from the fact that only those men will be discharged
who are in good physical condition, eventually leav-
ing only sick men in camp.
Six Million Deaths from Influenza. — It is be-
lieved that throughout the world about 6,000,000
persons have died from influenza and pneumonia
during the last three months. It has been esti-
mated that the war, during four years and a half,
caused the death of about 20,000,000 persons,
and it is pointed out that influenza is proved to be
five times deadlier than war. Never since the
Black Plague epidemic has such a plague swept over
the world.
Conference of Industrial Physicians. — Dr.
Francis D. Patterson, chief of the Division of In-
dustrial Hygiene and Engineering, Department of
Labor and Industry, Harrisburg, Pa., is desirous of
obtaining a complete list of all physicians engaged
in the practice of industrial medicine. It has been
the custom of this department to hold semiannusl
conferences of industrial physicians and surgeons.
As the next conference will be held early in 1919,
it is desirable that the names and addresses of all
industrial physicians and surgeons be in the hands
of Doctor Patterson as soon as possible.
A Bill Reorganizing the Personnel of the Medi-
cal Department. — A bill has been introduced into
Congress by Mr. Dyer affecting the personnel of
the Medical Department. This bill, H. R. 13344,
is general in character, providing for a surgeon
general with the rank of major general, and for
assistant surgeon generals in the ratio of one-half
of one per cent, of the total number of the officers
in the department. These will be equally distrib-
uted in the grades of major general and brigadier
general of the Medical Corps, the Sanitary Corps,
and the Veterinary Corps. The commissioned of-
ficers of the Medical Corps below the rank of
brigadier general are to be proportionately dis-
tributed in the several grades as now provided in
the Medical Corps of the Navy. The principle of
selection is recognized, the President being author-
ized to fill any vacancy by selection from among
the medical officers of not less than one year's con-
tinuous active service. It provides that retirement
shall be granted only after fifteen years' continu-
ous service. The ratio of dental surgeons is es-
tablished at 2 per thousand of the enlisted strength
of the Army.
Trachoma a Reportable Disease in North Caro-
lina.— As a result of the efi^orts made by the
health authorities to eradicate trachoma from
Mecklenburg County, Doctor Crouch, State epi-
demiologist, reports that the North Carolina State
Board of Health has made trachoma a reportable
disease.
Seventeen Thousand Deaths from Influenza in
Camps. — The War Department has issued a
statement that, up to December i, 338,257 cases of
epidemic influenza had been reported in the variou.s
army camps and military centres in the United
States, with approximately 17,000 deaths. The
deaths resulting from pneumonia and from influ-
enza were not reported separately, consequently,
the figures are only approximate. Between the
time that the influenza first made its appearance
September 13th and December ist, the deaths re-
ported from all quarters numbered 19,694.
National Committee for Prevention of Blind-
ness.— The fourth annual meeting of this com-
mittee was held in the New York Academy of Med-
icine, Tuesday evening, November 26th. Hon.
William Fellowes Morgan presided. The speaker
of the evening was Lieutenant Colonel James
Bordley, Medical Corps, U. S. Army, who is direc-
tor of the work for the blind of the Army and
Navy, and also director of the Red Cross Institute
for the Blind. He gave a very interesting talk,
illustrated with lantern slides, of the work of re-
education done in Hospital No. 7 for the soldiers
and sailors blinded in war.
Personal. — Dr. Cary Eggleston was elected
secretary of the Section in Medicine of the New
York Academy of Medicine, at the annual meeting
held on Tuesday evening, December 17th. Dr. Ed-
mond P. Shelby was elected chairman.
Brigadier General William H. Arthur, Medical
Corps, U. S. Army (colonel. Regular Army), was
retired on November 29th, upon his own applica-
tion, having reached the age of sixty-two years.
Colonel Louis Brechemin, Medical Corps, U. S.
Army, stationed in Boston as chief surgeon of the
Northeastern Department, was quite seriously in-
jured on December 13th, when the Army automo-
bile in which he was riding was struck by an auto-
mobile.
Meetings of Medical Societies to Be Held in
New York. — During the coming week the fol-
lowing medical societies will hold meetings in New
York :
Wednesday, January ist. — New York Academy
of Medicine (Section in Historical Medicine) ;
Bronx Medical Association ; Harlem Medical Asso-
ciation; Psychiatrical Society of New York (an-
nual); Society of Alumni of Bellevue Hospital;
Brooklyn Hospital Club ; Brooklyn Society for
Neurology.
Thursday, January 2d. — New York Academy of
Medicine (stated meeting) ; Brooklyn Surgical So-
ciety (semiannual meeting).
Friday, January 3d. — New York Academy of
Medicine (Section in Surgery) ; New York Micro-
scopical Society : Practitioners' Society of New
York : Gynecological Society of Brooklyn.
Saturday, January 4th. — Benj amin Rush Medical
Society.
Modern Treatment and Preventive Medicine
A Compendium of Therapeutics and Prophylaxis, Original and Adapted
POLYVALENT SERUM THERAPY IN CERE-
BROSPINAL MENINGITIS.
By Louis T. de M. Sajous, B. S., M. D.,
Philadelphia.
(Continued from page 1092.)
This bivalent serum was used clinically by Netter
in the later months of 191 7 and first three months
of 1918 in a series of seventeen cases of meningitis.
Twelve patients recovered, the gross mortality being,
therefore, 29.4 per cent. All the fatalities occurred,
however, within the first twenty-four hours after
admission or because of superadded nonmeningo-
coccic infectious complications. The corrected
mortality, arising directly from the meningococcus
with the case already brought under the influence
of serum treatment, was nil, as compared to eight
or more per cent. — up to 28.5 per cent. — in previous
series of cases treated with other kinds of serum.
Manifestly, then, polyvalent antimeningoccoccic se-
rum therapy is not only a feasible procedure, but
when appropriately adapted to the clinical cases
met with, promises to yield better results than other
methods of serum treatment previously applied.
In illustration of the beneficial action often pro-
cured from the use of Nicolle's bivalent serum, Net-
ter mentions the case of a little girl, aged seven, ad-
mitted to a hospital on the third day of the disease,
comatose and with universal purpura. The serum
was administered to the amount of 120 mils in three
injections of forty mils each in the course of thirty-
six hours. The temperature, originally above 40°
C, dropped to normal on the day after the third in-
jection, and prompt recovery followed. In another
patient, a little girl, aged three, admitted only on the
eighth day of the disease and presenting in addition
to diflfuse purpura, suppurative arthritis of the knees
and other joints, and an acute iridocyclitis, twenty-
five mils of bivalent serum were promptly injected
into the spinal canal and five mils into each knee
joint. Additional injections were given on the two
succeeding days. The temperature dropped to nor-
mal on the second day after the last injection, the
knees resumed their normal appearance, and the
other joint swellings subsided without surgical inter-
vention, though atrophy of the choroid followed the
iridocyclitis, injection of serum into the vitreous
body having been carried out too late.
The first of the two cases just referred to was
due to the B type of organism, or parameningocot-
cus, while in the second, identification of the type
of organism responsible could not be carried out.
In two other cases in which equally rapid recovery
took place under the bivalent serum, an organism of
Type A, i. e., a true meningococcus, was found. In
three additional cases, Type B was present, while
among three in which a larger number of serum in-
jections proved necessary, two showed Type B and
one, Type A. The feasibihty of obtaining a single
serum highly efficient against more than one type of
meningococcic organism was thus demonstrated.
The questions next arise: Are the serums now
available to the practitioner so prepared as to be
universally efficient against the various forms of or-
ganisms present in the cases of meningitis he en-
counters? Again, are all possible strains likely to
be adequately represented in the serums as so far
produced ? An answer to the first query is supplied
by the results of tests conducted by Amoss, 1917,
who states that most commercial serums are grossly
deficient in potency and usually fail to represent the
four essential strains — meningococcus, paramenin-
gococcus, and two intermediate strains, A and B.
A suitable serum, according to this author, should
agglutinate all four of these strains in dilutions be-
tween one in 400 and one in 1,000. In the ideal
serum "other and aberrant strains," he significantly
mentions, "should be added as they are isolated."
Andrews, 1917, whose work was based on Gordon's
classification of the meningococcic organisms into
Types I, II, III, and IV, found, among twenty-six
instances of cerebrospinal meningitis in children
under five years of age, eight organisms which ag-
glutinated so poorly with the four type serums sup-
plied him from Gordon's Central Cerebrospinal Lab-
oratory at Millbank, England, that he could not re-
gard them as conforming to the four standard types,
and was forced to conclude that the meningococcus
in the posterior basal meningitis of infants some-
times presents strains dif¥erent from those of the
epidemic form of the disease in adults.
Evidently the production of a universally efficient
serum is a more difficult matter than might at first
appear, and indeed, the inquiry seems pertinent,
whether it is permissible at all to rely on any single
serum, however carefully prepared, since the caus-
ative virus is liable to such wide variations at dififer-
ent times. Authoritative opinions are not wanting
which favor, after primary use of a polyvalent
serum of known all-around efficiency against ordi-
nary types of meningococcus, the administration of
serum freshly prepared from virus obtained in cases
forming part of a prevailing epidemic. This virus
may be taken from the cerebrospinal fluid ; but, ac-
cording to Andrews, it has been demonstrated by
several workers that the type of meningococcus in-
variably present in the pharynx early in the disease
is always the same as that found in the spinal fluid.
The proper virus can, therefore, also be secured
from the pharynx, and in fact, Paleani, 1917, spe-
cifically states that where he found the cerebrospinal
fluid limpid and sterile he took cultures from the
nasopharynx to make an antiserum. Numerous
pseudomeningococci and parameningococci are apt
to occur, he finds, in the nasopharyngeal secretions,
but these can generally be identified by agglutination
tests.
Another complicating factor in the treatment of
cerebrospinal meningitis is mixed infection. Pale-
ani, among forty-three specimens of cerebrospinal
fluid sent to him for examination, obtained positive
meningococci findings in only thirty, many of the
December 28, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
1 129
remaining specimens showing pneumococci or tuber-
cle or other baciUi. Netter, 1917, reports five of
his own and seventeen other cases of epidemic men-
ingitis in which the pneumococcus was found along
with the meningococcus in the cerebrospinal fluid.
AH died but two. Since then Netter has made it
a practice to inject two or three mils of antipneumo-
coccus serum whenever administering antimeningo-
coccus serum in meningitis cases. Of nineteen cases
thus dealt with only two showed the pneumococcus
in the cerebrospinal fluid, and both of these recov-
ered.
On the whole, it seems plain that in the serum
therapy of meningitis individual peculiarities of dif-
ferent cases or groups of cases require careful con-
sideration if the lowest possible mortality is to be se-
cured.
{To be continued.)
Treatment of Malaria. — A. J. Ochsner {South-
ern Medical Journal, October, 1918) gives the fol-
lowing treatment for malaria : The patient should
be impressed with the importance of following in-
structions absolutely, including the taking of quinine
at regular times at night. An alarm clock should be
used, if necessary. The quinine should be taken
with hot water to insure immediate absorption. On
the evening before commencing the treatment a
cathartic should be taken, preferably two ounces of
castor oil in beer foam, ginger ale, or root beer ; or
five grains of calomel with ten grains of bicarbonate
of soda at bedtime and a Seidlitz powder the fol-
lowing morning. During the period of treatment
it is best to live on hot soups. On the morning fol-
lowing the taking of the cathartic two grains of
quinine should be taken — bisulphate preferred, but
the sulphate or the muriate will do — with half a
pint of hot water every two hours night and day
for two full days and two full nights. This must
be done regularly ; missing once or twice will make
the treatment useless. Then no quinine for six full
days and six full nights is to be taken. On the
evening of the sixth day, another cathartic ; on the
morning of the seventh day the quinine again, two
grains every two hours for two full nights and two
full days. This treatment should then be stopped
and some simple tonic taken for a few weeks. The
quinine may be taken either in solution or in cap-
sule form, but in the latter case the cap must be
removed from the capsule before swallowing it. In
the interval of six days between the two courses of
quinine treatment a pill containing one fiftieth of a
grain of arsenious acid one hour before and after
each meal may be taken, each time with a glass of
hot water. In case the quinine disagrees with the
patient it is usually possible to correct this difficulty
by giving two to five grains of sodium bromide in
a little hot water before administering each dose of
quinine. This treatment is based on the following
well known facts: i. The adult Plasmodium o-f ma-
laria is destroyed in the blood of a patient saturated
continuously for forty-eight hours with quinine. 2.
The spores of malaria can live indefinitely in the
blood of patients, without regard to the amount of
quinine taken. 3. Spores of malarial plasmodia
remain latent in the presence of quinine in the blood
and begin to develop only after this drug has been
entirely eliminated. 4. These spores require seven
days before they can develop into adult sporebear-
ing Plasmodia. 5. Quinine must be absorbed in
order to do its work ; hence the importance of the
preliminary cathartic, the soup diet, and the hot
water taken with the quinine. 6. The blood must
remain continuously saturated with quinine ; hence
the importance of giving the remedy regularly night
and day. 7. The total amount of quinine required
is small.
Treatment of Nerve Injuries. — • Delageniere
{Prcssc mcdicalc, October 17, 1918) reports the re-
sults obtained in 358 cases of nerve wounds treated
surgically : by resection and suture, 236 cases ; by
resection and nerve grafting, nine cases, and by
nerve liberation, 113 cases. Seventeen cases of
causalgia treated by section of the nerve above the
lesion and followed by immediate suture are also
reported. Resection and suture is the method of
choice, yielding successful results in eighty-eight
per cent, of instances. When resection is to be so
extensive as to prevent approximation of the two
ends, even with the limb flexed, resection should be
done in two stages. At the first operation the
largest possible section of nerve should be removed
and the diseased ends sutured together ; three or
four months later, after the nerve has become
stretched, further resection and suture of healthy
nerve ends can be performed. In still more exten-
sive loss of nerve tissue, nerve grafting should be
performed, either by means of two fragments from
the musculocutaneous, side by side, or with a frag-
ment of nerve from an amputated limb. Nerve
liberation gives good results only in simple com-
pression. When the nerve is impaired it had better
be resected and sutured.
Nev\r Methods for Blood Transfusion and
Serum Therapy. — Frank W. Hartman {Journal
A. M. A., November 16, 1918) describes a cheap,
simple, and efficient apparatus for securing and ad-
ministering blood or plasma without the common
difficulties of clotting. A twelve-gage rubber
stopper is fitted into the neck of a one or two quart
E. Z. seal fruit jar. The neck of a round, four
ounce bottle is fitted into a large hole bored through
the centre of the stopper. The bottle thus hangs in
the large jar. A small hole is bored in the stopper
for pressure tubing and a second for the blood-
carrying tube. These two rubber tubes are passed
directly through the stopper and become sealed to
it by sterilization, while glass will sear the stopper
and cause leakage. The pressure tube reaches just
below the inside of the stopper, while the blood tube
extends to the bottom of the jar, glass being used
for the extension if desired. Suction or pressure is
made by means of an aspirating pump. The blood
tube is fitted with a clamp and needle connection for
the reception of a seventeen-gage platinum needle.
The small, inner bottle is filled with 2.5 per cent,
citrate solution, and fifteen to twenty mils of this
solution are placed in the bottom of the large jar.
The small bottle receives a rubber siphon tube,
carrying a screw clamp and a drop chamber for the
1 130
MODERN TREATMENT AND PREVENTIVE MEDICINE.
[New York
Medical Journ \l.
regulation of the flow of citrate, and this is con-
nected to the blood tube right close to the needle
mount by the insertion through the tube of a needle
attached to the citrate tube. For bleeding the citrate
in the jar is forced up to fill the bleeding tube and
needle, the needle is inserted into the donor's vein,
slight negative pressure is made in the jar, and a
free flow of citrate is allowed from the small bottle.
When bleeding becomes free the citrate is cut down
so as to enter the blood tube in the proportion of
about ten mils of citrate for ninety mils of blood.
For injection the pump is reversed and the blood is
slowly forced into the recipient's vein. Human
plasma can be collected by the apparatus, using one
per cent, citrate in normal saline in the proportion
of twenty-five mils to each seventy-five mils of
blood, the dilution hastening the sedimentation of
the corpuscles. For the grouping of donors and re-
cipients a simple technic is described, based on Lee's
method. Its essential feature lies in the preparation
and use of heavy filter paper which has been satu-
rated with known serums and dried. This paper
will keep indefinitely.
Scabies in Military and Civil Life. — Frank
Crozer Knowles {Journal A. M. A., November i6,
1918) points out that this parasitic skin disease is
much more frequent in military than in civil life and
that in the former it presents decided differences in
its clinical picture and in the lesions produced. Thus
in military life the hands are not frequently in-
volved ; the penis is usually much involved and
shows many pustules and burrows ; and complica-
tions are very common, including unusually large
numbers of pustules and boils, impetigo, and the so
called inflammation connective tissue, or secondary
pustular lesions. The treatment of scabies can be
made most efficient if properly conducted. The pa-
tient is given a warm bath on the first day, using
plenty of soap. Immediately after the bath he rubs
himself, or is rubbed, with an ointment containing
4.0 grams of precipitated sulphur to 30.0 grams of
petrolatum (one dram to the ounce). This rub-
bing must consume fifteen minutes and must be
done under the immediate inspection of the physi-
cian or of a trained person. It must include abso-
lutely every part of the skin from the collar line to
the toes and must be vigorous enough to open and
destroy all of the burrows. The rubbing is repeat-
ed on each of the next three days, and on the fifth
day another warm bath is given, followed by a com-
plete change of clothes. The entire body is then ex-
amined minutely to insure the absence of active dis-
ease. If this is present the treatment is repeated.
For the treatment of all of the secondary pustular
complications there is nothing more effective than
ammoniated mercury ointment in the strength of
1.3 to 2.6 grams in 30.0 grams of petroleum (twenty
to forty grains per ounce). Incipient boils can be
cured by daily rubbing for ten minutes with twenty-
five per cent, ichthyol ointment. When developed
they should be opened, and if present in large num-
bers, or if they continue to recur, an autogenous
vaccine should be given. Septic ulcer and inflam-
mation of connective tissue may require rest in bed
and should be treated by the local application of am-
moniated mercury in zinc oxide ointment.
Cutaneous Autoplasty after Operative Treat-
ment of Foci of Osteitis. — D. Thevenard (Presse
nicdicalc, October 7, 1918), where a deep recess in
a bone has been left through removal of bone tissue
for osteitis, makes superior and inferior transverse
skin incisions above and below the site of disease.
The resulting lateral flaps are mobilized for some
distance and then drawn together down into the
centre of the bone defect which they are intended to
fill. Three to six radiating incisions may be made
to permit of better coaptation of the skin flaps over
the defect. Dressings being insuflicient to hold the
flaps in place, the author, after retracting the flaps
laterally, makes holes with an awl through the bone
and passes through them bronze wire, which issues
near the bottom of the groove in the bone and holds
the margins of the flaps down in place. Usually
two or three bronze sutures are used for each flap.
At both ends of each bronze wire a small packet
of gauze is placed to prevent injury to the skin.
After having been fastened with the wire, the flaps
are united at their margins by a few sutures. The
bronze sutures should be kept under observation on
and after the third day, and should be removed
whenever the pressure at the point of fixation is
seen to be threatening the vitality of the flap. A
number of cases of osteitis after war wounds have
been treated successfully by the procedure.
An Improved Sugar Solution for Intravenous
or Subcutaneous Injection. — L. Duprat and A.
Demolon (Paris medical, October 5, 1918) refer to
the now frequent use of isotonic or hypertonic glu-
cose solution in preference to normal saline solution
in infections accompanied by renal reactions and
diminished permeability of the kidneys. Chemically
pure glucose is, however, difficult to obtain and
costly, while commercial glucose is very impure, al-
ways containing much dextrin and sometimes for-
eign substances derived from sulphuric saccharifica-
tion. Saccharose and lactose are pharmacologically
inferior to glucose, passing out unchanged and un-
utilized in the urine. Upon previous inversion of
the saccharose, however, the authors obtained com-
plete utilization of the sugar even in the presence of
severe hepatic insufficiency. Saccharose or cane
sugar has the advantage of being almost pure chem-
ically and of low cost. Uninverted saccharose or
lactose, while no doubt effectual in washing out the
blood, possibly constitute a strain on the kidneys, in
addition to being eliminated unutilized. The in-
verted sugar, on the other hand, is both nutriant and
diuretic. The formula for the production of a
neutral, isotonic invert sugar solution, with com-
plete hydrolysis of the saccharose and absence of
decomposition products is : saccharose, 5.4 grams ;
enough to make 100 mils ; normal hydrochloric acid
solution, six drops. For a hypertonic solution, the
quantity of saccharose is doubled. Either solution
is sterilized at 100° C. for forty minutes, then at
110° C. for fifteen minutes. Ampules of a solu-
tion containing eight drops of normal sodium bicar-
bonate solution to the mil are sterilized at the same
time. Before use, complete neutralization of the
sugar solution is insured by the addition of one mil
of the bicarbonate solution to every 100 mils of
sugar solution.
December 28, 1918.]
MODERN TREATMENT AND PREVENTIVE MEDICINE.
Treatment of Vulvovaginitis in Children. —
E. C. Sage {Joiinial of the Missouri Statt' Medical
Society, September, 191 8) finds that the Bulgarian
bacillus cannot be made to thrive in the human
vagina, and thus its use to overgrow and crowd out
the gonococcus is fruitless. The measures used in
his cases at the Barnes Hospital, St. Louis, were
instillation into the vagina of one to five per cent,
silver nitrate or five per cent, protargol ; douches of
potassium permanganate ; hot sitz baths ; application
of zinc ointment to the irritated vulva. The most
rational and efficient treatment seems to be mixed
vaccines injected in ascending doses every ten days.
Surgical Treatment of Cholangitis and Chole-
cystitis.— John Darrington {Soitthcrii Medical
Journal, September, 1918) gives the following rules
for removal or for drainage of the gallbladder. The
indications for removal are: i. When the wall of
the gallbladder is so damaged that it will remain a
source of infection; 2, cystic gallbladder, hydrops,
or empyema ; 3, when the glands along the common
duct are enlarged ; 4, gangrenous gallbladders,
where possible ; 5, stricture of the cystic duct ; 6,
pancreatitis, if stones are present; 7, any evidences
of malignancy. The indications for drainage are :
I. In all cases where the patient's condition or the
technical difficulties render removal unsafe ; 2,
greatly enlarged liver with jaundice; 3, pancreatitis,
if stones are not present ; 4, in all cases of common
or hepatic duct complications ; 5, in pregnancy and
very old patients ; 6, in those simple cases where the
infection has subsided and the stones have been left
as a monument to Nature's victory.
Galvanic Current in the Treatment of Exoph-
thalmic Goitre. — Olivier (Paris medical, October
5, 1918) reports two cases in which the ultimate re-
sults of treatment by galvanic electricity proved
highly gratifying. The first case was that of a
woman of twenty-six years, suffering from the dis-
ease for three years, in whom hematoethyroidin had
failed and section of the cervical sympathetic had
been refused by the surgeon, owing to the patient's
extreme weakness. Her weight had become reduced
to thirty-seven kilograms. A sixty volt galvanic
current was subsequently employed, with broad elec-
trodes over the neck and back, the former being neg-
ative and the latter positive. The amount of cur-
rent was gradually increased to eighty milliamperes.
Thirty-seven treatments in all were administered, at
first daily, later at increasing intervals, up to one
week. Each sitting lasted about half an hour. Five
months after the beginning of treatment, the patient
Aveighed fifty-nine kilograms and her pulse rate had
fallen from 140 or 150 to eighty. The second pa-
tient was a woman of forty-eight years, with ex-
treme tremor preventing locomotion, a pulse rate of
180, a large soft goitre, diarrhea, vomiting, and
marked emaciation. Forty-two galvanic treatments
were given. After the eighth treatment the patient
could already walk a considerable distance. When
seen three years later she was in good health. The
author deems the galvanic current one of the best
procedures in exophthalmic goitre. The ordinary
dose of twenty-five to thirty-five milliamperes is,
however, insufficient, even if combined with faradic
electricity ; a much stronger treatment is required.
Paralysis of Nerve Cells and Nerve Endings by
Curari, Strychnine, and Brucine and Its Antago-
nism by Nicotine. — J. N. Lan^l^y (Journal of
Physiology, October 18, 1918) adcls evidence to the
generally accepted fact that curari, strychnine, and
brucine paralyze peripheral nerve cells, and describes
a series of experiments on cats in which the paral-
ysis was demonstrated. From his results he be-
lieves that these poisons have some paralyzing ac-
tion on all preganglionic nerves. The different
preganglionic nerve fibres investigated are grouped
into classes according to the order of paralysis with
increasing amounts of curari in the following order:
cardioinhibitory fibres ; secretory fibres of the chorda
tympani, the secretory pupillodilator and pilomotor
fibres of the cervical sympathetic (probably also
bulbar and sacral vasodilators) ; cutaneous vasocon-
strictor fibres ; fibres for the nictitating membrane
and eyelids ; probably adrenalin secreting fibres and
abdominal vasoconstrictors. Nicotine, when given
in sufficient amount, antagonizes the paralyzing
effects of these poisons, and produces its usual stim-
ulating effect. The excitation of nerve cells by
nicotine, after curari has been administered, depends
upon the relative concentration of nicotine and
curari in contact with them. In general, nicotine
antagonizes the paralyzing action of curari on the
nerve cells in inverse proportion to the ease of par-
alysis by curari as determined by nerve stimulation.
No means were discovered of permanently raising
the blood pressure to any extent after a large dose
of a poison paralyzing peripheral nerves.
X Ray Treatment of Scars. — Zimmern, Cotte-
not, and Houde (Paris medical, September 14,
1918) state that adhesions formed by scar tissue be-
tween mobile structures can often be eliminated in
a few sittings with the x rays. This applies to ad-
hesions at the bend of the elbow or in the popliteal
space which offer obstruction to complete use of
the joint. In scars of the wrist or forearm, some-
times following prolonged suppuration and involv-
ing the synovial sheaths, compressing or agglutinat-
ing the tendons and impeding flexion, the x rays
constitute the therapeutic method of choice.
Argyrol Instead of Bismuth Paste. — Hugh
Crouse (Soiithzvestern Medicine, September, 1918),
having had unpleasant experiences with bismuth
paste, now uses in its stead a paste consisting of ar-
gyrol 200 grains, liquid albolene four drams in lano-
line q. s. four ounces. The advantages of argyrol
are high antiseptic potency, decidedly penetrating
properties, and harmlessness even in concentrated
solution. The paste should be made up each week
and kept cool. The technic is that of bismuth paste.
Vaccine Therapy in Gonorrhea. — Candido Ma-
derna (Gioriiale Italiano delle Malattic Venerce e
delta Pclle, September 30, 1918) sums up a large
series of cases as follows : Vaccine therapy in pri-
mary acute or subacute specific urethritis aflfects only
subjective symptoms and has no direct action on the
gonococcus ; however, as adjuncts to local treatment,
vaccines are of value in the subacute or chronic
cases. In the secondary or complicating localizations
of disease, as arthritis, epididymitis, and prostatitis,
vaccines are valuable, and here large doses are of
much more value than small ascending doses.
Proceedings of National and Local Societies
THE AMERICAN PUBLIC HEALTH
ASSOCIATION.
Forty-sixth Annual Convention, Held in Chicago,
December p, ipi8.
Dr. Ch.arles J. O. Hastings, of Toronto, in the Chair.
Relation of Income to Health. — From Presi-
dent Hastings's scathing criticisms of our democ-
racy and its iniquitous distribution of weahh, the
relation of income to health ran like a red thread
through the meandering discussions on industrial
hygiene, the social aspects of disease, the influenza
epidemic, and infant mortality. Summaries of
elaborate studies into the cost of living, and of the
existing direct relationship between the wage rate
and the sickness rate, were presented at the several
section meetings.
Miss Julia Lathrop submitted the results of eight
surveys made by the federal Children's Bureau,
pointing to the close correlation between income
and infant mortality. In families where the bread-
winner earned annually $1,250 or more, the infant
death rate per thousand live births varied from 22.2
to 87.6, while in the group of very small income of
under $550, the infant deaths, with one exception,
oscillated between 117.5 and 260.9 P^"" thousand
live births. The relationship between housing and
infant welfare was illustrated by a series of figures,
of which those pertaining to Manchester, N. H.,
are characteristic. In homes where the rental paid
was $7.50 per month, infant mortality was 21 1.4 —
or more than double the rate for the registration
area in 1915 of 100 per 1,000 living births. Among
the children in homes with a rental of from $7.50
to $12.49, the death rate was 172.1. In the third
group, with a rental range of from $12.50 to $17.49,
it was 156.7, and in the next higher group the rate
was about one in ten, or equivalent to the general
census figure of 191 5. The inference drawn from
thi^se statistics was to the effect that the rate of
infant mortality bears a sort of one sided inverse
ratio relationship to improvement in housing con-
ditions. The better the housing conditions, the
lower the infant death rate. Miss Lathrop dis-
counted the factor of ignorance on the part of the
mother as of negligible value in the working out of
this relation. .She shared the view of Sir Arthur
Newsholme, who maintains that the bugaboo of
■'maternal ignorance" was invented by the well to
do, to relieve their conscience, and is of the opinion
that "there is little reason to believe that the average
ignorance in matters of health of the working class
mother is much greater than that of mothers in
other classes of society." Miss Lathrop conceded,
however, that conditions antedating birth bear a
very distinct and direct relation to infant mortality,
as forty-six per cent, of the infant deaths occur
during the first month of life. Therefore, unless
wr analyzed the infant deaths by age, in one month
groups, we could not accept unqualifiedly the de-
ductions drawn from the figures quoted above, al-
though it must be admitted that in a considerable
proportion of cases, the cause of the unpropitious
prenatal conditions was easily traceable to the small
income of the family. The studies of the Children's
Bureau indicated that while the death rate for
babies of mothers at home, with no employment
save that of caring for their hotiseholds, was 122.0.
that of mothers employed outside the home was
312.9.
Race as an Element in the Incidence of Disease
and Death. — Another factor discussed was the
race composition of the groups under consideration.
Dr. W. H. Brown, the health officer of Bridgeport,
Conn., discussing the health problems of the foreign
born, pointed out the paramotmt need of more in-
tensive study of incidence of disease and death
among the several racial groups making up our
heterogeneous urban populations. From the studies
at hand, it was already known that, in so far as
infant mortality was concerned, the presence of
Russian and Austro-Hungarian Jews and of
Swedes was an asset in the public health ledger,
while the natives of England, Ireland, Germany,
and Italy constituted a liability in this particular
respect. It was also known that the general death
rate of the foreign born was higher than that of
the native population. Doctor Brown felt that a
variety of social and economic causes were re-
sponsible for this phenomenon, and he argued that
"sickness and death must be attacked by correcting
the social and economic conditions which, we now
realize, play such an important part in their causa-
tion."
State Medicine. — The most startling proposals
for social reform and race amelioration were made
by Dr. Victor C. Vatighan. He made an eloquent
plea for State medicine and for the assumption, by
the federal government, of control over certain
features in the education of the youth of the land.
He would draft annually all the boys of a certain
age for a two years' term of service and training
for health and good citizenship. He would have
everybody carry an identification card, with a de-
tailed record inscribed thereon, which would be
brought up to date every two years or so, whenever
a new physical examination was made. Through-
out the countrv he would establish health centres,
until they, at least, were as numerous as are high
schools. The advent of group medicine was attested
to by a circular of a New England promoting corpo-
ration, soliciting shares at $10 apiece ; and the dis-
cussion of health insurance was, as usual, not less
animated than a L^nited States Senate debate on
government ownership of railroads or cables.
Industrial Hygiene. — Industrial hygiene com-
manded serious attention, this being one of the
hitherto entirelv too much neglected phases of a
rational .public health programme. A representative
of organized labor argued in favor of health effi-
ciency engineers in our mills, mines, and factories,
and gave an outline of the labor platform for health
and safety. Among the planks in that platform
were a higher tninimum wage, an eight hour maxi-
December 2$. 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
1133
mum work day, fresh air clubs, temperance, rigid
inspection, enforcement of sanitary and safety laws,
community forums for the discussion of health
problems, a federal department of health, and the
elimination of Latin and substitution of English in
prescriptions. It was thought that this mystifying
practice was un-American, and did not help either
practitioner or patient. Professor E. R. Hayhurst
emphasized the need of a more extensive campaign
of education in order that all classes of society
might be reached and instructed in the principles
of prevention of industrial diseases. Personal
hygiene entered largely as a factor into the question
of industrial hygiene, and this feature must be made
the subject of popularization among pupils in the
schools and among industrial workers, by every
educational method devisable. There was no doubt
that our greatest advances in public health would
be made through the medium of education. The
training of physicians in industrial medicine was, of
course, also a recognized need. Here was a fruitful
field of opportunity for younger men and there were
indications that steps were being taken to provide
adequate training for this group of medical practi-
tioners.
Lessons of the Framingham Experiment. — At-
tention was directed to the fact that great oppor-
tunities lay before the Public Health Service, in
safeguarding the water supplies of the country, in
raising the sanitary standards of the smaller urban
and the rural districts, and in combating venereal
disease and tuberculosis. The antituberculosis work
seemed to have fallen into a rut, even in the most
progressive communities, and with the anticipated
increase of phthisis following the war strain, the
time had arrived when some action should be de-
cided upon. The demonstration financed by the
Metropolitan Life Insurance Company, at Framing-
ham, Mass., was noteworthy as to what could be
achieved by intensive work. On January i, 1917,
there were twenty-seven known cases of tubercu-
losis in Framingham, a fair sized typical New Eng-
land industrial town with average health conditions.
The introduction of a consultation service and a
vigorous search for active tuberculous patients in-
creased the number of known cases to 181 by
November, 1918. A careful physical examination
of two thirds of the population of the town showed
that approximately two per cent, of the people had
tuberculosis in either an active or an arrested form.
If this figure was applied to the whole country, as
it well might be, it might mean that we had
2,000,000 people suflFering from tuberculosis, with at
least 1,000,000 having the disease in ati active stage.
From our first draft alone, there were returned
50,000 cases of hitherto undiscover'^d tuberculosis.
A von Pirquet tuberculin test of children between
the ages of one and seven in Framingham indicated
that thirty-three per cent, of them had already been
infected, although the cases of actual disease were
very few. To deal adequately with the problem of
tuberculosis, one would have to adopt a very com-
prehensive general public health and welfare pro-
gramme. The carrying out of such a programme
was expensive, but if communities were to meet
their obligations, they must not be deterred by fi-
nancial considerations.
Health Services of the Federal Government. —
It was thought that the war had given impetus to
the extension of industrial hygiene. Lieutenant
Colonel P. S. Doane spoke of the measures taken
and the success achieved in securing healthful sur-
roundings for the many thousands of workers en-
gaged in shipbuilding. Assistant Surgeon General
Trask, of the United States Public Health Service,
gave a comprehensive summary of the relation of
the federal compensation act to the health and
welfare of the civil employees of the government.
PIc stated that this act was not strictly a war
measure, for it was passed by Congress in 1916,
and approved by the President on September 7th of
that year, but in its application it became a measure
of utmost importance in safeguarding the health
and safety of the several hundred thousand of gov-
ernment employees working under the most stress-
ful conditions. The success of the administration
of the federal sanitation boards and accident com-
missions and the liberal and scientific policy under-
lying it, had afforded a demonstration, the signifi-
cance of which could not be neglected by the large
industrial employers and by the compensation com-
mission of our several States. The United States
Public Health Service had expanded considerably
during the war, and had done a great deal of ex-
tremely important health work in the sanitary zones
throughout the country. The backward rural areas
were awakened to their opportunities in conserving
health and life. The plans for the expansion of the
Public Health Service were presented by Surgeon
General Blue, and heartily endorsed by the Public
Health Association.
Coordination of Public Health Endeavor. — To
obviate the waste of effort and money, to eliminate
competition and exaggeration of achievement in the
raising of funds, and to muster all available re-
sources for the most efficient health endeavor.
President Vincent of the Rockefeller Foundation
urged the consolidation of all of the private health
agencies under the auspices of the American Public
Health Association. The association, under the
guidance of Dr. Lee K. Frankel, its newly elected
president, planned to raise a much larger budget for
the coming year, to become more of an active and
directing force, and to employ field workers to stim-
ulate the work of the municipal and State public
health bodies. The Chicago convention undoubt-
edly marked an era in the life of the American
Public Health Association, and served as an indica-
tion of the powerful momentum the public health
movement had acquired in this country.
_The Influenza Pandemic. — Throughout most of
the general sessions of the convention there oc-
curred endless discussions on the influenza pan-
demic in which every one of the 1,000 members
present took part at least once. The pandemic,
according to the estimates of the United States
Public Health Service, caused approximately
350,000 deaths between September 15th and De-
cember 4th. The administrative problems of con-
trol were num.erous and baffling and demanded the
attention of this gathering of health officers and
sanitarians from all over the country. Unfortun-
ately, nothing of any consequence in relation to the
"34
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
[New York
Medical Journal.
etiology, epidemiology, prevention or control, could
be established. It seemed to be the consensus
of opinion that the cause of the disease was un-
known ; that it was most contagious in its in-
cipient stages; that the only method of prevention
was the segregation of those who were exposed;
that the closing of schools and of other public
places was next to futile ; and that the expediencj''
of mask wearing was problematical. The two in-
dubitably best epidemiological contributions were
made by Dr. W. H. Guilfoy, the registrar of the
New York City Dej>artment of Health, who pre-
pared a series of most interesting statistical charts,
and by Mr. Sydenstrycker, the statistician of the
United States Public Health Service, who summar-
ized the information gathered by the service from
all over the country. The generalizations presented
were made out with the utmost caution, and with
full realization that in many instances the data now
available did not warrant final conclusions. From
the material at hand, it seemed that there were
several foci of infection, although Boston appeared
to have been the earliest focus. The rapidity of the
development of the epidemic as well as its coin-
cident appearance in widely scattered localities sug-
gested that" sources of infection were present in
many different localities, possibly some time before
they were recognized or even suspected. The rapid
spread was from large urban centres to nearby
cities and towns, and thence to rural districts.
There did not appear to be any relation between the
severity of the epidemic and size of the city, but
the severity of the epidemic, as measured by mor-
tality, seemed to have decreased as the epidemic
spread. The epidemic developed later in the central
and western sections of the country, and did not
seem to have been so severe in those sections as in
the area along the eastern and southeastern coast.
The cases seemed to have been of less severe type
as the epidemic progressed. The case mortality ap-
peared to have been highest among children under
five years of age, among adults of twenty to thirty-
five years, and among those of sixty-five and over.
The further collection of data and careful analysis
were under way, and promised a most important
epidemiological contribution toward the study of
the scourge. The figure of approximately 350,000
deaths from influenza among the civilian population
of the United States in less than three months
called into question the reliability of the diagnoses
made. Ordinarily, the diagnosis of influenza as a
cause of death was regarded with scepticism. In
times of epidemic, the majority of the diagnoses
were undoubtedly correct.
Accuracy of Certified Causes of Death. — In
this connection the results of a study of the ac-
curacy of certified causes of death, based on 64,820
deaths reported among the industrial policy holders
of the Metropolitan Life Insurance Company, were
considered. The latter thought such a study to be
of sufficient interest to the public health movement
to be justifiable. The procedure consisted in divid-
ing the death certificates into two groups, in ac-
cordance with the recommendations of the special
committee of the Section of Vital Statistics of the
American Public Health Association published in
report No. 440, from the United States Public
Health reports. In the first group were diagnoses
which could be accepted as reliable without sup-
porting data or autopsy findings, such as typhoid,
scarlet fever, tuberculosis, exophthalmic goitre, etc.
This class comprised the majority of the 64,820
deaths under study. In Class II there were 10,108
cases, where no statement as to cause of death was
acceptable unless supported by autopsy findings or
by other specific supporting data. In every in-
stance of this ten thousand odd unreliable titles, the
Metropolitan Life Insurance Company wrote to the
physician, requesting him to give the necessary
information, in order to determine the reliability of
the diagnosis. In cases of malaria, for example, the
question was asked whether diagnosis was con-
firmed by autopsy or by finding the Plasmodium
malariae in the blood before death. In cancer of the
peritoneum, intestines, or rectum, the question was
asked if the diagnosis had been confirmed by au-
topsy, operation, pathological, microscopic, or other
proof ; and so on, in every questionable case. On
the basis of the replies received, it was determined
that 55,372, or 85.4 per cent., of the 64,820 deaths
in the industrial experience of the Metropolitan
Life Insurance Company were definitely and re-
liably classified as to cause of death. Considering
the fact that some diagnoses were tentatively placed
in the unreliable list because the physician con-
cerned did not reply at the time the classification
was made, it may safely be estimated that at least
ninety per cent, of the diagnoses made were correct.
It was thought that the study of the Metropolitan
Life Insurance was a welcome addition to medico-
statistical literature.
COLLEGE OF PHYSICIANS OF
PHILADELPHIA.
Special Meeting Held Tuesday, November 5, ipiS.
Dr. Thomas R. Neilson, Acting President, in the Chair.
Surgical Treatment of Wounds of the Lung. —
Major Pierre Duval, of Paris, called attention to
the fact that in the last two years the treatment of
lung wounds in the French army had changed from
the medical to the surgical. This surgical treatment
consisted in excising the lung wound and treat-
ing it as one would a wound in any other part of
the body. The chest was opened widely enough
to take the lung out ; it was examined on all its
surfaces ; hemorrhage was checked, the lung re-
placed, and the chest wall sutured completely. In
the first half of the war in 300 cases of lung wounds
treated medically there was a mortality of from
twenty-five to twenty-eight per cent. By the surgi-
cal treatment in cases brought in with severe
hemorrhage there were good results in from sixty-
five to sixty-eight per cent, of all cases. By the
operative treatment of war wounds of the lung the
mortality had fallen from twenty-eight to nine per
cent. The war experience in lung wounds had
opened a broad field for lung surgery in time of
peace.
December 28, 1918.]
PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.
Gunshot Wounds of the Chest. — Colonel
George E. Gask, of London, said that a very great
change had come over the whole of their treatment
of gunshot wounds. At the beginning of the war
they were horrified to find that every single wound
was suppurating. All ef¥orts to get clean wounds
had been futile and it seemed as if they had returned
to the pre-Listerian period. They now realized that
the essential treatment of all gunshot wounds was
the eai^ly mechanical cleansing by open operation
under aseptic precautions before the organism in-
troduced by the missile had a chance to multiply
and invade the tissues. A broad line of distinction
was drawn between contamination and infection.
In the majority of cases operation was done within
twelve or fifteen hours of the time of injury. For
the first two years of the war they were afraid to do
any sort of operation on the chest. The men were
put to bed, given morphia if in pain, a remedy for
cough if there was cough, and it was hoped they
would get well. Quite a large number did, but a larger
number died, and a large number became extremely
septic, had empyemata with pus discharge. The
only surgery that was done was the removal of an
inch or two of rib and a tube put in. Throughout
the time of the Somme fighting they had no time to
study these chest cases, for the number of urgent
operable cases was enormous. Gradually they found
that the thoracic cases could be divided into two cate-
gories : those dying on the battlefield or within a
few hours, and those dying in from forty-eight
hours to two or three weeks. Of the former class
death was the result of hemorrhage; of the latter,
usually death resulted from sepsis. The next step
was to find the channel of infection, and the great
principle they arrived at was to effect an early me-
chanical cleansing of the wound of the chest wall
and of the wound in the lung. Their method was to
put the patient to bed, the chest being examined for
complicating wounds, hemothorax, pneumothorax,
movements of the diaphragm, position of the heart,
and for any indication of respiratory distress.
X ray examination was used whenever possible.
Determining that the chest wall must be excised,
they cut down upon the rib or scapula, finding it
necessary often to excise ragged splinters with a
pair of scissors. Very often bleeding was found in
the costal artery, which was thought to come from
the lung ; this was tied. Inserting a finger, there
could be felt splinters of bone in the cavity or stick-
ing into the lung. Such cases with the air sucking
in and out were uniformly fatal. Later they were
led to enlarge the wound of entrance that the hand
might enter the thoracic cavity and remove foreign
bodies. Rather to their astonishment, the men stood
these operations much better than was anticipated.
There was banished forever the principle which
Colonel Gask had been taught to believe, that hand-
ling of the wounded lung would cause renewed
bleeding. Upon opening the chest the blood was
removed and search was made for foreign bodies.
The lung was examined for foreign bodies as would
be a coil of intestine. If the foreign body had
penetrated into the lung a fresh incision might be
required. This could be made without fear except
near the hilus, and any bleeding was easily con-
trolled by deep catgut sutures. The principle, that
a wound must be cleansed, must be applied in
wounds of the lungs as in any of the soft parts. As
evidence of the fact that the lung was able to take
care of many organisms without abscess formation,
gas gangrene of the lung was unknown in spite of
the many cases in which foreign bodies were left
in the lung. It was, therefore, a matter of practice
to close every wound in the lung. Cleansing of
the pleural cavity was of the utmost importance.
Closure of the chest was the final step in the opera-
tion, and this was done as in closure of the ab-
domen, when possible — muscle to muscle, and skin
to skin. An anesthetic might be given with safety
if there was fair function on the side of the chest
not opened. The type of anesthetic was of no great
importance so long as it was skillfully given. It was
his opinion that probably not more than thirty per
cent, of penetrating wounds of the chest should be
subjected to operation.
Indications for early operation were: i. Such
wounds of the soft parts as would require operation
in any other part of the body. 2, Bleeding from
that wound ; intracostal hemorrhage. 3, Fractured
ribs. 4, Cases with large foreign bodies lodged in
the lung. 5, Cases of pneumothorax in which air
was admitted through the wound. In hemothorax
without extensive wounds, splintered ribs, or re-
tained bodies, there was at present a diversity of
opinion. While they were inclined to operation, their
practice was not to operate unless there was some
sign of sepsis. Theoretically there should be no
such state as an infected hemothorax; but practi-
cally there were a considerable number of such
cases. We had no means of telling which cases
would become septic. He believed that closure of
the chest helped to expand the lung, for every
movement aided in this expansion as soon as the
air was absorbed. If pus was formed a stitch might
easily be removed and a tube inserted. The surgical
treatment of wounds of the chest was now being
practised in almost every hospital at the front line,
and many patients restored to health who would
have died under the former treatment.
Surgery of the Lungs. — Colonel Sir Thomas
AIyles, of Dublin, said that it must never be for-
gotten that the man with a bullet in his lungs had a
bullet in two places — in his lung, and also on his
mind. A second operation was often undertaken
in order to get rid of the bullet on his mind. Sir
Berkeley Moynihan believed that the mechanical
effect of the bullet in the lung was, in many cases,
comparatively small, while the effect upon the man's
mind was considerable. The only reliable method of
examination was by the x ray, and for the removal
of the foreign body Sir Berkeley Moynihan found
that, with few exceptions, an incision at the level of
the fourth rib offered an easy route of exit. The
lung had to be handled as gently as possible in
searching for the foreign body, and when located it
was a simple matter to make an incision and extract
it. A stitch was then inserted with a curved needle.
It was of great importance not to encourage a too
rapid inflation of the collapsed lung.
{To he continued.)
BOOK REVIEWS.— BIRTHS, MARRIAGES, AND DEATHS.
[New York
Meoical Journal.
Book Reviews.
[We publish full lists of hooks received, but we acknowl-
edge no obligation to reviciv them all. Nevertheless, so
far as space permits, 7vc review those in zvhich we think
our readers are likely to he interested.]
Principles and Practice of Filling Teeth. By C. N. John-
son, M. A., L. D. S., D. D. S., Professor of Operative
Dentistry in the Chicap^o College of Dental Surgery;
Editor of the Dental Review. Fourth Edition, Revised
and Enlarged. Illustrated. Philadelphia : P. Blakiston's
Son & Co., iqi8. Pp. x-280. (Price, $3.00.)
Rather extensive revision has been made by the
author in this edition of his well known, and now,
standard textbook. The chapter on the cast gold
inlay has been entirely rewritten, while the one deal-
ing with apicodontia (root canal treatment) has
been enlarged and brought up to date. The volume
very properly opens with a chapter on mouth
hygiene, calling attention to the fact that this is the
most fundamental and important feature of dental
practice ; that the most thorough cleansing of the
mouth and teeth should take precedence over every
other dental operation, except where relief of pain
is necessary. The chapter on dental caries, while
designed to be only a brief summary of the subject,
can hardly be regarded as being up to date. Those
dealing with cavity preparation and the manipula-
tion of the different filling materials, leave nothing
to be desired. It is doubtful whether they could be
improved upon, embodying as they do, principles
that have been found correct a ''^ng years of ex-
perience, by careful operate. ,i-y where. There
are also chapters dealing with che conservation and
destruction of the dental pulp, one on the treatment,
and one on the filling of root canals. The author's
seeming preference for arsenic in tooth devitaliza-
tion will be condemned by some, though there can
be no doubt that when properly employed it is as a
rule one of the best, if not the best agent that can
be used. It certainly cannot be regarded as obso-
lete. The advocates of nerve blocking and pressure
anesthesia too often overlook the trauma produced
by pulp extirpation, with the creation of a locus
minoris resist entice in the apical region which may
later become a focus for hematogenous infection.
The chapter dealing with the x ray in the manage-
ment of pulpless teeth rightly condemns the too
common practice of attempting to make a diagnosis
and prescribe treatment based solely on a study of
the rontgenograms. Especially is this condemned
where the rontgenologist happens to be one who has
had little or no clinical experience in the treatment
of such conditions. The statement that "we are
able to very efifectively manage most of these cases
(pulpless teeth) without the additional expense in-
volved in the use of the x ray" is open to question.
Pulpless teeth can undoubtedly be well filled, in cer-
tain cases, without resort to the rontgen ray, and
unfortunately there will be those who will continue
this "hit or miss" method, but it must always be
regarded as doubtful practice. The synonomous use
of the term x ray, skiagraph, radiograph, picture,
etc., is unfortunate. All scientific writers on the
subject are agreed in the use of the term rontgen
ray, rontgenologist, rontgenogram, etc., an example
which should be generally observed in the interest
of clearness. The volume closes with an excellent
chapter on the management of children's teeth, in-
cluding the deciduous and permanent set.
No better book has ever been written on the sub-
ject under consideration. It can be studied with
profit by both the student and practitioner of den-
tistry. It is sound in principle, and characterized
throughout by a sane conservatism that is greatly
needed.
Births, Marriages, and Deaths.
Died.
Allard. — In Fall River, Mass., on Monday, December
i6th, Dr. Joseph Allard, aged sixty-two years.
B.-\RKER. — In Carthage, N. Y., on Saturday, December
14th, Dr. Frank Justin Barker, aged fifty-eight years.
BowKN. — In Adams, Mass., on Thursday, December 5th,
Dr. David H Bo wen, aged eighty years.
Brothers. — In Brooklyn, N. Y., on Wednesday, Decem-
ber i8th, Dr. Samuel Brothers, aged fifty-five years.
BuRD. — In Philadelphia, Pa., on Monday, December i6th.
Dr. J. Patterson Burd.
Campbell. — In Oakland, Cal., on Wednesday, December
nth. Dr. John A. Campbell, aged eighty years.
Cronin.— In New London, Conn., on Sunday, December
8th, Dr. Joseph F. Cronin, aged sixty-four years.
Cross. — In Kingsville, Tex., on Saturday, December
7th, Dr. Edward Cross, aged eighty-one years.
Daughters. — In Fall River, Mass., on Friday, Decem-
ber 6th, Dr. Andrew N. Daughters, of Tiverton, R. I.,
aged fiftv-one years.
Dvorak • — In Chicago, III., on Friday, December 6th, Dr.
Albert Dvorak, of Casco, Wis., aged thirty-eight years.
Gentile. — In Chicago, 111., on Saturday, December 14th,
Dr. Joseph S. Gentile, aged thirty-three years.
Haddock. — In Beverly, Alass., on Friday, December 13th,
Dr. Charles W. Haddock, aged sixty-two years.
Healy. — In St. Louis, Mo., on Saturday, December 7th,
Dr. Roscoe H. Healy, aged twenty-four years.
Jacobson. — In New York, N. Y., on Tuesday, December
loth. Dr. Julius H. Jacobson, of Toledo, Ohio, aged thirty-
nine years.
Luce. — In Clinton, Me., on Sunday, December 15th, Dr.
Prince Edwin Luce.
McHenry.— In Millville, N. J., on Wednesday, Decem-
ber i8th. Dr. Robert N. McHenry, aged twenty-nine years.
McLean. — In Cloyne Court, Cal., on Wednesday, De-
cember 4th, Dr. Robert A. McLean, of San Francisco, Cal.,
aged sixty-seven years.
Martin. — In Fresno, Cal., on Friday, December 6th, Dr.
I. Fount Martin, aged eighty years.
Oberg.— In Berkeley, Cal., on Wednesday, December
Ath, Dr. John Ulrick Oberg, aged sixty-four years.
Reed. — In Atlantic City, N.. J., on Sunday, December
i.Sth, Dr. Eugene L. Reed, aged fifty-nine years.
Shelton. — In La Jolla, Cal., on Wednesday, December
nth. Dr. Charles Henry Shelton, of Montclair, N. J.,
aged sixty-four years.
Smith.— In Olean. N. Y., on Saturday, December 7th,
Dr. Cassar Smith, aged fifty-two years.
Stoltz.— In Colville, Wash., on Friday, December 6th,
Dr. Merlin G. Stoltz, First Lieutenant, Medical Reserve
Corps U. S. Army., aged twenty-four years.
Ury.— At Fort Oglethorpe, Ga., on Sunday, December
8th, Dr. John Busby Ury, of Defiance, Ohio, Captain,
Medical Corps, U. S. Army, aged thirty-nine years.
Van Vredenburgh.— In New York, N. Y., on Sunday,
December 22d, Dr. William Townsend Van Vredenburgh.
White.— In New York, N. Y., on Monday, December
i6th. Dr. Charles H. White.
Wiley. - In Walden, N. Y., on Friday, December 13th,
Dr. Adam Wiley, aged seventy years.
INDEX TO VOLUME CVIII.
Page.
ABDOMEN, menstrual fistula of 107s
military wounds of • >7i
Abdominal inflammations, diaphragmatic
movements in 657
operat'ons, selection of cases for 171
pain in amebic enteritis 5^5
surgery in pulmonary tuberculosis.... 652
Abnormalities, sexual, among prisoners.. 542
Abortion, induced, causing sterilization.. 926
repeated, corpus luteum extract in 215
treatment of 258
Abscess, bronchial, endobronchial treat-
ment of 6(>6
retropharyngeal 4'7
Acetonemic syndrome in children 481
Achilles reflexes, loss of, in arsenic treat-
ment 1005
Achylia gastrica, treatment of 478
Acidosis, etiology of 585
following administration of guanadine.. 130
in children .481, 916
in diabetes, influence of menstruation on 480
in infants 661
ir newborn 661
in pathology 227
in shock 877
Acne, etiology of 231
treatment of 38, 433
Acriflavine in infected wounds 257
Acrocy.^nnsis w 'ih bradycardia and low
blood pressure . 393
Actinomycosis, intestinal 970
Adams, Charles B. Treatment of acute
anterior gonorrhea 679
Address, anniversary, of Academy of Medi-
cine 1033
Adenoniyoma of rectovaginal septum 308
Adenoids and nocturnal enuresis. .... 394, 567
Adhesions, pleural, in intrathoracic ope-
rations 1095
Adrenal glands, focal necrosis of 394
Adrenalectomy, partial, antibody produc-
tion after 3<53
Adrenalin, action of, on gastric motility.. 482
and pituitrin, iniections of, in hay fever 51
effect of painting the pancreas with.... 438
test of card'ac function 436
tonus waves from sinoauricular muscle
affected by 833
vascular changes p'-oduced by 920
Adrenopathic hyperchlorhydrias 61
Age, cellular changes of, in relation to
tumors 173
Agglutination, effect of convection currents
on 348
of human '■cd cells by horse serum.... 175
Agglutinin diagnosis in triple inoculated
persons 128
Agglut'nins in blood of meningococcus car-
riers 1009
Air. absorption of, from pleural cavity.. 392
and light in surgical tuberculosis 36
fresh, value of. in tuberculosis and in-
fectious diseases 632
passages, upper, d'chloramine-T chlorco-
sane solution in infections of lo";!
spaces of lungs, moisture in 267, 833
Albumen content of cerebrospinal fluid. . 656
Alcohol, food value of, in diabetes 443
iniections of, in treatment of facial
neuralgia 739
pharmacology of 1093
poisoning :n manufacture of calcium
cyanamide 524
prescribing of, by Toronto doctors 207
Alcoholism in China 392
Alexin deficit in overwork 394
Alimentary disturbance of infants, mechan-
ical comminution of food in 7
Alkali reserve of blood serum in wound
cases 86
Allen-Joslin treatment of diabetes mellitus 764
Allen, Robert McDowell. Food value of
bread 236
Allen, Walter C Chemical poisons in
warfare 989
Allport, Frank. Operation for senile cat-
aract 841
Alopecia areata, pain in relation to 121
Amputation, circular, objection to 819
indications for 377
modified Stokes-Gritti 831
of epiglottis for tuberculosis 83
Amputations, occupational training of men
subjected to 520
Amyl nitrite diagnosis of mitral stenosis.. 41
Analgesia, chloroform, by self inhalation 697
general, for painful dressings 561
Analgesics in first stage of labor 39
Anaphylaxis, a case of 130
Anatomy, acquisition of knowledge of, by
ancient Egyptians 973
fetal, of female pelvis 308
fAGE.
Andresen, Albert F. R. Syphilis of the
stomach 544
Anemia, pernicious, diagnosis of .. 3y8
forcc<l feeding and nitrogen equilib-
rivun in 215
pregnancy complicated by 354
results of treatment in 37
postmalarial 5 70
Anemias, primary, recognition and treat-
ment of 179
splenectomy in treatment of 179
Anesthesia at the front 876
conductive, causes of failure in 917
discontinuous general 521
ether, with morphine 17s
local, Ciesarean section under 927
mastoid operation under 786
lumbar, sciatica cured by 1051
rectal 38
spinal 479
Anesthetic in wound cases, chloralose as.. 303
Anesthetics, local, comparative activity of,
37. 218, 43^
sterilization of 478
Aneurysm, traumatic, syphilitic 262
Angevine, Robert W. Cerebrospinal men-
ingitis 946
Angina. Vincent's 72, ios8
Animal powers not Mendelian characters 499
Ankylosis of j^w, operative treatment of 959
flexion, of wrist 11 17
Ant-igonisin, basis of measurement of.... 130
Ai;fh-nx, treatment of 872
Antibody and globulins 602
production after partial adrenalectomy.. 393
Antigen-antibody balance in pneumonia.. 261
gonoroccus 612
A.ntimeningococcic serum, a potent 4^9
therapeutic value of 478
Antimony in bilharziosis 917
Antipneimiococcic serum, treatment of... 213
Antiscorbutic principle, susceptibility of, to
alkalinity 920
Antiscorbutics, necessitv of, in diet 4^
Antisepsis, general, with urotropin and ura-
septine 3,
Antiseptics, chloramines as 25S
toxicity of 86
Antitetanic serum, intolerance to 424
Aorta, abdominal, limitations of operations
on 216
Aortic insufficiency, site of murmur of... 613
Ao'-titis. .nbdominal, diagnosis of 173
Apfel, Harry. Congenital stenosis of the
esophagus 108
Apparatus, automatic, for Carrel treatment 743
Appendicitis, acute, complicating influenza 923
chronic, x rays in 672
differential diagnosis of 502
endocrinous origin of 691
in ch'ldren 501
results of treatment in six hundred
cases of 1108
Aranow, Tla^ry. A post mortem on twi-
light sleep~ 64
Argyrol paste 1131
Arkansas Hot Springs 507
Army, French, size of 33
medical corps, readjustment of 28
rank 29
service in Australia 27
nurse corps, reorganization of 28
officers, doctors wanted as 297
prevention of disease in 793
Spanish influenza in 709
Aronson, Edwartl A. Hirschsprung's dis-
ease with eventration of right half of
diaphragm 196
Arrhenal, injections of, in relapsing fever 169
Arsenic, circulation of, in cerebrospinal
fluid 258
in urine, detection of 788
treatment, loss of Achilles reflexes in.. 1005
of syphilis, local reactions in 433
Arsenoben-ol in puerperal bacteriemia 334, 6g8
intraspinous injections of 212
treatment of syphilis, polyarthritis during 303
with lumbar puncture in syphilitic men-
ingomyelitis 390
A.rsphenamine, intrarectal administration of 61 1
report on 83
Arteries, femoral and popliteal, ligation of,
followed by intermittent claudication 217
tension of, and physical labor 1078
Arteriorrhaphy, technic of 785
Arthritis, protein treatment of 831
rheumatoid 38
secondary, resection of hip for 915
suppurative, simple arthrotomy in 172
teeth and tonsils causative factors in.. 959
tuberculous, of hip 654
Arthrodesis of wrist 11 17
Arthrotomy, simple, in suppurative arthritis 172
Ascariasis, role of, in gallbladder disease.. 963
t'AGE.
Asparagus forbidden during gonorrhea... 191
Asphyxiation 592
Asthenia, neurocirculatory 657
Aslhma, antianaphylactic treatment in ... . 655
bronchial, immunization therapy in 285
soamine in 5^9
treatment of 9°
vaccine for . 214
vic-ous circles in 565
in infancy and childhood 90
peptone in treatment of ^"9
Athletic equipment for men in training
camps 380
Atony, gastrointestinal, saline solutions for 522
Atoxyl, spontaneous deterioration of 84
Atropine test in typhoid infections 87
Auricular filnillation, digitalis in 80
flutter, digitalis in '^3
Australia, army medical service in 27
Autogenous vaccines in typhoid.... 521
Autolysis, muscular, and its bearing on
shock 524
Autoplasty, cutaneous, in osteitis 1130
Autopsy findings in fatal cases of influenza 746
Autoserotlierapy in pyocyaneus meningitis 569
Autoserum treatment of chorea 90
Auxohormones in infant feeding. 574
Aviation accidents, cardiovascular disturb-
ances a cause of 919
Aviators, blood pressure in 158
cardiac hypertrophy in 787
ear disturbances in 614
heart conditions in 787
nonphvsical standards for 29
physical tests for 381, 690
BABY who cannot take milk 84
Bacillus, dysentery, isolation of, from
stools . 41
Bacillus, Friedlarider, causative factor in
bronchopneumonia following influenza 1066
influenza', absence of, in present epi-
demic 613
lactic acid, in therapeutics 300
- • leprae, modes of transmission of 992
new. from must of beer 5
j-'feiffer's, medium for culture of 701
tubercle, in sputum, virulence of 87
welchii, significance of, in wounds. ... 1008
Back injuries in relation to workmen's
compensation law 983
painful, treatment of ... 814
Bacteriemia. puerperal, arsenobenzo! in... 698
Bacteriology, intestinal, recent develop-
ments in 743
Brdantidium coli infection, case of 617
Bandage, plaster of Paris, roller for 6
Barb'e, Leclerc and Orticoni. The micro-
bian flora of influenza....... 730
Eardou, Vincent. The epidemiology of
trench warfare 24
Barker, Lewellys F. General diagnostic
study by the internist 489, 538, 577
Barley, dietary qualities of 526
Bastedo, Walter A. Treatment of influenza 626
Bates, W. H. Improving the sight of sol-
diers and sailors and relieving pain.. 639
Beck, James M. The psychology of the
war 159
Beer, new bacillus from 5
Belirend, Moses. Surgical problems and
principles 153
Bellows, Charles M. Prophylactic treat-
ment of influenza for prevention of
pneumonia 730
Bennett, William H. A plaster of Paris
bandage roller 6
Benzene derivatives in warfare 989
Benzol in leukemia 82
Berg, Henry W., and Bullowa, Jesse G.
AT. Clinical aspects of influenza.... 624
I'.'le drainage, prolonged, in pancreatitis. . 742
Bilharziosis, antimony in 917
Biliary ducts, surgery of 345
tract, surgery of 89
Biology of democracy 1033
Biopsy in cancer 964
Birth rate in Germany, decreasing 290
Bismuth paste 1131
Blackwood, Norman J. The hospital ship
3/^ri:y 332
Bladder of women after operation 310
prolapse of 522
ulcer of 309
Blind, training of, in rehabilitation of sol-
diers and sailors 1014
Blindness, color, tests for 295
Blood, alkalinity of, in shock 877
analysis in eclampsia 524
and soul in ancient belief 93, 225, 271
cultures in pneumonia, importance of.. 964
dex^'O'ie. eff'C' on, of morphine and
ether anesthesia 175
films and parasites, Tribondeau method
of staining 461
I I3S
INDEX TO VOLUME CVIII.
Blood, human. agghitinatiiiK power of
horse serum on red cells of 175
in urine and foces, lesi for ^yy
is life 225
nitrogen determination in 848
of lungs tension of gases in 266
of meningococcus carriers, agglutinins in 1009
peripheral, nucleated red cells in 42
pressure, elTcct of epinephrine upon....io5i
high, kidney function in 877
treatment of 37^1
with tachycardia in soldiers 393
in aviators 158
in gout 143
in kidney disease 965
in war trai.niatisms 789
low, with bradycardia and acrocyanosis 393
measurement 788
studies in five hundred men 349
study of, by method of Gaertner.... 87
scrum, alkali reserve of. in wound cases 86
blue pigment in 261
transfusion, emergency method of 434
in hemophilia neonatorum 434
in infants 179
method of 39, 172, 377, 434
new method of 11 29
results of 390
simplified method of 39
technic of 377
with preserved red cells 47(1
variations in lipoid content of 531
vessels, large, dry wounds of 37S
Blumgarten, A. S. Bational treatment of
chronic nephritis 316
Bodies, antiembryonic, production of, as a
cure for csncer 6ig
foreign, in pleura and diaphragm 566
in wounds, x ray location of i
rickettsia, in lice with trench fever .... 1009
Body defenses, reinforcement of 289
distribution and elimination of zinc and
till in 174
foreign, in bronchus, without pathologi-
cal symptoms iioo
in eye, causing cellulitis 1032
temperature, influence of drugs on 834
Bolshevik bolus 1061, 1113
Bone disease, preventive treatment of.... 279
plates, cranial, in cranioplasty 218
transplantation 771
for tibial pseudarthrosis 784
Bones, bullet wounds of 2s
fractures of shafts of 521
growine, eitect of phosphorus on 214
long, plaster splints in fractures of.... 1028
Paget's disease of 678
BOOK REVIEWS:
Alcohol: Its action on the liuman or-
ganism 400
Bennett, Arnold. The Pretty Lady... 1059
Beultner, Oskar. Technik der Perito-
nealen Wunderbehandlung des Weib-
lichen Beckcns 1060
Bordet, E. Radiographics de I'adulte
normal 751
Erockli.->nk. E. M. The Diagnosis and
Treatment of Heart Disease 48
Brown, George van Ingen. Oral Di-
seases and Malformations 972
Browning, C. H. Applied Bacteriology 224
Butron y Rios. Antonio. Epidemologia :
Datos Histcricos Sobre la Peste Bu-
bonica 136
Carleton, Sprague. The Seriousness of
Venereal Disease -. ...488-a
CatltTi. Lucy Cornelia. The Hospital as
a Social Agent in the Community.... 620
Chase, Robert Rowland. The Ungeared
Mind 92
Church, Colonel Tames Cobb. The Doc-
tor's Part; What Happens to the
VVcunded in War 910, 1016
Darier, J. Precis de dermatologie. .. .488-a
Delheim, Louis, c-t Rousset, J. Radiolo-
gic dc guerre 136
Dispensatory of the United States 119
Drew, Oilman A. Invertebrate Zoology 620
Duke. William W. Oral sepsis in its
Relationship to Systemic Disease.... 268
EIHo». Rnb.rt Henry. Indian operation
of coucliing for cataract 752
Fisher, Irving, and Fisk, Eugene Lyman.
Health for the Soldier and Sailor. . . 48
Ford, Joseph H. Details of Military
Medical Administration 1060
Frazier, Charles II. .Surgery of the
Spine and Spinal Cord 839
Graves, Willi.-,m P. Gynecology 884
Gray, Henry. Anatomy of the Human
Body 971
Green, A A Russell. An X Ray Atlas
of the Skull 180
Harrison, L. W. Diagnosis and Treat-
ment of Ve nereal Diseases in General
Practice 532-a
P.VGE.
Hartmaiui, Henri. Les Plaies de guerre
et lenrs complications immediates . . . . 312
Hess, hilius II. Principles and Prac-
tice of Infi'nt Feeding 576
Ilodgc, Clifton 1"., and Dawson, Jean.
Civic Biology 575
International Medical Annual loift
Ivy, Robert II. Interpretation of Dental
and Maxillary Riintgenograms 180
Johnson, C. N. Principles and Practice
of Filling Teeth 1136
Joslin, Elliott P. A Diabetic Manual
for the Mutual Use of Doctor and
Patient 136
Keen, W. W, Treatment of War
Wounds 576
Laborderie, J. L'Electricite medicale en
clientele I'indispensable en elcctro-
therapie 708
La Vake, Lae Thornton. Talks on
Obstetrics 48
Le Moignic, E., et Sezary. A. Nouvelle
methode de vaccination antityplioidique 268
Le Moignic, E. Xouvelle methode de
vaccination antityphoidique Ic lipo-
vaccin T A B 1016
Libby, Walter. An Introduction to the
History of Science 312
Lutz, E. (j. Practical Art Anatomy .. 488-a
McCombe, John, and Menzics, A. F.
Medical Service at the Front 400
McDill, John R. Lessons from the
Enemy 399
Manson. Sir Patrick. Tropical Diseases 532-a
Medical Clinics of North America. Chi-
cago Number 92S
Morris, Robert T. The Way Out of
War 399
Pedrazzini, F. Commozionc Cercbro-
spinale 664
Perry, Maud A. Essentials of Dietetics
for Nurses 400, 576
Policard, A. L'Evolution de la plaie de
guerre 312
Price, Frederick W. Diseases of the
heart 444
Report of Advisory Committee of Cen-
tral Board (Liquor Traffic) in England 400
Reports, rwenty-seventh and Twenty-
eighth, of Eye, Ear, Nose and Throat
Hospital of New Orleans 664
Satlerthwaite, Thomas E. Diseases of
the Heart and Blood Vessels 532-a
.Scharlieh. Mary. How to Enlighten
Our Cliildrer, 444
Schiiller. Arthur. Rontgen Diagnosis of
Diseases of the Head 971
.Sludev. Greenfield. Headaches and Eye
Disorders of Nasal Origin 795
Smith, Arthur Hopewell. Normal and
Pathological Histology of the Mouth.. 224
Stewart, G. N. A Manual of Physiology. 927
Stitt, E. R. Bacteriology, Blood Work,
and Animal Parasitology 883
Todd, T. Wingate. Mammalian Den-
tition 1 104
Treves, Sir Frederick. .Surgical Applied
Anatomy 884
\'allery-Radot, Pasteur. Etudes sur le
fonctionnement renal dans les nephritis
chroniques 707
Warliasse, James Peter. Surgical Treat-
ment 883
Weinberg, M. La Gangrene gazeuse. . 92S
Williams, Henry Smith. The Proteqmor-
phic Theory and the New Medicine. 443
Books to win the war 76
Boorstein, Samuel W. Orthopedic cases
in the surgical division of Fordham
Hospital 812
Borden, W. C, Pasteur's relation to medi-
cine and surgery 357
Bordet-Wassermann reaction, application
of colorimctric scale to 1052
Bottleism in Toronto 207
Bower, John O. Appendicitis in children. 501
Bowers. Edwin F. How can we get
enough sleep? 196
Bradycardia with low blood pressure and
acrocyanosis 393
Brain i-hanges in gas poisoning 702
in-uries in war 772
sarcoma of 59"
tumors, surgical treatment of 304, 785
Bram, Israel. Nonsurgical treatment of
exophthalmic eoitre 942
Braun, Alfred. Diagnosis of sinus throm-
bosis .1069
Brav. Aaron. Clinical value of pupillary
clianges 143
Variations in the clinical picture of
interstitial keratitis 1078
Bread, food value of 236
Breast cancer 831
ion-zation in 300
railical opeiation for 88
feeding, maimeement of 170
nodules, ionization in 300
tumors, X ray treatment of 837
I'age.
Breath and the soul 93, 225, 271"
holding, attacks of 528
Breathing, rhythmical 366
Brewer, Isaac W. Certificates showing
previous infections in control of
communicable diseases 11 16
Bright's disease, urea retention in 304
Brilliant green in treatment of gunshot
wounds 256
British medical mission to America. ... 1 12, 121
Brodhead, George L. Modern obstetrical
technic 137
Bronchial abscess, endobronchial treat-
ment of 666
Bronchitis complicating measles 1052
Banguineous . '"4
Bronchopneumonia, epidemic streptococcal 700
following inHuenza 811, 1066
Bronchoscopy and esophagoscopy, concomi-
tant '127
Bronchus, foreign body in, without patii-
ological syn'ptoms 1100
Bruce, Herbert A. Problems of military
medicine in France 112
Brucinc, paralysis of nerve cells by "3'
Bubo, chancroidal, treatment of 698
Buerger, Leo. Renal and ureteral infec-
tion with the gonccoccus 1022
Bulimi;i, report of a case of 442
Fiullets, X ray location of 1
Bullowa, Jesse G. JL. and Berg, Henry
W. Clinical aspects of influenza..., 624
Burns due to xperite, treatment of .1566
iodine fumes in treatment of 223
modern treatment of 222
severe, treatment of 1006
treatment of 653
Byrne, Joseph, and McGratli, Jolin J.
Fracture depression of lamins of fifth
and sixth cervical vertebrae zG^
pABANES, Doctor, the indefatigable... 244
^ Coesarean section in eclampsia .. 5(17, 1049
in placenta pr^evia 1049
indications and contraindications for.. 927
under local anesthesia 927
Calcium cyanamide, poisoning by alcohol
in the manufacture of 524
therapy 520
Calculus, salivary . 109
ureteral, removal of, without operation 611
retrograde movement of 1009
treatment of 258
urinary, in childhood ..1028
Calomel, intravenous injections of, in
syphilis 301
Campbell. Major William Francis, of
Brooklyn, on tlie Western front (190
Camps, army, empyema in 864
infectious diseases in 793
pneumonia in ■ 46
protection of, against flies and mos-
quitoes 74
respiratory diseases in 646
sanitation of 835
( ancer, biopsy in 964
electrothermic treatment of 1050
immunity in 265
in Norway, investigation of..... 394
incipient, of breast, ionization in 300
magnesium salts in treatment of 570
of breast 831
radical operation for 88
of cervix com[ilicating pregnancy 396
of clitoris io43
of larynx 296
of rectum, treatment of 127
of uterus 89
problem 88
pioduction of antiendiryonic bodies as a
cure for 619
skin, contraind'cations to radiotherapy in 523
transplanted, lymphocytes in resistance
to 526
Candy, food value of 4ii8
Capsule, tubercle bacillus, evolution and
dissolution of 9S5
Carbon sulphide poisoning, polyneuritis
from .162
Carcinoma of cervix 307
of uterus, supravaginal hysterec*oniy for 307
Cardi'c disabilities among soldiers in
France 40
infection in childhood 4"
Cardiospasm followed by stricture of eso-
phagus ■ ("'^
Cardiovascular disturbances a cause of avi-
.ntion accidents 919
problems of the draft .■ ■ • • ""5
Carotid artery, wounds of ampulla of.... .523
Carrel-Dakin treatment of empyema 1006
of infected wounds S61
Carrel treatment, automatic apparatus for 743
Carrcra, Jose Luis. Spanish influenza.... 574
Carriers, diphtheria 878
meningococcus 425
agglutinins in blood of. 1009
bacteriological examination for 350
nasopharyngeal conditions in 614
INDEX TO VOLUME CVIII.
1 139
Page.
C arriers, problem of 220
(if the Entaintb;i histolytica 172
slreptococctis, predisposition (if, to com-
plicatious of measles 306
Cataract, senile, operation for 841
Catheterization in obstetrics 873
fausalgia, ligation treatment of 39
( aiitery excision of gastric nicer 347
< ccostoiny, temporary, in resection of colon 34(1
Celiac disease, symptomatology of 744
treatment of 784
( cllnlar changes of age in relation to
tumors 173
Cellnlitis of upper lid due to foreign body. 1032
( (.rebral edema 301
Cerebrospinal fluid, albumen conteni of. . fijfi
Bordet-VVasscrmann reaction of, in
paralysis 218
circulation of arsenic in 2.s8
in nervous connnotion 438
turbid, in syphilitic meningitis 1007
meningitis in army camps 793
polyvalent serum in .. 1002, 1 048, 1092, 1128
residuals of 1097
serum treatment of 439, 946
treatment of 654
syphilis, treatment of 303, 741
Cervix, bloodless repair of 213
cincer of, complicating pregnancy 39'>
carcinomatous, removal of, after supra-
vaginal hysterectomy 307
( hancres, bacteriological examination of. . 43I1
Cliancroidal bubo ggS
t hest, exjiloratory puncture of 52S
gunshot wounds of 345, 113.1
X ray study of 85
Child welfare vv'ork in France 662, 663
medical student in 44
Childbirth, accidents of 850
nitrous oxide in 4i'i3
Childhood, neglected period of 527
Children, French, work of American Red
Cross among 1103
school, ear conditions in 66
malnutrition among 241
undernutrition in 10 1
China, Yale's medical activities in 1030
Chiropody in relation to the practice of
medicine 780
Chloralose as anesthetic in wound cases 303
Chloramines in surgery and hygiene 25K
Chlorates, alkaline, physiological action of 831
Chlorine solutions, injections of, in typhus '
fever ,, , 171
yielding solutions, bactericidal properties
of 172
Cliloroform analgesia by self inhalation.. O97
Cholecystitis, accompanied by hepatitis.... 170
diagnosis of 173
surgical treatment of 11 31
Chondroma following trauma 815
Chorea, autoserum treatment of 90
normal horse serum in treatment of. . . . 662
senile 390
Chorioepitbelioma. clinical data on 395
Cimex lectularius. pathogenicity of 1091
Circles, vicious, in respiratory diseases,
344. 387, 431, 47.^. .=;i9, .165
Circulation, tyramine in failure of 259
Civilization and the liberty loan 533
Claudication, intermittent, following liga-
tion of femoral or popliteal artery... 217
Clifton Springs Sanitarium 510
Climate and health
Climenko, H. A case of dyspituitarism . . 5
Clinic, diagnostic, for pay patients 1057
for functional reeducation of disabled.. 687
malnutrition, of the Bowling Green
neighborhood association 241
Clinical congress week 411
Clitoris, cancer of 1043
Cobb, J. O. Psychopathic control of pros-
titution 758
Cohen, Solomon Solis. The relative value
of pasteurized and certified milk 445
Colds, early treatment of 347
Colitis, mucous 503
charcoal in ; 303
Collosol palladium in epilepsy 900
Colon, sigmoid, spastic contractures of. . . 830
surgery of 89
temi>orary cecostomy in resection of.... 346
Colonic membranes, congenital, a factor
in disease 970
Color blindness, tests for 295
Complement fixation in tuberculosis 919
clinical results of 220
studies on 87
technic of 219
test, gonorrheal, by new method 929
for Wassernif.nn, preservation of 217
Conflict, moral, in functional neuroses. . . go
Conjunctivitis, radium treatment of 742
Conklin, Edwin G. The biology of de-
mocracy 1033
Constipation in the army, treatinent of.. 741
in school girls, treatment of 432
treatment of pneumonia 1076
P.VCE.
Con^titiuion, eniclional 85
Contracture, flexion, of wrist and fingers. 11 17
spastic, of rectum and colon, magnesium
sulphate solutions in 830
Convulsion'^, rtllex, during dentition,,,. 7O9
( opcland, Koya! S. General survey of
influenza epidemic 715
Corcia, John. Papillary cystadenoma of
ovary , 457
Ci'viuvall, Kdwaid E. Constipation treat-
ment of pneumonia 1076
Spanish influenza 330
Coronary artery, tlirombosis of 441
Crrpus cavernosum, induration of 377
( orpus luteuni extract in Graves's disease 743
in repeated abortion 21,^
therapeutics of 401. 447
Cdryza, acute, diagnosis and treatment of 234
Cobton, II. K. Thrombosis and embolism 374
( ranioplasty lood
Craniuni, wounds of 1006
Cribbing with dilated stomach and spasm
of diaplnagm 617
Criminality and psychopathy 1124
Cripples, occupational training for 520
war, vocational reeducation of 264
Cumston, Charles Greene. Bacteriology of
gas gangrene 423
Bone transplantation 771
Combating disease 72
Diabetes among the troops 157
Diagnosis of staphylococcic infection... 15S
Diaphragmatic hernia 203
Lesions of peripheral nerves 11 20
Medical notes from the front.. 25, 72,
157, 203, 290, 377, 423, 511, 595, 771,
818, 903, 947, 992. 1091, 1 120
Modes of transmission of bacillus leprs. 992
Pathogenicity of cimex lectularius 1091
Resection of war wounds 25
Treatment of infected wounds 947
Cunningham, William P. A bolshevik
bolus 1 06 1, 1 1 13
Etiology en echelon 227
Orificial lues 851
Curari, paralysis of nerve cells by 1131
Current, galvanic, in e.xophthalmic goitre.. 1 131
Currents, convection, effect of, on agglu-
tination 348
Cyanocuprol, Koga's clinical experience
with 611
Cyst of tliyroglossal duct 11 02
C ystadenoma, papillary, of ovary ... .457, 837
Cystocele 352
Cystotomy, suprapubic, in wounds of spine
and cord 290
Cysts, hydatid, crigin of 9211
pancreatic 389
with kidney and intestinal complica-
tions 969
rvACRYOCYSTITIS, intranasal opera-
^ tion for 859
Dakin's solution, experimental work show-
ing dangers of 1054
in suppurations in the peritoneal cavity. 396
Danziger, Ernst. Acute coryza 234
Davin, Jolin P. Better care in army than
in private life 707
Deafness, chronic, pilocarpine in .S92
following trauma 774
Dtatli. accuracy of certified causes of.... 1 134
from heart failure in children 529
from influenza 1054
race an element in incidence of 1132
rates, battle and disease 425
signs of, in military practice 260, 875
Debarkation Hospital No. 3, description
of 1035
hospitals of the United States 55?
Defecation, mechanics of 94s
Defectives, mental, in Canada 44
Degeneracy, possible factor in 103
Delhno, D. Carbolic acid in tetanus 900
Delivery, obstetrical physiology in relation
to 391
Demobilization, problems of 912
Democracy, biology of 1033
l>emons and germs 953
Dt-ntition, reflex convulsions during 760
Depression fracture of lamina of fifth and
sixth cervical vertebr.-e 363
Dermatoses identified with rheumatism.. 230
Development, role of thyroid gland in.... 28 1
Deviations, latent ocular 936
l)i:ibetes, Allen treatment of 126
among the troops 157
insipidus, etiology of 877
mellitus, Allen-Joslin treatment of 764
comparative food value of protein, fat
and alcohol in 443
influence of menstruation on acidosis
in 480
salt metabolism in 394
modern conception of 523
I)roteins in causation of 162
starvation treatment of 208
witli dyspeptic symptoms, diet in 259
Pace.
Diauiond, Joseph .S. Intcslinal stasi>,
ileocecal valve incompetency anil
chronic appendicitis rontgenologicallv
considered '. 672
Diagnosis, avoidable errors in 767
clinical, general theory of 485
general study of, by the internist,
, . . , . 489, 538. 577
locomotion an aid in 494
of gastrointestinal diseases.... 150
surgical 148
Diaphragm, removal of missiles from 566
Diarrhea, unusual types of 485
Dichloramine-T chlorcosane solution in
iiifections of upper air passages 1051
Diet in celiac disease 784
in diabetes mellitus 259, 764
in eczema 804
in senile rheumatism 259
in treatment of liver diseases 1003
problems, in war tiire 604
relation of, to disease 49
to experimental scurvy 876
significance of fats in 699
Diets, adequate and inadequate 526
Digitalin, physiological action and thera-
peutic indications of 607
Digitalis therapy, recent observations on. 35
versus strophanthus in heart disease
651, 696, 828, 871, 914, 958
Diphtheria carriers 878
house disinfection after 44
immunization of infants against 221
paralysis after 789
toxin antitoxin injections in immuniza-
tion 267
Disease among the foreign born 11 32
and trauma, early pages in 250
congenital colonic membranes causative
factor in 970
functional 737
Graves's, medical treatment of 91C1
Hirschsprung's 165, igfi
local proce.-,ses of, in treatment of tulier-
culosis 81
methods of combating 72
Pott's, heliotherapy in 302
prevention of, in the army 793
race an element in incidence of 1132
Raynaud's, etiology of 1053
relation of diet to 49
role of thyroid gland in 281
von Recklinghausen's, inheritance of...
Diseases carried by flies and mosquitoes,
prevention of, in army camps 74
communicable, control of, in army ....11 16
infectious, face mask in control of 917
in army during war 793
mastoiditis complicating 656
value of fresh air in 6.^2
milk borne, role of milk products in... 251
naming of 825
occupational 486
Disinfection, house, after scarlet fever ancl
diphtheria 44
Dislocation, bilateral, of hip joint 812
congenital, of hip, in three generations 550
Dispensary abuse 17
Divergence paralysis 91
Diverticulum, Meckel's, umbilical polyp as-
sociated with 307
Doctor and liberty loan 560
Doctors, draft beard, commissions for.... 311
drafted in Great Britain 31
part of, in the war 910
wanted as officers in army 297
Doses, large versus small, of drugs 521
Douching, vaginal, bad habit of 125, 516
Drowning, T. J. A possible factor of de-
generacy 103
Draft, cardiovascular problems of 703
medical problems of 703
standardizing medical work of 704
Drainage, bile, in pancreatitis 742
of deep thigh wounds 214
of kidney, ureteral catheter 611
slab wound, in pelvic infections 925
tubes, abuse of 477
surgical, ether as .1094
Dressing, new, for wounds 411
Dressings, diachylon plaster, in war wounds 818
painful, general analgesia for 561
Diink, control of, in Great Britain 963
Drugs and treatment, notes on 123, 167, 255,
299, 466, 607
effect of war upon supplies of 910
influence of, on body temperature 834
h.rge versus small doses of 521
Duct, thyroglossal, cyst of i\o2
Duels, biliary, surgery of 34-
Di'ucan. Charles H. Milk as a galacta-
gogne 575
Duodenal ulcer, ambulatory treatment of.-iog.i
medical treatment of 301
Duodenojejunostomy, its indications and
technic
Duodenum, congenital stricture of 616
1 140
INDEX TO VOLUME CVIII.
Pace.
Duodenum, dilatation of 348
fractional examination of contents of . . . 443
Dynamic pathology, ep leptic attack in.... 139
Dysentery, ameb c, ipecac in 785
oil of clienopodium in 477
bacillary, bacteriological studies in... 42, 175
bacilli, isolation of, from stools 41
vaccination against 460
bacteriological diagnosis of 41
edema witb chloride retention after.... 437
prevention of, in the army 794
vaccination against 874
Dyspepsia among prisoners in Germany.. 657
and gastritis 525
in relation to disturbances of sympa-
thetic nervous system 305
pain in 878
war 39^
Dyspituitarism, a case of.... s
Dystrophia adiposogenitalis in women.... 3901
P" AR conditions in school children, sur-
^ vey of 66
disturbances in military aviators 614
middle, acute suppuration of 830
work at recruiting depot 69
Ears affected with symptoms of mening-
ismus in influenza 729
Eckles, C. II. and Palmer, Leroy S. Milk
as a galactagogue 375
Eclampsia, blood analysis in 524
Ciesarean section in 567, 1049
conservative treatment of 1049
nephrotomy and CiEsarean section in... 567
puerjieral. treatment of 170
venesection in 831
Eczema, acute, due to faulty metabolism. 804
etiology of 231
heliotherapy in - 302
ultraviolet light in treatment of 857
Edema, cerebral 301
chronic, treatuient of 290
in prisoners of war 260
pulmonary, diagnosis of 251
with chloride retention after dysentery. 437
EDITORIALS:
Alopecia areata and pain .. 121
Analgesia, general, for painful dressings 561
Angel, ministering, age of 209
Announcement of publishers 778
Antibody and globulins 602
Append'citis, endocrinous origin of 691
Approbation from Sir Hubert 1090
Army, French, size of 33
hospital plans 34-
Bandmasters, commissions for 429
Books to win the war 7^
Bottleism in Toronto 207
Camps, army, respiratory diseases in... 646
Cancer of clitoris 1043
of larynx 296
Carrx On, a new publication 118
Chemical Research Institute, .American 868
Chiropodist, work of 780
Climate and liealtli 649
Clitoris, cancer of 1043
Color blindness, tests for 295
Committee of fourteen and its fight for
a clean city 8t)*>
Criminality and psychopathy 1 1 24
Demobilization, problems of 912
Demon or germ • 9?3
Diabetes, proteins in the causation of.. 162
starvation trentment of 208
Diet, problems of, in war time.... 604
Disease and trauma, early pages m.... 250
function-d '^'^
Diseases, communicable, notification of 253
familial _ |52
the naming of 825
Dispensatory of the United States 119
Doctors drafted in Great Britain 31
part of, in the war 910
wanted as ofFcers in army 297
Douching, vaginal, bad habit of... 510
Dressings, painful, general analgesia for 561
Drug supply, effect of war upon 910
Edema, pulmonary, diagnosis of 251
Endocrine glands in gastric ulcer and
appendicitis "^^i
Epidemic ot influenza in Sjiain 75
Extrncts, ovarian and placental, greater
dcrmitencss in regard to 384
Faith and its vagaries in medicine 51.=;
Feebleminded, legal interest in 339
Gas, mustard, its effect upon skin 119
ocular lesions from ..■ 9ii
Gastric ulcer and appendicitis, endocrin-
ous origin of '''91
Gbnds, ductless, interrelation of 120
Globulins and ant-body 602
Gorgas, Surgeon General, successor to.. 296
Gout. nervou«; element in 31
Growths, malignant, of skin 473
Gum, American, for the soldiers 605
Harrison, Dr. Thomas Tipton S., a
general practitioner of Canada 692
Page.
Healers, nonmedical, in Ontario 1126
Health, Canadian Ministry of 648
community congress on 76
conditions in rural communities 1125
effect of monotony upon 427
matters, borough autonomy in 517
publ.c, old enemy of 1044
Heels, high, for men 1043
Heredity and disease 252
Heroes on parade 1089
Hospital plans of the army 342
service, rotating, elimination of 33
Toronto Military Base 867
Hypophysis, neoplasms of 909
Hysteria and mediums 1086
Infants, nursing, pyloric syndrome in.. 1 123
Influenza and the Public Health Service 647
due to a filterable virus 866
epidemic of 339, 514, 563
in Spain 7S
etiology, pathology and treatment of. . 645
in Eastern Canada 735
number of the New York Medical
TouiiNAL 645, 734
salicin in 1000
S'tuat on 605, 648, 694, 781, 869
Spanish, epidemic of 75, 339
therapeutics in history 778
Janitor or sanitor 517
Khaki IJnivers'ty of Canada 561
Laboratory, clinical, in the army 341
Larynx, cancer of 296
Liberty loan and the doctor ... 560
Literature Qnd secondary personality.. 869
Mastoiditis, primary 693
Mayo idea in med cine 164
Mecca of medical education after the war 602
Medical and surgical aspects of the work
of the A. iE. F 781
Corps, General Pershing praises work
of 1090
education after the war 602
mission, British 121
offif-ers, higher rank for . 121
Medicine, definition of practice of 1126
extension and limitation of the prac-
tice of 30
Mayo idea in 164
Medicotelescopist 385
Mediums and hysteria 1086
Men, half mended 253
Mental hygiene movement in Canada... 382
Metabolism in nervous tissues 428
Milk borne diseases, role of milk prod-
ucts in 251
Ministry of Health, Canadian 648
Monotony and health 427
Mortality, infant, in iMontreal . ■ . . ■ 472
Muscles, stump, functional utilization of 340
Museums, local medical . 78
Mustard gas and its effect upon the skin 119
ocular lesions produced by 911
iNapoleon and medicine 954
Neoplasms of hypophysis and x rays.... 909
Nervous system, vegetative, glycogenic
function in relation to.. 163
Neuralgia, trigeminal, etiological factors
of 78
Neurofibromatosis, generalized 826
Nurses, supply of 426
tlfficers' uniforms at cost 165
Ovarian and placental extracts, greater
definiteness in regard to 384
Pain, ultimate significance of 999
Paleontology in relation to medical pa-
thology _ 250
Patient, the unconscious 1089
Peace ; • • 823
Pensions for disabled soldiers, Canadian 826
questions regarding 206
Personality, secondary, and literature... 869
Pigment formation, important studies in 470
Pituitary exfact, standard-zation of . . . . 562
Polyneuritis from carbon sulphide poison-
ing 562
Pozzi, Jean Samuel 121
Practice of medicine defined 1126
extension and limitation of 3°
Praci itioner, general, of Canada 692
Prisoner of duty 297
Prisoners, exchange of, is robbery 3i
Prohibition and the public health 1044
Proteins in causation of diabetes 162
Psvcliic effects in surgery 384
Publishers' announcement 778
Pyloric syndiome in nursing infants ... 1 1 23
Reconstruction of the disabled 118
Recruits, physical examination of 78
Research, chtmical, American institute of 868
Respiratory diseases in army camps.... 646
Rheumatism, colloidal sulphur in treat-
ment of 1088
Salicin in influenza 1000
Saliyary glands, infection of, in infants. 383
Sanitation, train, needed advance in.... 824
Science and art of medicine 691
Serum and vacine therapy 1088
Service and sacrifice 1000
Page-
Shock, shell, manuaUtraining in 1045
surgical, at the front 341
torpedo 956
Skin, malignant growths of 473
Soldiers, disabled, reconstruction of.... 118
returned, parades of 1089
Specialists 385
Spine, surgery of 736
Spleen, ruptured 1087
Stump muscles, functional ut lization of 340
Sulphur, colloidal, in rheumatism 1088
Surgeon as a sculptor 253
at the front 694
Surgeons, honors for . 737
Surgery, modern, during war time 823
psychic effects in 384
Syphilis, modern treatment of 294
Tachycardia, continued, treatment of... 163
Thymus gland, hypertrophy of 779
Torpedo shock 956
Trauma and disease, early pages in.... 250
Tuberculin in diseases of the eye 428
Tuberculosis, erythema occurring in.... 209
problem of, in war 997
psychic influence upon 1044
Union and representation 164
Vaccination, results following 603
Vaccine and serum therapy 1088
Vegetables, desiccated, antiscorbutic
properties of 956
Venereal disease, establishment of bu-
reau of 471
diseases among negroes 998
Canadian legislation for 955
control of 32
Vices, masculine, assumed by women... 165
Vitamines and war dietary problems.... 604
Vivisection in England during 19 17.... 11 23
Volunteer Medical Service Corps... 470, 648
War dietary pioblems, vitamines in rela-
tion to 604
doctor's part in 910
industrial and educational conditions
after 602
surgery, modern 823
Wounded, return of 1042
Egyptians, anatomical knowledge of 973
Elbow, fractures of 125, 373
Electricity, galvanic, in exophthalmic
goitre 1 131
in treatment of the wounded 435
Elephantiasis, Kondoleon operation for. . . 962
Elimination, renal, normal and pathological 174
Ellis, A. G., and Fisher, H. M. Sarcoma
of the brain 590
Embarkation hospitals of the United States 553
influenza at the port of 641
surgeon of the port of 551
Embolism and thrombosis 374
pulmonary fat, in relation to traumatic
shock 1097
En;etine, sensitization to ipecac by injec-
tions of 1051
Emotion and etiology of tabes dorsalis. . . 394
and war commot'on 745
Empyema, Carrel-Dakin treatment of 1006
epidemic of 700
■in military camps 864
operation for 742
study of, at Camp Upton 397
treatment of 477, 478, 1003
Encephalitis, epidemic lethargic 306
Endocarditis, acute, and war wounds.... 483
bacterial 833
in scarlet fever 789
septicemic, with splenomegaly 214, 485
Endocrine glands in gastric ulcer and ap-
pend'citis 691
Endocrinology' 227
Endotoxin froin cultures of meningococcus 1054
Energy metabolism and amaurotic family
idiocy 619
Fntamreba histolytica carriers 172
Enterit s, amebic, abdominal pain in 525
chronic, examination of feces in 261
Enterocolitis, prolozoic, in the middle west 739
Enuresis, etiology and treatment of 655
nocturnal, and adeno ds 394, 567
Epidemic of influenza, general survey of.. 715
in 1918 1098
in Spain 75
strepi"ococcal bronchopneumonia 700
Epidemiology ot trench warfare 24
Epiglottis, amputation of, for tuberculosis 83
Epilepsy after scarlet fever 68
collosol palladium in 900
id'opathic ^ 347
Epileptic attack in dynamic pathology.... 139
Epinephrine, effect of, upon blood pres-
sure : .1051
Epitheliomatosis, multiple disseminated, in
workers in tar 876
Eirors, avoidable 767
Eruntions, seborrheic, treatment of 872
Erysipelas, facial, treatment of 831
Erythema multiforme 230
occurring in tuberculosis 209
solar 303
INDEX TO VOLUME CVIII. 1 141
Pace.
Esopliagoscopy and bronchoscopy 627
Efophagus, cicatricial stenosis of 39
ccngtiiital stenosis of 108
stricture of, following cardiospasm 616
Ether as a surgical dressing 1094
Ethylliydrocupreine in lobar pneumonia... 213
Etiology en echelon 227
Eucalyptol poisoning 44 1
Eucalyptus ail, ozonized chlorinated 213
toxicity of 1007
Evolut on, biblical, of medicine 21
Explosives, optic atrophy and multiple neu-
ritis from manufacture of . 218
Extract, pituitary, standardization of..... 562
Extracts, organic, with saline solution in
shock 960
ovarian and placental, greater definite-
ness in regard to 384
Eye changes in tabes and paresis. 181
foreign body in, causing cellulitis. ..... 1032
grounds, appearances of, in nephritics. . 803
injury, three interesting cases of 898
relation of stimulation of canals to re-
action of muscles 834
tuberculin in diseases of 428
work at recruiting depot 69
Eyelid, upper, cellulitis of 1032
Eyes. lesions ci. from mustard gas.. 911, 1093
r.furotic symptoms referred to 668
pupillary changes in I43
Eyes ght of soldiers and sailors, sugges-
tions for the improvement of 639
P ACE, gunshot wounds of 960
' plastic surgery of 114
serious injury to ■. 1099
Faith and its vagaries in medicine 515
Famine in Austria 379
Farnell, Frederic J. Psychanalysis 1018
Fasting in intestinal disorders of the tuber-
culous 127
Fat content of blood, variations in 531
embolism, pulmonary, in relation to trau-
matic shock 1097
food value of. in diabetes 443
percentages, low, disadvantages of 660
Fatigue in marching 743
industrial, reduct'on of .';32
Fats in diet, significance of 699
Feces, examination of, in chronic enteritis 261
test for blood in 877
Feebleminded, legal interest in 339
State care of 753. 790
Feeding, breast, management of 170
forced, in pernicious anemia 215
in hyperemesis gravidarum 171
rectal, plan of 83
Feet, weak, in children 303
Female remedies, action of, on uterus.... 347
Ftmur, abduction splint for 213
fractures of 1049, 36
Whitman's abduction treatment in.... 568
Fermen's, metallic, in malaria 435
Fever, bilious hemoglobinuric 697
enteric, tachycardia in 304
epidemic three day, on a French hospital
ship 700
gastric secretion during 130
intermittent, from meningococcal sep-
ticemia • 130
relapsing, injections of arrhenal in.... 169
Fibroids, radium treatment of 830
X ray treatment of 395
Fibrosa! coma ot soft tissues 816
Fingers, flexion contracture of H17
Finkelstein, Reuben. Diagnostic hints in-'
gastrointestinal diseases 15°
Fischer. Louis. Acute eczema due to
faultv metabolism of food elements.. 804
Fisher, H. iM., and Ellis, A. G. Sarcoma
of the brain 59°
Fistula, broncliial. following lung resection 523
congenital, of lacrymal sac . . 944
menstrual, of abdomen 1075
rectal, treatn-ent of 961
Fixation, immediate, in fracture of femur 1049
Fluids, pathological, test for blood in.... 877
Flying accidents, cardiovascular disturb-
ances a cause of 919
causes of breakdown in 906
Focal infection, lessened resistance in.... 976
Food elements, faulty metabolism of, caus-
ing eczema 804
idiosyncrasies in relation to disease.... 652
mechanical comminution of, in treatment
of alimentary disturbances 7
value, comparative, of protein, fat, and
alcohol in diabetes 443
of bread 236
of candy 458
of meat 156
Foot, flat, curability of 373
problem in the army 864
sprained, in military practice 198
strap around, to reduce fatigue in
marching 743
Forearm, reconstruction work on 11 17
Page.
Formaldehyde vapor, hot, sterilizing ac-
tion of 569
Fowler, W. Frank. Surgical diagnosis. . . . 148
Fracture depression of lamin.x of fifth
and sixth cervical vertcbr.'c 363
of elbow 373
of femur, immediate lixation in 1040
of patella 388
of spine without cord injury 1008
of tliigh, prognosis in 260
of tibia 155
Frr-Ctures, compound, of long bones, plas-
ter splints in treatment of 1028
of elbow 125
of femur, abduction splint for 213
treatment of 36
Whitman's abduction treatment in... 568
of hip 88
of mandible, nonunion of , 126
of phalanges and metacarpals, continuous
extension in 784
of shafts of bones 521
war, gas bubbles at sites of 702
Framingham experiment in tuberculosis
treatment 1133
Frankel, Bernard. Prophylaxis of Spanish
inlluenza 894
I'ranklin, George W. Sex hygiene 542
Frencli Lick Springs 508
Freudenthal, Wolff. Destruction of the
physiological function after operations
on nose and throat 797
Reciu rent teratomatous growth of trachea 582
F'riedel, Herman. Scarlet fever and epil-
epsy 68
Friedlander bacillus causative factor in
bronchopneumonia following influenza. 1066
Fuller, William. The Carrel-Dakin treat-
ment of infected wounds 861
Function, destruction of, after operations
on nose and throat 797
kidney, in hypertension 877
renal, in acute infections 525
Functional reeducation of the wounded.. 683
Furunculosis, abortive treatment of 257
collosol manganese in 84
AITS, classification of 494
Galactagogue properties of milk 375, 575
Gallbladder disease, diagnosis of 966
role of ascariasis in 963
function of 1007
surgery of 345
Gallstones, recurrence of symptoms follow-
ing removal of 966
surgical treatm.ent of 302
Galyl in treatment of syphilis 786
Ganglion, nasal, diseased conditions of... not
Gangrene, gas, bacteriology of 423
preventive Bnd curative serum for... 568
serum treatment of 568, 873, 1104
Garrison. Fielding iH. In memoriam: Dr.
Frank Bakei 859
Gas bubbles at site of war fractures 702
gangrene, bacteriology of 423
serum treatment of 568, 873, 1004
mustard, effect of, upon tlie skin 119
ocular lesions produced by 911, 1093
pains, prevention of 874
poisoning, brain charges in 702
syndrome 909
Gases, poisonous, in warfare 989
tension of, in blood of lungs z66
Gastric atony, adrenalin in 482
diseases, calcium in 520
secretion during fever 130
ulcer, arnbulatory treatment of 1095
endocrinous origin of 691
cautery excision of 347
medical treatment of 301
treatment of 915
Gastritis and dyspepsia 525
Gastrocolonopexy, Goffe's method of 396
Gastroenterostomy v/ith and without suture 667
Gastrointestinal atony, saline solutions for 522
diseases, antianaphylactic treatment in.. 655
diagnostic bints in 150
mucosa, influence of parathyroidectomy
on 217
Genital organs, female, prolapse of 874
war wounds of 830
Genu recurvatum, paralytic 960
Germs and demons 953
Gingivitis, suppuiative 1050
Gland, thyroid, in development and disease 281
Glands, ductless, interrelation of 120
role of 1097
tuberrnlous, of neck, x rays in 917
Glass, Jacob, and Kuhn, Russel. Vis-
ceroptosis 409
Glaucoma, cocainizing the eye for iridec-
tomy in 742
simple, treatment of gi
Glen Springs, description of 420
Globulins and antibody 602
Gluck, Charles. Real value of fresh air
in tuberculosis and many infectious
diseases 632
Pace.
(/lucknian, I. Edward. Advantages of
home treatment in tuberculosis 323
Glucose applications in superficial infec-
tions 433
injections of, as a therapeutic measure 653
(Jlycosuria 438
alimentary renal 613
GofTe's method of gastrocolonopexy 396
Goitre, exophthalmic, galvanic current in 1131
medical treatment of 916
nervous and mental symptoms in.... 480
nonsurgical treatment of 942
simple, prevention of 570
toxic noncxophthalmic 452
treatment of 873
Goldfader, Philip. Modern treatment of
syphilis 405
Gonococcus antigen, new 612
bacteriology of 929
infection of kidney and ureter 1022
vaccine treatment of 786
(ionorrhea, acute anterior, treatment of.. 679
asparagus forbidden during 191
silver iodide in treatment of 898
treatment of 123
vaccine treatment of 1131
Gonorrheal complement fixation test, new
method of making 929
infection of kidney and ureter 1022
Gorgas, Surgeon General, successor to... 296
Gout, Ijlood pressure in 143
nervous element in 31
Gradwohl, R. B. H. A new method of
making the gonorrheal complement
fixation test 929
Grafts, rubber, use of .., 37
skin 82
Graham, John Randolph. Two interesting
cases of measles 322
Graves's disease, corpus luteum extract in
treatment of 743
medical treatment of 916
Greefi', J. G. William and Kaplan, D. iM.
Adrenopathic hypei chlorhydrias 61
Greenhut building. Debarkation Hospital
No. 3 1035
Griffith, J. P. Crozer. Unusual hyperpy-
rexia in pneumonia 3
Growth of children, standards of 571
of mal-gnant tumors, fluctuations in... 347
teratomatous, of trachea 582
Growths, malignant, of skin 473, 303
Guanadine administration and acidosis.... 130
Gum, chewing, for soldiers 605
Gynecology, graduate degree in 396
problems of ureteral surgery in 969
teaching and research in, after the war 307
LJ ANCE, Irwin H. Rhythmical breathing 366
* ^ Hand, fractures of 784
orthopedic reconstruction work on 11 17
septic infection of 38
Hansen, Howard F. Successful extrac-
tion of an opaque and dislocated crys-
talline lens 1 120
Harris, f^ouis I. Epidemiology and ad-
nu'nistrative control of influenza 718
Hay fever, immunization in 609
pituitrin and adrenalin in 51
prophylaxis of 859
treatment of 302
Head, gunshot wounds of 740
shaking with nystagmus in infants 530
surgery 347
teaching of plastic surgery on 88
Headache, indurative or rheumatic 350
Health and sanitation in shipyards. .. 398, 880
Canadian iMinistry of 648
climate in relation to 649
conditions in army and navy 338
in rural communities 11 25
congress, community 76
department supplies prophylactic vaccine 732
effect of monotony upon 427
matters, borough autonomy in 517
public, and industrial medicine 486
coordination of endeavor in 1133
military training a factor in 1017
value of work in 43
relation of income to 1132
resorts of the United States 509, 419,
r , r , ■ 463, 507
services of the federal government. ... 1133
Heart, adhesion of, to diaphragm 41
adrenalin test of resistance of 436
arrhythmias, digitalis in.... 35, 80, 123, 168
condition of, after a marathon race. . . . 788
conditions in aviators 787
in recruits ui, 875
dilated, action of digitalis on 211
disease, congenital 618
digitalis versus strophanthus in.. 651, 6g6,
828, 871, 914, 958
renal function in 129
in children, nature and symptoms of. 40
in soldiers in France 40
strophanthus versus digitalis in.. 651, 696,
828, 871, 914, 958
vicious circles in 387
1 142
INDEX TO VOLUME CVIII.
Page.
Heart, (lisluibaucc of, in scaik-t fever... 130
fiiiliire in children, death from 529
in pregnancy 969
ir. puhnonary luberculosis 282
irregularities of. digitalis in 123
irritable, of soldier, digitalis in 35
psyclioneurotic factor in 305
mitral stenosis of 41
miirnnns :n draft candidates 46, 651)
significance of 481
normal, in tlie navy 1096
presystolic thrills of 451
resistance of, to strain 436
sarcoma of 788
soldier's 45, 657
Heat production 217
stroke 482
and malignant malaria 348
Heels, high., foi men 1043
Ikliollierapy 302
in Putt's disease 698
in surgical diseases 1122
Helmets, war 1040
Hcmatidrosis, case of 288
Hemeralopia, retina in 482
Hcmiiilegia due to localized focus of tu-
berculous meningitis 262
Hemochromatosis, diagnosis of 398
experimental 398
Hemoglobiiiuric fever, bilious 697
Htmopliilia 965
t>'ealment of 255, 299
neonatorum, blood transfusion in 434
Hemoptysis following exploratory punc-
ture of chest 528
recurring, after wounds of thorax 657
vicious circles in 344
Hemorrhage after scarlet fever 615
intravenous s.iline infusions after 961
meningeal, in war practice 128
pharyngeal, due to leeches 488
retinal, bacterial toxin causing 306
superficial, effects of various drugs on.. 1008
tubal and ovarian 351
Hemorrhoids, injection treatment of 303
knifeless treatment of 1090
Hemosiderin granules in cells of urine... 398
Hepatitis, an accompaniment of cholecys-
titis 170
Herb. Ferdinand. Technic of intravenous
medication 498
Heredity and disease 252
Hernia, diaphragmatic 203
inguinal, radical treatment of 301
injection treatment of 303
sloughing amniotic, of umbilicus 307
Hernias, use of rubber grafts in 37
Htrtzberg, G. R. R. Clinical congress
week
llexametliylenamine, injections of, in in-
fectious diseases 570
Hip, congenital dislocation of, in three
generations 55o
fractures of 88
joint, bilateral dislocation of...... 812
resection of, for secondary arthritis.... 915
sarcoma of 817
tuberculous arthritis of 6S4
Hirschsprung's disease 196. 615
Hodgson, Millaid B. Systematic develop-
ment of X ray plates and films 374
Hog Island, medical service at 881
Hcguet, J. P. and Ramirez, M. A. Ileo-
cecal insufficiency 146
Homohemotherapy, subcutaneous 4,1-2
Hospital, army, plans 342
debarkation. No. 3, description of 1035
emergency, in France 688
facilities, army 865
Fordhani, orthopedic cases in 812
heads, mobilization of...._ 381
interns, systematic instruction for 614
organization in France 77.t
records in FrJ.nce, American 205
service, rotating, elimination of 33
ship Mcrcw brief description of 332
Toronto Military Base 867
United States Naval, in England 907
Willard Parker, influenza at 624
Hospitals, American Women's 71
Britisli, in Frr.nce, bombing of 379
debarkation, of the United States 555
embarkation, of the United States...... ,^53
military, teclinical or educational side
of work in I77
naval, influenz.i in 921
rotating service in 47
Housing, government, in England S8j
shipyard employees, plans for 882
Howard. Tasker. Clinical types of ne-
phritis 313
Hydatid cysts, daughter, origin of 920
Hydrocele, injection treatment of 303
1 lydrocpplialus and hypothyroidism 281
I lydroiieplirosis, congenital 134
Hygiene, industrial 11 32
mental, in f-^nada 382
sex .■>42
Hyperchlorliydi ias, adrcnop.ilhic 61
Page.
Hypcremesis gravidarum, feeding in 171
Hyperesthesia in poliomyelitis 438
Hyperglycemia 438
Hyperpyrexia, unusual, in pneumonia.... 3
Hypertension, phases of 486
with tachycardia in soldiers 393
1 lyperthyroidism 282
psychoneurotic syndrome of 394
1 lypopliysis, neoplasms of 909
Hypothyroidism and hydrocephalus 281
Hysterectomy, efiect of, upon ovarian func-
tion 351
supravaginal, for carcinoma of uterus... 307
vaginal, technic of 352
Hysteria and mediums io86
I CHTIIYOL and glycerine in gunshot
* wounds 389
Icterus gravis, fatal, following novarseno-
benzol 84
Idiocy, amaurotic family, energy metabol-
ism in 619
Iglauer, Samuel. Concomitant broncho-
scopy and esophagoscopy 627
Ileocecal insufficiency 146
valve incompetency, x rays in 672
liiimunity in cancer 265
in tuberculosis 240
reactions in hydrated and concentrated
tissue 661
studies on 87
Immunization against diphtheria 221, 267
against influenza 922
in hay fever 609
therapy in bronchial asthma 285
Industrial aniline poisoning 872
hygiene 1 132
Infant feeding 91
dried milk in 91, S
in war time 44
problem of, in rural districts 44
value of auxohormones in 574
life, conservation of 353
mortality 472
Infantilism, Brisseud and Frohlic types of 529
Infpnts, breast and bottle fed, relative
morbidity of 660
nursing, pyloric syndrome in 1123
Infection, ascending, of urinary tract.... 661
cardiac, in childhood 40
focal, and diseased tonsils... 751
site of lessened resistance in 976
gonococcic, of kidney and ureter 1022
vaccine treatment of 786
influenzal, of cranial sinuses 86
intestinal, relative value of pasteurized
and certified milk in 445
kadu 895
means of, in venereal diseases 44
of salivary glands 383
paratyphoid B, noma following 21
protozoal, of intestines 964
puerperal, arsenobenzol treatment of... 354
septic, of hand 38
sources of, in wounds of joints 83
staphylococcic, diagnosis of 158
streptococcic, in wounds.... 787
Infections, acute, renal function in 525
injections of hexamethylenamine in.. 570
mould 398
moutli, X ray studies of.. ... 963
of respiratory organs, dichloramine-T
chlorcosane solution in 1051
parameningococcic, septicemia in 789
pathogenic, of lower respiratory tract. . 1S9
pelvic, stab wound drainage in 925
respiratory, in army camps .=;66
staphylococcal, stannoxyl in 831
superficial, glucose applications in 433
typhoid, atropine test in 87
of mouth and pharynx 42
Infectious diseases, mastoiditis compli-
cating •.■ 656
Inflammation, abdominal, diaphragmatic
movements in 657
local effects of hepatic lipoids on 783
Influenza, acute appendicitis complicating 923
advice to persons suffering from 733
and the Public Health Service 647
and suprarenal glands 895
at Base Hospital No. i 747
nt port of embarkation 641
autopsy findings in fatal cases of 746
clinical aspects of ;■ 624
committee appointed by Governor Whit-
man 733
complications of 729
deatli from 1054
due to a filterable virus 866
epidemic .SM, .■;63
absence of bacillus influcnzre in 613
at U. S. Marine Hospital 888
liactcriology of 921
complications of • 921
crowded camps and troop ships as
factors in ._ 7,Si
followed by bronchopneumonia 811
future study of 922
general survey of 71S. 747
Page.
Influenza, epidemic, in army camps 822
in France 918
in a military hospital 878
in Spain 75, 356
nasal complications of 886
of 1918 700, 1098
physical findings in pneumonia fol-
lowing 923
study of leucocytes in 1008
surgical pathology of 887
symptomatology of 722
epidemiology and administrative con-
trol of 718
etiology, pathology and treatment of... 645
face mask in 895, 750, 877
Friedlander bacillus causative factor in
bronchopneumonia following 1066
history of therapeutics in 778
in Eastern Canada 735
in naval hospitals 921
in navy 733
in pregnant women, mortality of 924
in Spain 356
informal discussion of 747
large doses of salicin in 697
mask 850
dangers of 895
moistening with antiseptic solution... 750
niicrobian flora of 730
nasal complications of 923
nervous and mental disturbances of,
725, 755, 807
number of New York Medical Journal,
645, 734
pandemic ii33
in civil hospitals ■ 1097
pathology of 621
pneumonia, serum treatment of 1006
prophylactic treatment of 730
salicin in 1000
situation 605, 648, 694, 781, 869
resolutions of the Academy concern-
ing 750
.Spanish 574
antiinfluenza vaccine as a prophylac-
tic in 621
liacteriology of 621
cases on Norwegian steamships 330
epidemic of 339
in army 709
in Switzerland 789
injections of a nonbacterial split pro-
tein in 843
morbid anatomy of 1008
prophylaxis of 894
symptoms and complications of 924
treatment of 626, 924, 984
nose and throat problem 728
vaccine supplied by Health Department 732
value of vaccines in prevention and
treatment of 922
warning from Academy of Medicine. . . 681
with pneumonia, treatment of 627
Influenzal pneumonitis 847
sinus disease 86
Instinct distortion resembling hysteria. . . . 744
Insufficiency, acute adrenal 394
aortic, site of murmur of 613
cardiac, renal function in 129
functional, of parathyroids 832
ileocecal '46
Internist, general diagnostic study by,
489, 538, 577
Intertrigo, mycotic, treatment of 520
Intestinal actinomycosis 970
bacteriology, recent developments in.... 743
complications of pancreatic cyst 969
disorders of the tuberculous 127
infection, relative value of pasteurized
and certified milk in 445
parasites among troops 86
stasis 547
conservative surgery of 962
X rays in 672
Intestines, protozoal infections of 964
removal of, through vaginal vault 967
Intracranial pressure, physiology of 90
Intrathoracic operations, treatment of
pleural adhesions in course of 1095
Intraureteral manipulation, value of 611
Intussusception, case of 617
Iodine, antiseptic and cytophylactic prop-
erties of 1093
fumes in treatment of burns 223
vapor, nascent, for sluggish wounds,... 522
Ionization in incipient breast cancer 300
Ipecac, sensitization to 105 1
Iridectomy in acute glaucoma 742
TACKSON Health Resort, Dansville,
J N. Y -. • ■ 509
Jaliss. Samuel A. Congenital dislocation
of the hip in tlirec generations 550
Jmnes, Walter B. New York State's prob-
lem of the care of the feebleminded.. 7S3
Janitor or sanilor 5^7
jaundice, acute infectious 706
epidemic '"S'
toxic, recovery from 07
\
INDEX TO VOLUME CVIII.
1 143
Page.
.l;i\v, aiiVylosis of ■ 959
gunshot woiiridc of 9i6
iriwer, restoration of 6'°
war wounds of 595
laws, cancer of, electrolhermic treatment
of ^ 1050
klliffe. Smith Ely. Nervous and mental
disturbances of influenza .... 725i 755. 807
'I he epileptic attack in dynamic path-
ology 130
Joint diseases, preventive treatment of... 279
loints, bullet wounds of 25
>yphilitic 105. 792
wounds of •.• ■ 83
Trues, Frank A. Confluent suffocative
bronchopneumonia in the wake of the
influenza epidemic 811
[(.sephson, Isidore. Problems in obstet-
rics oSi
KADU infection S95
Khaki University of Canada 561
K.Tlin, Alfred. A new dressing for
wounds 4' I
Complications of influenza 729
Kalin. Jloses. Spontaneous pneumotliorax
in pulmonary tuberculosis 63 j
K;.li azar, case of 617
Kane. P. A. Asphyxiation, respiration,
circulation 59.3
Kantor, John L. Experience with a class
in malnutrition 241
K:.plan, D. M., and Greeff, J. G. XVil-
liam. Adrenopathic hyperchlorhydrias Gi
Katzoff, Simon L. Knifeless treatment of
piles 1090
Kearney, J. A. Diagnostic value of eye
ground appearances in nephritics. . . . 803
Kennedy, J. W. Surgical pathology of
the present influenza epidemic 887
Keratitis, interstitial, variations in clini-
cal picture of 1078
Kidney, blood pressure in diseases of.... 96;
congenital anomalies of 134
drainage with ureteral catheter 611
embryology of 134
function, hypertension in 877
in acute infections 525
value of tests of 658
functional tests of, in prognosis of ne-
phritis loio
lead in, month after exposure to poison 657
living, quantity of secreting tissue in. . 702
spirochetes in 175
surgical tuberculosis of 135
tuberculosis, complicating pancreatic
cyst . • • 9'>9
X ray examination of tumors of 469
Kidneys, gonococcus infection of 1022
Klotz. Hermann G. Why is asparagus
forbidden during gonorrhea? 191
Knee joint, gunshot wounds of 476, 1003
penetrating wounds of 783
Knopf, S. Adolphus. The statue of Ed-
ward Livingstone Trudeau 330
Kobler, E. Willis. A survey of ear con-
ditions in school children 66
Kulin, I. Russel and Glass, Jacob. Vis-
ceroptosis 409
I ABOR, analgesics in first stage of.... 39
indications for induction of 963
late repair of injuries in 89
management of injuries during 969
normal 89
physical, effect of, on arterial tension. . 1078
pituitrin in - 829
scopolaminc-niorphine amnesia in 872
use of douche pan in second and third
stages of 96T
Laboratory, clinical, in the army 341
findings, negative, in syphilis 316
of port of embarkation 995
Lacrymal sac. corigenital fistula of 944
l.;:ctic acid bacillus therapy 300
liacteriotherapy in war woimds 378
T^THibert, Alexander. Trench fever 159
L.nmliright, George L. Clinical observa-
tions in splanchnoptosis 939
roundsman, Artliur A. Interesting rectal
cases 194
La:ie. Harold C. The prophylaxis of hay
fever 859
Lane. Sir William Arbuthnot. Plastic fa-
cial surgery 114
La Roque, G. Paul. Results of treatment
in six hundred cases of appendicitis. 1 108
Laryngitis, tuberculous, prevention versus
treatment in 287
Laryngovestibulitis, glandular 169
r^nrynx, cancer of 296
Lead poisoning 657
Lce'erc. Orticoni and Barbie. The micro-
bian flora of influenza 730
Leg ulcers, treatment of 223
T^cikauf. John E. Food value of candy.. 458
Lens, crystalline, successful extraction of. 1 120
Leprosy Iiacillus, modes of transmission of 992
clieiiuitherapy of 610
Page.
Leptospira icteroh.-emorrhagia', cultural
contlitions of 58
Lesions, ocular, from mustard gas.. 911, 1093
of nerves, Tinel's sign in 612
of peripheral nerves 785, 1120
LETTERS TO THE EDITOR:
Carrcra, Jose Luis. .Spanish influenza 574
Coghlan, Jolin. Conunissions for draft
board doctors 311
Davin, John P. Better care in army
than in private life 707
Duncan, Charles H. Milk as a galacta-
gogue 575
Cioldwater, S. S. Do avyay with ro-
tating service in hospitals 47
Meltzer, S. J. Face mask in influenza 730
Rosenberger, Randle C. Moistening the
influenza mask witli antiseptic solution 750
Sidis, Boris. Moderation versus inten-
sive training 75 1
Simonton. IL. J. Production of anti-
embryonic bodies as a cure for can-
cer ''"9
"Splanchnic" M. D. Stimulation of the
sympathetic as result of toxemia.. 311
Taylor, J. Madison. Eight hour day for
lihvsicians 180
Vbarra, A. M. Fernandez. Spanish in-
fluenza 35*5
Leucemia. myelocytic, influenced by
splenectomy 442
Lercocytes, distribution of, in the circu-
latory system 789
study of, in influenza 1008
Leucocytosis in extensive wounds 394
Leukemia, benzol in 82
Lcvbarg, John J. Retropharyngeal ab-
scess 417
Temperament a synonym for nervous-
ness in singers 811
Liberty loan and civilization 533
aiid the doctor 560
Lice, rickettsia bodies in. with trench
fever ioo9
Ligation treatment of causalgia 39
Light and air in surgical tuberculosis. ... 36
ultraviolet, in eczema 857
Liiider, Charles O. Military training as
a factor in public health 1017
Lipoids, hepatic, local effects of, on
wounds 783
Liquor traffic in England, control of 963
L'ver, atrophy of, recovery from 87
diseases, dietetic treatment of 1003
glycogenic function of.. 163
Locomotion as an aid in diagnosis 494
Louse bites, interesting reaction to 1098
clothes, impiegnation of underwear a
means of controlling
Lowenburg. Harry. Mechanical comminu-
tion of food in therapeusis of acute
alimentary disturbances in infancy
and childhood 7
Lubman, Max. Prevention versus treat-
ment in tuberculous laryngitis 287
Lues, orificial ■ 851
Lung, removal of tootli impacted in S34
surgery, modern military aspects of.... 949
Lungs, bronchial fistula following resec-
tion of 523
moisture in air spaces of 267, 833
surgery of 949, "34, ii35
tension of gases in blood of 266
treatment of wounds of 23, 11 34
Luttinger, Paul. Locomotion as an aid
in diagnosis 494
Luxation, vertebral, involvement of cer-
vical cord through 437
Lvmph nodes, tuberculous, transplantation
' of 267
Lymphocytes in resistance to transplanted
cancer 526
McGRATH, JOHN J. and Byrne, Jo-
seph. Fracture depression of lami-
na" of fifth and sixth cervical ver-
tebra; 363
>racKenzic. George W. Nasal complica-
tions of epidemic influenza 886
Mackenzie, Sir James. The spirit of Eng-
lisli medicine 113
^icKenzie, R. Tait. Functional reeduca-
tion of the wounded 683
McMurtrie, Douglas C. Reeducation of
disabled soldiers at Bombay 336
MacNair, Robert H. A few avoidable
errors 767
Magnesium salts in cancer. 570
sulphate enemas in spastic contractures
in rectum and colon 830
JIalaria, chronic, quinine hydrochloride
and cacodylate of soda in 389
injections of quinine collobiase in 1095
malignant, relation of, to heat stroke.. 34S
mercury in treatment of 743
metallic ferments and quinine in 435
pernicious anemia following 570
quinine in prevention and treatment of 522
Page.
Malaria, splenic enlargement in 216
treatment of 215, 389, 390, 1129
Malarial mastitis 965
Malignancy in mouth and throat, radium
treatment of 569
Malta fever, prophylaxis of 38
Mammary gland, malarial inflammation of 965
glands, action of internal secretions on 403
Mandible, war fractures of 126
Manges, Morris. Symptomatology of the
prevailing epidemic influenza 722
Marathon race, pulse after 788
Marcus, Joseph H. A brief biblical evo-
lution of medicine 21
Marlow, F. W. The detection and meas-
urement of latent ocular deviations.. 936
Martin, Franklin. Volunteer Medical
Service Corps 291
Mask, face, in control of infectious dis-
eases 877, 917
influenza 750, 850
dangers of 895
Mastitis, malarial 965
Mastoid operation following acute otitis. . 659
indications for 84
under local anesthesia 786
Mastoiditis complicating infectious dis-
eases 656
postoperative treatment of 125, 786
primary 693
Matrimony, syphilis in relation to 1021
Matson, Ralph C. Examination of re-
cruits for tuberculosis 199, 243
Mayer, Emil. Endobronchial treatment of
bronchiectasis and bronchial abscess 666
Measles complicated by bronchitis 1052
complications of 306
malignant, treatment of 212
throat smears in 348
two interesting cases of 322
Meat, food value of 156
Meatotomy, painless 461
Mecca of medicine for the future. .. .534, 602
Meckel's diverticulum, vimbilical polyp
associated with 307
Medical advisory boards 703
and dental students, navy 534
and surgical aspects of the work of the
A. E. F 781
corps. General Pershing praises work of 1099
readjustment of 28
new appointments in 28
education after the war 602
inspection in public schools 368
mission to America, special British.... 112
museums, local 78
notes from the front.. 25, 72, 157, 203,
290, 511, 395, 771, 903, 947, 1091, 1120
officers, higher rank for 121
in the navy 73
problems of the war draft 703
prophylactic work in the army 662
reserve corps, appeals to the American
Pediatric Society 613
service, army, in Australia 27
at Hog Island 881
Corps, Volunteer 291, 470, 648
student in child welfare work 44
teaching and research after the war.... 307
work of the draft, standardization of. . 704
Medication in children 435
intravenous, technic of 498
Medicine, art riiid science of 691
biblical evoliition of 21
Englisli, spirit of 115
faitli and its ■( agarics in 515
industrial, and public health 486
Mayo idea in 164
mecca of, for the future 534, 602
military, piolilems of, in France 112
of warfare, paraspecific serotherapy in 903
Pasteur's relation to 337
Medicine, practice of, defined 1126
extension and limitation of_. 30
preventive, and reconstruction of race 1103
Mediums and hysteria 1086
Megacolon 216
Meitzer, S. J. Face mask in influenza.. 750
Men rejected by war draft board, rehab-
ilitation of 703
types of, among recruits 992
Mendel, Lafayette B. Some relations of
diet to disease 49
Mendelian cliaracters and animal powers 499
Meningismus, symptoms of, in influenza. . 729
Meningitis, acute, in congenital syphilis. . 216
cerebrospinal, in army camps 793
polyvalent serum in.. 1002, 148, 1092, 1128
serum treatment of 946
treatment of 123, 654
complicated by mumps 42
. experimental meningococcus 834
in army camps, prophylaxis of 832
otitic 741
parameningococcic and septicemia 789
pyocyaneus, autoserotherapy 369
residuals of 1097
serum treatment of 439
1 144
INDEX TO VOLUME CVIII.
Pace.
Meningitis, tuberculous, localized focus of. 262
in an intant 618
vaccination against 1009
Mtnnigucocc, type determination of 608
sypliilitic 1007
Meningococcus antiendoloxin 1054
Carrie; s 35o, 425
agglutinins in blood of.... 1009
nasopharyngeal conditions in 614
problem o^ 220
cultivation of 172
mcnuigitis. operimental 834
Meningomyelitis, sypliilitic, arsenobenzol
treatment of . 390
Menopaiise, pathological uterus at 1090
vertigo of 967
Menstruation, action of thyroid secretion
on : • • • • 402
irithience of, on acidosis in diabetes.... 480
Mental defectives in Canada 44
disease, clinical diagnosis of 485
disturbances of influenza 725, 755, 807
hygiene movement in Canada 382
Mercuric cliloride poisoning 829
iodide, red, intravenous use of 262
Mercury in malaria 743
Mercy, hospital ship, brief description of 332
Mesenteric vascular occlusion 393
Metabolism, calcium and magnesium 42
energy, in amaurotic family idiocy.... 619
faulty, a cause of acute eczema 804
in nervous tissues 428
salt, in diabetes mellitus. 394
thyroid hormone in relation to 483
Michel, Leo L. Painless meatotomy 461
Microbian flora of influenza 730
Midwife, importance of 353
M'lk a source of water soluble vitamine 174
Milk as a galactagogue 375, 575
borne diseases, role of milk products in 251
certified and pasteurized, relative value
of 443
dried, in infant feeding 915
infected, spread of disease by 251
modification of, for babies 84
vegetable, use of 619
Miller, James Alexander. How America
is helping France with her tubercu-
losis problem 243
Miller, Julius Asher. New treatment for
compound fractures of long bones... 102S
Minor, J. C. Danger of the mask for pro-
tection against influenza 895
Miotics, action of, on incomplete sphincter
iridis 303
Mitral stenosis and Raynaud's disease .... 1 053
diagnosis of 4'
Mix, Charles L. Spanish influenza in the
army 709
Monotony and health 427
Moore, William. Impregnation of under-
wear a means of controlling the
clothes louse no
Morbidity, relative, of breast and bottle
fed infants 660
Mortality, disease and battle 425
fetal, methods for reducing 89
infant, in Montreal 472
Morton, Kosalic Slaughter. The Ameri-
can Women's Hospitals 71
Mould infections 39*^
Mount Clemens, Michigan 465
Mouth cancer, cltrtrothermic treatment of 1050
infections, chronic, x ray studies of.... 963
radium treatment of malignancy in.... 569
typhoid infections of........ 42
Mumps, complicating meningitis. 42
Murmur of aortic insufliciency, site of... 613
Murmurs, cardir.c, significance of 481
m draft candidates, significance of.... 656
Muscle, denervaled, atrophy of 961
destruction of, in gunshot wounds./... 511
Muscles, stump, functional utilization of. . 340
Mustard gas, effect of, upon the skin... 119
ocular lesions produced by 911, 1093
^Tyelitis, treatment of 123
Myelomata, multiple 347
Myocarditis, chronic r?^^' 3°5
Myomnta. uterine, pathological conditions
associated with 35 5
Myrtol poisoning 44'
toxicity of 1007
KJAPOLEO.NT ,Tnd medicine... . 954
Nasopliaryngeal conditions in menin-
gococcus carriers 614
Nasal ganglion cases, unusual not
polypi 418
Navy, licalth conditions in 338
sanitary conditions in 73
Neck, jilastic surgery of 88
tuberculous glands of 917
Necrosis, focal, of the adrenal 394
Negroes, venereal diseases among 998
Neoplasms of hypophysis, x rays in 909
Nephritis, chronic, treatment of 132, 316
clinical types of 313, 879
diagnosis of go, 131, 803, loio
etiology of 131
Pace.
Nephritis, eye ground appearances in.... 803
pathology of 132
prognosis in loio
senile, complications of 964
symptoms and diagnosis of 1010
treatment of loio
trencli, prognosis in 876
war, prognosis in 260
study of 128
Nephrotomy in eclampsia 567
Nerve d.sabilities, musculospiral 917
fibres, sensory, comparative activity of
local anesthetics on 218
injuries, treatment of 1129
lesions, per phtral, Tinel's sign in 612
suture, indirect, advantages of 568
Nerves of lung, study of, in tuberculosis 744
paralysis of, by curari, strychnine, and
brucine 1131
peripheral, lesions of 785, 1120
wounds of 829
Nervous commotion, cerebrospinal fluid in 438
diseases, calcium in 520
disturbances of influenza 725, 755, 807
system, sympathetic, disturbances of .... 305
vegetative and pathogenic function of. 163
tissues, metabolism in 428
Nervousness and temperament in sii:gers 811
in soldiers 160
Neuralgia, electricity in treatment of. . . . 435
facial, local alcoholization in 739
trigeminal, etiological factors of 78
treatment of 126
Neurasthenia, oiganic basis of 346
iveuritis, electricity in treatment of 435
multiple, from manufacture of explo-
sives 218
Neurofibromatosis, generalized 826
multiple, inheritance of 965
Neuropsychiatry in the army 379
Neurorrhaphy, technic of 785
Neuroses, functional, moral conflict in.... 90
traumatic 482
war, prevention of 45
resembling l.y.steria 744
Neurotic symptoms referred to the eyes. . 668
Nevi in adults 920
Newborn, acidotic state of 661
early vaccination of 300
whooping cough in 980
Nies, Edward H. The food value of meat. 156
Nisselson, Max. A case of salivary cal-
culus ' 109
Nitrogen determination in blood and urine 848
Noguchi's luetin test in syphilis 262
Noma following paratyphoid B infection 21
Norman, N. Pliilip. Mobilizing the spas
and health resorts of our nation,
419, 463, 507
Nose, destruction of function after oper-
ations on 797
operative cure of serious injury to.... 1099
work at recruiting depot 09
Novack. H T. Treatment of influenza.. 984
Novarsenobenzol, fatal icterus gravis fol-
lowing 84
Nurses needed by the army 426
supply of 426
Nutrition, disorders of, in children. . loi, 241
inorganic elements in 129
of school children, disturbances of.... 241
standards for 571
Nutritive value of maize 129
Nuzum's poliomyelitis serum 746
Nystagmus with head shaking, in infants 530
QBERNDORF, C. P. Neurotic symp-
toms referred to the eyes 668
OBITUARY:
Baker, Frank, M. D., of Washington,
D. C 859
Bissell, Joseph B., M. D., Major, Medi-
cal Corps, U. S. Army, of New
York 1000
Cragin, Edwin Bradford, M. D., of
New York 737
Fahnestock, Clarence, M. D., Major,
Med'cal Corps, U. .S. Army 649
Gulick, Luther Halsey, M. D., of New
York 342
Kemp, Robert Coleman, M. D., of New
York 781
Wheeler, Maior David Everett, M. R.
C., U. S. Army, Buffalo, N. Y 297
Obstetrician, avoidable errors of 769
Obstetrics, graduate degree in 396
modern technic of 137
problems in 981
teaching and research in, after the war 307
Occlusion, mesenteric vascular 393
of vena cava by hypernephroma 570
Occupations for cripples, education and
training for 520
Ocular deviations, latent 936
Oculomotor reaction to labyrinthine stim-
ulation 834
Operations, purgation preceding 434
Ophthalmia, sympathetic 378
Ophthalmoplegia in paresis 185
Face.
Optic nerves, atrophy of, from manufac-
ture of explosives 218
Optochin in lobar pneumonia 213
Organotherapy in treatment of wounds ... 1005
Orthopedics at Fordham Hospital 812
Orticoni, Barbie and Lcclerc. The micro-
bian flora of influeiiia 730
Osborne, Oliver T. Ovary: corpus lu-
teum 401, 447
Osteitis, cutaneous autoplasty in treatment
of 1 130
Otitis, acute, followed by mastoid opera-
tion 659
media and meningitis 741
Ovarian extract, definiteness in regard to 384
therapeutics of 401, 447
Ovaries, conservation of 787
symptoms resulting liom extirpation of 403
Ovary, conserved, results of 351
corpus luteum 401, 447
papillary cystadenoma of 457, 837
results of hysterectomy upon function
of ; 351
sarcoma of, in a child 968
Overwork, alexin deficit in 394
Ozena, cause of iioo
pAGET'S disepsc of the bones 678
^ Pain, abdominal, in amebic enteritis. . 525
from gas, pre\ention of 874
in dyspeptics 878
in relation tc alopecia 121
method of relieving 639
ultimate significance of 999
Palmer, Leroy S. and Eckles, C. H. Milk
as a galactagogue 375
Pancreas, cyst of 389, 969
pseudocysts of 389
painted with adrenalin, effect of, upon
hyperglycemia and glycosuria 438
Pancreatitis, catarrhal, treatment of 1004
prolonged bile drainage in 742
Paralysis, clinical types of 486
electricity in treatment of 435
facial, chronic peripheral 82
general, Bordet-Wassermann reaction of
cerebrospinal fluid in 218
infantile, transmitted by the rat 398
of divergence 91
of iilnar nerve 390
of nerves by curari, strychnine, and
brucine 1131
postdiphtheritic 789-
Paraplegia, diflerentiation between func-
tional and organic gig
Parasites, intestinal, among troops 86
Paratyphoid B infection, noma following. . 21
Parathyroid glands, functional insuffici-
ency of 832
Parathyroidectomy, influence of, on gas-
trointestinal mucosa 217-
Paratyplioids and typhoid, triple inocula-
tion against 37
Paresis, clinical diagnosis of 7go
electricity in treatment of 435
intracranial treatment of 742
ophthalmic changes in 181
treatment of 960
Park, William H. Bacteriology and pos-
sibility of antiinfluenza vaccine as a
prophylactic 621
Parker, George M. Analytic view of
psychic factor in shock 12, 58
Parotid gland, enlargement of, among
troops 43S
Parotitis, experimental study of 746, logS
Pasteur's relation to medicine and surgery 357
Patella, fracture of 388
Patient, the unconscious io8<)
Pediculosis capitis 501
Pelvic lavage, value of 611
Pelvis, female, fetal anatomy of 308
Pensions for disabled soldiers, Canadian.. 826
questions regarding 206
Peptic ulcer, healing of 442
x ray diagnosis of 442, 832
Peptone in treatment of asthma 609
Pericarditis, pulmonary compression signs
in 612
Perineum in piimipars 353
repair of 8g
Peritonitis, pneumococcic 761
syphilitic lojj
tuberculous, sterilization of women dur-
ing operation for 969
surgical treatment of. . 493
Personality, secondary, and literature.... 86g
Pertussis, morphine and pantopon in.... 167
Peterson, Frederick. Preventive medicine
and the reconstruction of the race... 1105
Pfeiffer's bacillus, medium for culture of 701
Phagocytic response to bacteria in clean
wounds 306
Phantasies, day, in a child 628
Pharynx, typhoid infections of 42
Phosphorus and calcium requirements of
healthy women 129
value of. in disorders of ossification.... 214
Phototherapy in surgical tuberculosis .... 36
INDEX TO VOLUME CVIII.
1 145
Page.
rhrenopericardifis, adhesive 41
Physicians, eight hour days for 180
German, b ii|::Iity of 1122
Physiology, obstetrical, and delivery 391
Pigment, blue, in blood serum 261
formation, important studies in 470
Piics. knifeless treatment of 1090
Pilocarpine in chronic deafness 592
Pisko, Edward. Syphilis and matrimony 1021
Pituitary body and polyuria 875
extract, standardization of 562
Pituitrin and adrenalin, injections of, in
hay fever 51
in obstetrics 829
Placenta prxvia 946
CiCParean section in 1049
Placental extract, greater definiteness in
regard to 384
riaster of Paris bandage roller 6
Vidal's white substitute for 917
Pleura, removal of missiles from 566
wound.s of ' 23
Pleural cavity, absorption of air from.... 392
Pldirisy, treatment of 1051
vicious c rcle.s in 519
I ncumococcMs, determination of type of,
in pneumonia 210
prophylactic inoculation against 6jS
Pneumonia, cases of, on Norwegian steam-
ship 330
constipation treatment of 1076
following influenza 811, 923
importance of blood cultures in 964
in army can:ps 46, 484
prevention of 794
prophylaxis of S32
reduction in mortality from 293
influenza, sert-m treatment of 1006
lobar, antigen-ant body balance in 261
antipneumococcus serum in 1094
ethylhydrocupreine in 213
.serum treatment of 484
pandf-mic, in civil hospital 1097
pneumococcus type determination in.... 210
prevention of, in influenza 730
streptococcal, epidemic of 700
Type I. ferun! treatment of 1006
unusual hyperpyrexia in 3
vaccination against 658
vicious circles in 387
Pneumonitis, influenzal, treatment of. . . . 847
Pneuniothorax, artificial, in private and
dispensary practice 127
spontaneous, in pulmonary tuberculosis 632
Polily. Albert E. Nasal pharyngeal polypi 418
Poisoning, alcohol, in manufacture of cal-
cium cyanpmide 524
arsenic, loss ot Achilles retlexes in....ioo?
carbon monoxide, brain changes in.... 702
carbon sulphide, polyneuritis from 562
gas, syndrome 990
industrial aniline §72
lead 657
mercuric chloride, treatment of 829
myrtol and eucalyptol 441
trinitrotoluene 160, 918
Poisons, chemical, in warfare 989
Poliomyelitis, epidemic, etiology of 745
immune horse serum in treatment of. . 569
Nuzuni's serum for 746
polyneuritis and hyperesthesia in 438
specific prevention of 219
transmission of, by the rat 1054
Polyarthritis during arsenobenzol treat-
ment 303
Polyneuritis from carbon sulphide poison-
ing 562
in poliomyelitis 438
treatment of 123
Polypi, nasal pharyngeal 418
Polyuria and tlie pituitary body 875
Popliteal 'artery, lateral suture of 567
Port of embarkation laboratory 995
surgeon of 551
Post mortem on twilight sleep 64
Pott's disease, heliotherapy in 302, 698
Pregnancy, complicated by pernicious
heart in 96g
medical supervision during 848
mortality of influenza in 924
pernicious vomiting of 303
ruptured extrauterine 307
toxemia of 89, 699, 829, 967
triplet, complicated by cancer of cervix 396
vomiting of 171
Pridham, Frederick. Preventive treatment
of bone and joint diseases 279
Prisoners, exchange of, is robbery 33
in Germany, dyspepsia among 057
edema in 260
sexual abnormalities among 542
war, brutality of German physicians to 1122
Proctitis, treatment of 212
Proflavine in infected wounds 257
Prohibition and public health 1044
Prolapse, genital, in women 874
of uterus and bladder 522
Prolapsus uteri J^gi
Pace.
Piostatitis, advanced, tieatment of 125
chronic, treatment of 1051
treatment of 786
Prostitution, psychopathic control of 758
Piotein. food value of, in diabetes 443
forei.gn, intravenous injections of, in in-
fluenza 843
maize, nutritive value of 129
treatment of arthritis 831
of psoriasis 326
Proteins in causation of diabetes 162
Protozoa in the intestines 964
Pruritis ani associated with pyorrhea.... 262
etiology and treatment of 1094
Pseudarthrosis, tibial, bone transplanta-
tion for 784
treatment of 962
Pseudocysts of pancreas 389
Psoriasis, etiology of 232
protein treatment of 326
sulphur solution in 916
treatment of 3C1
Psychanalyss 1018
in shell shock 962
Psychiatric f.Tinily studies 1054
Psychic effects in surgery 384
f;ictor in shock 12, 58
Psychology in the army 379
of war 136, 1S9
Psychoneuroses of war 962
Psychoneurotic syndrome of hyperthy-
roidism 394
Psychopathy and criminality 1124
Psychoses, manic depressive, lucid inter-
val in 1032
Public Health Service, offictrs needed in 29
Puerperal bacteriemia, arsenobenzol in... 698
blood stream infection, arsenobenzol
treatment of 354
Pulmonary compression signs in pericar-
ditis 612
edema, diagnosis of 251
Pulse after a marathon race 788
thready, in typhoid perforation 1020
Puncture, exploratory, of chest 528
lumb.'ir 524
in convulsions 769
in syphilitic meningomyelitis 390
spinal, in sciatica 302
Pupils, clinical value of changes in 143
Purgation, preoperative 434
Pyloric syndrome in nursing infants 1123
Pylorus, stenosis of 572
Pyorrh'ca alveolaris 389. 1050
associated with pruritus ani 262
QUININE collobiase, injections of, in
malaria 1095
in treatment and prevention of malaria 522
prophylactic use of 257
DACE, reconstruction of 1105
Radiography, stereoscopic, improve-
ment in 1098
Radiotherapy in skin cancer, contraindica-
tions to 523
Radium treatment of fibroid tumors. .355, 830
of malignancy in mouth and throat.. 509
of vernal conjunctivitis 742
iise of, by gynecologist 395
Rainbow Division commended 601
Ramirez, M. A., and Hoguet, J. P. Ileo-
cecal insufficiency 146
Rammstedt's operation for pyloric stenosis 572
Ration, civilian, during war 1085
Rations, adjustment of 156
Ray, E. L., and Stivelman, B. Paget's
disease of the bones 678
Raynaud's disease, etiology of 1053
Reaction. Bordet-Wassei mann, of cerebro-
spinal fluid in general paralysis 218
complement fixation, influence of tem-
perament upon 746
luetin in Evphilis 262
Reactions, circulatory, to graduated work 218
imniunity, in hydrated and concentrated
tissue (,C)i
Reconstruction and human conservation.. 263
of the disabled 118, 1014
of the wounded 1014
physical 176
therapeutics of 289
work in army 337
in Canada lo^
on hand and forearm .....11 17
Recruiting depot, eye, ear, nose and throat
work at 69
Recruits, examination of, for tuberculosis,
heart conditions in m, 875
physical examination of 78
types of men among 992
Rectal anesthesia 38
disease, interesting cases of 104
feeding, plan of 83
Rectovaginal septum, adenomyoma of.... 308
Rectum, cancer of 127
fistula of 061
spa.stic contractures of 830
Page.
Red Cross, An.erlcan, work of, among
French children 1103
Redfield, Casper L. Animal powers not
Meiidelian characters 499
Recde, Edward Hiram. Toxic nonexoph-
thalmic goitre 452
Reeducation centre for disabled soldiers
at iiombay 336
funct onal, of the wounded 683
vocational, of war cripples 264
Rehabilitation of rejected 703
of wounded 1012
Renal elimination, normal and pathologi-
cal 174
function in cardiac insufficiency 129
test meal for 129
Research, chemical, American institute of. 868
Resection of hip for secondary arthritis.. 915
of lung, bronchial fistula following. . . . 523
of war wounds 25
Resistance, lessened, in focal infection... 976
Respiration, artificial, in asphyxiation.... 592
Respiratory dise:;ses in army camps 646
vicious circles in 344, 387, 431,
. , . . 475, 519, 565
infections in army camps 566
tract, lower, chron c infections of 189
Resuscitation, manual methods of 1056
mechanical methods of 1055
third commis.cion on 1055
Ret.-n, George M Medical inspection in
public schools 36B
Retina, hemorrhage from, caused by bac-
terial toxin 306
Retropharyngeal abscess 417
Rheumatism, acidosis in 229
acute, new treatment in 743
chronic, colloidal sulphur in 1088
dermatoses idtntilied with 230
preventive treatment of 279
senile, treatment of 259
Rheumatoid arthritis, treatment of 38
Rhinitis, atrophic, cause of iioo
chronic hypertrophy 462
Richardson, Anna M. Undernutrition in
children loi
Rickets in relation to housing 526
Rickettsia bodies in lice with trench
fever 1099
Righthandedncss in relation to visual con-
ditions 269
Roberts, Percy Willard. Syphilitic joints. 105
Rocky Mountain spotted fever, etiology
and pathology of 268
Rodet's serum in typhoid fever 567
Rodman, Harry. Diseased tonsilitis and
focal infection 761
Rontgen rays (see x rays).
Rontgenography, sodium bromide in 878
Rosenberger, Rrndle C. Mo'stening the
mask with antiseptic solution 750
Ten thousand Wassermann tests in the
Philadelphia General Hospital 584
Rosenheck, Charles. Reflex convulsions
during dentition 769
Routh, Aniand. A need for medical su-
pervision during pregnancy 848
Rovinsky, Alexander. Cellulitis of upper
lid due to a foreign body 1032
Roy, Dunbar. Clinical report of three in-
teresting cases of eye injury 898
Rubella complicated by bronchitis 1052
throat smears in 348
Ruhenstone, A. I. Immunization therapy
in bronchial asthma 285
Rucker, James B., Jr., and Wenner, John
J. Friedlander bacillus the causative
factor in bronchopneumonia following
influenza 1066
Rural communities, health conditions in.. 1 125
C ABSHIN, Z. I. Influenza. Clinical ob-
"-^ servations of the epidemic in the U.
S. Marine Hospital, Stapleton, S. I. 888
Sadler, Mark. Notes on drugs and treat-
"if^nt 123, 167, 255, 299, 4^6, 607
Physiologcal action and therapeutic in-
dications of digitalin 607
Treatment of gonorrhea, cerebrospinal
meningitis, polyneuritis and myelitis. . 123
Treatment of hemophilia 255, 299
Treatment of infected wounds 466
Use of morphine and pantopon in per-
tussis 167
Sajous, Louis T. de M. Polvvalent seruni
in cerebrospinal meningitis ....1002,
1048, 1092, 1128
Recent observations in digitalis therapy,
^ , , , . 35. 80, 123, 168, 211
Strophanthus and its active principles
versus digitalis e^i, 696, 828,
ir- • ■ 1 • J- J r ^7^^
Vicious circles in disorders of the respi-
ratory system.. 387, 431, 475, 519, 565, 344
Salicin in infltienza 1000
large doses of, in influenza , 697
Sal'vary glands, infection of 383
Samsoen. Dr. Cesar, awarded the Legion
of Honor 249-
I
1 14'^'
Page.
Siiiiitalion of army camps S35
of shipyards 880
tiain, iinpi ovcireiit in S24
trench 84
work in the ;!hipyards 398
Saratoi-'a Springs, description of 421
Sarcoma of hr.-iin 590
of heart 788
of hip 817
of ovary in a cliild 968
of uterus 480
Sautter, (.'. M. Pilocarpine in chronic
deafness 592
Scabies in military and civil life 1130
treatment of 391
Seal, .Tosepli Back injuries and their
relation to workmen's compensation
law 983
Scale, colorimctric, application of, to Bor-
det-Wasscrniann reaction 1032
Scalp, replacement of, on denuded drv
skull ■. 84
Scarlatina, rapid cure of 697
Scarlet fever, cardiac disturbances in.... 130
endocarditis in 789
epilepsy due to 68
hemorrhage after 615
house disinfection after 44
rapid cure of 697
throat smears in 348
Scars, deep facial, treatment of 215
.X ray treatment of 1131
Schools, public, medical inspection in.... 368
Schwatt, H. Heart in pulmonary tuber-
culosis 282
Sciatica cured by lumbar anesthesia 1051
spinal punctiu-e in 302
Science and art of medicine 691
Scopolamine-morpliine amnesia in labor. . 872
Scurvy, experimental, in relation to diet 876
infantile, treatment of 1050
intravenous therapy for 485
Seborrhea, treatment of 872
Secretion, gastric, during fever 130
Sensitization to ipecas 1051
Sepsis, incarcerated 126
Septicemia in parameningococcic infec-
tions 789
meningococcal, intermittent fever from 130
of buccodental origin 920
puerperal, seriuns and vaccines in treat-
ment of . . ; 1 24
unrecognized forms of 1052
Serotherapy, paraspecific, in war medicine
and surgery 903
Serum, agglutinating properties of, in
vaccinated subjects 1092
antimeningococcic 439
therapeutic value of 478
antipneumococcus, in treatment of lobar
pneumonia 1094
antipneumococcic, potency of 213
antitetanic. intolerance to 424
horse, agglutinating power of, for hu-
man red cells 173
in treatment of chorea 662
intraspinal injections of, failure to de-
sensitize 69S
Nuziun's antipoliomyelitic 74C'
polyvalent, in cerebrospinal meningitis,
1002, 1048, 1092, 1 128
preventive and curative, for gas gan-
grene 3(18
Rodet's, in typhoid fever 367
therapy 1088
in massive doses, harmlessness of.... 770
new method of 11 29
■treatment of cerebrospinal meningitis... 946
of gas gangrene 873, 1004
of influenza pneumonia 1006
of meningiti.s 439
of puerperal septicemia 124
of Type I pneinnonia to66
.Sev hygiene 542
Se.Nual development in women, thyroid dis-
ease in relation to 281
Shaweker, Max. A Wassermann modifica-
tion 896
Sh.ctfield. Herman B. Whooping cough in
tlif- newly born 980
Shell shock, cure of goi
manual training in 1045
prevention of 45
psychanalysis in 962
psychic factor in 12. 38
Shipyard employees, plans for housing. . . . 8S2
Shipyards, healtl! and sanitation in... 398. 880
Shock, alkalinity of blood and acidosis in 877
bearing of muscular autolysis on 524
psychic factor in 12, 38
■valine solution with organic extracts in. 960
shell, cure of 901
manual training in 1043
prevention of 4;
psychanalysis in 962
l)sychic factor in 12, 58
surgical, and related jjroblems 81
at the front 341
INDEX TO VOLUME CVIII.
Page.
.Shock, torpedo | 956
traumatic 436
pulmonary fai: embolism in relation to 1097
treatment of 1051
wiunid, cure of 90 r
intravenous injection in 34(^1
Sidis, Boris. Moderation versus intensive
training 751
Sight of soldiers and sailors, suggestions
for improving 639
.Sigmoiditis, treatment of 212
.Sinionton, L. J. Production of antiembry-
onic bodies as a cure for cancer 619
The thyroid gland in development and
disease 281
Sinus disease, influenzal 86
superior longitudinal, its value in trans-
fusion and rapid medication 1051
thrombosis, diagnosis of 1069
Sinuses, accessory, operative cure of seri-
ous injury to 1099
Skin cancer, ccntraindications to radio-
therapy in 523
diseases, antianaphylactic treatment in.. 655
effect of mustard gas upon 119
flaps in osteitis 1130
grafting 82
malignant growths of 473
carbon dioxide snow in 303
sterilization of 302
Skull, denuded, replacement of scalp on.. 84
Sleep, broken, treatment of 653
how to get enough 196
Smallpox, intradural vaccination against.. 634
vaccination, violent reaction in 618
Smith, John J. Eye, car, nose and throat
work at recruiting depot 69
Snyder. R. Garfield. Spanish influenza;
its treatment by the use of intravenous
injection of a nonbacterial split protein 843
Soamine in bronchial asthma 569
SOCIETIES, PROCEEDINGS OF:
American Academy of Political and So-
cial Science 1012
American Association of Obstetricians
and Gynecologists 925, 966
American Gynecological Society 307, 351, 393
American Laryngological Association,
1057, 1099
American Pediatric Society 527, 571, 615, 659
American Public Health Association ... 1 132
Association of American Physicians 265, 307
439, 483
Bal)ies' Welfare Association 11 03
Canadian Medical Association 88
Canadian Medical Congress 43, 88
Canadian Public Health Association.... 43
College of Physicians of Philadelphia,
486, 1 1 34
Medical Association of the Greater City
of New York 703, 792, 833, 879
Medical Society of the State of New
York 131
Medical Society of the County of New
York 263
New York Academy of Medicine.. 176,219.
,r , „T '■47' 949> 1033
New York Neurological Society 790
Ontario Health Officers' Association .. . 43
Ontario Medical Association 88
Philadelphia County Medical Society.. 179,
222, 921, loio, 1103
Resuscitation Commission, third 1055
Soldiers, cardiac disabilities of 40
crippled, employment of 1013
Government aid for 161
disabled, employment of 1013
pensions for 826
reconstruction of 118, 176, 263
reeducation of, at Bombay 336
rehabilitation of .• 263
social after care for 264
nervousness in 160
retiuned, accommodations for 74
mental attitude of 43
jKirades of 10S9
problem of 43
wounded, functional reeducation 683
rehabilitation of 1012
return home 1035, 1042
.Solution, improved sugar, for injection .. 1 130
Solutions, chlorine yielding, bactericidal
properties of 172
Soul and blood in ancient belief. .93, 225, 271
and the breath 93, 225, 271
.'^pas and health resorts, mobilization of. . 419.
463, 507
of the United States, classification and
description of 419, 463, 507
Sphincter muscles, division of 479
.Spinal cord, involvement of, in fracture
depression of lamina; of cervical ver-
tebr.-E 363
Spine, fracture of, without cord injury.. looS
surgery of 736
wounds of, suprapubic cystotomy in.... 290
.Spirochetes in the kidney 175
Pace.
Spirochetosis, bi oncliopulmonary 479
hemorrhagic | ulmonary, differentiation of 613
hepatic form of 1022
iclcroha;morrhagica 706
Spivak, C. D. Mechanics of defecation.. 945
.Sjjlanchnoptosis, clinical observations in.. 929
Spleen, enlargement of, in malaria 216
rupture of 1087
Splenectomy from myelocytic leucemia . . . . 442
in treatment of anemia 179
Splenomegaly in septicemic endocarditis
214, 483
Splint, abduction, for the femur 213
simple, for wrist drop , . 239
Splints, plaster, in compound fractures of
long bones 1028
Spotted fever. Rocky Mountain, etiology
and pathology of 268
Springs, French Lick 508
Glen, description of 420
Hot, of Arkansas 507
Saratoga, description of 420
Virginia Hot, description of 464
White Sulphur, description of 463
Staining blood films and parasites, French
methods of 461
Tribondeau's method of 701
Staller, Max. Evolution and dissolution of
tubercle bacillus capsule 985
Immunity in tuberculosis 240
Slanunering, treatment of 873
Stannoxyl in staphylococcal infections.... 831
Starvation treatment of diabetes 20K
Stasis, intestinal 547
conservative surgery of 962
X rays in 672
Status lymphaticus, military aspects of... 1033
Steindler, A. Orthopedic reconstruction
work on hand and forearm 1117
Steinfield, Edward. The site of lessened
resistance in focal infection 976
Stenosis, cicatricial, of esophagus 39
congenital, of esophagus 108
laryngotracheal 963
mitral, amyl nitrite in diagnosis of 41
and Raynaud's disease 1033
pyloric, Ramstedt's operation for 572
Sterilization by nieans of hot formaldehyde
vapor 569
caused by induced abortions 926
of skin and other surfaces 302
ol \yomen during operation for periton-
itis 969
Stern, Adolph. Day phantasies in a child 628
Stevens, George T. Righthandedness in
its relation to visual conditions 269
Stewart, Douglas H. The ingrown toenail
and the coup d'hache 858
Stewart, George David. Civilization and
liberty loan 533
Stillbirths due to accidents of childbirth 850
Stivelman, B. and Ray, E. L. Paget's
disease of the bones 678
Stomach, dilated, cribbing with 617
syphilis of 544, 838
ulcer of 915
Stools, isolation of dysentery bacilli from 41
Streptococci in wounds 787
.Streptococcus carriers and complications
of measles 306
hemolytic, filterable toxic product of... 833
pneumonia, epidemic of 700
Stricture, congenital, of duodenum 616
of esophagus following cardio spasm... 616
urethral 568
treatment of 874
Slrophanthus and its active principles ver-
sus digitalis 631, 696, 828, 871, 914, 958
Strychnine, paralysis of nerve cells by....ii3i
Stump muscles, functional utilization of. . 3<io
Sugar in cerebrospinal fluid 236
in normal urine, determination of 175
solution, improved, for injection 1130
Sulphur, colloidal, in chronic rheumatism 1088
solution in psoriasis 916
tlierapeutics of oily solutions of 391
Suppurations in peritoneal cavity, Dakin's
solution in 396
Suprarenal glands and influenza 895
Surgeon as a sculptor 253
at the front 694
general, of the U. S. Army, the new... 597
in arms 1084
standardization of 1108
Surgeons, chief, location of, at close of
war 1085
contract, in the army 74
honors for 737
n^ethods of training 88
of allied armies discuss modern war
surgery 819
.Surgery, abdominal, in tuberculosis 652
chloramines in 258
cranial 347
military, training in, at Fort Oglethorpe 117
modern, of war 823
of lungs, modern military aspects of... 949
of warfare, paraspecific serotherapy in . 903
INDEX TO VOLUME CVIII.
114,7
Page.
Surgciy, Pasteur's relation to 357
plastic facifil II4
on head ami neck, teaching of 88
prohlenis anil principles of I53
p^ycliic elTecls in 384
si)inal, attention to 73^
war. discussed by surgeons from the
allied arnues 819, 949
.Surgical instruments, sliortage of ""6
Suture, delayed primary 479
inunediate or delayed, in gunshot wounds 965
indirect, of nerve 568
lateral, of polliteal artery 567
Symniers, Douglas. Pathology of pan-
demic influenza 621
.Sympathetic disturbances and dyspeptic
states • 305
nervous system, disturbances of, dys-
pepsia in relation to 305
stimulation of, result of toxemia 311
Svmptoms, neurotic, referred to eyes,,.. 668
of oversecretion of 403
Syphilis, antenatal 849
cerebrospinal 181
intraspinous treatment of 303, 741
treatment of 408
complement fixation reaction in 746
congenital, acute meningitis in 216
and the doctor 277
mercury treatment of 531
treatment of 40S
visceral manifestations in 437
detection of in primary stage 44
diagnosis of, by Tribondeau's method of
staining 701
galyl in treatment of 736
in relation to matrimony 1021
intravenous injections of calomel in.... 301
local reactions in arsenical treatment of 433
modern treatment of 294, 40.S
negative laboratory findings in 316
Noguchi's luetin test in 262
novarsenobenzol in 831
of stomach 838, 544
orificial 851
polyarthritis during arsenobenzol treat-
ment for 303
treatment of 831
Syphilitic joints 105, 792
meningitis 1007
'X'ABES dorsalis, emotion and etiology of 394
* ophthalmic changes in 181
Tachycardia, continued 163
in enteric fever 304
paroxysmal 40
digitalis in 35
of ventricular origin 41
with hypertension in soldiers 393
Talipes equinus 904
Taylor, J. Madison. Can flat foot be cured 373
Eight hour day for physicians 180
Reconstructive therapeutics 289
Treatment of influenzal pneumonitis.... 847
Types of men observed among recruits 992
Technic, modern obstetrical 137
Teeth, diseased, a factoi- in arthritis 959
Teething, conditions produced by, simulat-
ing disease 262
Temperament, synonym of nervousness in
singers 811
Tension, arterial, effect of physical labor
on 1078
Temperature, influence of, upon comple-
ment fixation reaction in syphilis 746
lest, atropine, in typhoid infections 87
for blood in urine and feces 877
meal for renal function 129
Tests of kidney function, value of 658
physical, for aviators 690
Tetanus, carbolic acid in 900
in the army, prevention of 794
partial 702
Therapeutics, reconstructive 289
Thigh, drainage of deep wounds of 214
fracture of, in military practice 260
Thorax, bony, promary malignant tumors
of gi6
war wounds of 1 . . . 657
Thrills, presystolic, in soldiers 4,1
Throat, cancer of, electrothermic treat-
ment of 1030
destruction of function after operations
ofi 797
raduun treatment of malignancy in 569
smears in measles, rubella, and scarlet
fever 348
work at recruiting depot 69
Tl.romhosis and embolism 374
of coronary artery 441
sinus, diagnosis of 1069
Thynuis gland, hypertrophy of 779
Thyroglossal duct, cyst of 1102
Tl.yroid extract, suppuration of gland fol-
lowing administration of 919
gland, function of 486
goitrous, suppuration of 919
in development and disease 281
iodine content of gfij
918
858
786
761
967
3"
86
306
P.VCE.
Thyroid, hoi mone in relation to metabolism 485
in relation to other ductless glands. . 1097
instability 437
tissue, transplantatioit of 481
Tibia, fracture of 155
Tilney, Frederick. A niecca of medicine
for the future 534
Tin, distribution and elimination of, in the
body 174
Tinel's sign in peripheral nerve lesions.. 612
Tissues, soft, fibrosarcoma of 816
TNT poisoning with high explosive shells
160,
Toenail, ingrown, and the coup d'hache.-
Tonsil, lingual, clinical observations on..
operation, indications for
Tonsillitis, treatment of
Tonsils, diseased, and focal infection
caused factor in arthritis 9.19
Tonus waves from sinoauricular muscle. . 833
Torpedo shock 956
Tousey, Sinclair. Device for x ray loca-
tion of bullets and other foreign bod-
ies in wounds i
Toxemia of pregnancy 89, 699, 829,
stimidation of sympathetic a result of. .
Toxicity of antiseptics
Toxin, bacterial, causing retinal hemor-
rhage
Trachea, recurrent teratomatous growth of 582
Tracheotomy for laryngotracheal stenosis. 965
Trachoma, treatment of gi6
Tract, biliary, surgery of 89
Training, manual, in shell shock 1045
military, a factor in public health 1017
occupational, for men crippled by ampu-
tations 520
Trains, railway, improvement in sanitation
of 824
Transfusion, new method of 1129
of citrated blood, method of 172
simplified method of 39
value of superior longitudinal sinus in.. 1 051
with preserved red cells 476
Transplantation of thyroid tissue........ 481
tendon 1118
TrasofT, Abraham. Errors in diagnosis of
pulmonary tuberculosis 665
Trauma and disease, early pages in 250
Treatment, symptomatic 706
Trench fever 136, 159
bacteriology of 37S
etiology of 483
prevention of, in the army 794
researches in 349
Rickettsia bodies in lice with 1009
nephritis, prognosis in 876
sanitation 84
warfare, epidtmology of 24
Tribondeau, L. French methods of stain-
ing blood films from blood parasites. 461
Tribondeau's method of staining smears. . 701
Trinitrotoluene poisoning 160, 918
Trudeau staf\ie at Saranac Lake 330
Tubercle bacilli, virulence of, in sputum.. 87
bac'llus capsule, evolution and dissolu-
tion of 985
Tuberculin in diseases of the eye 428
Tuberculosis, abilominal surgery in 652
advantages of home treatment in 323
amputation of epiglottis for 83
an army problem 740
chemotherapy of 610
clinical results of complement fixation in 220
complement fi.xation in 919
erythema occurring in 209
examination of recruits for 199, 245
fasting in treatment of intestinal disor-
ders of 127
Framinghani experiment in control of..ii33
immunity in 240
in army, errors in diagnosis of 665
in infancy, complement fixation test for 572
mechanism of production of 634
problem in France 243
in war 997
prophylactic work in, in France 662
psychic influence upon 1044
pulmonary, among soldiers 349
bimanual percussion in diagnosis of.. 701
errors in diagnosis of 665
heart in 282
local processes of disease and repair
in treatment of 81
spontaneous pneumothorax in 632
study of nerves and ganglia of lungs
.'■n 744
vicious circles in 431, 475
. surgical, phototherapy and the air cure in 36
renal, prognosis in 135
technic of complement fixation in 219
treatment of 127
value of fresh air in 632
vertebral, fusion treatment of 1005
Tuberculous lymph nodes, transplantation
of 267
Tumors, brain, removal of 304
surgical treatment of 785
breast, x ray treatment of 837
Page.
Tumors, libroid, radium treatment of. .35.=;. 830
hypophyseal 699
malignant, fluctuations in growth of.... 347
of bony thorax 916
of kidney, x ray examination of 469
relation of cellular changes of age to.. 173
spinal 698
Tuick, Fenton B. Wound and sliell shock
and their cure 901
Twilight sleep, post mortem on 64
Typhoid and paratyphoid fevers, prophy-
lactic triple inocuh-tion against 37
fever, auto.{enous vaccine therapy in... 521
in army camps, prevention of 794
in immunized soldiers 658
Rodet's serum in .167
vaccination against, in the French
army 72
infections, atropine test in 87
of mouth and pharynx 42
perforation, thready pulse in 1020
prophylaxis, p'-opaganda against 117
vaccination, triple 302
Typhus fever, injection of chlorine solu-
tions in 171
serological test in 964
Tyramine in circulatory failure 259.
ULCER, duodenal, ambulatory treatment
of 1095
medical treatment of 301
gastric, ambulatory treatment of 109.S
cautery excision of 347
medical treatment of 301
treatment of 91.S
of bladder 309
peptic, healing of 442
X ray diagnosis of 442, S32
Ulcers, leg, treatment of 223
Ulnar nerve, paialysis of 390
Umbilical polyp associated witii Meckel's
diverticulum 307
Umbilicus, sloughing amniotic hernia of. 307
Undernutrition in children loi
Universities, Canadian, tribute of, to the
war 4.1
University, Khaki, of Canada 561
LTpham, Roy. INIUcous colitis 503
Uremia, treatment of, in major wounds .. 109.=;
Ureter, congenital anomalies of 134
gonococcus infection of 1022
Ureteral calculi removed without opera-
tion 611
calculus, treatment of 258
L'reters, divided, method of dealing with 346
surgery of, in gynecological practice... 969
Urethra, stricture of 568, 874
Urinary tract, ascending infection of..., 661
Urine, detection and estimation of ar-
senic in 788
hemosiderin granules in cells of 398
nitrogen determination in 848
normal, determination of sugar in 175
test for blood in 877
Urobolin, el:mir.ati<m of, in normal and
anemic doLS 745
Urotropin and uraseptine, general anti-
sepsis wit!: 377
Urticaria 230
Uterine cavitv. escape of foreign material
ficiii, ill I lUerine veins 308
Uteruv nciiiii nf female remedies on.... 347
cancer of 89
carcinoma of 307
displaced, conservative treatment of.... 520
escape of foreign material from
myomata of, p.athological conditions as-
sociated with 355
pathological, at menopause 1090
prolapse of 351, 522
sarcoma of 480
WACCINATION against d>;sentery . .41-9, 874
" antimeningitis 1009
early, of newborn 300
intradural, against smallpox 654
results following 603
smallpox, v'olent reaction in 618
tr'ple typhoi'i 302
V'accine, antinfluenza, as a prophylactic . 621
supplied by Health Department 732
antityphoid 1092
combined, for typhoid and the paraty-
phoids 37
for bronchial asthma 214
therapy 1088
autogenous, in typhoid fever 521
treatment of gonococcic infection 786
of gono'-rhea 1131
triple, prophylactic inoculatinn with.... 128
virus, pure, cultivated in vivo 85
Vaccines in puerperal septicemia 124
value of, in prevention and treatment
of influenza 922
Vaginal douching, bad habit of 125, si&
Van Alstvne. Eleanor Van Ness. Protein
treatment of psoriasis 326
Varicella, pathogenesis of 662^
^^'PEX TO VOLUME CVIII.
Page.
Vegetables, desiccated, antiscorbutic prop-
erties of QSfi
Vena cava, extraction of bullet from.... 655
occlusion of, by hypernephroma... 570
wound of 819
Venereal disease amorig negroes 998
Canadinn legislation regarding 955
cl nical observations in 967
control of 32, 43
in the army, prevention of 794
means of infection in 44
prevention of 3S3
standards for discharge in 488
Venesection in eclampsia 831
Vertebr.Te, fifth and sixth cervical, fracture
depression of lamina of 363
luxation of 437
Vertigo of menopause, treatment of 967
Vessels, large, missies imbedded in walls
of 433
Vices, masculine, assumed by women.... 165
Vicious circles in respiratory diseases,
344, 387. 431. 475, 519, 565
Vidal's plaster, white substitute for 917
Vincent's angina 1058
Virginia Hot Springs, description of 464
Viscera, transposition of 619
Visceroptosis, acquired 940
congen tal 940
diagnostic importance of 409
Vitamine, water soluble, milk a source
of 174
Vitamines and war dietary problems 604
Vitiligo 920
Vivisection in England 11 23
Volunteer Medical Service Corps,
291, 338, 470, 648
Vomiting of pregnancy, feeding in 171
pernicious, of pregnancy, serum treat-
ment of 303
Von Recklinghausen's disease, inheritance
of 965
Von Tiling, Johannes H. M. A. Influ-
enza and tlie suprarenal glands 895
Voorhees, Irvinjr Wilson. Chronic patho-
gen c infections of the lower respira-
tory tract 189
Treatment of influenza from standpoint
of nose and throat specialist 728
Vulvovaginitis, treatment of 1131
W.M,LFIELD. J. iVr. Congenital syph-
ilis and the doctor 277
Waltz. C|-iiide D. Acidosis 585
War commotion and emotion 745
dietary problems, vitamines in relation
to 604
doctor's part in 910
neurcs'S 744
prevention of 45
psvchologv of T i;9
psvchonpi'roses of 962
rat'on, civiliai' 1085
surgery, modern 819
types of headwear used in 1041
Page.
War, use of chemical poisons in 989
W'asscrm.inn reaction, preservation of
complement for 217
studied po.stmortem 174
value of 86
test, modification of 896
tests, ten thousand, in the Philadel-
phia General Hospital 584
Waters, iodized mineral, properties of.... 1093
Wechsler, I. S. Ophthalmic changes in
tabes and paresis 181
Weidler, W:ilter Baer. Congenital fistula
of lacrymal sac 944
Weinstein, Julius W. Intestinal stasis. . 547
Welton, Carroll B. Tonsil operation and
indications which require it 98
Wenner, John J., and Rucker, James B.,
Jr. Friedlander bacillus the causative
factor in bronchopneumonia following
influenza 1066
White .Sulphur Springs, description of. 463
Whitman's abduction treatment in frac-
tures of femur 568
Whooping cough in the newborn 980
Wilder, Amos P. Yale's medical activities
in Changsha, China 1030
Wile, Ira S. Dispensary abuse 17
Woldert, Albert. The Allen-Joslin treat-
ment of diabetes mellitus 764
Work, graduated, circulatory reactions to 218
Workmen's compensation law, back in-
juries in relation to 983
Wound shock, cure of 901
intraven.ius injection in 346
Wounded, electr'city in treatment of.... ^■\^
liow they are handled in battle 1084
rehabilita'ion of 1012
return of 1035, 1042
Wounds, alkali reserve of blood serum in
cases of 86
B.icillus welchii in 1008
bacterial examination of 388
clean, phagocytic response to bacteria in 306
deep, of thigh, drainage of 214
dry, of large blood vessels 378
extensive, le"cccytosis in 394
gunshot, brilliant green in treatment of 256
comparison of immediate and delayed
suture of 965
destruction of muscle in 511
ichthvol and glycerine in 389
of chest 345, 1 135
of face, w't"'! destruction of lower lip
and mandible 960
of head 740
of jaw, control of fragments in 916
of knee jo'nt 476, 1003
infected, acriflav'ne and proflavine in.. 2';7
Carrel-Dakin treatment of 861
technic of closure of 2^6
treatment of 466, 783, 947
liouid tight closure of 391
loc5i! effects of hepatic lipoids on 783
major, treatment of uremia in 1095
new dressing for 411
Page.
Wounds, of ampulla of carotid 523
of cranium, treatment of 1006
of inferior vena cava, treatment of.... 819
of joints, sources of infection of 83
of lungs, surgical treatment of.... 949, 11 34
treatment of 23
of peripheral rerve, treatment of 829
of pleura, treatment of 23
of spine and cord, suprapubic cystotomy
in 290
of thorax, recurring hemoptysis after.. 657
organotherapy in treatment of 1005
penetrating, of knee, restoration of
function in 783,
septic treatment of 83, 784
sluggish, nascent iodine vapor for 522
streptococcic infection in 787
surgical closure of 1005
ulcerated, healing paste for 1005
war, bacterial flora of 214
di.ichylon plaster dressings in treat-
ment of 818
lactic bacteriotherapy in 378
of brain 772
of genital organs 830
of lower jaw 505
relation of, to acute endocarditis.... 483
resection of 25
X ray location of bullets in i
Wright, Jonathan. The blight of theory
on the acquisition of anatomical
knowledge by the ancient Egyptians.. 973
The blood and the soul in ancient be-
lief 93, 225, 271
Wrist, arthrodesis of 1117
drop, simple splint for 239
flexion ankylosis of 11 17
XRAY diagnosis of peptic ulcer. .442, 832
examination of kidney tumors 469
location of bullets, device for i
outfits for the army 74
plates and films, systematic develop-
ment of 374
studies of mouth infections 96^
study of chest 85
treatment of scars ,1131
.\ rays in abdominal disease 672
in breast tumors 837
in fibro-ds 395
in neoplasms of hypophysis 909
in tuberculous glands of neck 917
YALE'S medical activities in Changsha,
China 1030
Vfiws, Castellani's mixture in 697
Ybarra. A. M. Fernandez. Span'sh in-
fluenza 3=16
Yperite, war bums due to 56(>
^INC, distribution and elimination of,
^ in the body . 174
Zueblin, Ernest. Pituitrin and adrenalin
injections in hay fever 51
INDEX TO PAGES
July 6th 1-48
July 1.3th 49-92
July 20th 93-136
Jiilv 27th 137-180
Auaust 3d 181-224
Au,G;ust lOth 225-268
.AuRust 17th 269-312
August 24th 313-356
August 31st 357-400
September 7th 401-444
September 14th 445-488
September 21st 489-532
September 28th 533-576
October 5th 577-620
October 12th 621-664
October 19th 665-708
October 26th 709-752
November 2d 753-796
November 9th 797-840
November i6th 841-884
November 23d 885-920
November 30th 921-972
December 7th 973-1016
December 14th 1017-1060
December 21st 1061-1104
December 28th 1105-1148
!
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